I 

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. 

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

3 SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES, 

4 AND SUBTITLES. 

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

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


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1 (b) TABLE OF DIVISIONS, TITLES, AND SUB2 TITLES.—This Act is divided into divisions, titles, and 

3 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 


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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 

1 DIVISION A—AFFORDABLE 

2 HEALTH CARE CHOICES 

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

4 GENERAL DEFINITIONS. 

5 (a) PURPOSE.— 

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

7 is to provide affordable, quality health care for all 


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1 Americans and reduce the growth in health care 

2 spending. 

3 (2) BUILDING ON CURRENT SYSTEM.—This di4 vision achieves this purpose by building on what 

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

6 the aspects that are broken. 

7 (3) INSURANCE REFORMS.—This division— 

8 (A) enacts strong insurance market re9 forms; 

10 (B) creates a new Health Insurance Ex11 change, with a public health insurance option 

12 alongside private plans; 

13 (C) includes sliding scale affordability 

14 credits; and 

15 (D) initiates shared responsibility among 

16 workers, employers, and the Government; 

17 so that all Americans have coverage of essential 

18 health benefits. 

19 (4) HEALTH DELIVERY REFORM.—This division 

20 institutes health delivery system reforms both to in21 crease quality and to reduce growth in health spend22 ing so that health care becomes more affordable for 

23 businesses, families, and Government. 

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

25 of contents of this division is as follows: 

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


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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. 


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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 


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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 


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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. 


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1 (c) GENERAL DEFINITIONS.—Except as otherwise 

2 provided, in this division: 

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

5 in section 302(d)(2). 

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

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

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

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

12 includes deductibles, coinsurance, copayments, and 

13 similar charges, but does not include premiums, bal14 ance billing amounts for non-network providers, or 

15 spending for non-covered services. 

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

17 the meaning given such term by the Commissioner 

18 and includes a spouse. 

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

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

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

22 in section 733(a)(1) of the Employee Retire23 ment Income Security Act of 1974); 

24 (B) includes such a plan that is the fol25 lowing: 


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1 (i) FEDERAL, STATE, AND TRIBAL

2 GOVERNMENTAL PLANS.—A governmental 

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

4 Employee Retirement Income Security Act 

5 of 1974), including a health benefits plan 

6 offered under chapter 89 of title 5, United 

7 States Code. 

8 (ii) CHURCH PLANS.—A church plan 

9 (as defined in section 3(33) of the Em10 ployee Retirement Income Security Act of 

11 1974); and 

12 (C) excludes coverage described in section 

13 302(d)(2)(E) (relating to TRICARE). 

14 (7) ENHANCED PLAN.—The term ‘‘enhanced 

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

16 303(c). 

17 (8) ESSENTIAL BENEFITS PACKAGE.—The term 

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

19 222(a). 

20 (9) EXCHANGE-PARTICIPATING HEALTH BENE21 FITS PLAN.—The term ‘‘Exchange-participating 

22 health benefits plan’’ means a qualified health bene23 fits plan that is offered through the Health Insur24 ance Exchange and may be purchased directly from 


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1 the entity offering the plan or through enrollment 

2 agents and brokers. 

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

4 individual and includes the individual’s dependents. 

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

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

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

8 673(2) of the Community Services Block Grant Act 

9 (42 U.S.C. 9902(2)), including any revision required 

10 by such section. 

11 (12) HEALTH BENEFITS PLAN.—The term 

12 ‘‘health benefits plan’’ means health insurance cov13 erage and an employment-based health plan and in14 cludes the public health insurance option. 

15 (13) HEALTH INSURANCE COVERAGE.—The 

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

17 given such term in section 2791 of the Public 

18 Health Service Act, but does not include coverage in 

19 relation to its provision of excepted benefits— 

20 (A) described in paragraph (1) of sub21 section (c) of such section; or 

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

23 of such subsection if the benefits are provided 

24 under a separate policy, certificate, or contract 

25 of insurance. 


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1 (14) HEALTH INSURANCE ISSUER.—The term 

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

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

4 Service Act. 

5 (15) HEALTH INSURANCE EXCHANGE.—The 

6 term ‘‘Health Insurance Exchange’’ means the 

7 Health Insurance Exchange established under sec8 tion 301. 

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

10 meaning given such term in section 4 of the Indian 

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

12 (17) INDIAN HEALTH CARE PROVIDER.—The 

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

14 care program operated by the Indian Health Service, 

15 an Indian tribe, tribal organization, or urban Indian 

16 organization as such terms are defined in section 4 

17 of the Indian Health Care Improvement Act (25 

18 U.S.C. 1603). 

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

20 a State plan under title XIX of the Social Security 

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

22 waiver under section 1115 of such Act). 

23 (19) MEDICAID ELIGIBLE INDIVIDUAL.—The 

24 term ‘‘Medicaid eligible individual’’ means an indiVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 vidual who is eligible for medical assistance under 

2 Medicaid. 

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

4 the health insurance programs under title XVIII of 

5 the Social Security Act. 

6 (21) PLAN SPONSOR.—The term ‘‘plan spon7 sor’’ has the meaning given such term in section 

8 3(16)(B) of the Employee Retirement Income Secu9 rity Act of 1974. 

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

11 means— 

12 (A) with respect to an employment-based 

13 health plan, a plan year as specified under such 

14 plan; or 

15 (B) with respect to a health benefits plan 

16 other than an employment-based health plan, a 

17 12-month period as specified by the Commis18 sioner. 

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

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

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

22 303(c). 

23 (24) QHBP OFFERING ENTITY.—The terms 

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

25 health benefits plan that is— 


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1 (A) a group health plan (as defined, sub2 ject to subsection (d), in section 733(a)(1) of 

3 the Employee Retirement Income Security Act 

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

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

6 plan maintained jointly by 1 or more employers 

7 and 1 or more employee organizations and with 

8 respect to which an employer is the primary 

9 source of financing, such term means such em10 ployer; 

11 (B) health insurance coverage, the health 

12 insurance issuer offering the coverage; 

13 (C) the public health insurance option, the 

14 Secretary of Health and Human Services; 

15 (D) a non-Federal governmental plan (as 

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

17 Service Act), the State or political subdivision 

18 of a State (or agency or instrumentality of such 

19 State or subdivision) which establishes or main20 tains such plan; or 

21 (E) a Federal governmental plan (as de22 fined in section 2791(d) of the Public Health 

23 Service Act), the appropriate Federal official. 


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1 (25) QUALIFIED HEALTH BENEFITS PLAN.— 

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

3 health benefits plan that— 

4 (A) meets the requirements for such a plan 

5 under title II and includes the public health in6 surance option; and 

7 (B) is offered by a QHBP offering entity 

8 that meets the applicable requirements of such 

9 title with respect to such plan. 

10 (26) PUBLIC HEALTH INSURANCE OPTION.— 

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

12 the public health insurance option as provided under 

13 subtitle B of title III. 

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

15 The terms ‘‘service area’’ and ‘‘premium rating 

16 area’’ mean with respect to health insurance cov17 erage— 

18 (A) offered other than through the Health 

19 Insurance Exchange, such an area as estab20 lished by the QHBP offering entity of such cov21 erage in accordance with applicable State law; 

22 and 

23 (B) offered through the Health Insurance 

24 Exchange, such an area as established by such 

25 entity in accordance with applicable State law 


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1 and applicable rules of the Commissioner for 

2 Exchange-participating health benefits plans. 

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

4 States and the District of Columbia and includes— 

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

6 Virgin Islands, Guam, American Samoa, and 

7 the Northern Mariana Islands; and 

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

9 elected under and subject to section 346, Puer10 to Rico, the Virgin Islands, Guam, American 

11 Samoa, and the Northern Mariana Islands. 

12 (29) STATE MEDICAID AGENCY.—The term 

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

14 Medicaid plan, the single State agency responsible 

15 for administering such plan under title XIX of the 

16 Social Security Act. 

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

18 ‘‘Y3’’, ‘‘Y4’’, ‘‘Y5’’, and similar subsequently num19 bered terms, mean 2013 and subsequent years, re20 spectively. 

21 TITLE I—IMMEDIATE REFORMS 

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

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

24 Human Services (in this section referred to as the ‘‘Sec25 retary’’) shall establish a temporary national high-risk 


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1 pool program (in this section referred to as the ‘‘pro2 gram’’) to provide health benefits to eligible individuals 

3 during the period beginning on January 1, 2010, and, sub4 ject to subsection (h)(3)(B), ending on the date on which 

5 the Health Insurance Exchange is established. 

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

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

8 or contracts with States, through State high-risk pool pro9 grams provided that the requirements of this section are 

10 met. 

11 (c) ELIGIBILITY.—For purposes of this section, the 

12 term ‘‘eligible individual’’ means an individual— 

13 (1) who— 

14 (A) is not eligible for— 

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

16 XXI of the Social Security Act; or 

17 (ii) coverage under an employment18 based health plan (not including coverage 

19 under a COBRA continuation provision, as 

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

21 (B) who— 

22 (i) is an eligible individual under sec23 tion 2741(b) of the Public Health Service 

24 Act; or 


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1 (ii) is medically eligible for the pro2 gram by virtue of being an individual de3 scribed in subsection (d) at any time dur4 ing the 6-month period ending on the date 

5 the individual applies for high-risk pool 

6 coverage under this section; 

7 (2) who is the spouse or dependent of an indi8 vidual who is described in paragraph (1); or 

9 (3) who has not had health insurance coverage 

10 or coverage under an employment-based health plan 

11 for at least the 6-month period immediately pre12 ceding the date of the individual’s application for 

13 high-risk pool coverage under this section. 

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

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

16 Public Health Service Act shall not be considered to be 

17 eligible for coverage under an employment-based health 

18 plan. 

19 (d) MEDICALLY ELIGIBLE REQUIREMENTS.—For 

20 purposes of subsection (c)(1)(B)(ii), an individual de21 scribed in this subsection is an individual— 

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

23 the date the individual applies for high-risk pool cov24 erage under this section applied for individual health 

25 insurance coverage and— 


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1 (A) was denied such coverage because of a 

2 preexisting condition or health status; or 

3 (B) was offered such coverage— 

4 (i) under terms that limit the cov5 erage for such a preexisting condition; or 

6 (ii) at a premium rate that is above 

7 the premium rate for high risk pool cov8 erage under this section; or 

9 (2) who has an eligible medical condition as de10 fined by the Secretary. 

11 In making a determination under paragraph (1) of wheth12 er an individual was offered individual coverage at a pre13 mium rate above the premium rate for high risk pool cov14 erage, the Secretary shall make adjustments to offset dif15 ferences in premium rating that are attributable solely to 

16 differences in age rating. 

17 (e) ENROLLMENT.—To enroll in coverage in the pro18 gram, an individual shall— 

19 (1) submit to the Secretary an application for 

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

21 manner, and containing such information as the Sec22 retary shall require; 

23 (2) attest that the individual is an eligible indi24 vidual and is a resident of one of the 50 States or 

25 the District of Columbia; and 


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1 (3) if the individual had other prior health in2 surance coverage or coverage under an employment3 based health plan during the previous 6 months, 

4 provide information as to the nature and source of 

5 such coverage and reasons for its discontinuance. 

6 (f) PROTECTION AGAINST DUMPING RISKS BY IN7 SURERS.— 

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

9 criteria for determining whether health insurance 

10 issuers and employment-based health plans have dis11 couraged an individual from remaining enrolled in 

12 prior coverage based on that individual’s health sta13 tus. 

14 (2) SANCTIONS.—An issuer or employment15 based health plan shall be responsible for reimburs16 ing the program for the medical expenses incurred 

17 by the program for an individual who, based on cri18 teria established by the Secretary, the Secretary 

19 finds was encouraged by the issuer to disenroll from 

20 health benefits coverage prior to enrolling in the pro21 gram. The criteria shall include at least the fol22 lowing circumstances: 

23 (A) In the case of prior coverage obtained 

24 through an employer, the provision by the em25 ployer, group health plan, or the issuer of 


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1 money or other financial consideration for 

2 disenrolling from the coverage. 

3 (B) In the case of prior coverage obtained 

4 directly from an issuer or under an employ5 ment-based health plan— 

6 (i) the provision by the issuer or plan 

7 of money or other financial consideration 

8 for disenrolling from the coverage; or 

9 (ii) in the case of an individual whose 

10 premium for the prior coverage exceeded 

11 the premium required by the program (ad12 justed based on the age factors applied to 

13 the prior coverage)— 

14 (I) the prior coverage is a policy 

15 that is no longer being actively mar16 keted (as defined by the Secretary) by 

17 the issuer; or 

18 (II) the prior coverage is a policy 

19 for which duration of coverage form 

20 issue or health status are factors that 

21 can be considered in determining pre22 miums at renewal. 

23 (3) CONSTRUCTION.—Nothing in this sub24 section shall be construed as constituting exclusive 

25 remedies for violations of criteria established under 


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1 paragraph (1) or as preventing States from applying 

2 or enforcing such paragraph or other provisions 

3 under law with respect to health insurance issuers. 

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

5 AND CONSUMER PROTECTIONS.— 

6 (1) PREMIUM.—The monthly premium charged 

7 to eligible individuals for coverage under the pro8 gram— 

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

10 of the highest such premium to the lowest such 

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

12 (B) shall be set at a level that does not ex13 ceed 125 percent of the prevailing standard rate 

14 for comparable coverage in the individual mar15 ket; and 

16 (C) shall be adjusted for geographic vari17 ation in costs. 

18 Health insurance issuers shall provide such informa19 tion as the Secretary may require to determine pre20 vailing standard rates under this paragraph. The 

21 Secretary shall establish standard rates in consulta22 tion with the National Association of Insurance 

23 Commissioners. 

24 (2) COVERED BENEFITS.—Covered benefits 

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1 retary and shall be consistent with the basic cat2 egories in the essential benefits package described in 

3 section 222. Under such benefits package— 

4 (A) the annual deductible for such benefits 

5 may not be higher than $1,500 for an indi6 vidual or such higher amount for a family as 

7 determined by the Secretary; 

8 (B) there may not be annual or lifetime 

9 limits; and 

10 (C) the maximum cost-sharing with respect 

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

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

13 a family). 

14 (3) NO PREEXISTING CONDITION EXCLUSION

15 PERIODS.—No preexisting condition exclusion period 

16 shall be imposed on coverage under the program. 

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

18 appeals process for individuals to appeal a deter19 mination of the Secretary— 

20 (A) with respect to claims submitted under 

21 this section; and 

22 (B) with respect to eligibility determina23 tions made by the Secretary under this section. 

24 (5) STATE CONTRIBUTION, MAINTENANCE OF

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1 fits under this section to eligible individual residing 

2 in a State— 

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

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

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

7 shall require the State make a maintenance of 

8 effort payment each year that the high-risk pool 

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

10 amount of all sources of funding for high-risk 

11 pool coverage made by that State in the year 

12 ending July 1, 2009; and 

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

14 health insurance issuers to contribute to a State 

15 high-risk pool or similar arrangement for the 

16 assessment against such issuers for pool losses, 

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

19 (6) LIMITING PROGRAM EXPENDITURES.—The 

20 Secretary shall, with respect to the program— 

21 (A) establish procedures to protect against 

22 fraud, waste, and abuse under the program; 

23 and 

24 (B) provide for other program integrity 

25 methods. 


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1 (7) TREATMENT AS CREDITABLE COVERAGE.— 

2 Coverage under the program shall be treated, for 

3 purposes of applying the definition of ‘‘creditable 

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

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

6 title I of Employee Retirement Income Security Act 

7 of 1974, and chapter 100 of the Internal Revenue 

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

9 references such provisions) in the same manner as 

10 if it were coverage under a State health benefits risk 

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

12 Health Service Act. 

13 (h) FUNDING; TERMINATION OF AUTHORITY.— 

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

15 Secretary, out of any moneys in the Treasury not 

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

17 claims against (and administrative costs of) the 

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

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

21 available without fiscal year limitation. 

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

24 amounts available for payment of expenses of the 

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1 penses, the Secretary shall make such adjustments 

2 as are necessary to eliminate such deficit, including 

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

5 (3) TERMINATION OF AUTHORITY.— 

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

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

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

11 (B) TRANSITION TO EXCHANGE.—The 

12 Secretary shall develop procedures to provide 

13 for the transition of eligible individuals who are 

14 enrolled in health insurance coverage offered 

15 through a high-risk pool established under this 

16 section to be enrolled in acceptable coverage. 

17 Such procedures shall ensure that there is no 

18 lapse in coverage with respect to the individual 

19 and may extend coverage offered through such 

20 a high-risk pool beyond 2012 if the Secretary 

21 determines necessary to avoid such a lapse. 

22 SEC. 102. ENSURING VALUE AND LOWER PREMIUMS. 

23 (a) GROUP HEALTH INSURANCE COVERAGE.—Title 

24 XXVII of the Public Health Service Act is amended by 

25 inserting after section 2713 the following new section: 


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

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

3 that offers health insurance coverage in the small or large 

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

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

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

7 shall provide in a manner specified by the Secretary for 

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

9 medical loss ratio is less than the level so specified. 

10 ‘‘(b) IMPLEMENTATION.—The Secretary shall estab11 lish a uniform definition of medical loss ratio and method12 ology for determining how to calculate it based on the av13 erage medical loss ratio in a health insurance issuer’s book 

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

15 methodology shall be designed to take into account the 

16 special circumstances of smaller plans, different types of 

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

18 ratio, the Secretary shall exclude State taxes and licensing 

19 or regulatory fees. Such methodology shall be designed 

20 and exceptions shall be established to ensure adequate 

21 participation by health insurance issuers, competition in 

22 the health insurance market, and value for consumers so 

23 that their premiums are used for services. 

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

25 apply to health insurance coverage on and after the first 


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1 date that health insurance coverage is offered through the 

2 Health Insurance Exchange.’’. 

3 (b) INDIVIDUAL HEALTH INSURANCE COVERAGE.— 

4 Such title is further amended by inserting after section 

5 2753 the following new section: 

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

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

8 insurance coverage offered in the individual market in the 

9 same manner as such provisions apply to health insurance 

10 coverage offered in the small or large group market except 

11 to the extent the Secretary determines that the application 

12 of such section may destabilize the existing individual 

13 market.’’. 

14 (c) IMMEDIATE IMPLEMENTATION.—The amend15 ments made by this section shall apply in the group and 

16 individual market for plan years beginning on or after 

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

18 SEC. 103. ENDING HEALTH INSURANCE RESCISSION ABUSE. 

19 (a) CLARIFICATION REGARDING APPLICATION OF

20 GUARANTEED RENEWABILITY OF INDIVIDUAL AND

21 GROUP HEALTH INSURANCE COVERAGE.—Sections 2712 

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

23 300gg–12, 300gg–42) are each amended— 

24 (1) in its heading, by inserting ‘‘AND CON25 TINUATION IN FORCE, INCLUDING PROHIBIVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00028 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 TION OF RESCISSION,’’ after ‘‘GUARANTEED RE2 NEWABILITY’’; and 

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

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

5 (b) SECRETARIAL GUIDANCE REGARDING RESCIS6 SIONS.— 

7 (1) GROUP HEALTH INSURANCE MARKET.—Sec8 tion 2712 of such Act (42 U.S.C. 300gg–12) is 

9 amended by adding at the end the following: 

10 ‘‘(f) RESCISSION.—A health insurance issuer may re11 scind group health insurance coverage only upon clear and 

12 convincing evidence of fraud described in subsection 

13 (b)(2), under procedures that provide for independent, ex14 ternal third-party review.’’. 

15 (2) INDIVIDUAL HEALTH MARKET.—Section 

16 2742 of such Act (42 U.S.C. 300gg–42) is amended 

17 by adding at the end the following: 

18 ‘‘(f) RESCISSION.—A health insurance issuer may re19 scind individual health insurance coverage only upon clear 

20 and convincing evidence of fraud described in subsection 

21 (b)(2), under procedures that provide for independent, ex22 ternal third-party review.’’. 

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

24 Human Services, no later than 90 days after the 

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1 ance implementing the amendments made by para2 graphs (1) and (2), including procedures for inde3 pendent, external third-party review. 

4 (c) OPPORTUNITY FOR INDEPENDENT, EXTERNAL

5 THIRD-PARTY REVIEW IN CERTAIN CASES.— 

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

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

8 seq.) is amended by adding at the end the following: 

9 ‘‘SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL 

10 THIRD-PARTY REVIEW IN CASES OF RESCIS11 SION. 

12 ‘‘(a) NOTICE AND REVIEW RIGHT.—If a health in13 surance issuer determines to rescind health insurance cov14 erage for an individual in the individual market, before 

15 such rescission may take effect the issuer shall provide the 

16 individual with notice of such proposed rescission and an 

17 opportunity for a review of such determination by an inde18 pendent, external third-party under procedures specified 

19 by the Secretary under section 2742(f). 

20 ‘‘(b) INDEPENDENT DETERMINATION.—If the indi21 vidual requests such review by an independent, external 

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

23 the coverage shall remain in effect until such third party 

24 determines that the coverage may be rescinded under the 

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


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1 (2) APPLICATION TO GROUP HEALTH INSUR2 ANCE.—Such title is further amended by adding 

3 after section 2702 the following new section: 

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

5 THIRD-PARTY REVIEW IN CASES OF RESCIS6 SION. 

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

8 health insurance coverage in the same manner as such 

9 provisions apply to individual health insurance coverage, 

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

11 reference to section 2712(f).’’. 

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

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

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

15 after July 1, 2010, with respect to health insurance cov16 erage issued before, on, or after such date. 

17 SEC. 104. SUNSHINE ON PRICE GOUGING BY HEALTH IN18 SURANCE ISSUERS. 

19 The Secretary of Health and Human Services, in con20 junction with States, shall establish a process for the an21 nual review of increases in premiums for health insurance 

22 coverage. Such process shall require health insurance 

23 issuers to submit a justification for any premium increases 

24 prior to implementation of the increase. 


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1 SEC. 105. REQUIRING THE OPTION OF EXTENSION OF DE2 PENDENT COVERAGE FOR UNINSURED 

3 YOUNG ADULTS. 

4 (a) UNDER GROUP HEALTH PLANS.— 

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

6 Service Act is amended by inserting after section 

7 2702 the following new section: 

8 ‘‘SEC. 2703. REQUIRING THE OPTION OF EXTENSION OF DE9 PENDENT COVERAGE FOR UNINSURED 

10 YOUNG ADULTS. 

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

12 insurance issuer offering health insurance coverage in con13 nection with a group health plan that provides coverage 

14 for dependent children shall make available such coverage, 

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

16 qualified children (as defined in subsection (b)) of the par17 ticipant. 

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

19 the term ‘qualified child’ means, with respect to a partici20 pant in a group health plan or group health insurance cov21 erage, an individual who (but for age) would be treated 

22 as a dependent child of the participant under such plan 

23 or coverage and who— 

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

25 ‘‘(2) is not enrolled as a participant, bene26 ficiary, or enrollee (other than under this section, 


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1 section 2746, or section 704 of the Employee Retire2 ment Income Security Act of 1974) under any 

3 health insurance coverage or group health plan. 

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

5 construed as preventing a group health plan or health in6 surance issuer with respect to group health insurance cov7 erage from increasing the premiums otherwise required for 

8 coverage provided under this section consistent with 

9 standards established by the Secretary based upon family 

10 size.’’. 

11 (2) EMPLOYEE RETIREMENT INCOME SECURITY

12 ACT OF 1974.— 

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

14 title I of the Employee Retirement Income Se15 curity Act of 1974 is amended by inserting 

16 after section 703 the following new section: 

17 ‘‘SEC. 704. REQUIRING THE OPTION OF EXTENSION OF DE18 PENDENT COVERAGE FOR UNINSURED 

19 YOUNG ADULTS. 

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

21 insurance issuer offering health insurance coverage in con22 nection with a group health plan that provides coverage 

23 for dependent children shall make available such coverage, 

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


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1 qualified children (as defined in subsection (b)) of the par2 ticipant. 

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

4 the term ‘qualified child’ means, with respect to a partici5 pant in a group health plan or group health insurance cov6 erage, an individual who (but for age) would be treated 

7 as a dependent child of the participant under such plan 

8 or coverage and who— 

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

10 ‘‘(2) is not enrolled as a participant, bene11 ficiary, or enrollee (other than under this section) 

12 under any health insurance coverage or group health 

13 plan. 

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

15 construed as preventing a group health plan or health in16 surance issuer with respect to group health insurance cov17 erage from increasing the premiums otherwise required for 

18 coverage provided under this section consistent with 

19 standards established by the Secretary based upon family 

20 size.’’. 

21 (B) CLERICAL AMENDMENT.—The table of 

22 contents of such Act is amended by inserting 

23 after the item relating to section 703 the fol24 lowing new item: 

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


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1 (3) IRC.— 

2 (A) IN GENERAL.—Subchapter A of chap3 ter 100 of the Internal Revenue Code of 1986 

4 is amended by adding at the end the following 

5 new section: 

6 ‘‘SEC. 9804. REQUIRING THE OPTION OF EXTENSION OF DE7 PENDENT COVERAGE FOR UNINSURED 

8 YOUNG ADULTS. 

9 ‘‘(a) IN GENERAL.—A group health plan that pro10 vides coverage for dependent children shall make available 

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

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

13 (b)) of the participant. 

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

15 the term ‘qualified child’ means, with respect to a partici16 pant in a group health plan, an individual who (but for 

17 age) would be treated as a dependent child of the partici18 pant under such plan and who— 

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

20 ‘‘(2) is not enrolled as a participant, bene21 ficiary, or enrollee (other than under this section, 

22 section 704 of the Employee Retirement Income Se23 curity Act of 1974, or section 2704 or 2746 of the 

24 Public Health Service Act) under any health insur25 ance coverage or group health plan. 


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

2 construed as preventing a group health plan from increas3 ing the premiums otherwise required for coverage provided 

4 under this section consistent with standards established 

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

6 (B) CLERICAL AMENDMENT.—The table of 

7 sections of such chapter is amended by insert8 ing after the item relating to section 9803 the 

9 following: 

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

10 (b) INDIVIDUAL HEALTH INSURANCE COVERAGE.— 

11 Title XXVII of the Public Health Service Act is amended 

12 by inserting after section 2745 the following new section: 

13 ‘‘SEC. 2746. REQUIRING THE OPTION OF EXTENSION OF DE14 PENDENT COVERAGE FOR UNINSURED 

15 YOUNG ADULTS. 

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

17 insurance coverage offered by a health insurance issuer 

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

19 to health insurance coverage offered by a health insurance 

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

21 or large group market.’’. 

22 (c) EFFECTIVE DATES.— 

23 (1) GROUP HEALTH PLANS.—The amendments 

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


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1 plans for plan years beginning on or after January 

2 1, 2010. 

3 (2) INDIVIDUAL HEALTH INSURANCE COV4 ERAGE.—Section 2746 of the Public Health Service 

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

6 respect to health insurance coverage offered, sold, 

7 issued, renewed, in effect, or operated in the indi8 vidual market on or after January 1, 2010. 

9 SEC. 106. LIMITATIONS ON PREEXISTING CONDITION EX10 CLUSIONS IN GROUP HEALTH PLANS IN AD11 VANCE OF APPLICABILITY OF NEW PROHIBI12 TION OF PREEXISTING CONDITION EXCLU13 SIONS. 

14 (a) AMENDMENTS TO THE EMPLOYEE RETIREMENT

15 INCOME SECURITY ACT OF 1974.— 

16 (1) REDUCTION IN LOOK-BACK PERIOD.—Sec17 tion 701(a)(1) of the Employee Retirement Income 

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

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

20 ‘‘30-day period’’. 

21 (2) REDUCTION IN PERMITTED PREEXISTING

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

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

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


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

2 months’’. 

3 (3) SUNSET OF INTERIM LIMITATION.—Section 

4 701 of such Act (29 U.S.C. 1181) is amended by 

5 adding at the end the following new subsection: 

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

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

8 plan becomes subject to the requirements of section 211 

9 of the (relating to prohibiting preexisting condition exclu10 sions).’’. 

11 (b) AMENDMENTS TO THE INTERNAL REVENUE

12 CODE OF 1986.— 

13 (1) REDUCTION IN LOOK-BACK PERIOD.—Sec14 tion 9801(a)(1) of the Internal Revenue Code of 

15 1986 is amended by striking ‘‘6-month period’’ and 

16 inserting ‘‘30-day period’’. 

17 (2) REDUCTION IN PERMITTED PREEXISTING

18 CONDITION LIMITATION PERIOD.—Section 

19 9801(a)(2) of such Code is amended by striking ‘‘12 

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

21 ‘‘18 months’’ and inserting ‘‘9 months’’. 

22 (3) SUNSET OF INTERIM LIMITATION.—Section 

23 9801 of such Code is amended by adding at the end 

24 the following new subsection: 


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

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

3 plan becomes subject to the requirements of section 211 

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

6 (c) AMENDMENTS TO PUBLIC HEALTH SERVICE

7 ACT.— 

8 (1) REDUCTION IN LOOK-BACK PERIOD.—Sec9 tion 2701(a)(1) of the Public Health Service Act (42 

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

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

12 (2) REDUCTION IN PERMITTED PREEXISTING

13 CONDITION LIMITATION PERIOD.—Section 

14 2701(a)(2) of such Act (42 U.S.C. 300gg(a)(2)) is 

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

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

17 ‘‘9 months’’. 

18 (3) SUNSET OF INTERIM LIMITATION.—Section 

19 2701 of such Act (42 U.S.C. 300gg) is amended by 

20 adding at the end the following new subsection: 

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

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

23 plan becomes subject to the requirements of section 211 

24 of the (relating to prohibiting preexisting condition exclu25 sions).’’. 


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1 (4) MISCELLANEOUS TECHNICAL AMEND2 MENT.—Section 2702(a)(2) of such Act (42 U.S.C. 

3 300gg–1) is amended by striking ‘‘701’’ and insert4 ing ‘‘2701’’. 

5 (d) EFFECTIVE DATE.— 

6 (1) IN GENERAL.—Except as provided in para7 graph (2), the amendments made by this section 

8 shall apply with respect to group health plans for 

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

10 (2) SPECIAL RULE FOR COLLECTIVE BAR11 GAINING AGREEMENTS.—In the case of a group 

12 health plan maintained pursuant to 1 or more collec13 tive bargaining agreements between employee rep14 resentatives and 1 or more employers ratified before 

15 the date of the enactment of this Act, the amend16 ments made by this section shall not apply to plan 

17 years beginning before the earlier of— 

18 (A) the date on which the last of the col19 lective bargaining agreements relating to the 

20 plan terminates (determined without regard to 

21 any extension thereof agreed to after the date 

22 of the enactment of this Act); 

23 (B) 3 years after the date of the enact24 ment of this Act. 


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1 SEC. 107. PROHIBITING ACTS OF DOMESTIC VIOLENCE 

2 FROM BEING TREATED AS PREEXISTING CON3 DITIONS. 

4 (a) ERISA.—Section 701(d)(3) of the Employee Re5 tirement Income Security Act of 1974 (29 U.S.C. ) is 

6 amended— 

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

8 VIOLENCE’’ after ‘‘PREGNANCY’’; and 

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

10 ‘‘relating to pregnancy’’. 

11 (b) PHSA.— 

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

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

14 300gg(d)(3)) is amended— 

15 (A) in the heading, by inserting ‘‘OR DO16 MESTIC VIOLENCE’’ after ‘‘PREGNANCY’’; and 

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

18 after ‘‘relating to pregnancy’’. 

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

20 Act is amended by inserting after section 2753 the 

21 following new section: 

22 ‘‘SEC. 2754. PROHIBITION ON DOMESTIC VIOLENCE AS PRE23 EXISTING CONDITION. 

24 ‘‘A health insurance issuer offering health insurance 

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

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1 clusion (as defined in section 2701(b)(1)(A)) with respect 

2 to such coverage.’’. 

3 (c) IRC.—Section 9801(d)(3) of the Internal Rev4 enue Code of 1986 is amended— 

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

6 VIOLENCE’’ after ‘‘PREGNANCY’’; and 

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

8 ‘‘relating to pregnancy’’. 

9 (d) EFFECTIVE DATES.— 

10 (1) Except as otherwise provided in this sub11 section, the amendments made by this section shall 

12 apply with respect to group health plans (and health 

13 insurance issuers offering group health insurance 

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

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

17 shall apply with respect to health insurance coverage 

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

19 in the individual market on or after such date. 

20 SEC. 108. ENDING HEALTH INSURANCE DENIALS AND 

21 DELAYS OF NECESSARY TREATMENT FOR 

22 CHILDREN WITH DEFORMITIES. 

23 (a) AMENDMENTS TO THE EMPLOYEE RETIREMENT

24 INCOME SECURITY ACT OF 1974.— 


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1 (1) IN GENERAL.—Subpart B of part 7 of sub2 title B of title I of the Employee Retirement Income 

3 Security Act of 1974 is amended by adding at the 

4 end the following new section: 

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

6 CHILD’S CONGENITAL OR DEVELOPMENTAL 

7 DEFORMITY OR DISORDER. 

8 ‘‘(a) REQUIREMENTS FOR TREATMENT FOR CHIL9 DREN WITH DEFORMITIES.— 

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

11 health insurance issuer offering group health insur12 ance coverage, that provides coverage for surgical 

13 benefits shall provide coverage for outpatient and in14 patient diagnosis and treatment of a minor child’s 

15 congenital or developmental deformity, disease, or 

16 injury. A minor child shall include any individual 

17 who is 21 years of age or younger. 

18 ‘‘(2) TREATMENT DEFINED.— 

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

20 term ‘treatment’ includes reconstructive sur21 gical procedures (procedures that are generally 

22 performed to improve function, but may also be 

23 performed to approximate a normal appear24 ance) that are performed on abnormal struc25 tures of the body caused by congenital defects, 


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1 developmental abnormalities, trauma, infection, 

2 tumors, or disease, including— 

3 ‘‘(i) procedures that do not materially 

4 affect the function of the body part being 

5 treated; and 

6 ‘‘(ii) procedures for secondary condi7 tions and follow-up treatment. 

8 ‘‘(B) EXCEPTION.—Such term does not in9 clude cosmetic surgery performed to reshape 

10 normal structures of the body to improve ap11 pearance or self-esteem. 

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

13 shall comply with the notice requirement under section 

14 713(b) (other than paragraph (3)) with respect to the re15 quirements of this section.’’. 

16 (2) CONFORMING AMENDMENT.— 

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

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

19 inserting ‘‘sections 711 and 715’’. 

20 (B) The table of contents in section 1 of 

21 such Act is amended by inserting after the item 

22 relating to section 714 the following new item: 

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

23 (b) AMENDMENTS TO THE INTERNAL REVENUE

24 CODE OF 1986.— 


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

2 100 of the Internal Revenue Code of 1986 is amend3 ed by adding at the end the following new section: 

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

5 MINOR CHILD’S CONGENITAL OR DEVELOP6 MENTAL DEFORMITY OR DISORDER. 

7 ‘‘(a) REQUIREMENTS FOR TREATMENT FOR CHIL8 DREN WITH DEFORMITIES.—A group health plan that 

9 provides coverage for surgical benefits shall provide cov10 erage for outpatient and inpatient diagnosis and treat11 ment of a minor child’s congenital or developmental de12 formity, disease, or injury. A minor child shall include any 

13 individual who is 21 years of age or younger. 

14 ‘‘(b) TREATMENT DEFINED.— 

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

16 ‘treatment’ includes reconstructive surgical proce17 dures (procedures that are generally performed to 

18 improve function, but may also be performed to ap19 proximate a normal appearance) that are performed 

20 on abnormal structures of the body caused by con21 genital defects, developmental abnormalities, trau22 ma, infection, tumors, or disease, including— 

23 ‘‘(A) procedures that do not materially af24 fect the function of the body part being treated, 

25 and 


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1 ‘‘(B) procedures for secondary conditions 

2 and follow-up treatment. 

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

4 cosmetic surgery performed to reshape normal struc5 tures of the body to improve appearance or self-es6 teem.’’. 

7 (2) CLERICAL AMENDMENT.—The table of sec8 tions for subchapter B of chapter 100 of such Code 

9 is amended by adding at the end the following new 

10 item: 

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

11 (c) AMENDMENTS TO THE PUBLIC HEALTH SERVICE

12 ACT.— 

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

14 XXVII of the Public Health Service Act is amended 

15 by adding at the end the following new section: 

16 ‘‘SEC. 2708. STANDARDS RELATING TO BENEFITS FOR 

17 MINOR CHILD’S CONGENITAL OR DEVELOP18 MENTAL DEFORMITY OR DISORDER. 

19 ‘‘(a) REQUIREMENTS FOR TREATMENT FOR CHIL20 DREN WITH DEFORMITIES.— 

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

22 health insurance issuer offering group health insur23 ance coverage, that provides coverage for surgical 

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1 patient diagnosis and treatment of a minor child’s 

2 congenital or developmental deformity, disease, or 

3 injury. A minor child shall include any individual 

4 who is 21 years of age or younger. 

5 ‘‘(2) TREATMENT DEFINED.— 

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

7 term ‘treatment’ includes reconstructive sur8 gical procedures (procedures that are generally 

9 performed to improve function, but may also be 

10 performed to approximate a normal appear11 ance) that are performed on abnormal struc12 tures of the body caused by congenital defects, 

13 developmental abnormalities, trauma, infection, 

14 tumors, or disease, including— 

15 ‘‘(i) procedures that do not materially 

16 affect the function of the body part being 

17 treated; and 

18 ‘‘(ii) procedures for secondary condi19 tions and follow-up treatment. 

20 ‘‘(B) EXCEPTION.—Such term does not in21 clude cosmetic surgery performed to reshape 

22 normal structures of the body to improve ap23 pearance or self-esteem. 

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

25 shall comply with the notice requirement under section 


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1 715(b) of the Employee Retirement Income Security Act 

2 of 1974 with respect to the requirements of this section 

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

4 (2) INDIVIDUAL HEALTH INSURANCE.—Subpart 

5 2 of part B of title XXVII of the Public Health 

6 Service Act, as amended by section 161(b), is fur7 ther amended by adding at the end the following 

8 new section: 

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

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

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

13 insurance coverage offered by a health insurance issuer 

14 in the individual market in the same manner as such pro15 visions apply to health insurance coverage offered by a 

16 health insurance issuer in connection with a group health 

17 plan in the small or large group market.’’. 

18 (3) CONFORMING AMENDMENTS.— 

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

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

21 ‘‘section 2704’’ and inserting ‘‘sections 2704 

22 and 2708’’. 

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

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


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1 ‘‘section 2751’’ and inserting ‘‘sections 2751 

2 and 2755’’. 

3 (d) EFFECTIVE DATES.— 

4 (1) The amendments made by this section shall 

5 apply with respect to group health plans (and health 

6 insurance issuers offering group health insurance 

7 coverage) for plan years beginning on or after Janu8 ary 1, 2010. 

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

10 shall apply with respect to health insurance coverage 

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

12 in the individual market on or after such date. 

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

14 Insurance Portability and Accountability Act of 1996 is 

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

16 subtitle and section 401)’’ and inserting ‘‘, part 7 of sub17 title B of title I of the Employee Retirement Income Secu18 rity Act of 1974, parts A and C of title XXVII of the 

19 Public Health Service Act, and chapter 100 of the Internal 

20 Revenue Code of 1986’’. 

21 SEC. 109. ELIMINATION OF LIFETIME LIMITS. 

22 (a) AMENDMENTS TO THE EMPLOYEE RETIREMENT

23 INCOME SECURITY ACT OF 1974.— 

24 (1) IN GENERAL.—Subpart B of part 7 of sub25 title B of title I of the Employee Retirement Income 


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

2 amended by section 108, is amended by adding at 

3 the end the following: 

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

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

6 insurance issuer providing health insurance coverage in 

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

8 aggregate dollar lifetime limit with respect to benefits pay9 able under the plan or coverage. 

10 ‘‘(b) DEFINITION.—In this section, the term ‘aggre11 gate dollar lifetime limit’ means, with respect to benefits 

12 under a group health plan or health insurance coverage 

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

14 limitation on the total amount that may be paid with re15 spect to such benefits under the plan or health insurance 

16 coverage with respect to an individual or other coverage 

17 unit on a lifetime basis.’’. 

18 (2) CLERICAL AMENDMENT.—The table of con19 tents in section 1 of such Act, is amended by insert20 ing after the item relating to section 715 the fol21 lowing new item: 

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

22 (b) AMENDMENTS TO THE INTERNAL REVENUE

23 CODE OF 1986.— 

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

25 100 of the Internal Revenue Code of 1986, as 


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

2 the end the following new section: 

3 ‘‘SEC. 9815. ELIMINATION OF LIFETIME AGGREGATE LIM4 ITS. 

5 ‘‘(a) IN GENERAL.—A group health plan may not im6 pose an aggregate dollar lifetime limit with respect to ben7 efits payable under the plan. 

8 ‘‘(b) DEFINITION.—In this section, the term ‘aggre9 gate dollar lifetime limit’ means, with respect to benefits 

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

11 amount that may be paid with respect to such benefits 

12 under the plan with respect to an individual or other cov13 erage unit on a lifetime basis.’’. 

14 (2) CLERICAL AMENDMENT.—The table of sec15 tions for subchapter B of chapter 100 of such Code, 

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

17 at the end the following new item: 

‘‘Sec. 9854. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’’. 

18 (c) AMENDMENT TO THE PUBLIC HEALTH SERVICE

19 ACT RELATING TO THE GROUP MARKET.— 

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

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

22 300gg–4 et seq.) as amended by section 108(c)(1), 

23 is amended by adding at the end the following: 


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1 ‘‘SEC. 2709. ELIMINATION OF LIFETIME AGGREGATE LIM2 ITS. 

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

4 insurance issuer providing health insurance coverage in 

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

6 aggregate dollar lifetime limit with respect to benefits pay7 able under the plan or coverage. 

8 ‘‘(b) DEFINITION.—In this section, the term ‘aggre9 gate dollar lifetime limit’ means, with respect to benefits 

10 under a group health plan or health insurance coverage, 

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

12 with respect to such benefits under the plan or health in13 surance coverage with respect to an individual or other 

14 coverage unit on a lifetime basis.’’. 

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

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

17 U.S.C. 300gg–51 et seq.), as amended by section 

18 108(c)(2), is amended by adding at the end the fol19 lowing: 

20 ‘‘SEC. 2756. ELIMINATION OF ANNUAL OR LIFETIME AGGRE21 GATE LIMITS. 

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

23 insurance coverage offered by a health insurance issuer 

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

25 to health insurance coverage offered by a health insurance 


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

2 or large group market.’’. 

3 (d) EFFECTIVE DATES.— 

4 (1) The amendments made by this section shall 

5 apply with respect to group health plans (and health 

6 insurance issuers offering group health insurance 

7 coverage) for plan years beginning on or after Janu8 ary 1, 2010. 

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

10 shall apply with respect to health insurance coverage 

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

12 in the individual market on or after such date. 

13 SEC. 110. PROHIBITION AGAINST POSTRETIREMENT RE14 DUCTIONS OF RETIREE HEALTH BENEFITS 

15 BY GROUP HEALTH PLANS. 

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

17 the Employee Retirement Income Security Act of 1974, 

18 as amended by sections 108 and 109, is amended by in19 serting after section 716 the following new section: 

20 ‘‘SEC. 717. PROTECTION AGAINST POSTRETIREMENT RE21 DUCTION OF RETIREE HEALTH BENEFITS. 

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

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

24 fiduciary of the plan, from reducing the benefits provided 

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


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1 such participant, if such reduction affects the benefits pro2 vided to the participant or beneficiary as of the date the 

3 participant retired for purposes of the plan and such re4 duction occurs after the participant’s retirement unless 

5 such reduction is also made with respect to active partici6 pants. Nothing in this section shall prohibit a plan from 

7 enforcing a total aggregate cap on amounts paid for re8 tiree health coverage that is part of the plan at the time 

9 of retirement. 

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

11 health plan may contain a provision reserving the general 

12 power to amend or terminate the plan or a provision spe13 cifically authorizing the plan to make post-retirement re14 ductions in retiree health benefits, it shall be prohibited 

15 for any group health plan, whether through amendment 

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

17 participant or the participant’s beneficiary under the 

18 terms of the plan if such reduction of benefits occurs after 

19 the date the participant retired for purposes of the plan 

20 and reduces benefits that were provided to the participant, 

21 or the participant’s beneficiary, as of the date the partici22 pant retired unless such reduction is also made with re23 spect to active participants. 

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

25 section, a reduction in benefits— 


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

2 group health plan when a participant’s (or bene3 ficiary’s) share of the total premium (or, in the case 

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

5 plan substantially increases; or 

6 ‘‘(2) with respect to other cost-sharing and ben7 efits under a group health plan occurs when there is 

8 a substantial decrease in the actuarial value of the 

9 benefit package under the plan. 

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

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

12 the actuarial value of the benefit package that is greater 

13 than 5 percent.’’ 

14 (b) CONFORMING AMENDMENT.—The table of con15 tents in section 1 of such Act, as amended by sections 

16 108 and 109, is amended by inserting after the item relat17 ing to section 716 the following new item: 

‘‘Sec. 717. Protection against postretirement reduction of retiree health benefits.’’. 

18 (c) WAIVER.—An employer may, in a form and man19 ner which shall be prescribed by the Secretary of Labor, 

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

21 reasonably demonstrate that meeting the requirements of 

22 this section would impose an undue hardship on the em23 ployer. 


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

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

3 of this Act. 

4 SEC. 111. REINSURANCE PROGRAM FOR RETIREES. 

5 (a) ESTABLISHMENT.— 

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

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

8 of Health and Human Services shall establish a tem9 porary reinsurance program (in this section referred 

10 to as the ‘‘reinsurance program’’) to provide reim11 bursement to assist participating employment-based 

12 plans with the cost of providing health benefits to 

13 retirees and to eligible spouses, surviving spouses 

14 and dependents of such retirees. 

15 (2) DEFINITIONS.—For purposes of this sec16 tion: 

17 (A) The term ‘‘eligible employment-based 

18 plan’’ means a group health plan or employ19 ment-based health plan that— 

20 (i) is — 

21 (I) maintained by one or more 

22 employers (including without limita23 tion any State or political subdivision 

24 thereof, or any agency or instrumen25 tality of any of the foregoing), former 


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1 employers or employee organizations 

2 or associations, or a voluntary employ3 ees’ beneficiary association, or a com4 mittee or board of individuals ap5 pointed to administer such plan; or 

6 (II) a multiemployer plan (as de7 fined in section 3(37) of the Employee 

8 Retirement Income Security Act of 

9 1974); and 

10 (ii) provides health benefits to retir11 ees. 

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

13 medical, surgical, hospital, prescription drug, 

14 and such other benefits as shall be determined 

15 by the Secretary, whether self-funded or deliv16 ered through the purchase of insurance or oth17 erwise. 

18 (C) The term ‘‘participating employment19 based plan’’ means an eligible employment20 based plan that is participating in the reinsur21 ance program. 

22 (D) The term ‘‘retiree’’ means, with re23 spect to a participating employment-benefit 

24 plan, an individual who— 

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


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1 (ii) is not eligible for coverage under 

2 title XVIII of the Social Security Act; and 

3 (iii) is not an active employee of an 

4 employer maintaining the plan or of any 

5 employer that makes or has made substan6 tial contributions to fund such plan. 

7 (E) The term ‘‘Secretary’’ means Sec8 retary of Health and Human Services. 

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

10 the reinsurance program, an eligible employment-based 

11 plan shall submit to the Secretary an application for par12 ticipation in the program, at such time, in such manner, 

13 and containing such information as the Secretary shall re14 quire. 

15 (c) PAYMENT.— 

16 (1) SUBMISSION OF CLAIMS.— 

17 (A) IN GENERAL.—Under the reinsurance 

18 program, a participating employment-based 

19 plan shall submit claims for reimbursement to 

20 the Secretary which shall contain documenta21 tion of the actual costs of the items and serv22 ices for which each claim is being submitted. 

23 (B) BASIS FOR CLAIMS.—Each claim sub24 mitted under subparagraph (A) shall be based 

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1 pating employment-based plan involved within 

2 the plan year for the appropriate employment 

3 based health benefits provided to a retiree or to 

4 the spouse, surviving spouse, or dependent of a 

5 retiree. In determining the amount of any claim 

6 for purposes of this subsection, the partici7 pating employment-based plan shall take into 

8 account any negotiated price concessions (such 

9 as discounts, direct or indirect subsidies, re10 bates, and direct or indirect remunerations) ob11 tained by such plan with respect to such health 

12 benefits. For purposes of calculating the 

13 amount of any claim, the costs paid by the re14 tiree or by the spouse, surviving spouse, or de15 pendent of the retiree in the form of 

16 deductibles, copayments, and coinsurance shall 

17 be included along with the amounts paid by the 

18 participating employment-based plan. 

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

20 Secretary determines that a participating employ21 ment-based plan has submitted a valid claim under 

22 paragraph (1), the Secretary shall reimburse such 

23 plan for 80 percent of that portion of the costs at24 tributable to such claim that exceeds $15,000, but is 

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


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1 each year based on the percentage increase in the 

2 medical care component of the Consumer Price 

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

4 for the year involved. 

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

6 participating employment-based plan under this sub7 section shall only be used to reduce the costs of 

8 health care provided by the plan by reducing pre9 mium costs for the employer or employee association 

10 maintaining the plan, and reducing premium con11 tributions, deductibles, copayments, coinsurance, or 

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

13 beneficiaries. Where the benefits are provided by an 

14 employer to members of a represented bargaining 

15 unit, the allocation of payments among these pur16 poses shall be subject to collective bargaining. 

17 Amounts paid to the plan under this subsection shall 

18 not be used as general revenues by the employer or 

19 employee association maintaining the plan or for any 

20 other purposes. The Secretary shall develop a mech21 anism to monitor the appropriate use of such pay22 ments by such plans. 

23 (4) APPEALS AND PROGRAM PROTECTIONS.— 

24 The Secretary shall establish— 


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1 (A) an appeals process to permit partici2 pating employment-based plans to appeal a de3 termination of the Secretary with respect to 

4 claims submitted under this section; and 

5 (B) procedures to protect against fraud, 

6 waste, and abuse under the program. 

7 (5) AUDITS.—The Secretary shall conduct an8 nual audits of claims data submitted by partici9 pating employment-based plans under this section to 

10 ensure that they are in compliance with the require11 ments of this section. 

12 (d) RETIREE RESERVE TRUST FUND.— 

13 (1) ESTABLISHMENT.— 

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

15 the Treasury of the United States a trust fund 

16 to be known as the ‘‘Retiree Reserve Trust 

17 Fund’’ (referred to in this section as the ‘‘Trust 

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

19 may be appropriated or credited to the Trust 

20 Fund as provided for in this subsection to en21 able the Secretary to carry out the reinsurance 

22 program. Such amounts shall remain available 

23 until expended. 

24 (B) FUNDING.—There are hereby appro25 priated to the Trust Fund, out of any moneys 


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1 in the Treasury not otherwise appropriated, an 

2 amount requested by the Secretary as necessary 

3 to carry out this section, except that the total 

4 of all such amounts requested shall not exceed 

5 $10,000,000,000. 

6 (C) APPROPRIATIONS FROM THE TRUST

7 FUND.— 

8 (i) IN GENERAL.—Amounts in the 

9 Trust Fund are appropriated to provide 

10 funding to carry out the reinsurance pro11 gram and shall be used to carry out such 

12 program. 

13 (ii) LIMITATION TO AVAILABLE

14 FUNDS.—The Secretary has the authority 

15 to stop taking applications for participa16 tion in the program or take such other 

17 steps in reducing expenditures under the 

18 reinsurance program in order to ensure 

19 that expenditures under the reinsurance 

20 program do not exceed the funds available 

21 under this subsection. 

22 SEC. 112. WELLNESS PROGRAM GRANTS. 

23 (a) ALLOWANCE OF GRANT.— 

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

25 the Secretaries of Health and Human Services and 


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1 Labor shall jointly award wellness grants as deter2 mined under this section. Wellness program grants 

3 shall be awarded to small employers (as defined by 

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

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

6 employers in connection with a qualified wellness 

7 program during the plan year. For purposes of the 

8 preceding sentence, in the case of any qualified 

9 wellness program offered as part of an employment10 based health plan, only costs attributable to the 

11 qualified wellness program and not to the health 

12 plan, or health insurance coverage offered in connec13 tion with such a plan, may be taken into account. 

14 (2) LIMITATIONS.— 

15 (A) PERIOD.—A wellness grant awarded to 

16 an employer under this section shall be for up 

17 to 3 years. 

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

19 under paragraph (1) for an employer shall not 

20 exceed— 

21 (i) the product of $150 and the num22 ber of employees of the employer for any 

23 plan year; and 

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

25 the grant. 


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1 (b) QUALIFIED WELLNESS PROGRAM.—For purposes 

2 of this section: 

3 (1) QUALIFIED WELLNESS PROGRAM.—The 

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

5 that — 

6 (A) includes any 3 wellness components de7 scribed in subsection (c); and 

8 (B) is to be certified jointly by the Sec9 retary of Health and Human Services and the 

10 Secretary of Labor, in coordination with the Di11 rector of the Centers for Disease Control and 

12 Prevention, as a qualified wellness program 

13 under this section. 

14 (2) PROGRAMS MUST BE CONSISTENT WITH RE15 SEARCH AND BEST PRACTICES.— 

16 (A) IN GENERAL.—The Secretary of 

17 Health and Human Services and the Secretary 

18 of Labor shall not certify a program as a quali19 fied wellness program unless the program— 

20 (i) is consistent with evidence-based 

21 research and best practices, as identified 

22 by persons with expertise in employer 

23 health promotion and wellness programs; 

24 (ii) includes multiple, evidence-based 

25 strategies which are based on the existing 


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1 and emerging research and careful sci2 entific reviews, including the Guide to 

3 Community Preventative Services, the 

4 Guide to Clinical Preventative Services, 

5 and the National Registry for Effective 

6 Programs, and 

7 (iii) includes strategies which focus on 

8 prevention and support for employee popu9 lations at risk of poor health outcomes. 

10 (B) PERIODIC UPDATING AND REVIEW.— 

11 The Secretaries of Health and Human Services 

12 and Labor, in consultation with other appro13 priate agencies shall jointly establish procedures 

14 for periodic review, evaluation, and update of 

15 the programs under this subsection. 

16 (3) HEALTH LITERACY AND ACCESSIBILITY.— 

17 The Secretaries of Health and Human Services and 

18 Labor shall jointly, as part of the certification proc19 ess— 

20 (A) ensure that employers make the pro21 grams culturally competent, physically and pro22 grammatically accessible (including for individ23 uals with disabilities), and appropriate to the 

24 health literacy needs of the employees covered 

25 by the programs; 


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1 (B) require a health literacy component to 

2 provide special assistance and materials to em3 ployees with low literacy skills, limited English 

4 and from underserved populations; and 

5 (C) require the Secretaries to compile and 

6 disseminate to employer health plans informa7 tion on model health literacy curricula, instruc8 tional programs, and effective intervention 

9 strategies. 

10 (c) WELLNESS PROGRAM COMPONENTS.—For pur11 poses of this section, the wellness program components de12 scribed in this subsection are the following: 

13 (1) HEALTH AWARENESS COMPONENT.—A 

14 health awareness component which provides for the 

15 following: 

16 (A) HEALTH EDUCATION.—The dissemina17 tion of health information which addresses the 

18 specific needs and health risks of employees. 

19 (B) HEALTH SCREENINGS.—The oppor20 tunity for periodic screenings for health prob21 lems and referrals for appropriate follow-up 

22 measures. 

23 (2) EMPLOYEE ENGAGEMENT COMPONENT.— 

24 An employee engagement component which provides 

25 for the active engagement of employees in worksite 


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1 wellness programs through worksite assessments and 

2 program planning, onsite delivery, evaluation, and 

3 improvement efforts. 

4 (3) BEHAVIORAL CHANGE COMPONENT.—A be5 havioral change component which encourages 

6 healthy living through counseling, seminars, on-line 

7 programs, self-help materials, or other programs 

8 which provide technical assistance and problem solv9 ing skills. Such component may include programs re10 lating to— 

11 (A) tobacco use; 

12 (B) obesity; 

13 (C) stress management; 

14 (D) physical fitness; 

15 (E) nutrition; 

16 (F) substance abuse; 

17 (G) depression; and 

18 (H) mental health promotion. 

19 (4) SUPPORTIVE ENVIRONMENT COMPONENT.— 

20 A supportive environment component which includes 

21 the following: 

22 (A) ON-SITE POLICIES.—Policies and serv23 ices at the worksite which promote a healthy 

24 lifestyle, including policies relating to— 

25 (i) tobacco use at the worksite; 


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1 (ii) the nutrition of food available at 

2 the worksite through cafeterias and vend3 ing options; 

4 (iii) minimizing stress and promoting 

5 positive mental health in the workplace; 

6 and 

7 (iv) the encouragement of physical ac8 tivity before, during, and after work hours. 

9 (d) PARTICIPATION REQUIREMENT.—No grant shall 

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

11 Health and Human Services and Labor, in consultation 

12 with other appropriate agencies, jointly certify, as a part 

13 of any certification described in subsection (b), that each 

14 wellness program component of the qualified wellness pro15 gram— 

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

17 employer; 

18 (2) shall not mandate participation by employ19 ees; and 

20 (3) may provide a financial reward for partici21 pation of an individual in such program so long as 

22 such reward is not tied to the premium or cost-shar23 ing of the individual under the health benefits plan. 

24 (e) PRIVACY PROTECTIONS.—Data gathered for pur25 poses of the employer wellness program may be used solely 


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1 for the purposes of administering the program. The Secre2 taries of Health and Human Services and Labor shall de3 velop standards to ensure such data remain confidential 

4 and are not used for purposes beyond those for admin5 istering the program. 

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

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

8 food or health insurance shall not be taken into account 

9 under subsection (a). 

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

11 Human Services and Labor, in conjunction with other ap12 propriate agencies and members of the business commu13 nity, shall jointly institute an outreach program to inform 

14 businesses about the availability of the wellness program 

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

16 programs according to recognized and promising practices 

17 and on how to measure the success of implemented pro18 grams. 

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

20 on July 1, 2010. 

21 (i) AUTHORIZATION OF APPROPRIATIONS.—There 

22 are authorized to be appropriated such sums as are nec23 essary to carry out this section. 


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1 SEC. 113. EXTENSION OF COBRA CONTINUATION COV2 ERAGE. 

3 (a) EXTENSION OF CURRENT PERIODS OF CONTINU4 ATION COVERAGE.— 

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

6 who is, under a COBRA continuation coverage pro7 vision, covered under COBRA continuation coverage 

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

9 the required period of any such coverage which has 

10 not subsequently terminated under the terms of such 

11 provision for any reason other than the expiration of 

12 a period of a specified number of months shall, not13 withstanding such provision and subject to sub14 section (b), extend to the earlier of the date on 

15 which such individual becomes eligible for acceptable 

16 coverage or the date on which such individual be17 comes eligible for health insurance coverage through 

18 the Health Insurance Exchange (or a State-based 

19 Health Insurance Exchange operating in a State or 

20 group of States). 

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

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

23 Labor, in consultation with the Secretary of the 

24 Treasury and the Secretary of Health and Human 

25 Services, shall, in consultation with administrators 

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


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1 provide or administer the COBRA continuation cov2 erage involved, provide rules setting forth the form 

3 and manner in which prompt notice to individuals of 

4 the continued availability of COBRA continuation 

5 coverage to such individuals under paragraph (1). 

6 (b) CONTINUED EFFECT OF OTHER TERMINATING

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

8 period of COBRA continuation coverage which is extended 

9 under such subsection shall terminate upon the occur10 rence, prior to the date of termination otherwise provided 

11 in such subsection, of any terminating event specified in 

12 the applicable continuation coverage provision other than 

13 the expiration of a period of a specified number of months. 

14 (c) ACCESS TO STATE HEALTH BENEFITS RISK

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

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

17 that such provision has the effect of limiting or precluding 

18 access by a qualified beneficiary whose COBRA continu19 ation coverage has been extended under this section to a 

20 State health benefits risk pool recognized by the Commis21 sioner for purposes of this section solely by reason of the 

22 extension of such coverage beyond the date on which such 

23 coverage otherwise would have expired. 

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


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1 (1) COBRA CONTINUATION COVERAGE.—The 

2 term ‘‘COBRA continuation coverage’’ means con3 tinuation coverage provided pursuant to part 6 of 

4 subtitle B of title I of the Employee Retirement In5 come Security Act of 1974 (other than under section 

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

7 section 4980B of the Internal Revenue Code of 1986 

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

9 as it relates to pediatric vaccines), or section 905a 

10 of title 5, United States Code, or under a State pro11 gram that provides comparable continuation cov12 erage. Such term does not include coverage under a 

13 health flexible spending arrangement under a cafe14 teria plan within the meaning of section 125 of the 

15 Internal Revenue Code of 1986. 

16 (2) COBRA CONTINUATION PROVISION.—The 

17 term ‘‘COBRA continuation provision’’ means the 

18 provisions of law described in paragraph (1). 

19 SEC. 114. STATE HEALTH ACCESS PROGRAM GRANTS. 

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

21 Human Services (in this section referred to as the ‘‘Sec22 retary’’) shall provide grants to States (as defined for pur23 poses of title XIX of the Social Security Act) to establish 

24 programs to expand access to affordable health care cov25 erage for the uninsured populations in that State in a 


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1 manner consistent with reforms to take effect under this 

2 division in Y1. 

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

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

5 the following: 

6 (1) STATE INSURANCE EXCHANGES.—State in7 surance exchanges that develop new, less expensive, 

8 portable benefit packages for small employers and 

9 part-time and seasonal workers. 

10 (2) COMMUNITY COVERAGE PROGRAM.—Com11 munity coverage with shared responsibility between 

12 employers, governmental or nonprofit entity, and the 

13 individual. 

14 (3) REINSURANCE PLAN PROGRAM.—Reinsur15 ance plans that subsidize a certain share of carrier 

16 losses within a certain risk corridor health insurance 

17 premium assistance. 

18 (4) TRANSPARENT MARKETPLACE PROGRAM.— 

19 Transparent marketplace that provides an organized 

20 structure for the sale of insurance products such as 

21 a Web exchange or portal. 

22 (5) AUTOMATED ENROLLMENT PROGRAM.— 

23 Statewide or automated enrollment systems for pub24 lic assistance programs. 


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1 (6) INNOVATIVE STRATEGIES.—Innovative 

2 strategies to insure low-income childless adults. 

3 (7) PURCHASING COLLABORATIVES.—Business/ 

4 consumer collaborative that provides direct contract 

5 health care service purchasing options for group 

6 plan sponsors. 

7 (c) ELIGIBILITY AND ADMINISTRATION.— 

8 (1) IMPLEMENTATION OF KEY STATUTORY OR

9 REGULATORY CHANGES.—In order to be awarded a 

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

11 demonstrate that— 

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

13 statutory or regulatory changes required to 

14 begin implementing the new program within 1 

15 year after the initiation of funding under the 

16 grant; and 

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

18 without Federal funding after the end of the 

19 period of the grant. 

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

21 developed a comprehensive health insurance access 

22 program is not eligible for a grant under this sec23 tion. 

24 (3) APPLICATION REQUIRED.—No State shall 

25 receive a grant under this section unless the State 


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1 has approved by the Secretary such an application, 

2 in such form and manner as the Secretary specifies. 

3 (4) ADMINISTRATION BASED ON CURRENT PRO4 GRAM.—The program under this section is intended 

5 to build on the State Health Access Program funded 

6 under the Omnibus Appropriations Act, 2009 (Pub7 lic Law 111–8). 

8 (d) FUNDING LIMITATIONS.— 

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

10 shall— 

11 (A) only be available for expenditures be12 fore Y1; and 

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

14 supplant, funds otherwise provided. 

15 (2) MATCHING FUND REQUIREMENT.— 

16 (A) IN GENERAL.—Subject to subpara17 graph (B), no grant may be awarded to a State 

18 unless the State demonstrates the seriousness 

19 of its effort by matching at least 20 percent of 

20 the grant amount through non-Federal re21 sources, which may be a combination of State, 

22 local, private dollars from insurers, providers, 

23 and other private organizations. 

24 (B) WAIVER.—The Secretary may waive 

25 the requirement of subparagraph (A) if the 


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1 State demonstrates to the Secretary financial 

2 hardship in complying with such requirement. 

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

4 benchmark the progress and results of the programs fund5 ed under this section. 

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

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

8 practices and lessons learned through the grant to inform 

9 the health reform coverage expansions under this division 

10 beginning in Y1. 

11 (g) FUNDING.—There are authorized to be appro12 priated such sums as may be necessary to carry out this 

13 section. 

14 SEC. 115. ADMINISTRATIVE SIMPLIFICATION. 

15 (a) STANDARDIZING ELECTRONIC ADMINISTRATIVE

16 TRANSACTIONS.— 

17 (1) IN GENERAL.—Part C of title XI of the So18 cial Security Act (42 U.S.C. 1320d et seq.) is 

19 amended by inserting after section 1173 the fol20 lowing new sections: 

21 ‘‘SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE 

22 TRANSACTIONS. 

23 ‘‘(a) STANDARDS FOR FINANCIAL AND ADMINISTRA24 TIVE TRANSACTIONS.— 


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

2 and regularly update standards consistent with the 

3 goals described in paragraph (2). 

4 ‘‘(2) GOALS FOR FINANCIAL AND ADMINISTRA5 TIVE TRANSACTIONS.—The goals for standards 

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

7 to the extent practicable— 

8 ‘‘(A) be unique with no conflicting or re9 dundant standards; 

10 ‘‘(B) be authoritative, permitting no addi11 tions or constraints for electronic transactions, 

12 including companion guides; 

13 ‘‘(C) be comprehensive, efficient and ro14 bust, requiring minimal augmentation by paper 

15 transactions or clarification by further commu16 nications; 

17 ‘‘(D) enable the real-time (or near real18 time) determination of an individual’s financial 

19 responsibility at the point of service and, to the 

20 extent possible, prior to service, including 

21 whether the individual is eligible for a specific 

22 service with a specific physician at a specific fa23 cility, on a specific date or range of dates, in24 clude utilization of a machine-readable health 


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1 plan beneficiary identification card or similar 

2 mechanism; 

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

4 adjudication of claims; 

5 ‘‘(F) provide for timely acknowledgment, 

6 response, and status reporting applicable to any 

7 electronic transaction deemed appropriate by 

8 the Secretary; 

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

10 reason and remark codes) in unambiguous 

11 terms, not permit optional fields, require that 

12 data elements be either required or conditioned 

13 upon set values in other fields, and prohibit ad14 ditional conditions except where required by (or 

15 to implement) State or Federal law or to pro16 tect against fraud and abuse; and 

17 ‘‘(H) harmonize all common data elements 

18 across administrative and clinical transaction 

19 standards. 

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

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

22 the Secretary shall adopt standards under this sec23 tion by interim, final rule. 


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1 ‘‘(4) REQUIREMENTS FOR SPECIFIC STAND2 ARDS.—The standards under this section shall be 

3 developed, adopted, and enforced so as to— 

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

5 as needed, the standards required under section 

6 1173; 

7 ‘‘(B) require paper versions of standard8 ized transactions to comply with the same 

9 standards as to data content such that a fully 

10 compliant, equivalent electronic transaction can 

11 be populated from the data from a paper 

12 version; 

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

14 order to allow automated reconciliation with the 

15 related health care payment and remittance ad16 vice; 

17 ‘‘(D) require timely and transparent claim 

18 and denial management processes, including 

19 uniform claim edits, uniform reason and remark 

20 denial codes, tracking, adjudication, and appeal 

21 processing; 

22 ‘‘(E) require the use of a standard elec23 tronic transaction with which health care pro24 viders may quickly and efficiently enroll with a 


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1 health plan to conduct the other electronic 

2 transactions provided for in this part; and 

3 ‘‘(F) provide for other requirements relat4 ing to administrative simplification as identified 

5 by the Secretary, in consultation with stake6 holders. 

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

8 adopting the standards under this section, the Sec9 retary shall consider existing and planned standards. 

10 ‘‘(6) IMPLEMENTATION AND ENFORCEMENT.— 

11 Not later than 6 months after the date of the enact12 ment of this section, the Secretary shall submit to 

13 the appropriate committees of Congress a plan for 

14 the implementation and enforcement, by not later 

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

16 standards under this section. Such plan shall in17 clude— 

18 ‘‘(A) a process and timeframe with mile19 stones for developing the complete set of stand20 ards; 

21 ‘‘(B) a proposal for accommodating nec22 essary changes between version changes and a 

23 process for upgrading standards as often as an24 nually by interim, final rulemaking; 


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

2 and ease the burden of, implementation for cer3 tain health care providers, with special consid4 eration given to such providers serving rural or 

5 underserved areas and ensure coordination with 

6 standards, implementation specifications, and 

7 certification criteria being adopted under the 

8 HITECH Act; 

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

10 and ease the burden of, health care providers 

11 who volunteer to participate in the process of 

12 setting standards for electronic transactions; 

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

14 ensure timely completion of the implementation 

15 plan; and 

16 ‘‘(F) an enforcement process that includes 

17 timely investigation of complaints, random au18 dits to ensure compliance, civil monetary and 

19 programmatic penalties for noncompliance con20 sistent with existing laws and regulations, and 

21 a fair and reasonable appeals process building 

22 off of enforcement provisions under this part, 

23 and concurrent State enforcement jurisdiction. 

24 The Secretary may promulgate an annual audit and 

25 certification process to ensure that all health plans 


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1 and clearinghouses are both syntactically and func2 tionally compliant with all the standard transactions 

3 mandated pursuant to the administrative simplifica4 tion provisions of this part and the Health Insurance 

5 Portability and Accountability Act of 1996. 

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

7 this section shall be construed to permit the use of infor8 mation collected under this section in a manner that would 

9 violate State or Federal law. 

10 ‘‘(c) PROTECTION OF DATA.—The Secretary shall en11 sure (through the promulgation of regulations or other12 wise) that all data collected pursuant to subsection (a) are 

13 used and disclosed in a manner that meets the HIPAA 

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

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

16 or security standard adopted under section 3004 of such 

17 Act. 

18 ‘‘SEC. 1173B. INTERIM COMPANION GUIDES, INCLUDING OP19 ERATING RULES. 

20 ‘‘(a) IN GENERAL.—The Secretary shall adopt a sin21 gle, binding, comprehensive companion guide, that in22 cludes operating rules for each X12 Version 5010 trans23 action described in section 1173(a)(2), to be effective until 

24 the new version of these transactions which comply with 

25 section 1173A are adopted and implemented. 


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1 ‘‘(b) COMPANION GUIDE AND OPERATING RULES

2 DEVELOPMENT.—In adopting such interim companion 

3 guide and rules, the Secretary shall comply with section 

4 1172, except that a nonprofit entity that meets the fol5 lowing criteria shall also be consulted: 

6 ‘‘(1) The entity focuses its mission on adminis7 trative simplification. 

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

9 that creates consensus-based companion guides, in10 cluding operating rules using a voting process that 

11 ensures balanced representation by the critical 

12 stakeholders (including health plans and health care 

13 providers) so that no one group dominates the entity 

14 and shall include others such as standards develop15 ment organizations, and relevant Federal or State 

16 agencies. 

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

18 guiding principles that ensure the companion guide 

19 and operating rules and process are open and trans20 parent. 

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

22 the HIT Policy Committee, and the HIT Standards 

23 Committee (established under title XXX of the Pub24 lic Health Service Act) and complements the efforts 


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1 of the Office of the National Healthcare Coordinator 

2 and its related health information exchange goals. 

3 ‘‘(5) The entity incorporates the standards 

4 issued under Health Insurance Portability and Ac5 countability Act of 1996 and this part, and in devel6 oping the companion guide and operating rules does 

7 not change the definition, data condition or use of 

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

9 elements or segments to the maximum defined data 

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

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

12 specifications or are not in the standard’s implemen13 tation specifications, or change the meaning or in14 tent of the standard’s implementation specifications. 

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

16 and proven best practices. 

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

18 allow for the evaluation of their market impact and 

19 public reporting of aggregate stakeholder impact. 

20 ‘‘(8) The entity supports nondiscrimination and 

21 conflict of interest policies that demonstrate a com22 mitment to open, fair, and nondiscriminatory prac23 tices. 


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

2 comment on updates of the companion guide, includ3 ing the operating rules. 

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

5 a single, binding companion guide, including operating 

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

7 effective with the X12 Version 5010 transaction imple8 mentation, or as soon thereafter as feasible. The com9 panion guide, including operating rules for the trans10 actions for eligibility for health plan and health claims sta11 tus under this section shall be adopted not later than Oc12 tober 1, 2011, in a manner such that such set of rules 

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

14 companion guide, including operating rules for the remain15 der of the transactions described in section 1173(a)(2) 

16 shall be adopted not later than October 1, 2012, in a man17 ner such that such set of rules is effective beginning not 

18 later than January 1, 2014.’’. 

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

20 (42 U.S.C. 1320d) is amended— 

21 (A) in paragraph (1), by inserting ‘‘, and 

22 associated operational guidelines and instruc23 tions, as determined appropriate by the Sec24 retary’’ after ‘‘medical procedure codes’’; and 


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

2 paragraph: 

3 ‘‘(10) OPERATING RULES.—The term ‘oper4 ating rules’ means business rules for using and proc5 essing transactions, such as service level require6 ments, which do not impact the implementation 

7 specifications or other data content requirements.’’. 

8 (3) CONFORMING AMENDMENT.—Section 

9 1179(a) of such Act (42 U.S.C. 1320d–8(a)) is 

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

11 (A) by inserting ‘‘on behalf of an indi12 vidual’’ after ‘‘1978)’’; and 

13 (B) by inserting ‘‘on behalf of an indi14 vidual’’ after ‘‘for a financial institution’’ and 

15 (b) STANDARDS FOR CLAIMS ATTACHMENTS AND

16 COORDINATION OF BENEFITS.— 

17 (1) STANDARD FOR HEALTH CLAIMS ATTACH18 MENTS.—Not later than 1 year after the date of the 

19 enactment of this Act, the Secretary of Health and 

20 Human Services shall promulgate an interim, final 

21 rule to establish a standard for health claims attach22 ment transaction described in section 1173(a)(2)(B) 

23 of the Social Security Act (42 U.S.C. 1320d– 

24 2(a)(2)(B)) and coordination of benefits. 


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1 (2) REVISION IN PROCESSING PAYMENT TRANS2 ACTIONS BY FINANCIAL INSTITUTIONS.— 

3 (A) IN GENERAL.—Section 1179 of the So4 cial Security Act (42 U.S.C. 1320d–8) is 

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

6 (i) by striking ‘‘or is engaged’’ and in7 serting ‘‘and is engaged’’; and 

8 (ii) by inserting ‘‘(other than as a 

9 business associate for a covered entity)’’ 

10 after ‘‘for a financial institution’’. 

11 (B) COMPLIANCE DATE.—The amend12 ments made by subparagraph (A) shall apply to 

13 transactions occurring on or after such date 

14 (not later than January 1, 2014) as the Sec15 retary of Health and Human Services shall 

16 specify. 

17 (c) STANDARDS FOR FIRST REPORT OF INJURY.— 

18 Not later than January 1, 2014, the Secretary of Health 

19 and Human Services shall promulgate an interim final 

20 rule to establish a standard for the first report of injury 

21 transaction described in section 1173(a)(2)(G) of the So22 cial Security Act (42 U.S.C. 1320d–2(a)(2)(G)). 

23 (d) UNIQUE HEALTH PLAN IDENTIFIER.—Not later 

24 October 1, 2012, the Secretary of Health and Human 

25 Services shall promulgate an interim final rule to establish 


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1 a unique health plan identifier described in section 

2 1173(b) of the Social Security Act (42 U.S.C. 1320d– 

3 2(b)) based on the input of the National Committee of 

4 Vital and Health Statistics and consultation with health 

5 plans, health care providers, and other interested parties. 

6 (e) EXPANSION OF ELECTRONIC TRANSACTIONS IN

7 MEDICARE.—Section 1862(a) of the Social Security Act 

8 (42 U.S.C. 1395y(a)) is amended— 

9 (1) in paragraph (23), by striking ‘‘or’’ at the 

10 end; 

11 (2) in paragraph (24), by striking the period 

12 and inserting ‘‘; or’’; and 

13 (3) by inserting after paragraph (24) the fol14 lowing new paragraph: 

15 ‘‘(25) subject to subsection (h), not later than 

16 January 1, 2015, for which the payment is other 

17 than by electronic funds transfer (EFT) so long as 

18 the Secretary has adopted and implemented a stand19 ard for electronic funds transfer under section 

20 1173A.’’. 

21 (f) EXPANSION OF PENALTIES.—Section 1176 of 

22 such Act (42 U.S.C. 1320d–5) is amended by adding at 

23 the end the following new subsection: 

24 ‘‘(c) EXPANSION OF PENALTY AUTHORITY.—The 

25 Secretary may, in addition to the penalties provided under 


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1 subsections (a) and (b), provide for the imposition of pen2 alties for violations of this part that are comparable— 

3 ‘‘(1) in the case of health plans, to the sanc4 tions the Secretary is authorized to impose under 

5 part C or D of title XVIII in the case of a plan that 

6 violates a provision of such part; or 

7 ‘‘(2) in the case of a health care provider, to 

8 the sanctions the Secretary is authorized to impose 

9 under part A, B, or D of title XVIII in the case of 

10 a health care provider that violations a provision of 

11 such part with respect to that provider.’’. 

12 TITLE II—PROTECTIONS AND 

13 STANDARDS FOR QUALIFIED 

14 HEALTH BENEFITS PLANS 

15 Subtitle A—General Standards 

16 SEC. 201. REQUIREMENTS REFORMING HEALTH INSUR17 ANCE MARKETPLACE. 

18 (a) PURPOSE.—The purpose of this title is to estab19 lish standards to ensure that new health insurance cov20 erage and employment-based health plans that are offered 

21 meet standards guaranteeing access to affordable cov22 erage, essential benefits, and other consumer protections. 

23 (b) REQUIREMENTS FOR QUALIFIED HEALTH BENE24 FITS PLANS.—On or after the first day of Y1, a health 

25 benefits plan shall not be a qualified health benefits plan 


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1 under this division unless the plan meets the applicable 

2 requirements of the following subtitles for the type of plan 

3 and plan year involved: 

4 (1) Subtitle B (relating to affordable coverage). 

5 (2) Subtitle C (relating to essential benefits). 

6 (3) Subtitle D (relating to consumer protec7 tion). 

8 (c) TERMINOLOGY.—In this division: 

9 (1) ENROLLMENT IN EMPLOYMENT-BASED

10 HEALTH PLANS.—An individual shall be treated as 

11 being ‘‘enrolled’’ in an employment-based health 

12 plan if the individual is a participant or beneficiary 

13 (as such terms are defined in section 3(7) and 3(8), 

14 respectively, of the Employee Retirement Income Se15 curity Act of 1974) in such plan. 

16 (2) INDIVIDUAL AND GROUP HEALTH INSUR17 ANCE COVERAGE.—The terms ‘‘individual health in18 surance coverage’’ and ‘‘group health insurance cov19 erage’’ mean health insurance coverage offered in 

20 the individual market or large or small group mar21 ket, respectively, as defined in section 2791 of the 

22 Public Health Service Act. 


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1 SEC. 202. PROTECTING THE CHOICE TO KEEP CURRENT 

2 COVERAGE. 

3 (a) GRANDFATHERED HEALTH INSURANCE COV4 ERAGE DEFINED.—Subject to the succeeding provisions of 

5 this section, for purposes of establishing acceptable cov6 erage under this division, the term ‘‘grandfathered health 

7 insurance coverage’’ means individual health insurance 

8 coverage that is offered and in force and effect before the 

9 first day of Y1 if the following conditions are met: 

10 (1) LIMITATION ON NEW ENROLLMENT.— 

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

12 this paragraph, the individual health insurance 

13 issuer offering such coverage does not enroll 

14 any individual in such coverage if the first ef15 fective date of coverage is on or after the first 

16 day of Y1. 

17 (B) DEPENDENT COVERAGE PER18 MITTED.—Subparagraph (A) shall not affect 

19 the subsequent enrollment of a dependent of an 

20 individual who is covered as of such first day. 

21 (2) LIMITATION ON CHANGES IN TERMS OR

22 CONDITIONS.—Subject to paragraph (3) and except 

23 as required by law, the issuer does not change any 

24 of its terms or conditions, including benefits and 

25 cost-sharing, from those in effect as of the day be26 fore the first day of Y1. 


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1 (3) RESTRICTIONS ON PREMIUM INCREASES.— 

2 The issuer cannot vary the percentage increase in 

3 the premium for a risk group of enrollees in specific 

4 grandfathered health insurance coverage without 

5 changing the premium for all enrollees in the same 

6 risk group at the same rate, as specified by the 

7 Commissioner. 

8 (b) GRACE PERIOD FOR CURRENT EMPLOYMENT9 BASED HEALTH PLANS.— 

10 (1) GRACE PERIOD.— 

11 (A) IN GENERAL.—The Commissioner 

12 shall establish a grace period whereby, for plan 

13 years beginning after the end of the 5-year pe14 riod beginning with Y1, an employment-based 

15 health plan in operation as of the day before 

16 the first day of Y1 must meet the same require17 ments as apply to a qualified health benefits 

18 plan under section 201, including the essential 

19 benefit package requirement under section 221. 

20 (B) EXCEPTION FOR LIMITED BENEFITS

21 PLANS.—Subparagraph (A) shall not apply to 

22 an employment-based health plan in which the 

23 coverage consists only of one or more of the fol24 lowing: 


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1 (i) Any coverage described in section 

2 3001(a)(1)(B)(ii)(IV) of division B of the 

3 American Recovery and Reinvestment Act 

4 of 2009 (Public Law 111–5). 

5 (ii) Excepted benefits (as defined in 

6 section 733(c) of the Employee Retirement 

7 Income Security Act of 1974), including 

8 coverage under a specified disease or ill9 ness policy described in paragraph (3)(A) 

10 of such section. 

11 (iii) Such other limited benefits as the 

12 Commissioner may specify. 

13 In no case shall an employment-based health 

14 plan in which the coverage consists only of one 

15 or more of the coverage or benefits described in 

16 clauses (i) through (iii) be treated as acceptable 

17 coverage under this division. 

18 (2) TRANSITIONAL TREATMENT AS ACCEPT19 ABLE COVERAGE.—During the grace period specified 

20 in paragraph (1)(A), an employment-based health 

21 plan (which may be a high deducible health plan, as 

22 defined in section 223(c)(2) of the Internal Revenue 

23 Code of 1986) that is described in such paragraph 

24 shall be treated as acceptable coverage under this di25 vision. 


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1 (c) LIMITATION ON INDIVIDUAL HEALTH INSURANCE

2 COVERAGE.— 

3 (1) IN GENERAL.—Individual health insurance 

4 coverage that is not grandfathered health insurance 

5 coverage under subsection (a) may only be offered 

6 on or after the first day of Y1 as an Exchange-par7 ticipating health benefits plan. 

8 (2) SEPARATE, EXCEPTED COVERAGE PER9 MITTED.—Nothing in— 

10 (A) paragraph (1) shall prevent the offer11 ing of excepted benefits described in section 

12 2791(c) of the Public Health Service Act so 

13 long as such benefits are offered outside the 

14 Health Insurance Exchange and are priced sep15 arately from health insurance coverage; and 

16 (B) this division shall be construed— 

17 (i) to prevent the offering of a stand18 alone plan that offers coverage of excepted 

19 benefits described in section 2791(c)(2)(A) 

20 of the Public Health Service Act (relating 

21 to limited scope dental or vision benefits) 

22 for individuals and families from a State23 licensed dental and vision carrier; or 

24 (ii) as applying requirements for a 

25 qualified health benefits plan to such a 


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1 stand-alone plan that is offered and priced 

2 separately from a qualified health benefits 

3 plan. 

4 Subtitle B—Standards Guaran5 teeing Access to Affordable Cov6 erage 

7 SEC. 211. PROHIBITING PREEXISTING CONDITION EXCLU8 SIONS. 

9 A qualified health benefits plan may not impose any 

10 preexisting condition exclusion (as defined in section 

11 2701(b)(1)(A) of the Public Health Service Act) or other12 wise impose any limit or condition on the coverage under 

13 the plan with respect to an individual or dependent based 

14 on any of the following: health status, medical condition, 

15 claims experience, receipt of health care, medical history, 

16 genetic information, evidence of insurability, disability, or 

17 source of injury (including conditions arising out of acts 

18 of domestic violence) or any similar factors. 

19 SEC. 212. GUARANTEED ISSUE AND RENEWAL FOR IN20 SURED PLANS AND PROHIBITING RESCIS21 SIONS. 

22 The requirements of sections 2711 (other than sub23 sections (e) and (f)) and 2712 (other than paragraphs (3), 

24 and (6) of subsection (b) and subsection (e)) of the Public 

25 Health Service Act, relating to guaranteed availability and 


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1 renewability of health insurance coverage, shall apply to 

2 individuals and employers in all individual and group 

3 health insurance coverage, whether offered to individuals 

4 or employers through the Health Insurance Exchange, 

5 through any employment-based health plan, or otherwise, 

6 in the same manner as such sections apply to employers 

7 and health insurance coverage offered in the small group 

8 market, except that such section 2712(b)(1) shall apply 

9 only if, before nonrenewal or discontinuation of coverage, 

10 the issuer has provided the enrollee with notice of non11 payment of premiums and there is a grace period during 

12 which the enrollee has an opportunity to correct such non13 payment. Rescissions of such coverage shall be prohibited 

14 except in cases of fraud as defined in section 2712(b)(2) 

15 of such Act. 

16 SEC. 213. INSURANCE RATING RULES. 

17 (a) IN GENERAL.—The premium rate charged for a 

18 qualified health benefits plan that is health insurance cov19 erage may not vary except as follows: 

20 (1) LIMITED AGE VARIATION PERMITTED.—By 

21 age (within such age categories as the Commissioner 

22 shall specify) so long as the ratio of the highest such 

23 premium to the lowest such premium does not ex24 ceed the ratio of 2 to 1. 


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1 (2) BY AREA.—By premium rating area (as 

2 permitted by State insurance regulators or, in the 

3 case of Exchange-participating health benefits plans, 

4 as specified by the Commissioner in consultation 

5 with such regulators). 

6 (3) BY FAMILY ENROLLMENT.—By family en7 rollment (such as variations within categories and 

8 compositions of families) so long as the ratio of the 

9 premium for family enrollment (or enrollments) to 

10 the premium for individual enrollment is uniform, as 

11 specified under State law and consistent with rules 

12 of the Commissioner. 

13 (b) ACTUARIAL VALUE OF OPTIONAL SERVICE COV14 ERAGE.— 

15 (1) IN GENERAL.—The Commissioner shall esti16 mate the basic per enrollee, per month cost, deter17 mined on an average actuarial basis, for including 

18 coverage under a basic plan of the services described 

19 in section 222(d)(4)(A). 

20 (2) CONSIDERATIONS.—In making such esti21 mate the Commissioner— 

22 (A) may take into account the impact on 

23 overall costs of the inclusion of such coverage, 

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1 cluding prenatal care, delivery, or postnatal 

2 care; 

3 (B) shall estimate such costs as if such 

4 coverage were included for the entire population 

5 covered; and 

6 (C) may not estimate such a cost at less 

7 than $1 per enrollee, per month. 

8 (c) STUDY AND REPORTS.— 

9 (1) STUDY.—The Commissioner, in coordina10 tion with the Secretary of Health and Human Serv11 ices and the Secretary of Labor, shall conduct a 

12 study of the large-group-insured and self-insured 

13 employer health care markets. Such study shall ex14 amine the following: 

15 (A) The types of employers by key charac16 teristics, including size, that purchase insured 

17 products versus those that self-insure. 

18 (B) The similarities and differences be19 tween typical insured and self-insured health 

20 plans. 

21 (C) The financial solvency and capital re22 serve levels of employers that self-insure by em23 ployer size. 


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1 (D) The risk of self-insured employers not 

2 being able to pay obligations or otherwise be3 coming financially insolvent. 

4 (E) The extent to which rating rules are 

5 likely to cause adverse selection in the large 

6 group market or to encourage small and 

7 midsize employers to self-insure. 

8 (2) REPORTS.—Not later than 18 months after 

9 the date of the enactment of this Act, the Commis10 sioner shall submit to Congress and the applicable 

11 agencies a report on the study conducted under 

12 paragraph (1). Such report shall include any rec13 ommendations the Commissioner deems appropriate 

14 to ensure that the law does not provide incentives 

15 for small and midsize employers to self-insure or cre16 ate adverse selection in the risk pools of large group 

17 insurers and self-insured employers. Not later than 

18 18 months after the first day of Y1, the Commis19 sioner shall submit to Congress and the applicable 

20 agencies an updated report on such study, including 

21 updates on such recommendations. 


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1 SEC. 214. NONDISCRIMINATION IN BENEFITS; PARITY IN 

2 MENTAL HEALTH AND SUBSTANCE ABUSE 

3 DISORDER BENEFITS. 

4 (a) NONDISCRIMINATION IN BENEFITS.—A qualified 

5 health benefits plan shall comply with standards estab6 lished by the Commissioner to prohibit discrimination in 

7 health benefits or benefit structures for qualifying health 

8 benefits plans, building from section 702 of the Employee 

9 Retirement Income Security Act of 1974, section 2702 of 

10 the Public Health Service Act, and section 9802 of the 

11 Internal Revenue Code of 1986. 

12 (b) PARITY IN MENTAL HEALTH AND SUBSTANCE

13 ABUSE DISORDER BENEFITS.—To the extent such provi14 sions are not superceded by or inconsistent with subtitle 

15 C, the provisions of section 2705 (other than subsections 

16 (a)(1), (a)(2), and (c)) of the Public Health Service Act 

17 shall apply to a qualified health benefits plan, regardless 

18 of whether it is offered in the individual or group market, 

19 in the same manner as such provisions apply to health 

20 insurance coverage offered in the large group market. 

21 SEC. 215. ENSURING ADEQUACY OF PROVIDER NETWORKS. 

22 (a) IN GENERAL.—A qualified health benefits plan 

23 that uses a provider network for items and services shall 

24 meet such standards respecting provider networks as the 

25 Commissioner may establish to assure the adequacy of 

26 such networks in ensuring enrollee access to such items 


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1 and services and transparency in the cost-sharing differen2 tials among providers participating in the network and 

3 policies for accessing out-of-network providers. 

4 (b) INTERNET ACCESS TO INFORMATION.—A quali5 fied health benefits plan that uses a provider network shall 

6 provide a current listing of all providers in its network 

7 on its Website and such data shall be available on the 

8 Health Insurance Exchange Website as a part of the basic 

9 information on that plan. The Commissioner shall also es10 tablish an on-line system whereby an individual may select 

11 by name any medical provider (as defined by the Commis12 sioner) and be informed of the plan or plans with which 

13 that provider is contracting. 

14 (c) PROVIDER NETWORK DEFINED.—In this division, 

15 the term ‘‘provider network’’ means the providers with re16 spect to which covered benefits, treatments, and services 

17 are available under a health benefits plan. 

18 SEC. 216. REQUIRING THE OPTION OF EXTENSION OF DE19 PENDENT COVERAGE FOR UNINSURED 

20 YOUNG ADULTS. 

21 (a) IN GENERAL.—A qualified health benefits plan 

22 shall make available, at the option of the principal enrollee 

23 under the plan, coverage for one or more qualified children 

24 (as defined in subsection (b)) of the enrollee. 


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

2 the term ‘‘qualified child’’ means, with respect to a prin3 cipal enrollee in a qualified health benefits plan, an indi4 vidual who (but for age) would be treated as a dependent 

5 child of the enrollee under such plan and who— 

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

7 (2) is not enrolled in a health benefits plan 

8 other than under this section. 

9 (c) PREMIUMS.—Nothing in this section shall be con10 strued as preventing a qualified health benefits plan from 

11 increasing the premiums otherwise required for coverage 

12 provided under this section consistent with standards es13 tablished by the Commissioner based upon family size 

14 under section 213(a)(3). 

15 SEC. 217. CONSISTENCY OF COSTS AND COVERAGE UNDER 

16 QUALIFIED HEALTH BENEFITS PLANS DUR17 ING PLAN YEAR. 

18 In the case of health insurance coverage offered 

19 under a qualified health benefits plan, if the coverage de20 creases or the cost-sharing increases, the issuer of the cov21 erage shall notify enrollees of the change at least 90 days 

22 before the change takes effect (or such shorter period of 

23 time in cases where the change is necessary to ensure the 

24 health and safety of enrollees). 


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1 Subtitle C—Standards Guaran2 teeing Access to Essential Bene3 fits 

4 SEC. 221. COVERAGE OF ESSENTIAL BENEFITS PACKAGE. 

5 (a) IN GENERAL.—A qualified health benefits plan 

6 shall provide coverage that at least meets the benefit 

7 standards adopted under section 224 for the essential ben8 efits package described in section 222 for the plan year 

9 involved. 

10 (b) CHOICE OF COVERAGE.— 

11 (1) NON-EXCHANGE-PARTICIPATING HEALTH

12 BENEFITS PLANS.—In the case of a qualified health 

13 benefits plan that is not an Exchange-participating 

14 health benefits plan, such plan may offer such cov15 erage in addition to the essential benefits package as 

16 the QHBP offering entity may specify. 

17 (2) EXCHANGE-PARTICIPATING HEALTH BENE18 FITS PLANS.—In the case of an Exchange-partici19 pating health benefits plan, such plan is required 

20 under section 203 to provide specified levels of bene21 fits and, in the case of a plan offering a premium22 plus level of benefits, provide additional benefits. 

23 (3) CONTINUATION OF OFFERING OF SEPARATE

24 EXCEPTED BENEFITS COVERAGE.—Nothing in this 

25 division shall be construed as affecting the offering 


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1 outside of the Health Insurance Exchange and 

2 under State law of health benefits in the form of ex3 cepted benefits (described in section 

4 202(b)(1)(B)(ii)) if such benefits are offered under 

5 a separate policy, contract, or certificate of insur6 ance. 

7 (c) CLINICAL APPROPRIATENESS.—Nothing in this 

8 Act shall be construed to prohibit a group health plan or 

9 health insurance issuer from using medical management 

10 practices so long as such management practices are based 

11 on valid medical evidence and are relevant to the patient 

12 whose medical treatment is under review. 

13 (d) PROVISION OF BENEFITS.—Nothing in this divi14 sion shall be construed as prohibiting a qualified health 

15 benefits plan from subcontracting with stand-alone health 

16 insurance issuers or insurers for the provision of dental, 

17 vision, mental health, and other benefits and services. 

18 SEC. 222. ESSENTIAL BENEFITS PACKAGE DEFINED. 

19 (a) IN GENERAL.—In this division, the term ‘‘essen20 tial benefits package’’ means health benefits coverage, 

21 consistent with standards adopted under section 224, to 

22 ensure the provision of quality health care and financial 

23 security, that— 

24 (1) provides payment for the items and services 

25 described in subsection (b) in accordance with genVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00104 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 erally accepted standards of medical or other appro2 priate clinical or professional practice; 

3 (2) limits cost-sharing for such covered health 

4 care items and services in accordance with such ben5 efit standards, consistent with subsection (c); 

6 (3) does not impose any annual or lifetime limit 

7 on the coverage of covered health care items and 

8 services; 

9 (4) complies with section 215(a) (relating to 

10 network adequacy); and 

11 (5) is equivalent in its scope of benefits, as cer12 tified by Office of the Actuary of the Centers for 

13 Medicare & Medicaid Services, to the average pre14 vailing employer-sponsored coverage in Y1. 

15 In order to carry out paragraph (5), the Secretary of 

16 Labor shall conduct a survey of employer-sponsored cov17 erage to determine the benefits typically covered by em18 ployers, including multiemployer plans, and provide a re19 port on such survey to the Health Benefits Advisory Com20 mittee and to the Secretary of Health and Human Serv21 ices. 

22 (b) MINIMUM SERVICES TO BE COVERED.—Subject 

23 to subsection (d), the items and services described in this 

24 subsection are the following: 

25 (1) Hospitalization. 


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1 (2) Outpatient hospital and outpatient clinic 

2 services, including emergency department services. 

3 (3) Professional services of physicians and other 

4 health professionals. 

5 (4) Such services, equipment, and supplies inci6 dent to the services of a physician’s or a health pro7 fessional’s delivery of care in institutional settings, 

8 physician offices, patients’ homes or place of resi9 dence, or other settings, as appropriate. 

10 (5) Prescription drugs. 

11 (6) Rehabilitative and habilitative services. 

12 (7) Mental health and substance use disorder 

13 services, including behavioral health treatments. 

14 (8) Preventive services, including those services 

15 recommended with a grade of A or B by the Task 

16 Force on Clinical Preventive Services and those vac17 cines recommended for use by the Director of the 

18 Centers for Disease Control and Prevention. 

19 (9) Maternity care. 

20 (10) Well-baby and well-child care and oral 

21 health, vision, and hearing services, equipment, and 

22 supplies for children under 21 years of age. 

23 (11) Durable medical equipment, prosthetics, 

24 orthotics and related supplies. 


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1 (c) REQUIREMENTS RELATING TO COST-SHARING

2 AND MINIMUM ACTUARIAL VALUE.— 

3 (1) NO COST-SHARING FOR PREVENTIVE SERV4 ICES.—There shall be no cost-sharing under the es5 sential benefits package for— 

6 (A) preventive items and services rec7 ommended with a grade of A or B by the Task 

8 Force on Clinical Preventive Services and those 

9 vaccines recommended for use by the Director 

10 of the Centers for Disease Control and Preven11 tion; or 

12 (B) well-baby and well-child care. 

13 (2) ANNUAL LIMITATION.— 

14 (A) ANNUAL LIMITATION.—The cost-shar15 ing incurred under the essential benefits pack16 age with respect to an individual (or family) for 

17 a year does not exceed the applicable level spec18 ified in subparagraph (B). 

19 (B) APPLICABLE LEVEL.—The applicable 

20 level specified in this subparagraph for Y1 is 

21 not to exceed $5,000 for an individual and not 

22 to exceed $10,000 for a family. Such levels 

23 shall be increased (rounded to the nearest 

24 $100) for each subsequent year by the annual 

25 percentage increase in the enrollment-weighted 


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1 average of premium increases for basic plans 

2 applicable to such year, except that Secretary 

3 shall adjust such increase to ensure that the ap4 plicable level specified in this subparagraph 

5 meets the minimum actuarial value required 

6 under paragraph (3). 

7 (C) USE OF COPAYMENTS.—In establishing 

8 cost-sharing levels for basic, enhanced, and pre9 mium plans under this subsection, the Sec10 retary shall, to the maximum extent possible, 

11 use only copayments and not coinsurance. 

12 (3) MINIMUM ACTUARIAL VALUE.— 

13 (A) IN GENERAL.—The cost-sharing under 

14 the essential benefits package shall be designed 

15 to provide a level of coverage that is designed 

16 to provide benefits that are actuarially equiva17 lent to approximately 70 percent of the full ac18 tuarial value of the benefits provided under the 

19 reference benefits package described in sub20 paragraph (B). 

21 (B) REFERENCE BENEFITS PACKAGE DE22 SCRIBED.—The reference benefits package de23 scribed in this subparagraph is the essential 

24 benefits package if there were no cost-sharing 

25 imposed. 


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1 (d) ASSESSMENT AND COUNSELING FOR DOMESTIC

2 VIOLENCE.—The Secretary shall support the need for an 

3 assessment and brief counseling for domestic violence as 

4 part of a behavioral health assessment or primary care 

5 visit and determine the appropriate coverage for such as6 sessment and counseling. 

7 (e) ABORTION COVERAGE PROHIBITED AS PART OF

8 MINIMUM BENEFITS PACKAGE.— 

9 (1) PROHIBITION OF REQUIRED COVERAGE.— 

10 The Health Benefits Advisory Committee may not 

11 recommend under section 223(b), and the Secretary 

12 may not adopt in standards under section 224(b), 

13 the services described in paragraph (4)(A) or (4)(B) 

14 as part of the essential benefits package and the 

15 Commissioner may not require such services for 

16 qualified health benefits plans to participate in the 

17 Health Insurance Exchange. 

18 (2) VOLUNTARY CHOICE OF COVERAGE BY

19 PLAN.—In the case of a qualified health benefits 

20 plan, the plan is not required (or prohibited) under 

21 this Act from providing coverage of services de22 scribed in paragraph (4)(A) or (4)(B) and the 

23 QHBP offering entity shall determine whether such 

24 coverage is provided. 


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1 (3) COVERAGE UNDER PUBLIC HEALTH INSUR2 ANCE OPTION.—The public health insurance option 

3 shall provide coverage for services described in para4 graph (4)(B). Nothing in this Act shall be construed 

5 as preventing the public health insurance option 

6 from providing for or prohibiting coverage of serv7 ices described in paragraph (4)(A). 

8 (4) ABORTION SERVICES.— 

9 (A) ABORTIONS FOR WHICH PUBLIC FUND10 ING IS PROHIBITED.—The services described in 

11 this subparagraph are abortions for which the 

12 expenditure of Federal funds appropriated for 

13 the Department of Health and Human Services 

14 is not permitted, based on the law as in effect 

15 as of the date that is 6 months before the be16 ginning of the plan year involved. 

17 (B) ABORTIONS FOR WHICH PUBLIC FUND18 ING IS ALLOWED.—The services described in 

19 this subparagraph are abortions for which the 

20 expenditure of Federal funds appropriated for 

21 the Department of Health and Human Services 

22 is permitted, based on the law as in effect as 

23 of the date that is 6 months before the begin24 ning of the plan year involved. 


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1 (f) REPORT REGARDING INCLUSION OF ORAL

2 HEALTH CARE IN ESSENTIAL BENEFITS PACKAGE.—Not 

3 later than 1 year after the date of the enactment of this 

4 Act, the Secretary of Health and Human Services shall 

5 submit to Congress a report containing the results of a 

6 study determining the need and cost of providing acces7 sible and affordable oral health care to adults as part of 

8 the essential benefits package. 

9 SEC. 223. HEALTH BENEFITS ADVISORY COMMITTEE. 

10 (a) ESTABLISHMENT.— 

11 (1) IN GENERAL.—There is established a pri12 vate-public advisory committee which shall be a 

13 panel of medical and other experts to be known as 

14 the Health Benefits Advisory Committee to rec15 ommend covered benefits and essential, enhanced, 

16 and premium plans. 

17 (2) CHAIR.—The Surgeon General shall be a 

18 member and the chair of the Health Benefits Advi19 sory Committee. 

20 (3) MEMBERSHIP.—The Health Benefits Advi21 sory Committee shall be composed of the following 

22 members, in addition to the Surgeon General: 

23 (A) Nine members who are not Federal 

24 employees or officers and who are appointed by 

25 the President. 


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1 (B) Nine members who are not Federal 

2 employees or officers and who are appointed by 

3 the Comptroller General of the United States in 

4 a manner similar to the manner in which the 

5 Comptroller General appoints members to the 

6 Medicare Payment Advisory Commission under 

7 section 1805(c) of the Social Security Act. 

8 (C) Such even number of members (not to 

9 exceed 8) who are Federal employees and offi10 cers, as the President may appoint. 

11 Such initial appointments shall be made not later 

12 than 60 days after the date of the enactment of this 

13 Act. 

14 (4) TERMS.—Each member of the Health Bene15 fits Advisory Committee shall serve a 3-year term on 

16 the Committee, except that the terms of the initial 

17 members shall be adjusted in order to provide for a 

18 staggered term of appointment for all such mem19 bers. 

20 (5) PARTICIPATION.—The membership of the 

21 Health Benefits Advisory Committee shall at least 

22 reflect providers, patient representatives, employers 

23 (including small employers), labor, health insurance 

24 issuers, experts in health care financing and deliv25 ery, experts in oral health care, experts in racial and 


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1 ethnic disparities, experts on health care needs and 

2 disparities of individuals with disabilities, represent3 atives of relevant governmental agencies, and at 

4 least one practicing physician or other health profes5 sional and an expert in child and adolescent health 

6 and shall represent a balance among various sectors 

7 of the health care system so that no single sector 

8 unduly influences the recommendations of such 

9 Committee. 

10 (b) DUTIES.— 

11 (1) RECOMMENDATIONS ON BENEFIT STAND12 ARDS.—The Health Benefits Advisory Committee 

13 shall recommend to the Secretary of Health and 

14 Human Services (in this subtitle referred to as the 

15 ‘‘Secretary’’) benefit standards (as defined in para16 graph (5)), and periodic updates to such standards. 

17 In developing such recommendations, the Committee 

18 shall take into account innovation in health care and 

19 consider how such standards could reduce health dis20 parities. 

21 (2) DEADLINE.—The Health Benefits Advisory 

22 Committee shall recommend initial benefit standards 

23 to the Secretary not later than 1 year after the date 

24 of the enactment of this Act. 


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1 (3) STATE INPUT.—The Health Benefits Advi2 sory Committee shall examine the health coverage 

3 laws and benefits of each State in developing rec4 ommendations under this subsection and may incor5 porate such coverage and benefits as the Committee 

6 determines to be appropriate and consistent with 

7 this Act. The Health Benefits Advisory Committee 

8 shall also seek input from the States and consider 

9 recommendations on how to ensure quality of health 

10 coverage in all States. 

11 (4) PUBLIC INPUT.—The Health Benefits Advi12 sory Committee shall allow for public input as a part 

13 of developing recommendations under this sub14 section. 

15 (5) BENEFIT STANDARDS DEFINED.—In this 

16 subtitle, the term ‘‘benefit standards’’ means stand17 ards respecting— 

18 (A) the essential benefits package de19 scribed in section 222, including categories of 

20 covered treatments, items and services within 

21 benefit classes, and cost-sharing consistent with 

22 subsection (d) of such section; and 

23 (B) the cost-sharing levels for enhanced 

24 plans and premium plans (as provided under 

25 section 303(c)) consistent with paragraph (5). 


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1 (6) LEVELS OF COST-SHARING FOR ENHANCED

2 AND PREMIUM PLANS.— 

3 (A) ENHANCED PLAN.—The level of cost4 sharing for enhanced plans shall be designed so 

5 that such plans have benefits that are actuari6 ally equivalent to approximately 85 percent of 

7 the actuarial value of the benefits provided 

8 under the reference benefits package described 

9 in section 222(c)(3)(B). 

10 (B) PREMIUM PLAN.—The level of cost11 sharing for premium plans shall be designed so 

12 that such plans have benefits that are actuari13 ally equivalent to approximately 95 percent of 

14 the actuarial value of the benefits provided 

15 under the reference benefits package described 

16 in section 222(c)(3)(B). 

17 (c) OPERATIONS.— 

18 (1) PER DIEM PAY.—Each member of the 

19 Health Benefits Advisory Committee shall receive 

20 travel expenses, including per diem in accordance 

21 with applicable provisions under subchapter I of 

22 chapter 57 of title 5, United States Code, and shall 

23 otherwise serve without additional pay. 

24 (2) MEMBERS NOT TREATED AS FEDERAL EM25 PLOYEES.—Members of the Health Benefits AdviVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00115 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 sory Committee shall not be considered employees of 

2 the Federal Government solely by reason of any 

3 service on the Committee, except such members shall 

4 be considered to be within the meaning of section 

5 202(a) of title 18, United States Code, for the pur6 poses of disclosure and management of conflicts of 

7 interest. 

8 (3) APPLICATION OF FACA.—The Federal Advi9 sory Committee Act (5 U.S.C. App.), other than sec10 tion 14, shall apply to the Health Benefits Advisory 

11 Committee. 

12 (d) PUBLICATION.—The Secretary shall provide for 

13 publication in the Federal Register and the posting on the 

14 Internet Website of the Department of Health and Human 

15 Services of all recommendations made by the Health Ben16 efits Advisory Committee under this section. 

17 SEC. 224. PROCESS FOR ADOPTION OF RECOMMENDA18 TIONS; ADOPTION OF BENEFIT STANDARDS. 

19 (a) PROCESS FOR ADOPTION OF RECOMMENDA20 TIONS.— 

21 (1) REVIEW OF RECOMMENDED STANDARDS.— 

22 Not later than 45 days after the date of receipt of 

23 benefit standards recommended under section 223 

24 (including such standards as modified under para25 graph (2)(B)), the Secretary shall review such 


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1 standards and shall determine whether to propose 

2 adoption of such standards as a package. 

3 (2) DETERMINATION TO ADOPT STANDARDS.— 

4 If the Secretary determines— 

5 (A) to propose adoption of benefit stand6 ards so recommended as a package, the Sec7 retary shall, by regulation under section 553 of 

8 title 5, United States Code, propose adoption of 

9 such standards; or 

10 (B) not to propose adoption of such stand11 ards as a package, the Secretary shall notify 

12 the Health Benefits Advisory Committee in 

13 writing of such determination and the reasons 

14 for not proposing the adoption of such rec15 ommendation and provide the Committee with a 

16 further opportunity to modify its previous rec17 ommendations and submit new recommenda18 tions to the Secretary on a timely basis. 

19 (3) CONTINGENCY.—If, because of the applica20 tion of paragraph (2)(B), the Secretary would other21 wise be unable to propose initial adoption of such 

22 recommended standards by the deadline specified in 

23 subsection (b)(1), the Secretary shall, by regulation 

24 under section 553 of title 5, United States Code, 


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1 propose adoption of initial benefit standards by such 

2 deadline. 

3 (4) PUBLICATION.—The Secretary shall provide 

4 for publication in the Federal Register of all deter5 minations made by the Secretary under this sub6 section. 

7 (b) ADOPTION OF STANDARDS.— 

8 (1) INITIAL STANDARDS.—Not later than 18 

9 months after the date of the enactment of this Act, 

10 the Secretary shall, through the rulemaking process 

11 consistent with subsection (a), adopt an initial set of 

12 benefit standards. 

13 (2) PERIODIC UPDATING STANDARDS.—Under 

14 subsection (a), the Secretary shall provide for the 

15 periodic updating of the benefit standards previously 

16 adopted under this section. 

17 (3) REQUIREMENT.—The Secretary may not 

18 adopt any benefit standards for an essential benefits 

19 package or for level of cost-sharing that are incon20 sistent with the requirements for such a package or 

21 level under sections 222 (including subsection (d)) 

22 and 223(b)(5). 


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1 Subtitle D—Additional Consumer 

2 Protections 

3 SEC. 231. REQUIRING FAIR MARKETING PRACTICES BY 

4 HEALTH INSURERS. 

5 The Commissioner shall establish uniform marketing 

6 standards that all QHBP offering entities shall meet with 

7 respect to qualified health benefits plans that are health 

8 insurance coverage. 

9 SEC. 232. REQUIRING FAIR GRIEVANCE AND APPEALS 

10 MECHANISMS. 

11 (a) IN GENERAL.—A QHBP offering entity shall pro12 vide for timely grievance and appeals mechanisms with re13 spect to qualified health benefits plans that the Commis14 sioner shall establish consistent with this section. The 

15 Commissioner shall establish time limits for each of such 

16 mechanisms and implement them in a manner that is pro17 tective to the needs of patients. 

18 (b) INTERNAL CLAIMS AND APPEALS PROCESS.— 

19 Under a qualified health benefits plan the QHBP offering 

20 entity shall provide an internal claims and appeals process 

21 that initially incorporates the claims and appeals proce22 dures (including urgent claims) set forth at section 

23 2560.503–1 of title 29, Code of Federal Regulations, as 

24 published on November 21, 2000 (65 Fed. Reg. 70246) 


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1 and shall update such process in accordance with any 

2 standards that the Commissioner may establish. 

3 (c) EXTERNAL REVIEW PROCESS.— 

4 (1) IN GENERAL.—The Commissioner shall es5 tablish an external review process (including proce6 dures for expedited reviews of urgent claims) that 

7 provides for an impartial, independent, and de novo 

8 review of denied claims under this division. 

9 (2) REQUIRING FAIR GRIEVANCE AND APPEALS

10 MECHANISMS.—A determination made, with respect 

11 to a qualified health benefits plan offered by a 

12 QHBP offering entity, under the external review 

13 process established under this subsection shall be 

14 binding on the plan and the entity. 

15 (d) TIME LIMITS.—The Commissioner shall establish 

16 time limits for each of these processes and implement 

17 them in a manner that is protective to the patient. 

18 (e) CONSTRUCTION.—Nothing in this section shall be 

19 construed as affecting the availability of judicial review 

20 under State law for adverse decisions under subsection (b) 

21 or (c), subject to section 251. 

22 SEC. 233. REQUIRING INFORMATION TRANSPARENCY AND 

23 PLAN DISCLOSURE. 

24 (a) ACCURATE AND TIMELY DISCLOSURE.— 


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1 (1) FOR EXCHANGE-PARTICIPATING HEALTH

2 BENEFITS PLANS.—A QHBP offering entity offering 

3 an Exchange-participating health benefits plan shall 

4 comply with standards established by the Commis5 sioner for the accurate and timely disclosure to the 

6 Commissioner and the public of plan documents, 

7 plan terms and conditions, claims payment policies 

8 and practices, periodic financial disclosure, data on 

9 enrollment, data on disenrollment, data on the num10 ber of claims denials, data on rating practices, infor11 mation on cost-sharing and payments with respect to 

12 any out-of-network coverage, and other information 

13 as determined appropriate by the Commissioner. 

14 (2) EMPLOYMENT-BASED HEALTH PLANS.—The 

15 Secretary of Labor shall update and harmonize the 

16 Secretary’s rules concerning the accurate and timely 

17 disclosure to participants by group health plans of 

18 plan disclosure, plan terms and conditions, and peri19 odic financial disclosure with the standards estab20 lished by the Commissioner under paragraph (1). 

21 (3) USE OF PLAIN LANGUAGE.— 

22 (A) IN GENERAL.—The disclosures under 

23 paragraphs (1) and (2) shall be provided in 

24 plain language. 


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1 (B) DEFINITION.—In this paragraph, the 

2 term ‘‘plain language’’ means language that the 

3 intended audience, including individuals with 

4 limited English proficiency, can readily under5 stand and use because that language is concise, 

6 well-organized, and follows other best practices 

7 of plain language writing. 

8 (C) GUIDANCE.—The Commissioner and 

9 the Secretary of Labor shall jointly develop and 

10 issue guidance on best practices of plain lan11 guage writing. 

12 (4) INFORMATION ON RIGHTS.—The informa13 tion disclosed under this subsection shall include in14 formation on enrollee and participant rights under 

15 this division. 

16 (5) COST-SHARING TRANSPARENCY.—A quali17 fied health benefits plan shall allow individuals to 

18 learn the amount of cost-sharing (including 

19 deductibles, copayments, and coinsurance) under the 

20 individual’s plan or coverage that the individual 

21 would be responsible for paying with respect to the 

22 furnishing of a specific item or service by a partici23 pating provider in a timely manner upon request. At 

24 a minimum, this information shall be made available 


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1 to such individual via an Internet Website and other 

2 means for individuals without access to the Internet. 

3 (b) CONTRACTING REIMBURSEMENT.—A qualified 

4 health benefits plan shall comply with standards estab5 lished by the Commissioner to ensure transparency to each 

6 health care provider relating to reimbursement arrange7 ments between such plan and such provider. 

8 (c) PHARMACY BENEFIT MANAGERS TRANSPARENCY

9 REQUIREMENTS.— 

10 (1) IN GENERAL.—If a QHBP offering entity 

11 contracts with a pharmacy benefit manager or other 

12 entity (in this subsection referred to as a ‘‘PBM’’) 

13 to manage prescription drug coverage or otherwise 

14 control prescription drug costs under a qualified 

15 health benefits plan, the PBM shall provide at least 

16 annually to the Commissioner and to the QHBP of17 fering entity offering such plan the following infor18 mation, in a form and manner to be determined by 

19 the Commissioner: 

20 (A) Information on the number and total 

21 cost of prescriptions under the contract that are 

22 filled via mail order and at retail pharmacies. 

23 (B) An estimate of aggregate average pay24 ments under the contract, per prescription 

25 (weighted by prescription volume), made to mail 


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1 order and retail pharmacies, and the average 

2 amount, per prescription, that the PBM was 

3 paid by the plan for prescriptions filled at mail 

4 order and retail pharmacists. 

5 (C) An estimate of the aggregate average 

6 payment per prescription (weighted by prescrip7 tion volume) under the contract received from 

8 pharmaceutical manufacturers, including all re9 bates, discounts, prices concessions, or adminis10 trative, and other payments from pharma11 ceutical manufacturers, and a description of the 

12 types of payments, and the amount of these 

13 payments that were shared with the plan, and 

14 a description of the percentage of prescriptions 

15 for which the PBM received such payments. 

16 (D) Information on the overall percentage 

17 of generic drugs dispensed under the contract 

18 at retail and mail order pharmacies, and the 

19 percentage of cases in which a generic drug is 

20 dispensed when available. 

21 (E) Information on the percentage and 

22 number of cases under the contract in which in23 dividuals were switched because of PBM poli24 cies or at the direct or indirect control of the 

25 PBM from a prescribed drug that had a lower 


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1 cost for the QHBP offering entity to a drug 

2 that had a higher cost for the QHBP offering 

3 entity, the rationale for these switches, and a 

4 description of the PBM policies governing such 

5 switches. 

6 (2) CONFIDENTIALITY OF INFORMATION.—In7 formation disclosed by a PBM to the Commissioner 

8 or a QHBP offering entity under this subsection is 

9 confidential and shall not be disclosed by the Com10 missioner or the QHBP offering entity in a form 

11 which discloses the identity of a specific PBM or 

12 prices charged by such PBM or a specific retailer, 

13 manufacturer, or wholesaler, except only by the 

14 Commissioner— 

15 (A) to permit State or Federal law enforce16 ment authorities to use the information pro17 vided for program compliance purposes and for 

18 the purpose of combating waste, fraud, and 

19 abuse; 

20 (B) to permit the Comptroller General, the 

21 Medicare Payment Advisory Commission, or the 

22 Secretary of Health and Human Services to re23 view the information provided; and 


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1 (C) to permit the Director of the Congres2 sional Budget Office to review the information 

3 provided. 

4 (3) ANNUAL PUBLIC REPORT.—On an annual 

5 basis, the Commissioner shall prepare a public re6 port providing industrywide aggregate or average in7 formation to be used in assessing the overall impact 

8 of PBMs on prescription drug prices and spending. 

9 Such report shall not disclose the identity of a spe10 cific PBM, or prices charged by such PBM, or a 

11 specific retailer, manufacturer, or wholesaler, or any 

12 other confidential or trade secret information. 

13 (4) PENALTIES.—The provisions of subsection 

14 (b)(3)(C) of section 1927 shall apply to a PBM that 

15 fails to provide information required under sub16 section (a) or that knowingly provides false informa17 tion in the same manner as such provisions apply to 

18 a manufacturer with an agreement under such sec19 tion that fails to provide information under sub20 section (b)(3)(A) of such section or knowingly pro21 vides false information under such section, respec22 tively. 


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1 SEC. 234. APPLICATION TO QUALIFIED HEALTH BENEFITS 

2 PLANS NOT OFFERED THROUGH THE 

3 HEALTH INSURANCE EXCHANGE. 

4 The requirements of the previous provisions of this 

5 subtitle shall apply to qualified health benefits plans that 

6 are not being offered through the Health Insurance Ex7 change only to the extent specified by the Commissioner. 

8 SEC. 235. TIMELY PAYMENT OF CLAIMS. 

9 A QHBP offering entity shall comply with the re10 quirements of section 1857(f) of the Social Security Act 

11 with respect to a qualified health benefits plan it offers 

12 in the same manner as a Medicare Advantage organization 

13 is required to comply with such requirements with respect 

14 to a Medicare Advantage plan it offers under part C of 

15 Medicare. 

16 SEC. 236. STANDARDIZED RULES FOR COORDINATION AND 

17 SUBROGATION OF BENEFITS. 

18 The Commissioner shall establish standards for the 

19 coordination and subrogation of benefits and reimburse20 ment of payments in cases of qualified health benefits 

21 plans involving individuals and multiple plan coverage. 

22 SEC. 237. APPLICATION OF ADMINISTRATIVE SIMPLIFICA23 TION. 

24 A QHBP offering entity is required to comply with 

25 administrative simplification provisions under part C of 


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1 title XI of the Social Security Act with respect to qualified 

2 health benefits plans it offers. 

3 SEC. 238. STATE PROHIBITIONS ON DISCRIMINATION 

4 AGAINST HEALTH CARE PROVIDERS. 

5 This Act (and the amendments made by this Act) 

6 shall not be construed as superseding laws, as they now 

7 or hereinafter exist, of any State or jurisdiction designed 

8 to prohibit a qualified health benefits plan from discrimi9 nating with respect to participation, reimbursement, cov10 ered services, indemnification, or related requirements 

11 under such plan against a health care provider that is act12 ing within the scope of that provider’s license or certifi13 cation under applicable State law. 

14 SEC. 239. PROTECTION OF PHYSICIAN PRESCRIBER INFOR15 MATION. 

16 (a) STUDY.—The Secretary of Health and Human 

17 Services shall conduct a study on the use of physician pre18 scriber information in sales and marketing practices of 

19 pharmaceutical manufacturers. 

20 (b) REPORT.—Based on the study conducted under 

21 subsection (a), the Secretary shall submit to Congress a 

22 report on actions needed to be taken by the Congress or 

23 the Secretary to protect providers from biased marketing 

24 and sales practices. 


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1 SEC. 240. DISSEMINATION OF ADVANCE CARE PLANNING 

2 INFORMATION. 

3 (a) IN GENERAL.—The QHBP offering entity — 

4 (1) shall provide for the dissemination of infor5 mation related to end-of-life planning to individuals 

6 seeking enrollment in Exchange-participating health 

7 benefits plans offered through the Exchange; 

8 (2) shall present such individuals with— 

9 (A) the option to establish advanced direc10 tives and physician’s orders for life sustaining 

11 treatment according to the laws of the State in 

12 which the individual resides; and 

13 (B) information related to other planning 

14 tools; and 

15 (3) shall not promote suicide, assisted suicide, 

16 euthanasia, or mercy killing. 

17 The information presented under paragraph (2) shall not 

18 presume the withdrawal of treatment and shall include 

19 end-of-life planning information that includes options to 

20 maintain all or most medical interventions. 

21 (b) CONSTRUCTION.— Nothing in this section shall 

22 be construed— 

23 (1) to require an individual to complete an ad24 vanced directive or a physician’s order for life sus25 taining treatment or other end-of-life planning docu26 ment; 


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1 (2) to require an individual to consent to re2 strictions on the amount, duration, or scope of med3 ical benefits otherwise covered under a qualified 

4 health benefits plan; or 

5 (3) to promote suicide, assisted suicide, eutha6 nasia, or mercy killing. 

7 (c) ADVANCED DIRECTIVE DEFINED.—In this sec8 tion, the term ‘‘advanced directive’’ includes a living will, 

9 a comfort care order, or a durable power of attorney for 

10 health care. 

11 (d) PROHIBITION ON THE PROMOTION OF ASSISTED

12 SUICIDE.— 

13 (1) IN GENERAL.—Subject to paragraph (3), 

14 information provided to meet the requirements of 

15 subsection (a)(2) shall not include advanced direc16 tives or other planning tools that list or describe as 

17 an option suicide, assisted suicide, euthanasia, or 

18 mercy killing, regardless of legality. 

19 (2) CONSTRUCTION.—Nothing in paragraph (1) 

20 shall be construed to apply to or affect any option 

21 to— 

22 (A) withhold or withdraw of medical treat23 ment or medical care; 

24 (B) withhold or withdraw of nutrition or 

25 hydration; and 


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1 (C) provide palliative or hospice care or 

2 use an item, good, benefit, or service furnished 

3 for the purpose of alleviating pain or discom4 fort, even if such use may increase the risk of 

5 death, so long as such item, good, benefit, or 

6 service is not also furnished for the purpose of 

7 causing, or the purpose of assisting in causing, 

8 death, for any reason. 

9 (3) NO PREEMPTION OF STATE LAW.—Nothing 

10 in this section shall be construed to preempt or oth11 erwise have any effect on State laws regarding ad12 vance care planning, palliative care, or end-of-life de13 cision-making. 

14 Subtitle E—Governance 

15 SEC. 241. HEALTH CHOICES ADMINISTRATION; HEALTH 

16 CHOICES COMMISSIONER. 

17 (a) IN GENERAL.—There is hereby established, as an 

18 independent agency in the executive branch of the Govern19 ment, a Health Choices Administration (in this division 

20 referred to as the ‘‘Administration’’). 

21 (b) COMMISSIONER.— 

22 (1) IN GENERAL.—The Administration shall be 

23 headed by a Health Choices Commissioner (in this 

24 division referred to as the ‘‘Commissioner’’) who 


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1 shall be appointed by the President, by and with the 

2 advice and consent of the Senate. 

3 (2) COMPENSATION; ETC.—The provisions of 

4 paragraphs (2), (5), and (7) of subsection (a) (relat5 ing to compensation, terms, general powers, rule6 making, and delegation) of section 702 of the Social 

7 Security Act (42 U.S.C. 902) shall apply to the 

8 Commissioner and the Administration in the same 

9 manner as such provisions apply to the Commis10 sioner of Social Security and the Social Security Ad11 ministration. 

12 (c) INSPECTOR GENERAL.—For provision estab13 lishing an Office of the Inspector General for the Health 

14 Choices Administration, see section 1647. 

15 SEC. 242. DUTIES AND AUTHORITY OF COMMISSIONER. 

16 (a) DUTIES.—The Commissioner is responsible for 

17 carrying out the following functions under this division: 

18 (1) QUALIFIED PLAN STANDARDS.—The estab19 lishment of qualified health benefits plan standards 

20 under this title, including the enforcement of such 

21 standards in coordination with State insurance regu22 lators and the Secretaries of Labor and the Treas23 ury. 


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1 (2) HEALTH INSURANCE EXCHANGE.—The es2 tablishment and operation of a Health Insurance 

3 Exchange under subtitle A of title III. 

4 (3) INDIVIDUAL AFFORDABILITY CREDITS.— 

5 The administration of individual affordability credits 

6 under subtitle C of title III, including determination 

7 of eligibility for such credits. 

8 (4) ADDITIONAL FUNCTIONS.—Such additional 

9 functions as may be specified in this division. 

10 (b) PROMOTING ACCOUNTABILITY.— 

11 (1) IN GENERAL.—The Commissioner shall un12 dertake activities in accordance with this subtitle to 

13 promote accountability of QHBP offering entities in 

14 meeting Federal health insurance requirements, re15 gardless of whether such accountability is with re16 spect to qualified health benefits plans offered 

17 through the Health Insurance Exchange or outside 

18 of such Exchange. 

19 (2) COMPLIANCE EXAMINATION AND AUDITS.— 

20 (A) IN GENERAL.—The Commissioner 

21 shall, in coordination with States, conduct au22 dits of qualified health benefits plan compliance 

23 with Federal requirements. Such audits may 

24 include random compliance audits and targeted 


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1 audits in response to complaints or other sus2 pected noncompliance. 

3 (B) RECOUPMENT OF COSTS IN CONNEC4 TION WITH EXAMINATION AND AUDITS.—The 

5 Commissioner is authorized to recoup from 

6 qualified health benefits plans reimbursement 

7 for the costs of such examinations and audit of 

8 such QHBP offering entities. 

9 (c) DATA COLLECTION.—The Commissioner shall 

10 collect data for purposes of carrying out the Commis11 sioner’s duties, including for purposes of promoting qual12 ity and value, protecting consumers, and addressing dis13 parities in health and health care and may share such data 

14 with the Secretary of Health and Human Services. 

15 (d) SANCTIONS AUTHORITY.— 

16 (1) IN GENERAL.—In the case that the Com17 missioner determines that a QHBP offering entity 

18 violates a requirement of this title, the Commis19 sioner may, in coordination with State insurance 

20 regulators and the Secretary of Labor, provide, in 

21 addition to any other remedies authorized by law, 

22 for any of the remedies described in paragraph (2). 

23 (2) REMEDIES.—The remedies described in this 

24 paragraph, with respect to a qualified health benefits 

25 plan offered by a QHBP offering entity, are— 


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1 (A) civil money penalties of not more than 

2 the amount that would be applicable under 

3 similar circumstances for similar violations 

4 under section 1857(g) of the Social Security 

5 Act; 

6 (B) suspension of enrollment of individuals 

7 under such plan after the date the Commis8 sioner notifies the entity of a determination 

9 under paragraph (1) and until the Commis10 sioner is satisfied that the basis for such deter11 mination has been corrected and is not likely to 

12 recur; 

13 (C) in the case of an Exchange-partici14 pating health benefits plan, suspension of pay15 ment to the entity under the Health Insurance 

16 Exchange for individuals enrolled in such plan 

17 after the date the Commissioner notifies the en18 tity of a determination under paragraph (1) 

19 and until the Secretary is satisfied that the 

20 basis for such determination has been corrected 

21 and is not likely to recur; or 

22 (D) working with State insurance regu23 lators to terminate plans for repeated failure by 

24 the offering entity to meet the requirements of 

25 this title. 


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1 (e) STANDARD DEFINITIONS OF INSURANCE AND

2 MEDICAL TERMS.—The Commissioner shall provide for 

3 the development of standards for the definitions of terms 

4 used in health insurance coverage, including insurance-re5 lated terms. 

6 (f) EFFICIENCY IN ADMINISTRATION.—The Commis7 sioner shall issue regulations for the effective and efficient 

8 administration of the Health Insurance Exchange and af9 fordability credits under subtitle C, including, with respect 

10 to the determination of eligibility for affordability credits, 

11 the use of personnel who are employed in accordance with 

12 the requirements of title 5, United States Code, to carry 

13 out the duties of the Commissioner or, in the case of sec14 tions 308 and 341(b)(2), the use of State personnel who 

15 are employed in accordance with standards prescribed by 

16 the Office of Personnel Management pursuant to section 

17 208 of the Intergovernmental Personnel Act of 1970 (42 

18 U.S.C. 4728). 

19 SEC. 243. CONSULTATION AND COORDINATION. 

20 (a) CONSULTATION.—In carrying out the Commis21 sioner’s duties under this division, the Commissioner, as 

22 appropriate, shall consult at least with the following: 

23 (1) State attorneys general and State insurance 

24 regulators, including concerning the standards for 

25 health insurance coverage that is a qualified health 


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1 benefits plan under this title and enforcement of 

2 such standards. 

3 (2) The National Association of Insurance 

4 Commissioners, including for purposes of using 

5 model guidelines established by such association for 

6 purposes of subtitles B and D. 

7 (3) Appropriate State agencies, specifically con8 cerning the administration of individual affordability 

9 credits under subtitle C of title III and the offering 

10 of Exchange-participating health benefits plans, to 

11 Medicaid eligible individuals under subtitle A of such 

12 title. 

13 (4) The Federal Trade Commission, specifically 

14 concerning the development and issuance of guid15 ance, rules, or standards regarding fair marketing 

16 practices under section 231 or otherwise, or any con17 sumer disclosure requirements under section 233 or 

18 otherwise. 

19 (5) Other appropriate Federal agencies. 

20 (6) Indian tribes and tribal organizations. 

21 (b) COORDINATION.— 

22 (1) IN GENERAL.—In carrying out the func23 tions of the Commissioner, including with respect to 

24 the enforcement of the provisions of this division, 

25 the Commissioner shall work in coordination with 


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1 existing Federal and State entities to the maximum 

2 extent feasible consistent with this division and in a 

3 manner that prevents conflicts of interest in duties 

4 and ensures effective enforcement. 

5 (2) UNIFORM STANDARDS.—The Commissioner, 

6 in coordination with such entities, shall seek to 

7 achieve uniform standards that adequately protect 

8 consumers in a manner that does not unreasonably 

9 affect employers and insurers. 

10 SEC. 244. HEALTH INSURANCE OMBUDSMAN. 

11 (a) IN GENERAL.—The Commissioner shall appoint 

12 within the Health Choices Administration a Qualified 

13 Health Benefits Plan Ombudsman who shall have exper14 tise and experience in the fields of health care and edu15 cation of (and assistance to) individuals. 

16 (b) DUTIES.—The Qualified Health Benefits Plan 

17 Ombudsman shall, in a linguistically appropriate man18 ner— 

19 (1) receive complaints, grievances, and requests 

20 for information submitted by individuals through 

21 means such as the mail, by telephone, electronically, 

22 and in person; 

23 (2) provide assistance with respect to com24 plaints, grievances, and requests referred to in para25 graph (1), including— 


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1 (A) helping individuals determine the rel2 evant information needed to seek an appeal of 

3 a decision or determination; 

4 (B) assistance to such individuals in choos5 ing a qualified health benefits plan in which to 

6 enroll; 

7 (C) assistance to such individuals with any 

8 problems arising from disenrollment from such 

9 a plan; and 

10 (D) assistance to such individuals in pre11 senting information under subtitle C (relating 

12 to affordability credits); and 

13 (3) submit annual reports to Congress and the 

14 Commissioner that describe the activities of the Om15 budsman and that include such recommendations for 

16 improvement in the administration of this division as 

17 the Ombudsman determines appropriate. The Om18 budsman shall not serve as an advocate for any in19 creases in payments or new coverage of services, but 

20 may identify issues and problems in payment or cov21 erage policies. 


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1 Subtitle F—Relation to Other 

2 Requirements; Miscellaneous 

3 SEC. 251. RELATION TO OTHER REQUIREMENTS. 

4 (a) COVERAGE NOT OFFERED THROUGH EX5 CHANGE.— 

6 (1) IN GENERAL.—In the case of health insur7 ance coverage not offered through the Health Insur8 ance Exchange (whether or not offered in connection 

9 with an employment-based health plan), and in the 

10 case of employment-based health plans, the require11 ments of this title do not supercede any require12 ments applicable under titles XXII and XXVII of 

13 the Public Health Service Act, parts 6 and 7 of sub14 title B of title I of the Employee Retirement Income 

15 Security Act of 1974, or State law, except insofar as 

16 such requirements prevent the application of a re17 quirement of this division, as determined by the 

18 Commissioner. 

19 (2) CONSTRUCTION.—Nothing in paragraphs 

20 (1) or (2) shall be construed as affecting the appli21 cation of section 514 of the Employee Retirement 

22 Income Security Act of 1974. 

23 (b) COVERAGE OFFERED THROUGH EXCHANGE.— 


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1 (1) IN GENERAL.—In the case of health insur2 ance coverage offered through the Health Insurance 

3 Exchange— 

4 (A) the requirements of this title do not 

5 supercede any requirements (including require6 ments relating to genetic information non7 discrimination and mental health parity) appli8 cable under title XXVII of the Public Health 

9 Service Act or under State law, except insofar 

10 as such requirements prevent the application of 

11 a requirement of this division, as determined by 

12 the Commissioner; and 

13 (B) individual rights and remedies under 

14 State laws shall apply. 

15 (2) CONSTRUCTION.—In the case of coverage 

16 described in paragraph (1), nothing in such para17 graph shall be construed as preventing the applica18 tion of rights and remedies under State laws to 

19 health insurance issuers generally with respect to 

20 any requirement referred to in paragraph (1)(A). 

21 The previous sentence shall not be construed as pro22 viding for the applicability of rights or remedies 

23 under State laws with respect to requirements appli24 cable to employers or other plan sponsors in connec25 tion with arrangements which are treated as group 


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1 health plans under section 802(a)(1) of the Em2 ployee Retirement Income Security Act of 1974. 

3 SEC. 252. PROHIBITING DISCRIMINATION IN HEALTH CARE. 

4 (a) IN GENERAL.—Except as otherwise explicitly per5 mitted by this Act and by subsequent regulations con6 sistent with this Act, all health care and related services 

7 (including insurance coverage and public health activities) 

8 covered by this Act shall be provided without regard to 

9 personal characteristics extraneous to the provision of 

10 high quality health care or related services. 

11 (b) IMPLEMENTATION.—To implement the require12 ment set forth in subsection (a), the Secretary of Health 

13 and Human Services shall, not later than 18 months after 

14 the date of the enactment of this Act, promulgate such 

15 regulations as are necessary or appropriate to insure that 

16 all health care and related services (including insurance 

17 coverage and public health activities) covered by this Act 

18 are provided (whether directly or through contractual, li19 censing, or other arrangements) without regard to per20 sonal characteristics extraneous to the provision of high 

21 quality health care or related services. 

22 SEC. 253. WHISTLEBLOWER PROTECTION. 

23 (a) RETALIATION PROHIBITED.—No employer may 

24 discharge any employee or otherwise discriminate against 

25 any employee with respect to his compensation, terms, 


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1 conditions, or other privileges of employment because the 

2 employee (or any person acting pursuant to a request of 

3 the employee)— 

4 (1) provided, caused to be provided, or is about 

5 to provide or cause to be provided to the employer, 

6 the Federal Government, or the attorney general of 

7 a State information relating to any violation of, or 

8 any act or omission the employee reasonably believes 

9 to be a violation of any provision of this Act or any 

10 order, rule, or regulation promulgated under this 

11 Act; 

12 (2) testified or is about to testify in a pro13 ceeding concerning such violation; 

14 (3) assisted or participated or is about to assist 

15 or participate in such a proceeding; or 

16 (4) objected to, or refused to participate in, any 

17 activity, policy, practice, or assigned task that the 

18 employee (or other such person) reasonably believed 

19 to be in violation of any provision of this Act or any 

20 order, rule, or regulation promulgated under this 

21 Act. 

22 (b) ENFORCEMENT ACTION.—An employee covered 

23 by this section who alleges discrimination by an employer 

24 in violation of subsection (a) may bring an action governed 

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1 edies set forth in section 40(b) of the Consumer Product 

2 Safety Act (15 U.S.C. 2087(b)). 

3 (c) EMPLOYER DEFINED.—As used in this section, 

4 the term ‘‘employer’’ means any person (including one or 

5 more individuals, partnerships, associations, corporations, 

6 trusts, professional membership organization including a 

7 certification, disciplinary, or other professional body, unin8 corporated organizations, nongovernmental organizations, 

9 or trustees) engaged in profit or nonprofit business or in10 dustry whose activities are governed by this Act, and any 

11 agent, contractor, subcontractor, grantee, or consultant of 

12 such person. 

13 (d) RULE OF CONSTRUCTION.—The rule of construc14 tion set forth in section 20109(h) of title 49, United 

15 States Code, shall also apply to this section. 

16 SEC. 254. CONSTRUCTION REGARDING COLLECTIVE BAR17 GAINING. 

18 Nothing in this division shall be construed to alter 

19 or supersede any statutory or other obligation to engage 

20 in collective bargaining over the terms or conditions of em21 ployment related to health care. Any plan amendment 

22 made pursuant to a collective bargaining agreement relat23 ing to the plan which amends the plan solely to conform 

24 to any requirement added by this division shall not be 


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1 treated as a termination of such collective bargaining 

2 agreement. 

3 SEC. 255. SEVERABILITY. 

4 If any provision of this Act, or any application of such 

5 provision to any person or circumstance, is held to be un6 constitutional, the remainder of the provisions of this Act 

7 and the application of the provision to any other person 

8 or circumstance shall not be affected. 

9 SEC. 256. TREATMENT OF HAWAII PREPAID HEALTH CARE 

10 ACT. 

11 (a) IN GENERAL.—Subject to this section— 

12 (1) nothing in this division (or an amendment 

13 made by this division) shall be construed to modify 

14 or limit the application of the exemption for the Ha15 waii Prepaid Health Care Act (Haw. Rev. Stat. §§ 

16 393–1 et seq.) as provided for under section 

17 514(b)(5) of the Employee Retirement Income Secu18 rity Act of 1974 (29 U.S.C. 1144(b)(5)), and such 

19 exemption shall also apply with respect to the provi20 sions of this division; and 

21 (2) for purposes of this division (and the 

22 amendments made by this division), coverage pro23 vided pursuant to the Hawaii Prepaid Health Care 

24 Act shall be treated as a qualified health benefits 

25 plan providing acceptable coverage so long as the 


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1 Secretary of Labor determines that such coverage 

2 for employees (taking into account the benefits and 

3 the cost to employees for such benefits) is substan4 tially equivalent to or greater than the coverage pro5 vided for employees pursuant to the essential bene6 fits package. 

7 (b) COORDINATION WITH STATE LAW OF HAWAII.— 

8 The Commissioner shall, based on ongoing consultation 

9 with the appropriate officials of the State of Hawaii, make 

10 adjustments to rules and regulations of the Commissioner 

11 under this division as may be necessary, as determined 

12 by the Commissioner, to most effectively coordinate the 

13 provisions of this division with the provisions of the Ha14 waii Prepaid Health Care Act, taking into account any 

15 changes made from time to time to the Hawaii Prepaid 

16 Health Care Act and related laws of such State. 

17 SEC. 257. ACTIONS BY STATE ATTORNEYS GENERAL. 

18 Any State attorney general may bring a civil action 

19 in the name of such State as parens patriae on behalf of 

20 natural persons residing in such State, in any district 

21 court of the United States or State court having jurisdic22 tion of the defendant to secure monetary or equitable relief 

23 for violation of any provisions of this title or regulations 

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1 strued as affecting the application of section 514 of the 

2 Employee Retirement Income Security Act of 1974. 

3 SEC. 258. APPLICATION OF STATE AND FEDERAL LAWS RE4 GARDING ABORTION. 

5 (a) NO PREEMPTION OF STATE LAWS REGARDING

6 ABORTION.—Nothing in this Act shall be construed to 

7 preempt or otherwise have any effect on State laws regard8 ing the prohibition of (or requirement of) coverage, fund9 ing, or procedural requirements on abortions, including 

10 parental notification or consent for the performance of an 

11 abortion on a minor. 

12 (b) NO EFFECT ON FEDERAL LAWS REGARDING

13 ABORTION.— 

14 (1) IN GENERAL.—Nothing in this Act shall be 

15 construed to have any effect on Federal laws regard16 ing— 

17 (A) conscience protection; 

18 (B) willingness or refusal to provide abor19 tion; and 

20 (C) discrimination on the basis of the will21 ingness or refusal to provide, pay for, cover, or 

22 refer for abortion or to provide or participate in 

23 training to provide abortion. 

24 (c) NO EFFECT ON FEDERAL CIVIL RIGHTS LAW.— 

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1 tions of employees and employers under title VII of the 

2 Civil Rights Act of 1964. 

3 SEC. 259. NONDISCRIMINATION ON ABORTION AND RE4 SPECT FOR RIGHTS OF CONSCIENCE. 

5 (a) NONDISCRIMINATION.—A Federal agency or pro6 gram, and any State or local government that receives 

7 Federal financial assistance under this Act (or an amend8 ment made by this Act), may not— 

9 (1) subject any individual or institutional health 

10 care entity to discrimination; or 

11 (2) require any health plan created or regulated 

12 under this Act (or an amendment made by this Act) 

13 to subject any individual or institutional health care 

14 entity to discrimination, 

15 on the basis that the health care entity does not provide, 

16 pay for, provide coverage of, or refer for abortions. 

17 (b) DEFINITION.—In this section, the term ‘‘health 

18 care entity’’ includes an individual physician or other 

19 health care professional, a hospital, a provider-sponsored 

20 organization, a health maintenance organization, a health 

21 insurance plan, or any other kind of health care facility, 

22 organization, or plan. 

23 (c) ADMINISTRATION.—The Office for Civil Rights of 

24 the Department of Health and Human Services is des25 ignated to receive complaints of discrimination based on 


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1 this section, and coordinate the investigation of such com2 plaints. 

3 SEC. 260. AUTHORITY OF FEDERAL TRADE COMMISSION. 

4 Section 6 of the Federal Trade Commission Act (15 

5 U.S.C. 46) is amended by striking ‘‘and prepare reports’’ 

6 and all that follows and inserting the following: ‘‘and pre7 pare reports, and to share information under clauses (f) 

8 and (k), relating to the business of insurance. Notwith9 standing section 4, such authority shall include the au10 thority to conduct studies and prepare reports, and to 

11 share information under clauses (f) and (k), relating to 

12 the business of insurance, without regard to whether the 

13 entity or entities that is the subject of such studies, re14 ports, or information is a for-profit or not-for-profit enti15 ty.’’. 

16 SEC. 261. CONSTRUCTION REGARDING STANDARD OF 

17 CARE. 

18 (a) IN GENERAL.—The development, recognition, or 

19 implementation of any guideline or other standard under 

20 a provision described in subsection (b) shall not be con21 strued to establish the standard of care or duty of care 

22 owed by health care providers to their patients in any med23 ical malpractice action or claim (as defined in section 

24 431(7) of the Health Care Quality Improvement Act of 

25 1986 (42 U.S.C. 11151(7)). 


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1 (b) PROVISIONS DESCRIBED.—The provisions de2 scribed in this subsection are the following: 

3 (1) Section 324 (relating to modernized pay4 ment initiatives and delivery system reform under 

5 the public health option). 

6 (2) The amendments made by section 1151 (re7 lating to reducing potentially preventable hospital re8 admissions). 

9 (3) The amendments made by section 1751 (re10 lating to health care acquired conditions). 

11 (4) Section 3131 of the Public Health Service 

12 Act (relating to the Task Force on Clinical Preven13 tive Services), added by section 2301. 

14 (5) Part D of title IX of the Public Health 

15 Service Act (relating to implementation of best prac16 tices in the delivery of health care), added by section 

17 2401. 

18 SEC. 262. RESTORING APPLICATION OF ANTITRUST LAWS 

19 TO HEALTH SECTOR INSURERS. 

20 (a) AMENDMENT TO MCCARRAN-FERGUSON ACT.— 

21 Section 3 of the Act of March 9, 1945 (15 U.S.C. 1013), 

22 commonly known as the McCarran-Ferguson Act, is 

23 amended by adding at the end the following: 

24 ‘‘(c)(1) Except as provided in paragraph (2), nothing 

25 contained in this Act shall modify, impair, or supersede 


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1 the operation of any of the antitrust laws with respect to 

2 price fixing, market allocation, or monopolization (or at3 tempting to monopolize) by— 

4 ‘‘(A) a person engaged in the business of health 

5 insurance, in connection with providing health insur6 ance; or 

7 ‘‘(B) a person engaged in the business of med8 ical malpractice insurance, in connection with pro9 viding medical malpractice insurance. 

10 ‘‘(2) Paragraph (1) shall not apply to— 

11 ‘‘(A) collecting, compiling, classifying, or dis12 seminating historical loss data; 

13 ‘‘(B) determining a loss development factor ap14 plicable to historical loss data; 

15 ‘‘(C) performing actuarial services if doing so 

16 does not involve a restraint of trade; or 

17 ‘‘(D) information gathering and rate setting ac18 tivities of a State insurance commission or other 

19 State regulatory entity with authority to set insur20 ance rates. 

21 ‘‘(3) For purposes of this subsection— 

22 ‘‘(A) the term ‘antitrust laws’ has the meaning 

23 given it in subsection (a) of the first section of the 

24 Clayton Act, except that such term includes section 

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1 tent that such section 5 applies to unfair methods of 

2 competition; 

3 ‘‘(B) the term ‘historical loss data’ means infor4 mation respecting claims paid, or reserves held for 

5 claims reported, by any person engaged in the busi6 ness of insurance; and 

7 ‘‘(C) the term ‘loss development factor’ means 

8 an adjustment to be made to the aggregate of losses 

9 incurred during a prior period of time that have 

10 been paid, or for which claims have been received 

11 and reserves are being held, in order to estimate the 

12 aggregate of the losses incurred during such period 

13 that will ultimately be paid.’’. 

14 (b) RELATED PROVISION.—For purposes of section 

15 5 of the Federal Trade Commission Act (15 U.S.C. 45) 

16 to the extent such section applies to unfair methods of 

17 competition, section 3(c) of the McCarran-Ferguson Act 

18 shall apply with respect to the business of health insur19 ance, and with respect to the business of medical mal20 practice insurance, without regard to whether such busi21 ness is carried on for profit, notwithstanding the definition 

22 of ‘‘Corporation’’ contained in section 4 of the Federal 

23 Trade Commission Act. 

24 (c) RELATED PRESERVATION OF ANTITRUST

25 LAWS.—Except as provided in subsections (a) and (b), 


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1 nothing in this Act, or in the amendments made by this 

2 Act, shall be construed to modify, impair, or supersede 

3 the operation of any of the antitrust laws. For purposes 

4 of the preceding sentence, the term ‘‘antitrust laws’’ has 

5 the meaning given it in subsection (a) of the first section 

6 of the Clayton Act, except that it includes section 5 of 

7 the Federal Trade Commission Act to the extent that such 

8 section 5 applies to unfair methods of competition. 

9 SEC. 263. STUDY AND REPORT ON METHODS TO INCREASE 

10 EHR USE BY SMALL HEALTH CARE PRO11 VIDERS. 

12 (a) STUDY.—The Secretary of Health and Human 

13 Services shall conduct a study of potential methods to in14 crease the use of qualified electronic health records (as 

15 defined in section 3000(13) of the Public Health Service 

16 Act) by small health care providers. Such study shall con17 sider at least the following methods: 

18 (1) Providing for higher rates of reimbursement 

19 or other incentives for such health care providers to 

20 use electronic health records (taking into consider21 ation initiatives by private health insurance compa22 nies and incentives provided under Medicare under 

23 title XVIII of the Social Security Act, Medicaid 

24 under title XIX of such Act, and other programs). 


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1 (2) Promoting low-cost electronic health record 

2 software packages that are available for use by such 

3 health care providers, including software packages 

4 that are available to health care providers through 

5 the Veterans Administration and other sources. 

6 (3) Training and education of such health care 

7 providers on the use of electronic health records. 

8 (4) Providing assistance to such health care 

9 providers on the implementation of electronic health 

10 records. 

11 (b) REPORT.—Not later than December 31, 2013, 

12 the Secretary of Health and Human Services shall submit 

13 to Congress a report containing the results of the study 

14 conducted under subsection (a), including recommenda15 tions for legislation or administrative action to increase 

16 the use of electronic health records by small health care 

17 providers that include the use of both public and private 

18 funding sources. 


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1 TITLE III—HEALTH INSURANCE 

2 EXCHANGE AND RELATED 

3 PROVISIONS 

4 Subtitle A—Health Insurance 

5 Exchange 

6 SEC. 301. ESTABLISHMENT OF HEALTH INSURANCE EX7 CHANGE; OUTLINE OF DUTIES; DEFINITIONS. 

8 (a) ESTABLISHMENT.—There is established within 

9 the Health Choices Administration and under the direc10 tion of the Commissioner a Health Insurance Exchange 

11 in order to facilitate access of individuals and employers, 

12 through a transparent process, to a variety of choices of 

13 affordable, quality health insurance coverage, including a 

14 public health insurance option. 

15 (b) OUTLINE OF DUTIES OF COMMISSIONER.—In ac16 cordance with this subtitle and in coordination with appro17 priate Federal and State officials as provided under sec18 tion 243(b), the Commissioner shall— 

19 (1) under section 304 establish standards for, 

20 accept bids from, and negotiate and enter into con21 tracts with, QHBP offering entities for the offering 

22 of health benefits plans through the Health Insur23 ance Exchange, with different levels of benefits re24 quired under section 303, and including with respect 

25 to oversight and enforcement; 


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1 (2) under section 305 facilitate outreach and 

2 enrollment in such plans of Exchange-eligible indi3 viduals and employers described in section 302; and 

4 (3) conduct such activities related to the Health 

5 Insurance Exchange as required, including establish6 ment of a risk pooling mechanism under section 306 

7 and consumer protections under subtitle D of title 

8 II. 

9 SEC. 302. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOY10 ERS. 

11 (a) ACCESS TO COVERAGE.—In accordance with this 

12 section, all individuals are eligible to obtain coverage 

13 through enrollment in an Exchange-participating health 

14 benefits plan offered through the Health Insurance Ex15 change unless such individuals are enrolled in another 

16 qualified health benefits plan or other acceptable coverage. 

17 (b) DEFINITIONS.—In this division: 

18 (1) EXCHANGE-ELIGIBLE INDIVIDUAL.—The 

19 term ‘‘Exchange-eligible individual’’ means an indi20 vidual who is eligible under this section to be en21 rolled through the Health Insurance Exchange in an 

22 Exchange-participating health benefits plan and, 

23 with respect to family coverage, includes dependents 

24 of such individual. 


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1 (2) EXCHANGE-ELIGIBLE EMPLOYER.—The 

2 term ‘‘Exchange-eligible employer’’ means an em3 ployer that is eligible under this section to enroll 

4 through the Health Insurance Exchange employees 

5 of the employer (and their dependents) in Exchange6 eligible health benefits plans. 

7 (3) EMPLOYMENT-RELATED DEFINITIONS.— 

8 The terms ‘‘employer’’, ‘‘employee’’, ‘‘full-time em9 ployee’’, and ‘‘part-time employee’’ have the mean10 ings given such terms by the Commissioner for pur11 poses of this division. 

12 (c) TRANSITION.—Individuals and employers shall 

13 only be eligible to enroll or participate in the Health Insur14 ance Exchange in accordance with the following transition 

15 schedule: 

16 (1) FIRST YEAR.—In Y1 (as defined in section 

17 100(c))— 

18 (A) individuals described in subsection 

19 (d)(1), including individuals described in sub20 section (d)(3); and 

21 (B) smallest employers described in sub22 section (e)(1). 

23 (2) SECOND YEAR.—In Y2— 

24 (A) individuals and employers described in 

25 paragraph (1); and 


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1 (B) smaller employers described in sub2 section (e)(2). 

3 (3) THIRD AND SUBSEQUENT YEARS.—In Y3— 

4 (A) individuals and employers described in 

5 paragraph (2); 

6 (B) small employers described in sub7 section (e)(3); and 

8 (C) larger employers as permitted by the 

9 Commissioner under subsection (e)(4). 

10 (d) INDIVIDUALS.— 

11 (1) INDIVIDUAL DESCRIBED.—Subject to the 

12 succeeding provisions of this subsection, an indi13 vidual described in this paragraph is an individual 

14 who— 

15 (A) is not enrolled in coverage described in 

16 subparagraph (C) or (D) of paragraph (2); and 

17 (B) is not enrolled in coverage as a full18 time employee (or as a dependent of such an 

19 employee) under a group health plan if the cov20 erage and an employer contribution under the 

21 plan meet the requirements of section 412. 

22 For purposes of subparagraph (B), in the case of an 

23 individual who is self-employed, who has at least 1 

24 employee, and who meets the requirements of section 


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1 412, such individual shall be deemed a full-time em2 ployee described in such subparagraph. 

3 (2) ACCEPTABLE COVERAGE.—For purposes of 

4 this division, the term ‘‘acceptable coverage’’ means 

5 any of the following: 

6 (A) QUALIFIED HEALTH BENEFITS PLAN

7 COVERAGE.—Coverage under a qualified health 

8 benefits plan. 

9 (B) GRANDFATHERED HEALTH INSURANCE

10 COVERAGE; COVERAGE UNDER CURRENT GROUP

11 HEALTH PLAN.—Coverage under a grand12 fathered health insurance coverage (as defined 

13 in subsection (a) of section 202) or under a 

14 current group health plan (described in sub15 section (b) of such section). 

16 (C) MEDICARE.—Coverage under part A of 

17 title XVIII of the Social Security Act. 

18 (D) MEDICAID.—Coverage for medical as19 sistance under title XIX of the Social Security 

20 Act, excluding such coverage that is only avail21 able because of the application of subsection 

22 (u), (z), or (aa) of section 1902 of such Act. 

23 (E) MEMBERS OF THE ARMED FORCES

24 AND DEPENDENTS (INCLUDING TRICARE).— 

25 Coverage under chapter 55 of title 10, United 


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1 States Code, including similar coverage fur2 nished under section 1781 of title 38 of such 

3 Code. 

4 (F) VA.—Coverage under the veteran’s 

5 health care program under chapter 17 of title 

6 38, United States Code. 

7 (G) OTHER COVERAGE.—Such other health 

8 benefits coverage, such as a State health bene9 fits risk pool, as the Commissioner, in coordina10 tion with the Secretary of the Treasury, recog11 nizes for purposes of this paragraph. 

12 The Commissioner shall make determinations under 

13 this paragraph in coordination with the Secretary of 

14 the Treasury. 

15 (3) CONTINUING ELIGIBILITY PERMITTED.— 

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

17 subparagraph (B), once an individual qualifies 

18 as an Exchange-eligible individual under this 

19 subsection (including as an employee or depend20 ent of an employee of an Exchange-eligible em21 ployer) and enrolls under an Exchange-partici22 pating health benefits plan through the Health 

23 Insurance Exchange, the individual shall con24 tinue to be treated as an Exchange-eligible indi25 vidual until the individual is no longer enrolled 


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1 with an Exchange-participating health benefits 

2 plan. 

3 (B) EXCEPTIONS.— 

4 (i) IN GENERAL.—Subparagraph (A) 

5 shall not apply to an individual once the 

6 individual becomes eligible for coverage— 

7 (I) under part A of the Medicare 

8 program; 

9 (II) under the Medicaid program 

10 as a Medicaid-eligible individual, ex11 cept as permitted under clause (ii); or 

12 (III) in such other circumstances 

13 as the Commissioner may provide. 

14 (ii) TRANSITION PERIOD.—In the case 

15 described in clause (i)(II), the Commis16 sioner shall permit the individual to con17 tinue treatment under subparagraph (A) 

18 until such limited time as the Commis19 sioner determines it is administratively fea20 sible, consistent with minimizing disruption 

21 in the individual’s access to health care. 

22 (4) TRANSITION FOR CHIP ELIGIBLES.—An in23 dividual who is eligible for child health assistance 

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1 riod during Y1 shall not be an Exchange-eligible in2 dividual during such period. 

3 (e) EMPLOYERS.— 

4 (1) SMALLEST EMPLOYER.—Subject to para5 graph (5), smallest employers described in this para6 graph are employers with 25 or fewer employees. 

7 (2) SMALLER EMPLOYERS.—Subject to para8 graph (5), smaller employers described in this para9 graph are employers that are not smallest employers 

10 described in paragraph (1) and have 50 or fewer em11 ployees. 

12 (3) SMALL EMPLOYERS.—Subject to paragraph 

13 (5), small employers described in this paragraph are 

14 employers that are not described in paragraph (1) or 

15 (2) and have 100 or fewer employees. 

16 (4) LARGER EMPLOYERS.— 

17 (A) IN GENERAL.—Beginning with Y3, the 

18 Commissioner may permit employers not de19 scribed in paragraph (1), (2), or (3) to be Ex20 change-eligible employers. 

21 (B) PHASE-IN.—In applying subparagraph 

22 (A), the Commissioner may phase-in the appli23 cation of such subparagraph based on the num24 ber of full-time employees of an employer and 


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1 such other considerations as the Commissioner 

2 deems appropriate. 

3 (5) CONTINUING ELIGIBILITY.—Once an em4 ployer is permitted to be an Exchange-eligible em5 ployer under this subsection and enrolls employees 

6 through the Health Insurance Exchange, the em7 ployer shall continue to be treated as an Exchange8 eligible employer for each subsequent plan year re9 gardless of the number of employees involved unless 

10 and until the employer meets the requirement of sec11 tion 411(a) through paragraph (1) of such section 

12 by offering a group health plan and not through of13 fering an Exchange-participating health benefits 

14 plan. 

15 (6) EMPLOYER PARTICIPATION AND CONTRIBU16 TIONS.— 

17 (A) SATISFACTION OF EMPLOYER RESPON18 SIBILITY.—For any year in which an employer 

19 is an Exchange-eligible employer, such employer 

20 may meet the requirements of section 412 with 

21 respect to employees of such employer by offer22 ing such employees the option of enrolling with 

23 Exchange-participating health benefits plans 

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1 sistent with the provisions of subtitle B of title 

2 IV. 

3 (B) EMPLOYEE CHOICE.—Any employee 

4 offered Exchange-participating health benefits 

5 plans by the employer of such employee under 

6 subparagraph (A) may choose coverage under 

7 any such plan. That choice includes, with re8 spect to family coverage, coverage of the de9 pendents of such employee. 

10 (7) AFFILIATED GROUPS.—Any employer which 

11 is part of a group of employers who are treated as 

12 a single employer under subsection (b), (c), (m), or 

13 (o) of section 414 of the Internal Revenue Code of 

14 1986 shall be treated, for purposes of this subtitle, 

15 as a single employer. 

16 (8) TREATMENT OF MULTI-EMPLOYER

17 PLANS.—The plan sponsor of a group health plan 

18 (as defined in section 773(a) of the Employee Re19 tirement Income Security Act of 1974) that is a 

20 multi-employer plan (as defined in section 3(37) of 

21 such Act) may obtain health insurance coverage with 

22 respect to participants in the plan through the Ex23 change to the same extent that an employer not de24 scribed in paragraph (1) or (2) is permitted by the 

25 Commissioner to obtain health insurance coverage 


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1 through the Exchange as an Exchange-eligible em2 ployer. 

3 (9) OTHER COUNTING RULES.—The Commis4 sioner shall establish rules relating to how employees 

5 are counted for purposes of carrying out this sub6 section. 

7 (f) SPECIAL SITUATION AUTHORITY.—The Commis8 sioner shall have the authority to establish such rules as 

9 may be necessary to deal with special situations with re10 gard to uninsured individuals and employers participating 

11 as Exchange-eligible individuals and employers, such as 

12 transition periods for individuals and employers who gain, 

13 or lose, Exchange-eligible participation status, and to es14 tablish grace periods for premium payment. 

15 (g) SURVEYS OF INDIVIDUALS AND EMPLOYERS.— 

16 The Commissioner shall provide for periodic surveys of 

17 Exchange-eligible individuals and employers concerning 

18 satisfaction of such individuals and employers with the 

19 Health Insurance Exchange and Exchange-participating 

20 health benefits plans. 

21 (h) EXCHANGE ACCESS STUDY.— 

22 (1) IN GENERAL.—The Commissioner shall con23 duct a study of access to the Health Insurance Ex24 change for individuals and for employers, including 

25 individuals and employers who are not eligible and 


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1 enrolled in Exchange-participating health benefits 

2 plans. The goal of the study is to determine if there 

3 are significant groups and types of individuals and 

4 employers who are not Exchange-eligible individuals 

5 or employers, but who would have improved benefits 

6 and affordability if made eligible for coverage in the 

7 Exchange. 

8 (2) ITEMS INCLUDED IN STUDY.—Such study 

9 also shall examine— 

10 (A) the terms, conditions, and affordability 

11 of group health coverage offered by employers 

12 and QHBP offering entities outside of the Ex13 change compared to Exchange-participating 

14 health benefits plans; and 

15 (B) the affordability-test standard for ac16 cess of certain employed individuals to coverage 

17 in the Health Insurance Exchange. 

18 (3) REPORT.—Not later than January 1 of Y3, 

19 in Y6, and thereafter, the Commissioner shall sub20 mit to Congress a report on the study conducted 

21 under this subsection and shall include in such re22 port recommendations regarding changes in stand23 ards for Exchange eligibility for individuals and em24 ployers. 


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1 SEC. 303. BENEFITS PACKAGE LEVELS. 

2 (a) IN GENERAL.—The Commissioner shall specify 

3 the benefits to be made available under Exchange-partici4 pating health benefits plans during each plan year, con5 sistent with subtitle C of title II and this section. 

6 (b) LIMITATION ON HEALTH BENEFITS PLANS OF7 FERED BY OFFERING ENTITIES.—The Commissioner may 

8 not enter into a contract with a QHBP offering entity 

9 under section 304(c) for the offering of an Exchange-par10 ticipating health benefits plan in a service area unless the 

11 following requirements are met: 

12 (1) REQUIRED OFFERING OF BASIC PLAN.—The 

13 entity offers only one basic plan for such service 

14 area. 

15 (2) OPTIONAL OFFERING OF ENHANCED

16 PLAN.—If and only if the entity offers a basic plan 

17 for such service area, the entity may offer one en18 hanced plan for such area. 

19 (3) OPTIONAL OFFERING OF PREMIUM PLAN.— 

20 If and only if the entity offers an enhanced plan for 

21 such service area, the entity may offer one premium 

22 plan for such area. 

23 (4) OPTIONAL OFFERING OF PREMIUM-PLUS

24 PLANS.—If and only if the entity offers a premium 

25 plan for such service area, the entity may offer one 

26 or more premium-plus plans for such area. 


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1 All such plans may be offered under a single contract with 

2 the Commissioner. 

3 (c) SPECIFICATION OF BENEFIT LEVELS FOR

4 PLANS.— 

5 (1) IN GENERAL.—The Commissioner shall es6 tablish the following standards consistent with this 

7 subsection and title II: 

8 (A) BASIC, ENHANCED, AND PREMIUM

9 PLANS.—Standards for 3 levels of Exchange10 participating health benefits plans: basic, en11 hanced, and premium (in this division referred 

12 to as a ‘‘basic plan’’, ‘‘enhanced plan’’, and 

13 ‘‘premium plan’’, respectively). 

14 (B) PREMIUM-PLUS PLAN BENEFITS.— 

15 Standards for additional benefits that may be 

16 offered, consistent with this subsection and sub17 title C of title II, under a premium plan (such 

18 a plan with additional benefits referred to in 

19 this division as a ‘‘premium-plus plan’’) . 

20 (2) BASIC PLAN.— 

21 (A) IN GENERAL.—A basic plan shall offer 

22 the essential benefits package required under 

23 title II for a qualified health benefits plan with 

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1 tuarial value of the benefits provided under the 

2 reference benefits package. 

3 (B) TIERED COST-SHARING FOR AFFORD4 ABLE CREDIT ELIGIBLE INDIVIDUALS.—In the 

5 case of an affordable credit eligible individual 

6 (as defined in section 342(a)(1)) enrolled in an 

7 Exchange-participating health benefits plan, the 

8 benefits under a basic plan are modified to pro9 vide for the reduced cost-sharing for the income 

10 tier applicable to the individual under section 

11 324(c). 

12 (3) ENHANCED PLAN.—An enhanced plan shall 

13 offer, in addition to the level of benefits under the 

14 basic plan, a lower level of cost-sharing as provided 

15 under title II consistent with section 223(b)(5)(A). 

16 (4) PREMIUM PLAN.—A premium plan shall 

17 offer, in addition to the level of benefits under the 

18 basic plan, a lower level of cost-sharing as provided 

19 under title II consistent with section 223(b)(5)(B). 

20 (5) PREMIUM-PLUS PLAN.—A premium-plus 

21 plan is a premium plan that also provides additional 

22 benefits, such as adult oral health and vision care, 

23 approved by the Commissioner. The portion of the 

24 premium that is attributable to such additional ben25 efits shall be separately specified. 


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1 (6) RANGE OF PERMISSIBLE VARIATION IN

2 COST-SHARING.—The Commissioner shall establish a 

3 permissible range of variation of cost-sharing for 

4 each basic, enhanced, and premium plan, except with 

5 respect to any benefit for which there is no cost6 sharing permitted under the essential benefits pack7 age. Such variation shall permit a variation of not 

8 more than plus (or minus) 10 percent in cost-shar9 ing with respect to each benefit category specified 

10 under section 222. Nothing in this subtitle shall be 

11 construed as prohibiting tiering in cost-sharing, in12 cluding through preferred and participating pro13 viders and prescription drugs. In applying this para14 graph, a health benefits plan may increase the cost15 sharing by 10 percent within each category or tier, 

16 as applicable, and may decrease or eliminate cost17 sharing in any category or tier as compared to the 

18 essential benefits package. 

19 (d) TREATMENT OF STATE BENEFIT MANDATES.— 

20 Insofar as a State requires a health insurance issuer offer21 ing health insurance coverage to include benefits beyond 

22 the essential benefits package, such requirement shall con23 tinue to apply to an Exchange-participating health bene24 fits plan, if the State has entered into an arrangement 

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1 missioner for the amount of any net increase in afford2 ability premium credits under subtitle C as a result of an 

3 increase in premium in basic plans as a result of applica4 tion of such requirement. 

5 (e) RULES REGARDING COVERAGE OF AND AFFORD6 ABILITY CREDITS FOR SPECIFIED SERVICES.— 

7 (1) ASSURED AVAILABILITY OF VARIED COV8 ERAGE THROUGH THE HEALTH INSURANCE EX9 CHANGE.—The Commissioner shall assure that, of 

10 the Exchange participating health benefits plan of11 fered in each premium rating area of the Health In12 surance Exchange— 

13 (A) there is at least one such plan that 

14 provides coverage of services described in sub15 paragraphs (A) and (B) of section 222(d)(4); 

16 and 

17 (B) there is at least one such plan that 

18 does not provide coverage of services described 

19 in section 222(d)(4)(A) which plan may also be 

20 one that does not provide coverage of services 

21 described in section 222(d)(4)(B). 

22 (2) SEGREGATION OF FUNDS.—If a qualified 

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1 vide assurances satisfactory to the Commissioner 

2 that— 

3 (A) any affordability credits provided 

4 under subtitle C of title II are not used for pur5 poses of paying for such services; and 

6 (B) only premium amounts attributable to 

7 the actuarial value described in section 213(b) 

8 are used for such purpose. 

9 SEC. 304. CONTRACTS FOR THE OFFERING OF EXCHANGE10 PARTICIPATING HEALTH BENEFITS PLANS. 

11 (a) CONTRACTING DUTIES.—In carrying out section 

12 301(b)(1) and consistent with this subtitle: 

13 (1) OFFERING ENTITY AND PLAN STAND14 ARDS.—The Commissioner shall— 

15 (A) establish standards necessary to imple16 ment the requirements of this title and title II 

17 for— 

18 (i) QHBP offering entities for the of19 fering of an Exchange-participating health 

20 benefits plan; and 

21 (ii) Exchange-participating health 

22 benefits plans; and 

23 (B) certify QHBP offering entities and 

24 qualified health benefits plans as meeting such 


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1 standards and requirements of this title and 

2 title II for purposes of this subtitle. 

3 (2) SOLICITING AND NEGOTIATING BIDS; CON4 TRACTS.— 

5 (A) BID SOLICITATION.—The Commis6 sioner shall solicit bids from QHBP offering en7 tities for the offering of Exchange-participating 

8 health benefits plans. Such bids shall include 

9 justification for proposed premiums. 

10 (B) BID REVIEW AND NEGOTIATION.—The 

11 Commissioner shall, based upon a review of 

12 such bids including the premiums and their af13 fordability, negotiate with such entities for the 

14 offering of such plans. 

15 (C) DENIAL OF EXCESSIVE PREMIUMS.— 

16 The Commissioner shall deny excessive pre17 miums and premium increases. 

18 (D) CONTRACTS.—The Commissioner shall 

19 enter into contracts with such entities for the 

20 offering of such plans through the Health In21 surance Exchange under terms (consistent with 

22 this title) negotiated between the Commissioner 

23 and such entities. 

24 (3) FEDERAL ACQUISITION REGULATION.—In 

25 carrying out this subtitle, the Commissioner may 


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1 waive such provisions of the Federal Acquisition 

2 Regulation that the Commissioner determines to be 

3 inconsistent with the furtherance of this subtitle, 

4 other than provisions relating to confidentiality of 

5 information. Competitive procedures shall be used in 

6 awarding contracts under this subtitle to the extent 

7 that such procedures are consistent with this sub8 title. 

9 (b) STANDARDS FOR QHBP OFFERING ENTITIES TO

10 OFFER EXCHANGE-PARTICIPATING HEALTH BENEFITS

11 PLANS.—The standards established under subsection 

12 (a)(1)(A) shall require that, in order for a QHBP offering 

13 entity to offer an Exchange-participating health benefits 

14 plan, the entity must meet the following requirements: 

15 (1) LICENSED.—The entity shall be licensed to 

16 offer health insurance coverage under State law for 

17 each State in which it is offering such coverage. 

18 (2) DATA REPORTING.—The entity shall pro19 vide for the reporting of such information as the 

20 Commissioner may specify, including information 

21 necessary to administer the risk pooling mechanism 

22 described in section 306(b) and information to ad23 dress disparities in health and health care. 

24 (3) AFFORDABILITY.—The entity shall provide 

25 for affordable premiums. 


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1 (4) IMPLEMENTING AFFORDABILITY CRED2 ITS.—The entity shall provide for implementation of 

3 the affordability credits provided for enrollees under 

4 subtitle C, including the reduction in cost-sharing 

5 under section 344(c). 

6 (5) ENROLLMENT.—The entity shall accept all 

7 enrollments under this subtitle, subject to such ex8 ceptions (such as capacity limitations) in accordance 

9 with the requirements under title II for a qualified 

10 health benefits plan. The entity shall notify the 

11 Commissioner if the entity projects or anticipates 

12 reaching such a capacity limitation that would result 

13 in a limitation in enrollment. 

14 (6) RISK POOLING PARTICIPATION.—The entity 

15 shall participate in such risk pooling mechanism as 

16 the Commissioner establishes under section 306(b). 

17 (7) ESSENTIAL COMMUNITY PROVIDERS.—With 

18 respect to the basic plan offered by the entity, the 

19 entity shall include within the plan network those es20 sential community providers, where available, that 

21 serve predominantly low-income, medically-under22 served individuals, such as health care providers de23 fined in section 340B(a)(4) of the Public Health 

24 Service Act and providers described in section 

25 1927(c)(1)(D)(i)(IV) of the Social Security Act (as 


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1 amended by section 221 of Public Law 111–8). The 

2 Commissioner shall specify the extent to which and 

3 manner in which the previous sentence shall apply in 

4 the case of a basic plan with respect to which the 

5 Commissioner determines provides substantially all 

6 benefits through a health maintenance organization, 

7 as defined in section 2791(b)(3) of the Public 

8 Health Service Act. This paragraph shall not be con9 strued to require a basic plan to contract with a pro10 vider if such provider refuses to accept the generally 

11 applicable payment rates of such plan. 

12 (8) CULTURALLY AND LINGUISTICALLY APPRO13 PRIATE SERVICES AND COMMUNICATIONS.—The en14 tity shall provide for culturally and linguistically ap15 propriate communication and health services. 

16 (9) SPECIAL RULES WITH RESPECT TO INDIAN

17 ENROLLEES AND INDIAN HEALTH CARE PRO18 VIDERS.— 

19 (A) CHOICE OF PROVIDERS.—The entity 

20 shall— 

21 (i) demonstrate to the satisfaction of 

22 the Commissioner that it has contracted 

23 with a sufficient number of Indian health 

24 care providers to ensure timely access to 

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1 viders to individual Indians through the 

2 entity’s Exchange-participating health ben3 efits plan; and 

4 (ii) agree to pay Indian health care 

5 providers, whether such providers are par6 ticipating or nonparticipating providers 

7 with respect to the entity, for covered serv8 ices provided to those enrollees who are eli9 gible to receive services from such pro10 viders at a rate that is not less than the 

11 level and amount of payment which the en12 tity would make for the services of a par13 ticipating provider which is not an Indian 

14 health care provider. 

15 (B) SPECIAL RULE RELATING TO INDIAN

16 HEALTH CARE PROVIDERS.—Provision of serv17 ices by an Indian health care provider exclu18 sively to Indians and their dependents shall not 

19 constitute discrimination under this Act. 

20 (10) PROGRAM INTEGRITY STANDARDS.—The 

21 entity shall establish and operate a program to pro22 tect and promote the integrity of Exchange-partici23 pating health benefits plans it offers, in accordance 

24 with standards and functions established by the 

25 Commissioner. 


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1 (11) ADDITIONAL REQUIREMENTS.—The entity 

2 shall comply with other applicable requirements of 

3 this title, as specified by the Commissioner, which 

4 shall include standards regarding billing and collec5 tion practices for premiums and related grace peri6 ods and which may include standards to ensure that 

7 the entity does not use coercive practices to force 

8 providers not to contract with other entities offering 

9 coverage through the Health Insurance Exchange. 

10 (c) CONTRACTS.— 

11 (1) BID APPLICATION.—To be eligible to enter 

12 into a contract under this section, a QHBP offering 

13 entity shall submit to the Commissioner a bid at 

14 such time, in such manner, and containing such in15 formation as the Commissioner may require. 

16 (2) TERM.—Each contract with a QHBP offer17 ing entity under this section shall be for a term of 

18 not less than one year, but may be made automati19 cally renewable from term to term in the absence of 

20 notice of termination by either party. 

21 (3) ENFORCEMENT OF NETWORK ADEQUACY.— 

22 In the case of a health benefits plan of a QHBP of23 fering entity that uses a provider network, the con24 tract under this section with the entity shall provide 

25 that if— 


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1 (A) the Commissioner determines that 

2 such provider network does not meet such 

3 standards as the Commissioner shall establish 

4 under section 215; and 

5 (B) an individual enrolled in such plan re6 ceives an item or service from a provider that 

7 is not within such network; 

8 then any cost-sharing for such item or service shall 

9 be equal to the amount of such cost-sharing that 

10 would be imposed if such item or service was fur11 nished by a provider within such network. 

12 (4) OVERSIGHT AND ENFORCEMENT RESPON13 SIBILITIES.—The Commissioner shall establish proc14 esses, in coordination with State insurance regu15 lators, to oversee, monitor, and enforce applicable re16 quirements of this title with respect to QHBP offer17 ing entities offering Exchange-participating health 

18 benefits plans, including the marketing of such 

19 plans. Such processes shall include the following: 

20 (A) GRIEVANCE AND COMPLAINT MECHA21 NISMS.—The Commissioner shall establish, in 

22 coordination with State insurance regulators, a 

23 process under which Exchange-eligible individ24 uals and employers may file complaints con25 cerning violations of such standards. 


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1 (B) ENFORCEMENT.—In carrying out au2 thorities under this division relating to the 

3 Health Insurance Exchange, the Commissioner 

4 may impose one or more of the intermediate 

5 sanctions described in section 242(d). 

6 (C) TERMINATION.— 

7 (i) IN GENERAL.—The Commissioner 

8 may terminate a contract with a QHBP of9 fering entity under this section for the of10 fering of an Exchange-participating health 

11 benefits plan if such entity fails to comply 

12 with the applicable requirements of this 

13 title. Any determination by the Commis14 sioner to terminate a contract shall be 

15 made in accordance with formal investiga16 tion and compliance procedures established 

17 by the Commissioner under which— 

18 (I) the Commissioner provides 

19 the entity with the reasonable oppor20 tunity to develop and implement a 

21 corrective action plan to correct the 

22 deficiencies that were the basis of the 

23 Commissioner’s determination; and 

24 (II) the Commissioner provides 

25 the entity with reasonable notice and 


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1 opportunity for hearing (including the 

2 right to appeal an initial decision) be3 fore terminating the contract. 

4 (ii) EXCEPTION FOR IMMINENT AND

5 SERIOUS RISK TO HEALTH.—Clause (i) 

6 shall not apply if the Commissioner deter7 mines that a delay in termination, result8 ing from compliance with the procedures 

9 specified in such clause prior to termi10 nation, would pose an imminent and seri11 ous risk to the health of individuals en12 rolled under the qualified health benefits 

13 plan of the QHBP offering entity. 

14 (D) CONSTRUCTION.—Nothing in this sub15 section shall be construed as preventing the ap16 plication of other sanctions under subtitle E of 

17 title II with respect to an entity for a violation 

18 of such a requirement. 

19 (5) SPECIAL RULE RELATED TO COST-SHARING

20 AND INDIAN HEALTH CARE PROVIDERS.—The con21 tract under this section with a QHBP offering entity 

22 for a health benefits plan shall provide that if an in23 dividual who is an Indian is enrolled in such a plan 

24 and such individual receives a covered item or serv25 ice from an Indian health care provider (regardless 


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1 of whether such provider is in the plan’s provider 

2 network), the cost-sharing for such item or service 

3 shall be equal to the amount of cost-sharing that 

4 would be imposed if such item or service— 

5 (A) had been furnished by another pro6 vider in the plan’s provider network; or 

7 (B) in the case that the plan has no such 

8 network, was furnished by a non-Indian pro9 vider. 

10 (6) NATIONAL PLAN.—Nothing in this section 

11 shall be construed as preventing the Commissioner 

12 from entering into a contract under this subsection 

13 with a QHBP offering entity for the offering of a 

14 health benefits plan with the same benefits in every 

15 State so long as such entity is licensed to offer such 

16 plan in each State and the benefits meet the applica17 ble requirements in each such State. 

18 (d) NO DISCRIMINATION ON THE BASIS OF PROVI19 SION OF ABORTION.—No Exchange participating health 

20 benefits plan may discriminate against any individual 

21 health care provider or health care facility because of its 

22 willingness or unwillingness to provide, pay for, provide 

23 coverage of, or refer for abortions. 


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1 SEC. 305. OUTREACH AND ENROLLMENT OF EXCHANGE-EL2 IGIBLE INDIVIDUALS AND EMPLOYERS IN EX3 CHANGE-PARTICIPATING HEALTH BENEFITS 

4 PLAN. 

5 (a) IN GENERAL.— 

6 (1) OUTREACH.—The Commissioner shall con7 duct outreach activities consistent with subsection 

8 (c), including through use of appropriate entities as 

9 described in paragraph (3) of such subsection, to in10 form and educate individuals and employers about 

11 the Health Insurance Exchange and Exchange-par12 ticipating health benefits plan options. Such out13 reach shall include outreach specific to vulnerable 

14 populations, such as children, individuals with dis15 abilities, individuals with mental illness, and individ16 uals with other cognitive impairments. 

17 (2) ELIGIBILITY.—The Commissioner shall 

18 make timely determinations of whether individuals 

19 and employers are Exchange-eligible individuals and 

20 employers (as defined in section 302). 

21 (3) ENROLLMENT.—The Commissioner shall es22 tablish and carry out an enrollment process for Ex23 change-eligible individuals and employers, including 

24 at community locations, in accordance with sub25 section (b). 

26 (b) ENROLLMENT PROCESS.— 


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1 (1) IN GENERAL.—The Commissioner shall es2 tablish a process consistent with this title for enroll3 ments in Exchange-participating health benefits 

4 plans. Such process shall provide for enrollment 

5 through means such as the mail, by telephone, elec6 tronically, and in person. 

7 (2) ENROLLMENT PERIODS.— 

8 (A) OPEN ENROLLMENT PERIOD.—The 

9 Commissioner shall establish an annual open 

10 enrollment period during which an Exchange-el11 igible individual or employer may elect to enroll 

12 in an Exchange-participating health benefits 

13 plan for the following plan year and an enroll14 ment period for affordability credits under sub15 title C. Such periods shall be during September 

16 through November of each year, or such other 

17 time that would maximize timeliness of income 

18 verification for purposes of such subtitle. The 

19 open enrollment period shall not be less than 30 

20 days. 

21 (B) SPECIAL ENROLLMENT.—The Com22 missioner shall also provide for special enroll23 ment periods to take into account special cir24 cumstances of individuals and employers, such 

25 as an individual who— 


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1 (i) loses acceptable coverage; 

2 (ii) experiences a change in marital or 

3 other dependent status; 

4 (iii) moves outside the service area of 

5 the Exchange-participating health benefits 

6 plan in which the individual is enrolled; or 

7 (iv) experiences a significant change 

8 in income. 

9 (C) ENROLLMENT INFORMATION.—The 

10 Commissioner shall provide for the broad dis11 semination of information to prospective enroll12 ees on the enrollment process, including before 

13 each open enrollment period. In carrying out 

14 the previous sentence, the Commissioner may 

15 work with other appropriate entities to facilitate 

16 such provision of information. 

17 (3) AUTOMATIC ENROLLMENT FOR NON-MED18 ICAID ELIGIBLE INDIVIDUALS.— 

19 (A) IN GENERAL.—The Commissioner 

20 shall provide for a process under which individ21 uals who are Exchange-eligible individuals de22 scribed in subparagraph (B) are automatically 

23 enrolled under an appropriate Exchange-partici24 pating health benefits plan. Such process may 

25 involve a random assignment or some other 


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1 form of assignment that takes into account the 

2 health care providers used by the individual in3 volved or such other relevant factors as the 

4 Commissioner may specify. 

5 (B) SUBSIDIZED INDIVIDUALS DE6 SCRIBED.—An individual described in this sub7 paragraph is an Exchange-eligible individual 

8 who is either of the following: 

9 (i) AFFORDABILITY CREDIT ELIGIBLE

10 INDIVIDUALS.—The individual— 

11 (I) has applied for, and been de12 termined eligible for, affordability 

13 credits under subtitle C; 

14 (II) has not opted out from re15 ceiving such affordability credit; and 

16 (III) does not otherwise enroll in 

17 another Exchange-participating health 

18 benefits plan. 

19 (ii) INDIVIDUALS ENROLLED IN A

20 TERMINATED PLAN.—The individual who 

21 is enrolled in an Exchange-participating 

22 health benefits plan that is terminated 

23 (during or at the end of a plan year) and 

24 who does not otherwise enroll in another 


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1 Exchange-participating health benefits 

2 plan. 

3 (4) DIRECT PAYMENT OF PREMIUMS TO

4 PLANS.—Under the enrollment process, individuals 

5 enrolled in an Exchange-participating health benefits 

6 plan shall pay such plans directly, and not through 

7 the Commissioner or the Health Insurance Ex8 change. 

9 (c) COVERAGE INFORMATION AND ASSISTANCE.— 

10 (1) COVERAGE INFORMATION.—The Commis11 sioner shall provide for the broad dissemination of 

12 information on Exchange-participating health bene13 fits plans offered under this title. Such information 

14 shall be provided in a comparative manner, and shall 

15 include information on benefits, premiums, cost16 sharing, quality, provider networks, and consumer 

17 satisfaction. 

18 (2) CONSUMER ASSISTANCE WITH CHOICE.—To 

19 provide assistance to Exchange-eligible individuals 

20 and employers, the Commissioner shall— 

21 (A) provide for the operation of a toll-free 

22 telephone hotline to respond to requests for as23 sistance and maintain an Internet Web site 

24 through which individuals may obtain informaVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00187 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 tion on coverage under Exchange-participating 

2 health benefits plans and file complaints; 

3 (B) develop and disseminate information to 

4 Exchange-eligible enrollees on their rights and 

5 responsibilities; 

6 (C) assist Exchange-eligible individuals in 

7 selecting Exchange-participating health benefits 

8 plans and obtaining benefits through such 

9 plans; and 

10 (D) ensure that the Internet Web site de11 scribed in subparagraph (A) and the informa12 tion described in subparagraph (B) is developed 

13 using plain language (as defined in section 

14 233(a)(2)). 

15 (3) USE OF OTHER ENTITIES.—In carrying out 

16 this subsection, the Commissioner may work with 

17 other appropriate entities to facilitate the dissemina18 tion of information under this subsection and to pro19 vide assistance as described in paragraph (2). 

20 (d) COVERAGE FOR CERTAIN NEWBORNS UNDER

21 MEDICAID.— 

22 (1) IN GENERAL.—In the case of a child born 

23 in the United States who at the time of birth is not 

24 otherwise covered under acceptable coverage, for the 

25 period of time beginning on the date of birth and 


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1 ending on the date the child otherwise is covered 

2 under acceptable coverage (or, if earlier, the end of 

3 the month in which the 60-day period, beginning on 

4 the date of birth, ends), the child shall be deemed— 

5 (A) to be a Medicaid eligible individual for 

6 purposes of this division and Medicaid; and 

7 (B) to be automatically enrolled in Med8 icaid as a traditional Medicaid eligible indi9 vidual (as defined in section 1943(c) of the So10 cial Security Act). 

11 (2) EXTENDED TREATMENT AS MEDICAID ELI12 GIBLE INDIVIDUAL.—In the case of a child described 

13 in paragraph (1) who at the end of the period re14 ferred to in such paragraph is not otherwise covered 

15 under acceptable coverage, the child shall be deemed 

16 (until such time as the child obtains such coverage 

17 or the State otherwise makes a determination of the 

18 child’s eligibility for medical assistance under its 

19 Medicaid plan pursuant to section 1943(b)(1) of the 

20 Social Security Act) to be a Medicaid eligible indi21 vidual described in section 1902(l)(1)(B) of such 

22 Act. 

23 (e) MEDICAID COVERAGE FOR MEDICAID ELIGIBLE

24 INDIVIDUALS.— 


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1 (1) MEDICAID ENROLLMENT OBLIGATION.—An 

2 individual may apply, in the manner described in 

3 section 341(b)(1), for a determination of whether 

4 the individual is a Medicaid-eligible individual. If the 

5 individual is determined to be so eligible, the Com6 missioner, through the Medicaid memorandum of 

7 understanding under paragraph (2), shall provide 

8 for the enrollment of the individual under the State 

9 Medicaid plan in accordance with such memorandum 

10 of understanding. In the case of such an enrollment, 

11 the State shall provide for the same periodic redeter12 mination of eligibility under Medicaid as would oth13 erwise apply if the individual had directly applied for 

14 medical assistance to the State Medicaid agency. 

15 (2) COORDINATED ENROLLMENT WITH STATE

16 THROUGH MEMORANDUM OF UNDERSTANDING.— 

17 The Commissioner, in consultation with the Sec18 retary of Health and Human Services, shall enter 

19 into a memorandum of understanding with each 

20 State with respect to coordinating enrollment of in21 dividuals in Exchange-participating health benefits 

22 plans and under the State’s Medicaid program con23 sistent with this section and to otherwise coordinate 

24 the implementation of the provisions of this division 

25 with respect to the Medicaid program. Such memoVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00190 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 randum shall permit the exchange of information 

2 consistent with the limitations described in section 

3 1902(a)(7) of the Social Security Act. Nothing in 

4 this section shall be construed as permitting such 

5 memorandum to modify or vitiate any requirement 

6 of a State Medicaid plan. 

7 (f) EFFECTIVE CULTURALLY AND LINGUISTICALLY

8 APPROPRIATE COMMUNICATION.—In carrying out this 

9 section, the Commissioner shall establish effective methods 

10 for communicating in plain language and a culturally and 

11 linguistically appropriate manner. 

12 (g) ROLE FOR ENROLLMENT AGENTS AND BRO13 KERS.—Nothing in this division shall be construed to af14 fect the role of enrollment agents and brokers under State 

15 law, including with regard to the enrollment of individuals 

16 and employers in qualified health benefits plans including 

17 the public health insurance option. 

18 (h) ASSISTANCE FOR SMALL EMPLOYERS.— 

19 (1) IN GENERAL.—The Commissioner, in con20 sultation with the Small Business Administration, 

21 shall establish and carry out a program to provide 

22 to small employers counseling and technical assist23 ance with respect to the provision of health insur24 ance to employees of such employers through the 

25 Health Insurance Exchange. 


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1 (2) DUTIES.—The program established under 

2 paragraph (1) shall include the following services: 

3 (A) Educational activities to increase 

4 awareness of the Health Insurance Exchange 

5 and available small employer health plan op6 tions. 

7 (B) Distribution of information to small 

8 employers with respect to the enrollment and 

9 selection process for health plans available 

10 under the Health Insurance Exchange, includ11 ing standardized comparative information on 

12 the health plans available under the Health In13 surance Exchange. 

14 (C) Distribution of information to small 

15 employers with respect to available affordability 

16 credits or other financial assistance. 

17 (D) Referrals to appropriate entities of 

18 complaints and questions relating to the Health 

19 Insurance Exchange. 

20 (E) Enrollment and plan selection assist21 ance for employers with respect to the Health 

22 Insurance Exchange. 

23 (F) Responses to questions relating to the 

24 Health Insurance Exchange and the program 

25 established under paragraph (1). 


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1 (3) AUTHORITY TO PROVIDE SERVICES DI2 RECTLY OR BY CONTRACT.—The Commissioner may 

3 provide services under paragraph (2) directly or by 

4 contract with nonprofit entities that the Commis5 sioner determines capable of carrying out such serv6 ices. 

7 (4) SMALL EMPLOYER DEFINED.—In this sub8 section, the term ‘‘small employer’’ means an em9 ployer with less than 100 employees. 

10 (i) PARTICIPATION OF SMALL EMPLOYER BENEFIT

11 ARRANGEMENTS.— 

12 (1) IN GENERAL.—The Commissioner may 

13 enter into contracts with small employer benefit ar14 rangements to provide consumer information, out15 reach, and assistance in the enrollment of small em16 ployers (and their employees) who are members of 

17 such an arrangement under Exchange participating 

18 health benefits plans. 

19 (2) SMALL EMPLOYER BENEFIT ARRANGEMENT

20 DEFINED.—In this subsection, the term ‘‘small em21 ployer benefit arrangement’’ means a not-for-profit 

22 agricultural or other cooperative that— 

23 (A) consists solely of its members and is 

24 operated for the primary purpose of providing 

25 affordable employee benefits to its members; 


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1 (B) only has as members small employers 

2 in the same industry or line of business; 

3 (C) has no member that has more than a 

4 5 percent voting interest in the cooperative; and 

5 (D) is governed by a board of directors 

6 elected by its members. 

7 SEC. 306. OTHER FUNCTIONS. 

8 (a) COORDINATION OF AFFORDABILITY CREDITS.— 

9 The Commissioner shall coordinate the distribution of af10 fordability premium and cost-sharing credits under sub11 title C to QHBP offering entities offering Exchange-par12 ticipating health benefits plans. 

13 (b) COORDINATION OF RISK POOLING.—The Com14 missioner shall establish a mechanism whereby there is an 

15 adjustment made of the premium amounts payable among 

16 QHBP offering entities offering Exchange-participating 

17 health benefits plans of premiums collected for such plans 

18 that takes into account (in a manner specified by the Com19 missioner) the differences in the risk characteristics of in20 dividuals and employees enrolled under the different Ex21 change-participating health benefits plans offered by such 

22 entities so as to minimize the impact of adverse selection 

23 of enrollees among the plans offered by such entities. For 

24 purposes of the previous sentence, the Commissioner may 

25 utilize data regarding enrollee demographics, inpatient 


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1 and outpatient diagnoses (in a similar manner as such 

2 data are used under parts C and D of title XVIII of the 

3 Social Security Act), and such other information as the 

4 Secretary determines may be necessary, such as the actual 

5 medical costs of enrollees during the previous year. 

6 SEC. 307. HEALTH INSURANCE EXCHANGE TRUST FUND. 

7 (a) ESTABLISHMENT OF HEALTH INSURANCE EX8 CHANGE TRUST FUND.—There is created within the 

9 Treasury of the United States a trust fund to be known 

10 as the ‘‘Health Insurance Exchange Trust Fund’’ (in this 

11 section referred to as the ‘‘Trust Fund’’), consisting of 

12 such amounts as may be appropriated or credited to the 

13 Trust Fund under this section or any other provision of 

14 law. 

15 (b) PAYMENTS FROM TRUST FUND.—The Commis16 sioner shall pay from time to time from the Trust Fund 

17 such amounts as the Commissioner determines are nec18 essary to make payments to operate the Health Insurance 

19 Exchange, including payments under subtitle C (relating 

20 to affordability credits). 

21 (c) TRANSFERS TO TRUST FUND.— 

22 (1) DEDICATED PAYMENTS.—There are hereby 

23 appropriated to the Trust Fund amounts equivalent 

24 to the following: 


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1 (A) TAXES ON INDIVIDUALS NOT OBTAIN2 ING ACCEPTABLE COVERAGE.—The amounts re3 ceived in the Treasury under section 59B of the 

4 Internal Revenue Code of 1986 (relating to re5 quirement of health insurance coverage for indi6 viduals). 

7 (B) EMPLOYMENT TAXES ON EMPLOYERS

8 NOT PROVIDING ACCEPTABLE COVERAGE.—The 

9 amounts received in the Treasury under sec10 tions 3111(c) and 3221(c) of the Internal Rev11 enue Code of 1986 (relating to employers elect12 ing to not provide health benefits). 

13 (C) EXCISE TAX ON FAILURES TO MEET

14 CERTAIN HEALTH COVERAGE REQUIRE15 MENTS.—The amounts received in the Treasury 

16 under section 4980H(b) (relating to excise tax 

17 with respect to failure to meet health coverage 

18 participation requirements). 

19 (2) APPROPRIATIONS TO COVER GOVERNMENT

20 CONTRIBUTIONS.—There are hereby appropriated, 

21 out of any moneys in the Treasury not otherwise ap22 propriated, to the Trust Fund, an amount equivalent 

23 to the amount of payments made from the Trust 

24 Fund under subsection (b) plus such amounts as are 


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1 necessary reduced by the amounts deposited under 

2 paragraph (1). 

3 (d) APPLICATION OF CERTAIN RULES.—Rules simi4 lar to the rules of subchapter B of chapter 98 of the Inter5 nal Revenue Code of 1986 shall apply with respect to the 

6 Trust Fund. 

7 SEC. 308. OPTIONAL OPERATION OF STATE-BASED HEALTH 

8 INSURANCE EXCHANGES. 

9 (a) IN GENERAL.—If— 

10 (1) a State (or group of States, subject to the 

11 approval of the Commissioner) applies to the Com12 missioner for approval of a State-based Health In13 surance Exchange to operate in the State (or group 

14 of States); and 

15 (2) the Commissioner approves such State16 based Health Insurance Exchange, 

17 then, subject to subsections (c) and (d), the State-based 

18 Health Insurance Exchange shall operate, instead of the 

19 Health Insurance Exchange, with respect to such State 

20 (or group of States). The Commissioner shall approve a 

21 State-based Health Insurance Exchange if it meets the re22 quirements for approval under subsection (b). 

23 (b) REQUIREMENTS FOR APPROVAL.— 

24 (1) IN GENERAL.—The Commissioner may not 

25 approve a State-based Health Insurance Exchange 


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1 under this section unless the following requirements 

2 are met: 

3 (A) The State-based Health Insurance Ex4 change must demonstrate the capacity to and 

5 provide assurances satisfactory to the Commis6 sioner that the State-based Health Insurance 

7 Exchange will carry out the functions specified 

8 for the Health Insurance Exchange in the State 

9 (or States) involved, including— 

10 (i) negotiating and contracting with 

11 QHBP offering entities for the offering of 

12 Exchange-participating health benefits 

13 plans, which satisfy the standards and re14 quirements of this title and title II; 

15 (ii) enrolling Exchange-eligible indi16 viduals and employers in such State in 

17 such plans; 

18 (iii) the establishment of sufficient 

19 local offices to meet the needs of Ex20 change-eligible individuals and employers; 

21 (iv) administering affordability credits 

22 under subtitle B using the same meth23 odologies (and at least the same income 

24 verification methods) as would otherwise 

25 apply under such subtitle and at a cost to 


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1 the Federal Government which does exceed 

2 the cost to the Federal Government if this 

3 section did not apply; and 

4 (v) enforcement activities consistent 

5 with Federal requirements. 

6 (B) There is no more than one Health In7 surance Exchange operating with respect to any 

8 one State. 

9 (C) The State provides assurances satisfac10 tory to the Commissioner that approval of such 

11 an Exchange will not result in any net increase 

12 in expenditures to the Federal Government. 

13 (D) The State provides for reporting of 

14 such information as the Commissioner deter15 mines and assurances satisfactory to the Com16 missioner that it will vigorously enforce viola17 tions of applicable requirements. 

18 (E) Such other requirements as the Com19 missioner may specify. 

20 (2) PRESUMPTION FOR CERTAIN STATE-OPER21 ATED EXCHANGES.— 

22 (A) IN GENERAL.—In the case of a State 

23 operating an Exchange prior to January 1, 

24 2010, that seeks to operate the State-based 

25 Health Insurance Exchange under this section, 


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1 the Commissioner shall presume that such Ex2 change meets the standards under this section 

3 unless the Commissioner determines, after com4 pletion of the process established under sub5 paragraph (B), that the Exchange does not 

6 comply with such standards. 

7 (B) PROCESS.—The Commissioner shall 

8 establish a process to work with a State de9 scribed in subparagraph (A) to provide assist10 ance necessary to assure that the State’s Ex11 change comes into compliance with the stand12 ards for approval under this section. 

13 (c) CEASING OPERATION.— 

14 (1) IN GENERAL.—A State-based Health Insur15 ance Exchange may, at the option of each State in16 volved, and only after providing timely and reason17 able notice to the Commissioner, cease operation as 

18 such an Exchange, in which case the Health Insur19 ance Exchange shall operate, instead of such State20 based Health Insurance Exchange, with respect to 

21 such State (or States). 

22 (2) TERMINATION; HEALTH INSURANCE EX23 CHANGE RESUMPTION OF FUNCTIONS.—The Com24 missioner may terminate the approval (for some or 

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1 change under this section if the Commissioner deter2 mines that such Exchange no longer meets the re3 quirements of subsection (b) or is no longer capable 

4 of carrying out such functions in accordance with 

5 the requirements of this subtitle. In lieu of termi6 nating such approval, the Commissioner may tempo7 rarily assume some or all functions of the State8 based Health Insurance Exchange until such time as 

9 the Commissioner determines the State-based 

10 Health Insurance Exchange meets such require11 ments of subsection (b) and is capable of carrying 

12 out such functions in accordance with the require13 ments of this subtitle. 

14 (3) EFFECTIVENESS.—The ceasing or termi15 nation of a State-based Health Insurance Exchange 

16 under this subsection shall be effective in such time 

17 and manner as the Commissioner shall specify. 

18 (d) RETENTION OF AUTHORITY.— 

19 (1) AUTHORITY RETAINED.—Enforcement au20 thorities of the Commissioner shall be retained by 

21 the Commissioner. 

22 (2) DISCRETION TO RETAIN ADDITIONAL AU23 THORITY.—The Commissioner may specify functions 

24 of the Health Insurance Exchange that— 


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1 (A) may not be performed by a State2 based Health Insurance Exchange under this 

3 section; or 

4 (B) may be performed by the Commis5 sioner and by such a State-based Health Insur6 ance Exchange. 

7 (e) REFERENCES.—In the case of a State-based 

8 Health Insurance Exchange, except as the Commissioner 

9 may otherwise specify under subsection (d), any references 

10 in this subtitle to the Health Insurance Exchange or to 

11 the Commissioner in the area in which the State-based 

12 Health Insurance Exchange operates shall be deemed a 

13 reference to the State-based Health Insurance Exchange 

14 and the head of such Exchange, respectively. 

15 (f) FUNDING.—In the case of a State-based Health 

16 Insurance Exchange, there shall be assistance provided for 

17 the operation of such Exchange in the form of a matching 

18 grant with a State share of expenditures required. 

19 SEC. 309. INTERSTATE HEALTH INSURANCE COMPACTS. 

20 (a) IN GENERAL.—Effective January 1, 2015, 2 or 

21 more States may form Health Care Choice Compacts (in 

22 this section referred to as ‘‘compacts’’) to facilitate the 

23 purchase of individual health insurance coverage across 

24 State lines. 


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1 (b) MODEL GUIDELINES.—The Secretary of Health 

2 and Human Services (in this section referred to as the 

3 ‘‘Secretary’’) shall request the National Association of In4 surance Commissioners (in this section referred to as 

5 ‘‘NAIC’’) to develop model guidelines for the creation of 

6 compacts. In developing such guidelines, the NAIC shall 

7 consult with consumers, health insurance issuers, the Sec8 retary, and other interested parties. Such guidelines 

9 shall— 

10 (1) provide for the sale of health insurance cov11 erage to residents of all compacting States subject to 

12 the laws and regulations of a primary State des13 ignated by the health insurance issuer; 

14 (2) require health insurance issuers issuing 

15 health insurance coverage in secondary States to 

16 maintain licensure in every such State; 

17 (3) preserve the authority of the State of an in18 dividual’s residence to address— 

19 (A) market conduct; 

20 (B) unfair trade practices; 

21 (C) network adequacy; 

22 (D) consumer protection standards; 

23 (E) grievance and appeals; 

24 (F) fair claims payment requirements; and 

25 (G) prompt payment of claims; 


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1 (4) permit State insurance commissioners and 

2 other State agencies in secondary States access to 

3 the records of a health insurance issuer to the same 

4 extent as if the policy were written in that State; 

5 and 

6 (5) provide for clear and conspicuous disclosure 

7 to consumers that the policy may not be subject to 

8 all the laws and regulations of the State in which 

9 the purchaser resides. 

10 (c) REQUIRED CONSIDERATION.—If model guidelines 

11 developed under subsection (b) are submitted to the Sec12 retary by January 1, 2013, the Secretary shall issue them 

13 as regulations. If the NAIC fails to submit such model 

14 guidelines by such date, the Secretary shall, no later than 

15 October 1, 2013, develop and promulgate the regulations 

16 implementing model guidelines described in subsection (b). 

17 (d) NO REQUIREMENT TO COMPACT.—Nothing in 

18 this section shall be construed to require a State to join 

19 a compact. 

20 (e) STATE AUTHORITY.—A State may not enter into 

21 a compact under this subsection unless the State enacts 

22 a law after the date of enactment of this Act that specifi23 cally authorizes the State to enter into such compact. 

24 (f) CONSUMER PROTECTIONS.—If a State enters into 

25 a compact it must retain responsibility for the consumer 


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1 protections of its residents and its residents retain the 

2 right to bring a claim in a State court in the State in 

3 which the resident resides. 

4 (g) ASSISTANCE TO COMPACTING STATES.— 

5 (1) IN GENERAL.—Beginning January 1, 2015, 

6 the Secretary shall make awards, from amounts ap7 propriated under paragraph (5), to States in the 

8 amount specified in paragraph (2) for the uses de9 scribed in paragraph (3). 

10 (2) AMOUNT SPECIFIED.— 

11 (A) IN GENERAL.—For each fiscal year, 

12 the Secretary shall determine the total amount 

13 that the Secretary will make available for 

14 grants under this subsection. 

15 (B) STATE AMOUNT.—For each State that 

16 is awarded a grant under paragraph (1), the 

17 amount of such grants shall be based on a for18 mula established by the Secretary, not to exceed 

19 $1 million per State, under which States shall 

20 receive an award in the amount that is based 

21 on the following two components: 

22 (i) A minimum amount for each 

23 State. 

24 (ii) An additional amount based on 

25 population of the State. 


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1 (3) USE OF FUNDS.—A State shall use 

2 amounts awarded under this subsection for activities 

3 (including planning activities) related regulating 

4 health insurance coverage sold in secondary States. 

5 (4) RENEWABILITY OF GRANT.—The Secretary 

6 may renew a grant award under paragraph (1) if the 

7 State receiving the grant continues to be a member 

8 of a compact. 

9 (5) AUTHORIZATION OF APPROPRIATIONS.— 

10 There are authorized to be appropriated such sums 

11 as may be necessary to carry out this subsection in 

12 each of fiscal years 2015 through 2020. 

13 SEC. 310. HEALTH INSURANCE COOPERATIVES. 

14 (a) ESTABLISHMENT.—Not later than 6 months after 

15 the date of the enactment of this Act, the Commissioner, 

16 in consultation with the Secretary of the Treasury, shall 

17 establish a Consumer Operated and Oriented Plan pro18 gram (in this section referred to as the ‘‘CO–OP pro19 gram’’) under which the Commissioner may make grants 

20 and loans for the establishment and initial operation of 

21 not-for-profit, member–run health insurance cooperatives 

22 (in this section individually referred to as a ‘‘cooperative’’) 

23 that provide insurance through the Health Insurance Ex24 change or a State-based Health Insurance Exchange 


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1 under section 308. Nothing in this section shall be con2 strued as requiring a State to establish such a cooperative. 

3 (b) START-UP AND SOLVENCY GRANTS AND

4 LOANS.— 

5 (1) IN GENERAL.—Not later than 36 months 

6 after the date of the enactment of this Act, the 

7 Commissioner, acting through the CO–OP program, 

8 may make— 

9 (A) loans (of such period and with such 

10 terms as the Secretary may specify) to coopera11 tives to assist such cooperatives with start-up 

12 costs; and 

13 (B) grants to cooperatives to assist such 

14 cooperatives in meeting State solvency require15 ments in the States in which such cooperative 

16 offers or issues insurance coverage. 

17 (2) CONDITIONS.—A grant or loan may not be 

18 awarded under this subsection with respect to a co19 operative unless the following conditions are met: 

20 (A) The cooperative is structured as a not21 for-profit, member organization under the law 

22 of each State in which such cooperative offers, 

23 intends to offer, or issues insurance coverage, 

24 with the membership of the cooperative being 


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1 made up entirely of beneficiaries of the insur2 ance coverage offered by such cooperative. 

3 (B) The cooperative did not offer insur4 ance on or before July 16, 2009, and the coop5 erative is not an affiliate or successor to an in6 surance company offering insurance on or be7 fore such date. 

8 (C) The governing documents of the coop9 erative incorporate ethical and conflict of inter10 est standards designed to protect against insur11 ance industry involvement and interference in 

12 the governance of the cooperative. 

13 (D) The cooperative is not sponsored by a 

14 State government. 

15 (E) Substantially all of the activities of the 

16 cooperative consist of the issuance of qualified 

17 health benefits plans through the Health Insur18 ance Exchange or a State-based health insur19 ance exchange. 

20 (F) The cooperative is licensed to offer in21 surance in each State in which it offers insur22 ance. 

23 (G) The governance of the cooperative 

24 must be subject to a majority vote of its mem25 bers. 


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1 (H) As provided in guidance issued by the 

2 Secretary of Health and Human Services, the 

3 cooperative operates with a strong consumer 

4 focus, including timeliness, responsiveness, and 

5 accountability to members. 

6 (I) Any profits made by the cooperative 

7 are used to lower premiums, improve benefits, 

8 or to otherwise improve the quality of health 

9 care delivered to members. 

10 (3) PRIORITY.—The Commissioner, in making 

11 grants and loans under this subsection, shall give 

12 priority to cooperatives that— 

13 (A) operate on a statewide basis; 

14 (B) use an integrated delivery system; or 

15 (C) have a significant level of financial 

16 support from nongovernmental sources. 

17 (4) RULES OF CONSTRUCTION.—Nothing in 

18 this section shall be construed to prevent a coopera19 tive established in one State from integrating with a 

20 cooperative established in another State the adminis21 tration, issuance of coverage, or other activities re22 lated to acting as a QHBP offering entity. Nothing 

23 in this section shall be construed as preventing State 

24 governments from taking actions to permit such in25 tegration. 


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1 (5) AMORTIZATION OF GRANTS AND LOANS.— 

2 The Secretary shall provide for the repayment of 

3 grants or loans provided under this subsection to the 

4 Treasury in an amortized manner over a 10-year pe5 riod. 

6 (6) REPAYMENT FOR VIOLATIONS OF TERMS OF

7 PROGRAM.—If a cooperative violates the terms of the 

8 CO–OP program and fails to correct the violation 

9 within a reasonable period of time, as determined by 

10 the Commissioner, the cooperative shall repay the 

11 total amount of any loan or grant received by such 

12 cooperative under this section, plus interest (at a 

13 rate determined by the Secretary). 

14 (7) AUTHORIZATION OF APPROPRIATIONS.— 

15 There is authorized to be appropriated 

16 $5,000,000,000 for the period of fiscal years 2010 

17 through 2014 to provide for grants and loans under 

18 this subsection. 

19 (c) DEFINITIONS.—For purposes of this section: 

20 (1) STATE.—The term ‘‘State’’ means each of 

21 the 50 States and the District of Columbia. 

22 (2) MEMBER.—The term ‘‘member’’, with re23 spect to a cooperative, means an individual who, 

24 after the cooperative offers health insurance cov25 erage, is enrolled in such coverage. 


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1 SEC. 311. RETENTION OF DOD AND VA AUTHORITY. 

2 Nothing in this subtitle shall be construed as affect3 ing any authority under title 38, United States Code, or 

4 chapter 55 of title 10, United States Code. 

5 Subtitle B—Public Health 

6 Insurance Option 

7 SEC. 321. ESTABLISHMENT AND ADMINISTRATION OF A 

8 PUBLIC HEALTH INSURANCE OPTION AS AN 

9 EXCHANGE-QUALIFIED HEALTH BENEFITS 

10 PLAN. 

11 (a) ESTABLISHMENT.—For years beginning with Y1, 

12 the Secretary of Health and Human Services (in this sub13 title referred to as the ‘‘Secretary’’) shall provide for the 

14 offering of an Exchange-participating health benefits plan 

15 (in this division referred to as the ‘‘public health insurance 

16 option’’) that ensures choice, competition, and stability of 

17 affordable, high quality coverage throughout the United 

18 States in accordance with this subtitle. In designing the 

19 option, the Secretary’s primary responsibility is to create 

20 a low-cost plan without compromising quality or access to 

21 care. 

22 (b) OFFERING AS AN EXCHANGE-PARTICIPATING

23 HEALTH BENEFITS PLAN.— 

24 (1) EXCLUSIVE TO THE EXCHANGE.—The pub25 lic health insurance option shall only be made avail26 able through the Health Insurance Exchange. 


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1 (2) ENSURING A LEVEL PLAYING FIELD.—Con2 sistent with this subtitle, the public health insurance 

3 option shall comply with requirements that are ap4 plicable under this title to an Exchange-participating 

5 health benefits plan, including requirements related 

6 to benefits, benefit levels, provider networks, notices, 

7 consumer protections, and cost-sharing. 

8 (3) PROVISION OF BENEFIT LEVELS.—The pub9 lic health insurance option— 

10 (A) shall offer basic, enhanced, and pre11 mium plans; and 

12 (B) may offer premium-plus plans. 

13 (c) ADMINISTRATIVE CONTRACTING.—The Secretary 

14 may enter into contracts for the purpose of performing 

15 administrative functions (including functions described in 

16 subsection (a)(4) of section 1874A of the Social Security 

17 Act) with respect to the public health insurance option in 

18 the same manner as the Secretary may enter into con19 tracts under subsection (a)(1) of such section. The Sec20 retary has the same authority with respect to the public 

21 health insurance option as the Secretary has under sub22 sections (a)(1) and (b) of section 1874A of the Social Se23 curity Act with respect to title XVIII of such Act. Con24 tracts under this subsection shall not involve the transfer 

25 of insurance risk to such entity. 


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1 (d) OMBUDSMAN.—The Secretary shall establish an 

2 office of the ombudsman for the public health insurance 

3 option which shall have duties with respect to the public 

4 health insurance option similar to the duties of the Medi5 care Beneficiary Ombudsman under section 1808(c)(2) of 

6 the Social Security Act. 

7 (e) DATA COLLECTION.—The Secretary shall collect 

8 such data as may be required to establish premiums and 

9 payment rates for the public health insurance option and 

10 for other purposes under this subtitle, including to im11 prove quality and to reduce racial, ethnic, and other dis12 parities in health and health care. Nothing in this subtitle 

13 may be construed as authorizing the Secretary (or any em14 ployee or contractor) to create or maintain lists of non15 medical personal property. 

16 (f) TREATMENT OF PUBLIC HEALTH INSURANCE OP17 TION.—With respect to the public health insurance option, 

18 the Secretary shall be treated as a QHBP offering entity 

19 offering an Exchange-participating health benefits plan. 

20 (g) ACCESS TO FEDERAL COURTS.—The provisions 

21 of Medicare (and related provisions of title II of the Social 

22 Security Act) relating to access of Medicare beneficiaries 

23 to Federal courts for the enforcement of rights under 

24 Medicare, including with respect to amounts in con25 troversy, shall apply to the public health insurance option 


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1 and individuals enrolled under such option under this title 

2 in the same manner as such provisions apply to Medicare 

3 and Medicare beneficiaries. 

4 SEC. 322. PREMIUMS AND FINANCING. 

5 (a) ESTABLISHMENT OF PREMIUMS.— 

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

7 geographically adjusted premium rates for the public 

8 health insurance option— 

9 (A) in a manner that complies with the 

10 premium rules established by the Commissioner 

11 under section 213 for Exchange-participating 

12 health benefits plans; and 

13 (B) at a level sufficient to fully finance the 

14 costs of— 

15 (i) health benefits provided by the 

16 public health insurance option; and 

17 (ii) administrative costs related to op18 erating the public health insurance option. 

19 (2) CONTINGENCY MARGIN.—In establishing 

20 premium rates under paragraph (1), the Secretary 

21 shall include an appropriate amount for a contin22 gency margin (which shall be not less than 90 days 

23 of estimated claims). Before setting such appropriate 

24 amount for years starting with Y3, the Secretary 


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1 shall solicit a recommendation on such amount from 

2 the American Academy of Actuaries. 

3 (b) ACCOUNT.— 

4 (1) ESTABLISHMENT.—There is established in 

5 the Treasury of the United States an Account for 

6 the receipts and disbursements attributable to the 

7 operation of the public health insurance option, in8 cluding the start-up funding under paragraph (2). 

9 Section 1854(g) of the Social Security Act shall 

10 apply to receipts described in the previous sentence 

11 in the same manner as such section applies to pay12 ments or premiums described in such section. 

13 (2) START-UP FUNDING.— 

14 (A) IN GENERAL.—In order to provide for 

15 the establishment of the public health insurance 

16 option, there is hereby appropriated to the Sec17 retary, out of any funds in the Treasury not 

18 otherwise appropriated, $2,000,000,000. In 

19 order to provide for initial claims reserves be20 fore the collection of premiums, there are here21 by appropriated to the Secretary, out of any 

22 funds in the Treasury not otherwise appro23 priated, such sums as necessary to cover 90 

24 days worth of claims reserves based on pro25 jected enrollment. 


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1 (B) AMORTIZATION OF START-UP FUND2 ING.—The Secretary shall provide for the re3 payment of the startup funding provided under 

4 subparagraph (A) to the Treasury in an amor5 tized manner over the 10-year period beginning 

6 with Y1. 

7 (C) LIMITATION ON FUNDING.—Nothing in 

8 this section shall be construed as authorizing 

9 any additional appropriations to the Account, 

10 other than such amounts as are otherwise pro11 vided with respect to other Exchange-partici12 pating health benefits plans. 

13 (3) NO BAILOUTS.—In no case shall the public 

14 health insurance option receive any Federal funds 

15 for purposes of insolvency in any manner similar to 

16 the manner in which entities receive Federal funding 

17 under the Troubled Assets Relief Program of the 

18 Secretary of the Treasury. 

19 SEC. 323. PAYMENT RATES FOR ITEMS AND SERVICES. 

20 (a) NEGOTIATION OF PAYMENT RATES.— 

21 (1) IN GENERAL.—The Secretary shall nego22 tiate payment for the public health insurance option 

23 for health care providers and items and services, in24 cluding prescription drugs, consistent with this sec25 tion and section 324. 


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1 (2) MANNER OF NEGOTIATION.—The Secretary 

2 shall negotiate such rates in a manner that results 

3 in payment rates that are not lower, in the aggre4 gate, than rates under title XVIII of the Social Se5 curity Act, and not higher, in the aggregate, than 

6 the average rates paid by other QHBP offering enti7 ties for services and health care providers. 

8 (3) INNOVATIVE PAYMENT METHODS.—Nothing 

9 in this subsection shall be construed as preventing 

10 the use of innovative payment methods such as those 

11 described in section 324 in connection with the nego12 tiation of payment rates under this subsection. 

13 (b) ESTABLISHMENT OF A PROVIDER NETWORK.— 

14 (1) IN GENERAL.—Health care providers (in15 cluding physicians and hospitals) participating in 

16 Medicare are participating providers in the public 

17 health insurance option unless they opt out in a 

18 process established by the Secretary consistent with 

19 this subsection. 

20 (2) REQUIREMENTS FOR OPT-OUT PROCESS.— 

21 Under the process established under paragraph 

22 (1)— 

23 (A) providers described in such paragraph 

24 shall be provided at least a 1-year period prior 


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1 to the first day of Y1 to opt out of participating 

2 in the public health insurance option; 

3 (B) no provider shall be subject to a pen4 alty for not participating in the public health 

5 insurance option; 

6 (C) the Secretary shall include information 

7 on how providers participating in Medicare who 

8 chose to opt out of participating in the public 

9 health insurance option may opt back in; and 

10 (D) there shall be an annual enrollment 

11 period in which providers may decide whether 

12 to participate in the public health insurance op13 tion. 

14 (3) RULEMAKING.—Not later than 18 months 

15 before the first day of Y1, the Secretary shall pro16 mulgate rules (pursuant to notice and comment) for 

17 the process described in paragraph (1). 

18 (c) LIMITATIONS ON REVIEW.—There shall be no ad19 ministrative or judicial review of a payment rate or meth20 odology established under this section or under section 

21 324. 

22 SEC. 324. MODERNIZED PAYMENT INITIATIVES AND DELIV23 ERY SYSTEM REFORM. 

24 (a) IN GENERAL.—For plan years beginning with Y1, 

25 the Secretary may utilize innovative payment mechanisms 


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1 and policies to determine payments for items and services 

2 under the public health insurance option. The payment 

3 mechanisms and policies under this section may include 

4 patient-centered medical home and other care manage5 ment payments, accountable care organizations, value6 based purchasing, bundling of services, differential pay7 ment rates, performance or utilization based payments, 

8 partial capitation, and direct contracting with providers. 

9 (b) REQUIREMENTS FOR INNOVATIVE PAYMENTS.— 

10 The Secretary shall design and implement the payment 

11 mechanisms and policies under this section in a manner 

12 that— 

13 (1) seeks to— 

14 (A) improve health outcomes; 

15 (B) reduce health disparities (including ra16 cial, ethnic, and other disparities); 

17 (C) provide efficient and affordable care; 

18 (D) address geographic variation in the 

19 provision of health services; or 

20 (E) prevent or manage chronic illness; and 

21 (2) promotes care that is integrated, patient22 centered, quality, and efficient. 

23 (c) ENCOURAGING THE USE OF HIGH VALUE SERV24 ICES.—To the extent allowed by the benefit standards ap25 plied to all Exchange-participating health benefits plans, 


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1 the public health insurance option may modify cost-shar2 ing and payment rates to encourage the use of services 

3 that promote health and value. 

4 (d) PROMOTION OF DELIVERY SYSTEM REFORM.— 

5 The Secretary shall monitor and evaluate the progress of 

6 payment and delivery system reforms under this Act and 

7 shall seek to implement such reforms subject to the fol8 lowing: 

9 (1) To the extent that the Secretary finds a 

10 payment and delivery system reform successful in 

11 improving quality and reducing costs, the Secretary 

12 shall implement such reform on as large a geo13 graphic scale as practical and economical. 

14 (2) The Secretary may delay the implementa15 tion of such a reform in geographic areas in which 

16 such implementation would place the public health 

17 insurance option at a competitive disadvantage. 

18 (3) The Secretary may prioritize implementa19 tion of such a reform in high cost geographic areas 

20 or otherwise in order to reduce total program costs 

21 or to promote high value care. 

22 (e) NON-UNIFORMITY PERMITTED.—Nothing in this 

23 subtitle shall prevent the Secretary from varying payments 

24 based on different payment structure models (such as ac25 countable care organizations and medical homes) under 


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1 the public health insurance option for different geographic 

2 areas. 

3 SEC. 325. PROVIDER PARTICIPATION. 

4 (a) IN GENERAL.—The Secretary shall establish con5 ditions of participation for health care providers under the 

6 public health insurance option. 

7 (b) LICENSURE OR CERTIFICATION.— 

8 (1) IN GENERAL.—Except as provided in para9 graph (2), the Secretary shall not allow a health 

10 care provider to participate in the public health in11 surance option unless such provider is appropriately 

12 licensed, certified, or otherwise permitted to practice 

13 under State law. 

14 (2) SPECIAL RULE FOR IHS FACILITIES AND

15 PROVIDERS.—The requirements under paragraph (1) 

16 shall not apply to— 

17 (A) a facility that is operated by the In18 dian Health Service; 

19 (B) a facility operated by an Indian Tribe 

20 or tribal organization under the Indian Self-De21 termination Act (Public Law 93–638); 

22 (C) a health care professional employed by 

23 the Indian Health Service; or 

24 (D) a health care professional— 


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1 (i) who is employed to provide health 

2 care services in a facility operated by an 

3 Indian Tribe or tribal organization under 

4 the Indian Self-Determination Act; and 

5 (ii) who is licensed or certified in any 

6 State. 

7 (c) PAYMENT TERMS FOR PROVIDERS.— 

8 (1) PHYSICIANS.—The Secretary shall provide 

9 for the annual participation of physicians under the 

10 public health insurance option, for which payment 

11 may be made for services furnished during the year, 

12 in one of 2 classes: 

13 (A) PREFERRED PHYSICIANS.—Those phy14 sicians who agree to accept the payment under 

15 section 323 (without regard to cost-sharing) as 

16 the payment in full. 

17 (B) PARTICIPATING, NON-PREFERRED

18 PHYSICIANS.—Those physicians who agree not 

19 to impose charges (in relation to the payment 

20 described in section 323 for such physicians) 

21 that exceed the sum of the in-network cost22 sharing plus 15 percent of the total payment 

23 for each item and service. The Secretary shall 

24 reduce the payment described in section 323 for 

25 such physicians. 


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1 (2) OTHER PROVIDERS.—The Secretary shall 

2 provide for the participation (on an annual or other 

3 basis specified by the Secretary) of health care pro4 viders (other than physicians) under the public 

5 health insurance option under which payment shall 

6 only be available if the provider agrees to accept the 

7 payment under section 323 (without regard to cost8 sharing) as the payment in full. 

9 (d) EXCLUSION OF CERTAIN PROVIDERS.—The Sec10 retary shall exclude from participation under the public 

11 health insurance option a health care provider that is ex12 cluded from participation in a Federal health care pro13 gram (as defined in section 1128B(f) of the Social Secu14 rity Act). 

15 SEC. 326. APPLICATION OF FRAUD AND ABUSE PROVI16 SIONS. 

17 Provisions of civil law identified by the Secretary by 

18 regulation, in consultation with the Inspector General of 

19 the Department of Health and Human Services, that im20 pose sanctions with respect to waste, fraud, and abuse 

21 under Medicare, such as sections 3729 through 3733 of 

22 title 31, United States Code (commonly known as the 

23 False Claims Act), shall also apply to the public health 

24 insurance option. 


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1 SEC. 327. APPLICATION OF HIPAA INSURANCE REQUIRE2 MENTS. 

3 The requirements of sections 2701 through 2792 of 

4 the Public Health Service Act shall apply to the public 

5 health insurance option in the same manner as they apply 

6 to health insurance coverage offered by a health insurance 

7 issuer in the individual market. 

8 SEC. 328. APPLICATION OF HEALTH INFORMATION PRI9 VACY, SECURITY, AND ELECTRONIC TRANS10 ACTION REQUIREMENTS. 

11 Part C of title XI of the Social Security Act, relating 

12 to standards for protections against the wrongful disclo13 sure of individually identifiable health information, health 

14 information security, and the electronic exchange of health 

15 care information, shall apply to the public health insur16 ance option in the same manner as such part applies to 

17 other health plans (as defined in section 1171(5) of such 

18 Act). 

19 SEC. 329. ENROLLMENT IN PUBLIC HEALTH INSURANCE 

20 OPTION IS VOLUNTARY. 

21 Nothing in this division shall be construed as requir22 ing anyone to enroll in the public health insurance option. 

23 Enrollment in such option is voluntary. 


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1 SEC. 330. ENROLLMENT IN PUBLIC HEALTH INSURANCE 

2 OPTION BY MEMBERS OF CONGRESS. 

3 Notwithstanding any other provision of this Act, 

4 Members of Congress may enroll in the public health in5 surance option. 

6 SEC. 331. REIMBURSEMENT OF SECRETARY OF VETERANS 

7 AFFAIRS. 

8 The Secretary of Health and Human Services shall 

9 seek to enter into a memorandum of understanding with 

10 the Secretary of Veterans Affairs regarding the recovery 

11 of costs related to non-service-connected care or services 

12 provided by the Secretary of Veterans Affairs to an indi13 vidual covered under the public health insurance option 

14 in a manner consistent with recovery of costs related to 

15 non-service-connected care from private health insurance 

16 plans. 

17 Subtitle C—Individual 

18 Affordability Credits 

19 SEC. 341. AVAILABILITY THROUGH HEALTH INSURANCE EX20 CHANGE. 

21 (a) IN GENERAL.—Subject to the succeeding provi22 sions of this subtitle, in the case of an affordable credit 

23 eligible individual enrolled in an Exchange-participating 

24 health benefits plan— 


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1 (1) the individual shall be eligible for, in accord2 ance with this subtitle, affordability credits con3 sisting of— 

4 (A) an affordability premium credit under 

5 section 343 to be applied against the premium 

6 for the Exchange-participating health benefits 

7 plan in which the individual is enrolled; and 

8 (B) an affordability cost-sharing credit 

9 under section 344 to be applied as a reduction 

10 of the cost-sharing otherwise applicable to such 

11 plan; and 

12 (2) the Commissioner shall pay the QHBP of13 fering entity that offers such plan from the Health 

14 Insurance Exchange Trust Fund the aggregate 

15 amount of affordability credits for all affordable 

16 credit eligible individuals enrolled in such plan. 

17 (b) APPLICATION.— 

18 (1) IN GENERAL.—An Exchange eligible indi19 vidual may apply to the Commissioner through the 

20 Health Insurance Exchange or through another enti21 ty under an arrangement made with the Commis22 sioner, in a form and manner specified by the Com23 missioner. The Commissioner through the Health 

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1 sioner shall make a determination as to eligibility of 

2 an individual for affordability credits under this sub3 title. The Commissioner shall establish a process 

4 whereby, on the basis of information otherwise avail5 able, individuals may be deemed to be affordable 

6 credit eligible individuals. In carrying this subtitle, 

7 the Commissioner shall establish effective methods 

8 that ensure that individuals with limited English 

9 proficiency are able to apply for affordability credits. 

10 (2) USE OF STATE MEDICAID AGENCIES.—If 

11 the Commissioner determines that a State Medicaid 

12 agency has the capacity to make a determination of 

13 eligibility for affordability credits under this subtitle 

14 and under the same standards as used by the Com15 missioner, under the Medicaid memorandum of un16 derstanding under section 305(e)(2)— 

17 (A) the State Medicaid agency is author18 ized to conduct such determinations for any Ex19 change-eligible individual who requests such a 

20 determination; and 

21 (B) the Commissioner shall reimburse the 

22 State Medicaid agency for the costs of con23 ducting such determinations. 

24 (3) MEDICAID SCREEN AND ENROLL OBLIGA25 TION.—In the case of an application made under 


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1 paragraph (1), there shall be a determination of 

2 whether the individual is a Medicaid-eligible indi3 vidual. If the individual is determined to be so eligi4 ble, the Commissioner, through the Medicaid memo5 randum of understanding under section 305(e)(2), 

6 shall provide for the enrollment of the individual 

7 under the State Medicaid plan in accordance with 

8 such Medicaid memorandum of understanding. In 

9 the case of such an enrollment, the State shall pro10 vide for the same periodic redetermination of eligi11 bility under Medicaid as would otherwise apply if the 

12 individual had directly applied for medical assistance 

13 to the State Medicaid agency. 

14 (4) APPLICATION AND VERIFICATION OF RE15 QUIREMENT OF CITIZENSHIP OR LAWFUL PRESENCE

16 IN THE UNITED STATES.— 

17 (A) REQUIREMENT.—No individual shall 

18 be an affordable credit eligible individual (as 

19 defined in section 342(a)(1)) unless the indi20 vidual is a citizen or national of the United 

21 States or is lawfully present in a State in the 

22 United States (other than as a nonimmigrant 

23 described in a subparagraph (excluding sub24 paragraphs (K), (T), (U), and (V)) of section 


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1 101(a)(15) of the Immigration and Nationality 

2 Act). 

3 (B) DECLARATION OF CITIZENSHIP OR

4 LAWFUL IMMIGRATION STATUS.—No individual 

5 shall be an affordable credit eligible individual 

6 unless there has been a declaration made, in a 

7 form and manner specified by the Health 

8 Choices Commissioner similar to the manner re9 quired under section 1137(d)(1) of the Social 

10 Security Act and under penalty of perjury, that 

11 the individual— 

12 (i) is a citizen or national of the 

13 United States; or 

14 (ii) is not such a citizen or national 

15 but is lawfully present in a State in the 

16 United States (other than as a non17 immigrant described in a subparagraph 

18 (excluding subparagraphs (K), (T), (U), 

19 and (V)) of section 101(a)(15) of the Im20 migration and Nationality Act). 

21 Such declaration shall be verified in accordance 

22 with subparagraph (C) or (D), as the case may 

23 be. 

24 (C) VERIFICATION PROCESS FOR CITI25 ZENS.— 


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1 (i) IN GENERAL.—In the case of an 

2 individual making the declaration described 

3 in subparagraph (B)(i), subject to clause 

4 (ii), section 1902(ee) of the Social Security 

5 Act shall apply to such declaration in the 

6 same manner as such section applies to a 

7 declaration described in paragraph (1) of 

8 such section. 

9 (ii) SPECIAL RULES.—In applying sec10 tion 1902(ee) of such Act under clause 

11 (i)— 

12 (I) any reference in such section 

13 to a State is deemed a reference to 

14 the Commissioner (or other public en15 tity making the eligibility determina16 tion); 

17 (II) any reference to medical as18 sistance or enrollment under a State 

19 plan is deemed a reference to provi20 sion of affordability credits under this 

21 subtitle; 

22 (III) a reference to a newly en23 rolled individual under paragraph 

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1 ceipt of an affordability credit under 

2 this subtitle; 

3 (IV) approval by the Secretary 

4 shall not be required in applying para5 graph (2)(B)(ii) of such section; 

6 (V) paragraph (3) of such section 

7 shall not apply; and 

8 (VI) before the end of Y2, the 

9 Health Choices Commissioner, in con10 sultation with the Commissioner of 

11 Social Security, may extend the peri12 ods specified in paragraph (1)(B)(ii) 

13 of such section. 

14 (D) VERIFICATION PROCESS FOR NONCITI15 ZENS.— 

16 (i) IN GENERAL.—In the case of an 

17 individual making the declaration described 

18 in subparagraph (B)(ii), subject to clause 

19 (ii), the verification procedures of para20 graphs (2) through (5) of section 1137(d) 

21 of the Social Security Act shall apply to 

22 such declaration in the same manner as 

23 such procedures apply to a declaration de24 scribed in paragraph (1) of such section. 


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1 (ii) SPECIAL RULES.—In applying 

2 such paragraphs of section 1137(d) of such 

3 Act under clause (i)— 

4 (I) any reference in such para5 graphs to a State is deemed a ref6 erence to the Health Choices Commis7 sioner; and 

8 (II) any reference to benefits 

9 under a program is deemed a ref10 erence to affordability credits under 

11 this subtitle. 

12 (iii) APPLICATION TO STATE-BASED

13 EXCHANGES.—In the case of the applica14 tion of the verification process under this 

15 subparagraph to a State-based Health In16 surance Exchange approved under section 

17 308, section 1137(e) of such Act shall 

18 apply to the Health Choices Commissioner 

19 in relation to the State. 

20 (E) ANNUAL REPORTS.—The Health 

21 Choices Commissioner shall report to Congress 

22 annually on the number of applicants for af23 fordability credits under this subtitle, their citi24 zenship or immigration status, and the disposi25 tion of their applications. Such report shall be 


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1 made publicly available and shall include infor2 mation on— 

3 (i) the number of applicants whose 

4 declaration of citizenship or immigration 

5 status, name, or social security account 

6 number was not consistent with records 

7 maintained by the Commissioner of Social 

8 Security or the Department of Homeland 

9 Security and, of such applicants, the num10 ber who contested the inconsistency and 

11 sought to document their citizenship or im12 migration status, name, or social security 

13 account number or to correct the informa14 tion maintained in such records and, of 

15 those, the results of such contestations; 

16 and 

17 (ii) the administrative costs of con18 ducting the status verification under this 

19 paragraph. 

20 (F) GAO REPORT.—Not later than the end 

21 of Y2, the Comptroller General of the United 

22 States shall submit to the Committee on Ways 

23 and Means, the Committee on Energy and 

24 Commerce, the Committee on Education and 

25 Labor, and the Committee on the Judiciary of 


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1 the House of Representatives and the Com2 mittee on Finance, the Committee on Health, 

3 Education, Labor, and Pensions, and the Com4 mittee on the Judiciary of the Senate a report 

5 examining the effectiveness of the citizenship 

6 and immigration verification systems applied 

7 under this paragraph. Such report shall include 

8 an analysis of the following: 

9 (i) The causes of erroneous deter10 minations under such systems. 

11 (ii) The effectiveness of the processes 

12 used in remedying such erroneous deter13 minations. 

14 (iii) The impact of such systems on 

15 individuals, health care providers, and Fed16 eral and State agencies, including the ef17 fect of erroneous determinations under 

18 such systems. 

19 (iv) The effectiveness of such systems 

20 in preventing ineligible individuals from re21 ceiving for affordability credits. 

22 (v) The characteristics of applicants 

23 described in subparagraph (E)(i). 

24 (G) PROHIBITION OF DATABASE.—Nothing 

25 in this paragraph or the amendments made by 


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1 paragraph (6) shall be construed as authorizing 

2 the Health Choices Commissioner or the Com3 missioner of Social Security to establish a data4 base of information on citizenship or immigra5 tion status. 

6 (H) INITIAL FUNDING.— 

7 (i) IN GENERAL.—Out of any funds in 

8 the Treasury not otherwise appropriated, 

9 there is appropriated to the Commissioner 

10 of Social Security $30,000,000, to be avail11 able without fiscal year limit to carry out 

12 this paragraph and section 205(v) of the 

13 Social Security Act. 

14 (ii) FUNDING LIMITATION.—In no 

15 case shall funds from the Social Security 

16 Administration’s Limitation on Adminis17 trative Expenses be used to carry out ac18 tivities related to this paragraph or section 

19 205(v) of the Social Security Act. 

20 (5) AGREEMENT WITH SOCIAL SECURITY COM21 MISSIONER.— 

22 (A) IN GENERAL.—The Health Choices 

23 Commissioner shall enter into and maintain an 

24 agreement described in section 205(v)(2) of the 


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1 Social Security Act with the Commissioner of 

2 Social Security. 

3 (B) FUNDING.—The agreement entered 

4 into under subparagraph (A) shall, for each fis5 cal year (beginning with fiscal year 2013)— 

6 (i) provide funds to the Commissioner 

7 of Social Security for the full costs of the 

8 responsibilities of the Commissioner of So9 cial Security under paragraph (4), includ10 ing— 

11 (I) acquiring, installing, and 

12 maintaining technological equipment 

13 and systems necessary for the fulfill14 ment of the responsibilities of the 

15 Commissioner of Social Security 

16 under paragraph (4), but only that 

17 portion of such costs that are attrib18 utable to such responsibilities; and 

19 (II) responding to individuals 

20 who contest with the Commissioner of 

21 Social Security a reported inconsist22 ency with records maintained by the 

23 Commissioner of Social Security or 

24 the Department of Homeland Security 

25 relating to citizenship or immigration 


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1 status, name, or social security ac2 count number under paragraph (4); 

3 (ii) based on an estimating method4 ology agreed to by the Commissioner of 

5 Social Security and the Health Choices 

6 Commissioner, provide such funds, within 

7 10 calendar days of the beginning of the 

8 fiscal year for the first quarter and in ad9 vance for all subsequent quarters in that 

10 fiscal year; and 

11 (iii) provide for an annual accounting 

12 and reconciliation of the actual costs in13 curred and the funds provided under the 

14 agreement. 

15 (C) REVIEW OF ACCOUNTING.—The an16 nual accounting and reconciliation conducted 

17 pursuant to subparagraph (B)(iii) shall be re18 viewed by the Inspectors General of the Social 

19 Security Administration and the Health Choices 

20 Administration, including an analysis of consist21 ency with the requirements of paragraph (4). 

22 (D) CONTINGENCY.—In any case in which 

23 agreement with respect to the provisions re24 quired under subparagraph (B) for any fiscal 

25 year has not been reached as of the first day 


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1 of such fiscal year, the latest agreement with 

2 respect to such provisions shall be deemed in ef3 fect on an interim basis for such fiscal year 

4 until such time as an agreement relating to 

5 such provisions is subsequently reached. In any 

6 case in which an interim agreement applies for 

7 any fiscal year under this subparagraph, the 

8 Commissioner of Social Security shall, not later 

9 than the first day of such fiscal year, notify the 

10 appropriate Committees of the Congress of the 

11 failure to reach the agreement with respect to 

12 such provisions for such fiscal year. Until such 

13 time as the agreement with respect to such pro14 visions has been reached for such fiscal year, 

15 the Commissioner of Social Security shall, not 

16 later than the end of each 90-day period after 

17 October 1 of such fiscal year, notify such Com18 mittees of the status of negotiations between 

19 such Commissioner and the Health Choices 

20 Commissioner in order to reach such an agree21 ment. 

22 (E) APPLICATION TO PUBLIC ENTITIES

23 ADMINISTERING AFFORDABILITY CREDITS.—If 

24 the Health Choices Commissioner provides for 

25 the conduct of verifications under paragraph 


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1 (4) through a public entity, the Health Choices 

2 Commissioner shall require the public entity to 

3 enter into an agreement with the Commissioner 

4 of Social Security which provides the same 

5 terms as the agreement described in this para6 graph (and section 205(v) of the Social Security 

7 Act) between the Health Choices Commissioner 

8 and the Commissioner of Social Security, except 

9 that the Health Choices Commissioner shall be 

10 responsible for providing funds for the Commis11 sioner of Social Security in accordance with 

12 subparagraphs (B) through (D). 

13 (6) AMENDMENTS TO SOCIAL SECURITY ACT.— 

14 (A) COORDINATION OF INFORMATION BE15 TWEEN SOCIAL SECURITY ADMINISTRATION AND

16 HEALTH CHOICES ADMINISTRATION.— 

17 (i) IN GENERAL.—Section 205 of the 

18 Social Security Act (42 U.S.C. 405) is 

19 amended by adding at the end the fol20 lowing new subsection: 

21 ‘‘Coordination of Information With Health Choices 

22 Administration 

23 ‘‘(v)(1) The Health Choices Commissioner may col24 lect and use the names and social security account num25 bers of individuals as required to provide for verification 


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1 of citizenship under subsection (b)(4)(C) of section 341 

2 of the Affordable Health Care for America Act in connec3 tion with determinations of eligibility for affordability 

4 credits under such section. 

5 ‘‘(2)(A) The Commissioner of Social Security shall 

6 enter into and maintain an agreement with the Health 

7 Choices Commissioner for the purpose of establishing, in 

8 compliance with the requirements of section 1902(ee) as 

9 applied pursuant to section 341(b)(4)(C) of the Affordable 

10 Health Care for America Act, a program for verifying in11 formation required to be collected by the Health Choices 

12 Commissioner under such section 341(b)(4)(C). 

13 ‘‘(B) The agreement entered into pursuant to sub14 paragraph (A) shall include such safeguards as are nec15 essary to ensure the maintenance of confidentiality of any 

16 information disclosed for purposes of verifying information 

17 described in subparagraph (A) and to provide procedures 

18 for permitting the Health Choices Commissioner to use 

19 the information for purposes of maintaining the records 

20 of the Health Choices Administration. 

21 ‘‘(C) The agreement entered into pursuant to sub22 paragraph (A) shall provide that information provided by 

23 the Commissioner of Social Security to the Health Choices 

24 Commissioner pursuant to the agreement shall be provided 


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1 at such time, at such place, and in such manner as the 

2 Commissioner of Social Security determines appropriate. 

3 ‘‘(D) Information provided by the Commissioner of 

4 Social Security to the Health Choices Commissioner pur5 suant to an agreement entered into pursuant to subpara6 graph (A) shall be considered as strictly confidential and 

7 shall be used only for the purposes described in this para8 graph and for carrying out such agreement. Any officer 

9 or employee or former officer or employee of the Health 

10 Choices Commissioner, or any officer or employee or 

11 former officer or employee of a contractor of the Health 

12 Choices Commissioner, who, without the written authority 

13 of the Commissioner of Social Security, publishes or com14 municates any information in such individual’s possession 

15 by reason of such employment or position as such an offi16 cer shall be guilty of a felony and, upon conviction thereof, 

17 shall be fined or imprisoned, or both, as described in sec18 tion 208. 

19 ‘‘(3) The agreement entered into under paragraph (2) 

20 shall provide for funding to the Commissioner of Social 

21 Security consistent with section 341(b)(5) of Affordable 

22 Health Care for America Act. 

23 ‘‘(4) This subsection shall apply in the case of a pub24 lic entity that conducts verifications under section 

25 341(b)(4) of the Affordable Health Care for America Act 


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1 and the obligations of this subsection shall apply to such 

2 an entity in the same manner as such obligations apply 

3 to the Health Choices Commissioner when such Commis4 sioner is conducting such verifications.’’. 

5 (ii) CONFORMING AMENDMENT.—Sec6 tion 205(c)(2)(C) of such Act (42 U.S.C. 

7 405(c)(2)(C)) is amended by adding at the 

8 end the following new clause: 

9 ‘‘(x) For purposes of the administration of the 

10 verification procedures described in section 341(b)(4) of 

11 the Affordable Health Care for America Act, the Health 

12 Choices Commissioner may collect and use social security 

13 account numbers as provided for in section 205(v)(1).’’. 

14 (B) IMPROVING THE INTEGRITY OF DATA

15 AND EFFECTIVENESS OF SAVE.—Section 

16 1137(d) of the Social Security Act (42 U.S.C. 

17 1320b–7(d)) is amended by adding at the end 

18 the following new paragraphs: 

19 ‘‘(6)(A) With respect to the use by any agency of the 

20 system described in subsection (b) by programs specified 

21 in subsection (b) or any other use of such system, the U.S. 

22 Citizenship and Immigration Services and any other agen23 cy charged with the management of the system shall es24 tablish appropriate safeguards necessary to protect and 


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1 improve the integrity and accuracy of data relating to indi2 viduals by— 

3 ‘‘(i) establishing a process though which such 

4 individuals are provided access to, and the ability to 

5 amend, correct, and update, their own personally 

6 identifiable information contained within the system; 

7 ‘‘(ii) providing a written response, without 

8 undue delay, to any individual who has made such 

9 a request to amend, correct, or update such individ10 ual’s own personally identifiable information con11 tained within the system; and 

12 ‘‘(iii) developing a written notice for user agen13 cies to provide to individuals who are denied a ben14 efit due to a determination of ineligibility based on 

15 a final verification determination under the system. 

16 ‘‘(B) The notice described in subparagraph (A)(ii) 

17 shall include— 

18 ‘‘(i) information about the reason for such no19 tice; 

20 ‘‘(ii) a description of the right of the recipient 

21 of the notice under subparagraph (A)(i) to contest 

22 such notice; 

23 ‘‘(iii) a description of the right of the recipient 

24 under subparagraph (A)(i) to access and attempt to 

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1 sonally identifiable information contained within 

2 records of the system described in paragraph (3); 

3 and 

4 ‘‘(iv) instructions on how to contest such notice 

5 and attempt to correct records of such system relat6 ing to the recipient, including contact information 

7 for relevant agencies.’’. 

8 (C) STREAMLINING ADMINISTRATION OF

9 VERIFICATION PROCESS FOR UNITED STATES

10 CITIZENS.—Section 1902(ee)(2) of the Social 

11 Security Act (42 U.S.C. 1396a(ee)(2)) is 

12 amended by adding at the end the following: 

13 ‘‘(D) In carrying out the verification procedures 

14 under this subsection with respect to a State, if the Com15 missioner of Social Security determines that the records 

16 maintained by such Commissioner are not consistent with 

17 an individual’s allegation of United States citizenship, 

18 pursuant to procedures which shall be established by the 

19 State in coordination with the Commissioner of Social Se20 curity, the Secretary of Homeland Security, and the Sec21 retary of Health and Human Services— 

22 ‘‘(i) the Commissioner of Social Security shall 

23 inform the State of the inconsistency; 

24 ‘‘(ii) upon being so informed of the inconsist25 ency, the State shall submit the information on the 


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1 individual to the Secretary of Homeland Security for 

2 a determination of whether the records of the De3 partment of Homeland Security indicate that the in4 dividual is a citizen; 

5 ‘‘(iii) upon making such determination, the De6 partment of Homeland Security shall inform the 

7 State of such determination; and 

8 ‘‘(iv) information provided by the Commissioner 

9 of Social Security shall be considered as strictly con10 fidential and shall only be used by the State and the 

11 Secretary of Homeland Security for the purposes of 

12 such verification procedures. 

13 ‘‘(E) Verification of status eligibility pursuant to the 

14 procedures established under this subsection shall be 

15 deemed a verification of status eligibility for purposes of 

16 this title, title XXI, and affordability credits under section 

17 341(b)(4) of the Affordable Health Care for America Act, 

18 regardless of the program in which the individual is apply19 ing for benefits.’’. 

20 (c) USE OF AFFORDABILITY CREDITS.— 

21 (1) IN GENERAL.—In Y1 and Y2 an affordable 

22 credit eligible individual may use an affordability 

23 credit only with respect to a basic plan. 

24 (2) FLEXIBILITY IN PLAN ENROLLMENT AU25 THORIZED.—Beginning with Y3, the Commissioner 


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1 shall establish a process to allow an affordability 

2 premium credit under section 343, but not the af3 fordability cost-sharing credit under section 344, to 

4 be used for enrollees in enhanced or premium plans. 

5 In the case of an affordable credit eligible individual 

6 who enrolls in an enhanced or premium plan, the in7 dividual shall be responsible for any difference be8 tween the premium for such plan and the afford9 ability credit amount otherwise applicable if the indi10 vidual had enrolled in a basic plan. 

11 (3) PROHIBITION OF USE OF PUBLIC FUNDS

12 FOR ABORTION COVERAGE.—An affordability credit 

13 may not be used for payment for services described 

14 in section 222(d)(4)(A). 

15 (d) ACCESS TO DATA.—In carrying out this subtitle, 

16 the Commissioner shall request from the Secretary of the 

17 Treasury consistent with section 6103 of the Internal Rev18 enue Code of 1986 such information as may be required 

19 to carry out this subtitle. 

20 (e) NO CASH REBATES.—In no case shall an afford21 able credit eligible individual receive any cash payment as 

22 a result of the application of this subtitle. 

23 SEC. 342. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL. 

24 (a) DEFINITION.— 


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1 (1) IN GENERAL.—For purposes of this divi2 sion, the term ‘‘affordable credit eligible individual’’ 

3 means, subject to subsection (b) and section 346, an 

4 individual who is lawfully present in a State in the 

5 United States (other than as a nonimmigrant de6 scribed in a subparagraph (excluding subparagraphs 

7 (K), (T), (U), and (V)) of section 101(a)(15) of the 

8 Immigration and Nationality Act)— 

9 (A) who is enrolled under an Exchange10 participating health benefits plan and is not en11 rolled under such plan as an employee (or de12 pendent of an employee) through an employer 

13 qualified health benefits plan that meets the re14 quirements of section 412; 

15 (B) with modified adjusted gross income 

16 below 400 percent of the Federal poverty level 

17 for a family of the size involved; 

18 (C) who is not a Medicaid eligible indi19 vidual, other than an individual during a transi20 tion period under section 302(d)(3)(B)(ii); and 

21 (D) subject to paragraph (3), who is not 

22 enrolled in acceptable coverage (other than an 

23 Exchange-participating health benefits plan). 

24 (2) TREATMENT OF FAMILY.—Except as the 

25 Commissioner may otherwise provide, members of 


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1 the same family who are affordable credit eligible in2 dividuals shall be treated as a single affordable cred3 it individual eligible for the applicable credit for such 

4 a family under this subtitle. 

5 (3) SPECIAL RULE FOR INDIANS.—Subpara6 graph (D) of paragraph (1) shall not apply to an in7 dividual who has coverage that is treated as accept8 able coverage for purposes of section 59B(d)(2) of 

9 the Internal Revenue Code of 1986 but is not treat10 ed as acceptable coverage for purposes of this divi11 sion. 

12 (b) LIMITATIONS ON EMPLOYEE AND DEPENDENT

13 DISQUALIFICATION.— 

14 (1) IN GENERAL.—Subject to paragraph (2), 

15 the term ‘‘affordable credit eligible individual’’ does 

16 not include a full-time employee of an employer if 

17 the employer offers the employee coverage (for the 

18 employee and dependents) as a full-time employee 

19 under a group health plan if the coverage and em20 ployer contribution under the plan meet the require21 ments of section 412. 

22 (2) EXCEPTIONS.— 

23 (A) FOR CERTAIN FAMILY CIR24 CUMSTANCES.—The Commissioner shall estab25 lish such exceptions and special rules in the 


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1 case described in paragraph (1) as may be ap2 propriate in the case of a divorced or separated 

3 individual or such a dependent of an employee 

4 who would otherwise be an affordable credit eli5 gible individual. 

6 (B) FOR UNAFFORDABLE EMPLOYER COV7 ERAGE.—Beginning in Y2, in the case of full8 time employees for which the cost of the em9 ployee premium for coverage under a group 

10 health plan would exceed 12 percent of current 

11 modified adjusted gross income (determined by 

12 the Commissioner on the basis of verifiable doc13 umentation), paragraph (1) shall not apply. 

14 (c) INCOME DEFINED.— 

15 (1) IN GENERAL.—In this title, the term ‘‘in16 come’’ means modified adjusted gross income (as de17 fined in section 59B of the Internal Revenue Code 

18 of 1986). 

19 (2) STUDY OF INCOME DISREGARDS.—The 

20 Commissioner shall conduct a study that examines 

21 the application of income disregards for purposes of 

22 this subtitle. Not later than the first day of Y2, the 

23 Commissioner shall submit to Congress a report on 

24 such study and shall include such recommendations 

25 as the Commissioner determines appropriate. 


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1 (d) CLARIFICATION OF TREATMENT OF AFFORD2 ABILITY CREDITS.—Affordability credits under this sub3 title shall not be treated, for purposes of title IV of the 

4 Personal Responsibility and Work Opportunity Reconcili5 ation Act of 1996, to be a benefit provided under section 

6 403 of such title. 

7 SEC. 343. AFFORDABILITY PREMIUM CREDIT. 

8 (a) IN GENERAL.—The affordability premium credit 

9 under this section for an affordable credit eligible indi10 vidual enrolled in an Exchange-participating health bene11 fits plan is in an amount equal to the amount (if any) 

12 by which the reference premium amount specified in sub13 section (c), exceeds the affordable premium amount speci14 fied in subsection (b) for the individual, except that in no 

15 case shall the affordable premium credit exceed the pre16 mium for the plan. 

17 (b) AFFORDABLE PREMIUM AMOUNT.— 

18 (1) IN GENERAL.—The affordable premium 

19 amount specified in this subsection for an individual 

20 for the annual premium in a plan year shall be equal 

21 to the product of— 

22 (A) the premium percentage limit specified 

23 in paragraph (2) for the individual based upon 

24 the individual’s modified adjusted gross income 

25 for the plan year; and 


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1 (B) the individual’s modified adjusted 

2 gross income for such plan year. 

3 (2) PREMIUM PERCENTAGE LIMITS BASED ON

4 TABLE.—The Commissioner shall establish premium 

5 percentage limits so that for individuals whose modi6 fied adjusted gross income is within an income tier 

7 specified in the table in subsection (d) such percent8 age limits shall increase, on a sliding scale in a lin9 ear manner, from the initial premium percentage to 

10 the final premium percentage specified in such table 

11 for such income tier. 

12 (c) REFERENCE PREMIUM AMOUNT.—The reference 

13 premium amount specified in this subsection for a plan 

14 year for an individual in a premium rating area is equal 

15 to the average premium for the 3 basic plans in the area 

16 for the plan year with the lowest premium levels. In com17 puting such amount the Commissioner may exclude plans 

18 with extremely limited enrollments. 

19 (d) TABLE OF PREMIUM PERCENTAGE LIMITS, AC20 TUARIAL VALUE PERCENTAGES, AND OUT-OF-POCKET

21 LIMITS FOR Y1 BASED ON INCOME TIER.— 

22 (1) IN GENERAL.—For purposes of this sub23 title, subject to paragraph (3) and section 346, the 

24 table specified in this subsection is as follows: 


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In the case of 

modified adjusted 

gross income (expressed as a percent of FPL) within the following income tier: 

The initial 

premium 

percentage 

is— 

The final 

premium 

percentage 

is— 

The actuarial value 

percentage 

is— 

The out-ofpocket limit 

for Y1 is— 

133% through 

150% 

1.5% 3.0% 97% $500 

150% through 

200% 

3.0% 5.5% 93% $1,000 

200% through 

250% 

5.5% 8.0% 85% $2,000 

250% through 

300% 

8.0% 10.0% 78% $4,000 

300% through 

350% 

10.0% 11.0% 72% $4,500 

350% through 

400% 

11.0% 12.0% 70% $5,000 

1 (2) SPECIAL RULES.—For purposes of applying 

2 the table under paragraph (1): 

3 (A) FOR LOWEST LEVEL OF INCOME.—In 

4 the case of an individual with income that does 

5 not exceed 133 percent of FPL, the individual 

6 shall be considered to have income that is 133 

7 percent of FPL. 

8 (B) APPLICATION OF HIGHER ACTUARIAL

9 VALUE PERCENTAGE AT TIER TRANSITION

10 POINTS.—If two actuarial value percentages 

11 may be determined with respect to an indi12 vidual, the actuarial value percentage shall be 

13 the higher of such percentages. 

14 (3) INDEXING.—For years after Y1, the Com15 missioner shall adjust the initial and final premium 

16 percentages to maintain the ratio of governmental to 


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1 enrollee shares of premiums over time, for each in2 come tier identified in the table in paragraph (1). 

3 SEC. 344. AFFORDABILITY COST-SHARING CREDIT. 

4 (a) IN GENERAL.—The affordability cost-sharing 

5 credit under this section for an affordable credit eligible 

6 individual enrolled in an Exchange-participating health 

7 benefits plan is in the form of the cost-sharing reduction 

8 described in subsection (b) provided under this section for 

9 the income tier in which the individual is classified based 

10 on the individual’s modified adjusted gross income. 

11 (b) COST-SHARING REDUCTIONS.—The Commis12 sioner shall specify a reduction in cost-sharing amounts 

13 and the annual limitation on cost-sharing specified in sec14 tion 222(c)(2)(B) under a basic plan for each income tier 

15 specified in the table under section 343(d), with respect 

16 to a year, in a manner so that, as estimated by the Com17 missioner— 

18 (1) the actuarial value of the coverage with 

19 such reduced cost-sharing amounts (and the reduced 

20 annual cost-sharing limit) is equal to the actuarial 

21 value percentage (specified in the table under section 

22 343(d) for the income tier involved) of the full actu23 arial value if there were no cost-sharing imposed 

24 under the plan; and 


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1 (2) the annual limitation on cost-sharing speci2 fied in section 222(c)(2)(B) is reduced to a level 

3 that does not exceed the maximum out-of-pocket 

4 limit specified in subsection (c). 

5 (c) MAXIMUM OUT-OF-POCKET LIMIT.— 

6 (1) IN GENERAL.—Subject to paragraph (2), 

7 the maximum out-of-pocket limit specified in this 

8 subsection for an individual within an income tier— 

9 (A) for individual coverage— 

10 (i) for Y1 is the out-of-pocket limit 

11 for Y1 specified in subsection (c) in the 

12 table under section 343(d) for the income 

13 tier involved; or 

14 (ii) for a subsequent year is such out15 of-pocket limit for the previous year under 

16 this subparagraph increased (rounded to 

17 the nearest $10) for each subsequent year 

18 by the percentage increase in the enroll19 ment-weighted average of premium in20 creases for basic plans applicable to such 

21 year; or 

22 (B) for family coverage is twice the max23 imum out-of-pocket limit under subparagraph 

24 (A) for the year involved. 


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1 (2) ADJUSTMENT.—The Commissioner shall ad2 just the maximum out-of-pocket limits under para3 graph (1) to ensure that such limits meet the actu4 arial value percentage specified in the table under 

5 section 343(d) for the income tier involved. 

6 (d) DETERMINATION AND PAYMENT OF COST-SHAR7 ING AFFORDABILITY CREDIT.—In the case of an afford8 able credit eligible individual in a tier enrolled in an Ex9 change-participating health benefits plan offered by a 

10 QHBP offering entity, the Commissioner shall provide for 

11 payment to the offering entity of an amount equivalent 

12 to the increased actuarial value of the benefits under the 

13 plan provided under section 303(c)(2)(B) resulting from 

14 the reduction in cost-sharing described in subsections (b) 

15 and (c). 

16 SEC. 345. INCOME DETERMINATIONS. 

17 (a) IN GENERAL.—In applying this subtitle for an 

18 affordability credit for an individual for a plan year, the 

19 individual’s income shall be the income (as defined in sec20 tion 342(c)) for the individual for the most recent taxable 

21 year (as determined in accordance with rules of the Com22 missioner). The Federal poverty level applied shall be such 

23 level in effect as of the date of the application. 

24 (b) PROGRAM INTEGRITY; INCOME VERIFICATION

25 PROCEDURES.— 


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1 (1) PROGRAM INTEGRITY.—The Commissioner 

2 shall take such steps as may be appropriate to en3 sure the accuracy of determinations and redeter4 minations under this subtitle. 

5 (2) INCOME VERIFICATION.— 

6 (A) IN GENERAL.—Upon an initial applica7 tion of an individual for an affordability credit 

8 under this subtitle (or in applying section 

9 342(b)) or upon an application for a change in 

10 the affordability credit based upon a significant 

11 change in modified adjusted gross income de12 scribed in subsection (c)(1)— 

13 (i) the Commissioner shall request 

14 from the Secretary of the Treasury the dis15 closure to the Commissioner of such infor16 mation as may be permitted to verify the 

17 information contained in such application; 

18 and 

19 (ii) the Commissioner shall use the in20 formation so disclosed to verify such infor21 mation. 

22 (B) ALTERNATIVE PROCEDURES.—The 

23 Commissioner shall establish procedures for the 

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1 title if no income tax return is available for the 

2 most recent completed tax year. 

3 (c) SPECIAL RULES.— 

4 (1) CHANGES IN INCOME AS A PERCENT OF

5 FPL.—In the case that an individual’s income (ex6 pressed as a percentage of the Federal poverty level 

7 for a family of the size involved) for a plan year is 

8 expected (in a manner specified by the Commis9 sioner) to be significantly different from the income 

10 (as so expressed) used under subsection (a), the 

11 Commissioner shall establish rules requiring an indi12 vidual to report, consistent with the mechanism es13 tablished under paragraph (2), significant changes 

14 in such income (including a significant change in 

15 family composition) to the Commissioner and requir16 ing the substitution of such income for the income 

17 otherwise applicable. 

18 (2) REPORTING OF SIGNIFICANT CHANGES IN

19 INCOME.—The Commissioner shall establish rules 

20 under which an individual determined to be an af21 fordable credit eligible individual would be required 

22 to inform the Commissioner when there is a signifi23 cant change in the modified adjusted gross income 

24 of the individual (expressed as a percentage of the 

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1 formation regarding such change. Such mechanism 

2 shall provide for guidelines that specify the cir3 cumstances that qualify as a significant change, the 

4 verifiable information required to document such a 

5 change, and the process for submission of such in6 formation. If the Commissioner receives new infor7 mation from an individual regarding the modified 

8 adjusted gross income of the individual, the Commis9 sioner shall provide for a redetermination of the in10 dividual’s eligibility to be an affordable credit eligible 

11 individual. 

12 (3) TRANSITION FOR CHIP.—In the case of a 

13 child described in section 302(d)(2), the Commis14 sioner shall establish rules under which the modified 

15 adjusted gross income of the child is deemed to be 

16 no greater than the family income of the child as 

17 most recently determined before Y1 by the State 

18 under title XXI of the Social Security Act. 

19 (4) STUDY OF GEOGRAPHIC VARIATION IN AP20 PLICATION OF FPL.— 

21 (A) IN GENERAL.—The Secretary of 

22 Health and Human Services shall conduct a 

23 study to examine the feasibility and implication 

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1 graphic areas so as to reflect the variations in 

2 cost-of-living among different areas within the 

3 United States. If the Secretary determines that 

4 an adjustment is feasible, the study should in5 clude a methodology to make such an adjust6 ment. Not later than the first day of Y1, the 

7 Secretary shall submit to Congress a report on 

8 such study and shall include such recommenda9 tions as the Secretary determines appropriate. 

10 (B) INCLUSION OF TERRITORIES.— 

11 (i) IN GENERAL.—The Secretary shall 

12 ensure that the study under subparagraph 

13 (A) covers the territories of the United 

14 States and that special attention is paid to 

15 the disparity that exists among poverty lev16 els and the cost of living in such territories 

17 and to the impact of such disparity on ef18 forts to expand health coverage and ensure 

19 health care. 

20 (ii) TERRITORIES DEFINED.—In this 

21 subparagraph, the term ‘‘territories of the 

22 United States’’ includes the Common23 wealth of Puerto Rico, the United States 

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1 iana Islands, and any other territory or 

2 possession of the United States. 

3 (d) PENALTIES FOR MISREPRESENTATION.—In the 

4 case of an individual who intentionally misrepresents 

5 modified adjusted gross income or the individual fails 

6 (without regard to intent) to disclose to the Commissioner 

7 a significant change in modified adjusted gross income 

8 under subsection (c) in a manner that results in the indi9 vidual becoming an affordable credit eligible individual 

10 when the individual is not or in the amount of the afford11 ability credit exceeding the correct amount— 

12 (1) the individual is liable for repayment of the 

13 amount of the improper affordability credit; and 

14 (2) in the case of such an intentional misrepre15 sentation or other egregious circumstances specified 

16 by the Commissioner, the Commissioner may impose 

17 an additional penalty. 

18 SEC. 346. SPECIAL RULES FOR APPLICATION TO TERRI19 TORIES. 

20 (a) ONE-TIME ELECTION FOR TREATMENT AND AP21 PLICATION OF FUNDING.— 

22 (1) IN GENERAL.—A territory may elect, in a 

23 form and manner specified by the Commissioner in 

24 consultation with the Secretary of Health and 


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1 Human Services and the Secretary of the Treasury 

2 and not later than October 1, 2012, either— 

3 (A) to be treated as a State for purposes 

4 of applying this title and title II; or 

5 (B) not to be so treated but instead, to 

6 have the dollar limitation otherwise applicable 

7 to the territory under subsections (f) and (g) of 

8 section 1108 of the Social Security Act (42 

9 U.S.C. 1308) for a fiscal year increased by a 

10 dollar amount equivalent to the cap amount de11 termined under subsection (c)(2) for the terri12 tory as applied by the Secretary for the fiscal 

13 year involved. 

14 (2) CONDITIONS FOR ACCEPTANCE.—The Com15 missioner has the nonreviewable authority to accept 

16 or reject an election described in paragraph (1)(A). 

17 Any such acceptance is— 

18 (A) contingent upon entering into an 

19 agreement described in subsection (b) between 

20 the Commissioner and the territory and sub21 section (c); and 

22 (B) subject to the approval of the Sec23 retary of Health and Human Services and the 

24 Secretary of the Treasury and subject to such 

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1 sioner, in consultation with such Secretaries, 

2 may specify. 

3 (3) DEFAULT RULE.—A territory failing to 

4 make such an election (or having an election under 

5 paragraph (1)(A) not accepted under paragraph (2)) 

6 shall be treated as having made the election de7 scribed in paragraph (1)(B). 

8 (b) AGREEMENT FOR SUBSTITUTION OF PERCENT9 AGES FOR AFFORDABILITY CREDITS.— 

10 (1) NEGOTIATION.—In the case of a territory 

11 making an election under subsection (a)(1)(A) (in 

12 this section referred to as an ‘‘electing territory’’) , 

13 the Commissioner, in consultation with the Secre14 taries of Health and Human Services and the Treas15 ury, shall enter into negotiations with the govern16 ment of such territory so that, before Y1, there is 

17 an agreement reached between the parties on the 

18 percentages that shall be applied under paragraph 

19 (2) for that territory. The Commissioner shall not 

20 enter into such an agreement unless— 

21 (A) payments made under this subtitle 

22 with respect to residents of the territory are 

23 consistent with the cap established under sub24 section (c) for such territory and with sub25 section (d); and 


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1 (B) the requirements of paragraphs (3) 

2 and (4) are met. 

3 (2) APPLICATION OF SUBSTITUTE PERCENT4 AGES AND DOLLAR AMOUNTS.—In the case of an 

5 electing territory, there shall be substituted in sec6 tion 342(a)(1)(B) and in the table in section 

7 341(d)(1) for 400 percent, 133 percent, and other 

8 percentages and dollar amounts specified in such 

9 table, such respective percentages and dollar 

10 amounts as are established under the agreement 

11 under paragraph (1) consistent with the following: 

12 (A) NO INCOME GAP BETWEEN MEDICAID

13 AND AFFORDABILITY CREDITS.—The sub14 stituted percentages shall be specified in a man15 ner so as to prevent any gap in coverage for in16 dividuals between income level at which medical 

17 assistance is available through Medicaid and 

18 the income level at which affordability credits 

19 are available. 

20 (B) ADJUSTMENT FOR OUT-OF-POCKET

21 RESPONSIBILITY FOR PREMIUMS AND COST22 SHARING IN RELATION TO INCOME.—The sub23 stituted percentages of FPL for income tiers 

24 under such table shall be specified in a manner 

25 so that— 


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1 (i) affordable credit eligible individ2 uals residing in the territory bear the same 

3 out-of-pocket responsibility for premiums 

4 and cost-sharing in relation to average in5 come for residents in that territory, as 

6 (ii) the out-of-pocket responsibility for 

7 premiums and cost-sharing for affordable 

8 credit eligible individuals residing in the 50 

9 States or the District of Columbia in rela10 tion to average income for such residents. 

11 (3) SPECIAL RULES WITH RESPECT TO APPLI12 CATION OF TAX AND PENALTY PROVISIONS.—The 

13 electing territory shall enact one or more laws under 

14 which provisions similar to the following provisions 

15 apply with respect to such territory: 

16 (A) Section 59B of the Internal Revenue 

17 Code of 1986, except that any resident of the 

18 territory who is not an affordable credit eligible 

19 individual but who would be an affordable cred20 it eligible individual if such resident were a resi21 dent of one of the 50 States (and any quali22 fying child residing with such individual) may 

23 be treated as covered by acceptable coverage. 

24 (B) Section 4980H of the Internal Rev25 enue Code of 1986 and section 502(c)(11) of 


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1 the Employee Retirement Income Security Act 

2 of 1974. 

3 (C) Section 3121(c) of the Internal Rev4 enue Code of 1986. 

5 (4) IMPLEMENTATION OF INSURANCE REFORM

6 AND CONSUMER PROTECTION REQUIREMENTS.—The 

7 electing territory shall enact and implement such 

8 laws and regulations as may be required to apply the 

9 requirements of title II with respect to health insur10 ance coverage offered in the territory. 

11 (c) CAP ON ADDITIONAL EXPENDITURES.— 

12 (1) IN GENERAL.—In entering into an agree13 ment with an electing territory under subsection (b), 

14 the Commissioner shall ensure that the aggregate 

15 expenditures under this subtitle with respect to resi16 dents of such territory during the period beginning 

17 with Y1 and ending with 2019 will not exceed the 

18 cap amount specified in paragraph (2) for such ter19 ritory. The Commissioner shall adjust from time to 

20 time the percentages applicable under such agree21 ment as needed in order to carry out the previous 

22 sentence. 

23 (2) CAP AMOUNT.— 

24 (A) IN GENERAL.—The cap amount speci25 fied in this paragraph— 


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1 (i) for Puerto Rico is $3,700,000,000 

2 increased by the amount (if any) elected 

3 under subparagraph (C); or 

4 (ii) for another territory is the portion 

5 of $300,000,000 negotiated for such terri6 tory under subparagraph (B). 

7 (B) NEGOTIATION FOR CERTAIN TERRI8 TORIES.—The Commissioner in consultation 

9 with the Secretary of Health and Human Serv10 ices shall negotiate with the governments of the 

11 territories (other than Puerto Rico) to allocate 

12 the amount specified in subparagraph (A)(ii) 

13 among such territories. 

14 (C) OPTIONAL SUPPLEMENTATION FOR

15 PUERTO RICO.— 

16 (i) IN GENERAL.—Puerto Rico may 

17 elect, in a form and manner specified by 

18 the Secretary of Health and Human Serv19 ices in consultation with the Commissioner 

20 to increase the dollar amount specified in 

21 subparagraph (A)(i) by up to 

22 $1,000,000,000. 

23 (ii) OFFSET IN MEDICAID CAP.—If 

24 Puerto Rico makes the election described 

25 in clause (i), the Secretary shall decrease 


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1 the dollar limitation otherwise applicable to 

2 Puerto Rico under subsections (f) and (g) 

3 of section 1108 of the Social Security Act 

4 (42 U.S.C. 1308) for a fiscal year by the 

5 additional aggregate payments the Sec6 retary estimates will be payable under this 

7 section for the fiscal year because of such 

8 election. 

9 (d) LIMITATION ON FUNDING.—In no case shall this 

10 section (including the agreement under subsection (b)) 

11 permit— 

12 (1) the obligation of funds for expenditures 

13 under this subtitle for periods beginning on or after 

14 January 1, 2020; or 

15 (2) any increase in the dollar limitation de16 scribed in subsection (a)(1)(B) for any portion of 

17 any fiscal year occurring on or after such date. 

18 SEC. 347. NO FEDERAL PAYMENT FOR UNDOCUMENTED 

19 ALIENS. 

20 Nothing in this subtitle shall allow Federal payments 

21 for affordability credits on behalf of individuals who are 

22 not lawfully present in the United States. 


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1 TITLE IV—SHARED 

2 RESPONSIBILITY 

3 Subtitle A—Individual 

4 Responsibility 

5 SEC. 401. INDIVIDUAL RESPONSIBILITY. 

6 For an individual’s responsibility to obtain acceptable 

7 coverage, see section 59B of the Internal Revenue Code 

8 of 1986 (as added by section 501 of this Act). 

9 Subtitle B—Employer 

10 Responsibility 

11 PART 1—HEALTH COVERAGE PARTICIPATION 

12 REQUIREMENTS 

13 SEC. 411. HEALTH COVERAGE PARTICIPATION REQUIRE14 MENTS. 

15 An employer meets the requirements of this section 

16 if such employer does all of the following: 

17 (1) OFFER OF COVERAGE.—The employer of18 fers each employee individual and family coverage 

19 under a qualified health benefits plan (or under a 

20 current employment-based health plan (within the 

21 meaning of section 202(b))) in accordance with sec22 tion 412. 

23 (2) CONTRIBUTION TOWARDS COVERAGE.—If 

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1 ployer makes timely contributions towards such cov2 erage in accordance with section 412. 

3 (3) CONTRIBUTION IN LIEU OF COVERAGE.— 

4 Beginning with Y2, if an employee declines such 

5 offer but otherwise obtains coverage in an Exchange6 participating health benefits plan (other than by rea7 son of being covered by family coverage as a spouse 

8 or dependent of the primary insured), the employer 

9 shall make a timely contribution to the Health In10 surance Exchange with respect to each such em11 ployee in accordance with section 413. 

12 SEC. 412. EMPLOYER RESPONSIBILITY TO CONTRIBUTE TO13 WARD EMPLOYEE AND DEPENDENT COV14 ERAGE. 

15 (a) IN GENERAL.—An employer meets the require16 ments of this section with respect to an employee if the 

17 following requirements are met: 

18 (1) OFFERING OF COVERAGE.—The employer 

19 offers the coverage described in section 411(1). In 

20 the case of an Exchange-eligible employer, the em21 ployer may offer such coverage either through an 

22 Exchange-participating health benefits plan or other 

23 than through such a plan. 

24 (2) EMPLOYER REQUIRED CONTRIBUTION.— 

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1 erage an amount not less than the employer required 

2 contribution specified in subsection (b) for such cov3 erage. 

4 (3) PROVISION OF INFORMATION.—The em5 ployer provides the Health Choices Commissioner, 

6 the Secretary of Labor, the Secretary of Health and 

7 Human Services, and the Secretary of the Treasury, 

8 as applicable, with such information as the Commis9 sioner may require to ascertain compliance with the 

10 requirements of this section, including the following: 

11 (A) The name, date, and employer identi12 fication number of the employer. 

13 (B) A certification as to whether the em14 ployer offers to its full-time employees (and 

15 their dependents) the opportunity to enroll in a 

16 qualified health benefits plan or a current em17 ployment-based health plan (within the meaning 

18 of section 202(b)). 

19 (C) If the employer certifies that the em20 ployer did offer to its full-time employees (and 

21 their dependents) the opportunity to so enroll— 

22 (i) the months during the calendar 

23 year for which such coverage was available; 

24 and 


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1 (ii) the monthly premium for the low2 est cost option in each of the enrollment 

3 categories under each such plan offered to 

4 employees. 

5 (D) The name, address, and TIN of each 

6 full-time employee during the calendar year and 

7 the months (if any) during which such employee 

8 (and any dependents) were covered under any 

9 such plans. 

10 (4) AUTOENROLLMENT OF EMPLOYEES.—The 

11 employer provides for autoenrollment of the em12 ployee in accordance with subsection (c). 

13 This subsection shall supersede any law of a State which 

14 would prevent automatic payroll deduction of employee 

15 contributions to an employment-based health plan. 

16 (b) REDUCTION OF EMPLOYEE PREMIUMS THROUGH

17 MINIMUM EMPLOYER CONTRIBUTION.— 

18 (1) FULL-TIME EMPLOYEES.—The minimum 

19 employer contribution described in this subsection 

20 for coverage of a full-time employee (and, if any, the 

21 employee’s spouse and qualifying children (as de22 fined in section 152(c) of the Internal Revenue Code 

23 of 1986)) under a qualified health benefits plan (or 

24 current employment-based health plan) is equal to— 


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1 (A) in case of individual coverage, not less 

2 than 72.5 percent of the applicable premium 

3 (as defined in section 4980B(f)(4) of such 

4 Code, subject to paragraph (2)) of the lowest 

5 cost plan offered by the employer that is a 

6 qualified health benefits plan (or is such cur7 rent employment-based health plan); and 

8 (B) in the case of family coverage which 

9 includes coverage of such spouse and children, 

10 not less 65 percent of such applicable premium 

11 of such lowest cost plan. 

12 (2) APPLICABLE PREMIUM FOR EXCHANGE COV13 ERAGE.—In this subtitle, the amount of the applica14 ble premium of the lowest cost plan with respect to 

15 coverage of an employee under an Exchange-partici16 pating health benefits plan is the reference premium 

17 amount under section 343(c) for individual coverage 

18 (or, if elected, family coverage) for the premium rat19 ing area in which the individual or family resides. 

20 (3) MINIMUM EMPLOYER CONTRIBUTION FOR

21 EMPLOYEES OTHER THAN FULL-TIME EMPLOY22 EES.—In the case of coverage for an employee who 

23 is not a full-time employee, the amount of the min24 imum employer contribution under this subsection 

25 shall be a proportion (as determined in accordance 


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1 with rules of the Health Choices Commissioner, the 

2 Secretary of Labor, the Secretary of Health and 

3 Human Services, and the Secretary of the Treasury, 

4 as applicable) of the minimum employer contribution 

5 under this subsection with respect to a full-time em6 ployee that reflects the proportion of— 

7 (A) the average weekly hours of employ8 ment of the employee by the employer, to 

9 (B) the minimum weekly hours specified 

10 by the Commissioner for an employee to be a 

11 full-time employee. 

12 (4) SALARY REDUCTIONS NOT TREATED AS EM13 PLOYER CONTRIBUTIONS.—For purposes of this sec14 tion, any contribution on behalf of an employee with 

15 respect to which there is a corresponding reduction 

16 in the compensation of the employee shall not be 

17 treated as an amount paid by the employer. 

18 (c) AUTOMATIC ENROLLMENT FOR EMPLOYER SPON19 SORED HEALTH BENEFITS.— 

20 (1) IN GENERAL.—The requirement of this sub21 section with respect to an employer and an employee 

22 is that the employer automatically enroll such em23 ployee into the employment-based health benefits 

24 plan for individual coverage under the plan option 

25 with the lowest applicable employee premium. 


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1 (2) OPT-OUT.—In no case may an employer 

2 automatically enroll an employee in a plan under 

3 paragraph (1) if such employee makes an affirmative 

4 election to opt out of such plan or to elect coverage 

5 under an employment-based health benefits plan of6 fered by such employer. An employer shall provide 

7 an employee with a 30-day period to make such an 

8 affirmative election before the employer may auto9 matically enroll the employee in such a plan. 

10 (3) NOTICE REQUIREMENTS.— 

11 (A) IN GENERAL.—Each employer de12 scribed in paragraph (1) who automatically en13 rolls an employee into a plan as described in 

14 such paragraph shall provide the employees, 

15 within a reasonable period before the beginning 

16 of each plan year (or, in the case of new em17 ployees, within a reasonable period before the 

18 end of the enrollment period for such a new em19 ployee), written notice of the employees’ rights 

20 and obligations relating to the automatic enroll21 ment requirement under such paragraph. Such 

22 notice must be comprehensive and understood 

23 by the average employee to whom the automatic 

24 enrollment requirement applies. 


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1 (B) INCLUSION OF SPECIFIC INFORMA2 TION.—The written notice under subparagraph 

3 (A) must explain an employee’s right to opt out 

4 of being automatically enrolled in a plan and in 

5 the case that more than one level of benefits or 

6 employee premium level is offered by the em7 ployer involved, the notice must explain which 

8 level of benefits and employee premium level the 

9 employee will be automatically enrolled in the 

10 absence of an affirmative election by the em11 ployee. 

12 SEC. 413. EMPLOYER CONTRIBUTIONS IN LIEU OF COV13 ERAGE. 

14 (a) IN GENERAL.—A contribution is made in accord15 ance with this section with respect to an employee if such 

16 contribution is equal to an amount equal to 8 percent of 

17 the average wages paid by the employer during the period 

18 of enrollment (determined by taking into account all em19 ployees of the employer and in such manner as the Com20 missioner provides, including rules providing for the ap21 propriate aggregation of related employers) but not to ex22 ceed the minimum employer contribution described in sec23 tion 412(b)(1)(A). Any such contribution— 


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1 (1) shall be paid to the Health Choices Com2 missioner for deposit into the Health Insurance Ex3 change Trust Fund; and 

4 (2) shall not be applied against the premium of 

5 the employee under the Exchange-participating 

6 health benefits plan in which the employee is en7 rolled. 

8 (b) SPECIAL RULES FOR SMALL EMPLOYERS.— 

9 (1) IN GENERAL.—In the case of any employer 

10 who is a small employer for any calendar year, sub11 section (a) shall be applied by substituting the appli12 cable percentage determined in accordance with the 

13 following table for ‘‘8 percent’’: 

If the annual payroll of such employer for 

the preceding calendar year: 

The applicable 

percentage is: 

Does not exceed $500,000 ..................................... 0 percent 

Exceeds $500,000, but does not exceed $585,000 2 percent 

Exceeds $585,000, but does not exceed $670,000 4 percent 

Exceeds $670,000, but does not exceed $750,000 6 percent 

14 (2) SMALL EMPLOYER.—For purposes of this 

15 subsection, the term ‘‘small employer’’ means any 

16 employer for any calendar year if the annual payroll 

17 of such employer for the preceding calendar year 

18 does not exceed $750,000. 

19 (3) ANNUAL PAYROLL.—For purposes of this 

20 paragraph, the term ‘‘annual payroll’’ means, with 

21 respect to any employer for any calendar year, the 


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1 aggregate wages paid by the employer during such 

2 calendar year. 

3 (4) AGGREGATION RULES.—Related employers 

4 and predecessors shall be treated as a single em5 ployer for purposes of this subsection. 

6 SEC. 414. AUTHORITY RELATED TO IMPROPER STEERING. 

7 The Health Choices Commissioner (in coordination 

8 with the Secretary of Labor, the Secretary of Health and 

9 Human Services, and the Secretary of the Treasury) shall 

10 have authority to set standards for determining whether 

11 employers or insurers are undertaking any actions to af12 fect the risk pool within the Health Insurance Exchange 

13 by inducing individuals to decline coverage under a quali14 fied health benefits plan (or current employment-based 

15 health plan (within the meaning of section 202(b)) offered 

16 by the employer and instead to enroll in an Exchange-par17 ticipating health benefits plan. An employer violating such 

18 standards shall be treated as not meeting the require19 ments of this section. 

20 SEC. 415. IMPACT STUDY ON EMPLOYER RESPONSIBILITY 

21 REQUIREMENTS. 

22 (a) IN GENERAL.—The Secretary of Labor shall con23 duct a study to examine the effect of the exemptions under 

24 section 512(a) and coverage thresholds under this division 

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1 sponsibility requirements)on employment-based health 

2 plan sponsorship, generally and within specific industries, 

3 and the effect of such requirements and thresholds on em4 ployers, employment-based health plans, and employees in 

5 each industry. 

6 (b) ANNUAL REPORT.—The Secretary of Labor an7 nually shall submit to Congress a report on findings on 

8 how employer responsibility requirements have impacted 

9 and are likely to impact employers, plans, and employees 

10 during the previous year and projected trends. 

11 (c) LEGISLATIVE RECOMMENDATIONS.—No later 

12 than January 1, 2012 and on an annual basis thereafter, 

13 the Secretary of Labor shall submit legislative rec14 ommendations to Congress to modify the employer respon15 sibility requirements if the Secretary determines that the 

16 requirements are detrimentally affecting or will detrimen17 tally affect employer plan sponsorship or otherwise cre18 ating inequities among employers, health plans, and em19 ployees. The Secretary may also submit such recommenda20 tions as the Secretary determines necessary to improve 

21 and strengthen employment-based health plan sponsor22 ship, employer responsibility, and related proposals that 

23 would enhance the delivery of health care benefits between 

24 employers and employees. 


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1 SEC. 416. STUDY ON EMPLOYER HARDSHIP EXEMPTION. 

2 (a) IN GENERAL.—The Secretary of Labor together 

3 with the Secretary of Treasury, the Secretary of Health 

4 and Human Services, and the Commissioner, shall conduct 

5 a study to examine the impact of the employer responsi6 bility requirements described in section 415(a) and make 

7 a recommendation to Congress about whether an employer 

8 hardship exemption would be appropriate. 

9 (b) ITEMS INCLUDED IN STUDY.—Within such study 

10 the Secretaries and Commissioner shall examine cases 

11 where such employer responsibility requirements may pose 

12 a particular hardship, and specifically look at employers 

13 by industry, profit margin, length of time in business, and 

14 size. In this examination, the economic conditions shall be 

15 considered, including the rate of increase in business costs, 

16 the availability of short-term credit lines, and abilities to 

17 restructure debt. In addition, the study shall examine the 

18 impact an employer hardship waiver could have on employ19 ees. 

20 (c) REPORT.—Not later than January 1, 2012, the 

21 Secretaries and Commissioner shall report to Congress on 

22 their findings and make a recommendation regarding the 

23 need or lack of need for a partial or complete employer 

24 hardship waiver. The Secretaries and Commissioner may 

25 also submit recommendations about the criteria Congress 

26 should include when developing eligibility requirements for 


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1 the employer hardship waiver and what safeguards are 

2 necessary to protect the employees of that employer. 

3 PART 2—SATISFACTION OF HEALTH COVERAGE 

4 PARTICIPATION REQUIREMENTS 

5 SEC. 421. SATISFACTION OF HEALTH COVERAGE PARTICI6 PATION REQUIREMENTS UNDER THE EM7 PLOYEE RETIREMENT INCOME SECURITY 

8 ACT OF 1974. 

9 (a) IN GENERAL.—Subtitle B of title I of the Em10 ployee Retirement Income Security Act of 1974 is amend11 ed by adding at the end the following new part: 

12 ‘‘PART 8—NATIONAL HEALTH COVERAGE 

13 PARTICIPATION REQUIREMENTS 

14 ‘‘SEC. 801. ELECTION OF EMPLOYER TO BE SUBJECT TO NA15 TIONAL HEALTH COVERAGE PARTICIPATION 

16 REQUIREMENTS. 

17 ‘‘(a) IN GENERAL.—An employer may make an elec18 tion with the Secretary to be subject to the health coverage 

19 participation requirements. 

20 ‘‘(b) TIME AND MANNER.—An election under sub21 section (a) may be made at such time and in such form 

22 and manner as the Secretary may prescribe. 


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1 ‘‘SEC. 802. TREATMENT OF COVERAGE RESULTING FROM 

2 ELECTION. 

3 ‘‘(a) IN GENERAL.—If an employer makes an election 

4 to the Secretary under section 801— 

5 ‘‘(1) such election shall be treated as the estab6 lishment and maintenance of a group health plan (as 

7 defined in section 733(a)) for purposes of this title, 

8 subject to section 251 of the ; and 

9 ‘‘(2) the health coverage participation require10 ments shall be deemed to be included as terms and 

11 conditions of such plan. 

12 ‘‘(b) PERIODIC INVESTIGATIONS TO DISCOVER NON13 COMPLIANCE.—The Secretary shall regularly audit a rep14 resentative sampling of employers and group health plans 

15 and conduct investigations and other activities under sec16 tion 504 with respect to such sampling of plans so as to 

17 discover noncompliance with the health coverage participa18 tion requirements in connection with such plans. The Sec19 retary shall communicate findings of noncompliance made 

20 by the Secretary under this subsection to the Secretary 

21 of the Treasury and the Health Choices Commissioner. 

22 The Secretary shall take such timely enforcement action 

23 as appropriate to achieve compliance. 

24 ‘‘(c) RECORDKEEPING.—To facilitate the audits de25 scribed in subsection (b), the Secretary shall promulgate 

26 recordkeeping requirements for employers to account for 


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1 both employees of the employer and individuals whom the 

2 employer has not treated as employees of the employer but 

3 with whom the employer, in the course of its trade or busi4 ness, has engaged for the performance of labor or services. 

5 The scope and content of such recordkeeping requirements 

6 shall be determined by the Secretary and shall be designed 

7 to ensure that employees who are not properly treated as 

8 such may be identified and properly treated. 

9 ‘‘SEC. 803. HEALTH COVERAGE PARTICIPATION REQUIRE10 MENTS. 

11 ‘‘For purposes of this part, the term ‘health coverage 

12 participation requirements’ means the requirements of 

13 part 1 of subtitle B of title IV of division A of (as in effect 

14 on the date of the enactment of such Act). 

15 ‘‘SEC. 804. RULES FOR APPLYING REQUIREMENTS. 

16 ‘‘(a) AFFILIATED GROUPS.—In the case of any em17 ployer which is part of a group of employers who are treat18 ed as a single employer under subsection (b), (c), (m), or 

19 (o) of section 414 of the Internal Revenue Code of 1986, 

20 the election under section 801 shall be made by such em21 ployer as the Secretary may provide. Any such election, 

22 once made, shall apply to all members of such group. 

23 ‘‘(b) SEPARATE ELECTIONS.—Under regulations pre24 scribed by the Secretary, separate elections may be made 

25 under section 801 with respect to— 


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1 ‘‘(1) separate lines of business, and 

2 ‘‘(2) full-time employees and employees who are 

3 not full-time employees. 

4 ‘‘SEC. 805. TERMINATION OF ELECTION IN CASES OF SUB5 STANTIAL NONCOMPLIANCE. 

6 ‘‘The Secretary may terminate the election of any em7 ployer under section 801 if the Secretary (in coordination 

8 with the Health Choices Commissioner) determines that 

9 such employer is in substantial noncompliance with the 

10 health coverage participation requirements and shall refer 

11 any such determination to the Secretary of the Treasury 

12 as appropriate. 

13 ‘‘SEC. 806. REGULATIONS. 

14 ‘‘The Secretary may promulgate such regulations as 

15 may be necessary or appropriate to carry out the provi16 sions of this part, in accordance with section 424(a) of 

17 the . The Secretary may promulgate any interim final 

18 rules as the Secretary determines are appropriate to carry 

19 out this part.’’. 

20 (b) ENFORCEMENT OF HEALTH COVERAGE PARTICI21 PATION REQUIREMENTS.—Section 502 of such Act (29 

22 U.S.C. 1132) is amended— 

23 (1) in subsection (a)(6), by striking ‘‘para24 graph’’ and all that follows through ‘‘subsection (c)’’ 


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1 and inserting ‘‘paragraph (2), (4), (5), (6), (7), (8), 

2 (9), (10), or (11) of subsection (c)’’; and 

3 (2) in subsection (c), by redesignating the sec4 ond paragraph (10) as paragraph (12) and by in5 serting after the first paragraph (10) the following 

6 new paragraph: 

7 ‘‘(11) HEALTH COVERAGE PARTICIPATION RE8 QUIREMENTS.— 

9 ‘‘(A) CIVIL PENALTIES.—In the case of 

10 any employer who fails (during any period with 

11 respect to which an election under section 

12 801(a) is in effect) to satisfy the health cov13 erage participation requirements with respect to 

14 any employee, the Secretary may assess a civil 

15 penalty against the employer of $100 for each 

16 day in the period beginning on the date such 

17 failure first occurs and ending on the date such 

18 failure is corrected. 

19 ‘‘(B) HEALTH COVERAGE PARTICIPATION

20 REQUIREMENTS.—For purposes of this para21 graph, the term ‘health coverage participation 

22 requirements’ has the meaning provided in sec23 tion 803. 

24 ‘‘(C) LIMITATIONS ON AMOUNT OF PEN25 ALTY.— 


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1 ‘‘(i) PENALTY NOT TO APPLY WHERE

2 FAILURE NOT DISCOVERED EXERCISING

3 REASONABLE DILIGENCE.—No penalty 

4 shall be assessed under subparagraph (A) 

5 with respect to any failure during any pe6 riod for which it is established to the satis7 faction of the Secretary that the employer 

8 did not know, or exercising reasonable dili9 gence would not have known, that such 

10 failure existed. 

11 ‘‘(ii) PENALTY NOT TO APPLY TO

12 FAILURES CORRECTED WITHIN 30 DAYS.— 

13 No penalty shall be assessed under sub14 paragraph (A) with respect to any failure 

15 if— 

16 ‘‘(I) such failure was due to rea17 sonable cause and not to willful ne18 glect, and 

19 ‘‘(II) such failure is corrected 

20 during the 30-day period beginning on 

21 the 1st date that the employer knew, 

22 or exercising reasonable diligence 

23 would have known, that such failure 

24 existed. 


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1 ‘‘(iii) OVERALL LIMITATION FOR UN2 INTENTIONAL FAILURES.—In the case of 

3 failures which are due to reasonable cause 

4 and not to willful neglect, the penalty as5 sessed under subparagraph (A) for failures 

6 during any 1-year period shall not exceed 

7 the amount equal to the lesser of— 

8 ‘‘(I) 10 percent of the aggregate 

9 amount paid or incurred by the em10 ployer (or predecessor employer) dur11 ing the preceding 1-year period for 

12 group health plans, or 

13 ‘‘(II) $500,000. 

14 ‘‘(D) ADVANCE NOTIFICATION OF FAILURE

15 PRIOR TO ASSESSMENT.—Before a reasonable 

16 time prior to the assessment of any penalty 

17 under this paragraph with respect to any failure 

18 by an employer, the Secretary shall inform the 

19 employer in writing of such failure and shall 

20 provide the employer information regarding ef21 forts and procedures which may be undertaken 

22 by the employer to correct such failure. 

23 ‘‘(E) COORDINATION WITH EXCISE TAX.— 

24 Under regulations prescribed in accordance 

25 with section 424 of the , the Secretary and the 


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1 Secretary of the Treasury shall coordinate the 

2 assessment of penalties under this section in 

3 connection with failures to satisfy health cov4 erage participation requirements with the impo5 sition of excise taxes on such failures under sec6 tion 4980H(b) of the Internal Revenue Code of 

7 1986 so as to avoid duplication of penalties 

8 with respect to such failures. 

9 ‘‘(F) DEPOSIT OF PENALTY COLLECTED.— 

10 Any amount of penalty collected under this 

11 paragraph shall be deposited as miscellaneous 

12 receipts in the Treasury of the United States.’’. 

13 (c) CLERICAL AMENDMENTS.—The table of contents 

14 in section 1 of such Act is amended by inserting after the 

15 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.’’. 

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

17 this section shall apply to periods beginning after Decem18 ber 31, 2012. 


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1 SEC. 422. SATISFACTION OF HEALTH COVERAGE PARTICI2 PATION REQUIREMENTS UNDER THE INTER3 NAL REVENUE CODE OF 1986. 

4 (a) FAILURE TO ELECT, OR SUBSTANTIALLY COM5 PLY WITH, HEALTH COVERAGE PARTICIPATION RE6 QUIREMENTS.—For employment tax on employers who fail 

7 to elect, or substantially comply with, the health coverage 

8 participation requirements described in part 1, see section 

9 3111(c) of the Internal Revenue Code of 1986 (as added 

10 by section 512 of this Act). 

11 (b) OTHER FAILURES.—For excise tax on other fail12 ures of electing employers to comply with such require13 ments, see section 4980H of the Internal Revenue Code 

14 of 1986 (as added by section 511 of this Act). 

15 SEC. 423. SATISFACTION OF HEALTH COVERAGE PARTICI16 PATION REQUIREMENTS UNDER THE PUBLIC 

17 HEALTH SERVICE ACT. 

18 (a) IN GENERAL.—Part C of title XXVII of the Pub19 lic Health Service Act is amended by adding at the end 

20 the following new section: 

21 ‘‘SEC. 2793. NATIONAL HEALTH COVERAGE PARTICIPATION 

22 REQUIREMENTS. 

23 ‘‘(a) ELECTION OF EMPLOYER TO BE SUBJECT TO

24 NATIONAL HEALTH COVERAGE PARTICIPATION REQUIRE25 MENTS.— 


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1 ‘‘(1) IN GENERAL.—An employer may make an 

2 election with the Secretary to be subject to the 

3 health coverage participation requirements. 

4 ‘‘(2) TIME AND MANNER.—An election under 

5 paragraph (1) may be made at such time and in 

6 such form and manner as the Secretary may pre7 scribe. 

8 ‘‘(b) TREATMENT OF COVERAGE RESULTING FROM

9 ELECTION.— 

10 ‘‘(1) IN GENERAL.—If an employer makes an 

11 election to the Secretary under subsection (a)— 

12 ‘‘(A) such election shall be treated as the 

13 establishment and maintenance of a group 

14 health plan for purposes of this title, subject to 

15 section 251 of the Affordable Health Care for 

16 America Act; and 

17 ‘‘(B) the health coverage participation re18 quirements shall be deemed to be included as 

19 terms and conditions of such plan. 

20 ‘‘(2) PERIODIC INVESTIGATIONS TO DETERMINE

21 COMPLIANCE WITH HEALTH COVERAGE PARTICIPA22 TION REQUIREMENTS.—The Secretary shall regu23 larly audit a representative sampling of employers 

24 and conduct investigations and other activities with 

25 respect to such sampling of employers so as to disVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00289 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 cover noncompliance with the health coverage par2 ticipation requirements in connection with such em3 ployers (during any period with respect to which an 

4 election under subsection (a) is in effect). The Sec5 retary shall communicate findings of noncompliance 

6 made by the Secretary under this subsection to the 

7 Secretary of the Treasury and the Health Choices 

8 Commissioner. The Secretary shall take such timely 

9 enforcement action as appropriate to achieve compli10 ance. 

11 ‘‘(3) RECORDKEEPING.—To facilitate the audits 

12 described in subsection (b), the Secretary shall pro13 mulgate recordkeeping requirements for employers 

14 to account for both employees of the employer and 

15 individuals whom the employer has not treated as 

16 employees of the employer but with whom the em17 ployer, in the course of its trade or business, has en18 gaged for the performance of labor or services. The 

19 scope and content of such recordkeeping require20 ments shall be determined by the Secretary and 

21 shall be designed to ensure that employees who are 

22 not properly treated as such may be identified and 

23 properly treated. 

24 ‘‘(c) HEALTH COVERAGE PARTICIPATION REQUIRE25 MENTS.—For purposes of this section, the term ‘health 


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1 coverage participation requirements’ means the require2 ments of part 1 of subtitle B of title IV of division A of 

3 the (as in effect on the date of the enactment of this sec4 tion). 

5 ‘‘(d) SEPARATE ELECTIONS.—Under regulations pre6 scribed by the Secretary, separate elections may be made 

7 under subsection (a) with respect to full-time employees 

8 and employees who are not full-time employees. 

9 ‘‘(e) TERMINATION OF ELECTION IN CASES OF SUB10 STANTIAL NONCOMPLIANCE.—The Secretary may termi11 nate the election of any employer under subsection (a) if 

12 the Secretary (in coordination with the Health Choices 

13 Commissioner) determines that such employer is in sub14 stantial noncompliance with the health coverage participa15 tion requirements and shall refer any such determination 

16 to the Secretary of the Treasury as appropriate. 

17 ‘‘(f) ENFORCEMENT OF HEALTH COVERAGE PAR18 TICIPATION REQUIREMENTS.— 

19 ‘‘(1) CIVIL PENALTIES.—In the case of any em20 ployer who fails (during any period with respect to 

21 which the election under subsection (a) is in effect) 

22 to satisfy the health coverage participation require23 ments with respect to any employee, the Secretary 

24 may assess a civil penalty against the employer of 

25 $100 for each day in the period beginning on the 


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1 date such failure first occurs and ending on the date 

2 such failure is corrected. 

3 ‘‘(2) LIMITATIONS ON AMOUNT OF PENALTY.— 

4 ‘‘(A) PENALTY NOT TO APPLY WHERE

5 FAILURE NOT DISCOVERED EXERCISING REA6 SONABLE DILIGENCE.—No penalty shall be as7 sessed under paragraph (1) with respect to any 

8 failure during any period for which it is estab9 lished to the satisfaction of the Secretary that 

10 the employer did not know, or exercising rea11 sonable diligence would not have known, that 

12 such failure existed. 

13 ‘‘(B) PENALTY NOT TO APPLY TO FAIL14 URES CORRECTED WITHIN 30 DAYS.—No pen15 alty shall be assessed under paragraph (1) with 

16 respect to any failure if— 

17 ‘‘(i) such failure was due to reason18 able cause and not to willful neglect, and 

19 ‘‘(ii) such failure is corrected during 

20 the 30-day period beginning on the 1st 

21 date that the employer knew, or exercising 

22 reasonable diligence would have known, 

23 that such failure existed. 

24 ‘‘(C) OVERALL LIMITATION FOR UNINTEN25 TIONAL FAILURES.—In the case of failures 


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1 which are due to reasonable cause and not to 

2 willful neglect, the penalty assessed under para3 graph (1) for failures during any 1-year period 

4 shall not exceed the amount equal to the lesser 

5 of— 

6 ‘‘(i) 10 percent of the aggregate 

7 amount paid or incurred by the employer 

8 (or predecessor employer) during the pre9 ceding taxable year for group health plans, 

10 or 

11 ‘‘(ii) $500,000. 

12 ‘‘(3) ADVANCE NOTIFICATION OF FAILURE

13 PRIOR TO ASSESSMENT.—Before a reasonable time 

14 prior to the assessment of any penalty under para15 graph (1) with respect to any failure by an em16 ployer, the Secretary shall inform the employer in 

17 writing of such failure and shall provide the em18 ployer information regarding efforts and procedures 

19 which may be undertaken by the employer to correct 

20 such failure. 

21 ‘‘(4) ACTIONS TO ENFORCE ASSESSMENTS.— 

22 The Secretary may bring a civil action in any Dis23 trict Court of the United States to collect any civil 

24 penalty under this subsection. 


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1 ‘‘(5) COORDINATION WITH EXCISE TAX.— 

2 Under regulations prescribed in accordance with sec3 tion 424 of the , the Secretary and the Secretary of 

4 the Treasury shall coordinate the assessment of pen5 alties under paragraph (1) in connection with fail6 ures to satisfy health coverage participation require7 ments with the imposition of excise taxes on such 

8 failures under section 4980H(b) of the Internal Rev9 enue Code of 1986 so as to avoid duplication of pen10 alties with respect to such failures. 

11 ‘‘(6) DEPOSIT OF PENALTY COLLECTED.—Any 

12 amount of penalty collected under this subsection 

13 shall be deposited as miscellaneous receipts in the 

14 Treasury of the United States. 

15 ‘‘(g) REGULATIONS.—The Secretary may promulgate 

16 such regulations as may be necessary or appropriate to 

17 carry out the provisions of this section, in accordance with 

18 section 424(a) of the . The Secretary may promulgate any 

19 interim final rules as the Secretary determines are appro20 priate to carry out this section.’’. 

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

22 subsection (a) shall apply to periods beginning after De23 cember 31, 2012. 


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1 SEC. 424. ADDITIONAL RULES RELATING TO HEALTH COV2 ERAGE PARTICIPATION REQUIREMENTS. 

3 (a) ASSURING COORDINATION.—The officers con4 sisting of the Secretary of Labor, the Secretary of the 

5 Treasury, the Secretary of Health and Human Services, 

6 and the Health Choices Commissioner shall ensure, 

7 through the execution of an interagency memorandum of 

8 understanding among such officers, that— 

9 (1) regulations, rulings, and interpretations 

10 issued by such officers relating to the same matter 

11 over which two or more of such officers have respon12 sibility under subpart B of part 8 of subtitle B of 

13 title I of the Employee Retirement Income Security 

14 Act of 1974, section 4980H of the Internal Revenue 

15 Code of 1986, and section 2793 of the Public Health 

16 Service Act are administered so as to have the same 

17 effect at all times; and 

18 (2) coordination of policies relating to enforcing 

19 the same requirements through such officers in 

20 order to have a coordinated enforcement strategy 

21 that avoids duplication of enforcement efforts and 

22 assigns priorities in enforcement. 

23 (b) MULTIEMPLOYER PLANS.—In the case of a group 

24 health plan that is a multiemployer plan (as defined in 

25 section 3(37) of the Employee Retirement Income Secu26 rity Act of 1974), the regulations prescribed in accordance 


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1 with subsection (a) by the officers referred to in subsection 

2 (a) shall provide for the application of the health coverage 

3 participation requirements to the plan sponsor and con4 tributing employers of such plan. For purposes of this di5 vision, contributions made pursuant to a collective bar6 gaining agreement or other agreement to such a group 

7 health plan shall be treated as amounts paid by the em8 ployer. 

9 TITLE V—AMENDMENTS TO IN10 TERNAL REVENUE CODE OF 

11 1986 

12 Subtitle A—Provisions Relating to 

13 Health Care Reform 

14 PART 1—SHARED RESPONSIBILITY 

15 Subpart A—Individual Responsibility 

16 SEC. 501. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE 

17 HEALTH CARE COVERAGE. 

18 (a) IN GENERAL.—Subchapter A of chapter 1 of the 

19 Internal Revenue Code of 1986 is amended by adding at 

20 the end the following new part: 

21 ‘‘PART VIII—HEALTH CARE RELATED TAXES 

‘‘SUBPART A. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE

COVERAGE. 

22 ‘‘Subpart A—Tax on Individuals Without Acceptable 

23 Health Care Coverage 

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


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1 ‘‘SEC. 59B. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE 

2 HEALTH CARE COVERAGE. 

3 ‘‘(a) TAX IMPOSED.—In the case of any individual 

4 who does not meet the requirements of subsection (d) at 

5 any time during the taxable year, there is hereby imposed 

6 a tax equal to 2.5 percent of the excess of— 

7 ‘‘(1) the taxpayer’s modified adjusted gross in8 come for the taxable year, over 

9 ‘‘(2) the amount of gross income specified in 

10 section 6012(a)(1) with respect to the taxpayer. 

11 ‘‘(b) LIMITATIONS.— 

12 ‘‘(1) TAX LIMITED TO AVERAGE PREMIUM.— 

13 ‘‘(A) IN GENERAL.—The tax imposed 

14 under subsection (a) with respect to any tax15 payer for any taxable year shall not exceed the 

16 applicable national average premium for such 

17 taxable year. 

18 ‘‘(B) APPLICABLE NATIONAL AVERAGE

19 PREMIUM.— 

20 ‘‘(i) IN GENERAL.—For purposes of 

21 subparagraph (A), the ‘applicable national 

22 average premium’ means, with respect to 

23 any taxable year, the average premium (as 

24 determined by the Secretary, in coordina25 tion with the Health Choices Commis26 sioner) for self-only coverage under a basic 


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1 plan which is offered in a Health Insur2 ance Exchange for the calendar year in 

3 which such taxable year begins. 

4 ‘‘(ii) FAILURE TO PROVIDE COVERAGE

5 FOR MORE THAN ONE INDIVIDUAL.—In the 

6 case of any taxpayer who fails to meet the 

7 requirements of subsection (d) with respect 

8 to more than one individual during the tax9 able year, clause (i) shall be applied by 

10 substituting ‘family coverage’ for ‘self-only 

11 coverage’. 

12 ‘‘(2) PRORATION FOR PART YEAR FAILURES.— 

13 The tax imposed under subsection (a) with respect 

14 to any taxpayer for any taxable year shall not exceed 

15 the amount which bears the same ratio to the 

16 amount of tax so imposed (determined without re17 gard to this paragraph and after application of para18 graph (1)) as— 

19 ‘‘(A) the aggregate periods during such 

20 taxable year for which such individual failed to 

21 meet the requirements of subsection (d), bears 

22 to 

23 ‘‘(B) the entire taxable year. 

24 ‘‘(c) EXCEPTIONS.— 


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1 ‘‘(1) DEPENDENTS.—Subsection (a) shall not 

2 apply to any individual for any taxable year if a de3 duction is allowable under section 151 with respect 

4 to such individual to another taxpayer for any tax5 able year beginning in the same calendar year as 

6 such taxable year. 

7 ‘‘(2) NONRESIDENT ALIENS.—Subsection (a) 

8 shall not apply to any individual who is a non9 resident alien. 

10 ‘‘(3) INDIVIDUALS RESIDING OUTSIDE UNITED

11 STATES.—Any qualified individual (as defined in 

12 section 911(d)) (and any qualifying child residing 

13 with such individual) shall be treated for purposes of 

14 this section as covered by acceptable coverage during 

15 the period described in subparagraph (A) or (B) of 

16 section 911(d)(1), whichever is applicable. 

17 ‘‘(4) INDIVIDUALS RESIDING IN POSSESSIONS

18 OF THE UNITED STATES.—Any individual who is a 

19 bona fide resident of any possession of the United 

20 States (as determined under section 937(a)) for any 

21 taxable year (and any qualifying child residing with 

22 such individual) shall be treated for purposes of this 

23 section as covered by acceptable coverage during 

24 such taxable year. 

25 ‘‘(5) RELIGIOUS CONSCIENCE EXEMPTION.— 


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1 ‘‘(A) IN GENERAL.—Subsection (a) shall 

2 not apply to any individual (and any qualifying 

3 child residing with such individual) for any pe4 riod if such individual has in effect an exemp5 tion which certifies that such individual is a 

6 member of a recognized religious sect or divi7 sion thereof described in section 1402(g)(1) and 

8 an adherent of established tenets or teachings 

9 of such sect or division as described in such sec10 tion. 

11 ‘‘(B) EXEMPTION.—An application for the 

12 exemption described in subparagraph (A) shall 

13 be filed with the Secretary at such time and in 

14 such form and manner as the Secretary may 

15 prescribe. The Secretary may treat an applica16 tion for exemption under section 1402(g)(1) as 

17 an application for exemption under this section, 

18 or may otherwise coordinate applications under 

19 such sections, as the Secretary determines ap20 propriate. Any such exemption granted by the 

21 Secretary shall be effective for such period as 

22 the Secretary determines appropriate. 

23 ‘‘(d) ACCEPTABLE COVERAGE REQUIREMENT.— 

24 ‘‘(1) IN GENERAL.—The requirements of this 

25 subsection are met with respect to any individual for 


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1 any period if such individual (and each qualifying 

2 child of such individual) is covered by acceptable 

3 coverage at all times during such period. 

4 ‘‘(2) ACCEPTABLE COVERAGE.—For purposes 

5 of this section, the term ‘acceptable coverage’ means 

6 any of the following: 

7 ‘‘(A) QUALIFIED HEALTH BENEFITS PLAN

8 COVERAGE.—Coverage under a qualified health 

9 benefits plan (as defined in section 100(c) of 

10 the ). 

11 ‘‘(B) GRANDFATHERED HEALTH INSUR12 ANCE COVERAGE; COVERAGE UNDER GRAND13 FATHERED EMPLOYMENT-BASED HEALTH

14 PLAN.—Coverage under a grandfathered health 

15 insurance coverage (as defined in subsection (a) 

16 of section 202 of the ) or under a current em17 ployment-based health plan (within the meaning 

18 of subsection (b) of such section). 

19 ‘‘(C) MEDICARE.—Coverage under part A 

20 of title XVIII of the Social Security Act. 

21 ‘‘(D) MEDICAID.—Coverage for medical as22 sistance under title XIX of the Social Security 

23 Act. 

24 ‘‘(E) MEMBERS OF THE ARMED FORCES

25 AND DEPENDENTS (INCLUDING TRICARE).— 


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1 Coverage under chapter 55 of title 10, United 

2 States Code, including similar coverage fur3 nished under section 1781 of title 38 of such 

4 Code. 

5 ‘‘(F) VA.—Coverage under the veteran’s 

6 health care program under chapter 17 of title 

7 38, United States Code. 

8 ‘‘(G) MEMBERS OF INDIAN TRIBES.— 

9 Health care services made available through the 

10 Indian Health Service, a tribal organization (as 

11 defined in section 4 of the Indian Health Care 

12 Improvement Act), or an urban Indian organi13 zation (as defined in such section) to members 

14 of an Indian tribe (as defined in such section). 

15 ‘‘(H) OTHER COVERAGE.—Such other 

16 health benefits coverage as the Secretary, in co17 ordination with the Health Choices Commis18 sioner, recognizes for purposes of this sub19 section. 

20 ‘‘(e) OTHER DEFINITIONS AND SPECIAL RULES.— 

21 ‘‘(1) QUALIFYING CHILD.—For purposes of this 

22 section, the term ‘qualifying child’ has the meaning 

23 given such term by section 152(c). With respect to 

24 any period during which health coverage for a child 

25 must be provided by an individual pursuant to a 


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1 child support order, such child shall be treated as a 

2 qualifying child of such individual (and not as a 

3 qualifying child of any other individual). 

4 ‘‘(2) BASIC PLAN.—For purposes of this sec5 tion, the term ‘basic plan’ has the meaning given 

6 such term under section 100(c) of the . 

7 ‘‘(3) HEALTH INSURANCE EXCHANGE.—For 

8 purposes of this section, the term ‘Health Insurance 

9 Exchange’ has the meaning given such term under 

10 section 100(c) of the , including any State-based 

11 health insurance exchange approved for operation 

12 under section 308 of such Act. 

13 ‘‘(4) FAMILY COVERAGE.—For purposes of this 

14 section, the term ‘family coverage’ means any cov15 erage other than self-only coverage. 

16 ‘‘(5) MODIFIED ADJUSTED GROSS INCOME.— 

17 For purposes of this section, the term ‘modified ad18 justed gross income’ means adjusted gross income 

19 increased by— 

20 ‘‘(A) any amount excluded from gross in21 come under section 911, and 

22 ‘‘(B) any amount of interest received or 

23 accrued by the taxpayer during the taxable year 

24 which is exempt from tax. 


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1 ‘‘(6) NOT TREATED AS TAX IMPOSED BY THIS

2 CHAPTER FOR CERTAIN PURPOSES.—The tax im3 posed under this section shall not be treated as tax 

4 imposed by this chapter for purposes of determining 

5 the amount of any credit under this chapter or for 

6 purposes of section 55. 

7 ‘‘(f) REGULATIONS.—The Secretary shall prescribe 

8 such regulations or other guidance as may be necessary 

9 or appropriate to carry out the purposes of this section, 

10 including regulations or other guidance (developed in co11 ordination with the Health Choices Commissioner) which 

12 provide— 

13 ‘‘(1) exemption from the tax imposed under 

14 subsection (a) in cases of de minimis lapses of ac15 ceptable coverage, and 

16 ‘‘(2) a waiver of the application of subsection 

17 (a) in cases of hardship, including a process for ap18 plying for such a waiver.’’. 

19 (b) INFORMATION REPORTING.— 

20 (1) IN GENERAL.—Subpart B of part III of 

21 subchapter A of chapter 61 of such Code is amended 

22 by inserting after section 6050W the following new 

23 section: 


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1 ‘‘SEC. 6050X. RETURNS RELATING TO HEALTH INSURANCE 

2 COVERAGE. 

3 ‘‘(a) REQUIREMENT OF REPORTING.—Every person 

4 who provides acceptable coverage (as defined in section 

5 59B(d)) to any individual during any calendar year shall, 

6 at such time as the Secretary may prescribe, make the 

7 return described in subsection (b) with respect to such in8 dividual. 

9 ‘‘(b) FORM AND MANNER OF RETURNS.—A return 

10 is described in this subsection if such return— 

11 ‘‘(1) is in such form as the Secretary may pre12 scribe, and 

13 ‘‘(2) contains— 

14 ‘‘(A) the name, address, and TIN of the 

15 primary insured and the name of each other in16 dividual obtaining coverage under the policy, 

17 ‘‘(B) the period for which each such indi18 vidual was provided with the coverage referred 

19 to in subsection (a), and 

20 ‘‘(C) such other information as the Sec21 retary may require. 

22 ‘‘(c) STATEMENTS TO BE FURNISHED TO INDIVID23 UALS WITH RESPECT TO WHOM INFORMATION IS RE24 QUIRED.—Every person required to make a return under 

25 subsection (a) shall furnish to each primary insured whose 


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1 name is required to be set forth in such return a written 

2 statement showing— 

3 ‘‘(1) the name and address of the person re4 quired to make such return and the phone number 

5 of the information contact for such person, and 

6 ‘‘(2) the information required to be shown on 

7 the return with respect to such individual. 

8 The written statement required under the preceding sen9 tence shall be furnished on or before January 31 of the 

10 year following the calendar year for which the return 

11 under subsection (a) is required to be made. 

12 ‘‘(d) COVERAGE PROVIDED BY GOVERNMENTAL

13 UNITS.—In the case of coverage provided by any govern14 mental unit or any agency or instrumentality thereof, the 

15 officer or employee who enters into the agreement to pro16 vide such coverage (or the person appropriately designated 

17 for purposes of this section) shall make the returns and 

18 statements required by this section.’’. 

19 (2) PENALTY FOR FAILURE TO FILE.— 

20 (A) RETURN.—Subparagraph (B) of sec21 tion 6724(d)(1) of such Code is amended by 

22 striking ‘‘or’’ at the end of clause (xxii), by 

23 striking ‘‘and’’ at the end of clause (xxiii) and 

24 inserting ‘‘or’’, and by adding at the end the 

25 following new clause: 


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1 ‘‘(xxiv) section 6050X (relating to re2 turns relating to health insurance cov3 erage), and’’. 

4 (B) STATEMENT.—Paragraph (2) of sec5 tion 6724(d) of such Code is amended by strik6 ing ‘‘or’’ at the end of subparagraph (EE), by 

7 striking the period at the end of subparagraph 

8 (FF) and inserting ‘‘, or’’, and by inserting 

9 after subparagraph (FF) the following new sub10 paragraph: 

11 ‘‘(GG) section 6050X (relating to returns 

12 relating to health insurance coverage).’’. 

13 (c) RETURN REQUIREMENT.—Subsection (a) of sec14 tion 6012 of such Code is amended by inserting after 

15 paragraph (9) the following new paragraph: 

16 ‘‘(10) Every individual to whom section 59B(a) 

17 applies and who fails to meet the requirements of 

18 section 59B(d) with respect to such individual or 

19 any qualifying child (as defined in section 152(c)) of 

20 such individual.’’. 

21 (d) CLERICAL AMENDMENTS.— 

22 (1) The table of parts for subchapter A of chap23 ter 1 of the Internal Revenue Code of 1986 is 

24 amended by adding at the end the following new 

25 item: 

‘‘PART VIII. HEALTH CARE RELATED TAXES.’’. 


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1 (2) The table of sections for subpart B of part 

2 III of subchapter A of chapter 61 is amended by 

3 adding at the end the following new item: 

‘‘Sec. 6050X. Returns relating to health insurance coverage.’’. 

4 (e) SECTION 15 NOT TO APPLY.—The amendment 

5 made by subsection (a) shall not be treated as a change 

6 in a rate of tax for purposes of section 15 of the Internal 

7 Revenue Code of 1986. 

8 (f) EFFECTIVE DATE.— 

9 (1) IN GENERAL.—The amendments made by 

10 this section shall apply to taxable years beginning 

11 after December 31, 2012. 

12 (2) RETURNS.—The amendments made by sub13 section (b) shall apply to calendar years beginning 

14 after December 31, 2012. 

15 Subpart B—Employer Responsibility 

16 SEC. 511. ELECTION TO SATISFY HEALTH COVERAGE PAR17 TICIPATION REQUIREMENTS. 

18 (a) IN GENERAL.—Chapter 43 of the Internal Rev19 enue Code of 1986 is amended by adding at the end the 

20 following new section: 

21 ‘‘SEC. 4980H. ELECTION WITH RESPECT TO HEALTH COV22 ERAGE PARTICIPATION REQUIREMENTS. 

23 ‘‘(a) ELECTION OF EMPLOYER RESPONSIBILITY TO

24 PROVIDE HEALTH COVERAGE.— 


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1 ‘‘(1) IN GENERAL.—Subsection (b) shall apply 

2 to any employer with respect to whom an election 

3 under paragraph (2) is in effect. 

4 ‘‘(2) TIME AND MANNER.—An employer may 

5 make an election under this paragraph at such time 

6 and in such form and manner as the Secretary may 

7 prescribe. 

8 ‘‘(3) AFFILIATED GROUPS.—In the case of any 

9 employer which is part of a group of employers who 

10 are treated as a single employer under subsection 

11 (b), (c), (m), or (o) of section 414, the election 

12 under paragraph (2) shall be made by such person 

13 as the Secretary may provide. Any such election, 

14 once made, shall apply to all members of such 

15 group. 

16 ‘‘(4) SEPARATE ELECTIONS.—Under regula17 tions prescribed by the Secretary, separate elections 

18 may be made under paragraph (2) with respect to— 

19 ‘‘(A) separate lines of business, and 

20 ‘‘(B) full-time employees and employees 

21 who are not full-time employees. 

22 ‘‘(5) TERMINATION OF ELECTION IN CASES OF

23 SUBSTANTIAL NONCOMPLIANCE.—The Secretary 

24 may terminate the election of any employer under 

25 paragraph (2) if the Secretary (in coordination with 


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1 the Health Choices Commissioner) determines that 

2 such employer is in substantial noncompliance with 

3 the health coverage participation requirements. 

4 ‘‘(b) EXCISE TAX WITH RESPECT TO FAILURE TO

5 MEET HEALTH COVERAGE PARTICIPATION REQUIRE6 MENTS.— 

7 ‘‘(1) IN GENERAL.—In the case of any employer 

8 who fails (during any period with respect to which 

9 the election under subsection (a) is in effect) to sat10 isfy the health coverage participation requirements 

11 with respect to any employee to whom such election 

12 applies, there is hereby imposed on each such failure 

13 with respect to each such employee a tax of $100 for 

14 each day in the period beginning on the date such 

15 failure first occurs and ending on the date such fail16 ure is corrected. 

17 ‘‘(2) LIMITATIONS ON AMOUNT OF TAX.— 

18 ‘‘(A) TAX NOT TO APPLY WHERE FAILURE

19 NOT DISCOVERED EXERCISING REASONABLE

20 DILIGENCE.—No tax shall be imposed by para21 graph (1) on any failure during any period for 

22 which it is established to the satisfaction of the 

23 Secretary that the employer neither knew, nor 

24 exercising reasonable diligence would have 

25 known, that such failure existed. 


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1 ‘‘(B) TAX NOT TO APPLY TO FAILURES

2 CORRECTED WITHIN 30 DAYS.—No tax shall be 

3 imposed by paragraph (1) on any failure if— 

4 ‘‘(i) such failure was due to reason5 able cause and not to willful neglect, and 

6 ‘‘(ii) such failure is corrected during 

7 the 30-day period beginning on the 1st 

8 date that the employer knew, or exercising 

9 reasonable diligence would have known, 

10 that such failure existed. 

11 ‘‘(C) OVERALL LIMITATION FOR UNINTEN12 TIONAL FAILURES.—In the case of failures 

13 which are due to reasonable cause and not to 

14 willful neglect, the tax imposed by subsection 

15 (a) for failures during the taxable year of the 

16 employer shall not exceed the amount equal to 

17 the lesser of— 

18 ‘‘(i) 10 percent of the aggregate 

19 amount paid or incurred by the employer 

20 (or predecessor employer) during the pre21 ceding taxable year for employment-based 

22 health plans, or 

23 ‘‘(ii) $500,000. 

24 ‘‘(D) COORDINATION WITH OTHER EN25 FORCEMENT PROVISIONS.—The tax imposed 


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1 under paragraph (1) with respect to any failure 

2 shall be reduced (but not below zero) by the 

3 amount of any civil penalty collected under sec4 tion 502(c)(11) of the Employee Retirement In5 come Security Act of 1974 or section 2793(g) 

6 of the Public Health Service Act with respect to 

7 such failure. 

8 ‘‘(c) HEALTH COVERAGE PARTICIPATION REQUIRE9 MENTS.—For purposes of this section, the term ‘health 

10 coverage participation requirements’ means the require11 ments of part I of subtitle B of title IV of the (as in effect 

12 on the date of the enactment of this section).’’. 

13 (b) CLERICAL AMENDMENT.—The table of sections 

14 for chapter 43 of such Code is amended by adding at the 

15 end the following new item: 

‘‘Sec. 4980H. Election with respect to health coverage participation requirements.’’. 

16 (c) EFFECTIVE DATE.—The amendments made by 

17 this section shall apply to periods beginning after Decem18 ber 31, 2012. 

19 SEC. 512. HEALTH CARE CONTRIBUTIONS OF NON20 ELECTING EMPLOYERS. 

21 (a) IN GENERAL.—Section 3111 of the Internal Rev22 enue Code of 1986 is amended by redesignating subsection 

23 (c) as subsection (d) and by inserting after subsection (b) 

24 the following new subsection: 


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1 ‘‘(c) EMPLOYERS ELECTING NOT TO PROVIDE

2 HEALTH BENEFITS.— 

3 ‘‘(1) IN GENERAL.—In addition to other taxes, 

4 there is hereby imposed on every nonelecting em5 ployer an excise tax, with respect to having individ6 uals in his employ, equal to 8 percent of the wages 

7 (as defined in section 3121(a)) paid by him with re8 spect to employment (as defined in section 3121(b)). 

9 ‘‘(2) SPECIAL RULES FOR SMALL EMPLOY10 ERS.— 

11 ‘‘(A) IN GENERAL.—In the case of any em12 ployer who is small employer for any calendar 

13 year, paragraph (1) shall be applied by sub14 stituting the applicable percentage determined 

15 in accordance with the following table for ‘8 

16 percent’: 

‘‘If the annual payroll of such employer for 

the preceding calendar year: 

The applicable 

percentage is: 

Does not exceed $500,000 ..................................... 0 percent 

Exceeds $500,000, but does not exceed $585,000 2 percent 

Exceeds $585,000, but does not exceed $670,000 4 percent 

Exceeds $670,000, but does not exceed $750,000 6 percent 

17 ‘‘(B) SMALL EMPLOYER.—For purposes of 

18 this paragraph, the term ‘small employer’ 

19 means any employer for any calendar year if 

20 the annual payroll of such employer for the pre21 ceding calendar year does not exceed $750,000. 


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1 ‘‘(C) ANNUAL PAYROLL.—For purposes of 

2 this paragraph, the term ‘annual payroll’ 

3 means, with respect to any employer for any 

4 calendar year, the aggregate wages (as defined 

5 in section 3121(a)) paid by him with respect to 

6 employment (as defined in section 3121(b)) 

7 during such calendar year. 

8 ‘‘(3) NONELECTING EMPLOYER.—For purposes 

9 of paragraph (1), the term ‘nonelecting employer’ 

10 means any employer for any period with respect to 

11 which such employer does not have an election under 

12 section 4980H(a) in effect. 

13 ‘‘(4) SPECIAL RULE FOR SEPARATE ELEC14 TIONS.—In the case of an employer who makes a 

15 separate election described in section 4980H(a)(4) 

16 for any period, paragraph (1) shall be applied for 

17 such period by taking into account only the wages 

18 paid to employees who are not subject to such elec19 tion. 

20 ‘‘(5) AGGREGATION; PREDECESSORS.—For pur21 poses of this subsection— 

22 ‘‘(A) all persons treated as a single em23 ployer under subsection (b), (c), (m), or (o) of 

24 section 414 shall be treated as 1 employer, and 


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1 ‘‘(B) any reference to any person shall be 

2 treated as including a reference to any prede3 cessor of such person.’’. 

4 (b) DEFINITIONS.—Section 3121 of such Code is 

5 amended by adding at the end the following new sub6 section: 

7 ‘‘(aa) SPECIAL RULES FOR TAX ON EMPLOYERS

8 ELECTING NOT TO PROVIDE HEALTH BENEFITS.—For 

9 purposes of section 3111(c)— 

10 ‘‘(1) Paragraphs (1), (5), and (19) of sub11 section (b) shall not apply. 

12 ‘‘(2) Paragraph (7) of subsection (b) shall apply 

13 by treating all services as not covered by the retire14 ment systems referred to in subparagraphs (C) and 

15 (F) thereof. 

16 ‘‘(3) Subsection (e) shall not apply and the 

17 term ‘State’ shall include the District of Columbia.’’. 

18 (c) CONFORMING AMENDMENT.—Subsection (d) of 

19 section 3111 of such Code, as redesignated by this section, 

20 is amended by striking ‘‘this section’’ and inserting ‘‘sub21 sections (a) and (b)’’. 

22 (d) APPLICATION TO RAILROADS.— 

23 (1) IN GENERAL.—Section 3221 of such Code 

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1 section (d) and by inserting after subsection (b) the 

2 following new subsection: 

3 ‘‘(c) EMPLOYERS ELECTING NOT TO PROVIDE

4 HEALTH BENEFITS.— 

5 ‘‘(1) IN GENERAL.—In addition to other taxes, 

6 there is hereby imposed on every nonelecting em7 ployer an excise tax, with respect to having individ8 uals in his employ, equal to 8 percent of the com9 pensation paid during any calendar year by such em10 ployer for services rendered to such employer. 

11 ‘‘(2) EXCEPTION FOR SMALL EMPLOYERS.— 

12 Rules similar to the rules of section 3111(c)(2) shall 

13 apply for purposes of this subsection. 

14 ‘‘(3) NONELECTING EMPLOYER.—For purposes 

15 of paragraph (1), the term ‘nonelecting employer’ 

16 means any employer for any period with respect to 

17 which such employer does not have an election under 

18 section 4980H(a) in effect. 

19 ‘‘(4) SPECIAL RULE FOR SEPARATE ELEC20 TIONS.—In the case of an employer who makes a 

21 separate election described in section 4980H(a)(4) 

22 for any period, subsection (a) shall be applied for 

23 such period by taking into account only the com24 pensation paid to employees who are not subject to 

25 such election.’’. 


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1 (2) DEFINITIONS.—Subsection (e) of section 

2 3231 of such Code is amended by adding at the end 

3 the following new paragraph: 

4 ‘‘(13) SPECIAL RULES FOR TAX ON EMPLOYERS

5 ELECTING NOT TO PROVIDE HEALTH BENEFITS.— 

6 For purposes of section 3221(c)— 

7 ‘‘(A) Paragraph (1) shall be applied with8 out regard to the third sentence thereof. 

9 ‘‘(B) Paragraph (2) shall not apply.’’. 

10 (3) CONFORMING AMENDMENT.—Subsection (d) 

11 of section 3221 of such Code, as redesignated by 

12 this section, is amended by striking ‘‘subsections (a) 

13 and (b), see section 3231(e)(2)’’ and inserting ‘‘this 

14 section, see paragraphs (2) and (13)(B) of section 

15 3231(e)’’. 

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

17 this section shall apply to periods beginning after Decem18 ber 31, 2012. 

19 PART 2—CREDIT FOR SMALL BUSINESS 

20 EMPLOYEE HEALTH COVERAGE EXPENSES 

21 SEC. 521. CREDIT FOR SMALL BUSINESS EMPLOYEE 

22 HEALTH COVERAGE EXPENSES. 

23 (a) IN GENERAL.—Subpart D of part IV of sub24 chapter A of chapter 1 of the Internal Revenue Code of 


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1 1986 (relating to business-related credits) is amended by 

2 adding at the end the following new section: 

3 ‘‘SEC. 45R. SMALL BUSINESS EMPLOYEE HEALTH COV4 ERAGE CREDIT. 

5 ‘‘(a) IN GENERAL.—For purposes of section 38, in 

6 the case of a qualified small employer, the small business 

7 employee health coverage credit determined under this sec8 tion for the taxable year is an amount equal to the applica9 ble percentage of the qualified employee health coverage 

10 expenses of such employer for such taxable year. 

11 ‘‘(b) APPLICABLE PERCENTAGE.— 

12 ‘‘(1) IN GENERAL.—For purposes of this sec13 tion, the applicable percentage is 50 percent. 

14 ‘‘(2) PHASEOUT BASED ON AVERAGE COM15 PENSATION OF EMPLOYEES.—In the case of an em16 ployer whose average annual employee compensation 

17 for the taxable year exceeds $20,000, the percentage 

18 specified in paragraph (1) shall be reduced by a 

19 number of percentage points which bears the same 

20 ratio to 50 as such excess bears to $20,000. 

21 ‘‘(c) LIMITATIONS.— 

22 ‘‘(1) PHASEOUT BASED ON EMPLOYER SIZE.— 

23 In the case of an employer who employs more than 

24 10 qualified employees during the taxable year, the 

25 credit determined under subsection (a) shall be reVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00318 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 duced by an amount which bears the same ratio to 

2 the amount of such credit (determined without re3 gard to this paragraph and after the application of 

4 the other provisions of this section) as— 

5 ‘‘(A) the excess of— 

6 ‘‘(i) the number of qualified employees 

7 employed by the employer during the tax8 able year, over 

9 ‘‘(ii) 10, bears to 

10 ‘‘(B) 15. 

11 ‘‘(2) CREDIT NOT ALLOWED WITH RESPECT TO

12 CERTAIN HIGHLY COMPENSATED EMPLOYEES.—No 

13 credit shall be determined under subsection (a) with 

14 respect to qualified employee health coverage ex15 penses paid or incurred with respect to any employee 

16 for any taxable year if the aggregate compensation 

17 paid by the employer to such employee during such 

18 taxable year exceeds $80,000. 

19 ‘‘(3) CREDIT ALLOWED FOR ONLY 2 TAXABLE

20 YEARS.—No credit shall be determined under sub21 section (a) with respect to any employer for any tax22 able year unless the employer elects to have this sec23 tion apply for such taxable year. An employer may 

24 elect the application of this section with respect to 

25 not more than 2 taxable years. 


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1 ‘‘(d) QUALIFIED EMPLOYEE HEALTH COVERAGE EX2 PENSES.—For purposes of this section— 

3 ‘‘(1) IN GENERAL.—The term ‘qualified em4 ployee health coverage expenses’ means, with respect 

5 to any employer for any taxable year, the aggregate 

6 amount paid or incurred by such employer during 

7 such taxable year for coverage of any qualified em8 ployee of the employer (including any family cov9 erage which covers such employee) under qualified 

10 health coverage. 

11 ‘‘(2) QUALIFIED HEALTH COVERAGE.—The 

12 term ‘qualified health coverage’ means acceptable 

13 coverage (as defined in section 59B(d)) which— 

14 ‘‘(A) is provided pursuant to an election 

15 under section 4980H(a), and 

16 ‘‘(B) satisfies the requirements referred to 

17 in section 4980H(c). 

18 ‘‘(e) OTHER DEFINITIONS.—For purposes of this 

19 section— 

20 ‘‘(1) QUALIFIED SMALL EMPLOYER.—For pur21 poses of this section, the term ‘qualified small em22 ployer’ means any employer for any taxable year 

23 if— 


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1 ‘‘(A) the number of qualified employees 

2 employed by such employer during the taxable 

3 year does not exceed 25, and 

4 ‘‘(B) the average annual employee com5 pensation of such employer for such taxable 

6 year does not exceed the sum of the dollar 

7 amounts in effect under subsection (b)(2). 

8 ‘‘(2) QUALIFIED EMPLOYEE.—The term ‘quali9 fied employee’ means any employee of an employer 

10 for any taxable year of the employer if such em11 ployee received at least $5,000 of compensation from 

12 such employer for services performed in the trade or 

13 business of such employer during such taxable year. 

14 ‘‘(3) AVERAGE ANNUAL EMPLOYEE COMPENSA15 TION.—The term ‘average annual employee com16 pensation’ means, with respect to any employer for 

17 any taxable year, the average amount of compensa18 tion paid by such employer to qualified employees of 

19 such employer during such taxable year. 

20 ‘‘(4) COMPENSATION.—The term ‘compensa21 tion’ has the meaning given such term in section 

22 408(p)(6)(A). 

23 ‘‘(5) FAMILY COVERAGE.—The term ‘family 

24 coverage’ means any coverage other than self-only 

25 coverage. 


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1 ‘‘(f) SPECIAL RULES.—For purposes of this sec2 tion— 

3 ‘‘(1) SPECIAL RULE FOR PARTNERSHIPS AND

4 SELF-EMPLOYED.—In the case of a partnership (or 

5 a trade or business carried on by an individual) 

6 which has one or more qualified employees (deter7 mined without regard to this paragraph) with re8 spect to whom the election under section 4980H(a) 

9 applies, each partner (or, in the case of a trade or 

10 business carried on by an individual, such indi11 vidual) shall be treated as an employee. 

12 ‘‘(2) AGGREGATION RULE.—All persons treated 

13 as a single employer under subsection (b), (c), (m), 

14 or (o) of section 414 shall be treated as 1 employer. 

15 ‘‘(3) PREDECESSORS.—Any reference in this 

16 section to an employer shall include a reference to 

17 any predecessor of such employer. 

18 ‘‘(4) DENIAL OF DOUBLE BENEFIT.—Any de19 duction otherwise allowable with respect to amounts 

20 paid or incurred for health insurance coverage to 

21 which subsection (a) applies shall be reduced by the 

22 amount of the credit determined under this section. 

23 ‘‘(5) INFLATION ADJUSTMENT.—In the case of 

24 any taxable year beginning after 2013, each of the 


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1 dollar amounts in subsections (b)(2), (c)(2), and 

2 (e)(2) shall be increased by an amount equal to— 

3 ‘‘(A) such dollar amount, multiplied by 

4 ‘‘(B) the cost of living adjustment deter5 mined under section 1(f)(3) for the calendar 

6 year in which the taxable year begins deter7 mined by substituting ‘calendar year 2012’ for 

8 ‘calendar year 1992’ in subparagraph (B) 

9 thereof. 

10 If any increase determined under this paragraph is 

11 not a multiple of $50, such increase shall be rounded 

12 to the next lowest multiple of $50.’’. 

13 (b) CREDIT TO BE PART OF GENERAL BUSINESS

14 CREDIT.—Subsection (b) of section 38 of such Code (re15 lating to general business credit) is amended by striking 

16 ‘‘plus’’ at the end of paragraph (34), by striking the period 

17 at the end of paragraph (35) and inserting ‘‘, plus’’ , and 

18 by adding at the end the following new paragraph: 

19 ‘‘(36) in the case of a qualified small employer 

20 (as defined in section 45R(e)), the small business 

21 employee health coverage credit determined under 

22 section 45R(a).’’. 

23 (c) CLERICAL AMENDMENT.—The table of sections 

24 for subpart D of part IV of subchapter A of chapter 1 


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1 of such Code is amended by inserting after the item relat2 ing to section 45Q the following new item: 

‘‘Sec. 45R. Small business employee health coverage credit.’’. 

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

4 this section shall apply to taxable years beginning after 

5 December 31, 2012. 

6 PART 3—LIMITATIONS ON HEALTH CARE 

7 RELATED EXPENDITURES 

8 SEC. 531. DISTRIBUTIONS FOR MEDICINE QUALIFIED ONLY 

9 IF FOR PRESCRIBED DRUG OR INSULIN. 

10 (a) HSAS.—Subparagraph (A) of section 223(d)(2) 

11 of the Internal Revenue Code of 1986 is amended by add12 ing at the end the following: ‘‘Such term shall include an 

13 amount paid for medicine or a drug only if such medicine 

14 or drug is a prescribed drug or is insulin.’’. 

15 (b) ARCHER MSAS.—Subparagraph (A) of section 

16 220(d)(2) of such Code is amended by adding at the end 

17 the following: ‘‘Such term shall include an amount paid 

18 for medicine or a drug only if such medicine or drug is 

19 a prescribed drug or is insulin.’’. 

20 (c) HEALTH FLEXIBLE SPENDING ARRANGEMENTS

21 AND HEALTH REIMBURSEMENT ARRANGEMENTS.—Sec22 tion 106 of such Code is amended by adding at the end 

23 the following new subsection: 

24 ‘‘(f) REIMBURSEMENTS FOR MEDICINE RESTRICTED

25 TO PRESCRIBED DRUGS AND INSULIN.—For purposes of 


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1 this section and section 105, reimbursement for expenses 

2 incurred for a medicine or a drug shall be treated as a 

3 reimbursement for medical expenses only if such medicine 

4 or drug is a prescribed drug or is insulin.’’. 

5 (d) EFFECTIVE DATES.—The amendment made by 

6 this section shall apply to expenses incurred after Decem7 ber 31, 2010. 

8 SEC. 532. LIMITATION ON HEALTH FLEXIBLE SPENDING AR9 RANGEMENTS UNDER CAFETERIA PLANS. 

10 (a) IN GENERAL.—Section 125 of the Internal Rev11 enue Code of 1986 is amended— 

12 (1) by redesignating subsections (i) and (j) as 

13 subsections (j) and (k), respectively, and 

14 (2) by inserting after subsection (h) the fol15 lowing new subsection: 

16 ‘‘(i) LIMITATION ON HEALTH FLEXIBLE SPENDING

17 ARRANGEMENTS.— 

18 ‘‘(1) IN GENERAL.—For purposes of this sec19 tion, if a benefit is provided under a cafeteria plan 

20 through employer contributions to a health flexible 

21 spending arrangement, such benefit shall not be 

22 treated as a qualified benefit unless the cafeteria 

23 plan provides that an employee may not elect for 

24 any taxable year to have salary reduction contribu25 tions in excess of $2,500 made to such arrangement. 


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1 ‘‘(2) INFLATION ADJUSTMENT.—In the case of 

2 any taxable year beginning after 2013, the dollar 

3 amount in paragraph (1) shall be increased by an 

4 amount equal to— 

5 ‘‘(A) such dollar amount, multiplied by 

6 ‘‘(B) the cost of living adjustment deter7 mined under section 1(f)(3) for the calendar 

8 year in which the taxable year begins deter9 mined by substituting ‘calendar year 2012’ for 

10 ‘calendar year 1992’ in subparagraph (B) 

11 thereof. 

12 If any increase determined under this paragraph is 

13 not a multiple of $50, such increase shall be rounded 

14 to the next lowest multiple of $50.’’. 

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

16 this section shall apply to taxable years beginning after 

17 December 31, 2012. 

18 SEC. 533. INCREASE IN PENALTY FOR NONQUALIFIED DIS19 TRIBUTIONS FROM HEALTH SAVINGS AC20 COUNTS. 

21 (a) IN GENERAL.—Subparagraph (A) of section 

22 223(f)(4) of the Internal Revenue Code of 1986 is amend23 ed by striking ‘‘10 percent’’ and inserting ‘‘20 percent’’. 


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

2 this section shall apply to taxable years beginning after 

3 December 31, 2010. 

4 SEC. 534. DENIAL OF DEDUCTION FOR FEDERAL SUBSIDIES 

5 FOR PRESCRIPTION DRUG PLANS WHICH 

6 HAVE BEEN EXCLUDED FROM GROSS IN7 COME. 

8 (a) IN GENERAL.—Section 139A of the Internal Rev9 enue Code of 1986 is amended by striking the second sen10 tence. 

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

12 this section shall apply to taxable years beginning after 

13 December 31, 2010. 

14 PART 4—OTHER PROVISIONS TO CARRY OUT 

15 HEALTH INSURANCE REFORM 

16 SEC. 541. DISCLOSURES TO CARRY OUT HEALTH INSUR17 ANCE EXCHANGE SUBSIDIES. 

18 (a) IN GENERAL.—Subsection (l) of section 6103 of 

19 the Internal Revenue Code of 1986 is amended by adding 

20 at the end the following new paragraph: 

21 ‘‘(21) DISCLOSURE OF RETURN INFORMATION

22 TO CARRY OUT HEALTH INSURANCE EXCHANGE SUB23 SIDIES.— 

24 ‘‘(A) IN GENERAL.—The Secretary, upon 

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1 missioner or the head of a State-based health 

2 insurance exchange approved for operation 

3 under section 308 of the , shall disclose to offi4 cers and employees of the Health Choices Ad5 ministration or such State-based health insur6 ance exchange, as the case may be, return in7 formation of any taxpayer whose income is rel8 evant in determining any affordability credit de9 scribed in subtitle C of title III of the . Such 

10 return information shall be limited to— 

11 ‘‘(i) taxpayer identity information 

12 with respect to such taxpayer, 

13 ‘‘(ii) the filing status of such tax14 payer, 

15 ‘‘(iii) the modified adjusted gross in16 come of such taxpayer (as defined in sec17 tion 59B(e)(5)), 

18 ‘‘(iv) the number of dependents of the 

19 taxpayer, 

20 ‘‘(v) such other information as is pre21 scribed by the Secretary by regulation as 

22 might indicate whether the taxpayer is eli23 gible for such affordability credits (and the 

24 amount thereof), and 


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1 ‘‘(vi) the taxable year with respect to 

2 which the preceding information relates or, 

3 if applicable, the fact that such informa4 tion is not available. 

5 ‘‘(B) RESTRICTION ON USE OF DISCLOSED

6 INFORMATION.—Return information disclosed 

7 under subparagraph (A) may be used by offi8 cers and employees of the Health Choices Ad9 ministration or such State-based health insur10 ance exchange, as the case may be, only for the 

11 purposes of, and to the extent necessary in, es12 tablishing and verifying the appropriate amount 

13 of any affordability credit described in subtitle 

14 C of title III of the and providing for the repay15 ment of any such credit which was in excess of 

16 such appropriate amount.’’. 

17 (b) PROCEDURES AND RECORDKEEPING RELATED

18 TO DISCLOSURES.—Paragraph (4) of section 6103(p) of 

19 such Code is amended— 

20 (1) by inserting ‘‘, or any entity described in 

21 subsection (l)(21),’’ after ‘‘or (20)’’ in the matter 

22 preceding subparagraph (A), 

23 (2) by inserting ‘‘or any entity described in sub24 section (l)(21),’’ after ‘‘or (o)(1)(A),’’ in subpara25 graph (F)(ii), and 


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1 (3) by inserting ‘‘or any entity described in sub2 section (l)(21),’’ after ‘‘or (20),’’ both places it ap3 pears in the matter after subparagraph (F). 

4 (c) UNAUTHORIZED DISCLOSURE OR INSPECTION.— 

5 Paragraph (2) of section 7213(a) of such Code is amended 

6 by striking ‘‘or (20)’’ and inserting ‘‘(20), or (21)’’. 

7 SEC. 542. OFFERING OF EXCHANGE-PARTICIPATING 

8 HEALTH BENEFITS PLANS THROUGH CAFE9 TERIA PLANS. 

10 (a) IN GENERAL.—Subsection (f) of section 125 of 

11 the Internal Revenue Code of 1986 is amended by adding 

12 at the end the following new paragraph: 

13 ‘‘(3) CERTAIN EXCHANGE-PARTICIPATING

14 HEALTH BENEFITS PLANS NOT QUALIFIED.— 

15 ‘‘(A) IN GENERAL.—The term ‘qualified 

16 benefit’ shall not include any exchange-partici17 pating health benefits plan (as defined in sec18 tion 101(c) of the ). 

19 ‘‘(B) EXCEPTION FOR EXCHANGE-ELIGI20 BLE EMPLOYERS.—Subparagraph (A) shall not 

21 apply with respect to any employee if such em22 ployee’s employer is an exchange-eligible em23 ployer (as defined in section 302 of the ).’’. 

24 (b) CONFORMING AMENDMENTS.—Subsection (f) of 

25 section 125 of such Code is amended— 


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1 (1) by striking ‘‘For purposes of this section, 

2 the term’’ and inserting ‘‘For purposes of this sec3 tion— 

4 ‘‘(1) IN GENERAL.—The term’’, and 

5 (2) by striking ‘‘Such term shall not include’’ 

6 and inserting the following: 

7 ‘‘(2) LONG-TERM CARE INSURANCE NOT QUALI8 FIED.—The term ‘qualified benefit’ shall not in9 clude’’. 

10 (c) EFFECTIVE DATE.—The amendments made by 

11 this section shall apply to taxable years beginning after 

12 December 31, 2012. 

13 SEC. 543. EXCLUSION FROM GROSS INCOME OF PAYMENTS 

14 MADE UNDER REINSURANCE PROGRAM FOR 

15 RETIREES. 

16 (a) IN GENERAL.—Section 139A of the Internal Rev17 enue Code of 1986 is amended— 

18 (1) by striking ‘‘Gross income’’ and inserting 

19 the following: 

20 ‘‘(a) FEDERAL SUBSIDIES FOR PRESCRIPTION DRUG

21 PLANS.—Gross income’’, and 

22 (2) by adding at the end the following new sub23 section: 

24 ‘‘(b) FEDERAL REINSURANCE PROGRAM FOR RETIR25 EES.—A rule similar to the rule of subsection (a) shall 


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1 apply with respect to payments made under section 111 

2 of the Affordable Health Care for America Act.’’. 

3 (b) CONFORMING AMENDMENT.—The heading of sec4 tion 139A of such Code (and the item relating to such 

5 section in the table of sections for part III of subchapter 

6 B of chapter 1 of such Code) is amended by inserting 

7 ‘‘AND RETIREE HEALTH PLANS’’ after ‘‘PRESCRIP8 TION DRUG PLANS’’. 

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

10 this section shall apply to taxable years ending after the 

11 date of the enactment of this Act. 

12 SEC. 544. CLASS PROGRAM TREATED IN SAME MANNER AS 

13 LONG-TERM CARE INSURANCE. 

14 (a) IN GENERAL.—Subsection (f) of section 7702B 

15 of the Internal Revenue Code of 1986 is amended— 

16 (1) by striking ‘‘State long-term care plan’’ in 

17 paragraph (1)(A) and inserting ‘‘government long18 term care plan’’, 

19 (2) by redesignating paragraph (2) as para20 graph (3), and 

21 (3) by inserting after paragraph (2) the fol22 lowing new paragraph: 

23 ‘‘(2) GOVERNMENT LONG-TERM CARE PLAN.— 

24 For purposes of this subsection, the term ‘govern25 ment long-term care plan’ means— 


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1 ‘‘(A) the CLASS program established 

2 under title XXXII of the Public Health Service 

3 Act, and 

4 ‘‘(B) any State long-term care plan.’’. 

5 (b) CONFORMING AMENDMENTS.— 

6 (1) Paragraph (3) of section 7702B(f) of such 

7 Code, as redesignated by subsection (a), is amended 

8 by striking ‘‘paragraph (1)’’ and inserting ‘‘this sub9 section’’. 

10 (2) Subsection (f) of section 7702(B) of such 

11 Code is amended by striking ‘‘STATE-MAINTAINED’’ 

12 in the heading thereof and inserting ‘‘GOVERN13 MENT’’. 

14 (c) EFFECTIVE DATE.—The amendments made by 

15 this section shall apply to taxable years ending after De16 cember 31, 2010. 

17 SEC. 545. EXCLUSION FROM GROSS INCOME FOR MEDICAL 

18 CARE PROVIDED FOR INDIANS. 

19 (a) IN GENERAL.—Part III of subchapter B of chap20 ter 1 of the Internal Revenue Code of 1986 (relating to 

21 items specifically excluded from gross income) is amended 

22 by inserting after section 139C the following new section: 

23 ‘‘SEC. 139D. MEDICAL CARE PROVIDED FOR INDIANS. 

24 ‘‘(a) IN GENERAL.—Gross income does not include— 


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1 ‘‘(1) health services or benefits provided or pur2 chased by the Indian Health Service, either directly 

3 or indirectly, through a grant to or a contract or 

4 compact with an Indian tribe or tribal organization 

5 or through programs of third parties funded by the 

6 Indian Health Service, 

7 ‘‘(2) medical care provided by an Indian tribe 

8 or tribal organization to a member of an Indian 

9 tribe (including for this purpose, to the member’s 

10 spouse or dependents) through any one of the fol11 lowing: provided or purchased medical care services; 

12 accident or health insurance (or an arrangement 

13 having the effect of accident or health insurance); or 

14 amounts paid, directly or indirectly, to reimburse the 

15 member for expenses incurred for medical care, 

16 ‘‘(3) the value of accident or health plan cov17 erage provided by an Indian tribe or tribal organiza18 tion for medical care to a member of an Indian tribe 

19 (including for this purpose, coverage that extends to 

20 such member’s spouse or dependents) under an acci21 dent or health plan (or through an arrangement hav22 ing the effect of accident or health insurance), and 

23 ‘‘(4) any other medical care provided by an In24 dian tribe that supplements, replaces, or substitutes 


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1 for the programs and services provided by the Fed2 eral Government to Indian tribes or Indians. 

3 ‘‘(b) DEFINITIONS.—For purposes of this section— 

4 ‘‘(1) IN GENERAL.—The terms ‘accident or 

5 health insurance’ and ‘accident or health plan’ have 

6 the same meaning as when used in sections 104 and 

7 106. 

8 ‘‘(2) MEDICAL CARE.—The term ‘medical care’ 

9 has the meaning given such term in section 213. 

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

11 the meaning given such term in section 152, deter12 mined without regard to subsections (b)(1), (b)(2), 

13 and (d)(1)(B). 

14 ‘‘(4) INDIAN TRIBE.—The term ‘Indian tribe’ 

15 means any Indian tribe, band, nation, pueblo, or 

16 other organized group or community, including any 

17 Alaska Native village, or regional or village corpora18 tion, as defined in, or established pursuant to, the 

19 Alaska Native Claims Settlement Act (43 U.S.C. 

20 1601 et seq.), which is recognized as eligible for the 

21 special programs and services provided by the 

22 United States to Indians because of their status as 

23 Indians. 

24 ‘‘(5) TRIBAL ORGANIZATION.—The term ‘tribal 

25 organization’ has the meaning given such term in 


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1 section 4(l) of the Indian Self-Determination and 

2 Education Assistance Act (25 U.S.C. 450b(l)).’’. 

3 (b) CLERICAL AMENDMENT.—The table of sections 

4 for such part III is amended by inserting after the item 

5 relating to section 139C the following new item: 

‘‘Sec. 139D. Medical care provided for Indians.’’. 

6 (c) EFFECTIVE DATE.—The amendments made by 

7 this section shall apply to health benefits and coverage 

8 provided after the date of enactment of this Act. 

9 (d) NO INFERENCE.—Nothing in the amendments 

10 made by this section shall be construed to create an infer11 ence with respect to the exclusion from gross income of— 

12 (1) benefits provided by Indian tribes that are 

13 not within the scope of this section, and 

14 (2) health benefits or coverage provided by In15 dian tribes prior to the effective date of this section. 

16 Subtitle B—Other Revenue 

17 Provisions 

18 PART 1—GENERAL PROVISIONS 

19 SEC. 551. SURCHARGE ON HIGH INCOME INDIVIDUALS. 

20 (a) IN GENERAL.—Part VIII of subchapter A of 

21 chapter 1 of the Internal Revenue Code of 1986, as added 

22 by this title, is amended by adding at the end the following 

23 new subpart: 

24 ‘‘Subpart B—Surcharge on High Income Individuals 

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


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1 ‘‘SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS. 

2 ‘‘(a) GENERAL RULE.—In the case of a taxpayer 

3 other than a corporation, there is hereby imposed (in addi4 tion to any other tax imposed by this subtitle) a tax equal 

5 to 5.4 percent of so much of the modified adjusted gross 

6 income of the taxpayer as exceeds $1,000,000. 

7 ‘‘(b) TAXPAYERS NOT MAKING A JOINT RETURN.— 

8 In the case of any taxpayer other than a taxpayer making 

9 a joint return under section 6013 or a surviving spouse 

10 (as defined in section 2(a)), subsection (a) shall be applied 

11 by substituting ‘$500,000’ for ‘$1,000,000’. 

12 ‘‘(c) MODIFIED ADJUSTED GROSS INCOME.—For 

13 purposes of this section, the term ‘modified adjusted gross 

14 income’ means adjusted gross income reduced by any de15 duction (not taken into account in determining adjusted 

16 gross income) allowed for investment interest (as defined 

17 in section 163(d)). In the case of an estate or trust, ad18 justed gross income shall be determined as provided in sec19 tion 67(e). 

20 ‘‘(d) SPECIAL RULES.— 

21 ‘‘(1) NONRESIDENT ALIEN.—In the case of a 

22 nonresident alien individual, only amounts taken 

23 into account in connection with the tax imposed 

24 under section 871(b) shall be taken into account 

25 under this section. 


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1 ‘‘(2) CITIZENS AND RESIDENTS LIVING

2 ABROAD.—The dollar amount in effect under sub3 section (a) (after the application of subsection (b)) 

4 shall be decreased by the excess of— 

5 ‘‘(A) the amounts excluded from the tax6 payer’s gross income under section 911, over 

7 ‘‘(B) the amounts of any deductions or ex8 clusions disallowed under section 911(d)(6) 

9 with respect to the amounts described in sub10 paragraph (A). 

11 ‘‘(3) CHARITABLE TRUSTS.—Subsection (a) 

12 shall not apply to a trust all the unexpired interests 

13 in which are devoted to one or more of the purposes 

14 described in section 170(c)(2)(B). 

15 ‘‘(4) NOT TREATED AS TAX IMPOSED BY THIS

16 CHAPTER FOR CERTAIN PURPOSES.—The tax im17 posed under this section shall not be treated as tax 

18 imposed by this chapter for purposes of determining 

19 the amount of any credit under this chapter or for 

20 purposes of section 55.’’. 

21 (b) CLERICAL AMENDMENT.—The table of subparts 

22 for part VIII of subchapter A of chapter 1 of such Code, 

23 as added by this title, is amended by inserting after the 

24 item relating to subpart A the following new item: 

‘‘SUBPART B. SURCHARGE ON HIGH INCOME INDIVIDUALS.’’. 


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1 (c) SECTION 15 NOT TO APPLY.—The amendment 

2 made by subsection (a) shall not be treated as a change 

3 in a rate of tax for purposes of section 15 of the Internal 

4 Revenue Code of 1986. 

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

6 this section shall apply to taxable years beginning after 

7 December 31, 2010. 

8 SEC. 552. EXCISE TAX ON MEDICAL DEVICES. 

9 (a) IN GENERAL.—Chapter 31 of the Internal Rev10 enue Code of 1986 is amended by adding at the end the 

11 following new subchapter: 

12 ‘‘Subchapter D—Medical Devices 

‘‘Sec. 4061. Medical devices. 

13 ‘‘SEC. 4061. MEDICAL DEVICES. 

14 ‘‘(a) IN GENERAL.—There is hereby imposed on the 

15 first taxable sale of any medical device a tax equal to 2.5 

16 percent of the price for which so sold. 

17 ‘‘(b) FIRST TAXABLE SALE.—For purposes of this 

18 section— 

19 ‘‘(1) IN GENERAL.—The term ‘first taxable 

20 sale’ means the first sale, for a purpose other than 

21 for resale, after production, manufacture, or impor22 tation. 


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1 ‘‘(2) EXCEPTION FOR SALES AT RETAIL ESTAB2 LISHMENTS.—Such term shall not include the sale 

3 of any medical device if— 

4 ‘‘(A) such sale is made at a retail estab5 lishment on terms which are available to the 

6 general public, and 

7 ‘‘(B) such medical device is of a type (and 

8 purchased in a quantity) which is purchased by 

9 the general public. 

10 ‘‘(3) EXCEPTION FOR EXPORTS, ETC.—Rules 

11 similar to the rules of sections 4221 (other than 

12 paragraphs (3), (4), (5), and (6) of subsection (a) 

13 thereof) and 4222 shall apply for purposes of this 

14 section. To the extent provided by the Secretary, 

15 section 4222 may be extended to, and made applica16 ble with respect to, the exemption provided by para17 graph (2). 

18 ‘‘(4) SALES TO PATIENTS NOT TREATED AS RE19 SALES.—If a medical device is sold for use in con20 nection with providing any health care service to an 

21 individual, such sale shall not be treated as being for 

22 the purpose of resale (even if such device is sold to 

23 such individual). 

24 ‘‘(c) OTHER DEFINITIONS AND SPECIAL RULES.— 

25 For purposes of this section— 


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1 ‘‘(1) MEDICAL DEVICE.—The term ‘medical de2 vice’ means any device (as defined in section 201(h) 

3 of the Federal Food, Drug, and Cosmetic Act) in4 tended for humans. 

5 ‘‘(2) LEASE TREATED AS SALE.—Rules similar 

6 to the rules of section 4217 shall apply. 

7 ‘‘(3) USE TREATED AS SALE.— 

8 ‘‘(A) IN GENERAL.—If any person uses a 

9 medical device before the first taxable sale of 

10 such device, then such person shall be liable for 

11 tax under such subsection in the same manner 

12 as if such use were the first taxable sale of such 

13 device. 

14 ‘‘(B) EXCEPTIONS.—The preceding sen15 tence shall not apply to— 

16 ‘‘(i) use of a medical device as mate17 rial in the manufacture or production of, 

18 or as a component part of, another medical 

19 device to be manufactured or produced by 

20 such person, or 

21 ‘‘(ii) use of a medical device after a 

22 sale described in subsection (b)(2). 

23 ‘‘(4) DETERMINATION OF PRICE.— 


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1 ‘‘(A) IN GENERAL.—Rules similar to the 

2 rules of subsections (a), (c), and (d) of section 

3 4216 shall apply for purposes of this section. 

4 ‘‘(B) CONSTRUCTIVE SALE PRICE.—If— 

5 ‘‘(i) a medical device is sold (otherwise 

6 than through an arm’s length transaction) 

7 at less than the fair market price, or 

8 ‘‘(ii) a person is liable for tax for a 

9 use described in paragraph (3), 

10 the tax under this section shall be computed on 

11 the price for which such or similar devices are 

12 sold in the ordinary course of trade as deter13 mined by the Secretary. 

14 ‘‘(5) RESALES PURSUANT TO CERTAIN CON15 TRACT ARRANGEMENTS.— 

16 ‘‘(A) IN GENERAL.—In the case of a speci17 fied contract sale of a medical device, the seller 

18 referred to in subparagraph (B)(i) shall be enti19 tled to recover from the producer, manufac20 turer, or importer referred to in subparagraph 

21 (B)(ii) the amount of the tax paid by such sell22 er under this section with respect to such sale. 

23 ‘‘(B) SPECIFIED CONTRACT SALE.—For 

24 purposes of this paragraph, the term ‘specified 

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1 ical device, the first taxable sale of such device 

2 if— 

3 ‘‘(i) the seller is not the producer, 

4 manufacturer, or importer of such device, 

5 ‘‘(ii) the price at which such device is 

6 so sold is determined in accordance with a 

7 contract between the producer, manufac8 turer, or importer of such device and the 

9 person to whom such device is so sold. 

10 ‘‘(C) SPECIAL RULES RELATED TO CRED11 ITS AND REFUNDS.—In the case of any credit 

12 or refund under section 6416 of the tax im13 posed under this section on a specified contract 

14 sale of a medical device— 

15 ‘‘(i) such credit or refund shall be al16 lowed or made only if the seller has filed 

17 with the Secretary the written consent of 

18 the producer, manufacturer, or importer 

19 referred to in subparagraph (B)(ii) to the 

20 allowance of such credit or the making of 

21 such refund, and 

22 ‘‘(ii) the amount of tax taken into ac23 count under subparagraph (A) shall be re24 duced by the amount of such credit or re25 fund.’’. 


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1 (b) CONFORMING AMENDMENTS.— 

2 (1) Paragraph (2) of section 6416(b) of such 

3 Code is amended— 

4 (A) by inserting ‘‘or 4061’’ after ‘‘under 

5 section 4051’’, and 

6 (B) by adding at the end the following: ‘‘In 

7 the case of the tax imposed by section 4061, 

8 subparagraphs (B), (C), (D), and (E) shall not 

9 apply.’’. 

10 (2) The table of subchapters for chapter 31 of 

11 such Code is amended by adding at the end the fol12 lowing new item: 

‘‘SUBCHAPTER D. MEDICAL DEVICES.’’. 

13 (c) EFFECTIVE DATE.—The amendments made by 

14 this section shall apply to sales (and leases and uses treat15 ed as sales) after December 31, 2012. 

16 SEC. 553. EXPANSION OF INFORMATION REPORTING RE17 QUIREMENTS. 

18 (a) IN GENERAL.—Section 6041 of the Internal Rev19 enue Code of 1986 is amended by adding at the end the 

20 following new subsections: 

21 ‘‘(h) APPLICATION TO CORPORATIONS.—Notwith22 standing any regulation prescribed by the Secretary before 

23 the date of the enactment of this subsection, for purposes 

24 of this section the term ‘person’ includes any corporation 


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1 that is not an organization exempt from tax under section 

2 501(a). 

3 ‘‘(i) REGULATIONS.—The Secretary may prescribe 

4 such regulations and other guidance as may be appro5 priate or necessary to carry out the purposes of this sec6 tion, including rules to prevent duplicative reporting of 

7 transactions.’’. 

8 (b) PAYMENTS FOR PROPERTY AND OTHER GROSS

9 PROCEEDS.—Subsection (a) of section 6041 of the Inter10 nal Revenue Code of 1986 is amended— 

11 (1) by inserting ‘‘amounts in consideration for 

12 property,’’ after ‘‘wages,’’, 

13 (2) by inserting ‘‘gross proceeds,’’ after ‘‘emolu14 ments, or other’’, and 

15 (3) by inserting ‘‘gross proceeds,’’ after ‘‘setting 

16 forth the amount of such’’. 

17 (c) EFFECTIVE DATE.—The amendments made by 

18 this section shall apply to payments made after December 

19 31, 2011. 

20 SEC. 554. DELAY IN APPLICATION OF WORLDWIDE ALLOCA21 TION OF INTEREST. 

22 (a) IN GENERAL.—Paragraphs (5)(D) and (6) of sec23 tion 864(f) of the Internal Revenue Code of 1986 are each 

24 amended by striking ‘‘December 31, 2010’’ and inserting 

25 ‘‘December 31, 2019’’. 


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1 (b) TRANSITION.—Subsection (f) of section 864 of 

2 such Code is amended by striking paragraph (7). 

3 PART 2—PREVENTION OF TAX AVOIDANCE 

4 SEC. 561. LIMITATION ON TREATY BENEFITS FOR CERTAIN 

5 DEDUCTIBLE PAYMENTS. 

6 (a) IN GENERAL.—Section 894 of the Internal Rev7 enue Code of 1986 (relating to income affected by treaty) 

8 is amended by adding at the end the following new sub9 section: 

10 ‘‘(d) LIMITATION ON TREATY BENEFITS FOR CER11 TAIN DEDUCTIBLE PAYMENTS.— 

12 ‘‘(1) IN GENERAL.—In the case of any deduct13 ible related-party payment, any withholding tax im14 posed under chapter 3 (and any tax imposed under 

15 subpart A or B of this part) with respect to such 

16 payment may not be reduced under any treaty of the 

17 United States unless any such withholding tax would 

18 be reduced under a treaty of the United States if 

19 such payment were made directly to the foreign par20 ent corporation. 

21 ‘‘(2) DEDUCTIBLE RELATED-PARTY PAY22 MENT.—For purposes of this subsection, the term 

23 ‘deductible related-party payment’ means any pay24 ment made, directly or indirectly, by any person to 

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1 duction under this chapter and both persons are 

2 members of the same foreign controlled group of en3 tities. 

4 ‘‘(3) FOREIGN CONTROLLED GROUP OF ENTI5 TIES.—For purposes of this subsection— 

6 ‘‘(A) IN GENERAL.—The term ‘foreign 

7 controlled group of entities’ means a controlled 

8 group of entities the common parent of which 

9 is a foreign corporation. 

10 ‘‘(B) CONTROLLED GROUP OF ENTITIES.— 

11 The term ‘controlled group of entities’ means a 

12 controlled group of corporations as defined in 

13 section 1563(a)(1), except that— 

14 ‘‘(i) ‘more than 50 percent’ shall be 

15 substituted for ‘at least 80 percent’ each 

16 place it appears therein, and 

17 ‘‘(ii) the determination shall be made 

18 without regard to subsections (a)(4) and 

19 (b)(2) of section 1563. 

20 A partnership or any other entity (other than a 

21 corporation) shall be treated as a member of a 

22 controlled group of entities if such entity is con23 trolled (within the meaning of section 

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1 ing any entity treated as a member of such 

2 group by reason of this sentence). 

3 ‘‘(4) FOREIGN PARENT CORPORATION.—For 

4 purposes of this subsection, the term ‘foreign parent 

5 corporation’ means, with respect to any deductible 

6 related-party payment, the common parent of the 

7 foreign controlled group of entities referred to in 

8 paragraph (3)(A). 

9 ‘‘(5) REGULATIONS.—The Secretary may pre10 scribe such regulations or other guidance as are nec11 essary or appropriate to carry out the purposes of 

12 this subsection, including regulations or other guid13 ance which provide for— 

14 ‘‘(A) the treatment of two or more persons 

15 as members of a foreign controlled group of en16 tities if such persons would be the common par17 ent of such group if treated as one corporation, 

18 and 

19 ‘‘(B) the treatment of any member of a 

20 foreign controlled group of entities as the com21 mon parent of such group if such treatment is 

22 appropriate taking into account the economic 

23 relationships among such entities.’’. 


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

2 this section shall apply to payments made after the date 

3 of the enactment of this Act. 

4 SEC. 562. CODIFICATION OF ECONOMIC SUBSTANCE DOC5 TRINE; PENALTIES. 

6 (a) IN GENERAL.—Section 7701 of the Internal Rev7 enue Code of 1986 is amended by redesignating subsection 

8 (o) as subsection (p) and by inserting after subsection (n) 

9 the following new subsection: 

10 ‘‘(o) CLARIFICATION OF ECONOMIC SUBSTANCE

11 DOCTRINE.— 

12 ‘‘(1) APPLICATION OF DOCTRINE.—In the case 

13 of any transaction to which the economic substance 

14 doctrine is relevant, such transaction shall be treated 

15 as having economic substance only if— 

16 ‘‘(A) the transaction changes in a mean17 ingful way (apart from Federal income tax ef18 fects) the taxpayer’s economic position, and 

19 ‘‘(B) the taxpayer has a substantial pur20 pose (apart from Federal income tax effects) 

21 for entering into such transaction. 

22 ‘‘(2) SPECIAL RULE WHERE TAXPAYER RELIES

23 ON PROFIT POTENTIAL.— 

24 ‘‘(A) IN GENERAL.—The potential for 

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1 count in determining whether the requirements 

2 of subparagraphs (A) and (B) of paragraph (1) 

3 are met with respect to the transaction only if 

4 the present value of the reasonably expected 

5 pre-tax profit from the transaction is substan6 tial in relation to the present value of the ex7 pected net tax benefits that would be allowed if 

8 the transaction were respected. 

9 ‘‘(B) TREATMENT OF FEES AND FOREIGN

10 TAXES.—Fees and other transaction expenses 

11 and foreign taxes shall be taken into account as 

12 expenses in determining pre-tax profit under 

13 subparagraph (A). 

14 ‘‘(3) STATE AND LOCAL TAX BENEFITS.—For 

15 purposes of paragraph (1), any State or local income 

16 tax effect which is related to a Federal income tax 

17 effect shall be treated in the same manner as a Fed18 eral income tax effect. 

19 ‘‘(4) FINANCIAL ACCOUNTING BENEFITS.—For 

20 purposes of paragraph (1)(B), achieving a financial 

21 accounting benefit shall not be taken into account as 

22 a purpose for entering into a transaction if the ori23 gin of such financial accounting benefit is a reduc24 tion of Federal income tax. 


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1 ‘‘(5) DEFINITIONS AND SPECIAL RULES.—For 

2 purposes of this subsection— 

3 ‘‘(A) ECONOMIC SUBSTANCE DOCTRINE.— 

4 The term ‘economic substance doctrine’ means 

5 the common law doctrine under which tax bene6 fits under subtitle A with respect to a trans7 action are not allowable if the transaction does 

8 not have economic substance or lacks a business 

9 purpose. 

10 ‘‘(B) EXCEPTION FOR PERSONAL TRANS11 ACTIONS OF INDIVIDUALS.—In the case of an 

12 individual, paragraph (1) shall apply only to 

13 transactions entered into in connection with a 

14 trade or business or an activity engaged in for 

15 the production of income. 

16 ‘‘(C) OTHER COMMON LAW DOCTRINES

17 NOT AFFECTED.—Except as specifically pro18 vided in this subsection, the provisions of this 

19 subsection shall not be construed as altering or 

20 supplanting any other rule of law, and the re21 quirements of this subsection shall be construed 

22 as being in addition to any such other rule of 

23 law. 

24 ‘‘(D) DETERMINATION OF APPLICATION OF

25 DOCTRINE NOT AFFECTED.—The determination 


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1 of whether the economic substance doctrine is 

2 relevant to a transaction (or series of trans3 actions) shall be made in the same manner as 

4 if this subsection had never been enacted. 

5 ‘‘(6) REGULATIONS.—The Secretary shall pre6 scribe such regulations as may be necessary or ap7 propriate to carry out the purposes of this sub8 section.’’. 

9 (b) PENALTY FOR UNDERPAYMENTS ATTRIBUTABLE

10 TO TRANSACTIONS LACKING ECONOMIC SUBSTANCE.— 

11 (1) IN GENERAL.—Subsection (b) of section 

12 6662 of such Code is amended by inserting after 

13 paragraph (5) the following new paragraph: 

14 ‘‘(6) Any disallowance of claimed tax benefits 

15 by reason of a transaction lacking economic sub16 stance (within the meaning of section 7701(o)) or 

17 failing to meet the requirements of any similar rule 

18 of law.’’. 

19 (2) INCREASED PENALTY FOR NONDISCLOSED

20 TRANSACTIONS.—Section 6662 of such Code is 

21 amended by adding at the end the following new 

22 subsection: 

23 ‘‘(i) INCREASE IN PENALTY IN CASE OF NONDIS24 CLOSED NONECONOMIC SUBSTANCE TRANSACTIONS.— 


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1 ‘‘(1) IN GENERAL.—In the case of any portion 

2 of an underpayment which is attributable to one or 

3 more nondisclosed noneconomic substance trans4 actions, subsection (a) shall be applied with respect 

5 to such portion by substituting ‘40 percent’ for ‘20 

6 percent’. 

7 ‘‘(2) NONDISCLOSED NONECONOMIC SUB8 STANCE TRANSACTIONS.—For purposes of this sub9 section, the term ‘nondisclosed noneconomic sub10 stance transaction’ means any portion of a trans11 action described in subsection (b)(6) with respect to 

12 which the relevant facts affecting the tax treatment 

13 are not adequately disclosed in the return nor in a 

14 statement attached to the return. 

15 ‘‘(3) SPECIAL RULE FOR AMENDED RE16 TURNS.—Except as provided in regulations, in no 

17 event shall any amendment or supplement to a re18 turn of tax be taken into account for purposes of 

19 this subsection if the amendment or supplement is 

20 filed after the earlier of the date the taxpayer is first 

21 contacted by the Secretary regarding the examina22 tion of the return or such other date as is specified 

23 by the Secretary.’’. 


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1 (3) CONFORMING AMENDMENT.—Subparagraph 

2 (B) of section 6662A(e)(2) of such Code is amend3 ed— 

4 (A) by striking ‘‘section 6662(h)’’ and in5 serting ‘‘subsections (h) or (i) of section 6662’’, 

6 and 

7 (B) by striking ‘‘GROSS VALUATION

8 MISSTATEMENT PENALTY’’ in the heading and 

9 inserting ‘‘CERTAIN INCREASED UNDER10 PAYMENT PENALTIES’’. 

11 (c) REASONABLE CAUSE EXCEPTION NOT APPLICA12 BLE TO NONECONOMIC SUBSTANCE TRANSACTIONS AND

13 TAX SHELTERS.— 

14 (1) REASONABLE CAUSE EXCEPTION FOR UN15 DERPAYMENTS.—Subsection (c) of section 6664 of 

16 such Code is amended— 

17 (A) by redesignating paragraphs (2) and 

18 (3) as paragraphs (3) and (4), respectively, 

19 (B) by striking ‘‘paragraph (2)’’ in para20 graph (4)(A), as so redesignated, and inserting 

21 ‘‘paragraph (3)’’, and 

22 (C) by inserting after paragraph (1) the 

23 following new paragraph: 

24 ‘‘(2) EXCEPTION.—Paragraph (1) shall not 

25 apply to any portion of an underpayment which is 


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1 attributable to one or more tax shelters (as defined 

2 in section 6662(d)(2)(C)) or transactions described 

3 in section 6662(b)(6).’’. 

4 (2) REASONABLE CAUSE EXCEPTION FOR RE5 PORTABLE TRANSACTION UNDERSTATEMENTS.— 

6 Subsection (d) of section 6664 of such Code is 

7 amended— 

8 (A) by redesignating paragraphs (2) and 

9 (3) as paragraphs (3) and (4), respectively, 

10 (B) by striking ‘‘paragraph (2)(C)’’ in 

11 paragraph (4), as so redesignated, and inserting 

12 ‘‘paragraph (3)(C)’’, and 

13 (C) by inserting after paragraph (1) the 

14 following new paragraph: 

15 ‘‘(2) EXCEPTION.—Paragraph (1) shall not 

16 apply to any portion of a reportable transaction un17 derstatement which is attributable to one or more 

18 tax shelters (as defined in section 6662(d)(2)(C)) or 

19 transactions described in section 6662(b)(6).’’. 

20 (d) APPLICATION OF PENALTY FOR ERRONEOUS

21 CLAIM FOR REFUND OR CREDIT TO NONECONOMIC SUB22 STANCE TRANSACTIONS.—Section 6676 of such Code is 

23 amended by redesignating subsection (c) as subsection (d) 

24 and inserting after subsection (b) the following new sub25 section: 


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1 ‘‘(c) NONECONOMIC SUBSTANCE TRANSACTIONS

2 TREATED AS LACKING REASONABLE BASIS.—For pur3 poses of this section, any excessive amount which is attrib4 utable to any transaction described in section 6662(b)(6) 

5 shall not be treated as having a reasonable basis.’’. 

6 (e) EFFECTIVE DATE.— 

7 (1) IN GENERAL.—Except as otherwise pro8 vided in this subsection, the amendments made by 

9 this section shall apply to transactions entered into 

10 after the date of the enactment of this Act. 

11 (2) UNDERPAYMENTS.—The amendments made 

12 by subsections (b) and (c)(1) shall apply to under13 payments attributable to transactions entered into 

14 after the date of the enactment of this Act. 

15 (3) UNDERSTATEMENTS.—The amendments 

16 made by subsection (c)(2) shall apply to understate17 ments attributable to transactions entered into after 

18 the date of the enactment of this Act. 

19 (4) REFUNDS AND CREDITS.—The amendment 

20 made by subsection (d) shall apply to refunds and 

21 credits attributable to transactions entered into after 

22 the date of the enactment of this Act. 


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1 SEC. 563. CERTAIN LARGE OR PUBLICLY TRADED PERSONS 

2 MADE SUBJECT TO A MORE LIKELY THAN 

3 NOT STANDARD FOR AVOIDING PENALTIES 

4 ON UNDERPAYMENTS. 

5 (a) IN GENERAL.—Subsection (c) of section 6664 of 

6 the Internal Revenue Code of 1986, as amended by section 

7 562, is amended— 

8 (1) by redesignating paragraphs (3) and (4) as 

9 paragraphs (4) and (5), respectively, 

10 (2) by striking ‘‘paragraph (3)’’ in paragraph 

11 (4)(A), as so redesignated, and inserting ‘‘paragraph 

12 (4)’’, and 

13 (3) by inserting after paragraph (2) the fol14 lowing new paragraph: 

15 ‘‘(3) SPECIAL RULE FOR CERTAIN LARGE OR

16 PUBLICLY TRADED PERSONS.— 

17 ‘‘(A) IN GENERAL.—In the case of any 

18 specified person, paragraph (1) shall apply to 

19 the portion of an underpayment which is attrib20 utable to any item only if such person has a 

21 reasonable belief that the tax treatment of such 

22 item by such person is more likely than not the 

23 proper tax treatment of such item. 

24 ‘‘(B) SPECIFIED PERSON.—For purposes 

25 of this paragraph, the term ‘specified person’ 

26 means— 


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1 ‘‘(i) any person required to file peri2 odic or other reports under section 13 of 

3 the Securities Exchange Act of 1934, and 

4 ‘‘(ii) any corporation with gross re5 ceipts in excess of $100,000,000 for the 

6 taxable year involved. 

7 All persons treated as a single employer under 

8 section 52(a) shall be treated as one person for 

9 purposes of clause (ii).’’. 

10 (b) NONAPPLICATION OF SUBSTANTIAL AUTHORITY

11 AND REASONABLE BASIS STANDARDS FOR REDUCING

12 UNDERSTATEMENTS.—Paragraph (2) of section 6662(d) 

13 of such Code is amended by adding at the end the fol14 lowing new subparagraph: 

15 ‘‘(D) REDUCTION NOT TO APPLY TO CER16 TAIN LARGE OR PUBLICLY TRADED PERSONS.— 

17 Subparagraph (B) shall not apply to any speci18 fied person (as defined in section 

19 6664(c)(3)(B)).’’. 

20 (c) EFFECTIVE DATE.— 

21 (1) IN GENERAL.—Except as provided in para22 graph (2), the amendments made by this section 

23 shall apply to underpayments attributable to trans24 actions entered into after the date of the enactment 

25 of this Act. 


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1 (2) NONAPPLICATION OF UNDERSTATEMENT

2 REDUCTION.—The amendment made by subsection 

3 (b) shall apply to understatements attributable to 

4 transactions entered into after the date of the enact5 ment of this Act. 

6 PART 3—PARITY IN HEALTH BENEFITS 

7 SEC. 571. CERTAIN HEALTH RELATED BENEFITS APPLICA8 BLE TO SPOUSES AND DEPENDENTS EX9 TENDED TO ELIGIBLE BENEFICIARIES. 

10 (a) APPLICATION OF ACCIDENT AND HEALTH PLANS

11 TO ELIGIBLE BENEFICIARIES.— 

12 (1) EXCLUSION OF CONTRIBUTIONS.—Section 

13 106 of the Internal Revenue Code of 1986 (relating 

14 to contributions by employer to accident and health 

15 plans), as amended by section 531, is amended by 

16 adding at the end the following new subsection: 

17 ‘‘(g) COVERAGE PROVIDED FOR ELIGIBLE BENE18 FICIARIES OF EMPLOYEES.— 

19 ‘‘(1) IN GENERAL.—Subsection (a) shall apply 

20 with respect to any eligible beneficiary of the em21 ployee. 

22 ‘‘(2) ELIGIBLE BENEFICIARY.—For purposes of 

23 this subsection, the term ‘eligible beneficiary’ means 

24 any individual who is eligible to receive benefits or 

25 coverage under an accident or health plan.’’. 


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1 (2) EXCLUSION OF AMOUNTS EXPENDED FOR

2 MEDICAL CARE.—The first sentence of section 

3 105(b) of such Code (relating to amounts expended 

4 for medical care) is amended— 

5 (A) by striking ‘‘and his dependents’’ and 

6 inserting ‘‘his dependents’’, and 

7 (B) by inserting before the period the fol8 lowing: ‘‘and any eligible beneficiary (within the 

9 meaning of section 106(g)) with respect to the 

10 taxpayer’’. 

11 (3) PAYROLL TAXES.— 

12 (A) Section 3121(a)(2) of such Code is 

13 amended— 

14 (i) by striking ‘‘or any of his depend15 ents’’ in the matter preceding subpara16 graph (A) and inserting ‘‘, any of his de17 pendents, or any eligible beneficiary (with18 in the meaning of section 106(g)) with re19 spect to the employee’’, 

20 (ii) by striking ‘‘or any of his depend21 ents,’’ in subparagraph (A) and inserting 

22 ‘‘, any of his dependents, or any eligible 

23 beneficiary (within the meaning of section 

24 106(g)) with respect to the employee,’’, 

25 and 


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1 (iii) by striking ‘‘and their depend2 ents’’ both places it appears and inserting 

3 ‘‘and such employees’ dependents and eligi4 ble beneficiaries (within the meaning of 

5 section 106(g))’’. 

6 (B) Section 3231(e)(1) of such Code is 

7 amended— 

8 (i) by striking ‘‘or any of his depend9 ents’’ and inserting ‘‘, any of his depend10 ents, or any eligible beneficiary (within the 

11 meaning of section 106(g)) with respect to 

12 the employee,’’, and 

13 (ii) by striking ‘‘and their depend14 ents’’ both places it appears and inserting 

15 ‘‘and such employees’ dependents and eligi16 ble beneficiaries (within the meaning of 

17 section 106(g))’’. 

18 (C) Section 3306(b)(2) of such Code is 

19 amended— 

20 (i) by striking ‘‘or any of his depend21 ents’’ in the matter preceding subpara22 graph (A) and inserting ‘‘, any of his de23 pendents, or any eligible beneficiary (with24 in the meaning of section 106(g)) with re25 spect to the employee,’’, 


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1 (ii) by striking ‘‘or any of his depend2 ents’’ in subparagraph (A) and inserting ‘‘, 

3 any of his dependents, or any eligible bene4 ficiary (within the meaning of section 

5 106(g)) with respect to the employee’’, and 

6 (iii) by striking ‘‘and their depend7 ents’’ both places it appears and inserting 

8 ‘‘and such employees’ dependents and eligi9 ble beneficiaries (within the meaning of 

10 section 106(g))’’. 

11 (D) Section 3401(a) of such Code is 

12 amended by striking ‘‘or’’ at the end of para13 graph (22), by striking the period at the end of 

14 paragraph (23) and inserting ‘‘; or’’, and by in15 serting after paragraph (23) the following new 

16 paragraph: 

17 ‘‘(24) for any payment made to or for the ben18 efit of an employee or any eligible beneficiary (within 

19 the meaning of section 106(g)) if at the time of such 

20 payment it is reasonable to believe that the employee 

21 will be able to exclude such payment from income 

22 under section 106 or under section 105 by reference 

23 in section 105(b) to section 106(g).’’. 


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1 (b) EXPANSION OF DEPENDENCY FOR PURPOSES OF

2 DEDUCTION FOR HEALTH INSURANCE COSTS OF SELF3 EMPLOYED INDIVIDUALS.— 

4 (1) IN GENERAL.—Paragraph (1) of section 

5 162(l) of the Internal Revenue Code of 1986 (relat6 ing to special rules for health insurance costs of self7 employed individuals) is amended to read as follows: 

8 ‘‘(1) ALLOWANCE OF DEDUCTION.—In the case 

9 of a taxpayer who is an employee within the mean10 ing of section 401(c)(1), there shall be allowed as a 

11 deduction under this section an amount equal to the 

12 amount paid during the taxable year for insurance 

13 which constitutes medical care for— 

14 ‘‘(A) the taxpayer, 

15 ‘‘(B) the taxpayer’s spouse, 

16 ‘‘(C) the taxpayer’s dependents, 

17 ‘‘(D) any individual who— 

18 ‘‘(i) satisfies the age requirements of 

19 section 152(c)(3)(A), 

20 ‘‘(ii) bears a relationship to the tax21 payer described in section 152(d)(2)(H), 

22 and 

23 ‘‘(iii) meets the requirements of sec24 tion 152(d)(1)(C), and 

25 ‘‘(E) one individual who— 


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1 ‘‘(i) does not satisfy the age require2 ments of section 152(c)(3)(A), 

3 ‘‘(ii) bears a relationship to the tax4 payer described in section 152(d)(2)(H), 

5 ‘‘(iii) meets the requirements of sec6 tion 152(d)(1)(D), and 

7 ‘‘(iv) is not the spouse of the taxpayer 

8 and does not bear any relationship to the 

9 taxpayer described in subparagraphs (A) 

10 through (G) of section 152(d)(2).’’. 

11 (2) CONFORMING AMENDMENT.—Subparagraph 

12 (B) of section 162(l)(2) of such Code is amended by 

13 inserting ‘‘, any dependent, or individual described 

14 in subparagraph (D) or (E) of paragraph (1) with 

15 respect to’’ after ‘‘spouse’’. 

16 (c) EXTENSION TO ELIGIBLE BENEFICIARIES OF

17 SICK AND ACCIDENT BENEFITS PROVIDED TO MEMBERS

18 OF A VOLUNTARY EMPLOYEES’ BENEFICIARY ASSOCIA19 TION AND THEIR DEPENDENTS.—Section 501(c)(9) of 

20 the Internal Revenue Code of 1986 (relating to list of ex21 empt organizations) is amended by adding at the end the 

22 following new sentence: ‘‘For purposes of providing for the 

23 payment of sick and accident benefits to members of such 

24 an association and their dependents, the term ‘dependents’ 

25 shall include any individual who is an eligible beneficiary 


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1 (within the meaning of section 106(g)), as determined 

2 under the terms of a medical benefit, health insurance, 

3 or other program under which members and their depend4 ents are entitled to sick and accident benefits.’’. 

5 (d) FLEXIBLE SPENDING ARRANGEMENTS AND

6 HEALTH REIMBURSEMENT ARRANGEMENTS.—The Sec7 retary of Treasury shall issue guidance of general applica8 bility providing that medical expenses that otherwise qual9 ify— 

10 (1) for reimbursement from a flexible spending 

11 arrangement under regulations in effect on the date 

12 of the enactment of this Act may be reimbursed 

13 from an employee’s flexible spending arrangement, 

14 notwithstanding the fact that such expenses are at15 tributable to any individual who is not the employ16 ee’s spouse or dependent (within the meaning of sec17 tion 105(b) of the Internal Revenue Code of 1986) 

18 but is an eligible beneficiary (within the meaning of 

19 section 106(g) of such Code) under the flexible 

20 spending arrangement with respect to the employee, 

21 and 

22 (2) for reimbursement from a health reimburse23 ment arrangement under regulations in effect on the 

24 date of the enactment of this Act may be reimbursed 

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1 ment, notwithstanding the fact that such expenses 

2 are attributable to an individual who is not a spouse 

3 or dependent (within the meaning of section 105(b) 

4 of such Code) but is an eligible beneficiary (within 

5 the meaning of section 106(g) of such Code) under 

6 the health reimbursement arrangement with respect 

7 to the employee. 

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

9 this section shall apply to taxable years beginning after 

10 December 31, 2009. 

11 DIVISION B—MEDICARE AND 

12 MEDICAID IMPROVEMENTS 

13 SEC. 1001. TABLE OF CONTENTS OF DIVISION. 

14 The table of contents of this division is as follows: 

Sec. 1001. Table of contents of division. 

TITLE I—IMPROVING HEALTH CARE VALUE 

Subtitle A—Provisions Related to Medicare Part A 

PART 1—MARKET BASKET UPDATES

Sec. 1101. Skilled nursing facility payment update. 

Sec. 1102. Inpatient rehabilitation facility payment update. 

Sec. 1103. Incorporating productivity improvements into market basket updates 

that do not already incorporate such improvements. 

PART 2—OTHER MEDICARE PART A PROVISIONS

Sec. 1111. Payments to skilled nursing facilities. 

Sec. 1112. Medicare DSH report and payment adjustments in response to coverage expansion. 

Sec. 1113. Extension of hospice regulation moratorium. 

Sec. 1114. Permitting physician assistants to order post-hospital extended care 

services and to provide for recognition of attending physician 

assistants as attending physicians to serve hospice patients. 

Subtitle B—Provisions Related to Part B 

PART 1—PHYSICIANS’ SERVICES


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Sec. 1121. Resource-based feedback program for physicians in Medicare. 

Sec. 1122. Misvalued codes under the physician fee schedule. 

Sec. 1123. Payments for efficient areas. 

Sec. 1124. Modifications to the Physician Quality Reporting Initiative (PQRI). 

Sec. 1125. Adjustment to Medicare payment localities. 

PART 2—MARKET BASKET UPDATES

Sec. 1131. Incorporating productivity improvements into market basket updates 

that do not already incorporate such improvements. 

PART 3—OTHER PROVISIONS

Sec. 1141. Rental and purchase of power-driven wheelchairs. 

Sec. 1141A. Election to take ownership, or to decline ownership, of a certain 

item of complex durable medical equipment after the 13-month 

capped rental period ends. 

Sec. 1142. Extension of payment rule for brachytherapy. 

Sec. 1143. Home infusion therapy report to Congress. 

Sec. 1144. Require ambulatory surgical centers (ASCs) to submit cost data and 

other data. 

Sec. 1145. Treatment of certain cancer hospitals. 

Sec. 1146. Payment for imaging services. 

Sec. 1147. Durable medical equipment program improvements. 

Sec. 1148. MedPAC study and report on bone mass measurement. 

Sec. 1149. Timely access to post-mastectomy items. 

Sec. 1149A. Payment for biosimilar biological products. 

Sec. 1149B. Study and report on DME competitive bidding process. 

Subtitle C—Provisions Related to Medicare Parts A and B 

Sec. 1151. Reducing potentially preventable hospital readmissions. 

Sec. 1152. Post acute care services payment reform plan and bundling pilot 

program. 

Sec. 1153. Home health payment update for 2010. 

Sec. 1154. Payment adjustments for home health care. 

Sec. 1155. Incorporating productivity improvements into market basket update 

for home health services. 

Sec. 1155A. MedPAC study on variation in home health margins. 

Sec. 1155B. Permitting home health agencies to assign the most appropriate 

skilled service to make the initial assessment visit under a 

Medicare home health plan of care for rehabilitation cases. 

Sec. 1156. Limitation on Medicare exceptions to the prohibition on certain physician referrals made to hospitals. 

Sec. 1157. Institute of Medicine study of geographic adjustment factors under 

Medicare. 

Sec. 1158. Revision of medicare payment systems to address geographic inequities. 

Sec. 1159. Institute of Medicine study of geographic variation in health care 

spending and promoting high-value health care. 

Sec. 1160. Implementation, and Congressional review, of proposal to revise 

Medicare payments to promote high value health care. 

Subtitle D—Medicare Advantage Reforms 

PART 1—PAYMENT AND ADMINISTRATION


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Sec. 1161. Phase-in of payment based on fee-for-service costs; quality bonus 

payments. 

Sec. 1162. Authority for Secretarial coding intensity adjustment authority. 

Sec. 1163. Simplification of annual beneficiary election periods. 

Sec. 1164. Extension of reasonable cost contracts. 

Sec. 1165. Limitation of waiver authority for employer group plans. 

Sec. 1166. Improving risk adjustment for payments. 

Sec. 1167. Elimination of MA Regional Plan Stabilization Fund. 

Sec. 1168. Study regarding the effects of calculating Medicare Advantage payment rates on a regional average of Medicare fee for service 

rates. 

PART 2—BENEFICIARY PROTECTIONS AND ANTI-FRAUD

Sec. 1171. Limitation on cost-sharing for individual health services. 

Sec. 1172. Continuous open enrollment for enrollees in plans with enrollment 

suspension. 

Sec. 1173. Information for beneficiaries on MA plan administrative costs. 

Sec. 1174. Strengthening audit authority. 

Sec. 1175. Authority to deny plan bids. 

Sec. 1175A. State authority to enforce standardized marketing requirements. 

PART 3—TREATMENT OF SPECIAL NEEDS PLANS

Sec. 1176. Limitation on enrollment outside open enrollment period of individuals into chronic care specialized MA plans for special needs 

individuals. 

Sec. 1177. Extension of authority of special needs plans to restrict enrollment; 

service area moratorium for certain SNPs. 

Sec. 1178. Extension of Medicare senior housing plans. 

Subtitle E—Improvements to Medicare Part D 

Sec. 1181. Elimination of coverage gap. 

Sec. 1182. Discounts for certain part D drugs in original coverage gap. 

Sec. 1183. Repeal of provision relating to submission of claims by pharmacies 

located in or contracting with long-term care facilities. 

Sec. 1184. Including costs incurred by AIDS drug assistance programs and Indian Health Service in providing prescription drugs toward the 

annual out-of-pocket threshold under part D. 

Sec. 1185. No mid-year formulary changes permitted. 

Sec. 1186. Negotiation of lower covered part D drug prices on behalf of Medicare beneficiaries. 

Sec. 1187. Accurate dispensing in long-term care facilities. 

Sec. 1188. Free generic fill. 

Sec. 1189. State certification prior to waiver of licensure requirements under 

Medicare prescription drug program. 

Subtitle F—Medicare Rural Access Protections 

Sec. 1191. Telehealth expansion and enhancements. 

Sec. 1192. Extension of outpatient hold harmless provision. 

Sec. 1193. Extension of section 508 hospital reclassifications. 

Sec. 1194. Extension of geographic floor for work. 

Sec. 1195. Extension of payment for technical component of certain physician 

pathology services. 

Sec. 1196. Extension of ambulance add-ons. 


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TITLE II—MEDICARE BENEFICIARY IMPROVEMENTS 

Subtitle A—Improving and Simplifying Financial Assistance for Low Income 

Medicare Beneficiaries 

Sec. 1201. Improving assets tests for Medicare Savings Program and low-income subsidy program. 

Sec. 1202. Elimination of part D cost-sharing for certain non-institutionalized 

full-benefit dual eligible individuals. 

Sec. 1203. Eliminating barriers to enrollment. 

Sec. 1204. Enhanced oversight relating to reimbursements for retroactive low 

income subsidy enrollment. 

Sec. 1205. Intelligent assignment in enrollment. 

Sec. 1206. Special enrollment period and automatic enrollment process for certain subsidy eligible individuals. 

Sec. 1207. Application of MA premiums prior to rebate and quality bonus payments in calculation of low income subsidy benchmark. 

Subtitle B—Reducing Health Disparities 

Sec. 1221. Ensuring effective communication in Medicare. 

Sec. 1222. Demonstration to promote access for Medicare beneficiaries with 

limited English proficiency by providing reimbursement for culturally and linguistically appropriate services. 

Sec. 1223. IOM report on impact of language access services. 

Sec. 1224. Definitions. 

Subtitle C—Miscellaneous Improvements 

Sec. 1231. Extension of therapy caps exceptions process. 

Sec. 1232. Extended months of coverage of immunosuppressive drugs for kidney transplant patients and other renal dialysis provisions. 

Sec. 1233. Voluntary advance care planning consultation. 

Sec. 1234. Part B special enrollment period and waiver of limited enrollment 

penalty for TRICARE beneficiaries. 

Sec. 1235. Exception for use of more recent tax year in case of gains from sale 

of primary residence in computing part B income-related premium. 

Sec. 1236. Demonstration program on use of patient decisions aids. 

TITLE III—PROMOTING PRIMARY CARE, MENTAL HEALTH 

SERVICES, AND COORDINATED CARE 

Sec. 1301. Accountable Care Organization pilot program. 

Sec. 1302. Medical home pilot program. 

Sec. 1303. Payment incentive for selected primary care services. 

Sec. 1304. Increased reimbursement rate for certified nurse-midwives. 

Sec. 1305. Coverage and waiver of cost-sharing for preventive services. 

Sec. 1306. Waiver of deductible for colorectal cancer screening tests regardless 

of coding, subsequent diagnosis, or ancillary tissue removal. 

Sec. 1307. Excluding clinical social worker services from coverage under the 

medicare skilled nursing facility prospective payment system 

and consolidated payment. 

Sec. 1308. Coverage of marriage and family therapist services and mental 

health counselor services. 

Sec. 1309. Extension of physician fee schedule mental health add-on. 

Sec. 1310. Expanding access to vaccines. 


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Sec. 1311. Expansion of Medicare-Covered Preventive Services at Federally 

Qualified Health Centers. 

Sec. 1312. Independence at home demonstration program. 

Sec. 1313. Recognition of certified diabetes educators as certified providers for 

purposes of Medicare diabetes outpatient self-management 

training services. 

TITLE IV—QUALITY 

Subtitle A—Comparative Effectiveness Research 

Sec. 1401. Comparative effectiveness research. 

Subtitle B—Nursing Home Transparency 

PART 1—IMPROVING TRANSPARENCY OF INFORMATION ON SKILLED NURSING FACILITIES, NURSING FACILITIES, AND OTHER LONG-TERM CARE FACILITIES

Sec. 1411. Required disclosure of ownership and additional disclosable parties 

information. 

Sec. 1412. Accountability requirements. 

Sec. 1413. Nursing home compare Medicare website. 

Sec. 1414. Reporting of expenditures. 

Sec. 1415. Standardized complaint form. 

Sec. 1416. Ensuring staffing accountability. 

Sec. 1417. Nationwide program for national and State background checks on 

direct patient access employees of long-term care facilities and 

providers. 

PART 2—TARGETING ENFORCEMENT

Sec. 1421. Civil money penalties. 

Sec. 1422. National independent monitor pilot program. 

Sec. 1423. Notification of facility closure. 

PART 3—IMPROVING STAFF TRAINING

Sec. 1431. Dementia and abuse prevention training. 

Sec. 1432. Study and report on training required for certified nurse aides and 

supervisory staff. 

Sec. 1433. Qualification of director of food services of a skilled nursing facility 

or nursing facility. 

Subtitle C—Quality Measurements 

Sec. 1441. Establishment of national priorities for quality improvement. 

Sec. 1442. Development of new quality measures; GAO evaluation of data collection process for quality measurement. 

Sec. 1443. Multi-stakeholder pre-rulemaking input into selection of quality 

measures. 

Sec. 1444. Application of quality measures. 

Sec. 1445. Consensus-based entity funding. 

Subtitle D—Physician Payments Sunshine Provision 


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Sec. 1451. Reports on financial relationships between manufacturers and distributors of covered drugs, devices, biologicals, or medical supplies under Medicare, Medicaid, or CHIP and physicians and 

other health care entities and between physicians and other 

health care entities. 

Subtitle E—Public Reporting on Health Care-Associated Infections 

Sec. 1461. Requirement for public reporting by hospitals and ambulatory surgical centers on health care-associated infections. 

TITLE V—MEDICARE GRADUATE MEDICAL EDUCATION 

Sec. 1501. Distribution of unused residency positions. 

Sec. 1502. Increasing training in nonprovider settings. 

Sec. 1503. Rules for counting resident time for didactic and scholarly activities 

and other activities. 

Sec. 1504. Preservation of resident cap positions from closed hospitals. 

Sec. 1505. Improving accountability for approved medical residency training. 

TITLE VI—PROGRAM INTEGRITY 

Subtitle A—Increased Funding to Fight Waste, Fraud, and Abuse 

Sec. 1601. Increased funding and flexibility to fight fraud and abuse. 

Subtitle B—Enhanced Penalties for Fraud and Abuse 

Sec. 1611. Enhanced penalties for false statements on provider or supplier enrollment applications. 

Sec. 1612. Enhanced penalties for submission of false statements material to 

a false claim. 

Sec. 1613. Enhanced penalties for delaying inspections. 

Sec. 1614. Enhanced hospice program safeguards. 

Sec. 1615. Enhanced penalties for individuals excluded from program participation. 

Sec. 1616. Enhanced penalties for provision of false information by Medicare 

Advantage and part D plans. 

Sec. 1617. Enhanced penalties for Medicare Advantage and part D marketing 

violations. 

Sec. 1618. Enhanced penalties for obstruction of program audits. 

Sec. 1619. Exclusion of certain individuals and entities from participation in 

Medicare and State health care programs. 

Sec. 1620. OIG authority to exclude from Federal health care programs officers and owners of entities convicted of fraud. 

Sec. 1621. Self-referral disclosure protocol. 

Subtitle C—Enhanced Program and Provider Protections 

Sec. 1631. Enhanced CMS program protection authority. 

Sec. 1632. Enhanced Medicare, Medicaid, and CHIP program disclosure requirements relating to previous affiliations. 

Sec. 1633. Required inclusion of payment modifier for certain evaluation and 

management services. 

Sec. 1634. Evaluations and reports required under Medicare Integrity Program. 

Sec. 1635. Require providers and suppliers to adopt programs to reduce waste, 

fraud, and abuse. 


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Sec. 1636. Maximum period for submission of Medicare claims reduced to not 

more than 12 months. 

Sec. 1637. Physicians who order durable medical equipment or home health 

services required to be Medicare enrolled physicians or eligible 

professionals. 

Sec. 1638. Requirement for physicians to provide documentation on referrals to 

programs at high risk of waste and abuse. 

Sec. 1639. Face-to-face encounter with patient required before eligibility certifications for home health services or durable medical equipment. 

Sec. 1640. Extension of testimonial subpoena authority to program exclusion 

investigations. 

Sec. 1641. Required repayments of Medicare and Medicaid overpayments. 

Sec. 1642. Expanded application of hardship waivers for OIG exclusions to 

beneficiaries of any Federal health care program. 

Sec. 1643. Access to certain information on renal dialysis facilities. 

Sec. 1644. Billing agents, clearinghouses, or other alternate payees required to 

register under Medicare. 

Sec. 1645. Conforming civil monetary penalties to False Claims Act amendments. 

Sec. 1646. Requiring provider and supplier payments under Medicare to be 

made through direct deposit or electronic funds transfer (EFT) 

at insured depository institutions. 

Sec. 1647. Inspector General for the Health Choices Administration. 

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

Abuse 

Sec. 1651. Access to Information Necessary to Identify Fraud, Waste, and 

Abuse. 

Sec. 1652. Elimination of duplication between the Healthcare Integrity and 

Protection Data Bank and the National Practitioner Data 

Bank. 

Sec. 1653. Compliance with HIPAA privacy and security standards. 

TITLE VII—MEDICAID AND CHIP 

Sec. 1. Table of contents øTemporary¿. 

Subtitle A—Medicaid and Health Reform 

Sec. 1701. Eligibility for individuals with income below 150 percent of the Federal poverty level. 

Sec. 1702. Requirements and special rules for certain Medicaid eligible individuals. 

Sec. 1703. CHIP and Medicaid maintenance of eligibility. 

Sec. 1704. Reduction in Medicaid DSH. 

Sec. 1705. Expanded outstationing. 

Subtitle B—Prevention 

Sec. 1711. Required coverage of preventive services. 

Sec. 1712. Tobacco cessation. 

Sec. 1713. Optional coverage of nurse home visitation services. 

Sec. 1714. State eligibility option for family planning services. 

Subtitle C—Access 


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Sec. 1721. Payments to primary care practitioners. 

Sec. 1722. Medical home pilot program. 

Sec. 1723. Translation or interpretation services. 

Sec. 1724. Optional coverage for freestanding birth center services. 

Sec. 1725. Inclusion of public health clinics under the vaccines for children program. 

Sec. 1726. Requiring coverage of services of podiatrists. 

Sec. 1726A. Requiring coverage of services of optometrists. 

Sec. 1727. Therapeutic foster care. 

Sec. 1728. Assuring adequate payment levels for services. 

Sec. 1729. Preserving Medicaid coverage for youths upon release from public 

institutions. 

Sec. 1730. Quality measures for maternity and adult health services under 

Medicaid and CHIP. 

Sec. 1730A. Accountable care organization pilot program. 

Sec. 1730B. FQHC coverage. 

Subtitle D—Coverage 

Sec. 1731. Optional Medicaid coverage of low-income HIV-infected individuals. 

Sec. 1732. Extending transitional Medicaid Assistance (TMA). 

Sec. 1733. Requirement of 12-month continuous coverage under certain CHIP 

programs. 

Sec. 1734. Preventing the application under CHIP of coverage waiting periods 

for certain children. 

Sec. 1735. Adult day health care services. 

Sec. 1736. Medicaid coverage for citizens of Freely Associated States. 

Sec. 1737. Continuing requirement of Medicaid coverage of nonemergency 

transportation to medically necessary services. 

Sec. 1738. State option to disregard certain income in providing continued 

Medicaid coverage for certain individuals with extremely high 

prescription costs. 

Sec. 1739. Provisions relating to community living assistance services and supports (CLASS). 

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. 


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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. 


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1 TITLE I—IMPROVING HEALTH 

2 CARE VALUE 

3 Subtitle A—Provisions Related to 

4 Medicare Part A 

5 PART 1—MARKET BASKET UPDATES 

6 SEC. 1101. SKILLED NURSING FACILITY PAYMENT UPDATE. 

7 (a) IN GENERAL.—Section 1888(e)(4)(E)(ii) of the 

8 Social Security Act (42 U.S.C. 1395yy(e)(4)(E)(ii)) is 

9 amended— 

10 (1) in subclause (III), by striking ‘‘and’’ at the 

11 end; 

12 (2) by redesignating subclause (IV) as sub13 clause (VI); and 

14 (3) by inserting after subclause (III) the fol15 lowing new subclauses: 

16 ‘‘(IV) for each of fiscal years 

17 2004 through 2009, the rate com18 puted for the previous fiscal year in19 creased by the skilled nursing facility 

20 market basket percentage change for 

21 the fiscal year involved; 

22 ‘‘(V) for fiscal year 2010, the 

23 rate computed for the previous fiscal 

24 year; and’’. 


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1 (b) DELAYED EFFECTIVE DATE.—Section 

2 1888(e)(4)(E)(ii)(V) of the Social Security Act, as in3 serted by subsection (a)(3), shall not apply to payment 

4 for days before January 1, 2010. 

5 SEC. 1102. INPATIENT REHABILITATION FACILITY PAY6 MENT UPDATE. 

7 (a) IN GENERAL.—Section 1886(j)(3)(C) of the So8 cial Security Act (42 U.S.C. 1395ww(j)(3)(C)) is amended 

9 by striking ‘‘and 2009’’ and inserting ‘‘through 2010’’. 

10 (b) DELAYED EFFECTIVE DATE.—The amendment 

11 made by subsection (a) shall not apply to payment units 

12 occurring before January 1, 2010. 

13 SEC. 1103. INCORPORATING PRODUCTIVITY IMPROVE14 MENTS INTO MARKET BASKET UPDATES 

15 THAT DO NOT ALREADY INCORPORATE SUCH 

16 IMPROVEMENTS. 

17 (a) INPATIENT ACUTE HOSPITALS.—Section 

18 1886(b)(3)(B) of the Social Security Act (42 U.S.C. 

19 1395ww(b)(3)(B)) is amended— 

20 (1) in clause (iii)— 

21 (A) by striking ‘‘(iii) For purposes of this 

22 subparagraph,’’ and inserting ‘‘(iii)(I) For pur23 poses of this subparagraph, subject to the pro24 ductivity adjustment described in subclause 

25 (II),’’; and 


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

2 subclause: 

3 ‘‘(II) The productivity adjustment described in this 

4 subclause, with respect to an increase or change for a fis5 cal year or year or cost reporting period, or other annual 

6 period, is a productivity offset in the form of a reduction 

7 in such increase or change equal to the percentage change 

8 in the 10-year moving average of annual economy-wide 

9 private nonfarm business multi-factor productivity (as re10 cently published in final form before the promulgation or 

11 publication of such increase for the year or period in12 volved). Except as otherwise provided, any reference to the 

13 increase described in this clause shall be a reference to 

14 the percentage increase described in subclause (I) minus 

15 the percentage change under this subclause.’’; 

16 (2) in the first sentence of clause (viii)(I), by 

17 inserting ‘‘(but not below zero)’’ after ‘‘shall be re18 duced’’; and 

19 (3) in the first sentence of clause (ix)(I)— 

20 (A) by inserting ‘‘(determined without re21 gard to clause (iii)(II))’’ after ‘‘clause (i)’’ the 

22 second time it appears; and 

23 (B) by inserting ‘‘(but not below zero)’’ 

24 after ‘‘reduced’’. 


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1 (b) SKILLED NURSING FACILITIES.—Section 

2 1888(e)(5)(B) of such Act (42 U.S.C. 1395yy(e)(5)(B)) 

3 is amended by inserting ‘‘subject to the productivity ad4 justment described in section 1886(b)(3)(B)(iii)(II)’’ after 

5 ‘‘as calculated by the Secretary’’. 

6 (c) LONG TERM CARE HOSPITALS.—Section 

7 1886(m) of the Social Security Act (42 U.S.C. 

8 1395ww(m)) is amended by adding at the end the fol9 lowing new paragraph: 

10 ‘‘(3) PRODUCTIVITY ADJUSTMENT.—In imple11 menting the system described in paragraph (1) for 

12 discharges occurring on or after January 1, 2010, 

13 during the rate year ending in 2010 or any subse14 quent rate year for a hospital, to the extent that an 

15 annual percentage increase factor applies to a stand16 ard Federal rate for such discharges for the hos17 pital, such factor shall be subject to the productivity 

18 adjustment described in subsection 

19 (b)(3)(B)(iii)(II).’’. 

20 (d) INPATIENT REHABILITATION FACILITIES.—The 

21 second sentence of section 1886(j)(3)(C) of the Social Se22 curity Act (42 U.S.C. 1395ww(j)(3)(C)) is amended by in23 serting ‘‘(subject to the productivity adjustment described 

24 in subsection (b)(3)(B)(iii)(II))’’ after ‘‘appropriate per25 centage increase’’. 


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1 (e) PSYCHIATRIC HOSPITALS.—Section 1886 of the 

2 Social Security Act (42 U.S.C. 1395ww) is amended by 

3 adding at the end the following new subsection: 

4 ‘‘(o) PROSPECTIVE PAYMENT FOR PSYCHIATRIC

5 HOSPITALS.— 

6 ‘‘(1) REFERENCE TO ESTABLISHMENT AND IM7 PLEMENTATION OF SYSTEM.—For provisions related 

8 to the establishment and implementation of a pro9 spective payment system for payments under this 

10 title for inpatient hospital services furnished by psy11 chiatric hospitals (as described in clause (i) of sub12 section (d)(1)(B) and psychiatric units (as described 

13 in the matter following clause (v) of such sub14 section), see section 124 of the Medicare, Medicaid, 

15 and SCHIP Balanced Budget Refinement Act of 

16 1999. 

17 ‘‘(2) PRODUCTIVITY ADJUSTMENT.—In imple18 menting the system described in paragraph (1) for 

19 days occurring during the rate year ending in 2011 

20 or any subsequent rate year for a psychiatric hos21 pital or unit described in such paragraph, to the ex22 tent that an annual percentage increase factor ap23 plies to a base rate for such days for the hospital 

24 or unit, respectively, such factor shall be subject to 


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1 the productivity adjustment described in subsection 

2 (b)(3)(B)(iii)(II).’’. 

3 (f) HOSPICE CARE.—Subclause (VII) of section 

4 1814(i)(1)(C)(ii) of the Social Security Act (42 U.S.C. 

5 1395f(i)(1)(C)(ii)) is amended by inserting after ‘‘the 

6 market basket percentage increase’’ the following: ‘‘(which 

7 is subject to the productivity adjustment described in sec8 tion 1886(b)(3)(B)(iii)(II))’’. 

9 (g) EFFECTIVE DATES.— 

10 (1) IPPS.—The amendments made by sub11 section (a) shall apply to annual increases effected 

12 for fiscal years beginning with fiscal year 2010, but 

13 only with respect to discharges occurring on or after 

14 January 1, 2010. 

15 (2) SNF AND IRF.—The amendments made by 

16 subsections (b) and (d) shall apply to annual in17 creases effected for fiscal years beginning with fiscal 

18 year 2011. 

19 (3) HOSPICE CARE.—The amendment made by 

20 subsection (f) shall apply to annual increases ef21 fected for fiscal years beginning with fiscal year 

22 2010, but only with respect to days of care occurring 

23 on or after January 1, 2010. 


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1 PART 2—OTHER MEDICARE PART A PROVISIONS 

2 SEC. 1111. PAYMENTS TO SKILLED NURSING FACILITIES. 

3 (a) CHANGE IN RECALIBRATION FACTOR.— 

4 (1) ANALYSIS.—The Secretary of Health and 

5 Human Services shall conduct, using calendar year 

6 2006 claims data, an initial analysis comparing total 

7 payments under title XVIII of the Social Security 

8 Act for skilled nursing facility services under the 

9 RUG–53 and under the RUG–44 classification sys10 tems. 

11 (2) ADJUSTMENT IN RECALIBRATION FAC12 TOR.—Based on the initial analysis under paragraph 

13 (1), the Secretary shall adjust the case mix indexes 

14 under section 1888(e)(4)(G)(i) of the Social Security 

15 Act (42 U.S.C. 1395yy(e)(4)(G)(i)) for fiscal year 

16 2010 by the appropriate recalibration factor as pro17 posed in the proposed rule for Medicare skilled nurs18 ing facilities issued by such Secretary on May 12, 

19 2009 (74 Federal Register 22214 et seq.). 

20 (b) CHANGE IN PAYMENT FOR NONTHERAPY ANCIL21 LARY (NTA) SERVICES AND THERAPY SERVICES.— 

22 (1) CHANGES UNDER CURRENT SNF CLASSI23 FICATION SYSTEM.— 

24 (A) IN GENERAL.—Subject to subpara25 graph (B), the Secretary of Health and Human 

26 Services shall, under the system for payment of 


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1 skilled nursing facility services under section 

2 1888(e) of the Social Security Act (42 U.S.C. 

3 1395yy(e)), increase payment by 10 percent for 

4 non-therapy ancillary services (as specified by 

5 the Secretary in the notice issued on November 

6 27, 1998 (63 Federal Register 65561 et seq.)) 

7 and shall decrease payment for the therapy case 

8 mix component of such rates by 5.5 percent. 

9 (B) EFFECTIVE DATE.—The changes in 

10 payment described in subparagraph (A) shall 

11 apply for days on or after January 1, 2010, 

12 and until the Secretary implements an alter13 native case mix classification system for pay14 ment of skilled nursing facility services under 

15 section 1888(e) of the Social Security Act (42 

16 U.S.C. 1395yy(e)). 

17 (C) IMPLEMENTATION.—Notwithstanding 

18 any other provision of law, the Secretary may 

19 implement by program instruction or otherwise 

20 the provisions of this paragraph. 

21 (2) CHANGES UNDER A FUTURE SNF CASE MIX

22 CLASSIFICATION SYSTEM.— 

23 (A) ANALYSIS.— 

24 (i) IN GENERAL.—The Secretary of 

25 Health and Human Services shall analyze 


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1 payments for non-therapy ancillary services 

2 under a future skilled nursing facility clas3 sification system to ensure the accuracy of 

4 payment for non-therapy ancillary services. 

5 Such analysis shall consider use of appro6 priate predictors which may include age, 

7 physical and mental status, ability to per8 form activities of daily living, prior nursing 

9 home stay, diagnoses, broad RUG cat10 egory, and a proxy for length of stay. 

11 (ii) APPLICATION.—Such analysis 

12 shall be conducted in a manner such that 

13 the future skilled nursing facility classifica14 tion system is implemented to apply to 

15 services furnished during a fiscal year be16 ginning with fiscal year 2011. 

17 (B) CONSULTATION.—In conducting the 

18 analysis under subparagraph (A), the Secretary 

19 shall consult with interested parties, including 

20 the Medicare Payment Advisory Commission 

21 and other interested stakeholders, to identify 

22 appropriate predictors of nontherapy ancillary 

23 costs. 

24 (C) RULEMAKING.—The Secretary shall 

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1 paragraph (A) in the fiscal year 2011 rule2 making cycle for purposes of implementation 

3 beginning for such fiscal year. 

4 (D) IMPLEMENTATION.—Subject to sub5 paragraph (E) and consistent with subpara6 graph (A)(ii), the Secretary shall implement 

7 changes to payments for non-therapy ancillary 

8 services (which shall include a separate rate 

9 component for non-therapy ancillary services 

10 and may include use of a model that predicts 

11 payment amounts applicable for non-therapy 

12 ancillary services) under such future skilled 

13 nursing facility services classification system as 

14 the Secretary determines appropriate based on 

15 the analysis conducted pursuant to subpara16 graph (A). 

17 (E) BUDGET NEUTRALITY.—The Secretary 

18 shall implement changes described in subpara19 graph (D) in a manner such that the estimated 

20 expenditures under such future skilled nursing 

21 facility services classification system for a fiscal 

22 year beginning with fiscal year 2011 with such 

23 changes would be equal to the estimated ex24 penditures that would otherwise occur under 

25 title XVIII of the Social Security Act under 


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1 such future skilled nursing facility services clas2 sification system for such year without such 

3 changes. 

4 (c) OUTLIER POLICY FOR NTA AND THERAPY.—Sec5 tion 1888(e) of the Social Security Act (42 U.S.C. 

6 1395yy(e)) is amended by adding at the end the following 

7 new paragraph: 

8 ‘‘(13) OUTLIERS FOR NTA AND THERAPY.— 

9 ‘‘(A) IN GENERAL.—With respect to 

10 outliers because of unusual variations in the 

11 type or amount of medically necessary care, be12 ginning with October 1, 2010, the Secretary— 

13 ‘‘(i) shall provide for an addition or 

14 adjustment to the payment amount other15 wise made under this section with respect 

16 to non-therapy ancillary services in the 

17 case of such outliers; and 

18 ‘‘(ii) may provide for such an addition 

19 or adjustment to the payment amount oth20 erwise made under this section with re21 spect to therapy services in the case of 

22 such outliers. 

23 ‘‘(B) OUTLIERS BASED ON AGGREGATE

24 COSTS.—Outlier adjustments or additional pay25 ments described in subparagraph (A) shall be 


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1 based on aggregate costs during a stay in a 

2 skilled nursing facility and not on the number 

3 of days in such stay. 

4 ‘‘(C) BUDGET NEUTRALITY.—The Sec5 retary shall reduce estimated payments that 

6 would otherwise be made under the prospective 

7 payment system under this subsection with re8 spect to a fiscal year by 2 percent. The total 

9 amount of the additional payments or payment 

10 adjustments for outliers made under this para11 graph with respect to a fiscal year may not ex12 ceed 2 percent of the total payments projected 

13 or estimated to be made based on the prospec14 tive payment system under this subsection for 

15 the fiscal year.’’. 

16 (d) CONFORMING AMENDMENTS.—Section 

17 1888(e)(8) of such Act (42 U.S.C. 1395yy(e)(8)) is 

18 amended— 

19 (1) in subparagraph (A)— 

20 (A) by striking ‘‘and’’ before ‘‘adjust21 ments’’; and 

22 (B) by inserting ‘‘, and adjustment under 

23 section 1111(b) of the Affordable Health Care 

24 for America Act’’ before the semicolon at the 

25 end; 


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1 (2) in subparagraph (B), by striking ‘‘and’’; 

2 (3) in subparagraph (C), by striking the period 

3 and inserting ‘‘; and’’; and 

4 (4) by adding at the end the following new sub5 paragraph: 

6 ‘‘(D) the establishment of outliers under 

7 paragraph (13).’’. 

8 SEC. 1112. MEDICARE DSH REPORT AND PAYMENT ADJUST9 MENTS IN RESPONSE TO COVERAGE EXPAN10 SION. 

11 (a) DSH REPORT.— 

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

13 2016, the Secretary of Health and Human Services 

14 shall submit to Congress a report on Medicare DSH 

15 taking into account the impact of the health care re16 forms carried out under division A in reducing the 

17 number of uninsured individuals. The report shall 

18 include recommendations relating to the following: 

19 (A) The appropriate amount, targeting, 

20 and distribution of Medicare DSH to com21 pensate for higher Medicare costs associated 

22 with serving low-income beneficiaries (taking 

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1 sistent with the original intent of Medicare 

2 DSH. 

3 (B) The appropriate amount, targeting, 

4 and distribution of Medicare DSH to hospitals 

5 given their continued uncompensated care costs, 

6 to the extent such costs remain. 

7 (2) COORDINATION WITH MEDICAID DSH RE8 PORT.—The Secretary shall coordinate the report 

9 under this subsection with the report on Medicaid 

10 DSH under section 1704(a). 

11 (b) PAYMENT ADJUSTMENTS IN RESPONSE TO COV12 ERAGE EXPANSION.— 

13 (1) IN GENERAL.—If there is a significant de14 crease in the national rate of uninsurance as a result 

15 of this Act (as determined under paragraph (2)(A)), 

16 then the Secretary of Health and Human Services 

17 shall, beginning in fiscal year 2017, implement the 

18 following adjustments to Medicare DSH: 

19 (A) In lieu of the amount of Medicare 

20 DSH payment that would otherwise be made 

21 under section 1886(d)(5)(F) of the Social Secu22 rity Act, the amount of Medicare DSH payment 

23 shall be an amount based on the recommenda24 tions of the report under subsection (a)(1)(A) 

25 and shall take into account variations in the 


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1 empirical justification for Medicare DSH attrib2 utable to hospital characteristics, including bed 

3 size. 

4 (B) Subject to paragraph (3), make an ad5 ditional payment to a hospital by an amount 

6 that is estimated based on the amount of un7 compensated care provided by the hospital 

8 based on criteria for uncompensated care as de9 termined by the Secretary, which shall exclude 

10 bad debt. 

11 (2) SIGNIFICANT DECREASE IN NATIONAL RATE

12 OF UNINSURANCE AS A RESULT OF THIS ACT.—For 

13 purposes of this subsection— 

14 (A) IN GENERAL.—There is a ‘‘significant 

15 decrease in the national rate of uninsurance as 

16 a result of this Act’’ if there is a decrease in 

17 the national rate of uninsurance (as defined in 

18 subparagraph (B)) from 2012 to 2014 that ex19 ceeds 8 percentage points. 

20 (B) NATIONAL RATE OF UNINSURANCE

21 DEFINED.—The term ‘‘national rate of 

22 uninsurance’’ means, for a year, such rate for 

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1 sus in its Current Population Survey in or 

2 about September of the succeeding year. 

3 (3) UNCOMPENSATED CARE INCREASE.— 

4 (A) COMPUTATION OF DSH SAVINGS.—For 

5 each fiscal year (beginning with fiscal year 

6 2017), the Secretary shall estimate the aggre7 gate reduction in the amount of Medicare DSH 

8 payment that would be expected to result from 

9 the adjustment under paragraph (1)(A). 

10 (B) STRUCTURE OF PAYMENT IN11 CREASE.—The Secretary shall compute the ad12 ditional payment to a hospital as described in 

13 paragraph (1)(B) for a fiscal year in accordance 

14 with a formula established by the Secretary 

15 that provides that— 

16 (i) the estimated aggregate amount of 

17 such increase for the fiscal year does not 

18 exceed 50 percent of the aggregate reduc19 tion in Medicare DSH estimated by the 

20 Secretary for such fiscal year; and 

21 (ii) hospitals with higher levels of un22 compensated care receive a greater in23 crease. 

24 (c) MEDICARE DSH.—In this section, the term 

25 ‘‘Medicare DSH’’ means adjustments in payments under 


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1 section 1886(d)(5)(F) of the Social Security Act (42 

2 U.S.C. 1395ww(d)(5)(F)) for inpatient hospital services 

3 furnished by disproportionate share hospitals. 

4 SEC. 1113. EXTENSION OF HOSPICE REGULATION MORATO5 RIUM. 

6 Section 4301(a) of division B of the American Recov7 ery and Reinvestment Act of 2009 (Public Law 111–5) 

8 is amended— 

9 (1) by striking ‘‘October 1, 2009’’ and inserting 

10 ‘‘October 1, 2010’’; and 

11 (2) by striking ‘‘for fiscal year 2009’’ and in12 serting ‘‘for fiscal years 2009 and 2010’’. 

13 SEC. 1114. PERMITTING PHYSICIAN ASSISTANTS TO ORDER 

14 POST-HOSPITAL EXTENDED CARE SERVICES 

15 AND TO PROVIDE FOR RECOGNITION OF AT16 TENDING PHYSICIAN ASSISTANTS AS AT17 TENDING PHYSICIANS TO SERVE HOSPICE 

18 PATIENTS. 

19 (a) ORDERING POST-HOSPITAL EXTENDED CARE

20 SERVICES.—Section 1814(a) of the Social Security Act 

21 (42 U.S.C. 1395f(a)) is amended— 

22 (1) in paragraph (2) in the matter preceding 

23 subparagraph (A), is amended by striking ‘‘nurse 

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1 ing ‘‘nurse practitioner, a clinical nurse specialist, or 

2 a physician assistant’’. 

3 (2) in the second sentence, by striking ‘‘or clin4 ical nurse specialist’’ and inserting ‘‘clinical nurse 

5 specialist, or physician assistant’’. 

6 (b) RECOGNITION OF ATTENDING PHYSICIAN AS7 SISTANTS AS ATTENDING PHYSICIANS TO SERVE HOSPICE

8 PATIENTS.— 

9 (1) IN GENERAL.—Section 1861(dd)(3)(B) of 

10 such Act (42 U.S.C. 1395x(dd)(3)(B)) is amended— 

11 (A) by striking ‘‘or nurse’’ and inserting ‘‘, 

12 the nurse’’; and 

13 (B) by inserting ‘‘or the physician assist14 ant (as defined in such subsection),’’ after 

15 ‘‘subsection (aa)(5)),’’. 

16 (2) CONFORMING AMENDMENT.—Section 

17 1814(a)(7)(A)(i)(I) of such Act (42 U.S.C. 

18 1395f(a)(7)(A)(i)(I)) is amended by inserting ‘‘or a 

19 physician assistant’’ after ‘‘a nurse practitioner’’. 

20 (3) CONSTRUCTION.—Nothing in the amend21 ments made by this subsection shall be construed as 

22 changing the requirements of section 1842(b)(6)(C) 

23 of the Social Security Act (42 U.S.C. 

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1 ices of physician assistants under part B of title 

2 XVIII of such Act. 

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

4 this section shall apply to items and services furnished on 

5 or after January 1, 2010. 

6 Subtitle B—Provisions Related to 

7 Part B 

8 PART 1—PHYSICIANS’ SERVICES 

9 SEC. 1121. RESOURCE-BASED FEEDBACK PROGRAM FOR 

10 PHYSICIANS IN MEDICARE. 

11 Section 1848(n) of the Social Security Act (42 U.S.C. 

12 1395w–4(n)) is amended by adding at the end the fol13 lowing new paragraph: 

14 ‘‘(9) FEEDBACK IMPLEMENTATION PLAN.— 

15 ‘‘(A) TIMELINE FOR FEEDBACK PRO16 GRAM.— 

17 ‘‘(i) EVALUATION.—During 2011 the 

18 Secretary shall conduct the evaluation 

19 specified in subparagraph (E)(i). 

20 ‘‘(ii) EXPANSION.—The Secretary 

21 shall expand the Program under this sub22 section as specified in subparagraph 

23 (E)(ii). 

24 ‘‘(B) ESTABLISHMENT OF NATURE OF RE25 PORTS.— 


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1 ‘‘(i) IN GENERAL.—The Secretary 

2 shall develop and specify the nature of the 

3 reports that will be disseminated under 

4 this subsection, based on results and find5 ings from the Program under this sub6 section as in existence before the date of 

7 the enactment of this paragraph. Such re8 ports may be based on a per capita basis, 

9 an episode basis that combines separate 

10 but clinically related physicians’ services 

11 and other items and services furnished or 

12 ordered by a physician into an episode of 

13 care, as appropriate, or both. 

14 ‘‘(ii) TIMELINE FOR DEVELOP15 MENT.—The nature of the reports de16 scribed in clause (i) shall be developed by 

17 not later than January 1, 2012. 

18 ‘‘(iii) PUBLIC AVAILABILITY.—The 

19 Secretary shall make the details of the na20 ture of the reports developed under clause 

21 (i) available to the public. 

22 ‘‘(C) ANALYSIS OF DATA.—The Secretary 

23 shall, for purposes of preparing reports under 

24 this subsection, establish methodologies as ap25 propriate such as to— 


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1 ‘‘(i) attribute items and services, in 

2 whole or in part, to physicians; 

3 ‘‘(ii) identify appropriate physicians 

4 for purposes of comparison under subpara5 graph (B)(i); and 

6 ‘‘(iii) aggregate items and services at7 tributed to a physician under clause (i) 

8 into a composite measure per individual. 

9 ‘‘(D) FEEDBACK PROGRAM.—The Sec10 retary shall engage in efforts to disseminate re11 ports under this subsection. In disseminating 

12 such reports, the Secretary shall consider the 

13 following: 

14 ‘‘(i) Direct meetings between con15 tracted physicians, facilitated by the Sec16 retary, to discuss the contents of reports 

17 under this subsection, including any rea18 sons for divergence from local or national 

19 averages. 

20 ‘‘(ii) Contract with local, non-profit 

21 entities engaged in quality improvement ef22 forts at the community level. Such entities 

23 shall use the reports under this subsection, 

24 or such equivalent tool as specified by the 

25 Secretary. Any exchange of data under this 


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1 paragraph shall be protected by appro2 priate privacy safeguards. 

3 ‘‘(iii) Mailings or other methods of 

4 communication that facilitate large-scale 

5 dissemination. 

6 ‘‘(iv) Other methods specified by the 

7 Secretary. 

8 ‘‘(E) EVALUATION AND EXPANSION.— 

9 ‘‘(i) EVALUATION.—The Secretary 

10 shall evaluate the methods specified in sub11 paragraph (D) with regard to their efficacy 

12 in changing practice patterns to improve 

13 quality and decrease costs. 

14 ‘‘(ii) EXPANSION.—Taking into ac15 count the cost of each method specified in 

16 subparagraph (D), the Secretary shall de17 velop a plan to disseminate reports under 

18 this subsection in a significant manner in 

19 the regions and cities of the country with 

20 the highest utilization of services under 

21 this title. To the extent practicable, reports 

22 under this subsection shall be disseminated 

23 to increasing numbers of physicians each 

24 year, such that during 2014 and subse25 quent years, reports are disseminated at 


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1 least to physicians with utilization rates 

2 among the highest 5 percent of the nation, 

3 subject the authority to focus under para4 graph (4). 

5 ‘‘(F) ADMINISTRATION.— 

6 ‘‘(i) Chapter 35 of title 44, United 

7 States Code shall not apply to this para8 graph. 

9 ‘‘(ii) Notwithstanding any other provi10 sion of law, the Secretary may implement 

11 the provisions of this paragraph by pro12 gram instruction or otherwise.’’. 

13 SEC. 1122. MISVALUED CODES UNDER THE PHYSICIAN FEE 

14 SCHEDULE. 

15 (a) IN GENERAL.—Section 1848(c)(2) of the Social 

16 Security Act (42 U.S.C. 1395w-4(c)(2)) is amended by 

17 adding at the end the following new subparagraphs: 

18 ‘‘(K) POTENTIALLY MISVALUED CODES.— 

19 ‘‘(i) IN GENERAL.—The Secretary 

20 shall— 

21 ‘‘(I) periodically identify services 

22 as being potentially misvalued using 

23 criteria specified in clause (ii); and 

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1 ues established under this paragraph 

2 for services identified as being poten3 tially misvalued under subclause (I). 

4 ‘‘(ii) IDENTIFICATION OF POTEN5 TIALLY MISVALUED CODES.—For purposes 

6 of identifying potentially misvalued services 

7 pursuant to clause (i)(I), the Secretary 

8 shall examine (as the Secretary determines 

9 to be appropriate) codes (and families of 

10 codes as appropriate) for which there has 

11 been the fastest growth; codes (and fami12 lies of codes as appropriate) that have ex13 perienced substantial changes in practice 

14 expenses; codes for new technologies or 

15 services within an appropriate period (such 

16 as three years) after the relative values are 

17 initially established for such codes; mul18 tiple codes that are frequently billed in 

19 conjunction with furnishing a single serv20 ice; codes with low relative values, particu21 larly those that are often billed multiple 

22 times for a single treatment; codes which 

23 have not been subject to review since the 

24 implementation of the RBRVS (the so25 called ‘Harvard-valued codes’); and such 


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1 other codes determined to be appropriate 

2 by the Secretary. 

3 ‘‘(iii) REVIEW AND ADJUSTMENTS.— 

4 ‘‘(I) The Secretary may use ex5 isting processes to receive rec6 ommendations on the review and ap7 propriate adjustment of potentially 

8 misvalued services described clause 

9 (i)(II). 

10 ‘‘(II) The Secretary may conduct 

11 surveys, other data collection activi12 ties, studies, or other analyses as the 

13 Secretary determines to be appro14 priate to facilitate the review and ap15 propriate adjustment described in 

16 clause (i)(II). 

17 ‘‘(III) The Secretary may use 

18 analytic contractors to identify and 

19 analyze services identified under 

20 clause (i)(I), conduct surveys or col21 lect data, and make recommendations 

22 on the review and appropriate adjust23 ment of services described in clause 

24 (i)(II). 


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1 ‘‘(IV) The Secretary may coordi2 nate the review and appropriate ad3 justment described in clause (i)(II) 

4 with the periodic review described in 

5 subparagraph (B). 

6 ‘‘(V) As part of the review and 

7 adjustment described in clause (i)(II), 

8 including with respect to codes with 

9 low relative values described in clause 

10 (ii), the Secretary may make appro11 priate coding revisions (including 

12 using existing processes for consider13 ation of coding changes) which may 

14 include consolidation of individual 

15 services into bundled codes for pay16 ment under the fee schedule under 

17 subsection (b). 

18 ‘‘(VI) The provisions of subpara19 graph (B)(ii)(II) shall apply to adjust20 ments to relative value units made 

21 pursuant to this subparagraph in the 

22 same manner as such provisions apply 

23 to adjustments under subparagraph 

24 (B)(ii)(II). 


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1 ‘‘(L) VALIDATING RELATIVE VALUE

2 UNITS.— 

3 ‘‘(i) IN GENERAL.—The Secretary 

4 shall establish a process to validate relative 

5 value units under the fee schedule under 

6 subsection (b). 

7 ‘‘(ii) COMPONENTS AND ELEMENTS

8 OF WORK.—The process described in 

9 clause (i) may include validation of work 

10 elements (such as time, mental effort and 

11 professional judgment, technical skill and 

12 physical effort, and stress due to risk) in13 volved with furnishing a service and may 

14 include validation of the pre, post, and 

15 intra-service components of work. 

16 ‘‘(iii) SCOPE OF CODES.—The valida17 tion of work relative value units shall in18 clude a sampling of codes for services that 

19 is the same as the codes listed under sub20 paragraph (K)(ii) 

21 ‘‘(iv) METHODS.—The Secretary may 

22 conduct the validation under this subpara23 graph using methods described in sub24 clauses (I) through (V) of subparagraph 


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1 (K)(iii) as the Secretary determines to be 

2 appropriate. 

3 ‘‘(v) ADJUSTMENTS.—The Secretary 

4 shall make appropriate adjustments to the 

5 work relative value units under the fee 

6 schedule under subsection (b). The provi7 sions of subparagraph (B)(ii)(II) shall 

8 apply to adjustments to relative value units 

9 made pursuant to this subparagraph in the 

10 same manner as such provisions apply to 

11 adjustments under subparagraph 

12 (B)(ii)(II).’’. 

13 (b) IMPLEMENTATION.— 

14 (1) FUNDING.—For purposes of carrying out 

15 the provisions of subparagraphs (K) and (L) of 

16 1848(c)(2) of the Social Security Act, as added by 

17 subsection (a), in addition to funds otherwise avail18 able, out of any funds in the Treasury not otherwise 

19 appropriated, there are appropriated to the Sec20 retary of Health and Human Services for the Center 

21 for Medicare & Medicaid Services Program Manage22 ment Account $20,000,000 for fiscal year 2010 and 

23 each subsequent fiscal year. Amounts appropriated 

24 under this paragraph for a fiscal year shall be avail25 able until expended. 


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1 (2) ADMINISTRATION.— 

2 (A) Chapter 35 of title 44, United States 

3 Code and the provisions of the Federal Advisory 

4 Committee Act (5 U.S.C. App.) shall not apply 

5 to this section or the amendment made by this 

6 section. 

7 (B) Notwithstanding any other provision of 

8 law, the Secretary may implement subpara9 graphs (K) and (L) of 1848(c)(2) of the Social 

10 Security Act, as added by subsection (a), by 

11 program instruction or otherwise. 

12 (C) Section 4505(d) of the Balanced 

13 Budget Act of 1997 is repealed. 

14 (D) Except for provisions related to con15 fidentiality of information, the provisions of the 

16 Federal Acquisition Regulation shall not apply 

17 to this section or the amendment made by this 

18 section. 

19 (3) FOCUSING CMS RESOURCES ON POTEN20 TIALLY OVERVALUED CODES.—Section 1868(a) of 

21 the Social Security Act (42 1395ee(a)) is repealed. 

22 SEC. 1123. PAYMENTS FOR EFFICIENT AREAS. 

23 Section 1833 of the Social Security Act (42 U.S.C. 

24 1395l) is amended by adding at the end the following new 

25 subsection: 


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1 ‘‘(x) INCENTIVE PAYMENTS FOR EFFICIENT

2 AREAS.— 

3 ‘‘(1) IN GENERAL.—In the case of services fur4 nished under the physician fee schedule under sec5 tion 1848 on or after January 1, 2011, and before 

6 January 1, 2013, by a supplier that is paid under 

7 such fee schedule in an efficient area (as identified 

8 under paragraph (2)), in addition to the amount of 

9 payment that would otherwise be made for such 

10 services under this part, there also shall be paid (on 

11 a monthly or quarterly basis) an amount equal to 5 

12 percent of the payment amount for the services 

13 under this part. 

14 ‘‘(2) IDENTIFICATION OF EFFICIENT AREAS.— 

15 ‘‘(A) IN GENERAL.—Based upon available 

16 data, the Secretary shall identify those counties 

17 or equivalent areas in the United States in the 

18 lowest fifth percentile of utilization based on 

19 per capita spending under this part and part A 

20 for services provided in the most recent year for 

21 which data are available as of the date of the 

22 enactment of this subsection, as standardized to 

23 eliminate the effect of geographic adjustments 

24 in payment rates. 


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1 ‘‘(B) IDENTIFICATION OF COUNTIES

2 WHERE SERVICE IS FURNISHED..—For pur3 poses of paying the additional amount specified 

4 in paragraph (1), if the Secretary uses the 5- 

5 digit postal ZIP Code where the service is fur6 nished, the dominant county of the postal ZIP 

7 Code (as determined by the United States Post8 al Service, or otherwise) shall be used to deter9 mine whether the postal ZIP Code is in a coun10 ty described in subparagraph (A). 

11 ‘‘(C) LIMITATION ON REVIEW.—There 

12 shall be no administrative or judicial review 

13 under section 1869, 1878, or otherwise, respect14 ing— 

15 ‘‘(i) the identification of a county or 

16 other area under subparagraph (A); or 

17 ‘‘(ii) the assignment of a postal ZIP 

18 Code to a county or other area under sub19 paragraph (B). 

20 ‘‘(D) PUBLICATION OF LIST OF COUNTIES; 

21 POSTING ON WEBSITE.—With respect to a year 

22 for which a county or area is identified under 

23 this paragraph, the Secretary shall identify 

24 such counties or areas as part of the proposed 

25 and final rule to implement the physician fee 


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1 schedule under section 1848 for the applicable 

2 year. The Secretary shall post the list of coun3 ties identified under this paragraph on the 

4 Internet website of the Centers for Medicare & 

5 Medicaid Services.’’. 

6 SEC. 1124. MODIFICATIONS TO THE PHYSICIAN QUALITY 

7 REPORTING INITIATIVE (PQRI). 

8 (a) FEEDBACK.—Section 1848(m)(5) of the Social 

9 Security Act (42 U.S.C. 1395w–4(m)(5)) is amended by 

10 adding at the end the following new subparagraph: 

11 ‘‘(H) FEEDBACK.—The Secretary shall 

12 provide timely feedback to eligible professionals 

13 on the performance of the eligible professional 

14 with respect to satisfactorily submitting data on 

15 quality measures under this subsection.’’. 

16 (b) APPEALS.—Such section is further amended— 

17 (1) in subparagraph (E), by striking ‘‘There 

18 shall be’’ and inserting ‘‘Except as provided in sub19 paragraph (I), there shall be’’; and 

20 (2) by adding at the end the following new sub21 paragraph: 

22 ‘‘(I) INFORMAL APPEALS PROCESS.—By 

23 not later than January 1, 2011, the Secretary 

24 shall establish and have in place an informal 

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1 view of the determination that an eligible pro2 fessional did not satisfactorily submit data on 

3 quality measures under this subsection.’’. 

4 (c) INTEGRATION OF PHYSICIAN QUALITY REPORT5 ING AND EHR REPORTING.—Section 1848(m) of such 

6 Act is amended by adding at the end the following new 

7 paragraph: 

8 ‘‘(7) INTEGRATION OF PHYSICIAN QUALITY RE9 PORTING AND EHR REPORTING.—Not later than 

10 January 1, 2012, the Secretary shall develop a plan 

11 to integrate clinical reporting on quality measures 

12 under this subsection with reporting requirements 

13 under subsection (o) relating to the meaningful use 

14 of electronic health records. Such integration shall 

15 consist of the following: 

16 ‘‘(A) The development of measures, the re17 porting of which would both demonstrate— 

18 ‘‘(i) meaningful use of an electronic 

19 health record for purposes of subsection 

20 (o); and 

21 ‘‘(ii) clinical quality of care furnished 

22 to an individual. 

23 ‘‘(B) The collection of health data to iden24 tify deficiencies in the quality and coordination 


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1 of care for individuals eligible for benefits under 

2 this part. 

3 ‘‘(C) Such other activities as specified by 

4 the Secretary.’’. 

5 (d) EXTENSION OF INCENTIVE PAYMENTS.—Section 

6 1848(m)(1) of such Act (42 U.S.C. 1395w–4(m)(1)) is 

7 amended— 

8 (1) in subparagraph (A), by striking ‘‘2010’’ 

9 and inserting ‘‘2012’’; and 

10 (2) in subparagraph (B)(ii), by striking ‘‘2009 

11 and 2010’’ and inserting ‘‘for each of the years 2009 

12 through 2012’’. 

13 SEC. 1125. ADJUSTMENT TO MEDICARE PAYMENT LOCAL14 ITIES. 

15 (a) IN GENERAL.—Section 1848(e) of the Social Se16 curity Act (42 U.S.C.1395w–4(e)) is amended by adding 

17 at the end the following new paragraph: 

18 ‘‘(6) TRANSITION TO USE OF MSAS AS FEE

19 SCHEDULE AREAS IN CALIFORNIA.— 

20 ‘‘(A) IN GENERAL.— 

21 ‘‘(i) REVISION.—Subject to clause (ii) 

22 and notwithstanding the previous provi23 sions of this subsection, for services fur24 nished on or after January 1, 2011, the 

25 Secretary shall revise the fee schedule 


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1 areas used for payment under this section 

2 applicable to the State of California using 

3 the Metropolitan Statistical Area (MSA) 

4 iterative Geographic Adjustment Factor 

5 methodology as follows: 

6 ‘‘(I) The Secretary shall con7 figure the physician fee schedule areas 

8 using the Metropolitan Statistical 

9 Areas (each in this paragraph referred 

10 to as an ‘MSA’), as defined by the Di11 rector of the Office of Management 

12 and Budget and published in the Fed13 eral Register, using the most recent 

14 available decennial population data as 

15 of the date of the enactment of the 

16 Affordable Health Care for America 

17 Act, as the basis for the fee schedule 

18 areas. 

19 ‘‘(II) For purposes of this clause, 

20 the Secretary shall treat all areas not 

21 included in an MSA as a single rest of 

22 the State MSA. 

23 ‘‘(III) The Secretary shall list all 

24 MSAs within the State by Geographic 

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1 graph (2) (in this paragraph referred 

2 to as a ‘GAF’) in descending order. 

3 ‘‘(IV) In the first iteration, the 

4 Secretary shall compare the GAF of 

5 the highest cost MSA in the State to 

6 the weighted-average GAF of all the 

7 remaining MSAs in the State (includ8 ing the rest of State MSA described 

9 in subclause (II)). If the ratio of the 

10 GAF of the highest cost MSA to the 

11 weighted-average of the GAF of re12 maining lower cost MSAs is 1.05 or 

13 greater, the highest cost MSA shall be 

14 a separate fee schedule area. 

15 ‘‘(V) In the next iteration, the 

16 Secretary shall compare the GAF of 

17 the MSA with the second-highest 

18 GAF to the weighted-average GAF of 

19 the all the remaining MSAs (excluding 

20 MSAs that become separate fee sched21 ule areas). If the ratio of the second22 highest MSA’s GAF to the weighted23 average of the remaining lower cost 

24 MSAs is 1.05 or greater, the second25 highest MSA shall be a separate fee 


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1 schedule area. ‘‘(VI) The iterative 

2 process shall continue until the ratio 

3 of the GAF of the MSA with highest 

4 remaining GAF to the weighted-aver5 age of the remaining MSAs with lower 

6 GAFS is less than 1.05, and the re7 maining group of MSAs with lower 

8 GAFS shall be treated as a single fee 

9 schedule area. 

10 ‘‘(VI) For purposes of the 

11 iterative process described in this 

12 clause, if two MSAs have identical 

13 GAFs, they shall be combined. 

14 ‘‘(ii) TRANSITION.—For services fur15 nished on or after January 1, 2011, and 

16 before January 1, 2016, in the State of 

17 California, after calculating the work, prac18 tice expense, and malpractice geographic 

19 indices that would otherwise be determined 

20 under clauses (i), (ii), and (iii) of para21 graph (1)(A) for a fee schedule area deter22 mined under clause (i), if the index for a 

23 county within a fee schedule area is less 

24 than the index in effect for such county on 

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1 stead apply the index in effect for such 

2 county on such date. 

3 ‘‘(B) SUBSEQUENT REVISIONS.—After the 

4 transition described in subparagraph (A)(ii), 

5 not less than every 3 years the Secretary shall 

6 review and update the fee schedule areas using 

7 the methodology described in subparagraph 

8 (A)(i) and any updated MSAs as defined by the 

9 Director of the Office of Management and 

10 Budget and published in the Federal Register. 

11 The Secretary shall review and make any 

12 changes pursuant to such reviews concurrent 

13 with the application of the periodic review of 

14 the adjustment factors required under para15 graph (1)(C) for California. 

16 ‘‘(C) REFERENCES TO FEE SCHEDULE

17 AREAS.—Effective for services furnished on or 

18 after January 1, 2011, for the State of Cali19 fornia, any reference in this section to a fee 

20 schedule area shall be deemed a reference to an 

21 MSA in the State (including the single rest of 

22 state MSA described in subparagraph 

23 (A)(i)(II)).’’. 

24 (b) CONFORMING AMENDMENT TO DEFINITION OF

25 FEE SCHEDULE AREA.—Section 1848(j)(2) of the Social 


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1 Security Act (42 U.S.C. 1395w(j)(2)) is amended by strik2 ing ‘‘The term’’ and inserting ‘‘Except as provided in sub3 section (e)(6)(C), the term’’. 

4 PART 2—MARKET BASKET UPDATES 

5 SEC. 1131. INCORPORATING PRODUCTIVITY IMPROVE6 MENTS INTO MARKET BASKET UPDATES 

7 THAT DO NOT ALREADY INCORPORATE SUCH 

8 IMPROVEMENTS. 

9 (a) OUTPATIENT HOSPITALS.— 

10 (1) IN GENERAL.—Section 1833(t)(3)(C)(iv) of 

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

12 1395l(t)(3)(C)(iv)) is amended—— 

13 (A) in the first sentence— 

14 (i) by inserting ‘‘(which is subject to 

15 the productivity adjustment described in 

16 subclause (II) of such section)’’ after 

17 ‘‘1886(b)(3)(B)(iii)’’; and 

18 (ii) by inserting ‘‘(but not below 0)’’ 

19 after ‘‘reduced’’; and 

20 (B) in the second sentence, by inserting 

21 ‘‘and which is subject, beginning with 2010, to 

22 the productivity adjustment described in section 

23 1886(b)(3)(B)(iii)(II)’’. 


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1 (2) EFFECTIVE DATE.—The amendments made 

2 by this subsection shall apply to increase factors for 

3 services furnished in years beginning with 2010. 

4 (b) AMBULANCE SERVICES.—Section 1834(l)(3)(B) 

5 of such Act (42 U.S.C. 1395m(l)(3)(B))) is amended by 

6 inserting before the period at the end the following: ‘‘and, 

7 in the case of years beginning with 2010, subject to the 

8 productivity adjustment described in section 

9 1886(b)(3)(B)(iii)(II)’’. 

10 (c) AMBULATORY SURGICAL CENTER SERVICES.— 

11 Section 1833(i)(2)(D) of such Act (42 U.S.C. 

12 1395l(i)(2)(D)) is amended— 

13 (1) by redesignating clause (v) as clause (vi); 

14 and 

15 (2) by inserting after clause (iv) the following 

16 new clause: 

17 ‘‘(v) In implementing the system described in clause 

18 (i), for services furnished during 2010 or any subsequent 

19 year, to the extent that an annual percentage change fac20 tor applies, such factor shall be subject to the productivity 

21 adjustment described in section 1886(b)(3)(B)(iii)(II).’’. 

22 (d) LABORATORY SERVICES.—Section 1833(h)(2)(A) 

23 of such Act (42 U.S.C. 1395l(h)(2)(A)) is amended— 


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1 (1) in clause (i), by striking ‘‘for each of the 

2 years 2009 through 2013’’ and inserting ‘‘for 

3 2009’’; and 

4 (2) clause (ii)— 

5 (A) by striking ‘‘and’’ at the end of sub6 clause (III); 

7 (B) by striking the period at the end of 

8 subclause (IV) and inserting ‘‘; and’’; and 

9 (C) by adding at the end the following new 

10 subclause: 

11 ‘‘(V) the annual adjustment in the fee schedules 

12 determined under clause (i) for years beginning with 

13 2010 shall be subject to the productivity adjustment 

14 described in section 1886(b)(3)(B)(iii)(II).’’. 

15 (e) CERTAIN DURABLE MEDICAL EQUIPMENT.—Sec16 tion 1834(a)(14) of such Act (42 U.S.C. 1395m(a)(14)) 

17 is amended— 

18 (1) in subparagraph (K), by inserting before 

19 the semicolon at the end the following: ‘‘, subject to 

20 the productivity adjustment described in section 

21 1886(b)(3)(B)(iii)(II)’’; 

22 (2) in subparagraph (L)(i), by inserting after 

23 ‘‘June 2013,’’ the following: ‘‘subject to the produc24 tivity adjustment described in section 

25 1886(b)(3)(B)(iii)(II),’’; 


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1 (3) in subparagraph (L)(ii), by inserting after 

2 ‘‘June 2013’’ the following: ‘‘, subject to the produc3 tivity adjustment described in section 

4 1886(b)(3)(B)(iii)(II)’’; and 

5 (4) in subparagraph (M), by inserting before 

6 the period at the end the following: ‘‘, subject to the 

7 productivity adjustment described in section 

8 1886(b)(3)(B)(iii)(II)’’. 

9 PART 3—OTHER PROVISIONS 

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

11 WHEELCHAIRS. 

12 (a) IN GENERAL.—Section 1834(a)(7)(A)(iii) of the 

13 Social Security Act (42 U.S.C. 1395m(a)(7)(A)(iii)) is 

14 amended— 

15 (1) in the heading, by inserting ‘‘CERTAIN COM16 PLEX REHABILITATIVE’’ after ‘‘OPTION FOR’’; and 

17 (2) by striking ‘‘power-driven wheelchair’’ and 

18 inserting ‘‘complex rehabilitative power-driven wheel19 chair recognized by the Secretary as classified within 

20 group 3 or higher’’. 

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

22 subsection (a) shall take effect on January 1, 2011, and 

23 shall apply to power-driven wheelchairs furnished on or 

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1 rity Act (42 U.S.C. 1395w–3) pursuant to a bid submitted 

2 under such section before October 1, 2010, under sub3 section (a)(1)(B)(i)(I) of such section. 

4 SEC. 1141A. ELECTION TO TAKE OWNERSHIP, OR TO DE5 CLINE OWNERSHIP, OF A CERTAIN ITEM OF 

6 COMPLEX DURABLE MEDICAL EQUIPMENT 

7 AFTER THE 13-MONTH CAPPED RENTAL PE8 RIOD ENDS. 

9 (a) IN GENERAL.—Section 1834(a)(7)(A) of the So10 cial Security Act (42 U.S.C. 1395m(a)(7)(A)) is amend11 ed— 

12 (1) in clause (ii)— 

13 (A) by striking ‘‘RENTAL.—On’’ and in14 serting ‘‘RENTAL.— 

15 ‘‘(I) IN GENERAL.—Except as 

16 provided in subclause (II), on’’; and 

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

18 subclause: 

19 ‘‘(II) OPTION TO ACCEPT OR RE20 JECT TRANSFER OF TITLE TO GROUP

21 3 SUPPORT SURFACE.— 

22 ‘‘(aa) IN GENERAL.—During 

23 the 10th continuous month dur24 ing which payment is made for 

25 the rental of a Group 3 Support 


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1 Surface under clause (i), the sup2 plier of such item shall offer the 

3 individual the option to accept or 

4 reject transfer of title to a Group 

5 3 Support Surface after the 13th 

6 continuous month during which 

7 payment is made for the rental of 

8 the Group 3 Support Surface 

9 under clause (i). Such title shall 

10 be transferred to the individual 

11 only if the individual notifies the 

12 supplier not later than 1 month 

13 after the supplier makes such 

14 offer that the individual agrees to 

15 accept transfer of the title to the 

16 Group 3 Support Surface. Unless 

17 the individual accepts transfer of 

18 title to the Group 3 Support Sur19 face in the manner set forth in 

20 this subclause, the individual 

21 shall be deemed to have rejected 

22 transfer of title. If the individual 

23 agrees to accept the transfer of 

24 the title to the Group 3 Support 

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1 fer such title to the individual on 

2 the first day that begins after the 

3 13th continuous month during 

4 which payment is made for the 

5 rental of the Group 3 Support 

6 Surface under clause (i). 

7 ‘‘(bb) SPECIAL RULE.—If, 

8 on the effective date of this sub9 clause, an individual’s rental pe10 riod for a Group 3 Support Sur11 face has exceeded 10 continuous 

12 months, but the first day that be13 gins after the 13th continuous 

14 month during which payment is 

15 made for the rental under clause 

16 (i) has not been reached, the sup17 plier shall, within 1 month fol18 lowing such effective date, offer 

19 the individual the option to ac20 cept or reject transfer of title to 

21 a Group 3 Support Surface. Such 

22 title shall be transferred to the 

23 individual only if the individual 

24 notifies the supplier not later 

25 than 1 month after the supplier 


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1 makes such offer that the indi2 vidual agrees to accept transfer 

3 of title to the Group 3 Support 

4 Surface. Unless the individual ac5 cepts transfer of title to the 

6 Group 3 Support Surface in the 

7 manner set forth in this sub8 clause, the individual shall be 

9 deemed to have rejected transfer 

10 of title. If the individual agrees 

11 to accept the transfer of the title 

12 to the Group 3 Support Surface, 

13 the supplier shall transfer such 

14 title to the individual on the first 

15 day that begins after the 13th 

16 continuous month during which 

17 payment is made for the rental of 

18 the Group 3 Support Surface 

19 under clause (i) unless that day 

20 has passed, in which case the 

21 supplier shall transfer such title 

22 to the individual not later than 1 

23 month after notification that the 

24 individual accepts transfer of 

25 title. 


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1 ‘‘(cc) TREATMENT OF SUB2 SEQUENT RESUPPLY WITHIN PE3 RIOD OF REASONABLE USEFUL

4 LIFETIME OF GROUP 3 SUPPORT

5 SURFACE IN CASE OF NEED.—If 

6 an individual rejects transfer of 

7 title to a Group 3 Support Sur8 face under this subclause and the 

9 individual requires such Support 

10 Surface at any subsequent time 

11 during the period of the reason12 able useful lifetime of such equip13 ment (as defined by the Sec14 retary) beginning with the first 

15 month for which payment is 

16 made for the rental of such 

17 equipment under clause (i), the 

18 supplier shall supply the equip19 ment without charge to the indi20 vidual or the program under this 

21 title during the remainder of 

22 such period, other than payment 

23 for maintenance and servicing 

24 during such period which would 

25 otherwise have been paid if the 


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1 individual had accepted title to 

2 such equipment. The previous 

3 sentence shall not affect the pay4 ment of amounts under this part 

5 for such equipment after the end 

6 of such period of the reasonable 

7 useful lifetime of the equipment. 

8 ‘‘(dd) PAYMENTS.—Mainte9 nance and servicing payments 

10 shall be made in accordance with 

11 clause (iv), in the case of a sup12 plier that transfers title to the 

13 Group 3 Support Surface under 

14 this subclause, after such trans15 fer and, in the case of an indi16 vidual who rejects transfer of 

17 title under this subclause, after 

18 the end of the period of medical 

19 need during which payment is 

20 made under clause (i).’’; and 

21 (2) in clause (iv), by inserting ‘‘or, in the case 

22 of an individual who rejects transfer of title to a 

23 Group 3 Support Surface under clause (ii), after the 

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1 ment is made under clause (i),’’ after ‘‘under clause 

2 (ii)’’. 

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

4 this section shall apply with respect to durable medical 

5 equipment not later than January 1, 2011. 

6 SEC. 1142. EXTENSION OF PAYMENT RULE FOR 

7 BRACHYTHERAPY. 

8 Section 1833(t)(16)(C) of the Social Security Act (42 

9 U.S.C. 1395l(t)(16)(C)), as amended by section 142 of the 

10 Medicare Improvements for Patients and Providers Act of 

11 2008 (Public Law 110–275), is amended by striking, the 

12 first place it appears, ‘‘January 1, 2010’’ and inserting 

13 ‘‘January 1, 2012’’. 

14 SEC. 1143. HOME INFUSION THERAPY REPORT TO CON15 GRESS. 

16 Not later than July 1, 2011, the Medicare Payment 

17 Advisory Commission shall submit to Congress a report 

18 on the following: 

19 (1) The scope of coverage for home infusion 

20 therapy in the fee-for-service Medicare program 

21 under title XVIII of the Social Security Act, Medi22 care Advantage under part C of such title, the vet23 eran’s health care program under chapter 17 of title 

24 38, United States Code, and among private payers, 

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1 vided by home infusion therapy providers to their 

2 patients in such programs. 

3 (2) The benefits and costs of providing such 

4 coverage under the Medicare program, including a 

5 calculation of the potential savings achieved through 

6 avoided or shortened hospital and nursing home 

7 stays as a result of Medicare coverage of home infu8 sion therapy. 

9 (3) An assessment of sources of data on the 

10 costs of home infusion therapy that might be used 

11 to construct payment mechanisms in the Medicare 

12 program. 

13 (4) Recommendations, if any, on the structure 

14 of a payment system under the Medicare program 

15 for home infusion therapy, including an analysis of 

16 the payment methodologies used under Medicare Ad17 vantage plans and private health plans for the provi18 sion of home infusion therapy and their applicability 

19 to the Medicare program. 

20 SEC. 1144. REQUIRE AMBULATORY SURGICAL CENTERS 

21 (ASCS) TO SUBMIT COST DATA AND OTHER 

22 DATA. 

23 (a) COST REPORTING.— 


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1 (1) IN GENERAL.—Section 1833(i) of the Social 

2 Security Act (42 U.S.C. 1395l(i)) is amended by 

3 adding at the end the following new paragraph: 

4 ‘‘(8) The Secretary shall require, as a condition of 

5 the agreement described in section 1832(a)(2)(F)(i), the 

6 submission of such cost report as the Secretary may speci7 fy, taking into account the requirements for such reports 

8 under section 1815 in the case of a hospital.’’. 

9 (2) DEVELOPMENT OF COST REPORT.—Not 

10 later than 3 years after the date of the enactment 

11 of this Act, the Secretary of Health and Human 

12 Services shall develop a cost report form for use 

13 under section 1833(i)(8) of the Social Security Act, 

14 as added by paragraph (1). 

15 (3) AUDIT REQUIREMENT.—The Secretary shall 

16 provide for periodic auditing of cost reports sub17 mitted under section 1833(i)(8) of the Social Secu18 rity Act, as added by paragraph (1). 

19 (4) EFFECTIVE DATE.—The amendment made 

20 by paragraph (1) shall apply to agreements applica21 ble to cost reporting periods beginning 18 months 

22 after the date the Secretary develops the cost report 

23 form under paragraph (2). 

24 (b) ADDITIONAL DATA ON QUALITY.— 


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1 (1) IN GENERAL.—Section 1833(i)(7) of such 

2 Act (42 U.S.C. 1395l(i)(7)) is amended— 

3 (A) in subparagraph (B), by inserting 

4 ‘‘subject to subparagraph (C),’’ after ‘‘may oth5 erwise provide,’’; and 

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

7 subparagraph: 

8 ‘‘(C) Under subparagraph (B) the Secretary shall re9 quire the reporting of such additional data relating to 

10 quality of services furnished in an ambulatory surgical fa11 cility, including data on health care associated infections, 

12 as the Secretary may specify.’’. 

13 (2) EFFECTIVE DATE.—The amendment made 

14 by paragraph (1) shall to reporting for years begin15 ning with 2012. 

16 SEC. 1145. TREATMENT OF CERTAIN CANCER HOSPITALS. 

17 Section 1833(t) of the Social Security Act (42 U.S.C. 

18 1395l(t)) is amended by adding at the end the following 

19 new paragraph: 

20 ‘‘(18) AUTHORIZATION OF ADJUSTMENT FOR

21 CANCER HOSPITALS.— 

22 ‘‘(A) STUDY.—The Secretary shall conduct 

23 a study to determine if, under the system under 

24 this subsection, costs incurred by hospitals de25 scribed in section 1886(d)(1)(B)(v) with respect 


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1 to ambulatory payment classification groups ex2 ceed those costs incurred by other hospitals fur3 nishing services under this subsection (as deter4 mined appropriate by the Secretary). 

5 ‘‘(B) AUTHORIZATION OF ADJUSTMENT.— 

6 Insofar as the Secretary determines under sub7 paragraph (A) that costs incurred by hospitals 

8 described in section 1886(d)(1)(B)(v) exceed 

9 those costs incurred by other hospitals fur10 nishing services under this subsection, the Sec11 retary shall provide for an appropriate adjust12 ment under paragraph (2)(E) to reflect those 

13 higher costs effective for services furnished on 

14 or after January 1, 2011.’’. 

15 SEC. 1146. PAYMENT FOR IMAGING SERVICES. 

16 (a) ADJUSTMENT IN PRACTICE EXPENSE TO RE17 FLECT A PRESUMED LEVEL OF UTILIZATION.—Section 

18 1848 of the Social Security Act (42 U.S.C. 1395w–4) is 

19 amended— 

20 (1) in subsection (b)(4)— 

21 (A) in subparagraph (B), by striking ‘‘sub22 paragraph (A)’’ and inserting ‘‘this paragraph’’; 

23 and 

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

25 subparagraph: 


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1 ‘‘(C) ADJUSTMENT IN PRACTICE EXPENSE

2 TO REFLECT A PRESUMED LEVEL OF UTILIZA3 TION.—Consistent with the methodology for 

4 computing the number of practice expense rel5 ative value units under subsection (c)(2)(C)(ii) 

6 with respect to advanced diagnostic imaging 

7 services (as defined in section 1834(e)(1)(B)) 

8 furnished on or after January 1, 2011, the Sec9 retary shall adjust such number of units so it 

10 reflects a presumed rate of utilization of imag11 ing equipment of 75 percent.’’; and 

12 (2) in subsection (c)(2)(B)(v)), by adding at the 

13 end the following new subclause: 

14 ‘‘(III) CHANGE IN PRESUMED

15 UTILIZATION LEVEL OF CERTAIN AD16 VANCED DIAGNOSTIC IMAGING SERV17 ICES.—Effective for fee schedules es18 tablished beginning with 2011, re19 duced expenditures attributable to the 

20 presumed utilization of 75 percent 

21 under subsection (b)(4)(C) instead of 

22 a presumed utilization of imaging 

23 equipment of 50 percent.’’. 

24 (b) ADJUSTMENT IN TECHNICAL COMPONENT ‘‘DIS25 COUNT’’ ON SINGLE-SESSION IMAGING TO CONSECUTIVE


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1 BODY PARTS.—Section 1848 of such Act (42 U.S.C. 

2 1395w–4) is further amended— 

3 (1) in subsection (b)(4), by adding at the end 

4 the following new subparagraph: 

5 ‘‘(D) ADJUSTMENT IN TECHNICAL COMPO6 NENT DISCOUNT ON SINGLE-SESSION IMAGING

7 INVOLVING CONSECUTIVE BODY PARTS.—For 

8 services furnished on or after January 1, 2011, 

9 the Secretary shall increase the reduction in ex10 penditures attributable to the multiple proce11 dure payment reduction applicable to the tech12 nical component for imaging under the final 

13 rule published by the Secretary in the Federal 

14 Register on November 21, 2005 (part 405 of 

15 title 42, Code of Federal Regulations) from 25 

16 percent to 50 percent.’’; and 

17 (2) in subsection (c)(2)(B)(v), by adding at the 

18 end the following new subclause: 

19 ‘‘(III) ADDITIONAL REDUCED

20 PAYMENT FOR MULTIPLE IMAGING

21 PROCEDURES.—Effective for fee 

22 schedules established beginning with 

23 2011, reduced expenditures attrib24 utable to the increase in the multiple 

25 procedure payment reduction from 25 


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1 percent to 50 percent as described in 

2 subsection (b)(4)(D).’’. 

3 SEC. 1147. DURABLE MEDICAL EQUIPMENT PROGRAM IM4 PROVEMENTS. 

5 (a) WAIVER OF SURETY BOND REQUIREMENT.—Sec6 tion 1834(a)(16) of the Social Security Act (42 U.S.C. 

7 1395m(a)(16)) is amended by adding at the end the fol8 lowing sentence: ‘‘The requirement for a surety bond de9 scribed in subparagraph (B) shall not apply in the case 

10 of a pharmacy or supplier that exclusively furnishes eye11 glasses or contact lenses described in section 1861(s)(8) 

12 if the pharmacy or supply has been enrolled under section 

13 1866(j) as a supplier of durable medical equipment, pros14 thetics, orthotics, and supplies and has been issued (which 

15 may include renewal of) a supplier number (as described 

16 in the first sentence of this paragraph) for at least 5 years, 

17 and if a final adverse action (as defined in section 

18 424.57(a) of title 42, Code of Federal Regulations) has 

19 never been imposed for such pharmacy or supplier.’’. 

20 (b) ENSURING SUPPLY OF OXYGEN EQUIPMENT .— 

21 (1) IN GENERAL.—Section 1834(a)(5)(F) of the 

22 Social Security Act (42 U.S.C. 1395m(a)(5)(F)) is 

23 amended— 


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1 (A) in clause (ii), by striking ‘‘After the’’ 

2 and inserting ‘‘Except as provided in clause 

3 (iii), after the’’; and 

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

5 clause: 

6 ‘‘(iii) CONTINUATION OF SUPPLY.—In 

7 the case of a supplier furnishing such 

8 equipment to an individual under this sub9 section as of the 27th month of the 36 

10 months described in clause (i), the supplier 

11 furnishing such equipment as of such 

12 month shall continue to furnish such 

13 equipment to such individual (either di14 rectly or though arrangements with other 

15 suppliers of such equipment) during any 

16 subsequent period of medical need for the 

17 remainder of the reasonable useful lifetime 

18 of the equipment, as determined by the 

19 Secretary, regardless of the location of the 

20 individual, unless another supplier has ac21 cepted responsibility for continuing to fur22 nish such equipment during the remainder 

23 of such period.’’. 

24 (2) EFFECTIVE DATE.—The amendments made 

25 by paragraph (1) shall take effect as of the date of 


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1 the enactment of this Act and shall apply to the fur2 nishing of equipment to individuals for whom the 

3 27th month of a continuous period of use of oxygen 

4 equipment described in section 1834(a)(5)(F) of the 

5 Social Security Act occurs on or after July 1, 2010. 

6 (c) TREATMENT OF CURRENT ACCREDITATION AP7 PLICATIONS.—Section 1834(a)(20)(F) of such Act (42 

8 U.S.C. 1395m(a)(20)(F)) is amended— 

9 (1) in clause (i)— 

10 (A) by striking ‘‘clause (ii)’’ and inserting 

11 ‘‘clauses (ii) and (iii)’’; and 

12 (B) by striking ‘‘and’’ at the end; 

13 (2) by striking the period at the end of clause 

14 (ii)(II) and by inserting a semicolon; 

15 (3) by inserting after clause (ii) the following 

16 new clauses: 

17 ‘‘(iii) the requirement for accredita18 tion described in clause (i) shall not apply 

19 for purposes of supplying diabetic testing 

20 supplies, canes, and crutches in the case of 

21 a pharmacy that is enrolled under section 

22 1866(j) as a supplier of durable medical 

23 equipment, prosthetics, orthotics, and sup24 plies; and 


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1 ‘‘(iv) a supplier that has submitted an 

2 application for accreditation before August 

3 1, 2009, shall retain the supplier’s provider 

4 or supplier number until an independent 

5 accreditation organization determines if 

6 such supplier complies with requirements 

7 under this paragraph.’’; and 

8 (4) by adding at the end the following new sen9 tence: ‘‘Nothing in clauses (iii) and (iv) shall be con10 strued as affecting the application of an accredita11 tion requirement for suppliers to qualify for bidding 

12 in a competitive acquisition area under section 

13 1847,’’. 

14 (d) RESTORING 36-MONTH OXYGEN RENTAL PERIOD

15 IN CASE OF SUPPLIER BANKRUPTCY FOR CERTAIN INDI16 VIDUALS.—Section 1834(a)(5)(F) of such Act (42 U.S.C. 

17 1395m(a)(5)(F)), as amended by subsection (b), is further 

18 amended by adding at the end the following new clause: 

19 ‘‘(iv) EXCEPTION FOR BANK20 RUPTCY.—If a supplier who furnishes oxy21 gen and oxygen equipment to an individual 

22 is declared bankrupt and its assets are liq23 uidated and at the time of such declaration 

24 and liquidation more than 24 months of 

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1 dividual may begin a new 36-month rental 

2 period under this subparagraph with an3 other supplier of oxygen.’’. 

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

5 MEASUREMENT. 

6 (a) IN GENERAL.—The Medicare Payment Advisory 

7 Commission shall conduct a study regarding bone mass 

8 measurement, including computed tomography, duel-en9 ergy x-ray absorptriometry, and vertebral fracture assess10 ment. The study shall focus on the following: 

11 (1) An assessment of the adequacy of Medicare 

12 payment rates for such services, taking into account 

13 costs of acquiring the necessary equipment, profes14 sional work time, and practice expense costs. 

15 (2) The impact of Medicare payment changes 

16 since 2006 on beneficiary access to bone mass meas17 urement benefits in general and in rural and minor18 ity communities specifically. 

19 (3) A review of the clinically appropriate and 

20 recommended use among Medicare beneficiaries and 

21 how usage rates among such beneficiaries compares 

22 to such recommendations. 

23 (4) In conjunction with the findings under (3), 

24 recommendations, if necessary, regarding methods 


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1 for reaching appropriate use of bone mass measure2 ment studies among Medicare beneficiaries. 

3 (b) REPORT.—The Commission shall submit a report 

4 to the Congress, not later than 9 months after the date 

5 of the enactment of this Act, containing a description of 

6 the results of the study conducted under subsection (a) 

7 and the conclusions and recommendations, if any, regard8 ing each of the issues described in paragraphs (1), (2) (3) 

9 and (4) of such subsection. 

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

11 (a) IN GENERAL.—Section 1834(h)(1) of the Social 

12 Security Act (42 U.S.C. 1395m) is amended— 

13 (1) by redesignating subparagraph (H) as sub14 paragraph (I); and 

15 (2) by inserting after subparagraph (G) the fol16 lowing new subparagraph: 

17 ‘‘(H) SPECIAL PAYMENT RULE FOR POST18 MASTECTOMY EXTERNAL BREAST PROSTHESIS

19 GARMENTS.—Payment for post-mastectomy ex20 ternal breast prosthesis garments shall be made 

21 regardless of whether such items are supplied to 

22 the beneficiary prior to or after the mastectomy 

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1 tion safeguards for such items supplied to a 

2 beneficiary prior to the mastectomy or other 

3 breast cancer surgical procedure.’’ 

4 (b) EFFECTIVE DATE.—This amendment shall apply 

5 not later than January 1, 2011. 

6 SEC. 1149A. PAYMENT FOR BIOSIMILAR BIOLOGICAL PROD7 UCTS. 

8 (a) IN GENERAL.—Section 1847A of the Social Secu9 rity Act (42 U.S.C. 1395w–3a) is amended— 

10 (1) in subsection (b)(1)— 

11 (A) in subparagraph (A), by striking ‘‘or’’ 

12 at the end; 

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

14 period at the end and inserting ‘‘; or’’; and 

15 (C) by adding at the end the following new 

16 subparagraph: 

17 ‘‘(C) in the case of one or more inter18 changeable biological products (as defined in 

19 subsection (c)(6)(I)) and their reference biologi20 cal product (as defined in subsection (c)(6)(J)), 

21 which shall be included in the same billing and 

22 payment code, the sum of— 

23 ‘‘(i) the average sales price as deter24 mined using the methodology described in 

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1 able and reference products for all Na2 tional Drug Codes assigned to such prod3 ucts in the same manner as such para4 graph (6) is applied to multiple source 

5 drugs; and 

6 ‘‘(ii) 6 percent of the amount deter7 mined under clause (i); 

8 ‘‘(D) in the case of a biosimilar biological 

9 product (as defined in subsection (c)(6)(H)), 

10 the sum of— 

11 ‘‘(i) the average sales price as deter12 mined using the methodology described in 

13 paragraph (4) applied to such biosimilar 

14 biological product for all National Drug 

15 Codes assigned to such product in the 

16 same manner as such paragraph (4) is ap17 plied to a single source drug; and 

18 ‘‘(ii) 6 percent of the amount deter19 mined under paragraph (4) or the amount 

20 determined under subparagraph (C)(ii), as 

21 the case may be, for the reference biologi22 cal product (as defined in subsection 

23 (c)(6)(J)); or 

24 ‘‘(E) in the case of a reference biological 

25 product for both an interchangeable biological 


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1 product and a biosimilar product, the amount 

2 determined in subparagraph (C).’’; and 

3 (2) in subsection (c)(6)— 

4 (A) by amending subparagraph (D)(i) to 

5 read as follows: 

6 ‘‘(i) a biological, including a reference 

7 biological product for a biosimilar product, 

8 but excluding— 

9 ‘‘(I) a biosimilar biological prod10 uct; 

11 ‘‘(II) an interchangeable biologi12 cal product; 

13 ‘‘(III) a reference biological prod14 uct for an interchangeable biological 

15 product; and 

16 ‘‘(IV) a reference biological prod17 uct for both an interchangeable bio18 logical product and a biosimilar prod19 uct; or’’; and 

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

21 subparagraphs: 

22 ‘‘(H) BIOSIMILAR BIOLOGICAL PRODUCT.— 

23 The term ‘biosimilar biological product’ means 

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1 logical product under section 351(k) of the 

2 Public Health Service Act. 

3 ‘‘(I) INTERCHANGEABLE BIOLOGICAL

4 PRODUCT.—The term ‘interchangeable biologi5 cal product’ means a biological product licensed 

6 as an interchangeable biological product under 

7 section 351(k) of the Public Health Service Act 

8 ‘‘(J) REFERENCE BIOLOGICAL PRODUCT.— 

9 The term ‘reference biological product’ means 

10 the biological product that is referred to in the 

11 application for a biosimilar or interchangeable 

12 biological product licensed under section 351(k) 

13 of the Public Health Service Act.’’. 

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

15 subsection (a) shall apply to payments for biosimilar bio16 logical products, interchangeable biological products, and 

17 reference biological products beginning with the first day 

18 of the second calendar quarter after the date of the enact19 ment of this Act. 

20 SEC. 1149B. STUDY AND REPORT ON DME COMPETITIVE 

21 BIDDING PROCESS. 

22 (a) STUDY.—The Comptroller General of the United 

23 States shall conduct a study to evaluate the potential es24 tablishment of a program under Medicare under title 

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1 ical equipment and supplies through a competitive bidding 

2 process among manufacturers of such equipment and sup3 plies. Such study shall address the following: 

4 (1) Identification of types of durable medical 

5 equipment and supplies that would be appropriate 

6 for bidding under such a program. 

7 (2) Recommendations on how to structure such 

8 an acquisition program in order to promote fiscal re9 sponsibility while also ensuring beneficiary access to 

10 high quality equipment and supplies. 

11 (3) Recommendations on how such a program 

12 could be phased-in and on what geographic level 

13 would bidding be most appropriate. 

14 (4) In addition to price, recommendations on 

15 criteria that could be factored into the bidding proc16 ess. 

17 (5) Recommendations on how suppliers could be 

18 compensated for furnishing and servicing equipment 

19 and supplies acquired under such a program. 

20 (6) Comparison of such a program to the cur21 rent competitive bidding program under Medicare 

22 for durable medical equipment, as well as any other 

23 similar Federal acquisition programs, such as the 

24 General Services Administration’s vehicle purchasing 

25 program. 


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1 (7) Any other consideration relevant to the ac2 quisition, supply, and service of durable medical 

3 equipment and supplies that is deemed appropriate 

4 by the Comptroller General. 

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

6 date of the enactment of this Act, the Comptroller General 

7 of the United States shall submit to Congress a report 

8 on the findings of the study under subsection (a). 

9 Subtitle C—Provisions Related to 

10 Medicare Parts A and B 

11 SEC. 1151. REDUCING POTENTIALLY PREVENTABLE HOS12 PITAL READMISSIONS. 

13 (a) HOSPITALS.— 

14 (1) IN GENERAL.—Section 1886 of the Social 

15 Security Act (42 U.S.C. 1395ww), as amended by 

16 section 1103(a), is amended by adding at the end 

17 the following new subsection: 

18 ‘‘(p) ADJUSTMENT TO HOSPITAL PAYMENTS FOR

19 EXCESS READMISSIONS.— 

20 ‘‘(1) IN GENERAL.—With respect to payment 

21 for discharges from an applicable hospital (as de22 fined in paragraph (5)(C)) occurring during a fiscal 

23 year beginning on or after October 1, 2011, in order 

24 to account for excess readmissions in the hospital, 

25 the Secretary shall reduce the payments that would 


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1 otherwise be made to such hospital under subsection 

2 (d) (or section 1814(b)(3), as the case may be) for 

3 such a discharge by an amount equal to the product 

4 of— 

5 ‘‘(A) the base operating DRG payment 

6 amount (as defined in paragraph (2)) for the 

7 discharge; and 

8 ‘‘(B) the adjustment factor (described in 

9 paragraph (3)(A)) for the hospital for the fiscal 

10 year. 

11 ‘‘(2) BASE OPERATING DRG PAYMENT

12 AMOUNT.— 

13 ‘‘(A) IN GENERAL.—Except as provided in 

14 subparagraph (B), for purposes of this sub15 section, the term ‘base operating DRG payment 

16 amount’ means, with respect to a hospital for a 

17 fiscal year, the payment amount that would 

18 otherwise be made under subsection (d) for a 

19 discharge if this subsection did not apply, re20 duced by any portion of such amount that is at21 tributable to payments under subparagraphs 

22 (B) and (F) of paragraph (5). 

23 ‘‘(B) ADJUSTMENTS.—For purposes of 

24 subparagraph (A), in the case of a hospital that 

25 is paid under section 1814(b)(3), the term ‘base 


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1 operating DRG payment amount’ means the 

2 payment amount under such section. 

3 ‘‘(3) ADJUSTMENT FACTOR.— 

4 ‘‘(A) IN GENERAL.—For purposes of para5 graph (1), the adjustment factor under this 

6 paragraph for an applicable hospital for a fiscal 

7 year is equal to the greater of— 

8 ‘‘(i) the ratio described in subpara9 graph (B) for the hospital for the applica10 ble period (as defined in paragraph (5)(D)) 

11 for such fiscal year; or 

12 ‘‘(ii) the floor adjustment factor speci13 fied in subparagraph (C). 

14 ‘‘(B) RATIO.—The ratio described in this 

15 subparagraph for a hospital for an applicable 

16 period is equal to 1 minus the ratio of— 

17 ‘‘(i) the aggregate payments for ex18 cess readmissions (as defined in paragraph 

19 (4)(A)) with respect to an applicable hos20 pital for the applicable period; and 

21 ‘‘(ii) the aggregate payments for all 

22 discharges (as defined in paragraph 

23 (4)(B)) with respect to such applicable 

24 hospital for such applicable period. 


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1 ‘‘(C) FLOOR ADJUSTMENT FACTOR.—For 

2 purposes of subparagraph (A), the floor adjust3 ment factor specified in this subparagraph 

4 for— 

5 ‘‘(i) fiscal year 2012 is 0.99; 

6 ‘‘(ii) fiscal year 2013 is 0.98; 

7 ‘‘(iii) fiscal year 2014 is 0.97; or 

8 ‘‘(iv) a subsequent fiscal year is 0.95. 

9 ‘‘(4) AGGREGATE PAYMENTS, EXCESS READMIS10 SION RATIO DEFINED.—For purposes of this sub11 section: 

12 ‘‘(A) AGGREGATE PAYMENTS FOR EXCESS

13 READMISSIONS.—The term ‘aggregate payments 

14 for excess readmissions’ means, for a hospital 

15 for a fiscal year, the sum, for applicable condi16 tions (as defined in paragraph (5)(A)), of the 

17 product, for each applicable condition, of— 

18 ‘‘(i) the base operating DRG payment 

19 amount for such hospital for such fiscal 

20 year for such condition; 

21 ‘‘(ii) the number of admissions for 

22 such condition for such hospital for such 

23 fiscal year; and 

24 ‘‘(iii) the excess readmissions ratio (as 

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1 pital for the applicable period for such fis2 cal year minus 1. 

3 ‘‘(B) AGGREGATE PAYMENTS FOR ALL DIS4 CHARGES.—The term ‘aggregate payments for 

5 all discharges’ means, for a hospital for a fiscal 

6 year, the sum of the base operating DRG pay7 ment amounts for all discharges for all condi8 tions from such hospital for such fiscal year. 

9 ‘‘(C) EXCESS READMISSION RATIO.— 

10 ‘‘(i) IN GENERAL.—Subject to clauses 

11 (ii) and (iii), the term ‘excess readmissions 

12 ratio’ means, with respect to an applicable 

13 condition for a hospital for an applicable 

14 period, the ratio (but not less than 1.0) 

15 of— 

16 ‘‘(I) the risk adjusted readmis17 sions based on actual readmissions, as 

18 determined consistent with a readmis19 sion measure methodology that has 

20 been endorsed under paragraph 

21 (5)(A)(ii)(I), for an applicable hospital 

22 for such condition with respect to the 

23 applicable period; to 

24 ‘‘(II) the risk adjusted expected 

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1 sistent with such a methodology) for 

2 such hospital for such condition with 

3 respect to such applicable period. 

4 ‘‘(ii) EXCLUSION OF CERTAIN RE5 ADMISSIONS.—For purposes of clause (i), 

6 with respect to a hospital, excess readmis7 sions shall not include readmissions for an 

8 applicable condition for which there are 

9 fewer than a minimum number (as deter10 mined by the Secretary) of discharges for 

11 such applicable condition for the applicable 

12 period and such hospital. 

13 ‘‘(iii) ADJUSTMENT.—In order to pro14 mote a reduction over time in the overall 

15 rate of readmissions for applicable condi16 tions, the Secretary may provide, beginning 

17 with discharges for fiscal year 2014, for 

18 the determination of the excess readmis19 sions ratio under subparagraph (C) to be 

20 based on a ranking of hospitals by read21 mission ratios (from lower to higher read22 mission ratios) normalized to a benchmark 

23 that is lower than the 50th percentile. 

24 ‘‘(5) DEFINITIONS.—For purposes of this sub25 section: 


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1 ‘‘(A) APPLICABLE CONDITION.—The term 

2 ‘applicable condition’ means, subject to sub3 paragraph (B), a condition or procedure se4 lected by the Secretary among conditions and 

5 procedures for which— 

6 ‘‘(i) readmissions (as defined in sub7 paragraph (E)) that represent conditions 

8 or procedures that are high volume or high 

9 expenditures under this title (or other cri10 teria specified by the Secretary); and 

11 ‘‘(ii) measures of such readmissions— 

12 ‘‘(I) have been endorsed by the 

13 entity with a contract under section 

14 1890(a); and 

15 ‘‘(II) such endorsed measures 

16 have appropriate exclusions for re17 admissions that are unrelated to the 

18 prior discharge (such as a planned re19 admission or transfer to another ap20 plicable hospital). 

21 ‘‘(B) EXPANSION OF APPLICABLE CONDI22 TIONS.—Beginning with fiscal year 2013, the 

23 Secretary shall expand the applicable conditions 

24 beyond the 3 conditions for which measures 

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1 graph (A)(ii)(I) as of the date of the enactment 

2 of this subsection to the additional 4 conditions 

3 that have been so identified by the Medicare 

4 Payment Advisory Commission in its report to 

5 Congress in June 2007 and to other conditions 

6 and procedures which may include an all-condi7 tion measure of readmissions, as determined 

8 appropriate by the Secretary. In expanding 

9 such applicable conditions, the Secretary shall 

10 seek the endorsement described in subpara11 graph (A)(ii)(I) but may apply such measures 

12 without such an endorsement. 

13 ‘‘(C) APPLICABLE HOSPITAL.—The term 

14 ‘applicable hospital’ means a subsection (d) hos15 pital or a hospital that is paid under section 

16 1814(b)(3). 

17 ‘‘(D) APPLICABLE PERIOD.—The term ‘ap18 plicable period’ means, with respect to a fiscal 

19 year, such period as the Secretary shall specify 

20 for purposes of determining excess readmis21 sions. 

22 ‘‘(E) READMISSION.—The term ‘readmis23 sion’ means, in the case of an individual who is 

24 discharged from an applicable hospital, the ad25 mission of the individual to the same or another 


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1 applicable hospital within a time period speci2 fied by the Secretary from the date of such dis3 charge. Insofar as the discharge relates to an 

4 applicable condition for which there is an en5 dorsed measure described in subparagraph 

6 (A)(ii)(I), such time period (such as 30 days) 

7 shall be consistent with the time period speci8 fied for such measure. 

9 ‘‘(6) LIMITATIONS ON REVIEW.—There shall be 

10 no administrative or judicial review under section 

11 1869, section 1878, or otherwise of— 

12 ‘‘(A) the determination of base operating 

13 DRG payment amounts; 

14 ‘‘(B) the methodology for determining the 

15 adjustment factor under paragraph (3), includ16 ing excess readmissions ratio under paragraph 

17 (4)(C), aggregate payments for excess readmis18 sions under paragraph (4)(A), and aggregate 

19 payments for all discharges under paragraph 

20 (4)(B), and applicable periods and applicable 

21 conditions under paragraph (5); 

22 ‘‘(C) the measures of readmissions as de23 scribed in paragraph (5)(A)(ii); and 

24 ‘‘(D) the determination of a targeted hos25 pital under paragraph (8)(B)(i), the increase in 


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1 payment under paragraph (8)(B)(ii), the aggre2 gate cap under paragraph (8)(C)(i), the hos3 pital-specific limit under paragraph (8)(C)(ii), 

4 and the form of payment made by the Secretary 

5 under paragraph (8)(D). 

6 ‘‘(7) MONITORING INAPPROPRIATE CHANGES IN

7 ADMISSIONS PRACTICES.—The Secretary shall mon8 itor the activities of applicable hospitals to determine 

9 if such hospitals have taken steps to avoid patients 

10 at risk in order to reduce the likelihood of increasing 

11 readmissions for applicable conditions or taken other 

12 inappropriate steps involving readmissions or trans13 fers. If the Secretary determines that such a hos14 pital has taken such a step, after notice to the hos15 pital and opportunity for the hospital to undertake 

16 action to alleviate such steps, the Secretary may im17 pose an appropriate sanction. 

18 ‘‘(8) ASSISTANCE TO CERTAIN HOSPITALS.— 

19 ‘‘(A) IN GENERAL.—For purposes of pro20 viding funds to applicable hospitals to take 

21 steps described in subparagraph (E) to address 

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1 ment adjustment for a hospital described in 

2 subparagraph (B), with respect to each such 

3 fiscal year, by a percent estimated by the Sec4 retary to be consistent with subparagraph (C). 

5 The Secretary shall provide priority to hospitals 

6 that serve Medicare beneficiaries at highest risk 

7 for readmission or for a poor transition from 

8 such a hospital to a post-hospital site of care. 

9 ‘‘(B) TARGETED HOSPITALS.—Subpara10 graph (A) shall apply to an applicable hospital 

11 that— 

12 ‘‘(i) had (or, in the case of an 

13 1814(b)(3) hospital, otherwise would have 

14 had) a disproportionate patient percentage 

15 (as defined in section 1886(d)(5)(F)) of at 

16 least 30 percent, using the latest available 

17 data as estimated by the Secretary; and 

18 ‘‘(ii) provides assurances satisfactory 

19 to the Secretary that the increase in pay20 ment under this paragraph shall be used 

21 for purposes described in subparagraph 

22 (E). 

23 ‘‘(C) CAPS.— 

24 ‘‘(i) AGGREGATE CAP.—The aggregate 

25 amount of the payment adjustment under 


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1 this paragraph for a fiscal year shall not 

2 exceed 5 percent of the estimated dif3 ference in the spending that would occur 

4 for such fiscal year with and without appli5 cation of the adjustment factor described 

6 in paragraph (3) and applied pursuant to 

7 paragraph (1). 

8 ‘‘(ii) HOSPITAL-SPECIFIC LIMIT.—The 

9 aggregate amount of the payment adjust10 ment for a hospital under this paragraph 

11 shall not exceed the estimated difference in 

12 spending that would occur for such fiscal 

13 year for such hospital with and without ap14 plication of the adjustment factor de15 scribed in paragraph (3) and applied pur16 suant to paragraph (1). 

17 ‘‘(D) FORM OF PAYMENT.—The Secretary 

18 may make the additional payments under this 

19 paragraph on a lump sum basis, a periodic 

20 basis, a claim by claim basis, or otherwise. 

21 ‘‘(E) USE OF ADDITIONAL PAYMENT.— 

22 ‘‘(i) IN GENERAL.—Funding under 

23 this paragraph shall be used by targeted 

24 hospitals for activities designed to address 

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1 sult in higher than normal readmission 

2 rates, including transitional care services 

3 described in clause (ii) and any or all of 

4 the other activities described in clause (iii). 

5 ‘‘(ii) TRANSITIONAL CARE SERV6 ICES.—The transitional care services de7 scribed in this clause are transitional care 

8 services furnished by a qualified transi9 tional care provider, such as a nurse or 

10 other health professional, who meets rel11 evant experience and training requirements 

12 as specified by the Secretary that support 

13 a beneficiary under this section beginning 

14 on the date of an individual’s admission to 

15 a hospital for inpatient hospital services 

16 and ending at the latest on the last day of 

17 the 90-day period beginning on the date of 

18 the individual’s discharge from the applica19 ble hospital. The Secretary shall determine 

20 and update services to be included in tran21 sitional care services under this clause as 

22 appropriate, based on evidence of their ef23 fectiveness in reducing hospital readmis24 sions and improving health outcomes. Such 

25 services shall include the following: 


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1 ‘‘(I) Conduct of an assessment 

2 prior to discharge, which assessment 

3 may include an assessment of the in4 dividual’s physical and mental condi5 tion, cognitive and functional capac6 ities, medication regimen and adher7 ence, social and environmental needs, 

8 and primary caregiver needs and re9 sources. 

10 ‘‘(II) Development of a evidence11 based plan of transitional care for the 

12 individual developed after consultation 

13 with the individual and the individ14 ual’s primary caregiver and other 

15 health team members, as appropriate. 

16 Such plan shall include a list of cur17 rent therapies prescribed, treatment 

18 goals and may include other items or 

19 elements as determined by the Sec20 retary, such as identifying list of po21 tential health risks and future services 

22 for both the individual and any pri23 mary caregiver. 


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1 ‘‘(iii) OTHER ACTIVITIES.—The other 

2 activities described in this clause are the 

3 following: 

4 ‘‘(I) Providing other care coordi5 nation services not described under 

6 clause (ii). 

7 ‘‘(II) Hiring translators and in8 terpreters. 

9 ‘‘(III) Increasing services offered 

10 by discharge planners. 

11 ‘‘(IV) Ensuring that individuals 

12 receive a summary of care and medi13 cation orders upon discharge. 

14 ‘‘(V) Developing a quality im15 provement plan to assess and remedy 

16 preventable readmission rates. 

17 ‘‘(VI) Assigning appropriate fol18 low-up care for discharged individuals. 

19 ‘‘(VII) Doing other activities as 

20 determined appropriate by the Sec21 retary. 

22 ‘‘(F) GAO REPORT ON USE OF FUNDS.— 

23 Not later than 3 years after the date on which 

24 funds are first made available under this para25 graph, the Comptroller General of the United 


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1 States shall submit to Congress a report on the 

2 use of such funds. Such report shall consider 

3 information on the effective uses of such funds, 

4 how the uses of such funds affected hospital re5 admission rates (including at 6 months post6 discharge), health outcomes and quality, reduc7 tions in expenditures under this title and the 

8 experiences of beneficiaries, primary caregivers, 

9 and providers, as well as any appropriate rec10 ommendations.’’. 

11 (b) APPLICATION TO CRITICAL ACCESS HOS12 PITALS.—Section 1814(l) of the Social Security Act (42 

13 U.S.C. 1395f(l)) is amended— 

14 (1) in paragraph (5)— 

15 (A) by striking ‘‘and’’ at the end of sub16 paragraph (C); 

17 (B) by striking the period at the end of 

18 subparagraph (D) and inserting ‘‘; and’’; 

19 (C) by inserting at the end the following 

20 new subparagraph: 

21 ‘‘(E) the methodology for determining the ad22 justment factor under paragraph (5), including the 

23 determination of aggregate payments for actual and 

24 expected readmissions, applicable periods, applicable 

25 conditions and measures of readmissions.’’; and 


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1 (D) by redesignating such paragraph as 

2 paragraph (6); and 

3 (2) by inserting after paragraph (4) the fol4 lowing new paragraph: 

5 ‘‘(5) The adjustment factor described in section 

6 1886(p)(3) shall apply to payments with respect to a crit7 ical access hospital with respect to a cost reporting period 

8 beginning in fiscal year 2012 and each subsequent fiscal 

9 year (after application of paragraph (4) of this subsection) 

10 in a manner similar to the manner in which such section 

11 applies with respect to a fiscal year to an applicable hos12 pital as described in section 1886(p)(2).’’. 

13 (c) POST ACUTE CARE PROVIDERS.— 

14 (1) INTERIM POLICY.— 

15 (A) IN GENERAL.—With respect to a read16 mission to an applicable hospital or a critical 

17 access hospital (as described in section 1814(l) 

18 of the Social Security Act) from a post acute 

19 care provider (as defined in paragraph (3)) and 

20 such a readmission is not governed by section 

21 412.531 of title 42, Code of Federal Regula22 tions, if the claim submitted by such a post23 acute care provider under title XVIII of the So24 cial Security Act indicates that the individual 

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1 acute care provider or admitted from home and 

2 under the care of a home health agency within 

3 30 days of an initial discharge from an applica4 ble hospital or critical access hospital, the pay5 ment under such title on such claim shall be the 

6 applicable percent specified in subparagraph 

7 (B) of the payment that would otherwise be 

8 made under the respective payment system 

9 under such title for such post-acute care pro10 vider if this subsection did not apply. In apply11 ing the previous sentence, the Secretary shall 

12 exclude a period of 1 day from the date the in13 dividual is first admitted to or under the care 

14 of the post-acute care provider. 

15 (B) APPLICABLE PERCENT DEFINED.—For 

16 purposes of subparagraph (A), the applicable 

17 percent is— 

18 (i) for fiscal or rate year 2012 is 

19 0.996; 

20 (ii) for fiscal or rate year 2013 is 

21 0.993; and 

22 (iii) for fiscal or rate year 2014 is 

23 0.99. 

24 (C) EFFECTIVE DATE.—Subparagraph (1) 

25 shall apply to discharges or services furnished 


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1 (as the case may be with respect to the applica2 ble post acute care provider) on or after the 

3 first day of the fiscal year or rate year, begin4 ning on or after October 1, 2011, with respect 

5 to the applicable post acute care provider. 

6 (2) DEVELOPMENT AND APPLICATION OF PER7 FORMANCE MEASURES.— 

8 (A) IN GENERAL.—The Secretary of 

9 Health and Human Services shall develop ap10 propriate measures of readmission rates for 

11 post acute care providers. The Secretary shall 

12 seek endorsement of such measures by the enti13 ty with a contract under section 1890(a) of the 

14 Social Security Act but may adopt and apply 

15 such measures under this paragraph without 

16 such an endorsement. The Secretary shall ex17 pand such measures in a manner similar to the 

18 manner in which applicable conditions are ex19 panded under paragraph (5)(B) of section 

20 1886(p) of the Social Security Act, as added by 

21 subsection (a). 

22 (B) IMPLEMENTATION.—The Secretary 

23 shall apply, on or after October 1, 2014, with 

24 respect to post acute care providers, policies 

25 similar to the policies applied with respect to 


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1 applicable hospitals and critical access hospitals 

2 under the amendments made by subsection (a). 

3 The provisions of paragraph (1) shall apply 

4 with respect to any period on or after October 

5 1, 2014, and before such application date de6 scribed in the previous sentence in the same 

7 manner as such provisions apply with respect to 

8 fiscal or rate year 2014. 

9 (C) MONITORING AND PENALTIES.—The 

10 provisions of paragraph (7) of such section 

11 1886(p) shall apply to providers under this 

12 paragraph in the same manner as they apply to 

13 hospitals under such section. 

14 (3) DEFINITIONS.—For purposes of this sub15 section: 

16 (A) POST ACUTE CARE PROVIDER.—The 

17 term ‘‘post acute care provider’’ means— 

18 (i) a skilled nursing facility (as de19 fined in section 1819(a) of the Social Secu20 rity Act); 

21 (ii) an inpatient rehabilitation facility 

22 (described in section 1886(h)(1)(A) of such 

23 Act); 

24 (iii) a home health agency (as defined 

25 in section 1861(o) of such Act); and 


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1 (iv) a long term care hospital (as de2 fined in section 1861(ccc) of such Act). 

3 (B) OTHER TERMS .—The terms ‘‘applica4 ble condition’’, ‘‘applicable hospital’’, and ‘‘re5 admission’’ have the meanings given such terms 

6 in section 1886(p)(5) of the Social Security 

7 Act, as added by subsection (a)(1). 

8 (d) PHYSICIANS.— 

9 (1) STUDY.—The Secretary of Health and 

10 Human Services shall conduct a study to determine 

11 how the readmissions policy described in the pre12 vious subsections could be applied to physicians. 

13 (2) CONSIDERATIONS.—In conducting the 

14 study, the Secretary shall consider approaches such 

15 as— 

16 (A) creating a new code (or codes) and 

17 payment amount (or amounts) under the fee 

18 schedule in section 1848 of the Social Security 

19 Act (in a budget neutral manner) for services 

20 furnished by an appropriate physician who sees 

21 an individual within the first week after dis22 charge from a hospital or critical access hos23 pital; 

24 (B) developing measures of rates of read25 mission for individuals treated by physicians; 


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1 (C) applying a payment reduction for phy2 sicians who treat the patient during the initial 

3 admission that results in a readmission; and 

4 (D) methods for attributing payments or 

5 payment reductions to the appropriate physi6 cian or physicians. 

7 (3) REPORT.—The Secretary shall issue a pub8 lic report on such study not later than the date that 

9 is one year after the date of the enactment of this 

10 Act. 

11 (e) FUNDING.—For purposes of carrying out the pro12 visions of this section, in addition to funds otherwise avail13 able, out of any funds in the Treasury not otherwise ap14 propriated, there are appropriated to the Secretary of 

15 Health and Human Services for the Center for Medicare 

16 & Medicaid Services Program Management Account 

17 $25,000,000 for each fiscal year beginning with 2010. 

18 Amounts appropriated under this subsection for a fiscal 

19 year shall be available until expended. 

20 SEC. 1152. POST ACUTE CARE SERVICES PAYMENT REFORM 

21 PLAN AND BUNDLING PILOT PROGRAM. 

22 (a) PLAN.— 

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

24 Human Services (in this section referred to as the 

25 ‘‘Secretary’’) shall develop a detailed plan to reform 


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1 payment for post acute care (PAC) services under 

2 the Medicare program under title XVIII of the So3 cial Security Act (in this section referred to as the 

4 ‘‘Medicare program)’’. The goals of such payment 

5 reform are to— 

6 (A) improve the coordination, quality, and 

7 efficiency of such services; and 

8 (B) improve outcomes for individuals such 

9 as reducing the need for readmission to hos10 pitals from providers of such services. 

11 (2) BUNDLING POST ACUTE SERVICES.—The 

12 plan described in paragraph (1) shall include de13 tailed specifications for a bundled payment for post 

14 acute services (in this section referred to as the 

15 ‘‘post acute care bundle’’), and may include other 

16 approaches determined appropriate by the Secretary. 

17 (3) POST ACUTE SERVICES.—For purposes of 

18 this section, the term ‘‘post acute services’’ means 

19 services for which payment may be made under the 

20 Medicare program that are furnished by skilled 

21 nursing facilities, inpatient rehabilitation facilities, 

22 long term care hospitals, hospital based outpatient 

23 rehabilitation facilities and home health agencies to 

24 an individual after discharge of such individual from 


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1 a hospital, and such other services determined ap2 propriate by the Secretary. 

3 (b) DETAILS.—The plan described in subsection 

4 (a)(1) shall include consideration of the following issues: 

5 (1) The nature of payments under a post acute 

6 care bundle, including the type of provider or entity 

7 to whom payment should be made, the scope of ac8 tivities and services included in the bundle, whether 

9 payment for physicians’ services should be included 

10 in the bundle, and the period covered by the bundle. 

11 (2) Whether the payment should be consoli12 dated with the payment under the inpatient prospec13 tive system under section 1886 of the Social Secu14 rity Act (in this section referred to as MS–DRGs) 

15 or a separate payment should be established for such 

16 bundle, and if a separate payment is established, 

17 whether it should be made only upon use of post 

18 acute care services or for every discharge. 

19 (3) Whether the bundle should be applied 

20 across all categories of providers of inpatient serv21 ices (including critical access hospitals) and post 

22 acute care services or whether it should be limited 

23 to certain categories of providers, services, or dis24 charges, such as high volume or high cost MS– 

25 DRGs. 


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1 (4) The extent to which payment rates could be 

2 established to achieve offsets for efficiencies that 

3 could be expected to be achieved with a bundle pay4 ment, whether such rates should be established on a 

5 national basis or for different geographic areas, 

6 should vary according to discharge, case mix, 

7 outliers, and geographic differences in wages or 

8 other appropriate adjustments, and how to update 

9 such rates. 

10 (5) The nature of protections needed for indi11 viduals under a system of bundled payments to en12 sure that individuals receive quality care, are fur13 nished the level and amount of services needed as 

14 determined by an appropriate assessment instru15 ment, are offered choice of provider, and the extent 

16 to which transitional care services would improve 

17 quality of care for individuals and the functioning of 

18 a bundled post-acute system. 

19 (6) The nature of relationships that may be re20 quired between hospitals and providers of post acute 

21 care services to facilitate bundled payments, includ22 ing the application of gainsharing, anti-referral, 

23 anti-kickback, and anti-trust laws. 

24 (7) Quality measures that would be appropriate 

25 for reporting by hospitals and post acute providers 


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1 (such as measures that assess changes in functional 

2 status and quality measures appropriate for each 

3 type of post acute services provider including how 

4 the reporting of such quality measures could be co5 ordinated with other reporting of such quality meas6 ures by such providers otherwise required). 

7 (8) How cost-sharing for a post acute care bun8 dle should be treated relative to current rules for 

9 cost-sharing for inpatient hospital, home health, 

10 skilled nursing facility, and other services. 

11 (9) How other programmatic issues should be 

12 treated in a post acute care bundle, including rules 

13 specific to various types of post-acute providers such 

14 as the post-acute transfer policy, three-day hospital 

15 stay to qualify for services furnished by skilled nurs16 ing facilities, and the coordination of payments and 

17 care under the Medicare program and the Medicaid 

18 program. 

19 (10) Such other issues as the Secretary deems 

20 appropriate. 

21 (c) CONSULTATIONS AND ANALYSIS.— 

22 (1) CONSULTATION WITH STAKEHOLDERS.—In 

23 developing the plan under subsection (a)(1), the Sec24 retary shall consult with relevant stakeholders and 

25 shall consider experience with such research studies 


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1 and demonstrations that the Secretary determines 

2 appropriate. 

3 (2) ANALYSIS AND DATA COLLECTION.—In de4 veloping such plan, the Secretary shall— 

5 (A) analyze the issues described in sub6 section (b) and other issues that the Secretary 

7 determines appropriate; 

8 (B) analyze the impacts (including geo9 graphic impacts) of post acute service reform 

10 approaches, including bundling of such services 

11 on individuals, hospitals, post acute care pro12 viders, and physicians; 

13 (C) use existing data (such as data sub14 mitted on claims) and collect such data as the 

15 Secretary determines are appropriate to develop 

16 such plan required in this section; and 

17 (D) if patient functional status measures 

18 are appropriate for the analysis, to the extent 

19 practical, build upon the CARE tool being de20 veloped pursuant to section 5008 of the Deficit 

21 Reduction Act of 2005. 

22 (d) ADMINISTRATION.— 

23 (1) FUNDING.—For purposes of carrying out 

24 the provisions of this section, in addition to funds 

25 otherwise available, out of any funds in the Treasury 


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1 not otherwise appropriated, there are appropriated 

2 to the Secretary for the Center for Medicare & Med3 icaid Services Program Management Account 

4 $15,000,000 for each of the fiscal years 2010 

5 through 2012. Amounts appropriated under this 

6 paragraph for a fiscal year shall be available until 

7 expended. 

8 (2) EXPEDITED DATA COLLECTION.—Chapter 

9 35 of title 44, United States Code shall not apply to 

10 this section. 

11 (e) PUBLIC REPORTS.— 

12 (1) INTERIM REPORTS.—The Secretary shall 

13 issue interim public reports on a periodic basis on 

14 the plan described in subsection (a)(1), the issues 

15 described in subsection (b), and impact analyses as 

16 the Secretary determines appropriate. 

17 (2) FINAL REPORT.—Not later than the date 

18 that is 3 years after the date of the enactment of 

19 this Act, the Secretary shall issue a final public re20 port on such plan, including analysis of issues de21 scribed in subsection (b) and impact analyses. 

22 (f) CONVERSION OF ACUTE CARE EPISODE DEM23 ONSTRATION TO PILOT PROGRAM AND EXPANSION TO IN24 CLUDE POST ACUTE SERVICES.— 


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1 (1) IN GENERAL.—Part E of title XVIII of the 

2 Social Security Act is amended by inserting after 

3 section 1866C the following new section: 

4 ‘‘CONVERSION OF ACUTE CARE EPISODE DEMONSTRATION

5 TO PILOT PROGRAM AND EXPANSION TO INCLUDE

6 POST ACUTE SERVICES

7 ‘‘SEC. 1866D. (a) CONVERSION AND EXPANSION.— 

8 ‘‘(1) IN GENERAL.—By not later than January 

9 1, 2011, the Secretary shall, for the purpose of pro10 moting the use of bundled payments to promote effi11 cient, coordinated, and high quality delivery of 

12 care— 

13 ‘‘(A) convert the acute care episode dem14 onstration program conducted under section 

15 1866C to a pilot program; and 

16 ‘‘(B) subject to subsection (c), expand such 

17 program as so converted to include post acute 

18 services and such other services the Secretary 

19 determines to be appropriate, which may in20 clude transitional services. 

21 ‘‘(2) BUNDLED PAYMENT STRUCTURES.— 

22 ‘‘(A) IN GENERAL.—In carrying out para23 graph (1), the Secretary may apply bundled 

24 payments with respect to— 

25 ‘‘(i) hospitals and physicians; 


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1 ‘‘(ii) hospitals and post-acute care 

2 providers; 

3 ‘‘(iii) hospitals, physicians, and post4 acute care providers; or 

5 ‘‘(iv) combinations of post-acute pro6 viders. 

7 ‘‘(B) FURTHER APPLICATION.— 

8 ‘‘(i) IN GENERAL.—In carrying out 

9 paragraph (1), the Secretary shall apply 

10 bundled payments in a manner so as to in11 clude collaborative care networks and con12 tinuing care hospitals. 

13 ‘‘(ii) COLLABORATIVE CARE NETWORK

14 DEFINED.—For purposes of this subpara15 graph, the term ‘collaborative care net16 work’ means a consortium of health care 

17 providers that provides a comprehensive 

18 range of coordinated and integrated health 

19 care services to low-income patient popu20 lations (including the uninsured) which 

21 may include coordinated and comprehen22 sive care by safety net providers to reduce 

23 any unnecessary use of items and services 

24 furnished in emergency departments, man25 age chronic conditions, improve quality and 


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1 efficiency of care, increase preventive serv2 ices, and promote adherence to post-acute 

3 and follow-up care plans. 

4 ‘‘(iii) CONTINUING CARE HOSPITAL

5 DEFINED.—For purposes of this subpara6 graph, the term ‘continuing care hospital’ 

7 means an entity that has demonstrated the 

8 ability to meet patient care and patient 

9 safety standards and that provides under 

10 common management the medical and re11 habilitation services provided in inpatient 

12 rehabilitation hospitals and units (as de13 fined in section 1886(d)(1)(B)(ii)), long14 term care hospitals (as defined in section 

15 1886(d)(1)(B)(iv)(I)), and skilled nursing 

16 facilities (as defined in section 1819(a)) 

17 that are located in a hospital described in 

18 section 1886(d). 

19 ‘‘(b) SCOPE.—The Secretary shall set specific goals 

20 for the number of acute and post-acute bundling test sites 

21 under the pilot program to ensure that over time the pilot 

22 program is of sufficient size and scope to— 

23 ‘‘(1) test the approaches under the pilot pro24 gram in a variety of settings, including urban, rural, 

25 and underserved areas; 


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1 ‘‘(2) include geographic areas and additional 

2 conditions that account for significant program 

3 spending, as defined by the Secretary; and 

4 ‘‘(3) subject to subsection (d), disseminate the 

5 pilot program rapidly on a national basis. 

6 To the extent that the Secretary finds inpatient and post 

7 acute care bundling to be successful in improving quality 

8 and reducing costs, the Secretary shall implement such 

9 mechanisms and reforms under the pilot program on as 

10 large a geographic scale as practical and economical, con11 sistent with subsection (e). Nothing in this subsection 

12 shall be construed as limiting the number of hospital and 

13 physician groups or the number of hospital and post-acute 

14 provider groups that may participate in the pilot program. 

15 ‘‘(c) LIMITATION.—The Secretary shall only expand 

16 the pilot program under subsection (a) if the Secretary 

17 finds that— 

18 ‘‘(1) the demonstration program under section 

19 1866C and pilot program under this section main20 tain or increase the quality of care received by indi21 viduals enrolled under this title; and 

22 ‘‘(2) such demonstration program and pilot pro23 gram reduce program expenditures and, based on 

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1 mated spending that would be less than what spend2 ing would otherwise be in the absence of this section. 

3 ‘‘(d) CERTIFICATION.—For purposes of subsection 

4 (c), the Chief Actuary of the Centers for Medicare & Med5 icaid Services shall certify whether expansion of the pilot 

6 program under this section would result in estimated 

7 spending that would be less than what spending would 

8 otherwise be in the absence of this section. 

9 ‘‘(e) VOLUNTARY PARTICIPATION.—Nothing in this 

10 paragraph shall be construed as requiring the participa11 tion of an entity in the pilot program under this section. 

12 ‘‘(f) EVALUATION ON COST AND QUALITY OF

13 CARE.—The Secretary shall conduct an evaluation of the 

14 pilot program under subsection (a) to study the effect of 

15 such program on costs and quality of care. The findings 

16 of such evaluation shall be included in the final report re17 quired under section 1152(e)(2) of the Affordable Health 

18 Care for America Act. 

19 ‘‘(g) STUDY OF ADDITIONAL BUNDLING AND EPI20 SODE-BASED PAYMENT FOR PHYSICIANS’ SERVICES.— 

21 ‘‘(1) IN GENERAL.—The Secretary shall provide 

22 for a study of and development of a plan for testing 

23 additional ways to increase bundling of payments for 

24 physicians in connection with an episode of care, 

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1 ices or services rendered in physicians’ offices, other 

2 than those provided under the pilot program. 

3 ‘‘(2) APPLICATION.—The Secretary may imple4 ment such a plan through a demonstration pro5 gram.’’. 

6 (2) CONFORMING AMENDMENT.—Section 

7 1866C(b) of the Social Security Act (42 U.S.C. 

8 1395cc–3(b)) is amended by striking ‘‘The Sec9 retary’’ and inserting ‘‘Subject to section 1866D, the 

10 Secretary’’. 

11 SEC. 1153. HOME HEALTH PAYMENT UPDATE FOR 2010. 

12 Section 1895(b)(3)(B)(ii) of the Social Security Act 

13 (42 U.S.C. 1395fff(b)(3)(B)(ii)) is amended— 

14 (1) in subclause (IV), by striking ‘‘and’’; 

15 (2) by redesignating subclause (V) as subclause 

16 (VII); and 

17 (3) by inserting after subclause (IV) the fol18 lowing new subclauses: 

19 ‘‘(V) 2007, 2008, and 2009, sub20 ject to clause (v), the home health 

21 market basket percentage increase; 

22 ‘‘(VI) 2010, subject to clause (v), 

23 0 percent; and’’. 


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1 SEC. 1154. PAYMENT ADJUSTMENTS FOR HOME HEALTH 

2 CARE. 

3 (a) ACCELERATION OF ADJUSTMENT FOR CASE MIX

4 CHANGES.—Section 1895(b)(3)(B) of the Social Security 

5 Act (42 U.S.C. 1395fff(b)(3)(B)) is amended— 

6 (1) in clause (iv), by striking ‘‘Insofar as’’ and 

7 inserting ‘‘Subject to clause (vi), insofar as’’; and 

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

9 clause: 

10 ‘‘(vi) SPECIAL RULE FOR CASE MIX

11 CHANGES FOR 2011.— 

12 ‘‘(I) IN GENERAL.—With respect 

13 to the case mix adjustments estab14 lished in section 484.220(a) of title 

15 42, Code of Federal Regulations, the 

16 Secretary shall apply, in 2010, the ad17 justment established in paragraph (3) 

18 of such section for 2011, in addition 

19 to applying the adjustment established 

20 in paragraph (2) for 2010. 

21 ‘‘(II) CONSTRUCTION.—Nothing 

22 in this clause shall be construed as 

23 limiting the amount of adjustment for 

24 case mix for 2010 or 2011 if more re25 cent data indicate an appropriate ad26 justment that is greater than the 


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1 amount established in the section de2 scribed in subclause (I).’’. 

3 (b) REBASING HOME HEALTH PROSPECTIVE PAY4 MENT AMOUNT.—Section 1895(b)(3)(A) of the Social Se5 curity Act (42 U.S.C. 1395fff(b)(3)(A)) is amended— 

6 (1) in clause (i)— 

7 (A) in subclause (III), by inserting ‘‘and 

8 before 2011’’ after ‘‘after the period described 

9 in subclause (II)’’; and 

10 (B) by inserting after subclause (III) the 

11 following new subclauses: 

12 ‘‘(IV) Subject to clause (iii)(I), 

13 for 2011, such amount (or amounts) 

14 shall be adjusted by a uniform per15 centage determined to be appropriate 

16 by the Secretary based on analysis of 

17 factors such as changes in the average 

18 number and types of visits in an epi19 sode, the change in intensity of visits 

20 in an episode, growth in cost per epi21 sode, and other factors that the Sec22 retary considers to be relevant. 

23 ‘‘(V) Subject to clause (iii)(II), 

24 for a year after 2011, such a amount 

25 (or amounts) shall be equal to the 


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1 amount (or amounts) determined 

2 under this clause for the previous 

3 year, updated under subparagraph 

4 (B).’’; and 

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

6 clause: 

7 ‘‘(iii) SPECIAL RULE IN CASE OF IN8 ABILITY TO EFFECT TIMELY REBASING.— 

9 ‘‘(I) APPLICATION OF PROXY

10 AMOUNT FOR 2011.—If the Secretary 

11 is not able to compute the amount (or 

12 amounts) under clause (i)(IV) so as to 

13 permit, on a timely basis, the applica14 tion of such clause for 2011, the Sec15 retary shall substitute for such 

16 amount (or amounts) 95 percent of 

17 the amount (or amounts) that would 

18 otherwise be specified under clause 

19 (i)(III) if it applied for 2011. 

20 ‘‘(II) ADJUSTMENT FOR SUBSE21 QUENT YEARS BASED ON DATA.—If 

22 the Secretary applies subclause (I), 

23 the Secretary before July 1, 2011, 

24 shall compare the amount (or 

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1 clause with the amount (or amounts) 

2 that should have been applied under 

3 clause (i)(IV). The Secretary shall de4 crease or increase the prospective pay5 ment amount (or amounts) under 

6 clause (i)(V) for 2012 (or, at the Sec7 retary’s discretion, over a period of 

8 several years beginning with 2012) by 

9 the amount (if any) by which the 

10 amount (or amounts) applied under 

11 subclause (I) is greater or less, re12 spectively, than the amount (or 

13 amounts) that should have been ap14 plied under clause (i)(IV).’’. 

15 SEC. 1155. INCORPORATING PRODUCTIVITY IMPROVE16 MENTS INTO MARKET BASKET UPDATE FOR 

17 HOME HEALTH SERVICES. 

18 (a) IN GENERAL.—Section 1895(b)(3)(B) of the So19 cial Security Act (42 U.S.C. 1395fff(b)(3)(B)) is amend20 ed— 

21 (1) in clause (iii), by inserting ‘‘(including being 

22 subject to the productivity adjustment described in 

23 section 1886(b)(3)(B)(iii)(II))’’ after ‘‘in the same 

24 manner’’; and 


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1 (2) in clause (v)(I), by inserting ‘‘(but not 

2 below 0)’’ after ‘‘reduced’’. 

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

4 subsection (a) shall apply to home health market basket 

5 percentage increases for years beginning with 2011. 

6 SEC. 1155A. MEDPAC STUDY ON VARIATION IN HOME 

7 HEALTH MARGINS. 

8 (a) IN GENERAL.—The Medicare Payment Advisory 

9 Commission shall conduct a study regarding variation in 

10 performance of home health agencies in an effort to ex11 plain variation in Medicare margins for such agencies. 

12 Such study shall include an examination of at least the 

13 following issues: 

14 (1) The demographic characteristics of individ15 uals served and the geographic distribution associ16 ated with transportation costs. 

17 (2) The characteristics of such agencies, such 

18 as whether such agencies operate 24 hours each day, 

19 provide charity care, or are part of an integrated 

20 health system. 

21 (3) The socio-economic status of individuals 

22 served, such as the proportion of such individuals 

23 who are dually eligible for Medicare and Medicaid 

24 benefits. 


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1 (4) The presence of severe and or chronic dis2 ease or disability in individuals served, as evidenced 

3 by multiple discontinuous home health episodes with 

4 a high number of visits per episode. 

5 (5) The differences in services provided, such as 

6 therapy and non-therapy services. 

7 (b) REPORT.—Not later than June 1, 2011, the Com8 mission shall submit a report to the Congress on the re9 sults of the study conducted under subsection (a) and shall 

10 include in the report the Commission’s conclusions and 

11 recommendations, if appropriate, regarding each of the 

12 issues described in paragraphs (1), (2) and (3) of such 

13 subsection. 

14 SEC. 1155B. PERMITTING HOME HEALTH AGENCIES TO AS15 SIGN THE MOST APPROPRIATE SKILLED 

16 SERVICE TO MAKE THE INITIAL ASSESSMENT 

17 VISIT UNDER A MEDICARE HOME HEALTH 

18 PLAN OF CARE FOR REHABILITATION CASES. 

19 (a) IN GENERAL.—Notwithstanding section 

20 484.55(a)(2) of title 42 of the Code of Federal Regula21 tions or any other provision of law, a home health agency 

22 may determine the most appropriate skilled therapist to 

23 make the initial assessment visit for an individual who is 

24 referred (and may be eligible) for home health services 

25 under title XVIII of the Social Security Act but who does 


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1 not require skilled nursing care as long as the skilled serv2 ice (for which that therapist is qualified to provide the 

3 service) is included as part of the plan of care for home 

4 health services for such individual. 

5 (b) RULE OF CONSTRUCTION.—Nothing in sub6 section (a) shall be construed to provide for initial eligi7 bility for coverage of home health services under title 

8 XVIII of the Social Security Act on the basis of a need 

9 for occupational therapy. 

10 SEC. 1156. LIMITATION ON MEDICARE EXCEPTIONS TO THE 

11 PROHIBITION ON CERTAIN PHYSICIAN RE12 FERRALS MADE TO HOSPITALS. 

13 (a) IN GENERAL.—Section 1877 of the Social Secu14 rity Act (42 U.S.C. 1395nn) is amended— 

15 (1) in subsection (d)(2)— 

16 (A) in subparagraph (A), by striking 

17 ‘‘and’’ at the end; 

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

19 period at the end and inserting ‘‘; and’’; and 

20 (C) by adding at the end the following new 

21 subparagraph: 

22 ‘‘(C) in the case where the entity is a hos23 pital, the hospital meets the requirements of 

24 paragraph (3)(D).’’; 

25 (2) in subsection (d)(3)— 


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1 (A) in subparagraph (B), by striking 

2 ‘‘and’’ at the end; 

3 (B) in subparagraph (C), by striking the 

4 period at the end and inserting ‘‘; and’’; and 

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

6 subparagraph: 

7 ‘‘(D) the hospital meets the requirements 

8 described in subsection (i)(1).’’; 

9 (3) by amending subsection (f) to read as fol10 lows: 

11 ‘‘(f) REPORTING AND DISCLOSURE REQUIRE12 MENTS.— 

13 ‘‘(1) IN GENERAL.—Each entity providing cov14 ered items or services for which payment may be 

15 made under this title shall provide the Secretary 

16 with the information concerning the entity’s owner17 ship, investment, and compensation arrangements, 

18 including— 

19 ‘‘(A) the covered items and services pro20 vided by the entity, and 

21 ‘‘(B) the names and unique physician iden22 tification numbers of all physicians with an 

23 ownership or investment interest (as described 

24 in subsection (a)(2)(A)), or with a compensa25 tion arrangement (as described in subsection 


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1 (a)(2)(B)), in the entity, or whose immediate 

2 relatives have such an ownership or investment 

3 interest or who have such a compensation rela4 tionship with the entity. 

5 Such information shall be provided in such form, 

6 manner, and at such times as the Secretary shall 

7 specify. The requirement of this subsection shall not 

8 apply to designated health services provided outside 

9 the United States or to entities which the Secretary 

10 determines provide services for which payment may 

11 be made under this title very infrequently. 

12 ‘‘(2) REQUIREMENTS FOR HOSPITALS WITH

13 PHYSICIAN OWNERSHIP OR INVESTMENT.—In the 

14 case of a hospital that meets the requirements de15 scribed in subsection (i)(1), the hospital shall— 

16 ‘‘(A) submit to the Secretary an initial re17 port, and periodic updates at a frequency deter18 mined by the Secretary, containing a detailed 

19 description of the identity of each physician 

20 owner and physician investor and any other 

21 owners or investors of the hospital; 

22 ‘‘(B) require that any referring physician 

23 owner or investor discloses to the individual 

24 being referred, by a time that permits the indi25 vidual to make a meaningful decision regarding 


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1 the receipt of services, as determined by the 

2 Secretary, the ownership or investment interest, 

3 as applicable, of such referring physician in the 

4 hospital; and 

5 ‘‘(C) disclose the fact that the hospital is 

6 partially or wholly owned by one or more physi7 cians or has one or more physician investors— 

8 ‘‘(i) on any public website for the hos9 pital; and 

10 ‘‘(ii) in any public advertising for the 

11 hospital. 

12 The information to be reported or disclosed under 

13 this paragraph shall be provided in such form, man14 ner, and at such times as the Secretary shall specify. 

15 The requirements of this paragraph shall not apply 

16 to designated health services furnished outside the 

17 United States or to entities which the Secretary de18 termines provide services for which payment may be 

19 made under this title very infrequently. 

20 ‘‘(3) PUBLICATION OF INFORMATION.—The 

21 Secretary shall publish, and periodically update, the 

22 information submitted by hospitals under paragraph 

23 (2)(A) on the public Internet website of the Centers 

24 for Medicare & Medicaid Services.’’; 


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1 (4) by amending subsection (g)(5) to read as 

2 follows: 

3 ‘‘(5) FAILURE TO REPORT OR DISCLOSE INFOR4 MATION.— 

5 ‘‘(A) REPORTING.—Any person who is re6 quired, but fails, to meet a reporting require7 ment of paragraphs (1) and (2)(A) of sub8 section (f) is subject to a civil money penalty of 

9 not more than $10,000 for each day for which 

10 reporting is required to have been made. 

11 ‘‘(B) DISCLOSURE.—Any physician who is 

12 required, but fails, to meet a disclosure require13 ment of subsection (f)(2)(B) or a hospital that 

14 is required, but fails, to meet a disclosure re15 quirement of subsection (f)(2)(C) is subject to 

16 a civil money penalty of not more than $10,000 

17 for each case in which disclosure is required to 

18 have been made. 

19 ‘‘(C) APPLICATION.—The provisions of 

20 section 1128A (other than the first sentence of 

21 subsection (a) and other than subsection (b)) 

22 shall apply to a civil money penalty under sub23 paragraphs (A) and (B) in the same manner as 

24 such provisions apply to a penalty or proceeding 

25 under section 1128A(a).’’; and 


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1 (5) by adding at the end the following new sub2 section: 

3 ‘‘(i) REQUIREMENTS TO QUALIFY FOR RURAL PRO4 VIDER AND HOSPITAL OWNERSHIP EXCEPTIONS TO

5 SELF-REFERRAL PROHIBITION.— 

6 ‘‘(1) REQUIREMENTS DESCRIBED.—For pur7 poses of subsection (d)(3)(D), the requirements de8 scribed in this paragraph are as follows: 

9 ‘‘(A) PROVIDER AGREEMENT.—The hos10 pital had— 

11 ‘‘(i) physician ownership or invest12 ment on January 1, 2009; and 

13 ‘‘(ii) a provider agreement under sec14 tion 1866 in effect on such date. 

15 ‘‘(B) PROHIBITION ON PHYSICIAN OWNER16 SHIP OR INVESTMENT.—The percentage of the 

17 total value of the ownership or investment in18 terests held in the hospital, or in an entity 

19 whose assets include the hospital, by physician 

20 owners or investors in the aggregate does not 

21 exceed such percentage as of the date of enact22 ment of this subsection. 

23 ‘‘(C) PROHIBITION ON EXPANSION OF FA24 CILITY CAPACITY.—Except as provided in para25 graph (2), the number of operating rooms, proVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00486 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 cedure rooms, or beds of the hospital at any 

2 time on or after the date of the enactment of 

3 this subsection are no greater than the number 

4 of operating rooms, procedure rooms, or beds, 

5 respectively, as of such date. 

6 ‘‘(D) ENSURING BONA FIDE OWNERSHIP

7 AND INVESTMENT.— 

8 ‘‘(i) Any ownership or investment in9 terests that the hospital offers to a physi10 cian are not offered on more favorable 

11 terms than the terms offered to a person 

12 who is not in a position to refer patients 

13 or otherwise generate business for the hos14 pital. 

15 ‘‘(ii) The hospital (or any investors in 

16 the hospital) does not directly or indirectly 

17 provide loans or financing for any physi18 cian owner or investor in the hospital. 

19 ‘‘(iii) The hospital (or any investors in 

20 the hospital) does not directly or indirectly 

21 guarantee a loan, make a payment toward 

22 a loan, or otherwise subsidize a loan, for 

23 any physician owner or investor or group 

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1 lated to acquiring any ownership or invest2 ment interest in the hospital. 

3 ‘‘(iv) Ownership or investment returns 

4 are distributed to each owner or investor in 

5 the hospital in an amount that is directly 

6 proportional to the ownership or invest7 ment interest of such owner or investor in 

8 the hospital. 

9 ‘‘(v) The investment interest of the 

10 owner or investor is directly proportional 

11 to the owner’s or investor’s capital con12 tributions made at the time the ownership 

13 or investment interest is obtained. 

14 ‘‘(vi) Physician owners and investors 

15 do not receive, directly or indirectly, any 

16 guaranteed receipt of or right to purchase 

17 other business interests related to the hos18 pital, including the purchase or lease of 

19 any property under the control of other 

20 owners or investors in the hospital or lo21 cated near the premises of the hospital. 

22 ‘‘(vii) The hospital does not offer a 

23 physician owner or investor the oppor24 tunity to purchase or lease any property 

25 under the control of the hospital or any 


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1 other owner or investor in the hospital on 

2 more favorable terms than the terms of3 fered to a person that is not a physician 

4 owner or investor. 

5 ‘‘(viii) The hospital does not condition 

6 any physician ownership or investment in7 terests either directly or indirectly on the 

8 physician owner or investor making or in9 fluencing referrals to the hospital or other10 wise generating business for the hospital. 

11 ‘‘(E) PATIENT SAFETY.—In the case of a 

12 hospital that does not offer emergency services, 

13 the hospital has the capacity to— 

14 ‘‘(i) provide assessment and initial 

15 treatment for medical emergencies; and 

16 ‘‘(ii) if the hospital lacks additional 

17 capabilities required to treat the emergency 

18 involved, refer and transfer the patient 

19 with the medical emergency to a hospital 

20 with the required capability. 

21 ‘‘(F) LIMITATION ON APPLICATION TO

22 CERTAIN CONVERTED FACILITIES.—The hos23 pital was not converted from an ambulatory 

24 surgical center to a hospital on or after the date 

25 of enactment of this subsection. 


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1 ‘‘(2) EXCEPTION TO PROHIBITION ON EXPAN2 SION OF FACILITY CAPACITY.— 

3 ‘‘(A) PROCESS.— 

4 ‘‘(i) ESTABLISHMENT.—The Secretary 

5 shall establish and implement a process 

6 under which a hospital may apply for an 

7 exception from the requirement under 

8 paragraph (1)(C). 

9 ‘‘(ii) OPPORTUNITY FOR COMMUNITY

10 INPUT.—The process under clause (i) shall 

11 provide persons and entities in the commu12 nity in which the hospital applying for an 

13 exception is located with the opportunity to 

14 provide input with respect to the applica15 tion. 

16 ‘‘(iii) TIMING FOR IMPLEMENTA17 TION.—The Secretary shall implement the 

18 process under clause (i) on the date that is 

19 one month after the promulgation of regu20 lations described in clause (iv). 

21 ‘‘(iv) REGULATIONS.—Not later than 

22 the first day of the month beginning 18 

23 months after the date of the enactment of 

24 this subsection, the Secretary shall promul25 gate regulations to carry out the process 


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1 under clause (i). The Secretary may issue 

2 such regulations as interim final regula3 tions. 

4 ‘‘(B) FREQUENCY.—The process described 

5 in subparagraph (A) shall permit a hospital to 

6 apply for an exception up to once every 2 years. 

7 ‘‘(C) PERMITTED INCREASE.— 

8 ‘‘(i) IN GENERAL.—Subject to clause 

9 (ii) and subparagraph (D), a hospital 

10 granted an exception under the process de11 scribed in subparagraph (A) may increase 

12 the number of operating rooms, procedure 

13 rooms, or beds of the hospital above the 

14 baseline number of operating rooms, proce15 dure rooms, or beds, respectively, of the 

16 hospital (or, if the hospital has been grant17 ed a previous exception under this para18 graph, above the number of operating 

19 rooms, procedure rooms, or beds, respec20 tively, of the hospital after the application 

21 of the most recent increase under such an 

22 exception). 

23 ‘‘(ii) 100 PERCENT INCREASE LIMITA24 TION.—The Secretary shall not permit an 

25 increase in the number of operating rooms, 


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1 procedure rooms, or beds of a hospital 

2 under clause (i) to the extent such increase 

3 would result in the number of operating 

4 rooms, procedure rooms, or beds of the 

5 hospital exceeding 200 percent of the base6 line number of operating rooms, procedure 

7 rooms, or beds of the hospital. 

8 ‘‘(iii) BASELINE NUMBER OF OPER9 ATING ROOMS, PROCEDURE ROOMS, OR

10 BEDS.—In this paragraph, the term ‘base11 line number of operating rooms, procedure 

12 rooms, or beds’ means the number of oper13 ating rooms, procedure rooms, or beds of a 

14 hospital as of the date of enactment of this 

15 subsection. 

16 ‘‘(D) INCREASE LIMITED TO FACILITIES

17 ON THE MAIN CAMPUS OF THE HOSPITAL.— 

18 Any increase in the number of operating rooms, 

19 procedure rooms, or beds of a hospital pursuant 

20 to this paragraph may only occur in facilities on 

21 the main campus of the hospital. 

22 ‘‘(E) CONDITIONS FOR APPROVAL OF AN

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1 ess described in subparagraph (A) only to a 

2 hospital— 

3 ‘‘(i) that is located in a county in 

4 which the percentage increase in the popu5 lation during the most recent 5-year period 

6 for which data are available is estimated to 

7 be at least 150 percent of the percentage 

8 increase in the population growth of the 

9 State in which the hospital is located dur10 ing that period, as estimated by Bureau of 

11 the Census and available to the Secretary; 

12 ‘‘(ii) whose annual percent of total in13 patient admissions that represent inpatient 

14 admissions under the program under title 

15 XIX is estimated to be equal to or greater 

16 than the average percent with respect to 

17 such admissions for all hospitals located in 

18 the county in which the hospital is located; 

19 ‘‘(iii) that does not discriminate 

20 against beneficiaries of Federal health care 

21 programs and does not permit physicians 

22 practicing at the hospital to discriminate 

23 against such beneficiaries; 

24 ‘‘(iv) that is located in a State in 

25 which the average bed capacity in the 


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1 State is estimated to be less than the na2 tional average bed capacity; 

3 ‘‘(v) that has an average bed occu4 pancy rate that is estimated to be greater 

5 than the average bed occupancy rate in the 

6 State in which the hospital is located; and 

7 ‘‘(vi) that meets other conditions as 

8 determined by the Secretary. 

9 ‘‘(F) PROCEDURE ROOMS.—In this sub10 section, the term ‘procedure rooms’ includes 

11 rooms in which catheterizations, angiographies, 

12 angiograms, and endoscopies are furnished, but 

13 such term shall not include emergency rooms or 

14 departments (except for rooms in which cath15 eterizations, angiographies, angiograms, and 

16 endoscopies are furnished). 

17 ‘‘(G) PUBLICATION OF FINAL DECI18 SIONS.—Not later than 120 days after receiving 

19 a complete application under this paragraph, 

20 the Secretary shall publish on the public Inter21 net website of the Centers for Medicare & Med22 icaid Services the final decision with respect to 

23 such application. 

24 ‘‘(H) LIMITATION ON REVIEW.—There 

25 shall be no administrative or judicial review 


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1 under section 1869, section 1878, or otherwise 

2 of the exception process under this paragraph, 

3 including the establishment of such process, 

4 and any determination made under such proc5 ess. 

6 ‘‘(3) PHYSICIAN OWNER OR INVESTOR DE7 FINED.—For purposes of this subsection and sub8 section (f)(2), the term ‘physician owner or investor’ 

9 means a physician (or an immediate family member 

10 of such physician) with a direct or an indirect own11 ership or investment interest in the hospital. 

12 ‘‘(4) PATIENT SAFETY REQUIREMENT.—In the 

13 case of a hospital to which the requirements of para14 graph (1) apply, insofar as the hospital admits a pa15 tient and does not have any physician available on 

16 the premises 24 hours per day, 7 days per week, be17 fore admitting the patient— 

18 ‘‘(A) the hospital shall disclose such fact to 

19 the patient; and 

20 ‘‘(B) following such disclosure, the hospital 

21 shall receive from the patient a signed acknowl22 edgment that the patient understands such fact. 

23 ‘‘(5) CLARIFICATION.—Nothing in this sub24 section shall be construed as preventing the Sec25 retary from terminating a hospital’s provider agreeVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00495 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 ment if the hospital is not in compliance with regu2 lations pursuant to section 1866.’’. 

3 (b) VERIFYING COMPLIANCE.—The Secretary of 

4 Health and Human Services shall establish policies and 

5 procedures to verify compliance with the requirements de6 scribed in subsections (i)(1) and (i)(4) of section 1877 of 

7 the Social Security Act, as added by subsection (a)(5). 

8 The Secretary may use unannounced site reviews of hos9 pitals and audits to verify compliance with such require10 ments. 

11 (c) IMPLEMENTATION.— 

12 (1) FUNDING.—For purposes of carrying out 

13 the amendments made by subsection (a) and the 

14 provisions of subsection (b), in addition to funds 

15 otherwise available, out of any funds in the Treasury 

16 not otherwise appropriated there are appropriated to 

17 the Secretary of Health and Human Services for the 

18 Centers for Medicare & Medicaid Services Program 

19 Management Account $5,000,000 for each fiscal 

20 year beginning with fiscal year 2010. Amounts ap21 propriated under this paragraph for a fiscal year 

22 shall be available until expended. 

23 (2) ADMINISTRATION.—Chapter 35 of title 44, 

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1 ments made by subsection (a) and the provisions of 

2 subsection (b). 

3 SEC. 1157. INSTITUTE OF MEDICINE STUDY OF GEO4 GRAPHIC ADJUSTMENT FACTORS UNDER 

5 MEDICARE. 

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

7 Human Services shall enter into a contract with the Insti8 tute of Medicine of the National Academy of Science to 

9 conduct a comprehensive empirical study, and provide rec10 ommendations as appropriate, on the accuracy of the geo11 graphic adjustment factors established under sections 

12 1848(e) and 1886(d)(3)(E) of the Social Security Act (42 

13 U.S.C. 1395w–4(e), 1395ww(d)(3)(E)). 

14 (b) MATTERS INCLUDED.—Such study shall include 

15 an evaluation and assessment of the following with respect 

16 to such adjustment factors: 

17 (1) Empirical validity of the adjustment factors. 

18 (2) Methodology used to determine the adjust19 ment factors. 

20 (3) Measures used for the adjustment factors, 

21 taking into account— 

22 (A) timeliness of data and frequency of re23 visions to such data; 

24 (B) sources of data and the degree to 

25 which such data are representative of costs; and 


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1 (C) operational costs of providers who par2 ticipate in Medicare. 

3 (c) EVALUATION.—Such study shall, within the con4 text of the United States health care marketplace, evalu5 ate and consider the following: 

6 (1) The effect of the adjustment factors on the 

7 level and distribution of the health care workforce 

8 and resources, including— 

9 (A) recruitment and retention that takes 

10 into account workforce mobility between urban 

11 and rural areas; 

12 (B) ability of hospitals and other facilities 

13 to maintain an adequate and skilled workforce; 

14 and 

15 (C) patient access to providers and needed 

16 medical technologies. 

17 (2) The effect of the adjustment factors on pop18 ulation health and quality of care. 

19 (3) The effect of the adjustment factors on the 

20 ability of providers to furnish efficient, high value 

21 care. 

22 (d) REPORT.—The contract under subsection (a) 

23 shall provide for the Institute of Medicine to submit, not 

24 later than 1 year after the date of the enactment of this 

25 Act, to the Secretary and the Congress a report containing 


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1 results and recommendations of the study conducted 

2 under this section. 

3 (e) FUNDING.—There are authorized to be appro4 priated to carry out this section such sums as may be nec5 essary. 

6 SEC. 1158. REVISION OF MEDICARE PAYMENT SYSTEMS TO 

7 ADDRESS GEOGRAPHIC INEQUITIES. 

8 (a) REVISION OF MEDICARE PAYMENT SYSTEMS.— 

9 Taking into account the recommendations described in the 

10 report under section 1157, and notwithstanding the geo11 graphic adjustments that would otherwise apply under sec12 tion 1848(e) and section 1886(d)(3)(E) of the Social Se13 curity Act (42 U.S.C. 1395w–4(e), 1395ww(d)(3)(E)), the 

14 Secretary of Health and Human Services shall include in 

15 proposed rules applicable to the rulemaking cycle for pay16 ment systems for physicians’ services and inpatient hos17 pital services under sections 1848 and section 1886(d) of 

18 such Act, respectively, proposals (as the Secretary deter19 mines to be appropriate) to revise the geographic adjust20 ment factors used in such systems. Such proposals’ rules 

21 shall be contained in the next rulemaking cycle following 

22 the submission to the Secretary of the report described 

23 in section 1157. 

24 (b) PAYMENT ADJUSTMENTS.— 


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1 (1) FUNDING FOR IMPROVEMENTS.—For years 

2 before 2014, the Secretary shall ensure that the ad3 ditional expenditures resulting from the implementa4 tion of the provisions of this section, as estimated by 

5 the Secretary, do not exceed $8,000,000,000, and do 

6 not exceed half of such amount in any payment year. 

7 (2) HOLD HARMLESS.—In carrying out this 

8 subsection— 

9 (A) for payment years before 2014, the 

10 Secretary shall not reduce the geographic ad11 justment below the factor that applied for such 

12 payment system in the payment year before 

13 such changes; and 

14 (B) for payment years beginning with 

15 2014, the Secretary shall implement the geo16 graphic adjustment in a manner that does not 

17 result in any net change in aggregate expendi18 tures under title XVIII of the Social Security 

19 Act from the amount of such expenditures that 

20 the Secretary estimates would have occurred if 

21 no geographic adjustment had occurred under 

22 this section. 

23 (c) MEDICARE IMPROVEMENT FUND.— 

24 (1) Amounts in the Medicare Improvement 

25 Fund under section 1898 of the Social Security Act, 


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1 as amended by paragraph (2), shall be available to 

2 the Secretary to make changes to the geographic ad3 justments factors as described in subsections (a) and 

4 (b) with respect to services furnished before January 

5 1, 2014. No more than one-half of such amounts 

6 shall be available with respect to services furnished 

7 in any one payment year. 

8 (2) Section 1898(b) of the Social Security Act 

9 (42 U.S.C. 1395iii(b)) is amended— 

10 (A) by amending paragraph (1)(A) to read 

11 as follows: 

12 ‘‘(A) the period beginning with fiscal year 

13 2011 and ending with fiscal year 2019, 

14 $8,000,000,000; and’’; and 

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

16 paragraph: 

17 ‘‘(5) ADJUSTMENT FOR UNDERFUNDING.—For 

18 fiscal year 2014 or a subsequent fiscal year specified 

19 by the Secretary, the amount available to the fund 

20 under subsection (a) shall be increased by the Sec21 retary’s estimate of the amount (based on data on 

22 actual expenditures) by which— 

23 ‘‘(A) the additional expenditures resulting 

24 from the implementation of subsection (a) of 

25 section 1158 of the Affordable Health Care for 


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1 America Act for the period before fiscal year 

2 2014, is less than 

3 ‘‘(B) the maximum amount of funds avail4 able under subsection (a) of such section for 

5 funding for such expenditures.’’. 

6 SEC. 1159. INSTITUTE OF MEDICINE STUDY OF GEO7 GRAPHIC VARIATION IN HEALTH CARE 

8 SPENDING AND PROMOTING HIGH-VALUE 

9 HEALTH CARE. 

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

11 Human Services (in this section and the succeeding sec12 tion referred to as the ‘‘Secretary’’) shall enter into an 

13 agreement with the Institute of Medicine of the National 

14 Academies (referred to in this section as the ‘‘Institute’’) 

15 to conduct a study on geographic variation and growth 

16 in volume and intensity of services in per capita health 

17 care spending among the Medicare, Medicaid, privately in18 sured and uninsured populations. Such study may draw 

19 on recent relevant reports of the Institute and shall in20 clude each of the following: 

21 (1) An evaluation of the extent and range of 

22 such variation using various units of geographic 

23 measurement, including micro areas within larger 

24 areas. 


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1 (2) An evaluation of the extent to which geo2 graphic variation can be attributed to differences in 

3 input prices; health status; practice patterns; access 

4 to medical services; supply of medical services; socio5 economic factors, including race, ethnicity, gender, 

6 age, income and educational status; and provider 

7 and payer organizational models. 

8 (3) An evaluation of the extent to which vari9 ations in spending are correlated with patient access 

10 to care, insurance status, distribution of health care 

11 resources, health care outcomes, and consensus12 based measures of health care quality. 

13 (4) An evaluation of the extent to which vari14 ation can be attributed to physician and practitioner 

15 discretion in making treatment decisions, and the 

16 degree to which discretionary treatment decisions 

17 are made that could be characterized as different 

18 from the best available medical evidence. 

19 (5) An evaluation of the extent to which vari20 ation can be attributed to patient preferences and 

21 patient compliance with treatment protocols. 

22 (6) An assessment of the degree to which vari23 ation cannot be explained by empirical evidence. 

24 (7) For Medicare beneficiaries, An evaluation of 

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1 related with insurance status prior to enrollment in 

2 the Medicare program under title XVIII of the So3 cial Security Act, and institutionalization status; 

4 whether beneficiaries are dually eligible for the 

5 Medicare program and Medicaid under title XIX of 

6 such Act; and whether beneficiaries are enrolled in 

7 fee-for-service Medicare or Medicare Advantage. 

8 (8) An evaluation of such other factors as the 

9 Institute deems appropriate. 

10 The Institute shall conduct public hearings and provide 

11 an opportunity for comments prior to completion of the 

12 reports under subsection (e). 

13 (b) RECOMMENDATIONS.—Taking into account the 

14 findings under subsection (a) and the changes to the pay15 ment systems made by this Act, the Institute shall rec16 ommend changes to payment for items and services under 

17 parts A and B of title XVIII of the Social Security Act, 

18 for addressing variation in Medicare per capita spending 

19 for items and services (not including add-ons for graduate 

20 medical education, disproportionate share payments, and 

21 health information technology, as specified in sections 

22 1886(d)(5)(F), 1886(d)(5)(B), 1886(h), 1848(o), and 

23 1886(n), respectively, of such Act) by promoting high24 value care (as defined in subsection (f)), with particular 

25 attention to high-volume, high-cost conditions. In making 


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1 such recommendations, the Institute shall consider each 

2 of the following: 

3 (1) Measurement and reporting on quality and 

4 population health. 

5 (2) Reducing fragmented and duplicative care. 

6 (3) Promoting the practice of evidence-based 

7 medicine. 

8 (4) Empowering patients to make value-based 

9 care decisions. 

10 (5) Leveraging the use of health information 

11 technology. 

12 (6) The role of financial and other incentives 

13 affecting provision of care. 

14 (7) Variation in input costs. 

15 (8) The characteristics of the patient popu16 lation, including socio-economic factors (including 

17 race, ethnicity, gender, age, income and educational 

18 status), and whether the beneficiaries are dually eli19 gible for the Medicare program under title XVIII of 

20 the Social Security Act and Medicaid under title 

21 XIX of such Act. 

22 (9) Other topics the Institute deems appro23 priate. 

24 In making such recommendations, the Institute shall con25 sider an appropriate phase-in that takes into account the 


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1 impact of payment changes on providers and facilities and 

2 preserves access to care for Medicare beneficiaries. 

3 (c) SPECIFIC CONSIDERATIONS.—In making the rec4 ommendations under subsection (b), the Institute shall 

5 specifically address whether payment systems under title 

6 XVIII of the Social Security Act for physicians and hos7 pitals should be further modified to incentivize high-value 

8 care. In so doing, the Institute shall consider the adoption 

9 of a value index based on a composite of appropriate meas10 ures of quality and cost that would adjust provider pay11 ments on a regional or provider-level basis. If the Institute 

12 finds that application of such a value index would signifi13 cantly incentivize providers to furnish high-value care, it 

14 shall make specific recommendations on how such an 

15 index would be designed and implemented. In so doing, 

16 it should identify specific measures of quality and cost ap17 propriate for use in such an index, and include a thorough 

18 analysis (including on a geographic basis) of how pay19 ments and spending under such title would be affected by 

20 such an index. 

21 (d) ADDITIONAL CONSIDERATIONS.—The Institute 

22 shall consider the experience of governmental and commu23 nity-based programs that promote high-value care. 

24 (e) REPORTS.— 


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1 (1) Not later than April 15, 2011, the Institute 

2 shall submit to the Secretary and each House of 

3 Congress a report containing findings and rec4 ommendations of the study conducted under this 

5 section. 

6 (2) Following submission of the report under 

7 paragraph (1), the Institute shall use the data col8 lected and analyzed in this section to issue a subse9 quent report, or series of reports, on how best to ad10 dress geographic variation or efforts to promote 

11 high-value care for items and services reimbursed by 

12 private insurance or other programs. Such reports 

13 shall include a comparison to the Institute’s findings 

14 and recommendations regarding the Medicare pro15 gram. Such reports, and any recommendations, 

16 would not be subject to the procedures outlined in 

17 section 1160. 

18 (f) HIGH-VALUE CARE DEFINED.—For purposes of 

19 this section, the term ‘‘high-value care’’ means the effi20 cient delivery of high quality, evidence-based, patient-cen21 tered care. 

22 (g) APPROPRIATIONS.—There is appropriated from 

23 amounts in the general fund of the Treasury not otherwise 

24 appropriated $10,000,000 to carry out this section. Such 

25 sums are authorized to remain available until expended. 


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1 SEC. 1160. IMPLEMENTATION, AND CONGRESSIONAL RE2 VIEW, OF PROPOSAL TO REVISE MEDICARE 

3 PAYMENTS TO PROMOTE HIGH VALUE 

4 HEALTH CARE. 

5 (a) PREPARATION AND SUBMISSION OF IMPLEMEN6 TATION PLANS.— 

7 (1) FINAL IMPLEMENTATION PLAN.—Not later 

8 than 240 days after the date of receipt by the Sec9 retary and each House of Congress of the report 

10 under section 1159(e)(1), the Secretary shall submit 

11 to each House of Congress a final implementation 

12 plan describing proposed changes to payment for 

13 items and services under parts A and B of title 

14 XVIII of the Social Security Act (which may include 

15 payment for inpatient and outpatient hospital serv16 ices for services furnished in PPS and PPS-exempt 

17 hospitals, physicians’ services, dialysis facility serv18 ices, skilled nursing facility services, home health 

19 services, hospice care, clinical laboratory services, 

20 durable medical equipment, and other items and 

21 services, but which shall exclude add-on payments 

22 for graduate medical education, disproportionate 

23 share payments, and health information technology, 

24 as specified in sections 1886(d)(5)(F), 

25 1886(d)(5)(B), 1886(h), 1848(o), and 1886(n), re26 spectively, of the Social Security Act) taking into 


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1 consideration, as appropriate, the recommendations 

2 of the report submitted under section 1159(e)(1) 

3 and the changes to the payment systems made by 

4 this Act. To the extent such implementation plan re5 quires a substantial change to the payment system, 

6 it shall include a transition phase-in that takes into 

7 consideration possible disruption to provider partici8 pation in the Medicare program under title XVIII of 

9 the Social Security Act and preserves access to care 

10 for Medicare beneficiaries. 

11 (2) PRELIMINARY IMPLEMENTATION PLAN.— 

12 Not later than 90 days after the date the Institute 

13 of Medicine submits to each House of Congress the 

14 report under section 1159(e)(1), the Secretary shall 

15 submit to each House of Congress a preliminary 

16 version of the implementation plan provided for 

17 under paragraph (1)(A). 

18 (3) NO INCREASE IN BUDGET EXPENDI19 TURES.—The Secretary shall include with the sub20 mission of the final implementation plan under para21 graph (1) a certification by the Chief Actuary of the 

22 Centers for Medicare & Medicaid Services that over 

23 the initial 10-year period in which the plan is imple24 mented, the aggregate level of net expenditures 

25 under the Medicare program under title XVIII of 


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1 the Social Security Act will not exceed the aggregate 

2 level of such expenditures that would have occurred 

3 if the plan were not implemented. 

4 (4) WAIVERS REQUIRED.—To the extent the 

5 final implementation plan under paragraph (1) pro6 poses changes that are not otherwise permitted 

7 under title XVIII of the Social Security Act, the 

8 Secretary shall specify in the plan the specific waiv9 ers required under such title to implement such 

10 changes. Except as provided in subsection (c), the 

11 Secretary is authorized to waive the requirements so 

12 specified in order to implement such changes. 

13 (5) ASSESSMENT OF IMPACT.—In addition, 

14 both the preliminary and final implementation plans 

15 under this subsection shall include a detailed assess16 ment of the effects of the proposed payment changes 

17 by provider or supplier type and State relative to the 

18 payments that would otherwise apply. 

19 (b) REVIEW BY MEDPAC AND GAO.—Not later than 

20 45 days after the date the preliminary implementation 

21 plan is received by each House of Congress under sub22 section (a)(2), the Medicare Payment Advisory Committee 

23 and the Comptroller General of the United States shall 

24 each evaluate such plan and submit to each House of Con25 gress a report containing its analysis and recommendaVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00510 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 tions regarding implementation of the plan, including an 

2 analysis of the effects of the proposed changes in the plan 

3 on payments and projected spending. 

4 (c) IMPLEMENTATION.— 

5 (1) IN GENERAL.—The Secretary shall include, 

6 in applicable proposed rules for the next rulemaking 

7 cycle beginning after the Congressional action dead8 line, appropriate proposals to revise payments under 

9 title XVIII of the Social Security Act in accordance 

10 with the final implementation plan submitted under 

11 subsection (a)(1), and the waivers specified in sub12 section (a)(4) to the extent required to carry out 

13 such plan are effective, unless a joint resolution (de14 scribed in subsection (d)(5)(A)) with respect to such 

15 plan is enacted by not later than such deadline. If 

16 such a joint resolution is enacted, the Secretary is 

17 not authorized to implement such plan and the waiv18 er authority provided under subsection (a)(4) shall 

19 no longer be effective. 

20 (2) CONGRESSIONAL ACTION DEADLINE.—For 

21 purposes of this section, the term ‘‘Congressional ac22 tion deadline’’ means, with respect to a final imple23 mentation plan under subsection (a)(1), May 31, 

24 2012, or, if later, the date that is 145 days after the 


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1 date of receipt of such plan by each House of Con2 gress under subsection (a). 

3 (d) CONGRESSIONAL PROCEDURES.— 

4 (1) INTRODUCTION.—On the day on which the 

5 final implementation plan is received by the House 

6 of Representatives and the Senate under subsection 

7 (a), a joint resolution specified in paragraph (5)(A) 

8 shall be introduced in the House of Representatives 

9 by the majority leader and minority leader of the 

10 House of Representatives and in the Senate by the 

11 majority leader and minority leader of the Senate. If 

12 either House is not in session on the day on which 

13 such a plan is received, the joint resolution with re14 spect to such plan shall be introduced in that House, 

15 as provided in the preceding sentence, on the first 

16 day thereafter on which that House is in session. 

17 (2) CONSIDERATION IN THE HOUSE OF REP18 RESENTATIVES.— 

19 (A) REPORTING AND DISCHARGE.—Any 

20 committee of the House of Representatives to 

21 which a joint resolution introduced under para22 graph (1) is referred shall report such joint res23 olution to the House not later than 50 legisla24 tive days after the applicable date of introduc25 tion of the joint resolution. If a committee fails 


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1 to report such joint resolution within that pe2 riod, a motion to discharge the committee from 

3 further consideration of the joint resolution 

4 shall be in order. Such a motion shall be in 

5 order only at a time designated by the Speaker 

6 in the legislative schedule within two legislative 

7 days after the day on which the proponent an8 nounces an intention to offer the motion. Notice 

9 may not be given on an anticipatory basis. Such 

10 a motion shall not be in order after the last 

11 committee authorized to consider the joint reso12 lution reports it to the House or after the 

13 House has disposed of a motion to discharge 

14 the joint resolution. The previous question shall 

15 be considered as ordered on the motion to its 

16 adoption without intervening motion except 20 

17 minutes of debate equally divided and controlled 

18 by the proponent and an opponent. A motion to 

19 reconsider the vote by which the motion is dis20 posed of shall not be in order. 

21 (B) PROCEEDING TO CONSIDERATION.— 

22 After each committee authorized to consider a 

23 joint resolution reports such joint resolution to 

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1 ceed to consider such joint resolution shall be in 

2 order. Such a motion shall be in order only at 

3 a time designated by the Speaker in the legisla4 tive schedule within two legislative days after 

5 the day on which the proponent announces an 

6 intention to offer the motion. Notice may not be 

7 given on an anticipatory basis. Such a motion 

8 shall not be in order after the House of Rep9 resentatives has disposed of a motion to proceed 

10 on the joint resolution. The previous question 

11 shall be considered as ordered on the motion to 

12 its adoption without intervening motion. A mo13 tion to reconsider the vote by which the motion 

14 is disposed of shall not be in order. 

15 (C) CONSIDERATION.—The joint resolution 

16 shall be considered in the House and shall be 

17 considered as read. All points of order against 

18 a joint resolution and against its consideration 

19 are waived. The previous question shall be con20 sidered as ordered on the joint resolution to its 

21 passage without intervening motion except two 

22 hours of debate equally divided and controlled 

23 by the proponent and an opponent. A motion to 

24 reconsider the vote on passage of a joint resolu25 tion shall not be in order. 


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1 (3) CONSIDERATION IN THE SENATE.— 

2 (A) REPORTING AND DISCHARGE.—Any 

3 committee of the Senate to which a joint resolu4 tion introduced under paragraph (1) is referred 

5 shall report such joint resolution to the Senate 

6 within 50 legislative days. If a committee fails 

7 to report such joint resolution at the close of 

8 the 15th legislative day after its receipt by the 

9 Senate, such committee shall be automatically 

10 discharged from further consideration of such 

11 joint resolution and such joint resolution or 

12 joint resolutions shall be placed on the calendar. 

13 A vote on final passage of such joint resolution 

14 shall be taken in the Senate on or before the 

15 close of the second legislative day after such 

16 joint resolution is reported by the committee or 

17 committees of the Senate to which it was re18 ferred, or after such committee or committees 

19 have been discharged from further consider20 ation of such joint resolution. 

21 (B) PROCEEDING TO CONSIDERATION.—A 

22 motion in the Senate to proceed to the consider23 ation of a joint resolution shall be privileged 

24 and not debatable. An amendment to such a 

25 motion shall not be in order, nor shall it be in 


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1 order to move to reconsider the vote by which 

2 such a motion is agreed to or disagreed to. 

3 (C) CONSIDERATION.— 

4 (i) Debate in the Senate on a joint 

5 resolution, and all debatable motions and 

6 appeals in connection therewith, shall be 

7 limited to not more than 20 hours. The 

8 time shall be equally divided between, and 

9 controlled by, the majority leader and the 

10 minority leader or their designees. 

11 (ii) Debate in the Senate on any de12 batable motion or appeal in connection 

13 with a joint resolution shall be limited to 

14 not more than 1 hour, to be equally di15 vided between, and controlled by, the 

16 mover and the manager of the resolution, 

17 except that in the event the manager of the 

18 joint resolution is in favor of any such mo19 tion or appeal, the time in opposition 

20 thereto shall be controlled by the minority 

21 leader or a designee. Such leaders, or ei22 ther of them, may, from time under their 

23 control on the passage of a joint resolu24 tion, allot additional time to any Senator 


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1 during the consideration of any debatable 

2 motion or appeal. 

3 (iii) A motion in the Senate to further 

4 limit debate is not debatable. A motion to 

5 recommit a joint resolution is not in order. 

6 (4) RULES RELATING TO SENATE AND HOUSE

7 OF REPRESENTATIVES.— 

8 (A) COORDINATION WITH ACTION BY

9 OTHER HOUSE.—If, before the passage by one 

10 House of a joint resolution of that House, that 

11 House receives from the other House a joint 

12 resolution, then the following procedures shall 

13 apply: 

14 (i) The joint resolution of the other 

15 House shall not be referred to a com16 mittee. 

17 (ii) With respect to the joint resolu18 tion of the House receiving the resolution, 

19 the procedure in that House shall be the 

20 same as if no such joint resolution had 

21 been received from the other House; but 

22 the vote on passage shall be on the joint 

23 resolution of the other House. 

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1 tion in the Senate, the Senate then receives the 

2 companion measure from the House of Rep3 resentatives, the companion measure shall not 

4 be debatable. 

5 (C) RULES OF HOUSE OF REPRESENTA6 TIVES AND SENATE.—This paragraph and the 

7 preceding paragraphs are enacted by Con8 gress— 

9 (i) as an exercise of the rulemaking 

10 power of the Senate and House of Rep11 resentatives, respectively, and as such it is 

12 deemed a part of the rules of each House, 

13 respectively, but applicable only with re14 spect to the procedure to be followed in 

15 that House in the case of a joint resolu16 tion, and it supersedes other rules only to 

17 the extent that it is inconsistent with such 

18 rules; and 

19 (ii) with full recognition of the con20 stitutional right of either House to change 

21 the rules (so far as relating to the proce22 dure of that House) at any time, in the 

23 same manner, and to the same extent as in 

24 the case of any other rule of that House. 

25 (5) DEFINITIONS.—In this section: 


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1 (A) JOINT RESOLUTION.—The term ‘‘joint 

2 resolution’’ means only a joint resolution— 

3 (i) which does not have a preamble; 

4 (ii) the title of which is as follows: 

5 ‘‘Joint resolution disapproving a Medicare 

6 final implementation plan of the Secretary 

7 of Health and Human Services submitted 

8 under section 1160(a) of the Affordable 

9 Health Care for America Act’’; and 

10 (iii) the sole matter after the resolving 

11 clause of which is as follows: ‘‘That the 

12 Congress disapproves the final implementa13 tion plan of the Secretary of Health and 

14 Human Services transmitted to the Con15 gress on—————.’’, the blank space 

16 being filled with the appropriate date. 

17 (B) LEGISLATIVE DAY.—The term ‘‘legis18 lative day’’ means any calendar day excluding 

19 any day on which that House was not in ses20 sion. 

21 (6) BUDGETARY TREATMENT.—For the pur22 poses of consideration of a joint resolution, the 

23 Chairmen of the House of Representatives and Sen24 ate Committees on the Budget shall exclude from 

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1 ure, any such effects that are directly attributable to 

2 disapproving a Medicare final implementation plan 

3 of the Secretary submitted under subsection (a). 

4 Subtitle D—Medicare Advantage 

5 Reforms 

6 PART 1—PAYMENT AND ADMINISTRATION 

7 SEC. 1161. PHASE-IN OF PAYMENT BASED ON FEE-FOR8 SERVICE COSTS; QUALITY BONUS PAYMENTS. 

9 (a) PHASE-IN OF PAYMENT BASED ON FEE-FOR10 SERVICE COSTS.—Section 1853 of the Social Security Act 

11 (42 U.S.C. 1395w–23) is amended— 

12 (1) in subsection (j)(1)(A)— 

13 (A) by striking ‘‘beginning with 2007’’ and 

14 inserting ‘‘for 2007, 2008, 2009, and 2010’’; 

15 and 

16 (B) by inserting after ‘‘(k)(1)’’ the following: ‘‘, or, beginning with 2011, 1 17 ⁄12 of the 

18 blended benchmark amount determined under 

19 subsection (n)(1)’’; and 

20 (2) by adding at the end the following new sub21 section: 

22 ‘‘(n) DETERMINATION OF BLENDED BENCHMARK

23 AMOUNT.— 


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1 ‘‘(1) IN GENERAL.—For purposes of subsection 

2 (j), subject to paragraphs (3) and (4), the term 

3 ‘blended benchmark amount’ means for an area— 

4 ‘‘(A) for 2011 the sum of— 

‘‘(i) 2 5 ⁄3 of the applicable amount (as 

6 defined in subsection (k)) for the area and 

7 year; and 

‘‘(ii) 1 8 ⁄3 of the amount specified in 

9 paragraph (2) for the area and year; 

10 ‘‘(B) for 2012 the sum of— 

‘‘(i) 1 11 ⁄3 of the applicable amount for 

12 the area and year; and 

‘‘(ii) 2 13 ⁄3 of the amount specified in 

14 paragraph (2) for the area and year; and 

15 ‘‘(C) for a subsequent year the amount 

16 specified in paragraph (2) for the area and 

17 year. 

18 ‘‘(2) SPECIFIED AMOUNT.—The amount speci19 fied in this paragraph for an area and year is the 

20 amount specified in subsection (c)(1)(D)(i) for the 

21 area and year adjusted (in a manner specified by the 

22 Secretary) to take into account the phase-out in the 

23 indirect costs of medical education from capitation 

24 rates described in subsection (k)(4). 


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1 ‘‘(3) FEE-FOR-SERVICE PAYMENT FLOOR.—In 

2 no case shall the blended benchmark amount for an 

3 area and year be less than the amount specified in 

4 paragraph (2). 

5 ‘‘(4) EXCEPTION FOR PACE PLANS.—This sub6 section shall not apply to payments to a PACE pro7 gram under section 1894.’’. 

8 (b) QUALITY BONUS PAYMENTS.—Section 1853 of 

9 the Social Security Act (42 U.S.C. 1395w-23), as amend10 ed by subsection (a), is amended— 

11 (1) in subsection (j), by inserting ‘‘subject to 

12 subsection (o),’’ after ‘‘For purposes of this part,’’; 

13 and 

14 (2) by adding at the end the following new sub15 section: 

16 ‘‘(o) QUALITY BASED PAYMENT ADJUSTMENT.— 

17 ‘‘(1) IN GENERAL.—In the case of a qualifying 

18 plan in a qualifying county with respect to a year 

19 beginning with 2011, the blended benchmark 

20 amount under subsection (n)(1) shall be increased— 

21 ‘‘(A) for 2011, by 1.5 percent; 

22 ‘‘(B) for 2012, by 3.0 percent; and 

23 ‘‘(C) for a subsequent year, by 5.0 percent. 

24 ‘‘(2) QUALIFYING PLAN AND QUALIFYING

25 COUNTY DEFINED.—For purposes of this subsection: 


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1 ‘‘(A) QUALIFYING PLAN.—The term ‘quali2 fying plan’ means, for a year and subject to 

3 paragraph (4), a plan that, in a preceding year 

4 specified by the Secretary, had a quality rank5 ing (based on the quality ranking system estab6 lished by the Centers for Medicare & Medicaid 

7 Services for Medicare Advantage plans) of 4 

8 stars or higher. 

9 ‘‘(B) QUALIFYING COUNTY.—The term 

10 ‘qualifying county’ means, for a year, a coun11 ty— 

12 ‘‘(i) that ranked within the lowest 

13 third of counties in the amount specified in 

14 subsection (n)(2) for a year specified by 

15 the Secretary; and 

16 ‘‘(ii) for which, as of June of a year 

17 specified by the Secretary, of the Medicare 

18 Advantage eligible individuals residing in 

19 the county at least 20 percent of such indi20 viduals were enrolled in Medicare Advan21 tage plans. 

22 ‘‘(3) DETERMINATIONS OF QUALITY.— 

23 ‘‘(A) QUALITY PERFORMANCE.—The Sec24 retary shall provide for the computation of a 


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1 quality performance score for each Medicare 

2 Advantage plan to be applied for each year. 

3 ‘‘(B) COMPUTATION OF SCORE.— 

4 ‘‘(i) QUALITY PERFORMANCE SORE.— 

5 For years before a year specified by the 

6 Secretary, the quality performance score 

7 for a Medicare Advantage plan shall be 

8 computed based on a blend (as designated 

9 by the Secretary) of the plan’s perform10 ance on— 

11 ‘‘(I) HEDIS effectiveness of care 

12 quality measures; 

13 ‘‘(II) CAHPS quality measures; 

14 and 

15 ‘‘(III) such other measures of 

16 clinical quality as the Secretary may 

17 specify. 

18 Such measures shall be risk-adjusted as 

19 the Secretary deems appropriate. 

20 ‘‘(ii) ESTABLISHMENT OF OUTCOME21 BASED MEASURES.—By not later than for 

22 a year specified by the Secretary, the Sec23 retary shall implement reporting require24 ments for quality under this section on 

25 measures selected under clause (iii) that 


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1 reflect the outcomes of care experienced by 

2 individuals enrolled in Medicare Advantage 

3 plans (in addition to measures described in 

4 clause (i)). Such measures may include— 

5 ‘‘(I) measures of rates of admis6 sion and readmission to a hospital; 

7 ‘‘(II) measures of prevention 

8 quality, such as those established by 

9 the Agency for Healthcare Research 

10 and Quality (that include hospital ad11 mission rates for specified conditions); 

12 ‘‘(III) measures of patient mor13 tality and morbidity following surgery; 

14 ‘‘(IV) measures of health func15 tioning (such as limitations on activi16 ties of daily living) and survival for 

17 patients with chronic diseases; 

18 ‘‘(V) measures of patient safety; 

19 and 

20 ‘‘(VI) other measure of outcomes 

21 and patient quality of life as deter22 mined by the Secretary. 

23 Such measures shall be risk-adjusted as 

24 the Secretary deems appropriate. In deter25 mining the quality measures to be used 


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1 under this clause, the Secretary shall take 

2 into consideration the recommendations of 

3 the Medicare Payment Advisory Commis4 sion in its report to Congress under section 

5 168 of the Medicare Improvements for Pa6 tients and Providers Act of 2008 (Public 

7 Law 110–275) and shall provide pref8 erence to measures collected on and com9 parable to measures used in measuring 

10 quality under parts A and B. 

11 ‘‘(iii) RULES FOR SELECTION OF

12 MEASURES.—The Secretary shall select 

13 measures for purposes of clause (ii) con14 sistent with the following: 

15 ‘‘(I) The Secretary shall provide 

16 preference to clinical quality measures 

17 that have been endorsed by the entity 

18 with a contract with the Secretary 

19 under section 1890(a). 

20 ‘‘(II) Prior to any measure being 

21 selected under this clause, the Sec22 retary shall publish in the Federal 

23 Register such measure and provide for 

24 a period of public comment on such 

25 measure. 


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1 ‘‘(iv) TRANSITIONAL USE OF

2 BLEND.—For payments for years specified 

3 by the Secretary, the Secretary may com4 pute the quality performance score for a 

5 Medicare Advantage plan based on a blend 

6 of the measures specified in clause (i) and 

7 the measures described in clause (ii) and 

8 selected under clause (iii). 

9 ‘‘(v) USE OF QUALITY OUTCOMES

10 MEASURES.—For payments beginning with 

11 a year specified by the Secretary (begin12 ning after the years specified for section 

13 (iv)), the preponderance of measures used 

14 under this paragraph shall be quality out15 comes measures described in clause (ii) 

16 and selected under clause (iii). 

17 ‘‘(C) REPORTING OF DATA.—Each Medi18 care Advantage organization shall provide for 

19 the reporting to the Secretary of quality per20 formance data described in this paragraph (in 

21 order to determine a quality performance score 

22 under this paragraph) in such time and manner 

23 as the Secretary shall specify. 

24 ‘‘(4) NOTIFICATION.—The Secretary, in the an25 nual announcement required under subsection 


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1 (b)(1)(B) in 2010 and each succeeding year, shall 

2 notify the Medicare Advantage organization that is 

3 offering a qualifying plan in a qualifying county of 

4 such identification for the year. The Secretary shall 

5 provide for publication on the website for the Medi6 care program of the information described in the 

7 previous sentence. 

8 ‘‘(5) AUTHORITY TO DISQUALIFY DEFICIENT

9 PLANS.—The Secretary may determine that a Medi10 care Advantage plan is not a qualifying plan if the 

11 Secretary has identified deficiencies in the plan’s 

12 compliance with rules for Medicare Advantage plans 

13 under this part.’’. 

14 SEC. 1162. AUTHORITY FOR SECRETARIAL CODING INTEN15 SITY ADJUSTMENT AUTHORITY. 

16 Section 1853(a)(1)(C)(ii) of the Social Security Act 

17 (42 U.S.C. 1395w–23(a)(1)(C)(ii) is amended— 

18 (1) in the matter before subclause (I), by strik19 ing ‘‘through 2010’’ and inserting ‘‘and each subse20 quent year’’; and 

21 (2) in subclause (II)— 

22 (A) by inserting ‘‘periodically’’ before ‘‘con23 duct an analysis’’; 

24 (B) by inserting ‘‘on a timely basis’’ after 

25 ‘‘are incorporated’’; and 


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1 (C) by striking ‘‘only for 2008, 2009, and 

2 2010’’ and inserting ‘‘for 2008 and subsequent 

3 years’’. 

4 SEC. 1163. SIMPLIFICATION OF ANNUAL BENEFICIARY 

5 ELECTION PERIODS. 

6 (a) 2 WEEK PROCESSING PERIOD FOR ANNUAL EN7 ROLLMENT PERIOD (AEP).—Paragraph (3)(B) of section 

8 1851(e) of the Social Security Act (42 U.S.C. 1395w– 

9 21(e)) is amended— 

10 (1) by striking ‘‘and’’ at the end of clause (iii); 

11 (2) in clause (iv)— 

12 (A) by striking ‘‘and succeeding years’’ 

13 and inserting ‘‘, 2008, 2009, and 2010’’; and 

14 (B) by striking the period at the end and 

15 inserting ‘‘; and’’; and 

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

17 clause: 

18 ‘‘(v) with respect to 2011 and suc19 ceeding years, the period beginning on No20 vember 1 and ending on December 15 of 

21 the year before such year.’’. 

22 (b) ELIMINATION OF 3-MONTH ADDITIONAL OPEN

23 ENROLLMENT PERIOD (OEP).—Effective for plan years 

24 beginning with 2011, paragraph (2) of such section is 

25 amended by striking subparagraph (C). 


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1 SEC. 1164. EXTENSION OF REASONABLE COST CONTRACTS. 

2 Section 1876(h)(5)(C) of the Social Security Act (42 

3 U.S.C. 1395mm(h)(5)(C)) is amended— 

4 (1) in clause (ii), by striking ‘‘January 1, 

5 2010’’ and inserting ‘‘January 1, 2012’’; and 

6 (2) in clause (iii), by striking ‘‘the service area 

7 for the year’’ and inserting ‘‘the portion of the 

8 plan’s service area for the year that is within the 

9 service area of a reasonable cost reimbursement con10 tract’’. 

11 SEC. 1165. LIMITATION OF WAIVER AUTHORITY FOR EM12 PLOYER GROUP PLANS. 

13 (a) IN GENERAL.—The first sentence of each of para14 graphs (1) and (2) of section 1857(i) of the Social Secu15 rity Act (42 U.S.C. 1395w–27(i)) is amended by inserting 

16 before the period at the end the following: ‘‘, but only if 

17 90 percent of the Medicare Advantage eligible individuals 

18 enrolled under such plan reside in a county in which the 

19 MA organization offers an MA local plan’’. 

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

21 subsection (a) shall apply for plan years beginning on or 

22 after January 1, 2011, and shall not apply to plans which 

23 were in effect as of December 31, 2010. 

24 SEC. 1166. IMPROVING RISK ADJUSTMENT FOR PAYMENTS. 

25 (a) REPORT TO CONGRESS.—Not later than 1 year 

26 after the date of the enactment of this Act, the Secretary 


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1 of Health and Human Services shall submit to Congress 

2 a report that evaluates the adequacy of the risk adjust3 ment system under section 1853(a)(1)(C) of the Social Se4 curity Act (42 U.S.C. 1395–23(a)(1)(C)) in predicting 

5 costs for beneficiaries with chronic or co-morbid condi6 tions, beneficiaries dually-eligible for Medicare and Med7 icaid, and non-Medicaid eligible low-income beneficiaries; 

8 and the need and feasibility of including further grada9 tions of diseases or conditions and multiple years of bene10 ficiary data. 

11 (b) IMPROVEMENTS TO RISK ADJUSTMENT.—Not 

12 later than January 1, 2012, the Secretary shall implement 

13 necessary improvements to the risk adjustment system 

14 under section 1853(a)(1)(C) of the Social Security Act (42 

15 U.S.C. 1395–23(a)(1)(C)), taking into account the evalua16 tion under subsection (a). 

17 SEC. 1167. ELIMINATION OF MA REGIONAL PLAN STA18 BILIZATION FUND. 

19 (a) IN GENERAL.—Section 1858 of the Social Secu20 rity Act (42 U.S.C. 1395w–27a) is amended by striking 

21 subsection (e). 

22 (b) TRANSITION.—Any amount contained in the MA 

23 Regional Plan Stabilization Fund as of the date of the 

24 enactment of this Act shall be transferred to the Federal 

25 Supplementary Medical Insurance Trust Fund. 


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1 SEC. 1168. STUDY REGARDING THE EFFECTS OF CALCU2 LATING MEDICARE ADVANTAGE PAYMENT 

3 RATES ON A REGIONAL AVERAGE OF MEDI4 CARE FEE FOR SERVICE RATES. 

5 (a) IN GENERAL.—The Administrator of the Centers 

6 for Medicare and Medicaid Services shall conduct a study 

7 to determine the potential effects of calculating Medicare 

8 Advantage payment rates on a more aggregated geo9 graphic basis (such as metropolitan statistical areas or 

10 other regional delineations) rather than using county 

11 boundaries. In conducting such study, the Administrator 

12 shall consider the effect of such alternative geographic 

13 basis on the following: 

14 (1) The quality of care received by Medicare 

15 Advantage enrollees. 

16 (2) The networks of Medicare Advantage plans, 

17 including any implications for providers contracting 

18 with Medicare Advantage plans. 

19 (3) The predictability of benchmark amounts 

20 for Medicare advantage plans. 

21 (b) CONSULTATIONS.—In conducting the study, the 

22 Administrator shall consult with the following: 

23 (1) Experts in health care financing. 

24 (2) Representatives of foundations and other 

25 nonprofit entities that have conducted or supported 

26 research on Medicare financing issues. 


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1 (3) Representatives from Medicare Advantage 

2 plans. 

3 (4) Such other entities or people as determined 

4 by the Secretary. 

5 (c) REPORT.—Not later than one year after the date 

6 of the enactment of this Act, the Administrator shall 

7 transmit a report to the Congress on the study conducted 

8 under this section. The report shall contain a detailed 

9 statement of findings and conclusions of the study, to10 gether with its recommendations for such legislation and 

11 administrative actions as the Administrator considers ap12 propriate. 

13 PART 2—BENEFICIARY PROTECTIONS AND ANTI14 FRAUD 

15 SEC. 1171. LIMITATION ON COST-SHARING FOR INDIVIDUAL 

16 HEALTH SERVICES. 

17 (a) IN GENERAL.—Section 1852(a)(1) of the Social 

18 Security Act (42 U.S.C. 1395w–22(a)(1)) is amended— 

19 (1) in subparagraph (A), by inserting before the 

20 period at the end the following: ‘‘with cost-sharing 

21 that is no greater (and may be less) than the cost22 sharing that would otherwise be imposed under such 

23 program option’’; 


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1 (2) in subparagraph (B)(i), by striking ‘‘or an 

2 actuarially equivalent level of cost-sharing as deter3 mined in this part’’; and 

4 (3) by amending clause (ii) of subparagraph 

5 (B) to read as follows: 

6 ‘‘(ii) PERMITTING USE OF FLAT CO7 PAYMENT OR PER DIEM RATE.—Nothing in 

8 clause (i) shall be construed as prohibiting 

9 a Medicare Advantage plan from using a 

10 flat copayment or per diem rate, in lieu of 

11 the cost-sharing that would be imposed 

12 under part A or B, so long as the amount 

13 of the cost-sharing imposed does not ex14 ceed the amount of the cost-sharing that 

15 would be imposed under the respective part 

16 if the individual were not enrolled in a plan 

17 under this part.’’. 

18 (b) LIMITATION FOR DUAL ELIGIBLES AND QUALI19 FIED MEDICARE BENEFICIARIES.—Section 1852(a)(7) of 

20 such Act is amended to read as follows: 

21 ‘‘(7) LIMITATION ON COST-SHARING FOR DUAL

22 ELIGIBLES AND QUALIFIED MEDICARE BENE23 FICIARIES.—In the case of a individual who is a full24 benefit dual eligible individual (as defined in section 

25 1935(c)(6)) or a qualified medicare beneficiary (as 


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1 defined in section 1905(p)(1)) who is enrolled in a 

2 Medicare Advantage plan, the plan may not impose 

3 cost-sharing that exceeds the amount of cost-sharing 

4 that would be permitted with respect to the indi5 vidual under this title and title XIX if the individual 

6 were not enrolled with such plan.’’. 

7 (c) EFFECTIVE DATES.— 

8 (1) The amendments made by subsection (a) 

9 shall apply to plan years beginning on or after Janu10 ary 1, 2011. 

11 (2) The amendments made by subsection (b) 

12 shall apply to plan years beginning on or after Janu13 ary 1, 2011. 

14 SEC. 1172. CONTINUOUS OPEN ENROLLMENT FOR ENROLL15 EES IN PLANS WITH ENROLLMENT SUSPEN16 SION. 

17 Section 1851(e)(4) of the Social Security Act (42 

18 U.S.C. 1395w(e)(4)) is amended— 

19 (1) in subparagraph (C), by striking at the end 

20 ‘‘or’’; 

21 (2) in subparagraph (D)— 

22 (A) by inserting ‘‘, taking into account the 

23 health or well-being of the individual’’ before 

24 the period; and 


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1 (B) by redesignating such subparagraph as 

2 subparagraph (E); and 

3 (3) by inserting after subparagraph (C) the fol4 lowing new subparagraph: 

5 ‘‘(D) the individual is enrolled in an MA 

6 plan and enrollment in the plan is suspended 

7 under paragraph (2)(B) or (3)(C) of section 

8 1857(g) because of a failure of the plan to meet 

9 applicable requirements; or’’. 

10 SEC. 1173. INFORMATION FOR BENEFICIARIES ON MA PLAN 

11 ADMINISTRATIVE COSTS. 

12 (a) DISCLOSURE OF MEDICAL LOSS RATIOS AND

13 OTHER EXPENSE DATA.—Section 1851 of the Social Se14 curity Act (42 U.S.C. 1395w–21), as previously amended 

15 by this subtitle, is amended by adding at the end the fol16 lowing new subsection: 

17 ‘‘(p) PUBLICATION OF MEDICAL LOSS RATIOS AND

18 OTHER COST-RELATED INFORMATION.— 

19 ‘‘(1) IN GENERAL.—The Secretary shall pub20 lish, not later than November 1 of each year (begin21 ning with 2011), for each MA plan contract, the 

22 medical loss ratio of the plan in the previous year. 

23 ‘‘(2) SUBMISSION OF DATA.— 

24 ‘‘(A) IN GENERAL.—Each MA organization 

25 shall submit to the Secretary, in a form and 


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1 manner specified by the Secretary, data nec2 essary for the Secretary to publish the medical 

3 loss ratio on a timely basis. 

4 ‘‘(B) DATA FOR 2010 AND 2011.—The data 

5 submitted under subparagraph (A) for 2010 

6 and for 2011 shall be consistent in content with 

7 the data reported as part of the MA plan bid 

8 in June 2009 for 2010. 

9 ‘‘(C) USE OF STANDARDIZED ELEMENTS

10 AND DEFINITIONS.—The data to be submitted 

11 under subparagraph (A) relating to medical loss 

12 ratio for a year, beginning with 2012, shall be 

13 submitted based on the standardized elements 

14 and definitions developed under paragraph (3). 

15 ‘‘(3) DEVELOPMENT OF DATA REPORTING

16 STANDARDS.— 

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

18 develop and implement standardized data ele19 ments and definitions for reporting under this 

20 subsection, for contract years beginning with 

21 2012, of data necessary for the calculation of 

22 the medical loss ratio for MA plans. Not later 

23 than December 31, 2010, the Secretary shall 

24 publish a report describing the elements and 

25 definitions so developed. 


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1 ‘‘(B) CONSULTATION.—The Secretary 

2 shall consult with the Health Choices Commis3 sioner, representatives of MA organizations, ex4 perts on health plan accounting systems, and 

5 representatives of the National Association of 

6 Insurance Commissioners, in the development 

7 of such data elements and definitions. 

8 ‘‘(4) MEDICAL LOSS RATIO TO BE DEFINED.— 

9 For purposes of this part, the term ‘medical loss 

10 ratio’ has the meaning given such term by the Sec11 retary, taking into account the meaning given such 

12 term by the Health Choices Commissioner under 

13 section 116 of the Affordable Health Care for Amer14 ica Act.’’. 

15 (b) MINIMUM MEDICAL LOSS RATIO.—Section 

16 1857(e) of the Social Security Act (42 U.S.C. 1395w– 

17 27(e)) is amended by adding at the end the following new 

18 paragraph: 

19 ‘‘(4) REQUIREMENT FOR MINIMUM MEDICAL

20 LOSS RATIO.—If the Secretary determines for a con21 tract year (beginning with 2014) that an MA plan 

22 has failed to have a medical loss ratio (as defined in 

23 section 1851(p)(4)) of at least .85— 

24 ‘‘(A) the Secretary shall require the Medi25 care Advantage organization offering the plan 


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1 to give enrollees a rebate (in the second suc2 ceeding contract year) of premiums under this 

3 part (or part B or part D, if applicable) by 

4 such amount as would provide for a benefits 

5 ratio of at least .85; 

6 ‘‘(B) for 3 consecutive contract years, the 

7 Secretary shall not permit the enrollment of 

8 new enrollees under the plan for coverage dur9 ing the second succeeding contract year; and 

10 ‘‘(C) the Secretary shall terminate the plan 

11 contract if the plan fails to have such a medical 

12 loss ratio for 5 consecutive contract years.’’. 

13 SEC. 1174. STRENGTHENING AUDIT AUTHORITY. 

14 (a) FOR PART C PAYMENTS RISK ADJUSTMENT.— 

15 Section 1857(d)(1) of the Social Security Act (42 U.S.C. 

16 1395w–27(d)(1)) is amended by inserting after ‘‘section 

17 1858(c))’’ the following: ‘‘, and data submitted with re18 spect to risk adjustment under section 1853(a)(3)’’. 

19 (b) ENFORCEMENT OF AUDITS AND DEFI20 CIENCIES.— 

21 (1) IN GENERAL.—Section 1857(e) of such Act, 

22 as amended by section 1173, is amended by adding 

23 at the end the following new paragraph: 

24 ‘‘(5) ENFORCEMENT OF AUDITS AND DEFI25 CIENCIES.— 


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1 ‘‘(A) INFORMATION IN CONTRACT.—The 

2 Secretary shall require that each contract with 

3 an MA organization under this section shall in4 clude terms that inform the organization of the 

5 provisions in subsection (d). 

6 ‘‘(B) ENFORCEMENT AUTHORITY.—The 

7 Secretary is authorized, in connection with con8 ducting audits and other activities under sub9 section (d), to take such actions, including pur10 suit of financial recoveries, necessary to address 

11 deficiencies identified in such audits or other 

12 activities.’’. 

13 (2) APPLICATION UNDER PART D.—For provi14 sion applying the amendment made by paragraph 

15 (1) to prescription drug plans under part D, see sec16 tion 1860D–12(b)(3)(D) of the Social Security Act. 

17 (c) EFFECTIVE DATE.—The amendments made by 

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

19 of this Act and shall apply to audits and activities con20 ducted for contract years beginning on or after January 

21 1, 2011. 

22 SEC. 1175. AUTHORITY TO DENY PLAN BIDS. 

23 (a) IN GENERAL.—Section 1854(a)(5) of the Social 

24 Security Act (42 U.S.C. 1395w–24(a)(5)) is amended by 

25 adding at the end the following new subparagraph: 


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1 ‘‘(C) REJECTION OF BIDS.—Nothing in 

2 this section shall be construed as requiring the 

3 Secretary to accept any or every bid by an MA 

4 organization under this subsection.’’. 

5 (b) APPLICATION UNDER PART D.—Section 1860D– 

6 11(d) of such Act (42 U.S.C. 1395w–111(d)) is amended 

7 by adding at the end the following new paragraph: 

8 ‘‘(3) REJECTION OF BIDS.—Paragraph (5)(C) 

9 of section 1854(a) shall apply with respect to bids 

10 under this section in the same manner as it applies 

11 to bids by an MA organization under such section.’’. 

12 (c) EFFECTIVE DATE.—The amendments made by 

13 this section shall apply to bids for contract years begin14 ning on or after January 1, 2011. 

15 SEC. 1175A. STATE AUTHORITY TO ENFORCE STANDARD16 IZED MARKETING REQUIREMENTS. 

17 Section 1856(b)(3) of the Social Security Act (42 

18 U.S.C. 1395w–26(b)(3)) is amended— 

19 (1) by striking ‘‘The standards’’ and inserting 

20 ‘‘(A) IN GENERAL.—The standards’’ with appro21 priate indentation that is the same as for the sub22 paragraph (B) added by paragraph (2); and 

23 (2) by adding at the end the following new sub24 paragraph: 


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1 ‘‘(B) ENFORCEMENT OF FEDERAL STAND2 ARDS PERMITTED.— 

3 ‘‘(i) IN GENERAL.—Subject to the 

4 subsequent provision of this subparagraph, 

5 nothing in this title shall be construed to 

6 prohibit a State from conducting a market 

7 conduct examination or from imposing civil 

8 monetary penalties, in accordance with 

9 laws and procedures of the State, against 

10 Medicare Advantage organizations, PDP 

11 sponsors, or agents or brokers of such or12 ganizations or sponsors for violations of 

13 the marketing requirements under sub14 sections (h)(4), (h)(6), and (j) of section 

15 1851 and section 1857(g)(1)(E). 

16 ‘‘(ii) ADDITIONAL REMEDIES RESULT17 ING FROM FEDERAL-STATE COOPERA18 TION.— 

19 ‘‘(I) STATE RECOMMENDA20 TION.—A State may recommend to 

21 the Secretary the imposition of an in22 termediate sanction not described in 

23 clause (i) (such as those available 

24 under section 1857(g)) against a 

25 Medicare Advantage organization, 


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1 PDP sponsor, or agent or broker of 

2 such an organization or sponsor for a 

3 violation described in such clause. 

4 ‘‘(II) RESPONSE TO REC5 OMMENDATION.—Not later than 30 

6 days after receipt of a recommenda7 tion under subclause (I) from a State, 

8 with respect to a violation described in 

9 clause (i), the Secretary shall respond 

10 in writing to the State indicating the 

11 progress of any investigation involving 

12 such violation, whether the Secretary 

13 intends to pursue the recommendation 

14 from the State, and in the case the 

15 Secretary does not intend to pursue 

16 such recommendation, the reason for 

17 such decision. 

18 ‘‘(iii) NON-DUPLICATION OF PEN19 ALTIES.—In the case that an action has 

20 been initiated against a Medicare Advan21 tage organization, PDP sponsor, or agent 

22 or broker of such an organization or spon23 sor for a violation of a marketing require24 ment under subsection (h)(4), (h)(6), or (j) 

25 of section 1851 or section 1857(g)(1)(E)— 


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1 ‘‘(I) in the case such action has 

2 been initiated by the Secretary, no 

3 State may bring an action under such 

4 applicable subsection or section 

5 against such organization, sponsor, 

6 agent, or broker with respect to such 

7 violation during the pendency period 

8 of the action initiated by the Sec9 retary and, if a penalty is imposed 

10 pursuant to such action, after such 

11 period; and 

12 ‘‘(II) in the case such action has 

13 been initiated by a State, the Sec14 retary may not bring an action under 

15 such applicable subsection or section 

16 against such organization, sponsor, 

17 agent, or broker with respect to such 

18 violation during the pendency period 

19 of the action initiated by the Sec20 retary and, if a penalty is imposed 

21 pursuant to such action, after such 

22 period. 

23 Nothing in this clause shall be construed 

24 as limiting the ability of the Secretary to 

25 impose any sanction other than a civil 


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1 monetary penalty under section 1857 

2 against a Medicare Advantage organiza3 tion, PDP sponsor, or agent or broker of 

4 such an organization or sponsor for a vio5 lation described in clause (i). 

6 ‘‘(iv) CONSTRUCTION.—Nothing in 

7 this subparagraph shall be construed as af8 fecting any State authority to regulate bro9 kers described in this paragraph or any 

10 other conduct of a Medicare Advantage or11 ganization or PDP sponsor.’’. 

12 PART 3—TREATMENT OF SPECIAL NEEDS PLANS 

13 SEC. 1176. LIMITATION ON ENROLLMENT OUTSIDE OPEN 

14 ENROLLMENT PERIOD OF INDIVIDUALS INTO 

15 CHRONIC CARE SPECIALIZED MA PLANS FOR 

16 SPECIAL NEEDS INDIVIDUALS. 

17 Section 1859(f)(4) of the Social Security Act (42 

18 U.S.C. 1395w–28(f)(4)) is amended by adding at the end 

19 the following new subparagraph: 

20 ‘‘(C) The plan does not enroll an individual 

21 on or after January 1, 2011, other than— 

22 ‘‘(i) during an annual, coordinated 

23 open enrollment period; or 

24 ‘‘(ii) during a special election period 

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1 vidual has a chronic condition that quali2 fies the individual as an individual de3 scribed in subsection (b)(6)(B)(iii) for such 

4 plan and ending on the date on which the 

5 individual enrolls in such a plan on the 

6 basis of such condition. 

7 If an individual is enrolled in such a plan on 

8 the basis of a chronic condition and becomes el9 igible for another such plan on the basis of an10 other chronic condition, the other plan may en11 roll the individual on the basis of such other 

12 chronic condition during a special enrollment 

13 period described in clause (ii). An individual is 

14 eligible to apply such clause only once on the 

15 basis of any specific chronic condition.’’. 

16 SEC. 1177. EXTENSION OF AUTHORITY OF SPECIAL NEEDS 

17 PLANS TO RESTRICT ENROLLMENT; SERVICE 

18 AREA MORATORIUM FOR CERTAIN SNPS. 

19 (a) IN GENERAL.—Section 1859(f)(1) of the Social 

20 Security Act (42 U.S.C. 1395w–28(f)(1)) is amended by 

21 striking ‘‘January 1, 2011’’ and inserting ‘‘January 1, 

22 2013 (or January 1, 2016, in the case of a plan described 

23 in section 1177(b)(1) of the Affordable Health Care for 

24 America Act)’’. 

25 (b) EXTENSION OF CERTAIN PLANS.— 


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1 (1) PLANS DESCRIBED.—For purposes of Sec2 tion 1859(f)(1) of the Social Security Act (42 

3 U.S.C. 1395w-28(f)(1)), a plan described in this 

4 paragraph is a Medicare Advantage dual eligible spe5 cial needs plan that— 

6 (A) whose sponsoring Medicare Advantage 

7 organization, as of the date enactment of the 

8 Affordable Health Care for America Act, has a 

9 contract with a State Medicaid Agency that 

10 participated in the ‘‘Demonstrations Serving 

11 Those Dually-Eligible for Medicare and Med12 icaid’’ under the Medicare program; and 

13 (B) that has been approved by the Centers 

14 for Medicare & Medicaid Services as a dual eli15 gible special needs plan and that offers inte16 grated Medicare and Medicaid services under a 

17 contract with the State Medicaid agency. 

18 (2) ANALYSIS; REPORT.— 

19 (A) ANALYSIS.—The Secretary of Health 

20 and Human Services shall provide, through a 

21 contract with an independent health services 

22 evaluation organization, for an analysis of the 

23 plans described in paragraph (1) with regard to 

24 the impact of such plans on cost, quality of 

25 care, patient satisfaction, and other subjects 


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1 specified by the Secretary. Such report also will 

2 identify statutory changes needed to simplify 

3 access to needed services, improve coordination 

4 of benefits and services and ensure protection 

5 for dual eligibles as appropriate. 

6 (B) REPORT.—Not later than December 

7 31, 2011, the Secretary shall submit to the 

8 Congress a report on the analysis under sub9 paragraph (A) and shall include in such report 

10 such recommendations with regard to the treat11 ment of such plans as the Secretary deems ap12 propriate. 

13 (c) EXTENSION OF SERVICE AREA MORATORIUM FOR

14 CERTAIN SNPS.—Section 164(c)(2) of the Medicare Im15 provements for Patients and Providers Act of 2008 is 

16 amended by striking ‘‘December 31, 2010’’ and inserting 

17 ‘‘December 31, 2012’’. 

18 SEC. 1178. EXTENSION OF MEDICARE SENIOR HOUSING 

19 PLANS. 

20 Section 1859 of the Social Security Act (42 U.S.C. 

21 1395w-28) is amended by adding at the end the following 

22 new subsection: 

23 ‘‘(g) SPECIAL RULES FOR SENIOR HOUSING FACIL24 ITY PLANS.— 


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1 ‘‘(1) IN GENERAL.—Notwithstanding any other 

2 provision of this part, in the case of a Medicare Ad3 vantage senior housing facility plan described in 

4 paragraph (2) and for periods before January 1, 

5 2013— 

6 ‘‘(A) the service area of such plan may be 

7 limited to a senior housing facility in a geo8 graphic area; 

9 ‘‘(B) the service area of such plan may not 

10 be expanded; and 

11 ‘‘(C) additional senior housing facilities 

12 may not be serviced by such plan. 

13 ‘‘(2) MEDICARE ADVANTAGE SENIOR HOUSING

14 FACILITY PLAN DESCRIBED.—For purposes of this 

15 subsection, a Medicare Advantage senior housing fa16 cility plan is a Medicare Advantage plan that— 

17 ‘‘(A)(i) restricts enrollment of individuals 

18 under this part to individuals who reside in a 

19 continuing care retirement community (as de20 fined in section 1852(l)(4)(B)); 

21 ‘‘(ii) provides primary care services onsite 

22 and has a ratio of accessible providers to bene23 ficiaries that the Secretary determines is ade24 quate, taking into consideration the number of 

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1 dents, and the accessibility of providers offsite; 

2 and 

3 ‘‘(iii) provides transportation services for 

4 beneficiaries to providers outside of the facility; 

5 and 

6 ‘‘(B) is offered by a Medicare Advantage 

7 organization that has offered at least 1 plan de8 scribed in subparagraph (A) for at least 1 year 

9 prior to January 1, 2010, under a demonstra10 tion project established by the Secretary.’’. 

11 Subtitle E—Improvements to 

12 Medicare Part D 

13 SEC. 1181. ELIMINATION OF COVERAGE GAP. 

14 (a) IMMEDIATE REDUCTION IN COVERAGE GAP IN

15 2010.—Section 1860D–2(b) of the Social Security Act 

16 (42 U.S.C. 1395w–102(b)) is amended— 

17 (1) in paragraph (3)(A), by striking ‘‘paragraph 

18 (4)’’ and inserting ‘‘paragraphs (4) and (7)’’; and 

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

20 paragraph: 

21 ‘‘(7) INCREASE IN INITIAL COVERAGE LIMIT IN

22 2010.— 

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1 scribed in paragraph (3)(B) otherwise applica2 ble shall be increased by $500. 

3 ‘‘(B) APPLICATION.—In applying subpara4 graph (A)— 

5 ‘‘(i) except as otherwise provided in 

6 this subparagraph, there shall be no 

7 change in the premiums, bids, or any other 

8 parameters under this part or part C; 

9 ‘‘(ii) costs that would be treated as in10 curred costs for purposes of applying para11 graph (4) but for the application of sub12 paragraph (A) shall continue to be treated 

13 as incurred costs; 

14 ‘‘(iii) the Secretary shall establish pro15 cedures, which may include a reconciliation 

16 process, to fully reimburse PDP sponsors 

17 with respect to prescription drug plans and 

18 MA organizations with respect to MA–PD 

19 plans for the reduction in beneficiary cost 

20 sharing associated with the application of 

21 subparagraph (A); 

22 ‘‘(iv) the Secretary shall develop an 

23 estimate of the additional increased costs 

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1 nancing and administrative costs and shall 

2 use such estimate to adjust payments to 

3 PDP sponsors with respect to prescription 

4 drug plans under this part and MA organi5 zations with respect to MA–PD plans 

6 under part C; and 

7 ‘‘(v) the Secretary shall establish pro8 cedures for retroactive reimbursement of 

9 part D eligible individuals who are covered 

10 under such a plan for costs which are in11 curred before the date of initial implemen12 tation of subparagraph (A) and which 

13 would be reimbursed under such a plan if 

14 such implementation occurred as of Janu15 ary 1, 2010.’’. 

16 (b) ADDITIONAL CLOSURE IN GAP BEGINNING IN

17 2011.—Section 1860D–2(b) of such Act (42 U.S.C. 

18 1395w–102(b)) as amended by subsection (a), is further 

19 amended— 

20 (1) in paragraph (3)(A), by striking ‘‘and (7)’’ 

21 and inserting ‘‘, (7), and (8)’’ ; 

22 (2) in paragraph (4)(B)(i), by inserting ‘‘sub23 ject to paragraph (8)’’ after ‘‘purposes of this part’’; 

24 and 


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

2 paragraph: 

3 ‘‘(8) PHASED-IN ELIMINATION OF COVERAGE

4 GAP.— 

5 ‘‘(A) IN GENERAL.—For each year begin6 ning with 2011, the Secretary shall consistent 

7 with this paragraph progressively increase the 

8 initial coverage limit (described in subsection 

9 (b)(3)) and decrease the annual out-of-pocket 

10 threshold from the amounts otherwise computed 

11 until, beginning in 2019, there is a continuation 

12 of coverage from the initial coverage limit for 

13 expenditures incurred through the total amount 

14 of expenditures at which benefits are available 

15 under paragraph (4). 

16 ‘‘(B) INCREASE IN INITIAL COVERAGE

17 LIMIT.— 

18 ‘‘(i) IN GENERAL.—For a year begin19 ning with 2011, subject to clause (ii), the 

20 initial coverage limit otherwise computed 

21 without regard to this paragraph shall be 

22 increased by the cumulative ICL phase-in 

23 percentage (as defined in clause (iii) for 

24 the year) times the out-of-pocket gap 


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1 amount (as defined in subparagraph (D)) 

2 for the year. 

3 ‘‘(ii) MAINTENANCE OF 2010 INITIAL

4 COVERAGE LIMIT LEVEL.—If for a year the 

5 initial coverage limit otherwise computed 

6 under this paragraph would be less than 

7 the initial coverage limit applied during 

8 2010, taking into account paragraph (7), 

9 the initial coverage limit for that year shall 

10 be such initial coverage limit as so applied 

11 during 2010. 

12 ‘‘(iii) CUMULATIVE PHASE-IN PER13 CENTAGE.— 

14 ‘‘(I) IN GENERAL.—For purposes 

15 of this paragraph, subject to sub16 clause (II), the term ‘cumulative ICL 

17 phase-in percentage’ means for a year 

18 the sum of the annual ICL phase-in 

19 percentage (as defined in clause (iv)) 

20 for the year and the annual ICL 

21 phase-in percentages for each previous 

22 year beginning with 2011. 

23 ‘‘(II) LIMITATION.—If the sum 

24 of the cumulative ICL phase-in per25 centage and the cumulative OPT 


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1 phase-in percentage (as defined in 

2 subparagraph (C)(iii)) for a year 

3 would otherwise exceed 100 percent, 

4 each such percentage shall be reduced 

5 in a proportional amount so the sum 

6 does not exceed 100 percent. 

7 ‘‘(iv) ANNUAL ICL PHASE-IN PER8 CENTAGE.—For purposes of this para9 graph, the term ‘annual ICL phase-in per10 centage’ means— 

11 ‘‘(I) for 2011, 8.25 percent; 

12 ‘‘(II) for 2012, 2013, and 2014, 

13 4.5 percent; 

14 ‘‘(III) for 2015 and 2016, 6 per15 cent; 

16 ‘‘(IV) for 2017, 7.5 percent; 

17 ‘‘(V) for 2018, 8 percent; and 

18 ‘‘(VI) for 2019, 8 percent, or 

19 such other percent as may be nec20 essary to provide for a full continu21 ation of coverage as described in sub22 paragraph (A) in that year. 

23 ‘‘(C) DECREASE IN ANNUAL OUT-OF-POCK24 ET THRESHOLD.— 


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1 ‘‘(i) IN GENERAL.—For a year begin2 ning with 2011, subject to clause (ii), the 

3 annual out-of-pocket threshold otherwise 

4 computed without regard to this paragraph 

5 shall be decreased by the cumulative OPT 

6 phase-in percentage (as defined in clause 

7 (iii) for the year) of the out-of-pocket gap 

8 amount for the year multiplied by 1.75. 

9 ‘‘(ii) MAINTENANCE.—The Secretary 

10 shall adjust the annual out-of-pocket 

11 threshold for a year to the extent nec12 essary to ensure that the sum of the initial 

13 coverage limit described in subparagraph 

14 (A) and the out-of-pocket gap amount (de15 fined in subparagraph (D)), as determined 

16 for the year pursuant to the provisions of 

17 this paragraph for such year, does not ex18 ceed such sum that would have applied if 

19 this paragraph did not apply. 

20 ‘‘(iii) CUMULATIVE OPT PHASE-IN

21 PERCENTAGE.—For purposes of this para22 graph, subject to subparagraph (B)(iii)(II), 

23 the term ‘cumulative OPT phase-in per24 centage’ means for a year the sum of the 

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1 fined in clause (iv)) for the year and the 

2 annual OPT phase-in percentages for each 

3 previous year beginning with 2011. 

4 ‘‘(iv) ANNUAL OPT PHASE-IN PER5 CENTAGE.—For purposes of this para6 graph, the term ‘annual OPT phase-in per7 centage’ means— 

8 ‘‘(I) for 2011, 0 percent; 

9 ‘‘(II) for 2012, 2013, and 2014, 

10 4.5 percent; 

11 ‘‘(III) for 2015 and 2016, 6 per12 cent; 

13 ‘‘(IV) for 2017, 7.5 percent; and 

14 ‘‘(V) for 2018 and 2019, 8 per15 cent. 

16 ‘‘(D) OUT-OF-POCKET GAP AMOUNT.—For 

17 purposes of this paragraph, the term ‘out-of18 pocket gap amount’ means for a year the 

19 amount by which— 

20 ‘‘(i) the annual out-of-pocket thresh21 old specified in paragraph (4)(B) for the 

22 year (as determined as if this paragraph 

23 did not apply), exceeds 

24 ‘‘(ii) the sum of— 


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1 ‘‘(I) the annual deductible under 

2 paragraph (1) for the year; and 

‘‘(II) 1 3 ⁄4 of the amount by which 

4 the initial coverage limit under para5 graph (3) for the year (as determined 

6 as if this paragraph did not apply) ex7 ceeds such annual deductible. 

8 ‘‘(E) RELATION TO AAHCA TRANSITIONAL

9 INCREASE.—Except as otherwise specifically 

10 provided, this paragraph shall be applied as if 

11 no increase had been made in the initial cov12 erage limit under paragraph (7).’’. 

13 (c) REQUIRING DRUG MANUFACTURERS TO PROVIDE

14 DRUG REBATES FOR REBATE ELIGIBLE INDIVIDUALS.— 

15 (1) IN GENERAL.—Section 1860D–2 of the So16 cial Security Act (42 U.S.C. 1395w–102) is amend17 ed— 

18 (A) in subsection (e)(1), in the matter be19 fore subparagraph (A), by inserting ‘‘and sub20 section (f)’’ after ‘‘this subsection’’; and 

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

22 subsection: 

23 ‘‘(f) PRESCRIPTION DRUG REBATE AGREEMENT FOR

24 REBATE ELIGIBLE INDIVIDUALS.— 

25 ‘‘(1) REQUIREMENT.— 


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1 ‘‘(A) IN GENERAL.—For plan years begin2 ning on or after January 1, 2011, in this part, 

3 the term ‘covered part D drug’ does not include 

4 any drug or biological product that is manufac5 tured by a manufacturer that has not entered 

6 into and have in effect a rebate agreement de7 scribed in paragraph (2). 

8 ‘‘(B) 2010 PLAN YEAR REQUIREMENT.— 

9 Any drug or biological product manufactured by 

10 a manufacturer that declines to enter into a re11 bate agreement described in paragraph (2) for 

12 the period beginning on January 1, 2010, and 

13 ending on December 31, 2010, shall not be in14 cluded as a ‘covered part D drug ‘ for the sub15 sequent plan year. 

16 ‘‘(2) REBATE AGREEMENT.—A rebate agree17 ment under this subsection shall require the manu18 facturer to provide to the Secretary a rebate for 

19 each rebate period (as defined in paragraph (6)(B)) 

20 ending after December 31, 2009, in the amount 

21 specified in paragraph (3) for any covered part D 

22 drug of the manufacturer dispensed after December 

23 31, 2009, to any rebate eligible individual (as de24 fined in paragraph (6)(A)) for which payment was 

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1 ganization under part C for such period, including 

2 payments passed through the low-income and rein3 surance subsidies under sections 1860D–14 and 

4 1860D–15(b), respectively. Such rebate shall be paid 

5 by the manufacturer to the Secretary not later than 

6 30 days after the date of receipt of the information 

7 described in section 1860D–12(b)(7), including as 

8 such section is applied under section 1857(f)(3), or 

9 30 days after the receipt of information under sub10 paragraph (D) of paragraph (3), as determined by 

11 the Secretary. Insofar as not inconsistent with this 

12 subsection, the Secretary shall establish terms and 

13 conditions of such agreement relating to compliance, 

14 penalties, and program evaluations, investigations, 

15 and audits that are similar to the terms and condi16 tions for rebate agreements under paragraphs (3) 

17 and (4) of section 1927(b). 

18 ‘‘(3) REBATE FOR REBATE ELIGIBLE MEDICARE

19 DRUG PLAN ENROLLEES.— 

20 ‘‘(A) IN GENERAL.—The amount of the re21 bate specified under this paragraph for a manu22 facturer for a rebate period, with respect to 

23 each dosage form and strength of any covered 

24 part D drug provided by such manufacturer 


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1 and dispensed to a rebate eligible individual, 

2 shall be equal to the product of— 

3 ‘‘(i) the total number of units of such 

4 dosage form and strength of the drug so 

5 provided and dispensed for which payment 

6 was made by a PDP sponsor under part D 

7 or a MA organization under part C for the 

8 rebate period, including payments passed 

9 through the low-income and reinsurance 

10 subsidies under sections 1860D–14 and 

11 1860D–15(b), respectively; and 

12 ‘‘(ii) the amount (if any) by which— 

13 ‘‘(I) the Medicaid rebate amount 

14 (as defined in subparagraph (B)) for 

15 such form, strength, and period, ex16 ceeds 

17 ‘‘(II) the average Medicare drug 

18 program rebate eligible rebate amount 

19 (as defined in subparagraph (C)) for 

20 such form, strength, and period. 

21 ‘‘(B) MEDICAID REBATE AMOUNT.—For 

22 purposes of this paragraph, the term ‘Medicaid 

23 rebate amount’ means, with respect to each 

24 dosage form and strength of a covered part D 


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1 drug provided by the manufacturer for a rebate 

2 period— 

3 ‘‘(i) in the case of a single source 

4 drug or an innovator multiple source drug, 

5 the amount specified in paragraph 

6 (1)(A)(ii) of section 1927(c) plus the 

7 amount, if any, specified in paragraph 

8 (2)(A)(ii) of such section, for such form, 

9 strength, and period; or 

10 ‘‘(ii) in the case of any other covered 

11 outpatient drug, the amount specified in 

12 paragraph (3)(A)(i) of such section for 

13 such form, strength, and period. 

14 ‘‘(C) AVERAGE MEDICARE DRUG PROGRAM

15 REBATE ELIGIBLE REBATE AMOUNT.—For pur16 poses of this subsection, the term ‘average 

17 Medicare drug program rebate eligible rebate 

18 amount’ means, with respect to each dosage 

19 form and strength of a covered part D drug 

20 provided by a manufacturer for a rebate period, 

21 the sum, for all PDP sponsors under part D 

22 and MA organizations administering a MA–PD 

23 plan under part C, of— 

24 ‘‘(i) the product, for each such spon25 sor or organization, of— 


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1 ‘‘(I) the sum of all rebates, dis2 counts, or other price concessions (not 

3 taking into account any rebate pro4 vided under paragraph (2) for such 

5 dosage form and strength of the drug 

6 dispensed, calculated on a per-unit 

7 basis, but only to the extent that any 

8 such rebate, discount, or other price 

9 concession applies equally to drugs 

10 dispensed to rebate eligible Medicare 

11 drug plan enrollees and drugs dis12 pensed to PDP and MA–PD enrollees 

13 who are not rebate eligible individuals; 

14 and 

15 ‘‘(II) the number of the units of 

16 such dosage and strength of the drug 

17 dispensed during the rebate period to 

18 rebate eligible individuals enrolled in 

19 the prescription drug plans adminis20 tered by the PDP sponsor or the MA– 

21 PD plans administered by the MA or22 ganization; divided by 

23 ‘‘(ii) the total number of units of such 

24 dosage and strength of the drug dispensed 

25 during the rebate period to rebate eligible 


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1 individuals enrolled in all prescription drug 

2 plans administered by PDP sponsors and 

3 all MA–PD plans administered by MA or4 ganizations. 

5 ‘‘(D) USE OF ESTIMATES.—The Secretary 

6 may establish a methodology for estimating the 

7 average Medicare drug program rebate eligible 

8 rebate amounts for each rebate period based on 

9 bid and utilization information under this part 

10 and may use these estimates as the basis for 

11 determining the rebates under this section. If 

12 the Secretary elects to estimate the average 

13 Medicare drug program rebate eligible rebate 

14 amounts, the Secretary shall establish a rec15 onciliation process for adjusting manufacturer 

16 rebate payments not later than 3 months after 

17 the date that manufacturers receive the infor18 mation collected under section 1860D19 12(b)(7)(B). 

20 ‘‘(4) LENGTH OF AGREEMENT.—The provisions 

21 of paragraph (4) of section 1927(b) (other than 

22 clauses (iv) and (v) of subparagraph (B)) shall apply 

23 to rebate agreements under this subsection in the 

24 same manner as such paragraph applies to a rebate 

25 agreement under such section. 


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1 ‘‘(5) OTHER TERMS AND CONDITIONS.—The 

2 Secretary shall establish other terms and conditions 

3 of the rebate agreement under this subsection, in4 cluding terms and conditions related to compliance, 

5 that are consistent with this subsection. 

6 ‘‘(6) DEFINITIONS.—In this subsection and sec7 tion 1860D–12(b)(7): 

8 ‘‘(A) REBATE ELIGIBLE INDIVIDUAL.—The 

9 term ‘rebate eligible individual’— 

10 ‘‘(i) means a full-benefit dual eligible 

11 individual (as defined in section 

12 1935(c)(6)); and 

13 ‘‘(ii) includes, for drugs dispensed 

14 after December 31, 2014, a subsidy eligi15 ble individual (as defined in section 

16 1860D–14(a)(3)(A)). 

17 ‘‘(B) REBATE PERIOD.—The term ‘rebate 

18 period’ has the meaning given such term in sec19 tion 1927(k)(8). 

20 ‘‘(7) WAIVER.—Chapter 35 of title 44, United 

21 States Code, shall not apply to the requirements 

22 under this subsection for the period beginning on 

23 January 1, 2010, and ending on December 31, 

24 2010.’’. 


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1 (2) REPORTING REQUIREMENT FOR THE DE2 TERMINATION AND PAYMENT OF REBATES BY MANU3 FACTURES RELATED TO REBATE FOR REBATE ELIGI4 BLE MEDICARE DRUG PLAN ENROLLEES.— 

5 (A) REQUIREMENTS FOR PDP SPON6 SORS.—Section 1860D–12(b) of the Social Se7 curity Act (42 U.S.C. 1395w–112(b)) is amend8 ed by adding at the end the following new para9 graph: 

10 ‘‘(7) REPORTING REQUIREMENT FOR THE DE11 TERMINATION AND PAYMENT OF REBATES BY MANU12 FACTURERS RELATED TO REBATE FOR REBATE ELI13 GIBLE MEDICARE DRUG PLAN ENROLLEES.— 

14 ‘‘(A) IN GENERAL.—For purposes of the 

15 rebate under section 1860D–2(f) for contract 

16 years beginning on or after January 1, 2011, 

17 each contract entered into with a PDP sponsor 

18 under this part with respect to a prescription 

19 drug plan shall require that the sponsor comply 

20 with subparagraphs (B) and (C). 

21 ‘‘(B) REPORT FORM AND CONTENTS.—Not 

22 later than a date specified by the Secretary, a 

23 PDP sponsor of a prescription drug plan under 

24 this part shall report to each manufacturer— 


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1 ‘‘(i) information (by National Drug 

2 Code number) on the total number of units 

3 of each dosage, form, and strength of each 

4 drug of such manufacturer dispensed to re5 bate eligible Medicare drug plan enrollees 

6 under any prescription drug plan operated 

7 by the PDP sponsor during the rebate pe8 riod; 

9 ‘‘(ii) information on the price dis10 counts, price concessions, and rebates for 

11 such drugs for such form, strength, and 

12 period; 

13 ‘‘(iii) information on the extent to 

14 which such price discounts, price conces15 sions, and rebates apply equally to rebate 

16 eligible Medicare drug plan enrollees and 

17 PDP enrollees who are not rebate eligible 

18 Medicare drug plan enrollees; and 

19 ‘‘(iv) any additional information that 

20 the Secretary determines is necessary to 

21 enable the Secretary to calculate the aver22 age Medicare drug program rebate eligible 

23 rebate amount (as defined in paragraph 

24 (3)(C) of such section), and to determine 

25 the amount of the rebate required under 


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1 this section, for such form, strength, and 

2 period. 

3 Such report shall be in a form consistent with 

4 a standard reporting format established by the 

5 Secretary. 

6 ‘‘(C) SUBMISSION TO SECRETARY.—Each 

7 PDP sponsor shall promptly transmit a copy of 

8 the information reported under subparagraph 

9 (B) to the Secretary for the purpose of audit 

10 oversight and evaluation. 

11 ‘‘(D) CONFIDENTIALITY OF INFORMA12 TION.—The provisions of subparagraph (D) of 

13 section 1927(b)(3), relating to confidentiality of 

14 information, shall apply to information reported 

15 by PDP sponsors under this paragraph in the 

16 same manner that such provisions apply to in17 formation disclosed by manufacturers or whole18 salers under such section, except— 

19 ‘‘(i) that any reference to ‘this sec20 tion’ in clause (i) of such subparagraph 

21 shall be treated as being a reference to this 

22 section; 

23 ‘‘(ii) the reference to the Director of 

24 the Congressional Budget Office in clause 

25 (iii) of such subparagraph shall be treated 


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1 as including a reference to the Medicare 

2 Payment Advisory Commission; and 

3 ‘‘(iii) clause (iv) of such subparagraph 

4 shall not apply. 

5 ‘‘(E) OVERSIGHT.—Information reported 

6 under this paragraph may be used by the In7 spector General of the Department of Health 

8 and Human Services for the statutorily author9 ized purposes of audit, investigation, and eval10 uations. 

11 ‘‘(F) PENALTIES FOR FAILURE TO PRO12 VIDE TIMELY INFORMATION AND PROVISION OF

13 FALSE INFORMATION.—In the case of a PDP 

14 sponsor— 

15 ‘‘(i) that fails to provide information 

16 required under subparagraph (B) on a 

17 timely basis, the sponsor is subject to a 

18 civil money penalty in the amount of 

19 $10,000 for each day in which such infor20 mation has not been provided; or 

21 ‘‘(ii) that knowingly (as defined in 

22 section 1128A(i)) provides false informa23 tion under such subparagraph, the sponsor 

24 is subject to a civil money penalty in an 


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1 amount not to exceed $100,000 for each 

2 item of false information. 

3 Such civil money penalties are in addition to 

4 other penalties as may be prescribed by law. 

5 The provisions of section 1128A (other than 

6 subsections (a) and (b)) shall apply to a civil 

7 money penalty under this subparagraph in the 

8 same manner as such provisions apply to a pen9 alty or proceeding under section 1128A(a).’’. 

10 (B) APPLICATION TO MA ORGANIZA11 TIONS.—Section 1857(f)(3) of the Social Secu12 rity Act (42 U.S.C. 1395w–27(f)(3)) is amend13 ed by adding at the end the following: 

14 ‘‘(D) REPORTING REQUIREMENT RELATED

15 TO REBATE FOR REBATE ELIGIBLE MEDICARE

16 DRUG PLAN ENROLLEES.—Section 1860D– 

17 12(b)(7).’’. 

18 (3) DEPOSIT OF REBATES INTO MEDICARE PRE19 SCRIPTION DRUG ACCOUNT.—Section 1860D–16(c) 

20 of such Act (42 U.S.C. 1395w–116(c)) is amended 

21 by adding at the end the following new paragraph: 

22 ‘‘(6) REBATE FOR REBATE ELIGIBLE MEDICARE

23 DRUG PLAN ENROLLEES.—Amounts paid under a re24 bate agreement under section 1860D–2(f) shall be 

25 deposited into the Account and shall be used to pay 


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1 for all or part of the gradual elimination of the cov2 erage gap under section 1860D–2(b)(7).’’. 

3 SEC. 1182. DISCOUNTS FOR CERTAIN PART D DRUGS IN 

4 ORIGINAL COVERAGE GAP. 

5 Section 1860D–2 of the Social Security Act (42 

6 U.S.C. 1395w–102), as amended by section 1181, is 

7 amended— 

8 (1) in subsection (b)(4)(C)(ii), by inserting 

9 ‘‘subject to subsection (g)(2)(C),’’ after ‘‘(ii)’’; 

10 (2) in subsection (e)(1), in the matter before 

11 subparagraph (A), by striking ‘‘subsection (f)’’ and 

12 inserting ‘‘subsections (f) and (g)’’ after ‘‘this sub13 section’’; and 

14 (3) by adding at the end the following new sub15 section: 

16 ‘‘(g) REQUIREMENT FOR MANUFACTURER DISCOUNT

17 AGREEMENT FOR CERTAIN QUALIFYING DRUGS.— 

18 ‘‘(1) IN GENERAL.—In this part, the term ‘cov19 ered part D drug’ does not include any drug or bio20 logical product that is manufactured by a manufac21 turer that has not entered into and have in effect for 

22 all qualifying drugs (as defined in paragraph (5)(A)) 

23 a discount agreement described in paragraph (2). 

24 ‘‘(2) DISCOUNT AGREEMENT.— 


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1 ‘‘(A) PERIODIC DISCOUNTS.—A discount 

2 agreement under this paragraph shall require 

3 the manufacturer involved to provide, to each 

4 PDP sponsor with respect to a prescription 

5 drug plan or each MA organization with respect 

6 to each MA–PD plan, a discount in an amount 

7 specified in paragraph (3) for qualifying drugs 

8 (as defined in paragraph (5)(A)) of the manu9 facturer dispensed to a qualifying enrollee after 

10 January 1, 2010, insofar as the individual is in 

11 the original gap in coverage (as defined in para12 graph (5)(E)). 

13 ‘‘(B) DISCOUNT AGREEMENT.—Insofar as 

14 not inconsistent with this subsection, the Sec15 retary shall establish terms and conditions of 

16 such agreement, including terms and conditions 

17 relating to compliance, similar to the terms and 

18 conditions for rebate agreements under para19 graphs (2), (3), and (4) of section 1927(b), ex20 cept that— 

21 ‘‘(i) discounts shall be applied under 

22 this subsection to prescription drug plans 

23 and MA–PD plans instead of State plans 

24 under title XIX; 


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1 ‘‘(ii) PDP sponsors and MA organiza2 tions shall be responsible, instead of 

3 States, for provision of necessary utiliza4 tion information to drug manufacturers; 

5 and 

6 ‘‘(iii) sponsors and MA organizations 

7 shall be responsible for reporting informa8 tion on drug-component negotiated price. 

9 ‘‘(C) COUNTING DISCOUNT TOWARD TRUE

10 OUT-OF-POCKET COSTS.—Under the discount 

11 agreement, in applying subsection (b)(4), with 

12 regard to subparagraph (C)(i) of such sub13 section, if a qualified enrollee purchases the 

14 qualified drug insofar as the enrollee is in an 

15 actual gap of coverage (as defined in paragraph 

16 (5)(D)), the amount of the discount under the 

17 agreement shall be treated and counted as costs 

18 incurred by the plan enrollee. 

19 ‘‘(3) DISCOUNT AMOUNT.—The amount of the 

20 discount specified in this paragraph for a discount 

21 period for a plan is equal to 50 percent of the 

22 amount of the drug-component negotiated price (as 

23 defined in paragraph (5)(C)) for qualifying drugs for 

24 the period involved. 


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1 ‘‘(4) ADDITIONAL TERMS.—In the case of a dis2 count provided under this subsection with respect to 

3 a prescription drug plan offered by a PDP sponsor 

4 or an MA–PD plan offered by an MA organization, 

5 if a qualified enrollee purchases the qualified drug— 

6 ‘‘(A) insofar as the enrollee is in an actual 

7 gap of coverage (as defined in paragraph 

8 (5)(D)), the sponsor or plan shall provide the 

9 discount to the enrollee at the time the enrollee 

10 pays for the drug; and 

11 ‘‘(B) insofar as the enrollee is in the por12 tion of the original gap in coverage (as defined 

13 in paragraph (5)(E)) that is not in the actual 

14 gap in coverage, the discount shall not be ap15 plied against the negotiated price (as defined in 

16 subsection (d)(1)(B)) for the purpose of calcu17 lating the beneficiary payment. 

18 ‘‘(5) DEFINITIONS.—In this subsection: 

19 ‘‘(A) QUALIFYING DRUG.—The term 

20 ‘qualifying drug’ means, with respect to a pre21 scription drug plan or MA–PD plan, a drug or 

22 biological product that— 

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1 ministration, including a drug product 

2 marketed by any cross-licensed producers 

3 or distributors operating under the new 

4 drug application; 

5 ‘‘(II) is a drug that was originally 

6 marketed under an original new drug ap7 plication approved by the Food and Drug 

8 Administration; or 

9 ‘‘(III) is a biological product as ap10 proved under Section 351(a) of the Public 

11 Health Services Act; 

12 ‘‘(ii) is covered under the formulary of 

13 the plan or is treated as covered under the 

14 formulary of the plan as a result of a cov15 erage determination or appeal under sub16 section (g) or (h) of section 1860D–4; and 

17 ‘‘(iii) is dispensed to an individual 

18 who is in the original gap in coverage. 

19 ‘‘(B) QUALIFYING ENROLLEE.—The term 

20 ‘qualifying enrollee’ means an individual en21 rolled in a prescription drug plan or MA–PD 

22 plan other than such an individual who is a 

23 subsidy-eligible individual (as defined in section 

24 1860D–14(a)(3)). 


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1 ‘‘(C) DRUG-COMPONENT NEGOTIATED

2 PRICE.—The term ‘drug-component negotiated 

3 price’ means, with respect to a qualifying drug, 

4 the negotiated price (as defined in section 

5 423.100 of title 42, Code of Federal Regula6 tions, as in effect on the date of enactment of 

7 this subsection), as determined without regard 

8 to any dispensing fee, of the drug under the 

9 prescription drug plan or MA–PD plan in10 volved. 

11 ‘‘(D) ACTUAL GAP IN COVERAGE.—The 

12 term ‘actual gap in coverage’ means the gap in 

13 prescription drug coverage that occurs between 

14 the initial coverage limit (as modified under 

15 paragraph (7) and subparagraph (B) of para16 graph (8) of subsection (b)) and the annual 

17 out-of-pocket threshold (as modified under sub18 paragraph (C) of such subsection). 

19 ‘‘(E) ORIGINAL GAP IN COVERAGE.—The 

20 term ‘original in gap coverage’ means the gap 

21 in prescription drug coverage that would occur 

22 between the initial coverage limit (described in 

23 subsection (b)(3)) and the out-of-pocket thresh24 old (as defined in subsection (b)(4)(B)) if sub25 sections (b)(7) and (b)(8) did not apply. 


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1 ‘‘(6) SPECIAL RULE FOR 2010.—For the period 

2 beginning January 1, 2010, and ending December 

3 31, 2010, the Secretary may— 

4 ‘‘(A) enter into agreements with manufac5 turers to directly receive the discount amount 

6 described in paragraph (3); 

7 ‘‘(B) collect the necessary information 

8 from prescription drug plans and MA-PD plans 

9 to calculate the discount amount described in 

10 such paragraph; and 

11 ‘‘(C) provide the discount described in such 

12 paragraph to beneficiaries as close as prac13 ticable after the point of sale. 

14 ‘‘(7) WAIVER.—Chapter 35 of title 44, United 

15 States Code, shall not apply to the requirements 

16 under this subsection for the period beginning on 

17 January 1, 2010, and ending on December 31, 

18 2010.’’. 

19 SEC. 1183. REPEAL OF PROVISION RELATING TO SUBMIS20 SION OF CLAIMS BY PHARMACIES LOCATED 

21 IN OR CONTRACTING WITH LONG-TERM CARE 

22 FACILITIES. 

23 (a) PART D SUBMISSION.—Section 1860D–12(b) of 

24 the Social Security Act (42 U.S.C. 1395w–112(b)), as 

25 amended by section 172(a)(1) of Public Law 110–275, is 


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1 amended by striking paragraph (5) and redesignating 

2 paragraph (6) and paragraph (7), as added by section 

3 1181(c)(2)(A), as paragraph (5) and paragraph (6), re4 spectively. 

5 (b) SUBMISSION TO MA–PD PLANS.—Section 

6 1857(f)(3) of the Social Security Act (42 U.S.C. 1395w7 27(f)(3)), as added by section 171(b) of Public Law 110– 

8 275 and amended by section 172(a)(2) of such Public Law 

9 and section 1181 of this Act, is amended by striking sub10 paragraph (B) and redesignating subparagraphs (C) and 

11 (D) as subparagraphs (B) and (C) respectively. 

12 (c) EFFECTIVE DATE.—The amendments made by 

13 this section shall apply for contract years beginning with 

14 2010. 

15 SEC. 1184. INCLUDING COSTS INCURRED BY AIDS DRUG AS16 SISTANCE PROGRAMS AND INDIAN HEALTH 

17 SERVICE IN PROVIDING PRESCRIPTION 

18 DRUGS TOWARD THE ANNUAL OUT-OF-POCK19 ET THRESHOLD UNDER PART D. 

20 (a) IN GENERAL.—Section 1860D–2(b)(4)(C) of the 

21 Social Security Act (42 U.S.C. 1395w–102(b)(4)(C)) is 

22 amended— 

23 (1) in clause (i), by striking ‘‘and’’ at the end; 

24 (2) in clause (ii)— 


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1 (A) by striking ‘‘such costs shall be treated 

2 as incurred only if’’ and inserting ‘‘and subject 

3 to clause (iii), such costs shall be treated as in4 curred only if’’; 

5 (B) by striking ‘‘, under section 1860D– 

6 14, or under a State Pharmaceutical Assistance 

7 Program’’; and 

8 (C) by striking the period at the end and 

9 inserting ‘‘; and’’; and 

10 (3) by inserting after clause (ii) the following 

11 new clause: 

12 ‘‘(iii) such costs shall be treated as in13 curred and shall not be considered to be 

14 reimbursed under clause (ii) if such costs 

15 are borne or paid— 

16 ‘‘(I) under section 1860D–14; 

17 ‘‘(II) under a State Pharma18 ceutical Assistance Program; 

19 ‘‘(III) by the Indian Health Serv20 ice, an Indian tribe or tribal organiza21 tion, or an urban Indian organization 

22 (as defined in section 4 of the Indian 

23 Health Care Improvement Act); or 

24 ‘‘(IV) under an AIDS Drug As25 sistance Program under part B of 


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1 title XXVI of the Public Health Serv2 ice Act.’’. 

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

4 subsection (a) shall apply to costs incurred on or after 

5 January 1, 2011. 

6 SEC. 1185. NO MID-YEAR FORMULARY CHANGES PER7 MITTED. 

8 (a) IN GENERAL.—Section 1860D–4(b)(3)(E) of the 

9 Social Security Act (42 U.S.C. 1395w–104(b)(3)(E)) is 

10 amended— 

11 (1) in the heading, by inserting ‘‘; CERTAIN

12 FORMULARY CHANGES ONLY BEFORE INITIATING

13 MARKETING FOR A PLAN YEAR’’ after ‘‘STATUS OF

14 DRUG’’; 

15 (2) by striking ‘‘Any removal’’ and inserting 

16 ‘‘(i) NOTICE.—Any removal’’ with the same indenta17 tion as the clause added by paragraph (2); 

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

19 clause: 

20 ‘‘(ii) CERTAIN CHANGES IN FOR21 MULARY ONLY BEFORE INITIATING MAR22 KETING FOR A PLAN YEAR.—Any removal 

23 of a covered part D drug from a formulary 

24 used by a PDP sponsor of a prescription 

25 drug plan (or MA organization of a MA– 


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1 PD plan) or any other material change to 

2 the formulary so as to reduce the coverage 

3 (or increase the cost-sharing) of the drug 

4 under the plan for a plan year shall take 

5 effect by a date specified by the Secretary 

6 but no later than the start of plan mar7 keting activities for the plan year. In addi8 tion to any exceptions to the previous sen9 tence specified by the Secretary, the pre10 vious sentence shall not apply in the case 

11 that a drug is removed from the formulary 

12 of a plan because of a recall or withdrawal 

13 of the drug issued by the Food and Drug 

14 Administration, because the drug is re15 placed with a generic drug that is a thera16 peutic equivalent, or because of utilization 

17 management applied to— 

18 ‘‘(I) a drug whose labeling in19 cludes a boxed warning required by 

20 the Food and Drug Administration 

21 under section 201.57(c)(1) of title 21, 

22 Code of Federal Regulations (or a 

23 successor regulation); or 

24 ‘‘(II) a drug required under sub25 section (c)(2) of section 505–1 of the 


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1 Federal Food, Drug, and Cosmetic 

2 Act to have a Risk Evaluation and 

3 Management Strategy that includes 

4 elements under subsection (f) of such 

5 section.’’. 

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

7 subsection (a) shall apply to contract years beginning on 

8 or after January 1, 2011. 

9 SEC. 1186. NEGOTIATION OF LOWER COVERED PART D 

10 DRUG PRICES ON BEHALF OF MEDICARE 

11 BENEFICIARIES. 

12 (a) NEGOTIATION BY SECRETARY.—Section 1860D– 

13 11 of the Social Security Act (42 U.S.C. 1395w–111) is 

14 amended by striking subsection (i) (relating to noninter15 ference) and inserting the following: 

16 ‘‘(i) NEGOTIATION OF LOWER DRUG PRICES.— 

17 ‘‘(1) IN GENERAL.—Notwithstanding any other 

18 provision of law, the Secretary shall negotiate with 

19 pharmaceutical manufacturers the prices (including 

20 discounts, rebates, and other price concessions) that 

21 may be charged to PDP sponsors and MA organiza22 tions for covered part D drugs for part D eligible in23 dividuals who are enrolled under a prescription drug 

24 plan or under an MA-PD plan. 


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1 ‘‘(2) NO CHANGE IN RULES FOR

2 FORMULARIES.— 

3 ‘‘(A) IN GENERAL.—Nothing in paragraph 

4 (1) shall be construed to authorize the Sec5 retary to establish or require a particular for6 mulary. 

7 ‘‘(B) CONSTRUCTION.—Subparagraph (A) 

8 shall not be construed as affecting the Sec9 retary’s authority to ensure appropriate and 

10 adequate access to covered part D drugs under 

11 prescription drug plans and under MA-PD 

12 plans, including compliance of such plans with 

13 formulary requirements under section 1860D– 

14 4(b)(3). 

15 ‘‘(3) CONSTRUCTION.—Nothing in this sub16 section shall be construed as preventing the sponsor 

17 of a prescription drug plan, or an organization offer18 ing an MA-PD plan, from obtaining a discount or 

19 reduction of the price for a covered part D drug 

20 below the price negotiated under paragraph (1). 

21 ‘‘(4) ANNUAL REPORTS TO CONGRESS.—Not 

22 later than June 1, 2011, and annually thereafter, 

23 the Secretary shall submit to the Committees on 

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1 resentatives and the Committee on Finance of the 

2 Senate a report on negotiations conducted by the 

3 Secretary to achieve lower prices for Medicare bene4 ficiaries, and the prices and price discounts achieved 

5 by the Secretary as a result of such negotiations.’’. 

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

7 subsection (a) shall take effect on the date of the enact8 ment of this Act and shall first apply to negotiations and 

9 prices for plan years beginning on January 1, 2011. 

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

11 FACILITIES. 

12 Section 1860D–4(c) of the Social Security Act (42 

13 U.S.C. 1395w–104(c)) is amended by adding at the end 

14 the following new paragraph: 

15 ‘‘(3) REDUCTION OF WASTEFUL DISPENSING.— 

16 ‘‘(A) IN GENERAL.—For plan years begin17 ning on or after January 1, 2012, a PDP spon18 sor offering a prescription drug plan and MA 

19 organization offering a MA–PD plan under part 

20 C shall have in place the utilization manage21 ment techniques established under subpara22 graph (B). 

23 ‘‘(B) REQUIREMENTS.—The Secretary 

24 shall establish utilization management tech25 niques, such as daily, weekly, or automated 


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1 dose dispensing, to apply to PDP sponsors and 

2 MA organizations to reduce the quantities of 

3 covered part D drugs dispensed to enrollees 

4 who are residing in long-term care facilities in 

5 order to reduce waste associated with unused 

6 medications. 

7 ‘‘(C) CONSULTATION.—In establishing the 

8 requirements under subparagraph (A), the Sec9 retary shall consult with the Administrator of 

10 the Environmental Protection Agency, Adminis11 trator of the Food and Drug Administration, 

12 Administrator of the Drug Enforcement Admin13 istration, State Boards of Pharmacy, pharmacy 

14 and physician organizations, and other appro15 priate stakeholders to study and determine ad16 ditional methods for prescription drug plans to 

17 reduce waste associated with unused prescrip18 tion drugs.’’. 

19 SEC. 1188. FREE GENERIC FILL. 

20 (a) IN GENERAL.—Section 1128A(i)(6) of the Social 

21 Security Act (42 U.S.C. 1320a–7a(i)(6)) is amended— 

22 (1) in subparagraph (C), by striking ‘‘of 1996’’ 

23 and all that follows and inserting ‘‘of 1996;’’; 


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1 (2) in the first subparagraph (D), by striking 

2 ‘‘promulgated’’ and all that follows and inserting 

3 ‘‘promulgated;’’; 

4 (3) by redesignating the second subparagraph 

5 (D) as a subparagraph (E) and by striking the pe6 riod at the end of such subparagraph and inserting 

7 ‘‘; and’’; and 

8 (4) by adding at the end the following new sub9 paragraph: 

10 ‘‘(F) with regard to a prescription drug 

11 plan offered by a PDP sponsor or an MA–PD 

12 plan offered by an MA organization, a reduc13 tion in or waiver of the copayment amount 

14 under the plan given to an individual to induce 

15 the individual to switch to a generic, bioequiva16 lent drug, or biosimilar.’’. 

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

18 this subsection shall take effect on the date of the enact19 ment of this Act and shall first apply with respect to remu20 neration offered, paid, solicited, or received on or after 

21 January 1, 2011. 


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1 SEC. 1189. STATE CERTIFICATION PRIOR TO WAIVER OF LI2 CENSURE REQUIREMENTS UNDER MEDICARE 

3 PRESCRIPTION DRUG PROGRAM. 

4 (a) IN GENERAL.—Section 1860D–12(c) of the So5 cial Security Act (42 U.S.C. 1395w–112(c)) is amended— 

6 (1) in paragraph (1)(A), by striking ‘‘In the 

7 case’’ and inserting ‘‘Subject to paragraph (5), in 

8 the case’’; and 

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

10 paragraph: 

11 ‘‘(5) STATE CERTIFICATION REQUIRED.— 

12 ‘‘(A) IN GENERAL.—Except as provided in 

13 section 1860D–21(f)(4), the Secretary may only 

14 grant a waiver under paragraph (1)(A) if the 

15 Secretary has received a certification from the 

16 State insurance commissioner that the prescrip17 tion drug plan has a substantially complete ap18 plication pending in the State. 

19 ‘‘(B) REVOCATION OF WAIVER UPON FIND20 ING OF FRAUD AND ABUSE.—The Secretary 

21 shall revoke a waiver granted under paragraph 

22 (1)(A) if the State insurance commissioner sub23 mits a certification to the Secretary that the re24 cipient of such a waiver— 

25 ‘‘(i) has committed fraud or abuse 

26 with respect to such waiver; 


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1 ‘‘(ii) has failed to make a good faith 

2 effort to satisfy State licensing require3 ments; or 

4 ‘‘(iii) was determined ineligible for li5 censure by the State.’’. 

6 (b) EXCEPTION FOR PACE PROGRAMS.—Section 

7 1860D–21(f) of such Act (42 U.S.C. 1395w–131(f)) is 

8 amended— 

9 (1) in paragraph (1), by striking ‘‘paragraphs 

10 (2) and (3)’’ and inserting ‘‘the succeeding para11 graphs’’; and 

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

13 paragraph: 

14 ‘‘(4) INAPPLICABILITY OF CERTAIN LICENSURE

15 WAIVER REQUIREMENTS.—The provisions of para16 graph (1) of section 1860D–12(c) (relating to waiver 

17 of licensure under certain circumstances) shall apply 

18 without regard to paragraph (5) of such section in 

19 the case of a PACE program that elects to provide 

20 qualified prescription drug coverage to a part D eli21 gible individual who is enrolled under such pro22 gram.’’. 

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

24 this section shall apply with respect to plan years begin25 ning on or after January 1, 2010. 


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1 Subtitle F—Medicare Rural Access 

2 Protections 

3 SEC. 1191. TELEHEALTH EXPANSION AND ENHANCEMENTS. 

4 (a) ADDITIONAL TELEHEALTH SITE.— 

5 (1) IN GENERAL.—Paragraph (4)(C)(ii) of sec6 tion 1834(m) of the Social Security Act (42 U.S.C. 

7 1395m(m)) is amended by adding at the end the fol8 lowing new subclause: 

9 ‘‘(IX) A renal dialysis facility.’’ 

10 (2) EFFECTIVE DATE.—The amendment made 

11 by paragraph (1) shall apply to services furnished on 

12 or after January 1, 2011. 

13 (b) TELEHEALTH ADVISORY COMMITTEE.— 

14 (1) ESTABLISHMENT.—Section 1868 of the So15 cial Security Act (42 U.S.C. 1395ee) is amended— 

16 (A) in the heading, by adding at the end 

17 the following: ‘‘TELEHEALTH ADVISORY COM18 MITTEE’’; and 

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

20 subsection: 

21 ‘‘(c) TELEHEALTH ADVISORY COMMITTEE.— 

22 ‘‘(1) IN GENERAL.—The Secretary shall appoint 

23 a Telehealth Advisory Committee (in this subsection 

24 referred to as the ‘Advisory Committee’) to make 

25 recommendations to the Secretary on policies of the 


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1 Centers for Medicare & Medicaid Services regarding 

2 telehealth services as established under section 

3 1834(m), including the appropriate addition or dele4 tion of services (and HCPCS codes) to those speci5 fied in paragraphs (4)(F)(i) and (4)(F)(ii) of such 

6 section and for authorized payment under paragraph 

7 (1) of such section. 

8 ‘‘(2) MEMBERSHIP; TERMS.— 

9 ‘‘(A) MEMBERSHIP.— 

10 ‘‘(i) IN GENERAL.—The Advisory 

11 Committee shall be composed of 9 mem12 bers, to be appointed by the Secretary, of 

13 whom— 

14 ‘‘(I) 5 shall be practicing physi15 cians; 

16 ‘‘(II) 2 shall be practicing non17 physician health care practitioners; 

18 and 

19 ‘‘(III) 2 shall be administrators 

20 of telehealth programs. 

21 ‘‘(ii) REQUIREMENTS FOR APPOINT22 ING MEMBERS.—In appointing members of 

23 the Advisory Committee, the Secretary 

24 shall— 


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1 ‘‘(I) ensure that each member 

2 has prior experience with the practice 

3 of telemedicine or telehealth; 

4 ‘‘(II) give preference to individ5 uals who are currently providing tele6 medicine or telehealth services or who 

7 are involved in telemedicine or tele8 health programs; 

9 ‘‘(III) ensure that the member10 ship of the Advisory Committee rep11 resents a balance of specialties and 

12 geographic regions; and 

13 ‘‘(IV) take into account the rec14 ommendations of stakeholders. 

15 ‘‘(B) TERMS.—The members of the Advi16 sory Committee shall serve for such term as the 

17 Secretary may specify. 

18 ‘‘(C) CONFLICTS OF INTEREST.—An advi19 sory committee member may not participate 

20 with respect to a particular matter considered 

21 in an advisory committee meeting if such mem22 ber (or an immediate family member of such 

23 member) has a financial interest that could be 

24 affected by the advice given to the Secretary 

25 with respect to such matter. 


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1 ‘‘(3) MEETINGS.—The Advisory Committee 

2 shall meet twice each calendar year and at such 

3 other times as the Secretary may provide. 

4 ‘‘(4) PERMANENT COMMITTEE.—Section 14 of 

5 the Federal Advisory Committee Act (5 U.S.C. 

6 App.) shall not apply to the Advisory Committee.’’ 

7 (2) FOLLOWING RECOMMENDATIONS.—Section 

8 1834(m)(4)(F) of such Act (42 U.S.C. 

9 1395m(m)(4)(F)) is amended by adding at the end 

10 the following new clause: 

11 ‘‘(iii) RECOMMENDATIONS OF THE

12 TELEHEALTH ADVISORY COMMITTEE.—In 

13 making determinations under clauses (i) 

14 and (ii), the Secretary shall take into ac15 count the recommendations of the Tele16 health Advisory Committee (established 

17 under section 1868(c)) when adding or de18 leting services (and HCPCS codes) and in 

19 establishing policies of the Centers for 

20 Medicare & Medicaid Services regarding 

21 the delivery of telehealth services. If the 

22 Secretary does not implement such a rec23 ommendation, the Secretary shall publish 

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1 garding the reason such recommendation 

2 was not implemented.’’ 

3 (3) WAIVER OF ADMINISTRATIVE LIMITA4 TION.—The Secretary of Health and Human Serv5 ices shall establish the Telehealth Advisory Com6 mittee under the amendment made by paragraph (1) 

7 notwithstanding any limitation that may apply to 

8 the number of advisory committees that may be es9 tablished (within the Department of Health and 

10 Human Services or otherwise). 

11 (c) HOSPITAL CREDENTIALING OF TELEMEDICINE

12 PHYSICIANS AND PRACTITIONERS.— 

13 (1) IN GENERAL.—Not later than 60 days after 

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

15 of Health and Human Services shall issue guidance 

16 for hospitals (as defined in paragraph (4)) to sim17 plify requirements regarding compiling practitioner 

18 credentials for the purpose of rendering a medical 

19 staff privileging decision (under bylaws of the type 

20 described in section 1861(e)(3) of the Social Secu21 rity Act) for physicians and practitioners (as defined 

22 in paragraph (4)) delivering telehealth services that 

23 are furnished via a telecommunications system. 


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1 (2) FLEXIBILITY IN ACCEPTING

2 CREDENTIALING BY ANOTHER MEDICARE PARTICI3 PATING HOSPITAL.— 

4 (A) IN GENERAL.—Such guidance shall 

5 permit a hospital to accept credentialing pack6 ages compiled by another hospital participating 

7 under Medicare with regard to physicians and 

8 practitioners who seek medical staff privileges 

9 in the hospital to provide telehealth services via 

10 a telecommunications system from a site other 

11 than the hospital where the patient is located. 

12 (B) CONSTRUCTION.—Nothing in this sub13 section shall be construed to require a hospital 

14 to accept the credentialing package compiled by 

15 another facility. 

16 (C) NO OVERSIGHT REQUIRED.—If a hos17 pital does accept the credentialing materials 

18 prepared by another hospital, the hospital shall 

19 not be required to exercise oversight over the 

20 other hospital’s process for compiling and 

21 verifying credentials.

22 (D) PRIVILEGING.—This paragraph shall 

23 only apply to credentialing and does not relieve 

24 a hospital from any applicable privileging re25 quirements. 


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1 (3) CONSTRUCTION.—This subsection shall not 

2 be construed as limiting the ability of the Secretary 

3 to issue additional guidance regarding the require4 ments for the compilation of credentials for physi5 cians and practitioners not described in paragraph 

6 (1). 

7 (4) DEFINITIONS.—In this subsection: 

8 (A) The term ‘‘hospital’’ has the meaning 

9 given such term in subsection (e) of section 

10 1861 of the Social Security Act (42 U.S.C. 

11 1395x) and includes a critical access hospital 

12 (as defined in subsection (mm)(1) of such sec13 tion). 

14 (B) The term ‘‘physician’’ has the meaning 

15 given such term in subsection (r) of such sec16 tion. 

17 (C) The term ‘‘practitioner’’ means a prac18 titioner described in section 1842(b)(18)(C) of 

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

20 1395u(b)(18)(C)). 

21 SEC. 1192. EXTENSION OF OUTPATIENT HOLD HARMLESS 

22 PROVISION. 

23 Section 1833(t)(7)(D)(i) of the Social Security Act 

24 (42 U.S.C. 1395l(t)(7)(D)(i)) is amended— 

25 (1) in subclause (II)— 


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1 (A) in the first sentence, by striking 

2 ‘‘‘2010’’ and inserting ‘‘2012’’; and 

3 (B) in the second sentence, by striking ‘‘or 

4 2009’’ and inserting ‘‘, 2009, 2010, or 2011’’; 

5 and 

6 (2) in subclause (III), by striking ‘‘January 1, 

7 2010’’ and inserting ‘‘January 1, 2012’’. 

8 SEC. 1193. EXTENSION OF SECTION 508 HOSPITAL RECLAS9 SIFICATIONS. 

10 (a) IN GENERAL.—Subsection (a) of section 106 of 

11 division B of the Tax Relief and Health Care Act of 2006 

12 (42 U.S.C. 1395 note), as amended by section 117 of the 

13 Medicare, Medicaid, and SCHIP Extension Act of 2007 

14 (Public Law 110–173) and section 124 of the Medicare 

15 Improvements for Patients and Providers Act of 2008 

16 (Public Law 110–275), is amended by striking ‘‘Sep17 tember 30, 2009’’ and inserting ‘‘September 30, 2011’’. 

18 (b) USE OF PARTICULAR WAGE INDEX FOR FISCAL

19 YEAR 2010.—For purposes of implementation of the 

20 amendment made by subsection (a) for fiscal year 2010, 

21 the Secretary shall use the hospital wage index that was 

22 promulgated by the Secretary in the Federal Register on 

23 August 27, 2009 (74 Fed. Reg. 43754), and any subse24 quent corrections. 


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1 SEC. 1194. EXTENSION OF GEOGRAPHIC FLOOR FOR WORK. 

2 Section 1848(e)(1)(E) of the Social Security Act (42 

3 U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘before 

4 January 1, 2010’’ and inserting ‘‘before January 1, 

5 2012’’. 

6 SEC. 1195. EXTENSION OF PAYMENT FOR TECHNICAL COM7 PONENT OF CERTAIN PHYSICIAN PATHOL8 OGY SERVICES. 

9 Section 542(c) of the Medicare, Medicaid, and 

10 SCHIP Benefits Improvement and Protection Act of 2000 

11 (as enacted into law by section 1(a)(6) of Public Law 106– 

12 554), as amended by section 732 of the Medicare Prescrip13 tion Drug, Improvement, and Modernization Act of 2003 

14 (42 U.S.C. 1395w–4 note), section 104 of division B of 

15 the Tax Relief and Health Care Act of 2006 (42 U.S.C. 

16 1395w–4 note), section 104 of the Medicare, Medicaid, 

17 and SCHIP Extension Act of 2007 (Public Law 110– 

18 173), and section 136 of the Medicare Improvements for 

19 Patients and Providers Act of 1008 (Public Law 110– 

20 275), is amended by striking ‘‘and 2009’’ and inserting 

21 ‘‘2009, 2010, and 2011’’. 

22 SEC. 1196. EXTENSION OF AMBULANCE ADD-ONS. 

23 (a) IN GENERAL.—Section 1834(l)(13) of the Social 

24 Security Act (42 U.S.C. 1395m(l)(13)) is amended— 

25 (1) in subparagraph (A)— 


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1 (A) in the matter preceding clause (i), by 

2 striking ‘‘before January 1, 2010’’ and insert3 ing ‘‘before January 1, 2012’’; and 

4 (B) in each of clauses (i) and (ii), by strik5 ing ‘‘before January 1, 2010’’ and inserting 

6 ‘‘before January 1, 2012’’. 

7 (b) AIR AMBULANCE IMPROVEMENTS.—Section 

8 146(b)(1) of the Medicare Improvements for Patients and 

9 Providers Act of 2008 (Public Law 110–275) is amended 

10 by striking ‘‘ending on December 31, 2009’’ and inserting 

11 ‘‘ending on December 31, 2011’’. 

12 TITLE II—MEDICARE 

13 BENEFICIARY IMPROVEMENTS 

14 Subtitle A—Improving and Simpli15 fying Financial Assistance for 

16 Low Income Medicare Bene17 ficiaries 

18 SEC. 1201. IMPROVING ASSETS TESTS FOR MEDICARE SAV19 INGS PROGRAM AND LOW-INCOME SUBSIDY 

20 PROGRAM. 

21 (a) APPLICATION OF HIGHEST LEVEL PERMITTED

22 UNDER LIS TO ALL SUBSIDY ELIGIBLE INDIVIDUALS.— 

23 (1) IN GENERAL.—Section 1860D–14(a)(1) of 

24 the Social Security Act (42 U.S.C. 1395w– 

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1 graph (A), by inserting ‘‘(or, beginning with 2012, 

2 paragraph (3)(E))’’ after ‘‘paragraph (3)(D)’’. 

3 (2) ANNUAL INCREASE IN LIS RESOURCE

4 TEST.—Section 1860D–14(a)(3)(E)(i) of such Act 

5 (42 U.S.C. 1395w–114(a)(3)(E)(i)) is amended— 

6 (A) by striking ‘‘and’’ at the end of sub7 clause (I); 

8 (B) in subclause (II), by inserting ‘‘(before 

9 2012)’’ after ‘‘subsequent year’’; 

10 (C) by striking the period at the end of 

11 subclause (II) and inserting a semicolon; 

12 (D) by inserting after subclause (II) the 

13 following new subclauses: 

14 ‘‘(III) for 2012, $17,000 (or 

15 $34,000 in the case of the combined 

16 value of the individual’s assets or re17 sources and the assets or resources of 

18 the individual’s spouse); and 

19 ‘‘(IV) for a subsequent year, the 

20 dollar amounts specified in this sub21 clause (or subclause (III)) for the pre22 vious year increased by the annual 

23 percentage increase in the consumer 

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1 age) as of September of such previous 

2 year.’’; and 

3 (E) in the last sentence, by inserting ‘‘or 

4 (IV)’’ after ‘‘subclause (II)’’. 

5 (3) APPLICATION OF LIS TEST UNDER MEDI6 CARE SAVINGS PROGRAM.—Section 1905(p)(1)(C) of 

7 such Act (42 U.S.C. 1396d(p)(1)(C)) is amended— 

8 (A) by striking ‘‘effective beginning with 

9 January 1, 2010’’ and inserting ‘‘effective for 

10 the period beginning with January 1, 2010, and 

11 ending with December 31, 2011’’; and 

12 (B) by inserting before the period at the 

13 end the following: ‘‘or, effective beginning with 

14 January 1, 2012, whose resources (as so deter15 mined) do not exceed the maximum resource 

16 level applied for the year under subparagraph 

17 (E) of section 1860D–14(a)(3) (determined 

18 without regard to the life insurance policy ex19 clusion provided under subparagraph (G) of 

20 such section) applicable to an individual or to 

21 the individual and the individual’s spouse (as 

22 the case may be)’’. 

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

24 subsection (a) shall apply to eligibility determinations for 


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1 income-related subsidies and medicare cost-sharing fur2 nished for periods beginning on or after January 1, 2012. 

3 SEC. 1202. ELIMINATION OF PART D COST-SHARING FOR 

4 CERTAIN NON-INSTITUTIONALIZED FULL5 BENEFIT DUAL ELIGIBLE INDIVIDUALS. 

6 (a) IN GENERAL.—Section 1860D–14(a)(1)(D)(i) of 

7 the Social Security Act (42 U.S.C. 1395w– 

8 114(a)(1)(D)(i)) is amended— 

9 (1) by striking ‘‘INSTITUTIONALIZED INDIVID10 UALS.—In’’ and inserting ‘‘ELIMINATION OF COST11 SHARING FOR CERTAIN FULL-BENEFIT DUAL ELIGI12 BLE INDIVIDUALS.— 

13 ‘‘(I) INSTITUTIONALIZED INDI14 VIDUALS.—In’’; and 

15 (2) by adding at the end the following new sub16 clause: 

17 ‘‘(II) CERTAIN OTHER INDIVID18 UALS.—In the case of an individual 

19 who is a full-benefit dual eligible indi20 vidual and with respect to whom there 

21 has been a determination that but for 

22 the provision of home and community 

23 based care (whether under section 

24 1915, 1932, or under a waiver under 

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1 quire the level of care provided in a 

2 hospital or a nursing facility or inter3 mediate care facility for the mentally 

4 retarded the cost of which could be re5 imbursed under the State plan under 

6 title XIX, the elimination of any bene7 ficiary coinsurance described in sec8 tion 1860D–2(b)(2) (for all amounts 

9 through the total amount of expendi10 tures at which benefits are available 

11 under section 1860D–2(b)(4)).’’. 

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

13 subsection (a) shall apply to drugs dispensed on or after 

14 January 1, 2011. 

15 SEC. 1203. ELIMINATING BARRIERS TO ENROLLMENT. 

16 (a) ADMINISTRATIVE VERIFICATION OF INCOME AND

17 RESOURCES UNDER THE LOW-INCOME SUBSIDY PRO18 GRAM.— 

19 (1) IN GENERAL.—Clause (iii) of section 

20 1860D–14(a)(3)(E) of the Social Security Act (42 

21 U.S.C. 1395w–114(a)(3)(E)) is amended to read as 

22 follows: 

23 ‘‘(iii) CERTIFICATION OF INCOME AND

24 RESOURCES.—For purposes of applying 

25 this section— 


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1 ‘‘(I) an individual shall be per2 mitted to apply on the basis of self3 certification of income and resources; 

4 and 

5 ‘‘(II) matters attested to in the 

6 application shall be subject to appro7 priate methods of verification without 

8 the need of the individual to provide 

9 additional documentation, except in 

10 extraordinary situations as determined 

11 by the Commissioner.’’. 

12 (2) EFFECTIVE DATE.—The amendment made 

13 by paragraph (1) shall apply beginning January 1, 

14 2010. 

15 (b) DISCLOSURES TO FACILITATE IDENTIFICATION

16 OF INDIVIDUALS LIKELY TO BE INELIGIBLE FOR THE

17 LOW-INCOME ASSISTANCE UNDER THE MEDICARE PRE18 SCRIPTION DRUG PROGRAM TO ASSIST SOCIAL SECURITY

19 ADMINISTRATION’S OUTREACH TO ELIGIBLE INDIVID20 UALS.—For provision authorizing disclosure of return in21 formation to facilitate identification of individuals likely 

22 to be ineligible for low-income subsidies under Medicare 

23 prescription drug program, see section 1801. 


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1 SEC. 1204. ENHANCED OVERSIGHT RELATING TO REIM2 BURSEMENTS FOR RETROACTIVE LOW IN3 COME SUBSIDY ENROLLMENT. 

4 (a) IN GENERAL.—In the case of a retroactive LIS 

5 enrollment beneficiary who is enrolled under a prescription 

6 drug plan under part D of title XVIII of the Social Secu7 rity Act (or an MA–PD plan under part C of such title), 

8 the beneficiary (or any eligible third party) is entitled to 

9 reimbursement by the plan for covered drug costs incurred 

10 by the beneficiary during the retroactive coverage period 

11 of the beneficiary in accordance with subsection (b) and 

12 in the case of such a beneficiary described in subsection 

13 (c)(4)(A)(i), such reimbursement shall be made automati14 cally by the plan upon receipt of appropriate notice the 

15 beneficiary is eligible for assistance described in such sub16 section (c)(4)(A)(i) without further information required 

17 to be filed with the plan by the beneficiary. 

18 (b) ADMINISTRATIVE REQUIREMENTS RELATING TO

19 REIMBURSEMENTS.— 

20 (1) LINE-ITEM DESCRIPTION.—Each reimburse21 ment made by a prescription drug plan or MA–PD 

22 plan under subsection (a) shall include a line-item 

23 description of the items for which the reimbursement 

24 is made. 

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1 bursement under subsection (a) to a retroactive LIS 

2 enrollment beneficiary, with respect to a claim, not 

3 later than 45 days after— 

4 (A) in the case of a beneficiary described 

5 in subsection (c)(4)(A)(i), the date on which the 

6 plan receives notice from the Secretary that the 

7 beneficiary is eligible for assistance described in 

8 such subsection; or 

9 (B) in the case of a beneficiary described 

10 in subsection (c)(4)(A)(ii), the date on which 

11 the beneficiary files the claim with the plan. 

12 (3) REPORTING REQUIREMENT.—For each 

13 month beginning with January 2011, each prescrip14 tion drug plan and each MA–PD plan shall report 

15 to the Secretary the following: 

16 (A) The number of claims the plan has re17 adjudicated during the month due to a bene18 ficiary becoming retroactively eligible for sub19 sidies available under section 1860D–14 of the 

20 Social Security Act. 

21 (B) The total value of the readjudicated 

22 claim amount for the month. 

23 (C) The Medicare Health Insurance Claims 

24 Number of beneficiaries for whom claims were 

25 readjudicated. 


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1 (D) For the claims described in subpara2 graphs (A) and (B), an attestation to the Ad3 ministrator of the Centers for Medicare & Med4 icaid Services of the total amount of reimburse5 ment the plan has provided to beneficiaries for 

6 premiums and cost-sharing that the beneficiary 

7 overpaid for which the plan received payment 

8 from the Centers for Medicare & Medicaid Serv9 ices. 

10 (c) DEFINITIONS.—For purposes of this section: 

11 (1) COVERED DRUG COSTS.—The term ‘‘cov12 ered drug costs’’ means, with respect to a retroactive 

13 LIS enrollment beneficiary enrolled under a pre14 scription drug plan under part D of title XVIII of 

15 the Social Security Act (or an MA–PD plan under 

16 part C of such title), the amount by which— 

17 (A) the costs incurred by such beneficiary 

18 during the retroactive coverage period of the 

19 beneficiary for covered part D drugs, premiums, 

20 and cost-sharing under such title; exceeds 

21 (B) such costs that would have been in22 curred by such beneficiary during such period if 

23 the beneficiary had been both enrolled in the 

24 plan and recognized by such plan as qualified 

25 during such period for the low income subsidy 


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1 under section 1860D–14 of the Social Security 

2 Act to which the individual is entitled. 

3 (2) ELIGIBLE THIRD PARTY.—The term ‘‘eligi4 ble third party’’ means, with respect to a retroactive 

5 LIS enrollment beneficiary, an organization or other 

6 third party that is owed payment on behalf of such 

7 beneficiary for covered drug costs incurred by such 

8 beneficiary during the retroactive coverage period of 

9 such beneficiary. 

10 (3) RETROACTIVE COVERAGE PERIOD.—The 

11 term ‘‘retroactive coverage period’’ means— 

12 (A) with respect to a retroactive LIS en13 rollment beneficiary described in paragraph 

14 (4)(A)(i), the period— 

15 (i) beginning on the effective date of 

16 the assistance described in such paragraph 

17 for which the individual is eligible; and 

18 (ii) ending on the date the plan effec19 tuates the status of such individual as so 

20 eligible; and 

21 (B) with respect to a retroactive LIS en22 rollment beneficiary described in paragraph 

23 (4)(A)(ii), the period— 

24 (i) beginning on the date the indi25 vidual is both entitled to benefits under 


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1 part A, or enrolled under part B, of title 

2 XVIII of the Social Security Act and eligi3 ble for medical assistance under a State 

4 plan under title XIX of such Act; and 

5 (ii) ending on the date the plan effec6 tuates the status of such individual as a 

7 full-benefit dual eligible individual (as de8 fined in section 1935(c)(6) of such Act). 

9 (4) RETROACTIVE LIS ENROLLMENT BENE10 FICIARY.— 

11 (A) IN GENERAL.—The term ‘‘retroactive 

12 LIS enrollment beneficiary’’ means an indi13 vidual who— 

14 (i) is enrolled in a prescription drug 

15 plan under part D of title XVIII of the So16 cial Security Act (or an MA–PD plan 

17 under part C of such title) and subse18 quently becomes eligible as a full-benefit 

19 dual eligible individual (as defined in sec20 tion 1935(c)(6) of such Act), an individual 

21 receiving a low-income subsidy under sec22 tion 1860D–14 of such Act, an individual 

23 receiving assistance under the Medicare 

24 Savings Program implemented under 

25 clauses (i), (iii), and (iv) of section 


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1 1902(a)(10)(E) of such Act, or an indi2 vidual receiving assistance under the sup3 plemental security income program under 

4 section 1611 of such Act; or 

5 (ii) subject to subparagraph (B)(i), is 

6 a full-benefit dual eligible individual (as 

7 defined in section 1935(c)(6) of such Act) 

8 who is automatically enrolled in such a 

9 plan under section 1860D–1(b)(1)(C) of 

10 such Act. 

11 (B) EXCEPTION FOR BENEFICIARIES EN12 ROLLED IN RFP PLAN.— 

13 (i) IN GENERAL.—In no case shall an 

14 individual described in subparagraph 

15 (A)(ii) include an individual who is en16 rolled, pursuant to a RFP contract de17 scribed in clause (ii), in a prescription 

18 drug plan offered by the sponsor of such 

19 plan awarded such contract. 

20 (ii) RFP CONTRACT DESCRIBED.— 

21 The RFP contract described in this section 

22 is a contract entered into between the Sec23 retary and a sponsor of a prescription drug 

24 plan pursuant to the Centers for Medicare 

25 & Medicaid Services’ request for proposals 


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1 issued on February 17, 2009, relating to 

2 Medicare part D retroactive coverage for 

3 certain low income beneficiaries, or a simi4 lar subsequent request for proposals. 

5 SEC. 1205. INTELLIGENT ASSIGNMENT IN ENROLLMENT. 

6 (a) IN GENERAL.—Section 1860D–1(b)(1)(C) of the 

7 Social Security Act (42 U.S.C. 1395w–101(b)(1)(C)) is 

8 amended by adding after ‘‘PDP region’’ the following: ‘‘or 

9 through use of an intelligent assignment process that is 

10 designed to maximize the access of such individual to nec11 essary prescription drugs while minimizing costs to such 

12 individual and to the program under this part to the great13 est extent possible. In the case the Secretary enrolls such 

14 individuals through use of an intelligent assignment proc15 ess, such process shall take into account the extent to 

16 which prescription drugs necessary for the individual are 

17 covered in the case of a PDP sponsor of a prescription 

18 drug plan that uses a formulary, the use of prior author19 ization or other restrictions on access to coverage of such 

20 prescription drugs by such a sponsor, and the overall qual21 ity of a prescription drug plan as measured by quality rat22 ings established by the Secretary’’ 

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

24 subsection (a) shall take effect for contract years begin25 ning with 2012. 


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1 SEC. 1206. SPECIAL ENROLLMENT PERIOD AND AUTOMATIC 

2 ENROLLMENT PROCESS FOR CERTAIN SUB3 SIDY ELIGIBLE INDIVIDUALS. 

4 (a) SPECIAL ENROLLMENT PERIOD.—Section 

5 1860D–1(b)(3)(D) of the Social Security Act (42 U.S.C. 

6 1395w–101(b)(3)(D)) is amended to read as follows: 

7 ‘‘(D) SUBSIDY ELIGIBLE INDIVIDUALS.— 

8 In the case of an individual (as determined by 

9 the Secretary) who is determined under sub10 paragraph (B) of section 1860D–14(a)(3) to be 

11 a subsidy eligible individual.’’. 

12 (b) AUTOMATIC ENROLLMENT.—Section 1860D– 

13 1(b)(1) of the Social Security Act (42 U.S.C. 1395w– 

14 101(b)(1)) is amended by adding at the end the following 

15 new subparagraph: 

16 ‘‘(D) SPECIAL RULE FOR SUBSIDY ELIGI17 BLE INDIVIDUALS.—The process established 

18 under subparagraph (A) shall include, in the 

19 case of an individual described in section 

20 1860D–1(b)(3)(D) who fails to enroll in a pre21 scription drug plan or an MA–PD plan during 

22 the special enrollment established under such 

23 section applicable to such individual, the appli24 cation of the assignment process described in 

25 subparagraph (C) to such individual in the 

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1 plies to a part D eligible individual described in 

2 such subparagraph (C). Nothing in the previous 

3 sentence shall prevent an individual described in 

4 such sentence from declining enrollment in a 

5 plan determined appropriate by the Secretary 

6 (or in the program under this part) or from 

7 changing such enrollment.’’. 

8 (c) EFFECTIVE DATE.—The amendments made by 

9 this section shall apply to subsidy determinations made 

10 for months beginning with January 2011. 

11 SEC. 1207. APPLICATION OF MA PREMIUMS PRIOR TO RE12 BATE AND QUALITY BONUS PAYMENTS IN 

13 CALCULATION OF LOW INCOME SUBSIDY 

14 BENCHMARK. 

15 (a) IN GENERAL.—Section 1860D–14(b)(2)(B)(iii) 

16 of the Social Security Act (42 U.S.C. 1395w– 

17 114(b)(2)(B)(iii)) is amended by inserting before the pe18 riod the following: ‘‘before the application of the monthly 

19 rebate computed under section 1854(b)(1)(C)(i) for that 

20 plan and year involved and, in the case of a qualifying 

21 plan in a qualifying county, before the application of the 

22 increase under section 1853(o) for that plan and year in23 volved’’. 


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

2 subsection (a) shall apply to subsidy determinations made 

3 for months beginning with January 2011. 

4 Subtitle B—Reducing Health 

5 Disparities 

6 SEC. 1221. ENSURING EFFECTIVE COMMUNICATION IN 

7 MEDICARE. 

8 (a) ENSURING EFFECTIVE COMMUNICATION BY THE

9 CENTERS FOR MEDICARE & MEDICAID SERVICES.— 

10 (1) STUDY ON MEDICARE PAYMENTS FOR LAN11 GUAGE SERVICES.—The Secretary of Health and 

12 Human Services shall conduct a study that examines 

13 the extent to which Medicare service providers uti14 lize, offer, or make available language services for 

15 beneficiaries who are limited English proficient and 

16 ways that Medicare should develop payment systems 

17 for language services. 

18 (2) ANALYSES.—The study shall include an 

19 analysis of each of the following: 

20 (A) How to develop and structure appro21 priate payment systems for language services 

22 for all Medicare service providers. 

23 (B) The feasibility of adopting a payment 

24 methodology for on-site interpreters, including 

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1 tors and interpreters who work for agencies 

2 that provide on-site interpretation, pursuant to 

3 which such interpreters could directly bill Medi4 care for services provided in support of physi5 cian office services for an LEP Medicare pa6 tient. 

7 (C) The feasibility of Medicare contracting 

8 directly with agencies that provide off-site inter9 pretation including telephonic and video inter10 pretation pursuant to which such contractors 

11 could directly bill Medicare for the services pro12 vided in support of physician office services for 

13 an LEP Medicare patient. 

14 (D) The feasibility of modifying the exist15 ing Medicare resource-based relative value scale 

16 (RBRVS) by using adjustments (such as multi17 pliers or add-ons) when a patient is LEP. 

18 (E) How each of options described in a 

19 previous paragraph would be funded and how 

20 such funding would affect physician payments, 

21 a physician’s practice, and beneficiary cost22 sharing. 

23 (F) The extent to which providers under 

24 parts A and B of title XVIII of the Social Secu25 rity Act, MA organizations offering Medicare 


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1 Advantage plans under part C of such title and 

2 PDP sponsors of a prescription drug plan 

3 under part D of such title utilize, offer, or make 

4 available language services for beneficiaries with 

5 limited English proficiency. 

6 (G) The nature and type of language serv7 ices provided by States under title XIX of the 

8 Social Security Act and the extent to which 

9 such services could be utilized by beneficiaries 

10 and providers under title XVIII of such Act. 

11 (H) The extent to which interpreters and 

12 translators providing services to Medicare bene13 ficiaries under title XVIII of such Act are 

14 trained or accredited. 

15 (3) VARIATION IN PAYMENT SYSTEM DE16 SCRIBED.—The payment systems described in para17 graph (2)(A) may allow variations based upon types 

18 of service providers, available delivery methods, and 

19 costs for providing language services including such 

20 factors as— 

21 (A) the type of language services provided 

22 (such as provision of health care or health care 

23 related services directly in a non-English lan24 guage by a bilingual provider or use of an inter25 preter); 


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1 (B) type of interpretation services provided 

2 (such as in-person, telephonic, video interpreta3 tion); 

4 (C) the methods and costs of providing 

5 language services (including the costs of pro6 viding language services with internal staff or 

7 through contract with external independent con8 tractors or agencies, or both); 

9 (D) providing services for languages not 

10 frequently encountered in the United States; 

11 and 

12 (E) providing services in rural areas. 

13 (4) REPORT.—The Secretary shall submit a re14 port on the study conducted under subsection (a) to 

15 appropriate committees of Congress not later than 

16 12 months after the date of the enactment of this 

17 Act. 

18 (5) EXEMPTION FROM PAPERWORK REDUCTION

19 ACT.—Chapter 35 of title 44, United States Code 

20 (commonly known as the ‘‘Paperwork Reduction 

21 Act’’ ), shall not apply for purposes of carrying out 

22 this subsection. 

23 (6) AUTHORIZATION OF APPROPRIATIONS.— 

24 The Secretary shall provide for the transfer, from 

25 the Federal Supplementary Medical Insurance Trust 


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1 Fund under section 1841 of the Social Security Act 

2 (42 U.S.C. 1395t) of $2,000,000 for purposes of 

3 carrying out this subsection. 

4 (b) HEALTH PLANS.—Section 1857(g)(1) of the So5 cial Security Act (42 U.S.C. 1395w–27(g)(1)) is amend6 ed— 

7 (1) by striking ‘‘or’’ at the end of subparagraph 

8 (F); 

9 (2) by adding ‘‘or’’ at the end of subparagraph 

10 (G); and 

11 (3) by inserting after subparagraph (G) the fol12 lowing new subparagraph: 

13 ‘‘(H) fails substantially to provide lan14 guage services to limited English proficient 

15 beneficiaries enrolled in the plan that are re16 quired under law;’’. 

17 SEC. 1222. DEMONSTRATION TO PROMOTE ACCESS FOR 

18 MEDICARE BENEFICIARIES WITH LIMITED 

19 ENGLISH PROFICIENCY BY PROVIDING REIM20 BURSEMENT FOR CULTURALLY AND LINGUIS21 TICALLY APPROPRIATE SERVICES. 

22 (a) IN GENERAL.—Not later than 6 months after the 

23 date of the completion of the study described in section 

24 1221(a) of this Act, the Secretary, acting through the 

25 Centers for Medicare & Medicaid Services and the Center 


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1 for Medicare and Medicaid Innovation established under 

2 section 1115A of the Social Security Act (as added by sec3 tion 1907) and consistent with the applicable provisions 

4 of such section, shall carry out a demonstration program 

5 under which the Secretary shall award not fewer than 24 

6 3-year grants to eligible Medicare service providers (as de7 scribed in subsection (b)(1)) to improve effective commu8 nication between such providers and Medicare bene9 ficiaries who are living in communities where racial and 

10 ethnic minorities, including populations that face language 

11 barriers, are underserved with respect to such services. In 

12 designing and carrying out the demonstration the Sec13 retary shall take into consideration the results of the study 

14 conducted under section 1221(a) of this Act and adjust, 

15 as appropriate, the distribution of grants so as to better 

16 target Medicare beneficiaries who are in the greatest need 

17 of language services. The Secretary shall not authorize a 

18 grant larger than $500,000 over three years for any grant19 ee. 

20 (b) ELIGIBILITY; PRIORITY.— 

21 (1) ELIGIBILITY.—To be eligible to receive a 

22 grant under subsection (a) an entity shall— 

23 (A) be— 

24 (i) a provider of services under part A 

25 of title XVIII of the Social Security Act; 


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1 (ii) a service provider under part B of 

2 such title; 

3 (iii) a part C organization offering a 

4 Medicare part C plan under part C of such 

5 title; or 

6 (iv) a PDP sponsor of a prescription 

7 drug plan under part D of such title; and 

8 (B) prepare and submit to the Secretary 

9 an application, at such time, in such manner, 

10 and accompanied by such additional informa11 tion as the Secretary may require. 

12 (2) PRIORITY.— 

13 (A) DISTRIBUTION.—To the extent fea14 sible, in awarding grants under this section, the 

15 Secretary shall award— 

16 (i) at least 6 grants to providers of 

17 services described in paragraph (1)(A)(i); 

18 (ii) at least 6 grants to service pro19 viders described in paragraph (1)(A)(ii); 

20 (iii) at least 6 grants to organizations 

21 described in paragraph (1)(A)(iii); and 

22 (iv) at least 6 grants to sponsors de23 scribed in paragraph (1)(A)(iv). 

24 (B) FOR COMMUNITY ORGANIZATIONS.— 

25 The Secretary shall give priority to applicants 


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1 that have developed partnerships with commu2 nity organizations or with agencies with experi3 ence in language access. 

4 (C) VARIATION IN GRANTEES.—The Sec5 retary shall also ensure that the grantees under 

6 this section represent, among other factors— 

7 (i) different types of language services 

8 provided and of service providers and orga9 nizations under parts A through D of title 

10 XVIII of the Social Security Act; 

11 (ii) variations in languages needed 

12 and their frequency of use; 

13 (iii) urban and rural settings; 

14 (iv) at least two geographic regions, 

15 as defined by the Secretary; and 

16 (v) at least two large metropolitan 

17 statistical areas with diverse populations. 

18 (c) USE OF FUNDS.— 

19 (1) IN GENERAL.—A grantee shall use grant 

20 funds received under this section to pay for the pro21 vision of competent language services to Medicare 

22 beneficiaries who are limited English proficient. 

23 Competent interpreter services may be provided 

24 through on-site interpretation, telephonic interpreta25 tion, or video interpretation or direct provision of 


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1 health care or health care related services by a bilin2 gual health care provider. A grantee may use bilin3 gual providers, staff, or contract interpreters. A 

4 grantee may use grant funds to pay for competent 

5 translation services. A grantee may use up to 10 

6 percent of the grant funds to pay for administrative 

7 costs associated with the provision of competent lan8 guage services and for reporting required under sub9 section (e). 

10 (2) ORGANIZATIONS.—Grantees that are part C 

11 organizations or PDP sponsors must ensure that 

12 their network providers receive at least 50 percent of 

13 the grant funds to pay for the provision of com14 petent language services to Medicare beneficiaries 

15 who are limited English proficient, including physi16 cians and pharmacies. 

17 (3) DETERMINATION OF PAYMENTS FOR LAN18 GUAGE SERVICES.—Payments to grantees shall be 

19 calculated based on the estimated numbers of lim20 ited English proficient Medicare beneficiaries in a 

21 grantee’s service area utilizing— 

22 (A) data on the numbers of limited 

23 English proficient individuals who speak 

24 English less than ‘‘very well’’ from the most re25 cently available data from the Bureau of the 


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1 Census or other State-based study the Sec2 retary determines likely to yield accurate data 

3 regarding the number of such individuals served 

4 by the grantee; or 

5 (B) the grantee’s own data if the grantee 

6 routinely collects data on Medicare bene7 ficiaries’ primary language in a manner deter8 mined by the Secretary to yield accurate data 

9 and such data shows greater numbers of limited 

10 English proficient individuals than the data list11 ed in subparagraph (A). 

12 (4) LIMITATIONS.— 

13 (A) REPORTING.—Payments shall only be 

14 provided under this section to grantees that re15 port their costs of providing language services 

16 as required under subsection (e) and may be 

17 modified annually at the discretion of the Sec18 retary. If a grantee fails to provide the reports 

19 under such section for the first year of a grant, 

20 the Secretary may terminate the grant and so21 licit applications from new grantees to partici22 pate in the subsequent two years of the dem23 onstration program. 

24 (B) TYPE OF SERVICES.— 


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1 (i) IN GENERAL.—Subject to clause 

2 (ii), payments shall be provided under this 

3 section only to grantees that utilize com4 petent bilingual staff or competent inter5 preter or translation services which— 

6 (I) if the grantee operates in a 

7 State that has statewide health care 

8 interpreter standards, meet the State 

9 standards currently in effect; or 

10 (II) if the grantee operates in a 

11 State that does not have statewide 

12 health care interpreter standards, uti13 lizes competent interpreters who fol14 low the National Council on Inter15 preting in Health Care’s Code of Eth16 ics and Standards of Practice. 

17 (ii) EXEMPTIONS.—The requirements 

18 of clause (i) shall not apply— 

19 (I) in the case of a Medicare ben20 eficiary who is limited English pro21 ficient (who has been informed in the 

22 beneficiary’s primary language of the 

23 availability of free interpreter and 

24 translation services) and who requests 

25 the use of family, friends, or other 


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1 persons untrained in interpretation or 

2 translation and the grantee documents 

3 the request in the beneficiary’s record; 

4 and 

5 (II) in the case of a medical 

6 emergency where the delay directly as7 sociated with obtaining a competent 

8 interpreter or translation services 

9 would jeopardize the health of the pa10 tient. 

11 Nothing in clause (ii)(II) shall be con12 strued to exempt emergency rooms or simi13 lar entities that regularly provide health 

14 care services in medical emergencies from 

15 having in place systems to provide com16 petent interpreter and translation services 

17 without undue delay. 

18 (d) ASSURANCES.—Grantees under this section 

19 shall— 

20 (1) ensure that appropriate clinical and support 

21 staff receive ongoing education and training in lin22 guistically appropriate service delivery; 

23 (2) ensure the linguistic competence of bilingual 

24 providers; 


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1 (3) offer and provide appropriate language serv2 ices at no additional charge to each patient with lim3 ited English proficiency at all points of contact, in 

4 a timely manner during all hours of operation; 

5 (4) notify Medicare beneficiaries of their right 

6 to receive language services in their primary lan7 guage; 

8 (5) post signage in the languages of the com9 monly encountered group or groups present in the 

10 service area of the organization; and 

11 (6) ensure that— 

12 (A) primary language data are collected 

13 for recipients of language services and are con14 sistent with standards developed under section 

15 1709(b)(3)(B)(iv) of the Public Health Service 

16 Act, as added by section 2402 of this Act, to 

17 the extent such standards are available upon 

18 the initiation of the demonstration; and 

19 (B) consistent with the privacy protections 

20 provided under the regulations promulgated 

21 pursuant to section 264(c) of the Health Insur22 ance Portability and Accountability Act of 1996 

23 (42 U.S.C. 1320d–2 note), if the recipient of 

24 language services is a minor or is incapacitated, 


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1 the primary language of the parent or legal 

2 guardian is collected and utilized. 

3 (e) REPORTING REQUIREMENTS.—Grantees under 

4 this section shall provide the Secretary with reports at the 

5 conclusion of the each year of a grant under this section. 

6 Each report shall include at least the following informa7 tion: 

8 (1) The number of Medicare beneficiaries to 

9 whom language services are provided. 

10 (2) The languages of those Medicare bene11 ficiaries. 

12 (3) The types of language services provided 

13 (such as provision of services directly in non-English 

14 language by a bilingual health care provider or use 

15 of an interpreter). 

16 (4) Type of interpretation (such as in-person, 

17 telephonic, or video interpretation). 

18 (5) The methods of providing language services 

19 (such as staff or contract with external independent 

20 contractors or agencies). 

21 (6) The length of time for each interpretation 

22 encounter. 

23 (7) The costs of providing language services 

24 (which may be actual or estimated, as determined by 

25 the Secretary). 


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1 (8) An account of the training or accreditation 

2 of bilingual staff, interpreters, or translators pro3 viding services under this demonstration. 

4 (f) NO COST SHARING.—Limited English proficient 

5 Medicare beneficiaries shall not have to pay cost-sharing 

6 or co-pays for language services provided through this 

7 demonstration program. 

8 (g) EVALUATION AND REPORT.—The Secretary shall 

9 conduct an evaluation of the demonstration program 

10 under this section and shall submit to the appropriate 

11 committees of Congress a report not later than 1 year 

12 after the completion of the program. The report shall in13 clude the following: 

14 (1) An analysis of the patient outcomes and 

15 costs of furnishing care to the limited English pro16 ficient Medicare beneficiaries participating in the 

17 project as compared to such outcomes and costs for 

18 limited English proficient Medicare beneficiaries not 

19 participating. 

20 (2) The effect of delivering culturally and lin21 guistically appropriate services on beneficiary access 

22 to care, utilization of services, efficiency and cost-ef23 fectiveness of health care delivery, patient satisfac24 tion, and select health outcomes. 


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1 (3) The extent to which bilingual staff, inter2 preters, and translators providing services under 

3 such demonstration were trained or accredited and 

4 the nature of accreditation or training needed by 

5 type of provider, service, or other category as deter6 mined by the Secretary to ensure the provision of 

7 high-quality interpretation, translation, or other lan8 guage services to Medicare beneficiaries if such serv9 ices are expanded pursuant to subsection (c) of sec10 tion 1907 of this Act. 

11 (4) Recommendations, if any, regarding the ex12 tension of such project to the entire Medicare pro13 gram. 

14 (h) ACCREDITATION OR TRAINING FOR PROVIDERS

15 OF INTERPRETATION, TRANSLATION OR LANGUAGE

16 SERVICES IN MEDICARE.— 

17 (1) IN GENERAL.— 

18 (A) DESIGNATION OF STANDARDS.—If the 

19 Secretary, pursuant to section 1907(c) of this 

20 Act, expands the model initially developed 

21 through the demonstration program under this 

22 section, the Secretary shall use the results of 

23 the study under section 1221 and the dem24 onstration under this section to designate 

25 standards for training or accreditation. The 


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1 Secretary may designate one or more training 

2 or accreditation organizations, as appropriate 

3 for the nature and type of interpretation and 

4 translation services provided to Medicare bene5 ficiaries to ensure that payments are made only 

6 for approved services by trained or accredited 

7 language services providers. 

8 (B) ALTERNATIVES TO TRAINING OR AC9 CREDITATION.—If the Secretary designates one 

10 or more training or accreditation organiza11 tions but determines that accreditation is not 

12 available in all languages for which payments 

13 may be initiated, the Secretary shall provide 

14 payments for and accept alternatives to train15 ing or accreditation for certain languages, in16 cluding languages of lesser diffusion. The Sec17 retary must ensure that the alternatives to

18 training or accreditation provide, at a min19 imum— 

20 (i) a determination that the inter21 preter is proficient and able to commu22 nicate information accurately in both 

23 English and in the language for which in24 terpreting is needed; 


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1 (ii) an attestation from the interpreter 

2 to comply with and adhere to the role of 

3 an interpreter as defined by the National 

4 Code of Ethics and National Standards of 

5 Practice as published by the National 

6 Council on Interpreting in Health Care; 

7 and 

8 (iii) an attestation to adhere to 

9 HIPAA privacy and security law, as de10 fined in section 3009(a)(2) of the Public 

11 Health Service Act, to the same extent as 

12 the healthcare provider for whom inter13 preting is provided. 

14 (C) MODIFIERS, ADD-ONS, AND OTHER

15 FORMS OF PAYMENT.—If the Secretary decides 

16 that modifiers, add-ons, or other forms of pay17 ment may be made for the provision of services 

18 directly by bilingual providers, the Secretary 

19 shall designate standards to ensure the com20 petency of such providers delivering such serv21 ices in a non-English language. 

22 (2) CONSULTATION WITH STAKEHOLDERS AND

23 CONSIDERATIONS FOR ACCREDITATION OR TRAIN24 ING.— 


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1 (A) CONSULTATION.—In designating ac2 creditation or training requirements under this 

3 subsection, the Secretary shall consult with pa4 tients, providers, organizations that advocate on 

5 behalf of limited English proficient individuals, 

6 and other individuals or entities determined ap7 propriate by the Secretary. 

8 (B) CONSIDERATIONS.—In designating ac9 creditation or training requirements under this 

10 section, the Secretary shall consider, as appro11 priate— 

12 (i) standards for qualifications of 

13 health care interpreters who interpret in14 frequently encountered languages; 

15 (ii) standards for qualifications of 

16 health care interpreters who interpret in 

17 languages of lesser diffusion; 

18 (iii) standards for training of inter19 preters; and

20 (iv) standards for continuing edu21 cation of interpreters. 

22 (i) GENERAL PROVISIONS.—Nothing in this section 

23 shall be construed to limit otherwise existing obligations 

24 of recipients of Federal financial assistance under title VI 


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1 of the Civil Rights Act of 1964 (42 U.S.C. 2000(d) et 

2 seq.) or any other statute. 

3 (j) APPROPRIATIONS.—There are appropriated to 

4 carry out this section, in equal parts from the Federal 

5 Hospital Insurance Trust Fund and the Federal Supple6 mentary Medical Insurance Trust Fund, $16,000,000 for 

7 each fiscal year of the demonstration program. 

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

9 SERVICES. 

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

11 Human Services shall enter into an arrangement with the 

12 Institute of Medicine under which the Institute will pre13 pare and publish, not later than 3 years after the date 

14 of the enactment of this Act, a report on the impact of 

15 language access services on the health and health care of 

16 limited English proficient populations. 

17 (b) CONTENTS.—Such report shall include— 

18 (1) recommendations on the development and 

19 implementation of policies and practices by health 

20 care organizations and providers for limited English 

21 proficient patient populations; 

22 (2) a description of the effect of providing lan23 guage access services on quality of health care and 

24 access to care and reduced medical error; and 


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1 (3) a description of the costs associated with or 

2 savings related to provision of language access serv3 ices. 

4 SEC. 1224. DEFINITIONS. 

5 In this subtitle: 

6 (1) BILINGUAL.—The term ‘‘bilingual’’ with re7 spect to an individual means a person who has suffi8 cient degree of proficiency in two languages and can 

9 ensure effective communication can occur in both 

10 languages. 

11 (2) COMPETENT INTERPRETER SERVICES.—The 

12 term ‘‘competent interpreter services’’ means a 

13 trans-language rendition of a spoken message in 

14 which the interpreter comprehends the source lan15 guage and can speak comprehensively in the target 

16 language to convey the meaning intended in the 

17 source language. The interpreter knows health and 

18 health-related terminology and provides accurate in19 terpretations by choosing equivalent expressions that 

20 convey the best matching and meaning to the source 

21 language and captures, to the greatest possible ex22 tent, all nuances intended in the source message. 

23 (3) COMPETENT TRANSLATION SERVICES.—The 

24 term ‘‘competent translation services’’ means a 

25 trans-language rendition of a written document in 


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1 which the translator comprehends the source lan2 guage and can write comprehensively in the target 

3 language to convey the meaning intended in the 

4 source language. The translator knows health and 

5 health-related terminology and provides accurate 

6 translations by choosing equivalent expressions that 

7 convey the best matching and meaning to the source 

8 language and captures, to the greatest possible ex9 tent, all nuances intended in the source document. 

10 (4) EFFECTIVE COMMUNICATION.—The term 

11 ‘‘effective communication’’ means an exchange of in12 formation between the provider of health care or 

13 health care-related services and the limited English 

14 proficient recipient of such services that enables lim15 ited English proficient individuals to access, under16 stand, and benefit from health care or health care17 related services. 

18 (5) INTERPRETING/INTERPRETATION.—The 

19 terms ‘‘interpreting’’ and ‘‘interpretation’’ mean the 

20 transmission of a spoken message from one language 

21 into another, faithfully, accurately, and objectively. 

22 (6) HEALTH CARE SERVICES.—The term 

23 ‘‘health care services’’ means services that address 

24 physical as well as mental health conditions in all 

25 care settings. 


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1 (7) HEALTH CARE-RELATED SERVICES.—The 

2 term ‘‘health care-related services’’ means human or 

3 social services programs or activities that provide ac4 cess, referrals or links to health care. 

5 (8) LANGUAGE ACCESS.—The term ‘‘language 

6 access’’ means the provision of language services to 

7 an LEP individual designed to enhance that individ8 ual’s access to, understanding of or benefit from 

9 health care or health care-related services. 

10 (9) LANGUAGE SERVICES.—The term ‘‘lan11 guage services’’ means provision of health care serv12 ices directly in a non-English language, interpreta13 tion, translation, and non-English signage. 

14 (10) LIMITED ENGLISH PROFICIENT.—The 

15 term ‘‘limited English proficient’’ or ‘‘LEP’’ with re16 spect to an individual means an individual who 

17 speaks a primary language other than English and 

18 who cannot speak, read, write or understand the 

19 English language at a level that permits the indi20 vidual to effectively communicate with clinical or 

21 nonclinical staff at an entity providing health care or 

22 health care related services. 

23 (11) MEDICARE BENEFICIARY.—The term 

24 ‘‘Medicare beneficiary’’ means an individual entitled 


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1 to benefits under part A of title XVIII of the Social 

2 Security Act or enrolled under part B of such title. 

3 (12) MEDICARE PROGRAM.—The term ‘‘Medi4 care program’’ means the programs under parts A 

5 through D of title XVIII of the Social Security Act. 

6 (13) SERVICE PROVIDER.—The term ‘‘service 

7 provider’’ includes all suppliers, providers of services, 

8 or entities under contract to provide coverage, items 

9 or services under any part of title XVIII of the So10 cial Security Act. 

11 Subtitle C—Miscellaneous 

12 Improvements 

13 SEC. 1231. EXTENSION OF THERAPY CAPS EXCEPTIONS 

14 PROCESS. 

15 Section 1833(g)(5) of the Social Security Act (42 

16 U.S.C. 1395l(g)(5)), as amended by section 141 of the 

17 Medicare Improvements for Patients and Providers Act of 

18 2008 (Public Law 110–275), is amended by striking ‘‘De19 cember 31, 2009’’ and inserting ‘‘December 31, 2011’’. 


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1 SEC. 1232. EXTENDED MONTHS OF COVERAGE OF IMMUNO2 SUPPRESSIVE DRUGS FOR KIDNEY TRANS3 PLANT PATIENTS AND OTHER RENAL DIALY4 SIS PROVISIONS. 

5 (a) PROVISION OF APPROPRIATE COVERAGE OF IM6 MUNOSUPPRESSIVE DRUGS UNDER THE MEDICARE PRO7 GRAM FOR KIDNEY TRANSPLANT RECIPIENTS.— 

8 (1) CONTINUED ENTITLEMENT TO IMMUNO9 SUPPRESSIVE DRUGS.— 

10 (A) KIDNEY TRANSPLANT RECIPIENTS.— 

11 Section 226A(b)(2) of the Social Security Act 

12 (42 U.S.C. 426–1(b)(2)) is amended by insert13 ing ‘‘(except for coverage of immunosuppressive 

14 drugs under section 1861(s)(2)(J))’’ before ‘‘, 

15 with the thirty-sixth month’’. 

16 (B) APPLICATION.—Section 1836 of such 

17 Act (42 U.S.C. 1395o) is amended— 

18 (i) by striking ‘‘Every individual who’’ 

19 and inserting ‘‘(a) IN GENERAL.—Every 

20 individual who’’; and 

21 (ii) by adding at the end the following 

22 new subsection: 

23 ‘‘(b) SPECIAL RULES APPLICABLE TO INDIVIDUALS

24 ONLY ELIGIBLE FOR COVERAGE OF IMMUNOSUPPRESSIVE

25 DRUGS.— 


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1 ‘‘(1) IN GENERAL.—In the case of an individual 

2 whose eligibility for benefits under this title has 

3 ended on or after January 1, 2012, except for the 

4 coverage of immunosuppressive drugs by reason of 

5 section 226A(b)(2), the following rules shall apply: 

6 ‘‘(A) The individual shall be deemed to be 

7 enrolled under this part for purposes of receiv8 ing coverage of such drugs. 

9 ‘‘(B) The individual shall be responsible 

10 for providing for payment of the portion of the 

11 premium under section 1839 which is not cov12 ered under the Medicare savings program (as 

13 defined in section 1144(c)(7)) in order to re14 ceive such coverage. 

15 ‘‘(C) The provision of such drugs shall be 

16 subject to the application of— 

17 ‘‘(i) the deductible under section 

18 1833(b); and 

19 ‘‘(ii) the coinsurance amount applica20 ble for such drugs (as determined under 

21 this part). 

22 ‘‘(D) If the individual is an inpatient of a 

23 hospital or other entity, the individual is enti24 tled to receive coverage of such drugs under 

25 this part. 


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1 ‘‘(2) ESTABLISHMENT OF PROCEDURES IN

2 ORDER TO IMPLEMENT COVERAGE.—The Secretary 

3 shall establish procedures for— 

4 ‘‘(A) identifying individuals that are enti5 tled to coverage of immunosuppressive drugs by 

6 reason of section 226A(b)(2); and 

7 ‘‘(B) distinguishing such individuals from 

8 individuals that are enrolled under this part for 

9 the complete package of benefits under this 

10 part.’’. 

11 (C) TECHNICAL AMENDMENT TO CORRECT

12 DUPLICATE SUBSECTION DESIGNATION.—Sub13 section (c) of section 226A of such Act (42 

14 U.S.C. 426–1), as added by section 

15 201(a)(3)(D)(ii) of the Social Security Inde16 pendence and Program Improvements Act of 

17 1994 (Public Law 103–296; 108 Stat. 1497), is 

18 redesignated as subsection (d). 

19 (2) EXTENSION OF SECONDARY PAYER RE20 QUIREMENTS FOR ESRD BENEFICIARIES.—Section 

21 1862(b)(1)(C) of such Act (42 U.S.C. 

22 1395y(b)(1)(C)) is amended by adding at the end 

23 the following new sentence: ‘‘With regard to im24 munosuppressive drugs furnished on or after the 

25 date of the enactment of the Affordable Health Care 


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1 for America Act, this subparagraph shall be applied 

2 without regard to any time limitation.’’. 

3 (b) MEDICARE COVERAGE FOR ESRD PATIENTS.— 

4 Section 1881 of such Act is further amended— 

5 (1) in subsection (b)(14)(B)(iii), by inserting ‘‘, 

6 including oral drugs that are not the oral equivalent 

7 of an intravenous drug (such as oral phosphate bind8 ers and calcimimetics),’’ after ‘‘other drugs and 

9 biologicals’’; 

10 (2) in subsection (b)(14)(E)(ii)— 

11 (A) in the first sentence— 

12 (i) by striking ‘‘a one-time election to 

13 be excluded from the phase-in’’ and insert14 ing ‘‘an election, with respect to 2011, 

15 2012, or 2013, to be excluded from the 

16 phase-in (or the remainder of the phase17 in)’’; and 

18 (ii) by adding before the period at the 

19 end the following: ‘‘for such year and for 

20 each subsequent year during the phase-in 

21 described in clause (i)’’; and 

22 (B) in the second sentence— 

23 (i) by striking ‘‘January 1, 2011’’ and 

24 inserting ‘‘the first date of such year’’; and 


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1 (ii) by inserting ‘‘and at a time’’ after 

2 ‘‘form and manner’’; and 

3 (3) in subsection (h)(4)(E), by striking ‘‘lesser’’ 

4 and inserting ‘‘greater’’. 

5 SEC. 1233. VOLUNTARY ADVANCE CARE PLANNING CON6 SULTATION. 

7 (a) IN GENERAL.—Section 1861 of the Social Secu8 rity Act (42 U.S.C. 1395x) is amended— 

9 (1) in subsection (s)(2)— 

10 (A) by striking ‘‘and’’ at the end of sub11 paragraph (DD); 

12 (B) by adding ‘‘and’’ at the end of sub13 paragraph (EE); and 

14 (C) by adding at the end the following new 

15 subparagraph: 

16 ‘‘(FF) voluntary advance care planning con17 sultation (as defined in subsection (hhh)(1));’’; and 

18 (2) by adding at the end the following new sub19 section: 

20 ‘‘Voluntary Advance Care Planning Consultation 

21 ‘‘(hhh)(1) Subject to paragraphs (3) and (4), the 

22 term ‘voluntary advance care planning consultation’ 

23 means an optional consultation between the individual and 

24 a practitioner described in paragraph (2) regarding adVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00641 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 vance care planning. Such consultation may include the 

2 following, as specified by the Secretary: 

3 ‘‘(A) An explanation by the practitioner of ad4 vance care planning, including a review of key ques5 tions and considerations, advance directives (includ6 ing living wills and durable powers of attorney) and 

7 their uses. 

8 ‘‘(B) An explanation by the practitioner of the 

9 role and responsibilities of a health care proxy and 

10 of the continuum of end-of-life services and supports 

11 available, including palliative care and hospice, and 

12 benefits for such services and supports that are 

13 available under this title. 

14 ‘‘(C) An explanation by the practitioner of phy15 sician orders regarding life sustaining treatment or 

16 similar orders, in States where such orders or simi17 lar orders exist. 

18 ‘‘(2) A practitioner described in this paragraph is— 

19 ‘‘(A) a physician (as defined in subsection 

20 (r)(1)); and 

21 ‘‘(B) another health care professional (as speci22 fied by the Secretary and who has the authority 

23 under State law to sign orders for life sustaining 

24 treatments, such as a nurse practitioner or physician 

25 assistant). 


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1 ‘‘(3) An individual may receive the voluntary advance 

2 care planning care planning consultation provided for 

3 under this subsection no more than once every 5 years 

4 unless there is a significant change in the health or health5 related condition of the individual. 

6 ‘‘(4) For purposes of this section, the term ‘order re7 garding life sustaining treatment’ means, with respect to 

8 an individual, an actionable medical order relating to the 

9 treatment of that individual that effectively communicates 

10 the individual’s preferences regarding life sustaining treat11 ment, is signed and dated by a practitioner, and is in a 

12 form that permits it to be followed by health care profes13 sionals across the continuum of care.’’. 

14 (b) CONSTRUCTION.—The voluntary advance care 

15 planning consultation described in section 1861(hhh) of 

16 the Social Security Act, as added by subsection (a), shall 

17 be completely optional. Nothing in this section shall— 

18 (1) require an individual to complete an ad19 vance directive, an order for life sustaining treat20 ment, or other advance care planning document; 

21 (2) require an individual to consent to restric22 tions on the amount, duration, or scope of medical 

23 benefits an individual is entitled to receive under 

24 this title; or 


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1 (3) encourage the promotion of suicide or as2 sisted suicide. 

3 (c) PAYMENT.—Section 1848(j)(3) of such Act (42 

4 U.S.C. 1395w-4(j)(3)) is amended by inserting ‘‘(2)(FF),’’ 

5 after ‘‘(2)(EE),’’. 

6 (d) FREQUENCY LIMITATION.—Section 1862(a) of 

7 such Act (42 U.S.C. 1395y(a)) is amended— 

8 (1) in paragraph (1)— 

9 (A) in subparagraph (N), by striking 

10 ‘‘and’’ at the end; 

11 (B) in subparagraph (O) by striking the 

12 semicolon at the end and inserting ‘‘, and’’; and 

13 (C) by adding at the end the following new 

14 subparagraph: 

15 ‘‘(P) in the case of voluntary advance care 

16 planning consultations (as defined in paragraph 

17 (1) of section 1861(hhh)), which are performed 

18 more frequently than is covered under such sec19 tion;’’; and 

20 (2) in paragraph (7), by striking ‘‘or (K)’’ and 

21 inserting ‘‘(K), or (P)’’. 

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

23 this section shall apply to consultations furnished on or 

24 after January 1, 2011. 


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1 SEC. 1234. PART B SPECIAL ENROLLMENT PERIOD AND 

2 WAIVER OF LIMITED ENROLLMENT PENALTY 

3 FOR TRICARE BENEFICIARIES. 

4 (a) PART B SPECIAL ENROLLMENT PERIOD.— 

5 (1) IN GENERAL.—Section 1837 of the Social 

6 Security Act (42 U.S.C. 1395p) is amended by add7 ing at the end the following new subsection: 

8 ‘‘(l)(1) In the case of any individual who is a covered 

9 beneficiary (as defined in section 1072(5) of title 10, 

10 United States Code) at the time the individual is entitled 

11 to hospital insurance benefits under part A under section 

12 226(b) or section 226A and who is eligible to enroll but 

13 who has elected not to enroll (or to be deemed enrolled) 

14 during the individual’s initial enrollment period, there 

15 shall be a special enrollment period described in paragraph 

16 (2). 

17 ‘‘(2) The special enrollment period described in this 

18 paragraph, with respect to an individual, is the 12-month 

19 period beginning on the day after the last day of the initial 

20 enrollment period of the individual or, if later, the 12- 

21 month period beginning with the month the individual is 

22 notified of enrollment under this section. 

23 ‘‘(3) In the case of an individual who enrolls during 

24 the special enrollment period provided under paragraph 

25 (1), the coverage period under this part shall begin on the 

26 first day of the month in which the individual enrolls or, 


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1 at the option of the individual, on the first day of the sec2 ond month following the last month of the individual’s ini3 tial enrollment period. 

4 ‘‘(4) The Secretary of Defense shall establish a meth5 od for identifying individuals described in paragraph (1) 

6 and providing notice to them of their eligibility for enroll7 ment during the special enrollment period described in 

8 paragraph (2).’’. 

9 (2) EFFECTIVE DATE.—The amendment made 

10 by paragraph (1) shall apply to elections made on or 

11 after the date of the enactment of this Act. 

12 (b) WAIVER OF INCREASE OF PREMIUM.— 

13 (1) IN GENERAL.—Section 1839(b) of the So14 cial Security Act (42 U.S.C. 1395r(b)) is amended 

15 by striking ‘‘section 1837(i)(4)’’ and inserting ‘‘sub16 section (i)(4) or (l) of section 1837’’. 

17 (2) EFFECTIVE DATE.— 

18 (A) IN GENERAL.—The amendment made 

19 by paragraph (1) shall apply with respect to 

20 elections made on or after the date of the en21 actment of this Act. 

22 (B) REBATES FOR CERTAIN DISABLED

23 AND ESRD BENEFICIARIES.— 

24 (i) IN GENERAL.—With respect to 

25 premiums for months on or after January 


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1 2005 and before the month of the enact2 ment of this Act, no increase in the pre3 mium shall be effected for a month in the 

4 case of any individual who is a covered 

5 beneficiary (as defined in section 1072(5) 

6 of title 10, United States Code) at the time 

7 the individual is entitled to hospital insur8 ance benefits under part A of title XVIII 

9 of the Social Security Act under section 

10 226(b) or 226A of such Act, and who is el11 igible to enroll, but who has elected not to 

12 enroll (or to be deemed enrolled), during 

13 the individual’s initial enrollment period, 

14 and who enrolls under this part within the 

15 12-month period that begins on the first 

16 day of the month after the month of notifi17 cation of entitlement under this part. 

18 (ii) CONSULTATION WITH DEPART19 MENT OF DEFENSE.—The Secretary of 

20 Health and Human Services shall consult 

21 with the Secretary of Defense in identi22 fying individuals described in this para23 graph. 

24 (iii) REBATES.—The Secretary of 

25 Health and Human Services shall establish 


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1 a method for providing rebates of premium 

2 increases paid for months on or after Jan3 uary 1, 2005, and before the month of the 

4 enactment of this Act for which a penalty 

5 was applied and collected. 

6 SEC. 1235. EXCEPTION FOR USE OF MORE RECENT TAX 

7 YEAR IN CASE OF GAINS FROM SALE OF PRI8 MARY RESIDENCE IN COMPUTING PART B IN9 COME-RELATED PREMIUM. 

10 (a) IN GENERAL.—Section 1839(i)(4)(C)(ii)(II) of 

11 the Social Security Act (42 U.S.C. 1395r(i)(4)(C)(ii)(II)) 

12 is amended by inserting ‘‘sale of primary residence,’’ after 

13 ‘‘divorce of such individual,’’. 

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

15 subsection (a) shall apply to premiums and payments for 

16 years beginning with 2011. 

17 SEC. 1236. DEMONSTRATION PROGRAM ON USE OF PA18 TIENT DECISIONS AIDS. 

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

20 Human Services , acting through the Center for Medicare 

21 and Medicaid Innovation established under section 1115A 

22 of the Social Security Act (as added by section 1907) and 

23 consistent with the applicable provisions of such section, 

24 shall establish a shared decision making demonstration 

25 program (in this subsection referred to as the ‘‘program’’) 


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1 under the Medicare program using patient decision aids 

2 to meet the objective of improving the understanding by 

3 Medicare beneficiaries of their medical treatment options, 

4 as compared to comparable Medicare beneficiaries who do 

5 not participate in a shared decision making process using 

6 patient decision aids. 

7 (b) SITES.— 

8 (1) ENROLLMENT.—The Secretary shall enroll 

9 in the program not more than 30 eligible providers 

10 who have experience in implementing, and have in11 vested in the necessary infrastructure to implement, 

12 shared decision making using patient decision aids. 

13 (2) APPLICATION.—An eligible provider seeking 

14 to participate in the program shall submit to the 

15 Secretary an application at such time and containing 

16 such information as the Secretary may require. 

17 (3) PREFERENCE.—In enrolling eligible pro18 viders in the program, the Secretary shall give pref19 erence to eligible providers that— 

20 (A) have documented experience in using 

21 patient decision aids for the conditions identi22 fied by the Secretary and in using shared deci23 sion making; 

24 (B) have the necessary information tech25 nology infrastructure to collect the information 


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1 required by the Secretary for reporting pur2 poses; and 

3 (C) are trained in how to use patient deci4 sion aids and shared decision making. 

5 (c) FOLLOW-UP COUNSELING VISIT.— 

6 (1) IN GENERAL.—An eligible provider partici7 pating in the program shall routinely schedule Medi8 care beneficiaries for a counseling visit after the 

9 viewing of such a patient decision aid to answer any 

10 questions the beneficiary may have with respect to 

11 the medical care of the condition involved and to as12 sist the beneficiary in thinking through how their 

13 preferences and concerns relate to their medical 

14 care. 

15 (2) PAYMENT FOR FOLLOW-UP COUNSELING

16 VISIT.—The Secretary shall establish procedures for 

17 making payments for such counseling visits provided 

18 to Medicare beneficiaries under the program. Such 

19 procedures shall provide for the establishment— 

20 (A) of a code (or codes) to represent such 

21 services; and 

22 (B) of a single payment amount for such 

23 service that includes the professional time of 

24 the health care provider and a portion of the 

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1 gible provider such as would be made under the 

2 applicable payment systems to that provider for 

3 similar covered services. 

4 (d) COSTS OF AIDS.—An eligible provider partici5 pating in the program shall be responsible for the costs 

6 of selecting, purchasing, and incorporating such patient 

7 decision aids into the provider’s practice, and reporting 

8 data on quality and outcome measures under the program. 

9 (e) FUNDING.—The Secretary shall provide for the 

10 transfer from the Federal Supplementary Medical Insur11 ance Trust Fund established under section 1841 of the 

12 Social Security Act (42 U.S.C. 1395t) of such funds as 

13 are necessary for the costs of carrying out the program. 

14 (f) WAIVER AUTHORITY.—The Secretary may waive 

15 such requirements of titles XI and XVIII of the Social 

16 Security Act (42 U.S.C. 1301 et seq. and 1395 et seq.) 

17 as may be necessary for the purpose of carrying out the 

18 program. 

19 (g) REPORT.—Not later than 12 months after the 

20 date of completion of the program, the Secretary shall sub21 mit to Congress a report on such program, together with 

22 recommendations for such legislation and administrative 

23 action as the Secretary determines to be appropriate. The 

24 final report shall include an evaluation of the impact of 

25 the use of the program on health quality, utilization of 


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1 health care services, and on improving the quality of life 

2 of such beneficiaries. 

3 (h) DEFINITIONS.—In this section: 

4 (1) ELIGIBLE PROVIDER.—The term ‘‘eligible 

5 provider’’ means the following: 

6 (A) A primary care practice. 

7 (B) A specialty practice. 

8 (C) A multispecialty group practice. 

9 (D) A hospital. 

10 (E) A rural health clinic. 

11 (F) A Federally qualified health center (as 

12 defined in section 1861(aa)(4) of the Social Se13 curity Act (42 U.S.C. 1395x(aa)(4)). 

14 (G) An integrated delivery system. 

15 (H) A State cooperative entity that in16 cludes the State government and at least one 

17 other health care provider which is set up for 

18 the purpose of testing shared decision making 

19 and patient decision aids. 

20 (2) PATIENT DECISION AID.—The term ‘‘pa21 tient decision aid’’ means an educational tool (such 

22 as the Internet, a video, or a pamphlet) that helps 

23 patients (or, if appropriate, the family caregiver of 

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1 tions, and to decide with their health care provider 

2 what treatments are best for them based on their 

3 treatment options, scientific evidence, circumstances, 

4 beliefs, and preferences. 

5 (3) SHARED DECISION MAKING.—The term 

6 ‘‘shared decision making’’ means a collaborative 

7 process between patient and clinician that engages 

8 the patient in decision making, provides patients 

9 with information about trade-offs among treatment 

10 options, and facilitates the incorporation of patient 

11 preferences and values into the medical plan. 

12 TITLE III—PROMOTING PRI13 MARY CARE, MENTAL 

14 HEALTH SERVICES, AND CO15 ORDINATED CARE 

16 SEC. 1301. ACCOUNTABLE CARE ORGANIZATION PILOT 

17 PROGRAM. 

18 Title XVIII of the Social Security Act is amended by 

19 inserting after section 1866D, as added by section 

20 1152(f), the following new section: 

21 ‘‘ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM

22 ‘‘SEC. 1866E. (a) ESTABLISHMENT.— 

23 ‘‘(1) IN GENERAL.— The Secretary shall conduct a 

24 pilot program (in this section referred to as the ‘pilot pro25 gram’) to test different payment incentive models, includ26 ing (to the extent practicable) the specific payment incenVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00653 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 tive models described in subsection (c), designed to reduce 

2 the growth of expenditures and improve health outcomes 

3 in the provision of items and services under this title to 

4 applicable beneficiaries (as defined in subsection (e)) by 

5 qualifying accountable care organizations (as defined in 

6 subsection (b)(1)) in order to— 

7 ‘‘(A) promote accountability for a patient popu8 lation and coordinate items and services under parts 

9 A and B (and may include Part D, if the Secretary 

10 determines appropriate); 

11 ‘‘(B) encourage investment in infrastructure 

12 and redesigned care processes for high quality and 

13 efficient service delivery; and 

14 ‘‘(C) reward physician practices and other phy15 sician organizational models for the provision of high 

16 quality and efficient health care services. 

17 ‘‘(2) SCOPE.—The Secretary shall set specific goals 

18 for the number of accountable care organizations, partici19 pating practitioners, and patients served in the initial tests 

20 under the pilot program to ensure that the pilot program 

21 is of sufficient size and scope to— 

22 ‘‘(A) test the approach involved in a variety of 

23 settings, including urban, rural, and underserved 

24 areas; and 


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1 ‘‘(B) subject to subsection (g)(1), disseminate 

2 such approach rapidly on a national basis. 

3 To the extent that the Secretary finds a qualifying ac4 countable care organization model to be successful in im5 proving quality and reducing costs, the Secretary shall 

6 seek to implement such models on as large a geographic 

7 scale as practical and economical. 

8 ‘‘(b) QUALIFYING ACCOUNTABLE CARE ORGANIZA9 TIONS (ACOS).— 

10 ‘‘(1) QUALIFYING ACO DEFINED.—In this sec11 tion: 

12 ‘‘(A) IN GENERAL.—The terms ‘qualifying 

13 accountable care organization’ and ‘qualifying 

14 ACO’ mean a group of physicians or other phy15 sician organizational model (as defined in sub16 paragraph (D)) that— 

17 ‘‘(i) is organized at least in part for 

18 the purpose of providing physicians’ serv19 ices; and 

20 ‘‘(ii) meets such criteria as the Sec21 retary determines to be appropriate to par22 ticipate in the pilot program, including the 

23 criteria specified in paragraph (2). 

24 ‘‘(B) INCLUSION OF OTHER PROVIDERS OF

25 SERVICES AND SUPPLIERS.—Nothing in this 


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1 subsection shall be construed as preventing a 

2 qualifying ACO from including a hospital or 

3 any other provider of services or supplier fur4 nishing items or services for which payment 

5 may be made under this title that is affiliated 

6 with the ACO under an arrangement structured 

7 so that such provider or supplier participates in 

8 the pilot program and shares in any incentive 

9 payments under the pilot program. 

10 ‘‘(C) PHYSICIAN.—The term ‘physician’ in11 cludes, except as the Secretary may otherwise 

12 provide, any individual who furnishes services 

13 for which payment may be made as physicians’ 

14 services under this title. 

15 ‘‘(D) OTHER PHYSICIAN ORGANIZATIONAL

16 MODEL.—The term ‘other physician organiza17 tion model’ means, with respect to a qualifying 

18 ACO any model of organization under which 

19 physicians enter into agreements with other 

20 providers of services for the purposes of partici21 pation in the pilot program in order to provide 

22 high quality and efficient health care services 

23 and share in any incentive payments under such 

24 program 


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1 ‘‘(E) OTHER SERVICES.—Nothing in this 

2 paragraph shall be construed as preventing a 

3 qualifying ACO from furnishing items or serv4 ices, for which payment may not be made under 

5 this title, for purposes of achieving performance 

6 goals under the pilot program. 

7 ‘‘(2) QUALIFYING CRITERIA.—The following are 

8 criteria described in this paragraph for an organized 

9 group of physicians to be a qualifying ACO: 

10 ‘‘(A) The group has a legal structure that 

11 would allow the group to receive and distribute 

12 incentive payments under this section. 

13 ‘‘(B) The group includes a sufficient num14 ber of primary care physicians (regardless of 

15 specialty) for the applicable beneficiaries for 

16 whose care the group is accountable (as deter17 mined by the Secretary). 

18 ‘‘(C) The group reports on quality meas19 ures in such form, manner, and frequency as 

20 specified by the Secretary (which may be for 

21 the group, for providers of services and sup22 pliers, or both). 

23 ‘‘(D) The group reports to the Secretary 

24 (in a form, manner and frequency as specified 

25 by the Secretary) such data as the Secretary 


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1 determines appropriate to monitor and evaluate 

2 the pilot program. 

3 ‘‘(E) The group provides notice to applica4 ble beneficiaries regarding the pilot program (as 

5 determined appropriate by the Secretary). 

6 ‘‘(F) The group contributes to a best prac7 tices network or website, that shall be main8 tained by the Secretary for the purpose of shar9 ing strategies on quality improvement, care co10 ordination, and efficiency that the groups be11 lieve are effective. 

12 ‘‘(G) The group utilizes patient-centered 

13 processes of care, including those that empha14 size patient and caregiver involvement in plan15 ning and monitoring of ongoing care manage16 ment plan. 

17 ‘‘(H) The group meets other criteria deter18 mined to be appropriate by the Secretary. 

19 ‘‘(c) SPECIFIC PAYMENT INCENTIVE MODELS.—The 

20 specific payment incentive models described in this sub21 section are the following: 

22 ‘‘(1) PERFORMANCE TARGET MODEL.—Under 

23 the performance target model under this paragraph 

24 (in this paragraph referred to as the ‘performance 

25 target model’): 


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1 ‘‘(A) IN GENERAL.—A qualifying ACO 

2 qualifies to receive an incentive payment if ex3 penditures for items and services for applicable 

4 beneficiaries are less than a target spending 

5 level or a target rate of growth. The incentive 

6 payment shall be made only if savings are 

7 greater than would result from normal variation 

8 in expenditures for items and services covered 

9 under parts A and B (and may include Part D, 

10 if the Secretary determines appropriate). 

11 ‘‘(B) COMPUTATION OF PERFORMANCE

12 TARGET.— 

13 ‘‘(i) IN GENERAL.—The Secretary 

14 shall establish a performance target for 

15 each qualifying ACO comprised of a base 

16 amount (described in clause (ii)) increased 

17 to the current year by an adjustment fac18 tor (described in clause (iii)). Such a tar19 get may be established on a per capita 

20 basis or adjusted for risk, as the Secretary 

21 determines to be appropriate. 

22 ‘‘(ii) BASE AMOUNT.—For purposes of 

23 clause (i), the base amount in this sub24 paragraph is equal to the average total 

25 payments (or allowed charges) under parts 


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1 A and B (and may include part D, if the 

2 Secretary determines appropriate) for ap3 plicable beneficiaries for whom the quali4 fying ACO furnishes items and services in 

5 a base period determined by the Secretary. 

6 Such base amount may be determined on 

7 a per capita basis or adjusted for risk. 

8 ‘‘(iii) ADJUSTMENT FACTOR.—For 

9 purposes of clause (i), the adjustment fac10 tor in this clause may equal an annual per 

11 capita amount that reflects changes in ex12 penditures from the period of the base 

13 amount to the current year that would rep14 resent an appropriate performance target 

15 for applicable beneficiaries (as determined 

16 by the Secretary). 

17 ‘‘(iv) REBASING.—Under this model 

18 the Secretary shall periodically rebase the 

19 base expenditure amount described in 

20 clause (ii). 

21 ‘‘(C) MEETING TARGET.— 

22 ‘‘(i) IN GENERAL.—Subject to clause 

23 (ii), a qualifying ACO that meets or ex24 ceeds annual quality and performance tar25 gets for a year shall receive an incentive 


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1 payment for such year equal to a portion 

2 (as determined appropriate by the Sec3 retary) of the amount by which payments 

4 under this title for such year are estimated 

5 to be below the performance target for 

6 such year, as determined by the Secretary. 

7 The Secretary may establish a cap on in8 centive payments for a year for a quali9 fying ACO. 

10 ‘‘(ii) LIMITATION.— The Secretary 

11 shall limit incentive payments to each 

12 qualifying ACO under this paragraph as 

13 necessary to ensure that the aggregate ex14 penditures with respect to applicable bene15 ficiaries for such ACOs under this title (in16 clusive of incentive payments described in 

17 this subparagraph) do not exceed the 

18 amount that the Secretary estimates would 

19 be expended for such ACO for such bene20 ficiaries if the pilot program under this 

21 section were not implemented. 

22 ‘‘(D) REPORTING AND OTHER REQUIRE23 MENTS.—In carrying out such model, the Sec24 retary may (as the Secretary determines to be 

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1 ments, incentive payments, and penalties re2 lated to the physician quality reporting initia3 tive (PQRI), electronic prescribing, electronic 

4 health records, and other similar initiatives 

5 under section 1848, and may use alternative 

6 criteria than would otherwise apply under such 

7 section for determining whether to make such 

8 payments. The incentive payments described in 

9 this subparagraph shall not be included in the 

10 limit described in subparagraph (C)(ii) or in the 

11 performance target model described in this 

12 paragraph. 

13 ‘‘(2) PARTIAL CAPITATION MODEL.— 

14 ‘‘(A) IN GENERAL.—Subject to subpara15 graph (B), a partial capitation model described 

16 in this paragraph (in this paragraph referred to 

17 as a ‘partial capitation model’) is a model in 

18 which a qualifying ACO would be at financial 

19 risk for some, but not all, of the items and serv20 ices covered under parts A and B (and may in21 clude part D, if the Secretary determines ap22 propriate), such as at risk for some or all physi23 cians’ services or all items and services under 

24 part B. The Secretary may limit a partial capi25 tation model to ACOs that are highly integrated 


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1 systems of care and to ACOs capable of bearing 

2 risk, as determined to be appropriate by the 

3 Secretary. 

4 ‘‘(B) NO ADDITIONAL PROGRAM EXPENDI5 TURES.—Payments to a qualifying ACO for 

6 items and services under this title for applicable 

7 beneficiaries for a year under the partial capita8 tion model shall be established in a manner that 

9 does not result in spending more for such ACO 

10 for such beneficiaries than would otherwise be 

11 expended for such ACO for such beneficiaries 

12 for such year if the pilot program were not im13 plemented, as estimated by the Secretary. 

14 ‘‘(3) OTHER PAYMENT MODELS.— 

15 ‘‘(A) IN GENERAL.—Subject to subpara16 graph (B), the Secretary may develop other 

17 payment models that meet the goals of this 

18 pilot program to improve quality and efficiency. 

19 ‘‘(B) NO ADDITIONAL PROGRAM EXPENDI20 TURES.—Subparagraph (B) of paragraph (2) 

21 shall apply to a payment model under subpara22 graph (A) in a similar manner as such subpara23 graph (B) applies to the payment model under 

24 paragraph (2). 

25 ‘‘(d) ANNUAL QUALITY TARGETS.— 


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1 ‘‘(1) IN GENERAL.—The Secretary shall estab2 lish annual quality targets that qualifying ACOs 

3 must meet to receive incentive payments, operate at 

4 financial risk, or otherwise participate in alternative 

5 financing models under this section. The Secretary 

6 shall establish a process for developing annual tar7 gets based on ACO reporting of multiple quality 

8 measures. In selecting measures the Secretary 

9 shall— 

10 ‘‘(A) for years one and two of each ACOs 

11 participation in the pilot program established 

12 by this section, require reporting of a starter 

13 set of measures focused on clinical care, care 

14 coordination and patient experience of care; and 

15 ‘‘(B) for each subsequent year, require re16 porting of a more comprehensive set of clinical 

17 outcomes measures, care coordination measures 

18 and patient experience of care measures. 

19 ‘‘(2) MEASURE SELECTION.—To the extent fea20 sible, the Secretary shall select measures that reflect 

21 national priorities for quality improvement and pa22 tient-centered care consistent with the measures de23 veloped under section 1192(c)(1). 

24 ‘‘(e) APPLICABLE BENEFICIARIES.— 


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

2 ‘applicable beneficiary’ means, with respect to a 

3 qualifying ACO, an individual who— 

4 ‘‘(A) is enrolled under part B and entitled 

5 to benefits under part A; 

6 ‘‘(B) is not enrolled in a Medicare Advan7 tage plan under part C or a PACE program 

8 under section 1894; and 

9 ‘‘(C) meets such other criteria as the Sec10 retary determines appropriate, which may in11 clude criteria relating to frequency of contact 

12 with physicians in the ACO 

13 ‘‘(2) FOLLOWING APPLICABLE BENE14 FICIARIES.—The Secretary may monitor data on ex15 penditures and quality of services under this title 

16 after an applicable beneficiary discontinues receiving 

17 services under this title through a qualifying ACO. 

18 ‘‘(f) IMPLEMENTATION.— 

19 ‘‘(1) STARTING DATE.—The pilot program shall 

20 begin no later than January 1, 2012. An agreement 

21 with a qualifying ACO under the pilot program may 

22 cover a multi-year period of between 3 and 5 years. 

23 ‘‘(2) WAIVER.—The Secretary may waive such 

24 provisions of this title (including section 1877) and 


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1 title XI in the manner the Secretary determines nec2 essary in order implement the pilot program. 

3 ‘‘(3) PERFORMANCE RESULTS REPORTS.—The 

4 Secretary shall report performance results to quali5 fying ACOs under the pilot program at least annu6 ally. 

7 ‘‘(4) LIMITATIONS ON REVIEW.—There shall be 

8 no administrative or judicial review under section 

9 1869, section 1878, or otherwise of— 

10 ‘‘(A) the elements, parameters, scope, and 

11 duration of the pilot program; 

12 ‘‘(B) the selection of qualifying ACOs for 

13 the pilot program; 

14 ‘‘(C) the establishment of targets, meas15 urement of performance, determinations with 

16 respect to whether savings have been achieved 

17 and the amount of savings; 

18 ‘‘(D) determinations regarding whether, to 

19 whom, and in what amounts incentive payments 

20 are paid; and 

21 ‘‘(E) decisions about the extension of the 

22 program under subsection (h), expansion of the 

23 program under subsection (i) or extensions 

24 under subsections (j) or (k). 


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1 ‘‘(5) ADMINISTRATION.—Chapter 35 of title 44, 

2 United States Code shall not apply to this section. 

3 ‘‘(g) EVALUATION; MONITORING.— 

4 ‘‘(1) IN GENERAL.—The Secretary shall evalu5 ate the payment incentive model for each qualifying 

6 ACO under the pilot program to assess impacts on 

7 beneficiaries, providers of services, suppliers and the 

8 program under this title. The Secretary shall make 

9 such evaluation publicly available within 60 days of 

10 the date of completion of such report. 

11 ‘‘(2) MONITORING.—The Inspector General of 

12 the Department of Health and Human Services shall 

13 provide for monitoring of the operation of ACOs 

14 under the pilot program with regard to violations of 

15 section 1877 (popularly known as the ‘Stark law’). 

16 ‘‘(h) EXTENSION OF PILOT AGREEMENT WITH SUC17 CESSFUL ORGANIZATIONS.— 

18 ‘‘(1) REPORTS TO CONGRESS.—Not later than 

19 2 years after the date the first agreement is entered 

20 into under this section, and biennially thereafter for 

21 six years, the Secretary shall submit to Congress 

22 and make publicly available a report on the use of 

23 ACO payment models under the pilot program. Each 

24 report shall address the impact of the use of those 


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1 models on expenditures, access, and quality under 

2 this title. 

3 ‘‘(2) EXTENSION.—Subject to the report pro4 vided under paragraph (1), with respect to a quali5 fying ACO, the Secretary may extend the duration 

6 of the agreement for such ACO under the pilot pro7 gram as the Secretary determines appropriate if— 

8 ‘‘(A) the ACO receives incentive payments 

9 with respect to any of the first 4 years of the 

10 pilot agreement and is consistently meeting 

11 quality standards or 

12 ‘‘(B) the ACO is consistently exceeding 

13 quality standards and is not increasing spend14 ing under the program. 

15 ‘‘(3) TERMINATION.—The Secretary may termi16 nate an agreement with a qualifying ACO under the 

17 pilot program if such ACO did not receive incentive 

18 payments or consistently failed to meet quality 

19 standards in any of the first 3 years under the pro20 gram. 

21 ‘‘(i) EXPANSION TO ADDITIONAL ACOS.— 

22 ‘‘(1) TESTING AND REFINEMENT OF PAYMENT

23 INCENTIVE MODELS.—Subject to the evaluation de24 scribed in subsection (g), the Secretary may enter 

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1 tional qualifying ACOs to further test and refine 

2 payment incentive models with respect to qualifying 

3 ACOs. 

4 ‘‘(2) EXPANDING USE OF SUCCESSFUL MODELS

5 TO PROGRAM IMPLEMENTATION.— 

6 ‘‘(A) IN GENERAL.—Subject to subpara7 graph (B), the Secretary may issue regulations 

8 to implement, on a permanent basis, 1 or more 

9 models if, and to the extent that, such models 

10 are beneficial to the program under this title, as 

11 determined by the Secretary. 

12 ‘‘(B) CERTIFICATION.—The Chief Actuary 

13 of the Centers for Medicare & Medicaid Serv14 ices shall certify that 1 or more of such models 

15 described in subparagraph (A) would result in 

16 estimated spending that would be less than 

17 what spending would otherwise be estimated to 

18 be in the absence of such expansion. 

19 ‘‘(j) TREATMENT OF PHYSICIAN GROUP PRACTICE

20 DEMONSTRATION.— 

21 ‘‘(1) EXTENSION.—The Secretary may enter in 

22 to an agreement with a qualifying ACO under the 

23 demonstration under section 1866A, subject to re24 basing and other modifications deemed appropriate 


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1 by the Secretary, until the pilot program under this 

2 section is operational. 

3 ‘‘(2) TRANSITION.—For purposes of extension 

4 of an agreement with a qualifying ACO under sub5 section (h)(2), the Secretary shall treat receipt of an 

6 incentive payment for a year by an organization 

7 under the physician group practice demonstration 

8 pursuant to section 1866A as a year for which an 

9 incentive payment is made under such subsection, as 

10 long as such practice group practice organization 

11 meets the criteria under subsection (b)(2). 

12 ‘‘(k) ADDITIONAL PROVISIONS.— 

13 ‘‘(1) AUTHORITY FOR SEPARATE INCENTIVE

14 ARRANGEMENTS.—The Secretary may create sepa15 rate incentive arrangements (including using mul16 tiple years of data, varying thresholds, varying 

17 shared savings amounts, and varying shared savings 

18 limits) for different categories of qualifying ACOs to 

19 reflect variation in average annual attributable ex20 penditures and other matters the Secretary deems 

21 appropriate. 

22 ‘‘(2) ENCOURAGEMENT OF PARTICIPATION OF

23 SMALLER ORGANIZATIONS.—In order to encourage 

24 the participation of smaller accountable care organi25 zations under the pilot program, the Secretary may 


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1 limit a qualifying ACO’s exposure to high cost pa2 tients under the program. 

3 ‘‘(3) INVOLVEMENT IN PRIVATE PAYER AND

4 OTHER THIRD PARTY ARRANGEMENTS.—The Sec5 retary may give preference to ACOs who are partici6 pating in similar arrangements with other payers. 

7 ‘‘(4) ANTIDISCRIMINATION LIMITATION.—The 

8 Secretary shall not enter into an agreement with an 

9 entity to provide health care items or services under 

10 the pilot program, or with an entity to administer 

11 the program, unless such entity guarantees that it 

12 will not deny, limit, or condition the coverage or pro13 vision of benefits under the program, for individuals 

14 eligible to be enrolled under such program, based on 

15 any health status-related factor described in section 

16 2702(a)(1) of the Public Health Service Act. 

17 ‘‘(5) FUNDING.—For purposes of administering 

18 and carrying out the pilot program, other than for 

19 payments for items and services furnished under this 

20 title and incentive payments under subsection (c)(1), 

21 in addition to funds otherwise appropriated, there 

22 are appropriated to the Secretary for the Center for 

23 Medicare & Medicaid Services Program Management 

24 Account $25,000,000 for each of fiscal years 2010 

25 through 2014 and $20,000,000 for fiscal year 2015. 


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1 Amounts appropriated under this paragraph for a 

2 fiscal year shall be available until expended. 

3 ‘‘(6) NO DUPLICATION IN PAYMENTS TO PHYSI4 CIANS IN MULTIPLE PILOTS.—The Secretary shall 

5 not make payments under this section to any physi6 cian group that is paid under section 1866F (relat7 ing to medical homes) or section 1866G (relating to 

8 independence at home).’’. 

9 SEC. 1302. MEDICAL HOME PILOT PROGRAM. 

10 (a) IN GENERAL.—Title XVIII of the Social Security 

11 Act is amended by inserting after section 1866E, as in12 serted by section 1301, the following new section: 

13 ‘‘MEDICAL HOME PILOT PROGRAM

14 ‘‘SEC. 1866F. (a) ESTABLISHMENT AND MEDICAL

15 HOME MODELS.— 

16 ‘‘(1) ESTABLISHMENT OF PILOT PROGRAM.— 

17 The Secretary shall establish a medical home pilot 

18 program (in this section referred to as the ‘pilot pro19 gram’) for the purpose of evaluating the feasibility 

20 and advisability of reimbursing qualified patient-cen21 tered medical homes for furnishing medical home 

22 services (as defined under subsection (b)(1)) to 

23 beneficiaries (as defined in subsection (b)(4)) and to 

24 targeted high need beneficiaries (as defined in sub25 section (c)(1)(C)). 


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1 ‘‘(2) SCOPE.—Subject to subsection (g), the 

2 Secretary shall set specific goals for the number of 

3 practices and communities, and the number of pa4 tients served, under the pilot program in the initial 

5 tests to ensure that the pilot program is of sufficient 

6 size and scope to— 

7 ‘‘(A) test the approach involved in a vari8 ety of settings, including urban, rural, and un9 derserved areas; and 

10 ‘‘(B) subject to subsection (e)(1), dissemi11 nate such approach rapidly on a national basis. 

12 To the extent that the Secretary finds a medical 

13 home model to be successful in improving quality 

14 and reducing costs, the Secretary shall implement 

15 such model on as large a geographic scale as prac16 tical and economical. 

17 ‘‘(3) MODELS OF MEDICAL HOMES IN THE

18 PILOT PROGRAM.—The pilot program shall evaluate 

19 each of the following medical home models: 

20 ‘‘(A) INDEPENDENT PATIENT-CENTERED

21 MEDICAL HOME MODEL.—Independent patient22 centered medical home model under subsection 

23 (c). 


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1 ‘‘(B) COMMUNITY-BASED MEDICAL HOME

2 MODEL.—Community-based medical home 

3 model under subsection (d). 

4 ‘‘(4) PARTICIPATION OF NURSE PRACTITIONERS

5 AND PHYSICIAN ASSISTANTS.— 

6 ‘‘(A) Nothing in this section shall be con7 strued as preventing a nurse practitioner from 

8 leading a patient centered medical home so long 

9 as— 

10 ‘‘(i) all the requirements of this sec11 tion are met; and 

12 ‘‘(ii) the nurse practitioner is acting 

13 in a manner that is consistent with State 

14 law. 

15 ‘‘(B) Nothing in this section shall be con16 strued as preventing a physician assistant from 

17 participating in a patient centered medical 

18 home so long as— 

19 ‘‘(i) all the requirements of this sec20 tion are met; and 

21 ‘‘(ii) the physician assistant is acting 

22 in a manner that is consistent with State 

23 law. 

24 ‘‘(b) DEFINITIONS.—For purposes of this section: 


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1 ‘‘(1) PATIENT-CENTERED MEDICAL HOME

2 SERVICES.—The term ‘patient-centered medical 

3 home services’ means services that— 

4 ‘‘(A) provide beneficiaries with direct and 

5 ongoing access to a primary care or principal 

6 care physician or nurse practitioner who accepts 

7 responsibility for providing first contact, contin8 uous and comprehensive care to such bene9 ficiary; 

10 ‘‘(B) coordinate the care provided to a ben11 eficiary by a team of individuals at the practice 

12 level across office, provider of services, and 

13 home settings led by a primary care or principal 

14 care physician or nurse practitioner, as needed 

15 and appropriate; 

16 ‘‘(C) provide for all the patient’s health 

17 care needs or take responsibility for appro18 priately arranging care with other qualified 

19 physicians or providers for all stages of life; 

20 ‘‘(D) provide continuous access to care and 

21 communication with participating beneficiaries; 

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1 tient-centered processes, and coordination with 

2 community resources; 

3 ‘‘(F) integrate readily accessible, clinically 

4 useful information on participating patients 

5 that enables the practice to treat such patients 

6 comprehensively and systematically; and 

7 ‘‘(G) implement evidence-based guidelines 

8 and apply such guidelines to the identified 

9 needs of beneficiaries over time and with the in10 tensity needed by such beneficiaries. 

11 ‘‘(2) PRIMARY CARE.—The term ‘primary care’ 

12 means health care that is provided by a physician, 

13 nurse practitioner, or physician assistant who prac14 tices in the field of family medicine, general internal 

15 medicine, geriatric medicine, or pediatric medicine. 

16 ‘‘(3) PRINCIPAL CARE.—The term ‘principal 

17 care’ means integrated, accessible health care that is 

18 provided by a physician who is a medical specialist 

19 or subspecialist that addresses the majority of the 

20 personal health care needs of patients with chronic 

21 conditions requiring the specialist’s or subspecialist’s 

22 expertise, and for whom the specialist or sub23 specialist assumes care management. 


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1 ‘‘(4) BENEFICIARIES.—The term ‘beneficiaries’ 

2 means, with respect to a qualifying medical home, 

3 an individual who— 

4 ‘‘(A) is enrolled under part B and entitled 

5 to benefits under part A; 

6 ‘‘(B) is not enrolled in a Medicare Advan7 tage plan under part C or a PACE program 

8 under section 1894; and 

9 ‘‘(C) meets such other criteria as the Sec10 retary determines appropriate. 

11 ‘‘(c) INDEPENDENT PATIENT-CENTERED MEDICAL

12 HOME MODEL.— 

13 ‘‘(1) IN GENERAL.— 

14 ‘‘(A) PAYMENT AUTHORITY.—Under the 

15 independent patient-centered medical home 

16 model under this subsection, the Secretary shall 

17 make payments for medical home services fur18 nished by an independent patient-centered med19 ical home (as defined in subparagraph (B)) 

20 pursuant to paragraph (3) for targeted high 

21 need beneficiaries (as defined in subparagraph 

22 (C)). 

23 ‘‘(B) INDEPENDENT PATIENT-CENTERED

24 MEDICAL HOME DEFINED.—In this section, the 

25 term ‘independent patient-centered medical 


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1 home’ means a physician-directed or nurse2 practitioner-directed practice that is qualified 

3 under paragraph (2) as— 

4 ‘‘(i) providing beneficiaries with pa5 tient-centered medical home services; and 

6 ‘‘(ii) meets such other requirements as 

7 the Secretary may specify. 

8 ‘‘(C) TARGETED HIGH NEED BENEFICIARY

9 DEFINED.—For purposes of this subsection, the 

10 term ‘targeted high need beneficiary’ means a 

11 beneficiary who, based on a risk score as speci12 fied by the Secretary, is generally within the 

13 upper 50th percentile of Medicare beneficiaries. 

14 ‘‘(D) BENEFICIARY ELECTION TO PARTICI15 PATE.—The Secretary shall determine an ap16 propriate method of ensuring that beneficiaries 

17 have agreed to participate in the pilot program. 

18 ‘‘(E) IMPLEMENTATION.—The pilot pro19 gram under this subsection shall begin no later 

20 than 12 months after the date of the enactment 

21 of this section and shall operate for 5 years. 

22 ‘‘(2) QUALIFICATION PROCESS FOR PATIENT23 CENTERED MEDICAL HOMES.—The Secretary shall 

24 establish a process for practices to qualify as med25 ical homes. 


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1 ‘‘(3) PAYMENT.— 

2 ‘‘(A) ESTABLISHMENT OF METHOD3 OLOGY.—The Secretary shall establish a meth4 odology for the payment for medical home serv5 ices furnished by independent patient-centered 

6 medical homes. Under such methodology, the 

7 Secretary shall adjust payments to medical 

8 homes based on beneficiary risk scores to en9 sure that higher payments are made for higher 

10 risk beneficiaries. 

11 ‘‘(B) PER BENEFICIARY PER MONTH PAY12 MENTS.—Under such payment methodology, the 

13 Secretary shall pay independent patient-cen14 tered medical homes a monthly fee for each tar15 geted high need beneficiary who consents to re16 ceive medical home services through such med17 ical home. 

18 ‘‘(C) PROSPECTIVE PAYMENT.—The fee 

19 under subparagraph (B) shall be paid on a pro20 spective basis. 

21 ‘‘(D) AMOUNT OF PAYMENT.—In deter22 mining the amount of such fee, the Secretary 

23 shall consider the following: 

24 ‘‘(i) The clinical work and practice ex25 penses involved in providing the medical 


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1 home services provided by the independent 

2 patient-centered medical home (such as 

3 providing increased access, care coordina4 tion, population disease management, and 

5 teaching self-care skills for managing 

6 chronic illnesses) for which payment is not 

7 made under this title as of the date of the 

8 enactment of this section. 

9 ‘‘(ii) Allow for differential payments 

10 based on capabilities of the independent 

11 patient-centered medical home. 

12 ‘‘(iii) Use appropriate risk-adjustment 

13 in determining the amount of the per bene14 ficiary per month payment under this 

15 paragraph in a manner that ensures that 

16 higher payments are made for higher risk 

17 beneficiaries. 

18 ‘‘(4) ENCOURAGING PARTICIPATION OF VARI19 ETY OF PRACTICES.—The pilot program under this 

20 subsection shall be designed to include the participa21 tion of physicians in practices with fewer than 10 

22 full-time equivalent physicians, as well as physicians 

23 in larger practices, particularly in underserved and 

24 rural areas, as well as federally qualified health cen25 ters, and rural health centers. 


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1 ‘‘(d) COMMUNITY-BASED MEDICAL HOME MODEL.— 

2 ‘‘(1) IN GENERAL.— 

3 ‘‘(A) AUTHORITY FOR PAYMENTS.—Under 

4 the community-based medical home model 

5 under this subsection (in this section referred to 

6 as the ‘CBMH model’), the Secretary shall 

7 make payments for the furnishing of medical 

8 home services by a community-based medical 

9 home (as defined in subparagraph (B)) pursu10 ant to paragraph (5)(B) for beneficiaries. 

11 ‘‘(B) COMMUNITY-BASED MEDICAL HOME

12 DEFINED.—In this section, the term ‘commu13 nity-based medical home’ means a nonprofit 

14 community-based or State-based organization or 

15 a State that is certified under paragraph (2) as 

16 meeting the following requirements: 

17 ‘‘(i) The organization provides bene18 ficiaries with medical home services. 

19 ‘‘(ii) The organization provides med20 ical home services under the supervision of 

21 and in close collaboration with the primary 

22 care or principal care physician, nurse 

23 practitioner, or physician assistant des24 ignated by the beneficiary as his or her 

25 community-based medical home provider. 


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1 ‘‘(iii) The organization employs com2 munity health workers, including nurses or 

3 other non-physician practitioners, lay 

4 health workers, or other persons as deter5 mined appropriate by the Secretary, that 

6 assist the primary or principal care physi7 cian, nurse practitioner, or physician as8 sistant in chronic care management activi9 ties such as teaching self-care skills for 

10 managing chronic illnesses, transitional 

11 care services, care plan setting, nutritional 

12 counseling, medication therapy manage13 ment services for patients with multiple 

14 chronic diseases, or help beneficiaries ac15 cess the health care and community-based 

16 resources in their local geographic area. 

17 ‘‘(iv) The organization meets such 

18 other requirements as the Secretary may 

19 specify. 

20 ‘‘(2) QUALIFICATION PROCESS FOR COMMU21 NITY-BASED MEDICAL HOMES.—The Secretary shall 

22 establish a process to provide for the review and 

23 qualification of community-based medical homes 

24 pursuant to criteria established by the Secretary. 


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1 ‘‘(3) DURATION.—The pilot program for com2 munity-based medical homes under this subsection 

3 shall start no later than 2 years after the date of the 

4 enactment of this section. Each demonstration site 

5 under the pilot program shall operate for a period 

6 of up to 5 years after the initial implementation 

7 phase, without regard to the receipt of a initial im8 plementation funding under paragraph (6). 

9 ‘‘(4) PREFERENCE.—In selecting sites for the 

10 CBMH model, the Secretary shall give preference to 

11 applications which seek to eliminate health dispari12 ties, as defined in section 3171 of the Public Health 

13 Service Act and may give preference to any of the 

14 following: 

15 ‘‘(A) Applications that propose to coordi16 nate health care items and services under this 

17 title for chronically ill beneficiaries who rely, for 

18 primary care, on small physician or nurse prac19 titioner practices, federally qualified health cen20 ters, rural health clinics, or other settings with 

21 limited resources and scope of services. 

22 ‘‘(B) Applications that include other third23 party payors that furnish medical home services 

24 for chronically ill patients covered by such 

25 third-party payors. 


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1 ‘‘(C) Applications from States that propose 

2 to use the medical home model to coordinate 

3 health care services for— 

4 ‘‘(i) individuals enrolled under this 

5 title; 

6 ‘‘(ii) individuals enrolled under title 

7 XIX; and 

8 ‘‘(iii) full-benefit dual eligible individ9 uals (as defined in section 1935(c)(6)), 

10 with chronic diseases across a variety of health 

11 care settings. 

12 ‘‘(5) PAYMENTS.— 

13 ‘‘(A) ESTABLISHMENT OF METHOD14 OLOGY.—The Secretary shall establish a meth15 odology for the payment for medical home serv16 ices furnished under the CBMH model. 

17 ‘‘(B) PER BENEFICIARY PER MONTH PAY18 MENTS.—Under such payment methodology, the 

19 Secretary shall make two separate monthly pay20 ments for each beneficiary who consents to re21 ceive medical home services through such med22 ical home, as follows: 

23 ‘‘(i) PAYMENT TO COMMUNITY-BASED

24 ORGANIZATION.—One monthly payment to 


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1 a community-based or State-based organi2 zation or State. 

3 ‘‘(ii) PAYMENT TO PRIMARY OR PRIN4 CIPAL CARE PRACTICE.—One monthly pay5 ment to the primary or principal care prac6 tice for such beneficiary. 

7 ‘‘(C) PROSPECTIVE PAYMENT.—The pay8 ments under subparagraph (B) shall be paid on 

9 a prospective basis. 

10 ‘‘(D) AMOUNT OF PAYMENT.—In deter11 mining the amount of such payment under sub12 paragraph (B), the Secretary shall consider the 

13 following: 

14 ‘‘(i) The clinical work and practice ex15 penses involved in providing the medical 

16 home services provided by the primary or 

17 principal care practice (such as providing 

18 increased access, care coordination, care 

19 planning, population disease management, 

20 and teaching self-care skills for managing 

21 chronic illnesses) for which payment is not 

22 made under this title as of the date of the 

23 enactment of this section. 

24 ‘‘(ii) Use appropriate risk-adjustment 

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1 ficiary per month payment under this 

2 paragraph. 

3 ‘‘(iii) In the case of the models de4 scribed in subparagraphs (B) and (C) of 

5 paragraph (4), the Secretary may deter6 mine an appropriate payment amount. 

7 ‘‘(6) INITIAL IMPLEMENTATION FUNDING.— 

8 The Secretary may make available initial implemen9 tation funding to a non-profit community based or 

10 State-based organization or a State that is partici11 pating in the pilot program under this subsection. 

12 Such organization shall provide the Secretary with a 

13 detailed implementation plan that includes how such 

14 funds will be used. The Secretary shall select a terri15 tory of the United States as one of the locations in 

16 which to implement the pilot program under this 

17 subsection, unless no organization in a territory is 

18 able to comply with the requirements under para19 graph (1)(B). 

20 ‘‘(e) EXPANSION OF PROGRAM.— 

21 ‘‘(1) EVALUATION OF COST AND QUALITY.— 

22 The Secretary shall evaluate the pilot program to 

23 determine— 

24 ‘‘(A) the extent to which medical homes re25 sult in— 


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1 ‘‘(i) improvement in the quality and 

2 coordination of items and services under 

3 this title, particularly with regard to the 

4 care of complex patients; 

5 ‘‘(ii) improvement in reducing health 

6 disparities; 

7 ‘‘(iii) reductions in preventable hos8 pitalizations; 

9 ‘‘(iv) prevention of readmissions; 

10 ‘‘(v) reductions in emergency room 

11 visits; 

12 ‘‘(vi) improvement in health outcomes, 

13 including patient functional status where 

14 applicable; 

15 ‘‘(vii) improvement in patient satisfac16 tion; 

17 ‘‘(viii) improved efficiency of care such 

18 as reducing duplicative diagnostic tests and 

19 laboratory tests; and 

20 ‘‘(ix) reductions in health care ex21 penditures; and 

22 ‘‘(B) the feasability and advisability of re23 imbursing medical homes for medical home 

24 services under this title on a permanent basis. 


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1 ‘‘(2) REPORT.—Not later than 60 days after 

2 the date of completion of the evaluation under para3 graph (1), the Secretary shall submit to Congress 

4 and make available to the public a report on the 

5 findings of the evaluation under paragraph (1) and 

6 the extent to which standards for the certification of 

7 medical homes need to be periodically updated. 

8 ‘‘(3) EXPANSION OF PROGRAM.— 

9 ‘‘(A) IN GENERAL.—Subject to the results 

10 of the evaluation under paragraph (1) and sub11 paragraph (B), the Secretary may issue regula12 tions to implement, on a permanent basis, one 

13 or more models, if, and to the extent that such 

14 model or models, are beneficial to the program 

15 under this title, including that such implemen16 tation will improve quality of care, as deter17 mined by the Secretary. 

18 ‘‘(B) CERTIFICATION REQUIREMENT.—The 

19 Secretary may not issue such regulations unless 

20 the Chief Actuary of the Centers for Medicare 

21 & Medicaid Services certifies that the expansion 

22 of the components of the pilot program de23 scribed in subparagraph (A) would result in es24 timated spending under this title that would be 

25 no more than the level of spending that the 


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1 Secretary estimates would otherwise be spent 

2 under this title in the absence of such expan3 sion. 

4 ‘‘(C) UPDATED STANDARDS.—The Sec5 retary shall periodically review and update the 

6 standards for qualification as an independent 

7 patient centered medical home and as a com8 munity based medical home and shall establish 

9 a process for ensuring that medical homes meet 

10 such updated standards, as applicable 

11 ‘‘(f) ADMINISTRATIVE PROVISIONS.— 

12 ‘‘(1) NO DUPLICATION IN PAYMENTS FOR INDI13 VIDUALS IN MEDICAL HOMES.—During any month, 

14 the Secretary may not make payments under this 

15 section under more than one model or through more 

16 than one medical home under any model for the fur17 nishing of medical home services to an individual. 

18 ‘‘(2) NO EFFECT ON PAYMENT FOR MEDICAL

19 VISITS.—Payments made under this section are in 

20 addition to, and have no effect on the amount of, 

21 payment for medical visits made under this title 

22 ‘‘(3) ADMINISTRATION.—Chapter 35 of title 44, 

23 United States Code shall not apply to this section. 

24 ‘‘(4) NO DUPLICATION IN PHYSICIAN PILOT

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1 ments to an independent or community based med2 ical home both under this section and section 1866E 

3 or 1866G, unless the pilot program under this sec4 tion has been implemented on a permanent basis 

5 under subsection (e)(3). 

6 ‘‘(5) WAIVER.—The Secretary may waive such 

7 provisions of this title and title XI in the manner the 

8 Secretary determines necessary in order to imple9 ment this section. 

10 ‘‘(g) FUNDING.— 

11 ‘‘(1) OPERATIONAL COSTS.—For purposes of 

12 administering and carrying out the pilot program 

13 (including the design, implementation, technical as14 sistance for and evaluation of such program), in ad15 dition to funds otherwise available, there shall be 

16 transferred from the Federal Supplementary Medical 

17 Insurance Trust Fund under section 1841 to the 

18 Secretary for the Centers for Medicare & Medicaid 

19 Services Program Management Account $6,000,000 

20 for each of fiscal years 2010 through 2014. 

21 Amounts appropriated under this paragraph for a 

22 fiscal year shall be available until expended. 

23 ‘‘(2) PATIENT-CENTERED MEDICAL HOME

24 SERVICES.—In addition to funds otherwise available, 

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1 ters for Medicare & Medicaid Services, from the 

2 Federal Supplementary Medical Insurance Trust 

3 Fund under section 1841— 

4 ‘‘(A) $200,000,000 for each of fiscal years 

5 2010 through 2014 for payments for medical 

6 home services under subsection (c)(3); and 

7 ‘‘(B) $125,000,000 for each of fiscal years 

8 2012 through 2016, for payments under sub9 section (d)(5). 

10 Amounts available under this paragraph for a fiscal 

11 year shall be available until expended. 

12 ‘‘(3) INITIAL IMPLEMENTATION.—In addition 

13 to funds otherwise available, there shall be available 

14 to the Secretary for the Centers for Medicare & 

15 Medicaid Services, from the Federal Supplementary 

16 Medical Insurance Trust Fund under section 1841, 

17 $2,500,000 for each of fiscal years 2010 through 

18 2012, under subsection (d)(6). Amounts available 

19 under this paragraph for a fiscal year shall be avail20 able until expended. 

21 ‘‘(h) TREATMENT OF TRHCA MEDICARE MEDICAL

22 HOME DEMONSTRATION FUNDING.— 

23 ‘‘(1) In addition to funds otherwise available for 

24 payment of medical home services under subsection 

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1 vided in subsection (g) of section 204 of division B 

2 of the Tax Relief and Health Care Act of 2006 (42 

3 U.S.C. 1395b–1 note), as added by section 133 of 

4 the Medicare Improvements for Patients and Pro5 viders Act of 2008 (Public Law 110-275). 

6 ‘‘(2) Notwithstanding section 1302(c) of the Af7 fordable Health Care for America Act, in addition to 

8 funds provided in paragraph (1) and subsection 

9 (g)(2)(A), the funding for medical home services 

10 that would otherwise have been available if such sec11 tion 204 medical home demonstration had been im12 plemented (without regard to subsection (g) of such 

13 section) shall be available to the independent pa14 tient-centered medical home model described in sub15 section (c).’’. 

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

17 this section shall apply to services furnished on or after 

18 the date of the enactment of this Act. 

19 (c) CONFORMING REPEAL.—Section 204 of division 

20 B of the Tax Relief and Health Care Act of 2006 (42 

21 U.S.C. 1395b–1 note), as amended by section 133(a)(2) 

22 of the Medicare Improvements for Patients and Providers 

23 Act of 2008 (Public Law 110–275), is repealed. 


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1 SEC. 1303. PAYMENT INCENTIVE FOR SELECTED PRIMARY 

2 CARE SERVICES. 

3 (a) IN GENERAL.—Section 1833 of the Social Secu4 rity Act is amended by inserting after subsection (o) the 

5 following new subsection: 

6 ‘‘(p) PRIMARY CARE PAYMENT INCENTIVES.— 

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

8 services (as defined in paragraph (2)) furnished on 

9 or after January 1, 2011, by a primary care practi10 tioner (as defined in paragraph (3)) for which 

11 amounts are payable under section 1848, in addition 

12 to the amount otherwise paid under this part there 

13 shall also be paid to the practitioner (or to an em14 ployer or facility in the cases described in clause (A) 

15 of section 1842(b)(6)) (on a monthly or quarterly 

16 basis) from the Federal Supplementary Medical In17 surance Trust Fund an amount equal 5 percent (or 

18 10 percent if the practitioner predominately fur19 nishes such services in an area that is designated 

20 (under section 332(a)(1)(A) of the Public Health 

21 Service Act) as a primary care health professional 

22 shortage area. 

23 ‘‘(2) PRIMARY CARE SERVICES DEFINED.—In 

24 this subsection, the term ‘primary care services’— 

25 ‘‘(A) mean evaluation and management 

26 services, without regard to the specialty of the 


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1 physician furnishing the services, that are pro2 cedure codes (for services covered under this 

3 title) for— 

4 ‘‘(i) services in the category des5 ignated Evaluation and Management in the 

6 Health Care Common Procedure Coding 

7 System (established by the Secretary under 

8 section 1848(c)(5) as of December 31, 

9 2009, and as subsequently modified by the 

10 Secretary); and 

11 ‘‘(ii) preventive services (as defined in 

12 section 1861(iii) for which payment is 

13 made under this section; and 

14 ‘‘(B) includes services furnished by another 

15 health care professional that would be described 

16 in subparagraph (A) if furnished by a physi17 cian. 

18 ‘‘(3) PRIMARY CARE PRACTITIONER DE19 FINED.—In this subsection, the term ‘primary care 

20 practitioner’— 

21 ‘‘(A) means a physician or other health 

22 care practitioner (including a nurse practi23 tioner) who— 

24 ‘‘(i) specializes in family medicine, 

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1 rics, geriatrics, or obstetrics and gyne2 cology; and 

3 ‘‘(ii) has allowed charges for primary 

4 care services that account for at least 50 

5 percent of the physician’s or practitioner’s 

6 total allowed charges under section 1848, 

7 as determined by the Secretary for the 

8 most recent period for which data are 

9 available; and 

10 ‘‘(B) includes a physician assistant who is 

11 under the supervision of a physician described 

12 in subparagraph (A). 

13 ‘‘(4) LIMITATION ON REVIEW.—There shall be 

14 no administrative or judicial review under section 

15 1869, section 1878, or otherwise, respecting— 

16 ‘‘(A) any determination or designation 

17 under this subsection; 

18 ‘‘(B) the identification of services as pri19 mary care services under this subsection; and 

20 ‘‘(C) the identification of a practitioner as 

21 a primary care practitioner under this sub22 section. 

23 ‘‘(5) COORDINATION WITH OTHER PAY24 MENTS.— 


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1 ‘‘(A) WITH OTHER PRIMARY CARE INCEN2 TIVES.—The provisions of this subsection shall 

3 not be taken into account in applying sub4 sections (m) and (u) and any payment under 

5 such subsections shall not be taken into account 

6 in computing payments under this subsection. 

7 ‘‘(B) WITH QUALITY INCENTIVES.—Pay8 ments under this subsection shall not be taken 

9 into account in determining the amounts that 

10 would otherwise be paid under this part for 

11 purposes of section 1834(g)(2)(B).’’. 

12 (b) CONFORMING AMENDMENTS.— 

13 (1) Section 1833(m) of such Act (42 U.S.C. 

14 1395l(m)) is amended by redesignating paragraph 

15 (4) as paragraph (5) and by inserting after para16 graph (3) the following new paragraph: 

17 ‘‘(4) The provisions of this subsection shall not be 

18 taken into account in applying subsections (m) or (u) and 

19 any payment under such subsections shall not be taken 

20 into account in computing payments under this sub21 section.’’. 

22 (2) Section 1848(m)(5)(B) of such Act (42 

23 U.S.C. 1395w–4(m)(5)(B)) is amended by inserting 

24 ‘‘, (p),’’ after ‘‘(m)’’. 


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1 (3) Section 1848(o)(1)(B)(iv) of such Act (42 

2 U.S.C. 1395w–4(o)(1)(B)(iv)) is amended by insert3 ing ‘‘primary care’’ before ‘‘health professional 

4 shortage area’’. 

5 SEC. 1304. INCREASED REIMBURSEMENT RATE FOR CER6 TIFIED NURSE-MIDWIVES. 

7 (a) IN GENERAL.—Section 1833(a)(1)(K) of the So8 cial Security Act (42 U.S.C.1395l(a)(1)(K)) is amended 

9 by striking ‘‘(but in no event’’ and all that follows through 

10 ‘‘performed by a physician)’’. 

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

12 subsection (a) shall apply to services furnished on or after 

13 January 1, 2011. 

14 SEC. 1305. COVERAGE AND WAIVER OF COST-SHARING FOR 

15 PREVENTIVE SERVICES. 

16 (a) MEDICARE COVERED PREVENTIVE SERVICES DE17 FINED.—Section 1861 of the Social Security Act (42 

18 U.S.C. 1395x), as amended by section 1233(a)(1)(B), is 

19 amended by adding at the end the following new sub20 section: 

21 ‘‘Medicare Covered Preventive Services 

22 ‘‘(iii)(1) Subject to the succeeding provisions of this 

23 subsection, the term ‘Medicare covered preventive services’ 

24 means the following: 


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

2 in subsection (oo)). 

3 ‘‘(B) Colorectal cancer screening tests (as de4 fined in subsection (pp). 

5 ‘‘(C) Diabetes outpatient self-management 

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

7 ‘‘(D) Screening for glaucoma for certain indi8 viduals (as described in subsection (s)(2)(U)). 

9 ‘‘(E) Medical nutrition therapy services for cer10 tain individuals (as described in subsection 

11 (s)(2)(V)). 

12 ‘‘(F) An initial preventive physical examination 

13 (as defined in subsection (ww)). 

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

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

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

17 subsection (yy)). 

18 ‘‘(I) Ultrasound screening for abdominal aortic 

19 aneurysm for certain individuals (as described in 

20 subsection (s)(2)(AA)). 

21 ‘‘(J) Federally approved and recommended vac22 cines and their administration as described in sub23 section (s)(10). 

24 ‘‘(K) Screening mammography (as defined in 

25 subsection (jj)). 


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1 ‘‘(L) Screening pap smear and screening pelvic 

2 exam (as defined in subsection (nn)). 

3 ‘‘(M) Bone mass measurement (as defined in 

4 subsection (rr)). 

5 ‘‘(N) Kidney disease education services (as de6 fined in subsection (ggg)). 

7 ‘‘(O) Additional preventive services (as defined 

8 in subsection (ddd)). 

9 ‘‘(2) With respect to specific Medicare covered pre10 ventive services, the limitations and conditions described 

11 in the provisions referenced in paragraph (1) with respect 

12 to such services shall apply.’’. 

13 (b) PAYMENT AND ELIMINATION OF COST-SHAR14 ING.— 

15 (1) IN GENERAL.— 

16 (A) IN GENERAL.—Section 1833(a) of the 

17 Social Security Act (42 U.S.C. 1395l(a)) is 

18 amended by adding after and below paragraph 

19 (9) the following: 

20 ‘‘With respect to Medicare covered preventive services, in 

21 any case in which the payment rate otherwise provided 

22 under this part is computed as a percent of less than 100 

23 percent of an actual charge, fee schedule rate, or other 

24 rate, such percentage shall be increased to 100 percent.’’. 


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1 (B) APPLICATION TO SIGMOIDOSCOPIES

2 AND COLONOSCOPIES.—Section 1834(d) of such 

3 Act (42 U.S.C. 1395m(d)) is amended— 

4 (i) in paragraph (2)(C), by amending 

5 clause (ii) to read as follows: 

6 ‘‘(ii) NO COINSURANCE.—In the case 

7 of a beneficiary who receives services de8 scribed in clause (i), there shall be no coin9 surance applied.’’; and 

10 (ii) in paragraph (3)(C), by amending 

11 clause (ii) to read as follows: 

12 ‘‘(ii) NO COINSURANCE.—In the case 

13 of a beneficiary who receives services de14 scribed in clause (i), there shall be no coin15 surance applied.’’. 

16 (2) ELIMINATION OF COINSURANCE IN OUT17 PATIENT HOSPITAL SETTINGS.— 

18 (A) EXCLUSION FROM OPD FEE SCHED19 ULE.—Section 1833(t)(1)(B)(iv) of the Social 

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

21 amended by striking ‘‘screening mammography 

22 (as defined in section 1861(jj)) and diagnostic 

23 mammography’’ and inserting ‘‘diagnostic 

24 mammograms and Medicare covered preventive 

25 services (as defined in section 1861(iii)(1))’’. 


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1 (B) CONFORMING AMENDMENTS.—Section 

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

3 U.S.C. 1395l(a)(2)) is amended— 

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

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

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

7 ‘‘and’’ at the end; and 

8 (iii) by adding at the end the fol9 lowing new subparagraph: 

10 ‘‘(H) with respect to additional preventive 

11 services (as defined in section 1861(ddd)) fur12 nished by an outpatient department of a hos13 pital, the amount determined under paragraph 

14 (1)(W);’’. 

15 (3) WAIVER OF APPLICATION OF DEDUCTIBLE

16 FOR ALL PREVENTIVE SERVICES.—The first sen17 tence of section 1833(b) of the Social Security Act 

18 (42 U.S.C. 1395l(b)) is amended— 

19 (A) in clause (1), by striking ‘‘items and 

20 services described in section 1861(s)(10)(A)’’ 

21 and inserting ‘‘Medicare covered preventive 

22 services (as defined in section 1861(iii))’’; 

23 (B) by inserting ‘‘and’’ before ‘‘(4)’’; and 

24 (C) by striking clauses (5) through (8). 


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1 (4) APPLICATION TO PROVIDERS OF SERV2 ICES.—Section 1866(a)(2)(A)(ii) of such Act (42 

3 U.S.C. 1395cc(a)(2)(A)(ii)) is amended by inserting 

4 ‘‘other than for Medicare covered preventive services 

5 and’’ after ‘‘for such items and services (’’. 

6 (c) EFFECTIVE DATE.—The amendments made by 

7 this section shall apply to services furnished on or after 

8 January 1, 2011. 

9 (d) PREVENTIVE SERVICES.— 

10 (1) REPORT TO CONGRESS ON BARRIERS TO

11 PREVENTIVE SERVICES.—Not later than 12 months 

12 after the date of the enactment of this Act, the Sec13 retary of Health and Human Services shall report to 

14 Congress on barriers, if any, facing Medicare bene15 ficiaries in accessing the benefit to abdominal aortic 

16 aneurysm screening and other preventative services 

17 through the Welcome to Medicare Physical Exam. 

18 (2) ABDOMINAL AORTIC ANEURYSM SCREEN AC19 CESS.—The Secretary shall, to the extent practical, 

20 identify and implement policies promoting proper 

21 use of abdominal aortic aneurysm screening among 

22 Medicare beneficiaries at risk for such aneurysms. 


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1 SEC. 1306. WAIVER OF DEDUCTIBLE FOR COLORECTAL 

2 CANCER SCREENING TESTS REGARDLESS OF 

3 CODING, SUBSEQUENT DIAGNOSIS, OR ANCIL4 LARY TISSUE REMOVAL. 

5 (a) IN GENERAL.—Section 1833 of the Social Secu6 rity Act (42 U.S.C. 1395l(b)), as amended by section 

7 1305(b), is further amended— 

8 (1) in subsection (a), in the sentence added by 

9 section 1305(b)(1)(A), by inserting ‘‘(including serv10 ices described in the last sentence of section 

11 1833(b))’’ after ‘‘preventive services’’; and 

12 (2) in subsection (b), by adding at the end the 

13 following new sentence: ‘‘Clause (1) of the first sen14 tence of this subsection shall apply with respect to 

15 a colorectal cancer screening test regardless of the 

16 code that is billed for the establishment of a diag17 nosis as a result of the test, or for the removal of 

18 tissue or other matter or other procedure that is fur19 nished in connection with, as a result of, and in the 

20 same clinical encounter as, the screening test.’’. 

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

22 subsection (a) shall apply to items and services furnished 

23 on or after January 1, 2011. 


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1 SEC. 1307. EXCLUDING CLINICAL SOCIAL WORKER SERV2 ICES FROM COVERAGE UNDER THE MEDI3 CARE SKILLED NURSING FACILITY PROSPEC4 TIVE PAYMENT SYSTEM AND CONSOLIDATED 

5 PAYMENT. 

6 (a) IN GENERAL.—Section 1888(e)(2)(A)(ii) of the 

7 Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is 

8 amended by inserting ‘‘clinical social worker services,’’ 

9 after ‘‘qualified psychologist services,’’. 

10 (b) CONFORMING AMENDMENT.—Section 

11 1861(hh)(2) of the Social Security Act (42 U.S.C. 

12 1395x(hh)(2)) is amended by striking ‘‘and other than 

13 services furnished to an inpatient of a skilled nursing facil14 ity which the facility is required to provide as a require15 ment for participation’’. 

16 (c) EFFECTIVE DATE.—The amendments made by 

17 this section shall apply to items and services furnished on 

18 or after October 1, 2010. 

19 SEC. 1308. COVERAGE OF MARRIAGE AND FAMILY THERA20 PIST SERVICES AND MENTAL HEALTH COUN21 SELOR SERVICES. 

22 (a) COVERAGE OF MARRIAGE AND FAMILY THERA23 PIST SERVICES.— 

24 (1) COVERAGE OF SERVICES.—Section 

25 1861(s)(2) of the Social Security Act (42 U.S.C. 


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1 1395x(s)(2)), as amended by section 1235, is 

2 amended— 

3 (A) in subparagraph (EE), by striking 

4 ‘‘and’’ at the end; 

5 (B) in subparagraph (FF), by adding 

6 ‘‘and’’ at the end; and 

7 (C) by adding at the end the following new 

8 subparagraph: 

9 ‘‘(GG) marriage and family therapist serv10 ices (as defined in subsection (jjj));’’. 

11 (2) DEFINITION.—Section 1861 of the Social 

12 Security Act (42 U.S.C. 1395x), as amended by sec13 tions 1233 and 1305, is amended by adding at the 

14 end the following new subsection: 

15 ‘‘Marriage and Family Therapist Services 

16 ‘‘(jjj)(1) The term ‘marriage and family therapist 

17 services’ means services performed by a marriage and 

18 family therapist (as defined in paragraph (2)) for the diag19 nosis and treatment of mental illnesses, which the mar20 riage and family therapist is legally authorized to perform 

21 under State law (or the State regulatory mechanism pro22 vided by State law) of the State in which such services 

23 are performed, as would otherwise be covered if furnished 

24 by a physician or as incident to a physician’s professional 

25 service, but only if no facility or other provider charges 


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1 or is paid any amounts with respect to the furnishing of 

2 such services. 

3 ‘‘(2) The term ‘marriage and family therapist’ means 

4 an individual who— 

5 ‘‘(A) possesses a master’s or doctoral degree 

6 which qualifies for licensure or certification as a 

7 marriage and family therapist pursuant to State 

8 law; 

9 ‘‘(B) after obtaining such degree has performed 

10 at least 2 years of clinical supervised experience in 

11 marriage and family therapy; and 

12 ‘‘(C) is licensed or certified as a marriage and 

13 family therapist in the State in which marriage and 

14 family therapist services are performed.’’. 

15 (3) PROVISION FOR PAYMENT UNDER PART

16 B.—Section 1832(a)(2)(B) of the Social Security 

17 Act (42 U.S.C. 1395k(a)(2)(B)) is amended by add18 ing at the end the following new clause: 

19 ‘‘(v) marriage and family therapist 

20 services;’’. 

21 (4) AMOUNT OF PAYMENT.— 

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

23 the Social Security Act (42 U.S.C. 1395l(a)(1)) 

24 is amended— 


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

2 and 

3 (ii) by inserting before the semicolon 

4 at the end the following: ‘‘, and (X) with 

5 respect to marriage and family therapist 

6 services under section 1861(s)(2)(GG), the 

7 amounts paid shall be 80 percent of the 

8 lesser of the actual charge for the services 

9 or 75 percent of the amount determined 

10 for payment of a psychologist under clause 

11 (L)’’. 

12 (B) DEVELOPMENT OF CRITERIA WITH RE13 SPECT TO CONSULTATION WITH A HEALTH

14 CARE PROFESSIONAL.—The Secretary of Health 

15 and Human Services shall, taking into consider16 ation concerns for patient confidentiality, de17 velop criteria with respect to payment for mar18 riage and family therapist services for which 

19 payment may be made directly to the marriage 

20 and family therapist under part B of title 

21 XVIII of the Social Security Act (42 U.S.C. 

22 1395j et seq.) under which such a therapist 

23 must agree to consult with a patient’s attending 

24 or primary care physician or nurse practitioner 

25 in accordance with such criteria. 


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1 (5) EXCLUSION OF MARRIAGE AND FAMILY

2 THERAPIST SERVICES FROM SKILLED NURSING FA3 CILITY PROSPECTIVE PAYMENT SYSTEM.—Section 

4 1888(e)(2)(A)(ii) of the Social Security Act (42 

5 U.S.C. 1395yy(e)(2)(A)(ii)), as amended by section 

6 1307(a), is amended by inserting ‘‘marriage and 

7 family therapist services (as defined in subsection 

8 (jjj)(1)),’’ after ‘‘clinical social worker services,’’. 

9 (6) COVERAGE OF MARRIAGE AND FAMILY

10 THERAPIST SERVICES PROVIDED IN RURAL HEALTH

11 CLINICS AND FEDERALLY QUALIFIED HEALTH CEN12 TERS.—Section 1861(aa)(1)(B) of the Social Secu13 rity Act (42 U.S.C. 1395x(aa)(1)(B)) is amended by 

14 striking ‘‘or by a clinical social worker (as defined 

15 in subsection (hh)(1)),’’ and inserting ‘‘, by a clinical 

16 social worker (as defined in subsection (hh)(1)), or 

17 by a marriage and family therapist (as defined in 

18 subsection (jjj)(2)),’’. 

19 (7) INCLUSION OF MARRIAGE AND FAMILY

20 THERAPISTS AS PRACTITIONERS FOR ASSIGNMENT

21 OF CLAIMS.—Section 1842(b)(18)(C) of the Social 

22 Security Act (42 U.S.C. 1395u(b)(18)(C)) is amend23 ed by adding at the end the following new clause: 

24 ‘‘(vii) A marriage and family therapist (as de25 fined in section 1861(jjj)(2)).’’. 


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1 (b) COVERAGE OF MENTAL HEALTH COUNSELOR

2 SERVICES.— 

3 (1) COVERAGE OF SERVICES.—Section 

4 1861(s)(2) of the Social Security Act (42 U.S.C. 

5 1395x(s)(2)), as previously amended, is further 

6 amended— 

7 (A) in subparagraph (FF), by striking 

8 ‘‘and’’ at the end; 

9 (B) in subparagraph (GG), by inserting 

10 ‘‘and’’ at the end; and 

11 (C) by adding at the end the following new 

12 subparagraph: 

13 ‘‘(HH) mental health counselor services (as de14 fined in subsection (kkk)(1));’’. 

15 (2) DEFINITION.—Section 1861 of the Social 

16 Security Act (42 U.S.C. 1395x), as previously 

17 amended, is amended by adding at the end the fol18 lowing new subsection: 

19 ‘‘Mental Health Counselor Services 

20 ‘‘(kkk)(1) The term ‘mental health counselor services’ 

21 means services performed by a mental health counselor (as 

22 defined in paragraph (2)) for the diagnosis and treatment 

23 of mental illnesses which the mental health counselor is 

24 legally authorized to perform under State law (or the 

25 State regulatory mechanism provided by the State law) of 


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1 the State in which such services are performed, as would 

2 otherwise be covered if furnished by a physician or as inci3 dent to a physician’s professional service, but only if no 

4 facility or other provider charges or is paid any amounts 

5 with respect to the furnishing of such services. 

6 ‘‘(2) The term ‘mental health counselor’ means an 

7 individual who— 

8 ‘‘(A) possesses a master’s or doctor’s degree 

9 which qualifies the individual for licensure or certifi10 cation for the practice of mental health counseling in 

11 the State in which the services are performed; 

12 ‘‘(B) after obtaining such a degree has per13 formed at least 2 years of supervised mental health 

14 counselor practice; and 

15 ‘‘(C) is licensed or certified as a mental health 

16 counselor or professional counselor by the State in 

17 which the services are performed.’’. 

18 (3) PROVISION FOR PAYMENT UNDER PART

19 B.—Section 1832(a)(2)(B) of the Social Security 

20 Act (42 U.S.C. 1395k(a)(2)(B)), as amended by 

21 subsection (a)(3), is further amended— 

22 (A) by striking ‘‘and’’ at the end of clause 

23 (iv); 

24 (B) by adding ‘‘and’’ at the end of clause 

25 (v); and 


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1 (C) by adding at the end the following new 

2 clause: 

3 ‘‘(vi) mental health counselor serv4 ices;’’. 

5 (4) AMOUNT OF PAYMENT.— 

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

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

8 1395l(a)(1)), as amended by subsection (a), is 

9 further amended— 

10 (i) by striking ‘‘and’’ before ‘‘(X)’’; 

11 and 

12 (ii) by inserting before the semicolon 

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

14 respect to mental health counselor services 

15 under section 1861(s)(2)(HH), the 

16 amounts paid shall be 80 percent of the 

17 lesser of the actual charge for the services 

18 or 75 percent of the amount determined 

19 for payment of a psychologist under clause 

20 (L)’’. 

21 (B) DEVELOPMENT OF CRITERIA WITH RE22 SPECT TO CONSULTATION WITH A PHYSICIAN.— 

23 The Secretary of Health and Human Services 

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1 spect to payment for mental health counselor 

2 services for which payment may be made di3 rectly to the mental health counselor under part 

4 B of title XVIII of the Social Security Act (42 

5 U.S.C. 1395j et seq.) under which such a coun6 selor must agree to consult with a patient’s at7 tending or primary care physician in accordance 

8 with such criteria. 

9 (5) EXCLUSION OF MENTAL HEALTH COUN10 SELOR SERVICES FROM SKILLED NURSING FACILITY

11 PROSPECTIVE PAYMENT SYSTEM.—Section 

12 1888(e)(2)(A)(ii) of the Social Security Act (42 

13 U.S.C. 1395yy(e)(2)(A)(ii)), as amended by section 

14 1307(a) and subsection (a), is amended by inserting 

15 ‘‘mental health counselor services (as defined in sec16 tion 1861(kkk)(1)),’’ after ‘‘marriage and family 

17 therapist services (as defined in subsection 

18 (jjj)(1)),’’. 

19 (6) COVERAGE OF MENTAL HEALTH COUN20 SELOR SERVICES PROVIDED IN RURAL HEALTH

21 CLINICS AND FEDERALLY QUALIFIED HEALTH CEN22 TERS.—Section 1861(aa)(1)(B) of the Social Secu23 rity Act (42 U.S.C. 1395x(aa)(1)(B)), as amended 

24 by subsection (a), is amended by striking ‘‘or by a 

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1 section (jjj)(2)),’’ and inserting ‘‘by a marriage and 

2 family therapist (as defined in subsection (jjj)(2)), 

3 or a mental health counselor (as defined in sub4 section (kkk)(2)),’’. 

5 (7) INCLUSION OF MENTAL HEALTH COUN6 SELORS AS PRACTITIONERS FOR ASSIGNMENT OF

7 CLAIMS.—Section 1842(b)(18)(C) of the Social Se8 curity Act (42 U.S.C. 1395u(b)(18)(C)), as amended 

9 by subsection (a)(7), is amended by adding at the 

10 end the following new clause: 

11 ‘‘(viii) A mental health counselor (as defined in 

12 section 1861(kkk)(2)).’’. 

13 (c) EFFECTIVE DATE.—The amendments made by 

14 this section shall apply to items and services furnished on 

15 or after January 1, 2011. 

16 SEC. 1309. EXTENSION OF PHYSICIAN FEE SCHEDULE MEN17 TAL HEALTH ADD-ON. 

18 Section 138(a)(1) of the Medicare Improvements for 

19 Patients and Providers Act of 2008 (Public Law 110–275) 

20 is amended by striking ‘‘December 31, 2009’’ and insert21 ing ‘‘December 31, 2011’’. 

22 SEC. 1310. EXPANDING ACCESS TO VACCINES. 

23 (a) IN GENERAL.—Paragraph (10) of section 

24 1861(s) of the Social Security Act (42 U.S.C. 1395w(s)) 

25 is amended to read as follows: 


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1 ‘‘(10) federally approved and recommended vac2 cines (as defined in subsection (lll)) and their re3 spective administration;’’. 

4 (b) FEDERALLY APPROVED AND RECOMMENDED

5 VACCINES DEFINED.—Section 1861 of such Act is further 

6 amended by adding at the end the following new sub7 section: 

8 ‘‘Federally Approved and Recommended Vaccines 

9 ‘‘(lll) The term ‘federally approved and recommended 

10 vaccine’ means a vaccine that— 

11 ‘‘(1) is licensed under section 351 of the Public 

12 Health Service Act, approved under the Federal 

13 Food, Drug, and Cosmetic Act, or authorized for 

14 emergency use under section 564 of the Federal, 

15 Food, Drug, and Cosmetic Act; and 

16 ‘‘(2) is recommended by the Director of the 

17 Centers for Disease Control and Prevention.’’. 

18 (c) CONFORMING AMENDMENTS.— 

19 (1) Section 1833 of such Act (42 U.S.C. 1395l) 

20 is amended, in each of subsections (a)(1)(B), 

21 (a)(2)(G), and (a)(3)(A), by striking 

22 ‘‘1861(s)(10)(A)’’ and inserting ‘‘1861(s)(10)’’ each 

23 place it appears. 

24 (2) Section 1842(o)(1)(A)(iv) of such Act (42 

25 U.S.C. 1395u(o)(1)(A)(iv)) is amended— 


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1 (A) by striking ‘‘subparagraph (A) or (B) 

2 of’’; and 

3 (B) by inserting before the period the fol4 lowing: ‘‘and before January 1, 2011, and influ5 enza vaccines furnished on or after January 1, 

6 2011’’. 

7 (3) Section 1847A(c)(6) of such Act (42 U.S.C. 

8 1395w–3a(c)(6)) is amended— 

9 (A) in subparagraph (D)(i), by inserting ‘‘, 

10 including a vaccine furnished on or after Janu11 ary 1, 2010’’; and 

12 (B) by the following new paragraph: 

13 ‘‘(H) IMPLEMENTATION.—Chapter 35 of 

14 title 44, United States Code shall not apply to 

15 manufacturer provision of information pursuant 

16 to section 1927(b)(3)(A)(iii) or subsection 

17 (f)(2) for purposes of implementation of this 

18 section.’’. 

19 (4) Section 1860D–2(e)(1) of such Act (42 

20 U.S.C. 1395w–102(e)(1)) is amended by striking 

21 ‘‘such term includes a vaccine’’ and all that follows 

22 through ‘‘its administration) and’’. 

23 (5) Section 1861(ww)(2)(A) of such Act (42 

24 U.S.C. 1395x(ww)(2)(A))) is amended by striking 

25 ‘‘Pneumococcal, influenza, and hepatitis B vaccine 


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1 and administration’’ and inserting ‘‘federally ap2 proved or authorized vaccines (as defined in sub3 section (lll)) and their respective administration’’. 

4 (6) Section 1927(b)(3)(A)(iii) of such Act (42 

5 U.S.C. 1396r–8(b)(3)(A)(iii)) is amended, in the 

6 matter following subclause (III), by inserting 

7 ‘‘(A)(iv) (including influenza vaccines furnished on 

8 or after January 1, 2011),’’ after ‘‘described in sub9 paragraph’’. 

10 (7) Section 1847A(f) of such Act (42 U.S.C. 

11 1395w–3a(f)) is amended— 

12 (A) by striking ‘‘For’’ and inserting ‘‘(1) 

13 IN GENERAL.—For’’; 

14 (B) by indenting paragraph (1), as redes15 ignated in subparagraph (A), 2 ems to the left; 

16 and— 

17 (C) by adding at the end the following new 

18 paragraph: 

19 ‘‘(2) TREATMENT OF CERTAIN MANUFACTUR20 ERS.—In the case of a manufacturer of a drug or 

21 biological described in subparagraphs (A)(iv), (C), 

22 (D), (E), or (G) of section 1842(o)(1) that does not 

23 have a rebate agreement under section 1927(a), no 

24 payment may be made under this part for such drug 

25 or biological if such manufacturer does not submit 


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1 the information described in section 

2 1927(b)(3)(A)(iii) in the same manner as if the 

3 manufacturer had such a rebate agreement in effect. 

4 Subparagraphs (C) and (D) of section 1927(b)(3) 

5 shall apply to information reported pursuant to the 

6 previous sentence in the same manner as such sub7 paragraphs apply with respect to information re8 ported pursuant to such section.’’.’’. 

9 (d) EFFECTIVE DATES.—The amendments made— 

10 (1) by this section (other than by subsection 

11 (c)(6)) shall apply to vaccines administered on or 

12 after January 1, 2011; and 

13 (2) by subsection (c)(6) shall apply to calendar 

14 quarters beginning on or after January 1, 2010. 

15 SEC. 1311. EXPANSION OF MEDICARE-COVERED PREVEN16 TIVE SERVICES AT FEDERALLY QUALIFIED 

17 HEALTH CENTERS. 

18 (a) IN GENERAL.—Section 1861(aa)(3)(A) of the So19 cial Security Act (42 U.S.C. 1395w (aa)(3)(A)) is amend20 ed to read as follows:

21 ‘‘(A) services of the type described sub22 paragraphs (A) through (C) of paragraph (1) 

23 and services described in section 1861(iii); 

24 and’’. 


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

2 subsection (a) shall apply not later than January 1, 2011. 

3 SEC. 1312. INDEPENDENCE AT HOME DEMONSTRATION 

4 PROGRAM. 

5 Title XVIII of the Social Security Act is amended by 

6 inserting after section 1866F, as inserted by section 1302, 

7 the following new section: 

8 ‘‘INDEPENDENCE AT HOME MEDICAL PRACTICE

9 DEMONSTRATION PROGRAM

10 ‘‘SEC. 1866G. (a) ESTABLISHMENT.— 

11 ‘‘(1) IN GENERAL.—The Secretary shall con12 duct a demonstration program (in this section re13 ferred to as the ‘demonstration program’) to test a 

14 payment incentive and service delivery model that 

15 utilizes physician and nurse practitioner directed 

16 home-based primary care teams designed to reduce 

17 expenditures and improve health outcomes in the 

18 provision of items and services under this title to ap19 plicable beneficiaries (as defined in subsection (d)). 

20 ‘‘(2) REQUIREMENT.—The demonstration pro21 gram shall test whether a model described in para22 graph (1), which is accountable for providing com23 prehensive, coordinated, continuous, and accessible 

24 care to high-need populations at home and coordi25 nating health care across all treatment settings, re26 sults in— 


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1 ‘‘(A) reducing preventable hospitalizations; 

2 ‘‘(B) preventing hospital readmissions; 

3 ‘‘(C) reducing emergency room visits; 

4 ‘‘(D) improving health outcomes commen5 surate with the beneficiaries’ stage of chronic 

6 illness; 

7 ‘‘(E) improving the efficiency of care, such 

8 as by reducing duplicative diagnostic and lab9 oratory tests; 

10 ‘‘(F) reducing the cost of health care serv11 ices covered under this title; and 

12 ‘‘(G) achieving beneficiary and family care13 giver satisfaction. 

14 ‘‘(b) INDEPENDENCE AT HOME MEDICAL PRAC15 TICE.— 

16 ‘‘(1) INDEPENDENCE AT HOME MEDICAL PRAC17 TICE DEFINED.—In this section: 

18 ‘‘(A) IN GENERAL.—The term ‘independ19 ence at home medical practice’ means a legal 

20 entity that— 

21 ‘‘(i) is comprised of an individual phy22 sician or nurse practitioner or group of 

23 physicians and nurse practitioners that 

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1 ants, pharmacists, and other health and 

2 social services staff as appropriate who 

3 have experience providing home-based pri4 mary care to applicable beneficiaries, make 

5 in-home visits, and are available 24 hours 

6 per day, 7 days per week to carry out 

7 plans of care that are tailored to the indi8 vidual beneficiary’s chronic conditions and 

9 designed to achieve the results in sub10 section (a); 

11 ‘‘(ii) is organized at least in part for 

12 the purpose of providing physicians’ serv13 ices; 

14 ‘‘(iii) has documented experience in 

15 providing home-based primary care serv16 ices to high cost chronically ill bene17 ficiaries, as determined appropriate by the 

18 Secretary; 

19 ‘‘(iv) includes at least 200 applicable 

20 beneficiaries as defined in subsection (d); 

21 ‘‘(v) has entered into an agreement 

22 with the Secretary; 

23 ‘‘(vi) uses electronic health informa24 tion systems, remote monitoring, and mo25 bile diagnostic technology; and 


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1 ‘‘(vii) meets such other criteria as the 

2 Secretary determines to be appropriate to 

3 participate in the demonstration program. 

4 ‘‘(B) PHYSICIAN.—The term ‘physician’ in5 cludes, except as the Secretary may otherwise 

6 provide, any individual who furnishes services 

7 for which payment may be made as physicians’ 

8 services and has the medical training or experi9 ence to fulfill the physician’s role described in 

10 subparagraph (A)(i). 

11 ‘‘(2) PARTICIPATION OF NURSE PRACTITIONERS

12 AND PHYSICIAN ASSISTANTS.—Nothing in this sec13 tion shall be construed to prevent a nurse practi14 tioner or physician assistant from participating in, 

15 or leading, a home-based primary care team as part 

16 of an independence at home medical practice if— 

17 ‘‘(A) all the requirements of this section 

18 are met; 

19 ‘‘(B) the nurse practitioner or physician 

20 assistant, as the case may be, is acting con21 sistent with State law; and 

22 ‘‘(C) the nurse practitioner or physician 

23 assistant has the medical training or experience 

24 to fulfill the nurse practitioner or physician as25 sistant role described in paragraph (1)(A)(i). 


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1 ‘‘(3) INCLUSION OF PROVIDERS AND PRACTI2 TIONERS.—Nothing in this subsection shall be con3 strued as preventing an independence at home med4 ical practice from including a provider of services or 

5 a participating practitioner described in section 

6 1842(b)(18)(C) that is affiliated with the practice 

7 under an arrangement structured so that such pro8 vider of services or practitioner participates in the 

9 demonstration program and shares in any savings 

10 under the demonstration program. 

11 ‘‘(4) QUALITY AND PERFORMANCE STAND12 ARDS.— 

13 ‘‘(A) IN GENERAL.—An independence at 

14 home medical practice participating in the dem15 onstration program shall report on quality 

16 measures (in such form, manner, and frequency 

17 as specified by the Secretary, which may be for 

18 the group, for providers of services and sup19 pliers, or both) and report to the Secretary (in 

20 a form, manner, and frequency as specified by 

21 the Secretary) such data as the Secretary deter22 mines appropriate to monitor and evaluate the 

23 demonstration program. 

24 ‘‘(B) DEVELOPMENT OF QUALITY PER25 FORMANCE STANDARDS.—The Secretary shall 


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1 develop quality performance standards for inde2 pendence at home medical practices partici3 pating in the demonstration program. 

4 ‘‘(c) SHARED SAVINGS PAYMENT METHODOLOGY.— 

5 ‘‘(1) ESTABLISHMENT OF TARGET SPENDING

6 LEVEL.—The Secretary shall establish annual target 

7 spending levels for items and services covered under 

8 parts A and B furnished to applicable beneficiaries 

9 by qualifying independence at home medical prac10 tices under this section. The Secretary may set an 

11 aggregate target spending level for all qualifying 

12 practices, or may set different target spending levels 

13 for groups of practices or a single practice. Such 

14 target spending levels may be determined on a per 

15 capita basis and shall take into account normal vari16 ation in expenditures for items and services covered 

17 under parts A and B furnished to such beneficiaries. 

18 The target shall also be adjusted for the size of the 

19 practice, number of practices included in the target 

20 spending level, characteristics of applicable bene21 ficiaries and such other factors as the Secretary de22 termines appropriate. The Secretary may periodi23 cally adjust or rebase the target spending level 

24 under this paragraph. 

25 ‘‘(2) SHARED SAVINGS AMOUNTS.— 


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1 ‘‘(A) IN GENERAL.—Subject to subpara2 graph (B), qualifying independence at home 

3 medical practices are eligible to receive an in4 centive payment under this section if aggregate 

5 expenditures for a year for applicable bene6 ficiaries are less than the target spending level 

7 for qualifying independence at home medical 

8 practices for such year. An incentive payment 

9 for such year shall be equal to a portion (as de10 termined by the Secretary) of the amount by 

11 which total payments for applicable bene12 ficiaries under parts A and B for such year are 

13 estimated to be less than 5 percent less than 

14 the target spending level for such year, as de15 termined by the Secretary. 

16 ‘‘(B) APPORTIONMENT OF SAVINGS.—The 

17 Secretary shall designate how, and to what ex18 tent, an incentive payment under this section is 

19 to be apportioned among qualifying independ20 ence at home medical practices, taking into ac21 count the size of the practice, characteristics of 

22 the individuals enrolled in each practice, per23 formance on quality performance measures, and 

24 such other factors as the Secretary determines 

25 appropriate. 


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1 ‘‘(3) SAVINGS TO THE MEDICARE PROGRAM.— 

2 The Secretary shall limit incentive payments to each 

3 qualifying independence at home medical practice 

4 under this paragraph, with respect to a year, as nec5 essary to ensure that the aggregate expenditures for 

6 items and services under parts A and B with respect 

7 to applicable beneficiaries for such independence at 

8 home medical practice (inclusive of shared savings 

9 payments) do not exceed the amount that the Sec10 retary estimates would be expended for such items 

11 and services for such beneficiaries during such year 

12 (taking into account normal variation in expendi13 tures and other factors the Secretary deems appro14 priate) if the demonstration program under this sec15 tion were not implemented, minus 5 percent. 

16 ‘‘(d) APPLICABLE BENEFICIARIES.— 

17 ‘‘(1) DEFINITION.—In this section, the term 

18 ‘applicable beneficiary’ means, with respect to a 

19 qualifying independence at home medical practice, 

20 an individual who the practice has determined— 

21 ‘‘(A) is entitled to benefits under part A 

22 and enrolled for benefits under part B; 

23 ‘‘(B) is not enrolled in a Medicare Advan24 tage plan under part C or a PACE program 

25 under section 1894; 


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1 ‘‘(C) has 2 or more chronic illnesses, such 

2 as congestive heart failure, diabetes, other de3 mentias designated by the Secretary, chronic 

4 obstructive pulmonary disease, ischemic heart 

5 disease, stroke, Alzheimer’s Disease and 

6 neurodegenerative diseases, and other diseases 

7 and conditions designated by the Secretary 

8 which result in high costs under this title; 

9 ‘‘(D) within the past 12 months has had a 

10 nonelective hospital admission; 

11 ‘‘(E) within the past 12 months has re12 ceived acute or subacute rehabilitation services; 

13 ‘‘(F) has 2 or more functional depend14 encies requiring the assistance of another per15 son (such as bathing, dressing, toileting, walk16 ing, or feeding); and 

17 ‘‘(G) meets such other criteria as the Sec18 retary determines appropriate. 

19 ‘‘(2) PATIENT ELECTION TO PARTICIPATE.— 

20 The Secretary shall determine an appropriate meth21 od of ensuring that applicable beneficiaries have 

22 agreed to enroll in an independence at home medical 

23 practice under the demonstration program. Enroll24 ment in the demonstration program shall be vol25 untary. 


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1 ‘‘(3) BENEFICIARY ACCESS TO SERVICES.— 

2 Nothing in this section shall be construed as encour3 aging physicians or nurse practitioners to limit ap4 plicable beneficiary access to services covered under 

5 this title and applicable beneficiaries shall not be re6 quired to relinquish access to any benefit under this 

7 title as a condition of receiving services from an 

8 independence at home medical practice. 

9 ‘‘(e) IMPLEMENTATION.— 

10 ‘‘(1) STARTING DATE.—The demonstration pro11 gram shall begin not later than January 1, 2012. An 

12 agreement with an independence at home medical 

13 practice under the demonstration program may 

14 cover not more than a 3-year period. 

15 ‘‘(2) NO PHYSICIAN DUPLICATION IN DEM16 ONSTRATION PARTICIPATION.—The Secretary shall 

17 not pay an independence at home medical practice 

18 under this section that participates in section 1866D 

19 or section 1866E. 

20 ‘‘(3) NO BENEFICIARY DUPLICATION IN DEM21 ONSTRATION PARTICIPATION.—The Secretary shall 

22 ensure that no applicable beneficiary enrolled in an 

23 independence at home medical practice under this 

24 section is participating in the programs under sec25 tion 1866D or section 1866E. 


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1 ‘‘(4) PREFERENCE.—In approving an independ2 ence at home medical practice, the Secretary shall 

3 give preference to practices that are— 

4 ‘‘(A) located in high-cost areas of the 

5 country; 

6 ‘‘(B) have experience in furnishing health 

7 care services to applicable beneficiaries in the 

8 home; and 

9 ‘‘(C) use electronic medical records, health 

10 information technology, and individualized plans 

11 of care. 

12 ‘‘(5) NUMBER OF PRACTICES.— 

13 ‘‘(A) IN GENERAL.—Subject to subpara14 graph (B), the Secretary shall enter into agree15 ments with as many independence at home me16 dial practices as practicable and consistent with 

17 this subsection to test the potential of the inde18 pendence at home medical practice model under 

19 this section in order to achieve the results de20 scribed in subsection (a) across practices serv21 ing varying numbers of applicable beneficiaries. 

22 ‘‘(B) LIMITATION.—In selecting qualified 

23 independence at home medial practices to par24 ticipate under the demonstration program, the 

25 Secretary shall limit the number of applicable 


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1 beneficiaries that may participate in the dem2 onstration program to 10,000. 

3 ‘‘(6) WAIVER.—The Secretary may waive such 

4 provisions of this title and title XI as the Secretary 

5 determines necessary in order to implement the dem6 onstration program. 

7 ‘‘(7) ADMINISTRATION.—Chapter 35 of title 44, 

8 United States Code, shall not apply to this section. 

9 ‘‘(f) EVALUATION AND MONITORING.— 

10 ‘‘(1) IN GENERAL.—The Secretary shall evalu11 ate each independence at home medical practice 

12 under the demonstration program to assess whether 

13 the practice achieved the results described in sub14 section (a). 

15 ‘‘(2) FOLLOWING APPLICABLE BENE16 FICIARIES.—The Secretary may monitor data on ex17 penditures and quality of services under this title 

18 after an applicable beneficiary discontinues receiving 

19 services under this title through a qualifying inde20 pendence at home medical practice. 

21 ‘‘(g) REPORTS TO CONGRESS.—The Secretary shall 

22 conduct an independent evaluation of the demonstration 

23 program and submit to Congress a final report, including 

24 best practices under the demonstration program. Such re25 port shall include an analysis of the demonstration proVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00729 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 gram on coordination of care, expenditures under this 

2 title, applicable beneficiary access to services, and the 

3 quality of health care services provided to applicable bene4 ficiaries. 

5 ‘‘(h) FUNDING.—For purposes of administering and 

6 carrying out the demonstration program, other than for 

7 payments for items and services furnished under this title 

8 and shared savings under subsection (c), in addition to 

9 funds otherwise appropriated, there shall be transferred 

10 to the Secretary for the Center for Medicare & Medicaid 

11 Services Program Management Account from the Federal 

12 Hospital Insurance Trust Fund under section 1817 and 

13 the Federal Supplementary Medical Insurance Trust 

14 Fund under section 1841 $5,000,000 for each of fiscal 

15 years 2010 through 2015. Amounts transferred under this 

16 subsection for a fiscal year shall be available until ex17 pended. 

18 ‘‘(i) ANTIDISCRIMINATION LIMITATION.—The Sec19 retary shall not enter into an agreement with an entity 

20 to provide health care items or services under the dem21 onstration program unless such entity guarantees that for 

22 individuals eligible to be enrolled in such program, the en23 tity will not deny, limit, or condition the coverage or provi24 sion of benefits to which the individual would have otherVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00730 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 wise been entitled to on the basis of health status if not 

2 included in this program. 

3 ‘‘(j) TERMINATION.—The Secretary may terminate 

4 an agreement with an independence at home medical prac5 tice if such practice does not receive incentive payments 

6 under subsection (c)(2) or consistently fails to meet qual7 ity standards.’’. 

8 SEC. 1313. RECOGNITION OF CERTIFIED DIABETES EDU9 CATORS AS CERTIFIED PROVIDERS FOR PUR10 POSES OF MEDICARE DIABETES OUTPATIENT 

11 SELF-MANAGEMENT TRAINING SERVICES. 

12 (a) IN GENERAL.—Section 1861(qq) of the Social Se13 curity Act (42 U.S.C. 1395x(qq)) is amended— 

14 (1) in paragraph (1), by inserting ‘‘or by a cer15 tified diabetes educator (as defined in paragraph 

16 (3))’’ after ‘‘paragraph (2)(B)’’; and 

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

18 paragraphs: 

19 ‘‘(3) For purposes of paragraph (1), the term 

20 ‘certified diabetes educator’ means an individual 

21 who— 

22 ‘‘(A) is licensed or registered by the State 

23 in which the services are performed as a health 

24 care professional; 


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1 ‘‘(B) specializes in teaching individuals 

2 with diabetes to develop the necessary skills and 

3 knowledge to manage the individual’s diabetic 

4 condition; and 

5 ‘‘(C) is certified as a diabetes educator by 

6 a recognized certifying body (as defined in 

7 paragraph (4)). 

8 ‘‘(4)(A) For purposes of paragraph (3)(C), the 

9 term ‘recognized certifying body’ means— 

10 ‘‘(i) the National Certification Board for 

11 Diabetes Educators, or 

12 ‘‘(ii) a certifying body for diabetes edu13 cators, which is recognized by the Secretary as 

14 authorized to grant certification of diabetes 

15 educators for purposes of this subsection pursu16 ant to standards established by the Secretary, 

17 if the Secretary determines such Board or body, 

18 respectively, meets the requirement of subpara19 graph (B). 

20 ‘‘(B) The National Certification Board for Dia21 betes Educators or a certifying body for diabetes 

22 educators meets the requirement of this subpara23 graph, with respect to the certification of an indi24 vidual, if the Board or body, respectively, is incor25 porated and registered to do business in the United 


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1 States and requires as a condition of such certifi2 cation each of the following: 

3 ‘‘(i) The individual has a qualifying cre4 dential in a specified health care profession. 

5 ‘‘(ii) The individual has professional prac6 tice experience in diabetes self-management 

7 training that includes a minimum number of 

8 hours and years of experience in such training. 

9 ‘‘(iii) The individual has successfully com10 pleted a national certification examination of11 fered by such entity. 

12 ‘‘(iv) The individual periodically renews 

13 certification status following initial certifi14 cation.’’. 

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

16 subsection (a) shall apply to diabetes outpatient self-man17 agement training services furnished on or after the first 

18 day of the first calendar year that is at least 6 months 

19 after the date of the enactment of this Act. 

20 TITLE IV—QUALITY 

21 Subtitle A—Comparative 

22 Effectiveness Research 

23 SEC. 1401. COMPARATIVE EFFECTIVENESS RESEARCH. 

24 (a) IN GENERAL.—Title XI of the Social Security Act 

25 is amended by adding at the end the following new part: 


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1 ‘‘PART D—COMPARATIVE EFFECTIVENESS RESEARCH

2 ‘‘COMPARATIVE EFFECTIVENESS RESEARCH

3 ‘‘SEC. 1181. (a) CENTER FOR COMPARATIVE EFFEC4 TIVENESS RESEARCH ESTABLISHED.— 

5 ‘‘(1) IN GENERAL.—The Secretary shall estab6 lish within the Agency for Healthcare Research and 

7 Quality a Center for Comparative Effectiveness Re8 search (in this section referred to as the ‘Center’) to 

9 conduct, support, and synthesize research (including 

10 research conducted or supported under section 1013 

11 of the Medicare Prescription Drug, Improvement, 

12 and Modernization Act of 2003) with respect to the 

13 outcomes, effectiveness, and appropriateness of 

14 health care services and procedures in order to iden15 tify the manner in which diseases, disorders, and 

16 other health conditions can most effectively and ap17 propriately be prevented, diagnosed, treated, and 

18 managed clinically. 

19 ‘‘(2) DUTIES.—The Center shall— 

20 ‘‘(A) conduct, support, and synthesize re21 search relevant to the comparative effectiveness 

22 of the full spectrum of health care items, serv23 ices and systems, including pharmaceuticals, 

24 medical devices, medical and surgical proce25 dures, and other medical interventions; 


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1 ‘‘(B) conduct and support systematic re2 views of clinical research, including original re3 search conducted subsequent to the date of the 

4 enactment of this section; 

5 ‘‘(C) continuously develop rigorous sci6 entific methodologies for conducting compara7 tive effectiveness studies, and use such meth8 odologies appropriately; 

9 ‘‘(D) submit to the Comparative Effective10 ness Research Commission, the Secretary, and 

11 Congress appropriate relevant reports described 

12 in subsection (d)(2); 

13 ‘‘(E) not later than one year after the date 

14 of the enactment of this section, enter into an 

15 arrangement under which the Institute of Medi16 cine of the National Academy of Sciences shall 

17 conduct an evaluation and report on standards 

18 of evidence for highly credible research; 

19 ‘‘(F) encourage, as appropriate, the devel20 opment and use of clinical registries and the de21 velopment of clinical effectiveness research data 

22 networks from electronic health records, post 

23 marketing drug and medical device surveillance 

24 efforts, and other forms of electronic health 

25 data; and 


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1 ‘‘(G) appoint clinical perspective advisory 

2 panels for research priorities under this section, 

3 which shall consult with patients and other 

4 stakeholders and advise the Center on research 

5 questions, methods, and evidence gaps in terms 

6 of clinical outcomes for the specific research in7 quiry to be examined with respect to such pri8 ority to ensure that the information produced 

9 from such research is clinically relevant to deci10 sions made by clinicians and patients at the 

11 point of care. 

12 ‘‘(3) POWERS.— 

13 ‘‘(A) OBTAINING OFFICIAL DATA.—The 

14 Center may secure directly from any depart15 ment or agency of the United States informa16 tion necessary to enable it to carry out this sec17 tion. Upon request of the Center, the head of 

18 such department or agency shall furnish that 

19 information to the Center on an agreed upon 

20 schedule. 

21 ‘‘(B) DATA COLLECTION.—In order to 

22 carry out its functions, the Center shall— 

23 ‘‘(i) utilize existing information, both 

24 published and unpublished, where possible, 

25 collected and assessed either by its own 


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1 staff or under other arrangements made in 

2 accordance with this section; 

3 ‘‘(ii) carry out, or award grants or 

4 contracts for, original research and experi5 mentation, where existing information is 

6 inadequate; and 

7 ‘‘(iii) adopt procedures allowing any 

8 interested party to submit information for 

9 the use by the Center in making reports 

10 and recommendations. 

11 In carrying out clause (ii), the Center may 

12 award grants or contracts (or provide for inter13 governmental transfers, as applicable) to pri14 vate entities and governmental agencies with 

15 experience in conducting comparative effective16 ness research, such as the National Institutes 

17 of Health and other relevant Federal health 

18 agencies. 

19 ‘‘(C) ACCESS OF GAO TO INFORMATION.— 

20 The Comptroller General shall have unrestricted 

21 access to all deliberations, records, and non22 proprietary data of the Center and Commission 

23 under subsection (b), immediately upon request. 

24 ‘‘(D) PERIODIC AUDIT.—The Center and 

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1 ject to periodic audit by the Comptroller Gen2 eral. 

3 ‘‘(b) COMPARATIVE EFFECTIVENESS RESEARCH

4 COMMISSION.— 

5 ‘‘(1) IN GENERAL.—There is established an 

6 independent Comparative Effectiveness Research 

7 Commission (in this section referred to as the ‘Com8 mission’) to advise the Center and evaluate the ac9 tivities carried out by the Center under subsection 

10 (a) to ensure such activities result in highly credible 

11 research and information resulting from such re12 search. 

13 ‘‘(2) DUTIES.—The Commission shall— 

14 ‘‘(A)(i) recommend to the Center national 

15 priorities for research described in subsection 

16 (a) which shall take into account— 

17 ‘‘(I) disease incidence, prevalence, and 

18 burden in the United States; 

19 ‘‘(II) evidence gaps in terms of clinical 

20 outcomes; 

21 ‘‘(III) variations in practice, delivery, 

22 and outcomes by geography, treatment 

23 site, provider type, disability, variation in 

24 age group (including children, adolescents, 

25 adults, and seniors), racial and ethnic 


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1 background, gender, genetic and molecular 

2 subtypes, and other appropriate popu3 lations or subpopulations; and 

4 ‘‘(IV) the potential for new evidence 

5 concerning certain categories, health care 

6 services, or treatments to improve patient 

7 health and well-being, and the quality of 

8 care; and 

9 ‘‘(ii) in making such recommendations con10 sult with a broad array of public and private 

11 stakeholders, including patients and health care 

12 providers and payers; 

13 ‘‘(B) monitor the appropriateness of use of 

14 the CERTF described in subsection (g) with re15 spect to the timely production of comparative 

16 effectiveness research recommended to be a na17 tional priority under subparagraph (A); 

18 ‘‘(C) identify highly credible research 

19 methods and standards of evidence for such re20 search to be considered by the Center; 

21 ‘‘(D) review the methodologies developed 

22 by the center under subsection (a)(2)(C); 

23 ‘‘(E) support forums to increase stake24 holder awareness and permit stakeholder feed25 back on the efforts of the Center to advance 


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1 methods and standards that promote highly 

2 credible research; 

3 ‘‘(F) make recommendations to the Center 

4 for policies that would allow for public access of 

5 data produced under this section, in accordance 

6 with appropriate privacy and proprietary prac7 tices, while ensuring that the information pro8 duced through such data is timely and credible; 

9 ‘‘(G) make recommendations to the Center 

10 for the priority for periodic reviews of previous 

11 comparative effectiveness research and studies 

12 conducted by the Center under subsection (a); 

13 ‘‘(H) at least annually review the processes 

14 of the Center and make reports to Congress 

15 and the President regarding research con16 ducted, supported, or synthesized by the Center 

17 to confirm that the information produced by 

18 such research is objective, credible, consistent 

19 with standards of evidence developed under this 

20 section, and developed through a transparent 

21 process that includes consultations with appro22 priate stakeholders; 

23 ‘‘(I) make recommendations to the Center 

24 for the broad dissemination, consistent with 

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1 ducted and supported under this section that 

2 enables clinicians, patients, consumers, and 

3 payers to make more informed health care deci4 sions that improve quality and value; and 

5 ‘‘(J) at least twice each year, hold a public 

6 meeting with an opportunity for stakeholder 

7 input. 

8 The reports under subparagraph (H) shall not be 

9 submitted to the Office of Management and Budget 

10 or to any other Federal agency or executive depart11 ment for any purpose prior to transmittal to Con12 gress and the President. Such reports shall be pub13 lished on the public internet website of the Commis14 sion after the date of such transmittal. 

15 ‘‘(3) COMPOSITION OF COMMISSION.— 

16 ‘‘(A) IN GENERAL.—The members of the 

17 Commission shall consist of— 

18 ‘‘(i) the Director of the Agency for 

19 Healthcare Research and Quality or their 

20 designee; 

21 ‘‘(ii) the Chief Medical Officer of the 

22 Centers for Medicare & Medicaid Services 

23 or their designee; 

24 ‘‘(iii) the Director of the National In25 stitutes of Health or their designee; and 


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1 ‘‘(iv) 16 additional members who shall 

2 represent broad constituencies of stake3 holders including clinicians, patients, re4 searchers, third-party payers, and con5 sumers of Federal and State beneficiary 

6 programs. 

7 Of such members, at least 10 shall be prac8 ticing physicians, health care practitioners, con9 sumers, or patients. 

10 ‘‘(B) QUALIFICATIONS.— 

11 ‘‘(i) DIVERSE REPRESENTATION OF

12 PERSPECTIVES.—The members of the 

13 Commission shall represent a broad range 

14 of perspectives and shall collectively have 

15 experience in the following areas: 

16 ‘‘(I) Epidemiology. 

17 ‘‘(II) Health services research. 

18 ‘‘(III) Bioethics. 

19 ‘‘(IV) Decision sciences. 

20 ‘‘(V) Health disparities. 

21 ‘‘(VI) Health economics. 

22 ‘‘(ii) DIVERSE REPRESENTATION OF

23 HEALTH CARE COMMUNITY.—At least one 

24 member shall represent each of the fol25 lowing health care communities: 


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1 ‘‘(I) Patients. 

2 ‘‘(II) Health care consumers. 

3 ‘‘(III) Practicing Physicians, in4 cluding surgeons. 

5 ‘‘(IV) Other health care practi6 tioners engaged in clinical care. 

7 ‘‘(V) Organizations with proven 

8 expertise in racial and ethnic minority 

9 health research. 

10 ‘‘(VI) Employers. 

11 ‘‘(VII) Public payers. 

12 ‘‘(VIII) Insurance plans. 

13 ‘‘(IX) Clinical researchers who 

14 conduct research on behalf of pharma15 ceutical or device manufacturers. 

16 ‘‘(C) LIMITATION.—No more than 3 of the 

17 Members of the Commission may be representa18 tives of pharmaceutical or device manufacturers 

19 and such representatives shall be clinical re20 searchers described under subparagraph 

21 (B)(ii)(IX). 

22 ‘‘(4) APPOINTMENT.—The Comptroller General 

23 shall appoint the members of the Commission. 

24 ‘‘(5) CHAIRMAN; VICE CHAIRMAN.—The Comp25 troller General shall designate a member of the 


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1 Commission, at the time of appointment of the mem2 ber, as Chairman and a member as Vice Chairman 

3 for that term of appointment, except that in the case 

4 of vacancy of the Chairmanship or Vice Chairman5 ship, the Comptroller General may designate another 

6 member for the remainder of that member’s term. 

7 The Chairman shall serve as an ex officio member 

8 of the National Advisory Council of the Agency for 

9 Health Care Research and Quality under section 

10 931(c)(3)(B) of the Public Health Service Act. 

11 ‘‘(6) TERMS.— 

12 ‘‘(A) IN GENERAL.—Except as provided in 

13 subparagraph (B), each member of the Com14 mission shall be appointed for a term of 4 

15 years. 

16 ‘‘(B) TERMS OF INITIAL APPOINTEES.—Of 

17 the members first appointed— 

18 ‘‘(i) 8 shall be appointed for a term of 

19 4 years; and 

20 ‘‘(ii) 8 shall be appointed for a term 

21 of 3 years. 

22 ‘‘(7) COMPENSATION.—While serving on the 

23 business of the Commission (including travel time), 

24 a member of the Commission shall be entitled to 

25 compensation at the per diem equivalent of the rate 


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1 provided for level IV of the Executive Schedule 

2 under section 5315 of title 5, United States Code; 

3 and while so serving away from home and the mem4 ber’s regular place of business, a member may be al5 lowed travel expenses, as authorized by the Director 

6 of the Commission. 

7 ‘‘(8) DIRECTOR AND STAFF; EXPERTS AND

8 CONSULTANTS.—Subject to such review as the 

9 Comptroller General deems necessary to assure the 

10 efficient administration of the Commission, the Com11 mission may— 

12 ‘‘(A) appoint and set the compensation for 

13 an Executive Director (subject to the approval 

14 of the Comptroller General) and such other per15 sonnel as Federal employees under section 2105 

16 of title 5, United States Code, as may be nec17 essary to carry out its duties (without regard to 

18 the provisions of title 5, United States Code, 

19 governing appointments in the competitive serv20 ice); 

21 ‘‘(B) seek such assistance and support as 

22 may be required in the performance of its du23 ties from appropriate Federal departments and 

24 agencies; 


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1 ‘‘(C) enter into contracts or make other ar2 rangements, as may be necessary for the con3 duct of the work of the Commission (without 

4 regard to section 3709 of the Revised Statutes 

5 (41 U.S.C. 5)); 

6 ‘‘(D) make advance, progress, and other 

7 payments which relate to the work of the Com8 mission; 

9 ‘‘(E) provide transportation and subsist10 ence for persons serving without compensation; 

11 and 

12 ‘‘(F) prescribe such rules and regulations 

13 as it deems necessary with respect to the inter14 nal organization and operation of the Commis15 sion. 

16 ‘‘(9) OBTAINING OFFICIAL DATA.—The Com17 mission may secure directly from any department or 

18 agency of the United States information necessary 

19 to enable the Commission to carry out this section. 

20 Upon request of the Chairman of the Commission, 

21 the head of such department or agency shall furnish 

22 the information to the Commission on an agreed 

23 upon schedule. 

24 ‘‘(10) AVAILABILITY OF REPORTS.—The Com25 mission shall transmit to the Secretary a copy of 


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1 each report submitted under this subsection and 

2 shall make such reports available to the public. 

3 ‘‘(11) COORDINATION.—To enhance effective4 ness and coordination, the Secretary is encouraged, 

5 to the greatest extent possible, to seek coordination 

6 between the Commission and the National Advisory 

7 Council of the Agency for Healthcare Research and 

8 Quality. 

9 ‘‘(12) CONFLICTS OF INTEREST.— 

10 ‘‘(A) IN GENERAL.—In appointing the 

11 members of the Commission or a clinical per12 spective advisory panel described in subsection 

13 (a)(2)(G), the Comptroller General or the Sec14 retary, respectively, shall take into consider15 ation any financial interest (as defined in sub16 paragraph (D)), consistent with this paragraph, 

17 and develop a plan for managing any identified 

18 conflicts. 

19 ‘‘(B) EVALUATION AND CRITERIA.—When 

20 considering an appointment to the Commission 

21 or a clinical perspective advisory panel de22 scribed subsection (a)(2)(G), the Comptroller 

23 General or the Secretary, respectively, shall re24 view the expertise of the individual and the fi25 nancial disclosure report filed by the individual 


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1 pursuant to the Ethics in Government Act of 

2 1978 for each individual under consideration 

3 for the appointment, so as to reduce the likeli4 hood that an appointed individual will later re5 quire a written determination as referred to in 

6 section 208(b)(1) of title 18, United States 

7 Code, a written certification as referred to in 

8 section 208(b)(3) of title 18, United States 

9 Code, or a waiver as referred to in subpara10 graph (D)(iii) for service on the Commission at 

11 a meeting of the Commission. 

12 ‘‘(C) DISCLOSURES; PROHIBITIONS ON

13 PARTICIPATION; WAIVERS.— 

14 ‘‘(i) DISCLOSURE OF FINANCIAL IN15 TEREST.—Prior to a meeting of the Com16 mission or a clinical perspective advisory 

17 panel described in subsection (a)(2)(G) re18 garding a ‘particular matter’ (as that term 

19 is used in section 208 of title 18, United 

20 States Code), each member of the Commis21 sion or the clinical perspective advisory 

22 panel who is a full-time Government em23 ployee or special Government employee 

24 shall disclose to the Comptroller General or 

25 Secretary, respectively, financial interests 


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1 in accordance with requiring a waiver 

2 under section 208(b) of title 18, United 

3 States Code, or other interests as deemed 

4 relevant by the Secretary. 

5 ‘‘(ii) PROHIBITIONS ON PARTICIPA6 TION.—Except as provided under clause 

7 (iii), a member of the Commission or a 

8 clinical perspective advisory panel de9 scribed in subsection (a)(2)(G) may not 

10 participate with respect to a particular 

11 matter considered in meeting of the Com12 mission or the clinical perspective advisory 

13 panel if such member has a financial inter14 est that could be affected by the advice 

15 given to the Secretary with respect to such 

16 matter, excluding interests exempted in 

17 regulations issued by the Director of the 

18 Office of Government Ethics as too remote 

19 or inconsequential to affect the integrity of 

20 the services of the Government officers or 

21 employees to which such regulations apply. 

22 ‘‘(iii) WAIVER.—If the Comptroller 

23 General or Secretary, as applicable, deter24 mines it necessary to afford the Commis25 sion or a clinical perspective advisory panel 


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1 described in subsection (a)(2)(G) essential 

2 expertise, the Comptroller General or Sec3 retary, respectively, may grant a waiver of 

4 the prohibition in clause (ii) to permit a 

5 member described in such subparagraph 

6 to— 

7 ‘‘(I) participate as a non-voting 

8 member with respect to a particular 

9 matter considered in a meeting of the 

10 Commission or a clinical perspective 

11 advisory panel, respectively; or 

12 ‘‘(II) participate as a voting 

13 member with respect to a particular 

14 matter considered in a meeting of the 

15 Commission. 

16 ‘‘(iv) LIMITATION ON WAIVERS AND

17 OTHER EXCEPTIONS.— 

18 ‘‘(I) DETERMINATION OF ALLOW19 ABLE EXCEPTIONS FOR THE COMMIS20 SION.—The number of waivers grant21 ed to members of the Commission 

22 cannot exceed one-half of the total 

23 number of members for the Commis24 sion. 


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1 ‘‘(II) PROHIBITION ON VOTING

2 STATUS ON CLINICAL PERSPECTIVE

3 ADVISORY PANELS.—No voting mem4 ber of any clinical perspective advisory 

5 panel shall be in receipt of a waiver. 

6 No more than two nonvoting members 

7 of any clinical perspective advisory 

8 panel shall receive a waiver. 

9 ‘‘(D) FINANCIAL INTEREST DEFINED.— 

10 For purposes of this paragraph, the term ‘fi11 nancial interest’ means a financial interest 

12 under section 208(a) of title 18, United States 

13 Code. 

14 ‘‘(13) APPLICATION OF FACA.—The Federal 

15 Advisory Committee Act (other than section 14 of 

16 such Act) shall apply to the Commission to the ex17 tent that the provisions of such Act do not conflict 

18 with the requirements of this subsection. 

19 ‘‘(c) RESEARCH REQUIREMENTS.—Any research con20 ducted, supported, or synthesized under this section shall 

21 meet the following requirements: 

22 ‘‘(1) ENSURING TRANSPARENCY, CREDIBILITY, 

23 AND ACCESS.— 

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1 tional priorities for research recommended 

2 under subsection (b)(2)(A). 

3 ‘‘(B) The establishment of the agenda and 

4 conduct of the research shall be insulated from 

5 inappropriate political or stakeholder influence. 

6 ‘‘(C) Methods of conducting such research 

7 shall be scientifically based. 

8 ‘‘(D) Consistent with applicable law, all as9 pects of the prioritization of research, conduct 

10 of the research, and development of conclusions 

11 based on the research shall be transparent to 

12 all stakeholders. 

13 ‘‘(E) Consistent with applicable law, the 

14 process and methods for conducting such re15 search shall be publicly documented and avail16 able to all stakeholders. 

17 ‘‘(F) Throughout the process of such re18 search, the Center shall provide opportunities 

19 for all stakeholders involved to review and pro20 vide public comment on the methods and find21 ings of such research. 

22 ‘‘(G) Such research shall consider advice 

23 given to the Center by the clinical perspective 

24 advisory panel for the particular national re25 search priority. 


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1 ‘‘(2) STAKEHOLDER INPUT.— 

2 ‘‘(A) IN GENERAL.—The Commission shall 

3 consult with patients, health care providers, 

4 health care consumer representatives, and other 

5 appropriate stakeholders with an interest in the 

6 research through a transparent process rec7 ommended by the Commission. 

8 ‘‘(B) SPECIFIC AREAS OF CONSULTA9 TION.—Consultation shall include where 

10 deemed appropriate by the Commission— 

11 ‘‘(i) recommending research priorities 

12 and questions; 

13 ‘‘(ii) recommending research meth14 odologies; and 

15 ‘‘(iii) advising on and assisting with 

16 efforts to disseminate research findings. 

17 ‘‘(C) OMBUDSMAN.—The Secretary shall 

18 designate a patient ombudsman. The ombuds19 man shall— 

20 ‘‘(i) serve as an available point of con21 tact for any patients with an interest in 

22 proposed comparative effectiveness studies 

23 by the Center; and 

24 ‘‘(ii) ensure that any comments from 

25 patients regarding proposed comparative 


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1 effectiveness studies are reviewed by the 

2 Center. 

3 ‘‘(3) TAKING INTO ACCOUNT POTENTIAL DIF4 FERENCES.—Research shall— 

5 ‘‘(A) be designed, as appropriate, to take 

6 into account the potential for differences in the 

7 effectiveness of health care items, services, and 

8 systems used with various subpopulations such 

9 as racial and ethnic minorities, women, dif10 ferent age groups (including children, adoles11 cents, adults, and seniors), individuals with dis12 abilities, and individuals with different 

13 comorbidities and genetic and molecular 

14 subtypes; and— 

15 ‘‘(B) seek, as feasible and appropriate, to 

16 include members of such subpopulations as sub17 jects in the research. 

18 ‘‘(d) PUBLIC ACCESS TO COMPARATIVE EFFECTIVE19 NESS INFORMATION.— 

20 ‘‘(1) IN GENERAL.—Not later than 90 days 

21 after receipt by the Center or Commission, as appli22 cable, of a relevant report described in paragraph 

23 (2) made by the Center, Commission, or clinical per24 spective advisory panel under this section, appro25 priate information contained in such report shall be 


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1 posted on the official public Internet site of the Cen2 ter and of the Commission, as applicable. 

3 ‘‘(2) RELEVANT REPORTS DESCRIBED.—For 

4 purposes of this section, a relevant report is each of 

5 the following submitted by the Center or a grantee 

6 or contractor of the Center: 

7 ‘‘(A) Any interim or progress reports as 

8 deemed appropriate by the Secretary. 

9 ‘‘(B) Stakeholder comments. 

10 ‘‘(C) A final report. 

11 ‘‘(e) DISSEMINATION AND INCORPORATION OF COM12 PARATIVE EFFECTIVENESS INFORMATION.— 

13 ‘‘(1) DISSEMINATION.—The Center shall pro14 vide for the dissemination of appropriate findings 

15 produced by research supported, conducted, or syn16 thesized under this section to health care providers, 

17 patients, vendors of health information technology 

18 focused on clinical decision support, relevant expert 

19 organizations (as defined in subsection (i)(3)(A)), 

20 and Federal and private health plans, and other rel21 evant stakeholders. In disseminating such findings 

22 the Center shall— 

23 ‘‘(A) convey findings of research so that 

24 they are comprehensible and useful to patients 

25 and providers in making health care decisions; 


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1 ‘‘(B) discuss findings and other consider2 ations specific to certain sub-populations, risk 

3 factors, and comorbidities as appropriate; 

4 ‘‘(C) include considerations such as limita5 tions of research and what further research 

6 may be needed, as appropriate; 

7 ‘‘(D) not include any data that the dis8 semination of which would violate the privacy of 

9 research participants or violate any confiden10 tiality agreements made with respect to the use 

11 of data under this section; and 

12 ‘‘(E) assist the users of health information 

13 technology focused on clinical decision support 

14 to promote the timely incorporation of such 

15 findings into clinical practices and promote the 

16 ease of use of such incorporation. 

17 ‘‘(2) DISSEMINATION PROTOCOLS AND STRATE18 GIES.—The Center shall develop protocols and strat19 egies for the appropriate dissemination of research 

20 findings in order to ensure effective communication 

21 of findings and the use and incorporation of such 

22 findings into relevant activities for the purpose of in23 forming higher quality and more effective and effi24 cient decisions regarding medical items and services. 

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1 egies, the Center shall consult with stakeholders con2 cerning the types of dissemination that will be most 

3 useful to the end users of information and may pro4 vide for the utilization of multiple formats for con5 veying findings to different audiences, including dis6 semination to individuals with limited English pro7 ficiency. 

8 ‘‘(f) REPORTS TO CONGRESS.— 

9 ‘‘(1) ANNUAL REPORTS.—Beginning not later 

10 than one year after the date of the enactment of this 

11 section, the Director of the Agency of Healthcare 

12 Research and Quality shall submit to Congress an 

13 annual report on the activities of the Center, as well 

14 as the research, conducted under this section. Each 

15 such report shall include a discussion of the Center’s 

16 compliance with subsection (c)(3)(B), including any 

17 reasons for lack of compliance with such subsection. 

18 ‘‘(2) RECOMMENDATION FOR FAIR SHARE PER

19 CAPITA AMOUNT FOR ALL-PAYER FINANCING.—Be20 ginning not later than December 31, 2011, the Sec21 retary shall submit to Congress an annual rec22 ommendation for a fair share per capita amount de23 scribed in subsection (c)(1) of section 9511 of the 

24 Internal Revenue Code of 1986 for purposes of 

25 funding the CERTF under such section. 


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1 ‘‘(3) ANALYSIS AND REVIEW.—Not later than 

2 December 31, 2013, the Secretary, in consultation 

3 with the Commission, shall submit to Congress a re4 port on all activities conducted or supported under 

5 this section as of such date. Such report shall in6 clude an evaluation of the overall costs of such ac7 tivities and an analysis of the backlog of any re8 search proposals approved by the Center but not 

9 funded. 

10 ‘‘(g) FUNDING OF COMPARATIVE EFFECTIVENESS

11 RESEARCH.—For fiscal year 2010 and each subsequent 

12 fiscal year, amounts in the Comparative Effectiveness Re13 search Trust Fund (referred to in this section as the 

14 ‘CERTF’) under section 9511 of the Internal Revenue 

15 Code of 1986 shall be available in accordance with such 

16 section, without the need for further appropriations and 

17 without fiscal year limitation, to carry out this section. 

18 ‘‘(h) CONSTRUCTION.— 

19 ‘‘(1) COVERAGE.—Nothing in this section shall 

20 be construed— 

21 ‘‘(A) to permit the Center or Commission 

22 to mandate coverage, reimbursement, or other 

23 policies for any public or private payer; or 

24 ‘‘(B) as preventing the Secretary from cov25 ering the routine costs of clinical care received 


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1 by an individual entitled to, or enrolled for, ben2 efits under title XVIII, XIX, or XXI in the case 

3 where such individual is participating in a clin4 ical trial and such costs would otherwise be cov5 ered under such title with respect to the bene6 ficiary. 

7 ‘‘(2) REPORTS AND FINDINGS.—None of the re8 ports submitted under this section or research find9 ings disseminated by the Center or Commission shall 

10 be construed as mandates, for payment, coverage, or 

11 treatment. 

12 ‘‘(3) PROTECTING THE PHYSICIAN-PATIENT RE13 LATIONSHIP.—Nothing in this section shall be con14 strued to authorize any Federal officer or employee 

15 to exercise any supervision or control over the prac16 tice of medicine. 

17 ‘‘(i) CONSULTATION WITH RELEVANT EXPERT OR18 GANIZATIONS.— 

19 ‘‘(1) CONSULTATION PRIOR TO INITIATION OF

20 RESEARCH.—Prior to recommending priorities or 

21 initiating research described in this section, the 

22 Commission or the Center shall consult with the rel23 evant expert organizations responsible for standards 

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1 tion shall be consistent with the processes estab2 lished under subsection (c)(2). 

3 ‘‘(2) CONSULTATION IN DISSEMINATION OF RE4 SEARCH.—Any dissemination of research from the 

5 Commission or the Center and findings made by the 

6 Commission or the Center shall be consistent with 

7 processes established under subsection (e) and 

8 shall— 

9 ‘‘(A) be based upon evidence-based medi10 cine; and 

11 ‘‘(B) take into consideration standards and 

12 protocols of clinical excellence developed by rel13 evant expert organizations. 

14 ‘‘(3) DEFINITIONS.—For purposes of this sub15 section: 

16 ‘‘(A) RELEVANT EXPERT ORGANIZA17 TIONS.—The term ‘relevant expert organization’ 

18 means an organization with expertise in the rig19 orous application of evidence-based scientific 

20 methods for the design of clinical studies, the 

21 interpretation of clinical data, and the develop22 ment of national clinical practice guidelines, in23 cluding a voluntary health organization, clinical 

24 specialty, or other professional organization 

25 that represents physicians based on the field of 


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1 medicine in which each such physician practices 

2 or is board certified. 

3 ‘‘(B) STANDARDS AND PROTOCOLS OF

4 CLINICAL EXCELLENCE.—The term ‘standards 

5 and protocols of clinical excellence’ means clin6 ical or practice guidelines that consist of a set 

7 of directions or principles that is based on evi8 dence and is designed to assist a health care 

9 practitioner with decisions about appropriate di10 agnostic, therapeutic, or other clinical proce11 dures for specific clinical circumstances. 

12 ‘‘(j) RESEARCH MAY NOT BE USED TO DENY OR RA13 TION CARE.—Nothing in this section shall be construed 

14 to make more stringent or otherwise change the standards 

15 or requirements for coverage of items and services under 

16 this Act.’’. 

17 (b) COMPARATIVE EFFECTIVENESS RESEARCH

18 TRUST FUND; FINANCING FOR THE TRUST FUND.—For 

19 the provision establishing a Comparative Effectiveness Re20 search Trust Fund and financing such Trust Fund, see 

21 section 1802. 


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1 Subtitle B—Nursing Home 

2 Transparency 

3 PART 1—IMPROVING TRANSPARENCY OF INFOR4 MATION ON SKILLED NURSING FACILITIES, 

5 NURSING FACILITIES, AND OTHER LONG6 TERM CARE FACILITIES 

7 SEC. 1411. REQUIRED DISCLOSURE OF OWNERSHIP AND 

8 ADDITIONAL DISCLOSABLE PARTIES INFOR9 MATION. 

10 (a) IN GENERAL.—Section 1124 of the Social Secu11 rity Act (42 U.S.C. 1320a–3) is amended by adding at 

12 the end the following new subsection: 

13 ‘‘(c) REQUIRED DISCLOSURE OF OWNERSHIP AND

14 ADDITIONAL DISCLOSABLE PARTIES INFORMATION.— 

15 ‘‘(1) DISCLOSURE.—A facility (as defined in 

16 paragraph (6)(B)) shall have the information de17 scribed in paragraph (3) available— 

18 ‘‘(A) during the period beginning on the 

19 date of the enactment of this subsection and 

20 ending on the date such information is made 

21 available to the public under section 1411(b) of 

22 the Affordable Health Care for America Act, 

23 for submission to the Secretary, the Inspector 

24 General of the Department of Health and 

25 Human Services, the State in which the facility 


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1 is located, and the State long-term care om2 budsman in the case where the Secretary, the 

3 Inspector General, the State, or the State long4 term care ombudsman requests such informa5 tion; and 

6 ‘‘(B) beginning on the effective date of the 

7 final regulations promulgated under paragraph 

8 (4)(A), for reporting such information in ac9 cordance with such final regulations. 

10 Nothing in subparagraph (A) shall be construed as 

11 authorizing a facility to dispose of or delete informa12 tion described in such subparagraph after the effec13 tive date of the final regulations promulgated under 

14 paragraph (4)(A). 

15 ‘‘(2) PUBLIC AVAILABILITY OF INFORMATION.— 

16 During the period described in paragraph (1)(A), a 

17 facility shall— 

18 ‘‘(A) make the information described in 

19 paragraph (3) available to the public upon re20 quest and update such information as may be 

21 necessary to reflect changes in such informa22 tion; and 

23 ‘‘(B) post a notice of the availability of 

24 such information in the lobby of the facility in 

25 a prominent manner. 


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1 ‘‘(3) INFORMATION DESCRIBED.— 

2 ‘‘(A) IN GENERAL.—The following infor3 mation is described in this paragraph: 

4 ‘‘(i) The information described in sub5 sections (a) and (b), subject to subpara6 graph (C). 

7 ‘‘(ii) The identity of and information 

8 on— 

9 ‘‘(I) each member of the gov10 erning body of the facility, including 

11 the name, title, and period of service 

12 of each such member; 

13 ‘‘(II) each person or entity who is 

14 an officer, director, member, partner, 

15 trustee, or managing employee of the 

16 facility, including the name, title, and 

17 date of start of service of each such 

18 person or entity; and 

19 ‘‘(III) each person or entity who 

20 is an additional disclosable party of 

21 the facility. 

22 ‘‘(iii) A description of the organiza23 tional structure and the relationship of 

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1 clauses (II) and (III) of clause (ii) to the 

2 facility and to one another. 

3 ‘‘(B) SPECIAL RULE WHERE INFORMATION

4 IS ALREADY REPORTED OR SUBMITTED.—To 

5 the extent that information reported by a facil6 ity to the Internal Revenue Service on Form 

7 990, information submitted by a facility to the 

8 Securities and Exchange Commission, or infor9 mation otherwise submitted to the Secretary or 

10 any other Federal agency contains the informa11 tion described in clauses (i), (ii), or (iii) of sub12 paragraph (A), the Secretary may allow, to the 

13 extent practicable, such Form or such informa14 tion to meet the requirements of paragraph (1) 

15 and to be submitted in a manner specified by 

16 the Secretary. 

17 ‘‘(C) SPECIAL RULE.—In applying sub18 paragraph (A)(i)— 

19 ‘‘(i) with respect to subsections (a) 

20 and (b), ‘ownership or control interest’ 

21 shall include direct or indirect interests, in22 cluding such interests in intermediate enti23 ties; and 

24 ‘‘(ii) subsection (a)(3)(A)(ii) shall in25 clude the owner of a whole or part interest 


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1 in any mortgage, deed of trust, note, or 

2 other obligation secured, in whole or in 

3 part, by the entity or any of the property 

4 or assets thereof, if the interest is equal to 

5 or exceeds 5 percent of the total property 

6 or assets of the entirety. 

7 ‘‘(4) REPORTING.— 

8 ‘‘(A) IN GENERAL.—Not later than the 

9 date that is 2 years after the date of the enact10 ment of this subsection, the Secretary shall pro11 mulgate regulations requiring a facility to re12 port the information described in paragraph (3) 

13 to the Secretary in a standardized format, and 

14 such other regulations as are necessary to carry 

15 out this subsection. Such regulations shall 

16 specify the frequency of reporting, as deter17 mined by the Secretary. Such final regulations 

18 shall also require— 

19 ‘‘(i) the reporting of such information 

20 on or after the first day of the first cal21 endar quarter beginning after the date 

22 that is 90 days after the date on which 

23 such final regulations are published in the 

24 Federal Register; and— 


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1 ‘‘(ii) the certification, as a condition 

2 of participation under the program under 

3 title XVIII or XIX, that such information 

4 is accurate and current. 

5 ‘‘(B) GUIDANCE.—The Secretary shall pro6 vide guidance and technical assistance to States 

7 on how to adopt the standardized format under 

8 subparagraph (A). 

9 ‘‘(5) NO EFFECT ON EXISTING REPORTING RE10 QUIREMENTS.—Nothing in this subsection shall re11 duce, diminish, or alter any reporting requirement 

12 for a facility that is in effect as of the date of the 

13 enactment of this subsection. 

14 ‘‘(6) DEFINITIONS.—In this subsection: 

15 ‘‘(A) ADDITIONAL DISCLOSABLE PARTY.— 

16 The term ‘additional disclosable party’ means, 

17 with respect to a facility, any person or entity 

18 who, through ownership interest, partnership 

19 interest, contract, or otherwise— 

20 ‘‘(i) directly or indirectly exercises 

21 operational, financial, administrative, or 

22 managerial control or direction over the fa23 cility or a part thereof, or provides policies 

24 or procedures for any of the operations of 


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1 the facility, or provides financial or cash 

2 management services to the facility; 

3 ‘‘(ii) leases or subleases real property 

4 to the facility, or owns a whole or part in5 terest equal to or exceeding 5 percent of 

6 the total value of such real property; 

7 ‘‘(iii) lends funds or provides a finan8 cial guarantee to the facility in an amount 

9 which is equal to or exceeds $50,000; or 

10 ‘‘(iv) provides management or admin11 istrative services, clinical consulting serv12 ices, or accounting or financial services to 

13 the facility. 

14 ‘‘(B) FACILITY.—The term ‘facility’ means 

15 a disclosing entity which is— 

16 ‘‘(i) a skilled nursing facility (as de17 fined in section 1819(a)); or 

18 ‘‘(ii) a nursing facility (as defined in 

19 section 1919(a)). 

20 ‘‘(C) MANAGING EMPLOYEE.—The term 

21 ‘managing employee’ means, with respect to a 

22 facility, an individual (including a general man23 ager, business manager, administrator, director, 

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1 ages, advises, or supervises any element of the 

2 practices, finances, or operations of the facility. 

3 ‘‘(D) ORGANIZATIONAL STRUCTURE.—The 

4 term ‘organizational structure’ means, in the 

5 case of— 

6 ‘‘(i) a corporation, the officers, direc7 tors, and shareholders of the corporation 

8 who have an ownership interest in the cor9 poration which is equal to or exceeds 5 

10 percent; 

11 ‘‘(ii) a limited liability company, the 

12 members and managers of the limited li13 ability company (including, as applicable, 

14 what percentage each member and man15 ager has of the ownership interest in the 

16 limited liability company); 

17 ‘‘(iii) a general partnership, the part18 ners of the general partnership; 

19 ‘‘(iv) a limited partnership, the gen20 eral partners and any limited partners of 

21 the limited partnership who have an own22 ership interest in the limited partnership 

23 which is equal to or exceeds 10 percent; 

24 ‘‘(v) a trust, the trustees of the trust; 


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1 ‘‘(vi) an individual, contact informa2 tion for the individual; and 

3 ‘‘(vii) any other person or entity, such 

4 information as the Secretary determines 

5 appropriate.’’. 

6 (b) PUBLIC AVAILABILITY OF INFORMATION.—Not 

7 later than the date that is 1 year after the date on which 

8 the final regulations promulgated under section 

9 1124(c)(4)(A) of the Social Security Act, as added by sub10 section (a), are published in the Federal Register, the in11 formation reported in accordance with such final regula12 tions shall be made available to the public in accordance 

13 with procedures established by the Secretary of Health 

14 and Human Services. 

15 (a) CONFORMING AMENDMENTS.— 

16 (1) SKILLED NURSING FACILITIES.—Section 

17 1819(d)(1) of the Social Security Act (42 U.S.C. 

18 1395i–3(d)(1)) is amended by striking subparagraph 

19 (B) and redesignating subparagraph (C) as subpara20 graph (B). 

21 (2) NURSING FACILITIES.—Section 1919(d)(1) 

22 of the Social Security Act (42 U.S.C. 1396r(d)(1)) 

23 is amended by striking subparagraph (B) and redes24 ignating subparagraph (C) as subparagraph (B). 


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1 SEC. 1412. ACCOUNTABILITY REQUIREMENTS. 

2 (a) EFFECTIVE COMPLIANCE AND ETHICS PRO3 GRAMS.— 

4 (1) SKILLED NURSING FACILITIES.—Section 

5 1819(d)(1) of the Social Security Act (42 U.S.C. 

6 1395i–3(d)(1)), as amended by section 1411(c)(1), 

7 is amended by adding at the end the following new 

8 subparagraph: 

9 ‘‘(C) COMPLIANCE AND ETHICS PRO10 GRAMS.— 

11 ‘‘(i) REQUIREMENT.—On or after the 

12 first day of the first calendar quarter be13 ginning after the date that is 1 year after 

14 the date on which regulations developed 

15 under clause (ii) are published in the Fed16 eral Register, a skilled nursing facility 

17 shall, with respect to the entity that oper18 ates or controls the facility (in this sub19 paragraph referred to as the ‘operating or20 ganization’ or ‘organization’), have in oper21 ation a compliance and ethics program 

22 that is effective in preventing and detect23 ing criminal, civil, and administrative viola24 tions under this Act and in promoting 

25 quality of care consistent with such regula26 tions. 


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1 ‘‘(ii) DEVELOPMENT OF REGULA2 TIONS.— 

3 ‘‘(I) IN GENERAL.—Not later 

4 than the date that is 2 years after the 

5 date of the enactment of this subpara6 graph, the Secretary, in consultation 

7 with the Inspector General of the De8 partment of Health and Human Serv9 ices, shall promulgate regulations for 

10 an effective compliance and ethics 

11 program for operating organizations, 

12 which may include a model compliance 

13 program. 

14 ‘‘(II) DESIGN OF REGULA15 TIONS.—Such regulations with respect 

16 to specific elements or formality of a 

17 program may vary with the size of the 

18 organization, such that larger organi19 zations should have a more formal 

20 and rigorous program and include es21 tablished written policies defining the 

22 standards and procedures to be fol23 lowed by its employees. Such require24 ments shall specifically apply to the 


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1 corporate level management of multi2 unit nursing home chains. 

3 ‘‘(III) EVALUATION.—Not later 

4 than 3 years after the date on which 

5 compliance and ethics programs estab6 lished under this subparagraph are in 

7 operation pursuant to clause (i), the 

8 Secretary shall complete an evaluation 

9 of such programs. Such evaluation 

10 shall determine if such programs led 

11 to changes in deficiency citations, 

12 changes in quality performance, or 

13 changes in other metrics of resident 

14 quality of care. The Secretary shall 

15 submit to Congress a report on such 

16 evaluation and shall include in such 

17 report such recommendations regard18 ing changes in the requirements for 

19 such programs as the Secretary deter20 mines appropriate. 

21 ‘‘(iii) REQUIREMENTS FOR COMPLI22 ANCE AND ETHICS PROGRAMS.—In this 

23 subparagraph, the term ‘compliance and 

24 ethics program’ means, with respect to a 


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1 skilled nursing facility, a program of the 

2 operating organization that— 

3 ‘‘(I) has been reasonably de4 signed, implemented, and enforced so 

5 that it generally will be effective in 

6 preventing and detecting criminal, 

7 civil, and administrative violations 

8 under this Act and in promoting qual9 ity of care; and 

10 ‘‘(II) includes at least the re11 quired components specified in clause 

12 (iv). 

13 ‘‘(iv) REQUIRED COMPONENTS OF

14 PROGRAM.—The required components of a 

15 compliance and ethics program of an orga16 nization are the following: 

17 ‘‘(I) The organization must have 

18 established compliance standards and 

19 procedures to be followed by its em20 ployees, contractors, and other agents 

21 that are reasonably capable of reduc22 ing the prospect of criminal, civil, and 

23 administrative violations under this 

24 Act. 


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1 ‘‘(II) Specific individuals within 

2 high-level personnel of the organiza3 tion must have been assigned overall 

4 responsibility to oversee compliance 

5 with such standards and procedures 

6 and have sufficient resources and au7 thority to assure such compliance. 

8 ‘‘(III) The organization must 

9 have used due care not to delegate 

10 substantial discretionary authority to 

11 individuals whom the organization 

12 knew, or should have known through 

13 the exercise of due diligence, had a 

14 propensity to engage in criminal, civil, 

15 and administrative violations under 

16 this Act. 

17 ‘‘(IV) The organization must 

18 have taken steps to communicate ef19 fectively its standards and procedures 

20 to all employees and other agents, 

21 such as by requiring participation in 

22 training programs or by disseminating 

23 publications that explain in a practical 

24 manner what is required. 


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1 ‘‘(V) The organization must have 

2 taken reasonable steps to achieve com3 pliance with its standards, such as by 

4 utilizing monitoring and auditing sys5 tems reasonably designed to detect 

6 criminal, civil, and administrative vio7 lations under this Act by its employ8 ees and other agents and by having in 

9 place and publicizing a reporting sys10 tem whereby employees and other 

11 agents could report violations by oth12 ers within the organization without 

13 fear of retribution. 

14 ‘‘(VI) The standards must have 

15 been consistently enforced through ap16 propriate disciplinary mechanisms, in17 cluding, as appropriate, discipline of 

18 individuals responsible for the failure 

19 to detect an offense. 

20 ‘‘(VII) After an offense has been 

21 detected, the organization must have 

22 taken all reasonable steps to respond 

23 appropriately to the offense and to 

24 prevent further similar offenses, in25 cluding repayment of any funds to 


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1 which it was not entitled and any nec2 essary modification to its program to 

3 prevent and detect criminal, civil, and 

4 administrative violations under this 

5 Act. 

6 ‘‘(VIII) The organization must 

7 periodically undertake reassessment of 

8 its compliance program to identify 

9 changes necessary to reflect changes 

10 within the organization and its facili11 ties. 

12 ‘‘(v) COORDINATION.—The provisions 

13 of this subparagraph shall apply with re14 spect to a skilled nursing facility in lieu of 

15 section 1874(d).’’. 

16 (2) NURSING FACILITIES.—Section 1919(d)(1) 

17 of the Social Security Act (42 U.S.C. 1396r(d)(1)), 

18 as amended by section 1411(c)(2), is amended by 

19 adding at the end the following new subparagraph: 

20 ‘‘(C) COMPLIANCE AND ETHICS PRO21 GRAM.— 

22 ‘‘(i) REQUIREMENT.—On or after the 

23 first day of the first calendar quarter be24 ginning after the date that is 1 year after 

25 the date on which regulations developed 


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1 under clause (ii) are published in the Fed2 eral Register, a skilled nursing facility 

3 shall, with respect to the entity that oper4 ates or controls the facility (in this sub5 paragraph referred to as the ‘operating or6 ganization’ or ‘organization’), have in oper7 ation a compliance and ethics program 

8 that is effective in preventing and detect9 ing criminal, civil, and administrative viola10 tions under this Act and in promoting 

11 quality of care consistent with such regula12 tions. 

13 ‘‘(iii) DEVELOPMENT OF REGULA14 TIONS.— 

15 ‘‘(I) IN GENERAL.—Not later 

16 than the date that is 2 years after the 

17 date of the enactment of this subpara18 graph, the Secretary, in consultation 

19 with the Inspector General of the De20 partment of Health and Human Serv21 ices, shall promulgate regulations for 

22 an effective compliance and ethics 

23 program for operating organizations, 

24 which may include a model compliance 

25 program. 


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1 ‘‘(II) DESIGN OF REGULA2 TIONS.—Such regulations with respect 

3 to specific elements or formality of a 

4 program may vary with the size of the 

5 organization, such that larger organi6 zations should have a more formal 

7 and rigorous program and include es8 tablished written policies defining the 

9 standards and procedures to be fol10 lowed by its employees. Such require11 ments shall specifically apply to the 

12 corporate level management of multi13 unit nursing home chains. 

14 ‘‘(III) EVALUATION.—Not later 

15 than 3 years after the date on which 

16 compliance and ethics programs estab17 lished under this subparagraph are in 

18 operation pursuant to clause (i), the 

19 Secretary shall complete an evaluation 

20 of such programs. Such evaluation 

21 shall determine if such programs led 

22 to changes in deficiency citations, 

23 changes in quality performance, or 

24 changes in other metrics of resident 

25 quality of care. The Secretary shall 


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1 submit to Congress a report on such 

2 evaluation and shall include in such 

3 report such recommendations regard4 ing changes in the requirements for 

5 such programs as the Secretary deter6 mines appropriate. 

7 ‘‘(v) REQUIREMENTS FOR COMPLI8 ANCE AND ETHICS PROGRAMS.—In this 

9 subparagraph, the term ‘compliance and 

10 ethics program’ means, with respect to a 

11 nursing facility, a program of the oper12 ating organization that— 

13 ‘‘(I) has been reasonably de14 signed, implemented, and enforced so 

15 that it generally will be effective in 

16 preventing and detecting criminal, 

17 civil, and administrative violations 

18 under this Act and in promoting qual19 ity of care; and 

20 ‘‘(II) includes at least the re21 quired components specified in clause 

22 (iv). 

23 ‘‘(vi) REQUIRED COMPONENTS OF

24 PROGRAM.—The required components of a 


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1 compliance and ethics program of an orga2 nization are the following: 

3 ‘‘(I) The organization must have 

4 established compliance standards and 

5 procedures to be followed by its em6 ployees and other agents that are rea7 sonably capable of reducing the pros8 pect of criminal, civil, and administra9 tive violations under this Act. 

10 ‘‘(II) Specific individuals within 

11 high-level personnel of the organiza12 tion must have been assigned overall 

13 responsibility to oversee compliance 

14 with such standards and procedures 

15 and has sufficient resources and au16 thority to assure such compliance. 

17 ‘‘(III) The organization must 

18 have used due care not to delegate 

19 substantial discretionary authority to 

20 individuals whom the organization 

21 knew, or should have known through 

22 the exercise of due diligence, had a 

23 propensity to engage in criminal, civil, 

24 and administrative violations under 

25 this Act. 


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1 ‘‘(IV) The organization must 

2 have taken steps to communicate ef3 fectively its standards and procedures 

4 to all employees and other agents, 

5 such as by requiring participation in 

6 training programs or by disseminating 

7 publications that explain in a practical 

8 manner what is required. 

9 ‘‘(V) The organization must have 

10 taken reasonable steps to achieve com11 pliance with its standards, such as by 

12 utilizing monitoring and auditing sys13 tems reasonably designed to detect 

14 criminal, civil, and administrative vio15 lations under this Act by its employ16 ees and other agents and by having in 

17 place and publicizing a reporting sys18 tem whereby employees and other 

19 agents could report violations by oth20 ers within the organization without 

21 fear of retribution. 

22 ‘‘(VI) The standards must have 

23 been consistently enforced through ap24 propriate disciplinary mechanisms, in25 cluding, as appropriate, discipline of 


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1 individuals responsible for the failure 

2 to detect an offense. 

3 ‘‘(VII) After an offense has been 

4 detected, the organization must have 

5 taken all reasonable steps to respond 

6 appropriately to the offense and to 

7 prevent further similar offenses, in8 cluding repayment of any funds to 

9 which it was not entitled and any nec10 essary modification to its program to 

11 prevent and detect criminal, civil, and 

12 administrative violations under this 

13 Act. 

14 ‘‘(VIII) The organization must 

15 periodically undertake reassessment of 

16 its compliance program to identify 

17 changes necessary to reflect changes 

18 within the organization and its facili19 ties. 

20 ‘‘(vii) COORDINATION.—The provi21 sions of this subparagraph shall apply with 

22 respect to a nursing facility in lieu of sec23 tion 1902(a)(77).’’. 

24 (b) QUALITY ASSURANCE AND PERFORMANCE IM25 PROVEMENT PROGRAM.— 


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1 (1) SKILLED NURSING FACILITIES.—Section 

2 1819(b)(1)(B) of the Social Security Act (42 U.S.C. 

3 1396r(b)(1)(B)) is amended— 

4 (A) by striking ‘‘ASSURANCE’’ and insert5 ing ‘‘ASSURANCE AND QUALITY ASSURANCE

6 AND PERFORMANCE IMPROVEMENT PROGRAM’’; 

7 (B) by designating the matter beginning 

8 with ‘‘A skilled nursing facility’’ as a clause (i) 

9 with the heading ‘‘IN GENERAL.—’’ and the ap10 propriate indentation; 

11 (C) in clause (i) (as so designated by sub12 paragraph (B)), by redesignating clauses (i) 

13 and (ii) as subclauses (I) and (II), respectively; 

14 and 

15 (D) by adding at the end the following new 

16 clause: 

17 ‘‘(ii) QUALITY ASSURANCE AND PER18 FORMANCE IMPROVEMENT PROGRAM.— 

19 ‘‘(I) IN GENERAL.—Not later 

20 than December 31, 2011, the Sec21 retary shall establish and implement a 

22 quality assurance and performance 

23 improvement program (in this clause 

24 referred to as the ‘QAPI program’) 

25 for skilled nursing facilities, including 


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1 multi-unit chains of such facilities. 

2 Under the QAPI program, the Sec3 retary shall establish standards relat4 ing to such facilities and provide tech5 nical assistance to such facilities on 

6 the development of best practices in 

7 order to meet such standards. Not 

8 later than 1 year after the date on 

9 which the regulations are promulgated 

10 under subclause (II), a skilled nursing 

11 facility must submit to the Secretary 

12 a plan for the facility to meet such 

13 standards and implement such best 

14 practices, including how to coordinate 

15 the implementation of such plan with 

16 quality assessment and assurance ac17 tivities conducted under clause (i). 

18 ‘‘(II) REGULATIONS.—The Sec19 retary shall promulgate regulations to 

20 carry out this clause.’’. 

21 (2) NURSING FACILITIES.—Section 

22 1919(b)(1)(B) of the Social Security Act (42 U.S.C. 

23 1396r(b)(1)(B)) is amended— 


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1 (A) by striking ‘‘ASSURANCE’’ and insert2 ing ‘‘ASSURANCE AND QUALITY ASSURANCE

3 AND PERFORMANCE IMPROVEMENT PROGRAM’’; 

4 (B) by designating the matter beginning 

5 with ‘‘A nursing facility’’ as a clause (i) with 

6 the heading ‘‘IN GENERAL.—’’ and the appro7 priate indentation; and 

8 (C) by adding at the end the following new 

9 clause: 

10 ‘‘(ii) QUALITY ASSURANCE AND PER11 FORMANCE IMPROVEMENT PROGRAM.— 

12 ‘‘(I) IN GENERAL.—Not later 

13 than December 31, 2011, the Sec14 retary shall establish and implement a 

15 quality assurance and performance 

16 improvement program (in this clause 

17 referred to as the ‘QAPI program’) 

18 for nursing facilities, including multi19 unit chains of such facilities. Under 

20 the QAPI program, the Secretary 

21 shall establish standards relating to 

22 such facilities and provide technical 

23 assistance to such facilities on the de24 velopment of best practices in order to 

25 meet such standards. Not later than 1 


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1 year after the date on which the regu2 lations are promulgated under sub3 clause (II), a nursing facility must 

4 submit to the Secretary a plan for the 

5 facility to meet such standards and 

6 implement such best practices, includ7 ing how to coordinate the implementa8 tion of such plan with quality assess9 ment and assurance activities con10 ducted under clause (i). 

11 ‘‘(II) REGULATIONS.—The Sec12 retary shall promulgate regulations to 

13 carry out this clause.’’. 

14 (3) PROPOSAL TO REVISE QUALITY ASSURANCE

15 AND PERFORMANCE IMPROVEMENT PROGRAMS.— 

16 The Secretary shall implement policies that modify 

17 and strengthen quality assurance and performance 

18 improvement programs in skilled nursing facilities 

19 and nursing facilities on a periodic basis, as deter20 mined by the Secretary. 

21 (4) FACILITY PLAN.—Not later than 1 year 

22 after the date on which the regulations are promul23 gated under subclause (II) of clause (ii) of sections 

24 1819(b)(1)(B) and 1919(b)(1)(B) of the Social Se25 curity Act, as added by paragraphs (1) and (2), a 


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1 skilled nursing facility and a nursing facility must 

2 submit to the Secretary a plan for the facility to 

3 meet the standards under such regulations and im4 plement such best practices, including how to coordi5 nate the implementation of such plan with quality 

6 assessment and assurance activities conducted under 

7 clause (i) of such sections. 

8 (c) GAO STUDY ON NURSING FACILITY UNDER9 CAPITALIZATION.— 

10 (1) IN GENERAL.—The Comptroller General of 

11 the United States shall conduct a study that exam12 ines the following: 

13 (A) The extent to which corporations that 

14 own or operate large numbers of nursing facili15 ties, taking into account ownership type (includ16 ing private equity and control interests), are 

17 undercapitalizing such facilities. 

18 (B) The effects of such undercapitalization 

19 on quality of care, including staffing and food 

20 costs, at such facilities. 

21 (C) Options to address such undercapital22 ization, such as requirements relating to surety 

23 bonds, liability insurance, or minimum capital24 ization. 


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1 (2) REPORT.—Not later than 18 months after 

2 the date of the enactment of this Act, the Comp3 troller General shall submit to Congress a report on 

4 the study conducted under paragraph (1). 

5 (3) NURSING FACILITY.—In this subsection, the 

6 term ‘‘nursing facility’’ includes a skilled nursing fa7 cility. 

8 SEC. 1413. NURSING HOME COMPARE MEDICARE WEBSITE. 

9 (a) SKILLED NURSING FACILITIES.— 

10 (1) IN GENERAL.—Section 1819 of the Social 

11 Security Act (42 U.S.C. 1395i–3) is amended— 

12 (A) by redesignating subsection (i) as sub13 section (j); and 

14 (B) by inserting after subsection (h) the 

15 following new subsection: 

16 ‘‘(i) NURSING HOME COMPARE WEBSITE.— 

17 ‘‘(1) INCLUSION OF ADDITIONAL INFORMA18 TION.— 

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

20 ensure that the Department of Health and 

21 Human Services includes, as part of the infor22 mation provided for comparison of nursing 

23 homes on the official Internet website of the 

24 Federal Government for Medicare beneficiaries 

25 (commonly referred to as the ‘Nursing Home 


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1 Compare’ Medicare website) (or a successor 

2 website), the following information in a manner 

3 that is prominent, easily accessible, readily un4 derstandable to consumers of long-term care 

5 services, and searchable: 

6 ‘‘(i) Information that is reported to 

7 the Secretary under section 1124(c)(4). 

8 ‘‘(ii) Information on the ‘Special 

9 Focus Facility program’ (or a successor 

10 program) established by the Centers for 

11 Medicare and Medicaid Services, according 

12 to procedures established by the Secretary. 

13 Such procedures shall provide for the in14 clusion of information with respect to, and 

15 the names and locations of, those facilities 

16 that, since the previous quarter— 

17 ‘‘(I) were newly enrolled in the 

18 program; 

19 ‘‘(II) are enrolled in the program 

20 and have failed to significantly im21 prove; 

22 ‘‘(III) are enrolled in the pro23 gram and have significantly improved; 

24 ‘‘(IV) have graduated from the 

25 program; and 


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1 ‘‘(V) have closed voluntarily or 

2 no longer participate under this title. 

3 ‘‘(iii) Staffing data for each facility 

4 (including resident census data and data 

5 on the hours of care provided per resident 

6 per day) based on data submitted under 

7 subsection (b)(8)(C), including information 

8 on staffing turnover and tenure, in a for9 mat that is clearly understandable to con10 sumers of long-term care services and al11 lows such consumers to compare dif12 ferences in staffing between facilities and 

13 State and national averages for the facili14 ties. Such format shall include— 

15 ‘‘(I) concise explanations of how 

16 to interpret the data (such as a plain 

17 English explanation of data reflecting 

18 ‘nursing home staff hours per resident 

19 day’); 

20 ‘‘(II) differences in types of staff 

21 (such as training associated with dif22 ferent categories of staff); 

23 ‘‘(III) the relationship between 

24 nurse staffing levels and quality of 

25 care; and 


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1 ‘‘(IV) an explanation that appro2 priate staffing levels vary based on 

3 patient case mix. 

4 ‘‘(iv) Links to State internet websites 

5 with information regarding State survey 

6 and certification programs, links to Form 

7 2567 State inspection reports (or a suc8 cessor form) on such websites, information 

9 to guide consumers in how to interpret and 

10 understand such reports, and the facility 

11 plan of correction or other response to 

12 such report. 

13 ‘‘(v) The standardized complaint form 

14 developed under subsection (f)(8), includ15 ing explanatory material on what com16 plaint forms are, how they are used, and 

17 how to file a complaint with the State sur18 vey and certification program and the 

19 State long-term care ombudsman program. 

20 ‘‘(vi) Summary information on the 

21 number, type, severity, and outcome of 

22 substantiated complaints. 

23 ‘‘(vii) The number of adjudicated in24 stances of criminal violations by employees 

25 of a nursing facility— 


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1 ‘‘(I) that were committed inside 

2 the facility; 

3 ‘‘(II) with respect to such in4 stances of violations or crimes com5 mitted inside of the facility that were 

6 the violations or crimes of abuse, ne7 glect, and exploitation, criminal sexual 

8 abuse, or other violations or crimes 

9 that resulted in serious bodily injury; 

10 and 

11 ‘‘(viii) The number of civil monetary 

12 penalties levied against the facility, em13 ployees, contractors, and other agents. 

14 ‘‘(ix) Any other information that the 

15 Secretary determines appropriate. 

16 The facility shall not make available under 

17 clause (iv) identifying information on complain18 ants or residents. 

19 ‘‘(B) DEADLINE FOR PROVISION OF INFOR20 MATION.— 

21 ‘‘(i) IN GENERAL.—Except as pro22 vided in clause (ii), the Secretary shall en23 sure that the information described in sub24 paragraph (A) is included on such website 

25 (or a successor website) not later than 1 


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1 year after the date of the enactment of this 

2 subsection. 

3 ‘‘(ii) EXCEPTION.—The Secretary 

4 shall ensure that the information described 

5 in subparagraph (A)(i) and (A)(iii) is in6 cluded on such website (or a successor 

7 website) not later than 1 year after the 

8 dates on which the data are submitted to 

9 the Secretary pursuant to section 

10 1124(c)(4) and subsection (b)(8)(C), re11 spectively. 

12 ‘‘(2) REVIEW AND MODIFICATION OF

13 WEBSITE.— 

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

15 establish a process— 

16 ‘‘(i) to review the accuracy, clarity of 

17 presentation, timeliness, and comprehen18 siveness of information reported on such 

19 website as of the day before the date of the 

20 enactment of this subsection; and 

21 ‘‘(ii) not later than 1 year after the 

22 date of the enactment of this subsection, to 

23 modify or revamp such website in accord24 ance with the review conducted under 

25 clause (i). 


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1 ‘‘(B) CONSULTATION.—In conducting the 

2 review under subparagraph (A)(i), the Sec3 retary shall consult with— 

4 ‘‘(i) State long-term care ombudsman 

5 programs; 

6 ‘‘(ii) consumer advocacy groups; 

7 ‘‘(iii) provider stakeholder groups; and 

8 ‘‘(iv) any other representatives of pro9 grams or groups the Secretary determines 

10 appropriate.’’. 

11 (2) TIMELINESS OF SUBMISSION OF SURVEY

12 AND CERTIFICATION INFORMATION.— 

13 (A) IN GENERAL.—Section 1819(g)(5) of 

14 the Social Security Act (42 U.S.C. 1395i– 

15 3(g)(5)) is amended by adding at the end the 

16 following new subparagraph: 

17 ‘‘(E) SUBMISSION OF SURVEY AND CER18 TIFICATION INFORMATION TO THE SEC19 RETARY.—In order to improve the timeliness of 

20 information made available to the public under 

21 subparagraph (A) and provided on the Nursing 

22 Home Compare Medicare website under sub23 section (i), each State shall submit information 

24 respecting any survey or certification rec25 ommendation made respecting a skilled nursing 


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1 facility (including any enforcement actions 

2 taken by the State or any Federal enforcement 

3 action recommended by the State) to the Sec4 retary not later than the date on which the 

5 State sends such information to the facility. 

6 The Secretary shall use the information sub7 mitted under the preceding sentence to update 

8 the information provided on the Nursing Home 

9 Compare Medicare website as expeditiously as 

10 practicable but not less frequently than quar11 terly.’’. 

12 (B) EFFECTIVE DATE.—The amendment 

13 made by this paragraph shall take effect 1 year 

14 after the date of the enactment of this Act. 

15 (3) SPECIAL FOCUS FACILITY PROGRAM.—Sec16 tion 1819(f) of such Act is amended by adding at 

17 the end the following new paragraph: 

18 ‘‘(8) SPECIAL FOCUS FACILITY PROGRAM.— 

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

20 conduct a special focus facility program for en21 forcement of requirements for skilled nursing 

22 facilities that the Secretary has identified as 

23 having a poor compliance history or that sub24 stantially failed to meet applicable requirements 

25 of this Act 


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1 ‘‘(B) PERIODIC SURVEYS.—Under such 

2 program the Secretary shall conduct surveys of 

3 each facility in the program not less than once 

4 every 6 months.’’. 

5 (b) NURSING FACILITIES.— 

6 (1) IN GENERAL.—Section 1919 of the Social 

7 Security Act (42 U.S.C. 1396r) is amended— 

8 (A) by redesignating subsection (i) as sub9 section (j); and 

10 (B) by inserting after subsection (h) the 

11 following new subsection: 

12 ‘‘(i) NURSING HOME COMPARE WEBSITE.— 

13 ‘‘(1) INCLUSION OF ADDITIONAL INFORMA14 TION.— 

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

16 ensure that the Department of Health and 

17 Human Services includes, as part of the infor18 mation provided for comparison of nursing 

19 homes on the official internet website of the 

20 Federal Government for Medicare beneficiaries 

21 (commonly referred to as the ‘Nursing Home 

22 Compare’ Medicare website) (or a successor 

23 website), the following information in a manner 

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1 derstandable to consumers of long-term care 

2 services, and searchable: 

3 ‘‘(i) Information that is reported to 

4 the Secretary under section 1124(c)(4) 

5 ‘‘(ii) Information on the ‘Special 

6 Focus Facility program’ (or a successor 

7 program) established by the Centers for 

8 Medicare & Medicaid Services, according to 

9 procedures established by the Secretary. 

10 Such procedures shall provide for the in11 clusion of information with respect to, and 

12 the names and locations of, those facilities 

13 that, since the previous quarter— 

14 ‘‘(I) were newly enrolled in the 

15 program; 

16 ‘‘(II) are enrolled in the program 

17 and have failed to significantly im18 prove; 

19 ‘‘(III) are enrolled in the pro20 gram and have significantly improved; 

21 ‘‘(IV) have graduated from the 

22 program; and 

23 ‘‘(V) have closed voluntarily or 

24 no longer participate under this title. 


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1 ‘‘(iii) Staffing data for each facility 

2 (including resident census data and data 

3 on the hours of care provided per resident 

4 per day) based on data submitted under 

5 subsection (b)(8)(C)(ii), including informa6 tion on staffing turnover and tenure, in a 

7 format that is clearly understandable to 

8 consumers of long-term care services and 

9 allows such consumers to compare dif10 ferences in staffing between facilities and 

11 State and national averages for the facili12 ties. Such format shall include— 

13 ‘‘(I) concise explanations of how 

14 to interpret the data (such as plain 

15 English explanation of data reflecting 

16 ‘nursing home staff hours per resident 

17 day’); 

18 ‘‘(II) differences in types of staff 

19 (such as training associated with dif20 ferent categories of staff); 

21 ‘‘(III) the relationship between 

22 nurse staffing levels and quality of 

23 care; and 


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1 ‘‘(IV) an explanation that appro2 priate staffing levels vary based on 

3 patient case mix. 

4 ‘‘(iv) Links to State internet websites 

5 with information regarding State survey 

6 and certification programs, links to Form 

7 2567 State inspection reports (or a suc8 cessor form) on such websites, information 

9 to guide consumers in how to interpret and 

10 understand such reports, and the facility 

11 plan of correction or other response to 

12 such report. 

13 ‘‘(v) The standardized complaint form 

14 developed under subsection (f)(10), includ15 ing explanatory material on what com16 plaint forms are, how they are used, and 

17 how to file a complaint with the State sur18 vey and certification program and the 

19 State long-term care ombudsman program. 

20 ‘‘(vi) Summary information on the 

21 number, type, severity, and outcome of 

22 substantiated complaints. 

23 ‘‘(vii) The number of adjudicated in24 stances of criminal violations by employees 

25 of a nursing facility— 


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1 ‘‘(I) that were committed inside 

2 of the facility; and 

3 ‘‘(II) with respect to such in4 stances of violations or crimes com5 mitted inside of the facility that were 

6 the violations or crimes of abuse, ne7 glect, and exploitation, criminal sexual 

8 abuse, or other violations or crimes 

9 that resulted in serious bodily injury. 

10 ‘‘(viii) the number of civil monetary 

11 penalties levied against the facility, em12 ployees, contractors, and other agents. 

13 ‘‘(ix) Any other information that the 

14 Secretary determines appropriate. 

15 The facility shall not make available under 

16 clause (ii) identifying information about com17 plainants or residents. 

18 ‘‘(B) DEADLINE FOR PROVISION OF INFOR19 MATION.— 

20 ‘‘(i) IN GENERAL.—Except as pro21 vided in clause (ii), the Secretary shall en22 sure that the information described in sub23 paragraph (A) is included on such website 

24 (or a successor website) not later than 1 


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1 year after the date of the enactment of this 

2 subsection. 

3 ‘‘(ii) EXCEPTION.—The Secretary 

4 shall ensure that the information described 

5 in subparagraph (A)(i) and (A)(iii) is in6 cluded on such website (or a successor 

7 website) not later than 1 year after the 

8 dates on which the data are submitted to 

9 the Secretary pursuant to section 

10 1124(c)(4) and subsection (b)(8)(C), re11 spectively. 

12 ‘‘(2) REVIEW AND MODIFICATION OF

13 WEBSITE.— 

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

15 establish a process— 

16 ‘‘(i) to review the accuracy, clarity of 

17 presentation, timeliness, and comprehen18 siveness of information reported on such 

19 website as of the day before the date of the 

20 enactment of this subsection; and 

21 ‘‘(ii) not later than 1 year after the 

22 date of the enactment of this subsection, to 

23 modify or revamp such website in accord24 ance with the review conducted under 

25 clause (i). 


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1 ‘‘(B) CONSULTATION.—In conducting the 

2 review under subparagraph (A)(i), the Sec3 retary shall consult with— 

4 ‘‘(i) State long-term care ombudsman 

5 programs; 

6 ‘‘(ii) consumer advocacy groups; 

7 ‘‘(iii) provider stakeholder groups; 

8 ‘‘(iv) skilled nursing facility employees 

9 and their representatives; and 

10 ‘‘(v) any other representatives of pro11 grams or groups the Secretary determines 

12 appropriate.’’. 

13 (2) TIMELINESS OF SUBMISSION OF SURVEY

14 AND CERTIFICATION INFORMATION.— 

15 (A) IN GENERAL.—Section 1919(g)(5) of 

16 the Social Security Act (42 U.S.C. 1396r(g)(5)) 

17 is amended by adding at the end the following 

18 new subparagraph: 

19 ‘‘(E) SUBMISSION OF SURVEY AND CER20 TIFICATION INFORMATION TO THE SEC21 RETARY.—In order to improve the timeliness of 

22 information made available to the public under 

23 subparagraph (A) and provided on the Nursing 

24 Home Compare Medicare website under sub25 section (i), each State shall submit information 


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1 respecting any survey or certification rec2 ommendation made respecting a nursing facility 

3 (including any enforcement actions taken by the 

4 State or any Federal enforcement action rec5 ommended by the State) to the Secretary not 

6 later than the date on which the State sends 

7 such information to the facility. The Secretary 

8 shall use the information submitted under the 

9 preceding sentence to update the information 

10 provided on the Nursing Home Compare Medi11 care website as expeditiously as practicable but 

12 not less frequently than quarterly.’’. 

13 (B) EFFECTIVE DATE.—The amendment 

14 made by this paragraph shall take effect 1 year 

15 after the date of the enactment of this Act. 

16 (3) SPECIAL FOCUS FACILITY PROGRAM.—Sec17 tion 1919(f) of such Act is amended by adding at 

18 the end of the following new paragraph: 

19 ‘‘(10) SPECIAL FOCUS FACILITY PROGRAM.— 

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

21 conduct a special focus facility program for en22 forcement of requirements for nursing facilities 

23 that the Secretary has identified as having a 

24 poor compliance history or that substantially 


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1 failed to meet applicable requirements of this 

2 Act 

3 ‘‘(B) PERIODIC SURVEYS.—Under such 

4 program the Secretary shall conduct surveys of 

5 each facility in the program not less often than 

6 once every 6 months.’’. 

7 (c) AVAILABILITY OF REPORTS ON SURVEYS, CER8 TIFICATIONS, AND COMPLAINT INVESTIGATIONS.— 

9 (1) SKILLED NURSING FACILITIES.—Section 

10 1819(d)(1) of the Social Security Act (42 U.S.C. 

11 1395i–3(d)(1)), as amended by sections 1411 and 

12 1412, is amended by adding at the end the following 

13 new subparagraph: 

14 ‘‘(D) AVAILABILITY OF SURVEY, CERTIFI15 CATION, AND COMPLAINT INVESTIGATION RE16 PORTS.—A skilled nursing facility must— 

17 ‘‘(i) have reports with respect to any 

18 surveys, certifications, and complaint in19 vestigations made respecting the facility 

20 during the 3 preceding years available for 

21 any individual to review upon request; and 

22 ‘‘(ii) post notice of the availability of 

23 such reports in areas of the facility that 

24 are prominent and accessible to the public. 


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1 The facility shall not make available under 

2 clause (i) identifying information about com3 plainants or residents.’’. 

4 (2) NURSING FACILITIES.—Section 1919(d)(1) 

5 of the Social Security Act (42 U.S.C. 1396r(d)(1)), 

6 as amended by sections 1411 and 1412, is amended 

7 by adding at the end the following new subpara8 graph: 

9 ‘‘(D) AVAILABILITY OF SURVEY, CERTIFI10 CATION, AND COMPLAINT INVESTIGATION RE11 PORTS.—A nursing facility must— 

12 ‘‘(i) have reports with respect to any 

13 surveys, certifications, and complaint in14 vestigations made respecting the facility 

15 during the 3 preceding years available for 

16 any individual to review upon request; and 

17 ‘‘(ii) post notice of the availability of 

18 such reports in areas of the facility that 

19 are prominent and accessible to the public. 

20 The facility shall not make available under 

21 clause (i) identifying information about com22 plainants or residents.’’. 

23 (3) EFFECTIVE DATE.—The amendments made 

24 by this subsection shall take effect 1 year after the 

25 date of the enactment of this Act. 


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1 (d) GUIDANCE TO STATES ON FORM 2567 STATE IN2 SPECTION REPORTS AND COMPLAINT INVESTIGATION RE3 PORTS.— 

4 (1) GUIDANCE.—The Secretary of Health and 

5 Human Services (in this subtitle referred to as the 

6 ‘‘Secretary’’) shall provide guidance to States on 

7 how States can establish electronic links to Form 

8 2567 State inspection reports (or a successor form), 

9 complaint investigation reports, and a facility’s plan 

10 of correction or other response to such Form 2567 

11 State inspection reports (or a successor form) on the 

12 Internet website of the State that provides informa13 tion on skilled nursing facilities and nursing facili14 ties and the Secretary shall, if possible, include such 

15 information on Nursing Home Compare. 

16 (2) REQUIREMENT.—Section 1902(a)(9) of the 

17 Social Security Act (42 U.S.C. 1396a(a)(9)) is 

18 amended— 

19 (A) by striking ‘‘and’’ at the end of sub20 paragraph (B); 

21 (B) by striking the semicolon at the end of 

22 subparagraph (C) and inserting ‘‘, and’’; and 

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

24 subparagraph: 


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1 ‘‘(D) that the State maintain a consumer2 oriented website providing useful information to 

3 consumers regarding all skilled nursing facili4 ties and all nursing facilities in the State, in5 cluding for each facility, Form 2567 State in6 spection reports (or a successor form), com7 plaint investigation reports, the facility’s plan of 

8 correction, and such other information that the 

9 State or the Secretary considers useful in as10 sisting the public to assess the quality of long 

11 term care options and the quality of care pro12 vided by individual facilities;’’. 

13 (3) DEFINITIONS.—In this subsection: 

14 (A) NURSING FACILITY.—The term ‘‘nurs15 ing facility’’ has the meaning given such term 

16 in section 1919(a) of the Social Security Act 

17 (42 U.S.C. 1396r(a)). 

18 (B) SECRETARY.—The term ‘‘Secretary’’ 

19 means the Secretary of Health and Human 

20 Services. 

21 (C) SKILLED NURSING FACILITY.—The 

22 term ‘‘skilled nursing facility’’ has the meaning 

23 given such term in section 1819(a) of the Social 

24 Security Act (42 U.S.C. 1395i–3(a)). 


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1 SEC. 1414. REPORTING OF EXPENDITURES. 

2 Section 1888 of the Social Security Act (42 U.S.C. 

3 1395yy) is amended by adding at the end the following 

4 new subsection: 

5 ‘‘(f) REPORTING OF DIRECT CARE EXPENDI6 TURES.— 

7 ‘‘(1) IN GENERAL.—For cost reports submitted 

8 under this title for cost reporting periods beginning 

9 on or after the date that is no more than two years 

10 after the redesign of the report specified in subpara11 graph (2), skilled nursing facilities shall— 

12 ‘‘(A) separately report expenditures for 

13 wages and benefits for direct care staff (break14 ing out (at a minimum) registered nurses, li15 censed professional nurses, certified nurse as16 sistants, and other medical and therapy staff); 

17 and 

18 ‘‘(B) take into account agency and con19 tract staff in a manner to be determined by the 

20 Administrator. 

21 ‘‘(2) MODIFICATION OF FORM.—The Secretary, 

22 in consultation with private sector accountants expe23 rienced with skilled nursing facility cost reports, 

24 shall redesign such reports to meet the requirement 

25 of paragraph (1) not later than 2 years after the 

26 date of the enactment of this subsection. 


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1 ‘‘(3) CATEGORIZATION BY FUNCTIONAL AC2 COUNTS.—Beginning with cost reports submitted 

3 under paragraph (1) , the Secretary, working in con4 sultation with the Medicare Payment Advisory Com5 mission, the Inspector General of the Department of 

6 Health and Human Services, and other expert par7 ties the Secretary determines appropriate, shall cat8 egorize the expenditures listed on cost reports, as 

9 modified under paragraph (1), submitted by skilled 

10 nursing facilities, regardless of any source of pay11 ment for such expenditures, for each skilled nursing 

12 facility into the following functional accounts on an 

13 annual basis: 

14 ‘‘(A) Spending on direct care services (in15 cluding nursing, therapy, and medical services). 

16 ‘‘(B) Spending on indirect care (including 

17 housekeeping and dietary services). 

18 ‘‘(C) Capital assets (including building and 

19 land costs). 

20 ‘‘(D) Administrative services costs. 

21 ‘‘(4) AVAILABILITY OF INFORMATION SUB22 MITTED.—The Secretary shall establish procedures 

23 to make information on expenditures submitted 

24 under this subsection readily available to interested 

25 parties upon request, subject to such requirements 


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1 as the Secretary may specify under the procedures 

2 established under this paragraph.’’. 

3 SEC. 1415. STANDARDIZED COMPLAINT FORM. 

4 (a) SKILLED NURSING FACILITIES.— 

5 (1) DEVELOPMENT BY THE SECRETARY.—Sec6 tion 1819(f) of the Social Security Act (42 U.S.C. 

7 1395i–3(f)), as amended by section 1413(a)(3), is 

8 amended by adding at the end the following new 

9 paragraph: 

10 ‘‘(9) STANDARDIZED COMPLAINT FORM.—The 

11 Secretary shall develop a standardized complaint 

12 form for use by a resident (or a person acting on the 

13 resident’s behalf) in filing a complaint with a State 

14 survey and certification agency and a State long15 term care ombudsman program with respect to a 

16 skilled nursing facility.’’. 

17 (2) STATE REQUIREMENTS.—Section 1819(e) 

18 of the Social Security Act (42 U.S.C. 1395i–3(e)) is 

19 amended by adding at the end the following new 

20 paragraph: 

21 ‘‘(6) COMPLAINT PROCESSES AND WHISTLE22 BLOWER PROTECTION.— 

23 ‘‘(A) COMPLAINT FORMS.—The State must 

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1 oped under subsection (f)(9) available upon re2 quest to— 

3 ‘‘(i) a resident of a skilled nursing fa4 cility; 

5 ‘‘(ii) any person acting on the resi6 dent’s behalf; and 

7 ‘‘(iii) any person who works at a 

8 skilled nursing facility or is a representa9 tive of such a worker. 

10 ‘‘(B) COMPLAINT RESOLUTION PROCESS.— 

11 The State must establish a complaint resolution 

12 process in order to ensure that a resident, the 

13 legal representative of a resident of a skilled 

14 nursing facility, or other responsible party is 

15 not retaliated against if the resident, legal rep16 resentative, or responsible party has com17 plained, in good faith, about the quality of care 

18 or other issues relating to the skilled nursing 

19 facility, that the legal representative of a resi20 dent of a skilled nursing facility or other re21 sponsible party is not denied access to such 

22 resident or otherwise retaliated against if such 

23 representative party has complained, in good 

24 faith, about the quality of care provided by the 

25 facility or other issues relating to the facility, 


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1 and that a person who works at a skilled nurs2 ing facility is not retaliated against if the work3 er has complained, in good faith, about quality 

4 of care or services or an issue relating to the 

5 quality of care or services provided at the facil6 ity, whether the resident, legal representative, 

7 other responsible party, or worker used the 

8 form developed under subsection (f)(9) or some 

9 other method for submitting the complaint. 

10 Such complaint resolution process shall in11 clude— 

12 ‘‘(i) procedures to assure accurate 

13 tracking of complaints received, including 

14 notification to the complainant that a com15 plaint has been received; 

16 ‘‘(ii) procedures to determine the like17 ly severity of a complaint and for the in18 vestigation of the complaint; 

19 ‘‘(iii) deadlines for responding to a 

20 complaint and for notifying the complain21 ant of the outcome of the investigation; 

22 and 

23 ‘‘(iv) procedures to ensure that the 

24 identity of the complainant will be kept 

25 confidential. 


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1 ‘‘(C) WHISTLEBLOWER PROTECTION.— 

2 ‘‘(i) PROHIBITION AGAINST RETALIA3 TION.—No person who works at a skilled 

4 nursing facility may be penalized, discrimi5 nated, or retaliated against with respect to 

6 any aspect of employment, including dis7 charge, promotion, compensation, terms, 

8 conditions, or privileges of employment, or 

9 have a contract for services terminated, be10 cause the person (or anyone acting at the 

11 person’s request) complained, in good 

12 faith, about the quality of care or services 

13 provided by a skilled nursing facility or 

14 about other issues relating to quality of 

15 care or services, whether using the form 

16 developed under subsection (f)(9) or some 

17 other method for submitting the complaint. 

18 ‘‘(ii) RETALIATORY REPORTING.—A 

19 skilled nursing facility may not file a com20 plaint or a report against a person who 

21 works (or has worked at the facility) with 

22 the appropriate State professional discipli23 nary agency because the person (or anyone 

24 acting at the person’s request) complained 

25 in good faith, as described in clause (i). 


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1 ‘‘(iii) RELIEF.—Any person aggrieved 

2 by a violation of clause (i) or clause (ii) 

3 may, in a civil action, obtain all appro4 priate relief, including reinstatement, reim5 bursement of lost wages, compensation, 

6 and benefits, and exemplary damages 

7 where warranted, and such other relief as 

8 the court deems appropriate, as well as 

9 costs of suit and reasonable attorney and 

10 expert witness fees. 

11 ‘‘(iv) RIGHTS NOT WAIVABLE.—The 

12 rights protected by this paragraph may not 

13 be diminished by contract or other agree14 ment, and nothing in this paragraph shall 

15 be construed to diminish any greater or 

16 additional protection provided by Federal 

17 or State law or by contract or other agree18 ment. 

19 ‘‘(v) REQUIREMENT TO POST NOTICE

20 OF EMPLOYEE RIGHTS.—Each skilled 

21 nursing facility shall post conspicuously in 

22 an appropriate location a sign (in a form 

23 specified by the Secretary) specifying the 

24 rights of persons under this paragraph and 

25 including a statement that an employee 


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1 may file a complaint with the Secretary 

2 against a skilled nursing facility that vio3 lates the provisions of this paragraph and 

4 information with respect to the manner of 

5 filing such a complaint. 

6 ‘‘(D) RULE OF CONSTRUCTION.—Nothing 

7 in this paragraph shall be construed as pre8 venting a resident of a skilled nursing facility 

9 (or a person acting on the resident’s behalf) 

10 from submitting a complaint in a manner or 

11 format other than by using the standardized 

12 complaint form developed under subsection 

13 (f)(9) (including submitting a complaint orally). 

14 ‘‘(E) GOOD FAITH DEFINED.—For pur15 poses of this paragraph, an individual shall be 

16 deemed to be acting in good faith with respect 

17 to the filing of a complaint if the individual rea18 sonably believes— 

19 ‘‘(i) the information reported or dis20 closed in the complaint is true; and 

21 ‘‘(ii) the violation of this title has oc22 curred or may occur in relation to such in23 formation.’’. 

24 (b) NURSING FACILITIES.— 


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1 (1) DEVELOPMENT BY THE SECRETARY.—Sec2 tion 1919(f) of the Social Security Act (42 U.S.C. 

3 1395i–3(f)), as amended by section 1413(b), is 

4 amended by adding at the end the following new 

5 paragraph: 

6 ‘‘(11) STANDARDIZED COMPLAINT FORM.—The 

7 Secretary shall develop a standardized complaint 

8 form for use by a resident (or a person acting on the 

9 resident’s behalf) in filing a complaint with a State 

10 survey and certification agency and a State long11 term care ombudsman program with respect to a 

12 nursing facility.’’. 

13 (2) STATE REQUIREMENTS.—Section 1919(e) 

14 of the Social Security Act (42 U.S.C. 1395i–3(e)) is 

15 amended by adding at the end the following new 

16 paragraph: 

17 ‘‘(8) COMPLAINT PROCESSES AND WHISTLE18 BLOWER PROTECTION.— 

19 ‘‘(A) COMPLAINT FORMS.—The State must 

20 make the standardized complaint form devel21 oped under subsection (f)(11) available upon re22 quest to— 

23 ‘‘(i) a resident of a nursing facility; 

24 ‘‘(ii) any person acting on the resi25 dent’s behalf; and 


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1 ‘‘(iii) any person who works at a nurs2 ing facility or a representative of such a 

3 worker. 

4 ‘‘(B) COMPLAINT RESOLUTION PROCESS.— 

5 The State must establish a complaint resolution 

6 process in order to ensure that a resident, the 

7 legal representative of a resident of a nursing 

8 facility, or other responsible party is not retali9 ated against if the resident, legal representa10 tive, or responsible party has complained, in 

11 good faith, about the quality of care or other 

12 issues relating to the nursing facility, that the 

13 legal representative of a resident of a nursing 

14 facility or other responsible party is not denied 

15 access to such resident or otherwise retaliated 

16 against if such representative party has com17 plained, in good faith, about the quality of care 

18 provided by the facility or other issues relating 

19 to the facility, and that a person who works at 

20 a nursing facility is not retaliated against if the 

21 worker has complained, in good faith, about 

22 quality of care or services or an issue relating 

23 to the quality of care or services provided at the 

24 facility, whether the resident, legal representa25 tive, other responsible party, or worker used the 


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1 form developed under subsection (f)(11) or 

2 some other method for submitting the com3 plaint. Such complaint resolution process shall 

4 include— 

5 ‘‘(i) procedures to assure accurate 

6 tracking of complaints received, including 

7 notification to the complainant that a com8 plaint has been received; 

9 ‘‘(ii) procedures to determine the like10 ly severity of a complaint and for the in11 vestigation of the complaint; 

12 ‘‘(iii) deadlines for responding to a 

13 complaint and for notifying the complain14 ant of the outcome of the investigation; 

15 and 

16 ‘‘(iv) procedures to ensure that the 

17 identity of the complainant will be kept 

18 confidential. 

19 ‘‘(C) WHISTLEBLOWER PROTECTION.— 

20 ‘‘(i) PROHIBITION AGAINST RETALIA21 TION.—No person who works at a nursing 

22 facility may be penalized, discriminated, or 

23 retaliated against with respect to any as24 pect of employment, including discharge, 

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1 tions, or privileges of employment, or have 

2 a contract for services terminated, because 

3 the person (or anyone acting at the per4 son’s request) complained, in good faith, 

5 about the quality of care or services pro6 vided by a nursing facility or about other 

7 issues relating to quality of care or serv8 ices, whether using the form developed 

9 under subsection (f)(11) or some other 

10 method for submitting the complaint. 

11 ‘‘(ii) RETALIATORY REPORTING.—A 

12 nursing facility may not file a complaint or 

13 a report against a person who works (or 

14 has worked at the facility with the appro15 priate State professional disciplinary agen16 cy because the person (or anyone acting at 

17 the person’s request) complained in good 

18 faith, as described in clause (i). 

19 ‘‘(iii) RELIEF.—Any person aggrieved 

20 by a violation of clause (i) or clause (ii) 

21 may, in a civil action, obtain all appro22 priate relief, including reinstatement, reim23 bursement of lost wages, compensation, 

24 and benefits, and exemplary damages 

25 where warranted, and such other relief as 


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1 the court deems appropriate, as well as 

2 costs of suit and reasonable attorney and 

3 expert witness fees. 

4 ‘‘(iv) RIGHTS NOT WAIVABLE.—The 

5 rights protected by this paragraph may not 

6 be diminished by contract or other agree7 ment, and nothing in this paragraph shall 

8 be construed to diminish any greater or 

9 additional protection provided by Federal 

10 or State law or by contract or other agree11 ment. 

12 ‘‘(v) REQUIREMENT TO POST NOTICE

13 OF EMPLOYEE RIGHTS.—Each nursing fa14 cility shall post conspicuously in an appro15 priate location a sign (in a form specified 

16 by the Secretary) specifying the rights of 

17 persons under this paragraph and includ18 ing a statement that an employee may file 

19 a complaint with the Secretary against a 

20 nursing facility that violates the provisions 

21 of this paragraph and information with re22 spect to the manner of filing such a com23 plaint. 

24 ‘‘(D) RULE OF CONSTRUCTION.—Nothing 

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1 venting a resident of a nursing facility (or a 

2 person acting on the resident’s behalf) from 

3 submitting a complaint in a manner or format 

4 other than by using the standardized complaint 

5 form developed under subsection (f)(11) (in6 cluding submitting a complaint orally). 

7 ‘‘(E) GOOD FAITH DEFINED.—For pur8 poses of this paragraph, an individual shall be 

9 deemed to be acting in good faith with respect 

10 to the filing of a complaint if the individual rea11 sonably believes— 

12 ‘‘(i) the information reported or dis13 closed in the complaint is true; and 

14 ‘‘(ii) the violation of this title has oc15 curred or may occur in relation to such in16 formation.’’. 

17 (c) EFFECTIVE DATE.—The amendments made by 

18 this section shall take effect 1 year after the date of the 

19 enactment of this Act. 

20 SEC. 1416. ENSURING STAFFING ACCOUNTABILITY. 

21 (a) SKILLED NURSING FACILITIES.—Section 

22 1819(b)(8) of the Social Security Act (42 U.S.C. 1395i– 

23 3(b)(8)) is amended by adding at the end the following 

24 new subparagraph: 


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1 ‘‘(C) SUBMISSION OF STAFFING INFORMA2 TION BASED ON PAYROLL DATA IN A UNIFORM

3 FORMAT.—On and after the first day of the 

4 first calendar quarter beginning after the date 

5 that is 2 years after the date of enactment of 

6 this subparagraph, and after consulting with 

7 State long-term care ombudsman programs, 

8 consumer advocacy groups, provider stakeholder 

9 groups, employees and their representatives, 

10 and other parties the Secretary deems appro11 priate, the Secretary shall require a skilled 

12 nursing facility to electronically submit to the 

13 Secretary direct care staffing information (in14 cluding information with respect to agency and 

15 contract staff) based on payroll and other 

16 verifiable and auditable data in a uniform for17 mat (according to specifications established by 

18 the Secretary in consultation with such pro19 grams, groups, and parties). Such specifications 

20 shall require that the information submitted 

21 under the preceding sentence— 

22 ‘‘(i) specify the category of work a 

23 certified employee performs (such as 

24 whether the employee is a registered nurse, 

25 licensed practical nurse, licensed vocational 


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1 nurse, certified nursing assistant, thera2 pist, or other medical personnel); 

3 ‘‘(ii) include resident census data and 

4 information on resident case mix; 

5 ‘‘(iii) include a regular reporting 

6 schedule; and 

7 ‘‘(iv) include information on employee 

8 turnover and tenure and on the hours of 

9 care provided by each category of certified 

10 employees referenced in clause (i) per resi11 dent per day. 

12 Nothing in this subparagraph shall be con13 strued as preventing the Secretary from requir14 ing submission of such information with respect 

15 to specific categories, such as nursing staff, be16 fore other categories of certified employees. In17 formation under this subparagraph with respect 

18 to agency and contract staff shall be kept sepa19 rate from information on employee staffing.’’. 

20 (b) NURSING FACILITIES.—Section 1919(b)(8) of the 

21 Social Security Act (42 U.S.C. 1396r(b)(8)) is amended 

22 by adding at the end the following new subparagraph: 

23 ‘‘(C) SUBMISSION OF STAFFING INFORMA24 TION BASED ON PAYROLL DATA IN A UNIFORM

25 FORMAT.—On and after the first day of the 


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1 first calendar quarter beginning after the date 

2 that is 2 years after the date of enactment of 

3 this subparagraph, and after consulting with 

4 State long-term care ombudsman programs, 

5 consumer advocacy groups, provider stakeholder 

6 groups, employees and their representatives, 

7 and other parties the Secretary deems appro8 priate, the Secretary shall require a nursing fa9 cility to electronically submit to the Secretary 

10 direct care staffing information (including in11 formation with respect to agency and contract 

12 staff) based on payroll and other verifiable and 

13 auditable data in a uniform format (according 

14 to specifications established by the Secretary in 

15 consultation with such programs, groups, and 

16 parties). Such specifications shall require that 

17 the information submitted under the preceding 

18 sentence— 

19 ‘‘(i) specify the category of work a 

20 certified employee performs (such as 

21 whether the employee is a registered nurse, 

22 licensed practical nurse, licensed vocational 

23 nurse, certified nursing assistant, thera24 pist, or other medical personnel); 


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1 ‘‘(ii) include resident census data and 

2 information on resident case mix; 

3 ‘‘(iii) include a regular reporting 

4 schedule; and 

5 ‘‘(iv) include information on employee 

6 turnover and tenure and on the hours of 

7 care provided by each category of certified 

8 employees referenced in clause (i) per resi9 dent per day. 

10 Nothing in this subparagraph shall be con11 strued as preventing the Secretary from requir12 ing submission of such information with respect 

13 to specific categories, such as nursing staff, be14 fore other categories of certified employees. In15 formation under this subparagraph with respect 

16 to agency and contract staff shall be kept sepa17 rate from information on employee staffing.’’. 

18 SEC. 1417. NATIONWIDE PROGRAM FOR NATIONAL AND 

19 STATE BACKGROUND CHECKS ON DIRECT PA20 TIENT ACCESS EMPLOYEES OF LONG-TERM 

21 CARE FACILITIES AND PROVIDERS. 

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

23 Human Services (in this section referred to as the ‘‘Sec24 retary’’), shall establish a program to identify efficient, ef25 fective, and economical procedures for long term care faVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00826 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 cilities or providers to conduct background checks on pro2 spective direct patient access employees on a nationwide 

3 basis (in this subsection, such program shall be referred 

4 to as the ‘‘nationwide program’’). The Secretary shall 

5 carry out the nationwide program under similar terms and 

6 conditions as the pilot program under section 307 of the 

7 Medicare Prescription Drug, Improvement, and Mod8 ernization Act of 2003 (Public Law 108–173; 117 Stat. 

9 2257), including the prohibition on hiring abusive workers 

10 and the authorization of the imposition of penalties by a 

11 participating State under subsections (b)(3)(A) and 

12 (b)(6), respectively, of such section 307. The program 

13 under this subsection shall contain the following modifica14 tions to such pilot program: 

15 (1) AGREEMENTS.— 

16 (A) NEWLY PARTICIPATING STATES.—The 

17 Secretary shall enter into agreements with each 

18 State— 

19 (i) that the Secretary has not entered 

20 into an agreement with under subsection 

21 (c)(1) of such section 307; 

22 (ii) that agrees to conduct background 

23 checks under the nationwide program on a 

24 Statewide basis; and 


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1 (iii) that submits an application to the 

2 Secretary containing such information and 

3 at such time as the Secretary may specify. 

4 (B) CERTAIN PREVIOUSLY PARTICIPATING

5 STATES.—The Secretary shall enter into agree6 ments with each State— 

7 (i) that the Secretary has entered into 

8 an agreement with under such subsection 

9 (c)(1); 

10 (ii) that agrees to conduct background 

11 checks under the nationwide program on a 

12 Statewide basis; and 

13 (iii) that submits an application to the 

14 Secretary containing such information and 

15 at such time as the Secretary may specify. 

16 (2) NONAPPLICATION OF SELECTION CRI17 TERIA.—The selection criteria required under sub18 section (c)(3)(B) of such section 307 shall not apply. 

19 (3) REQUIRED FINGERPRINT CHECK AS PART

20 OF CRIMINAL BACKGROUND CHECK.—The proce21 dures established under subsection (b)(1) of such 

22 section 307 shall— 

23 (A) require that the long-term care facility 

24 or provider (or the designated agent of the 

25 long-term care facility or provider) obtain State 


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1 and national criminal or other background 

2 checks on the prospective employee through 

3 such means as the Secretary determines appro4 priate that utilize a search of State-based abuse 

5 and neglect registries and databases, including 

6 the abuse and neglect registries of another 

7 State in the case where a prospective employee 

8 previously resided in that State, State criminal 

9 history records, the records of any proceedings 

10 in the State that may contain disqualifying in11 formation about prospective employees (such as 

12 proceedings conducted by State professional li13 censing and disciplinary boards and State Med14 icaid Fraud Control Units), and Federal crimi15 nal history records, including a fingerprint 

16 check using the Integrated Automated Finger17 print Identification System of the Federal Bu18 reau of Investigation; and 

19 (B) require States to describe and test 

20 methods that reduce duplicative fingerprinting, 

21 including providing for the development of ‘‘rap 

22 back’’ capability by the State such that, if a di23 rect patient access employee of a long-term care 

24 facility or provider is convicted of a crime fol25 lowing the initial criminal history background 


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1 check conducted with respect to such employee, 

2 and the employee’s fingerprints match the 

3 prints on file with the State law enforcement 

4 department, the department will immediately 

5 inform the State and the State will immediately 

6 inform the long-term care facility or provider 

7 which employs the direct patient access em8 ployee of such conviction. 

9 (4) STATE REQUIREMENTS.—An agreement en10 tered into under paragraph (1) shall require that a 

11 participating State— 

12 (A) be responsible for monitoring compli13 ance with the requirements of the nationwide 

14 program; 

15 (B) have procedures in place to— 

16 (i) conduct screening and criminal or 

17 other background checks under the nation18 wide program in accordance with the re19 quirements of this section; 

20 (ii) monitor compliance by long-term 

21 care facilities and providers with the proce22 dures and requirements of the nationwide 

23 program; 

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1 term care facility or provider of a direct 

2 patient access employee, not to exceed 60 

3 days, pending completion of the required 

4 criminal history background check and, in 

5 the case where the employee has appealed 

6 the results of such background check, 

7 pending completion of the appeals process, 

8 during which the employee shall be subject 

9 to direct on-site supervision (in accordance 

10 with procedures established by the State to 

11 ensure that a long-term care facility or 

12 provider furnishes such direct on-site su13 pervision); 

14 (iv) provide an independent process by 

15 which a provisional employee or an em16 ployee may appeal or dispute the accuracy 

17 of the information obtained in a back18 ground check performed under the nation19 wide program, including the specification 

20 of criteria for appeals for direct patient ac21 cess employees found to have disqualifying 

22 information which shall include consider23 ation of the passage of time, extenuating 

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1 qualifying information with respect to the 

2 current employment of the individual; 

3 (v) provide for the designation of a 

4 single State agency as responsible for— 

5 (I) overseeing the coordination of 

6 any State and national criminal his7 tory background checks requested by 

8 a long-term care facility or provider 

9 (or the designated agent of the long10 term care facility or provider) utilizing 

11 a search of State and Federal crimi12 nal history records, including a finger13 print check of such records; 

14 (II) overseeing the design of ap15 propriate privacy and security safe16 guards for use in the review of the re17 sults of any State or national criminal 

18 history background checks conducted 

19 regarding a prospective direct patient 

20 access employee to determine whether 

21 the employee has any conviction for a 

22 relevant crime; 

23 (III) immediately reporting to 

24 the long-term care facility or provider 

25 that requested the criminal history 


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1 background check the results of such 

2 review; and 

3 (IV) in the case of an employee 

4 with a conviction for a relevant crime 

5 that is subject to reporting under sec6 tion 1128E of the Social Security Act 

7 (42 U.S.C. 1320a–7e), reporting the 

8 existence of such conviction to the 

9 database established under that sec10 tion; 

11 (vi) determine which individuals are 

12 direct patient access employees (as defined 

13 in paragraph (6)(B)) for purposes of the 

14 nationwide program; 

15 (vii) as appropriate, specify offenses, 

16 including convictions for violent crimes, for 

17 purposes of the nationwide program; and 

18 (viii) describe and test methods that 

19 reduce duplicative fingerprinting, including 

20 providing for the development of ‘‘rap 

21 back’’ capability such that, if a direct pa22 tient access employee of a long-term care 

23 facility or provider is convicted of a crime 

24 following the initial criminal history back25 ground check conducted with respect to 


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1 such employee, and the employee’s finger2 prints match the prints on file with the 

3 State law enforcement department— 

4 (I) the department will imme5 diately inform the State agency des6 ignated under clause (v) and such 

7 agency will immediately inform the fa8 cility or provider which employs the 

9 direct patient access employee of such 

10 conviction; and 

11 (II) the State will provide, or will 

12 require the facility to provide, to the 

13 employee a copy of the results of the 

14 criminal history background check 

15 conducted with respect to the em16 ployee at no charge in the case where 

17 the individual requests such a copy. 

18 Background checks and screenings under 

19 this subsection shall be valid for a period 

20 of no longer than 2 years, as determined 

21 by the State and approved by the Sec22 retary. 

23 (5) PAYMENTS.— 

24 (A) NEWLY PARTICIPATING STATES.— 


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1 (i) IN GENERAL.—As part of the ap2 plication submitted by a State under para3 graph (1)(A)(iii), the State shall guar4 antee, with respect to the costs to be in5 curred by the State in carrying out the na6 tionwide program, that the State will make 

7 available (directly or through donations 

8 from public or private entities) a particular 

9 amount of non-Federal contributions, as a 

10 condition of receiving the Federal match 

11 under clause (ii). 

12 (ii) FEDERAL MATCH.—The payment 

13 amount to each State that the Secretary 

14 enters into an agreement with under para15 graph (1)(A) shall be 3 times the amount 

16 that the State guarantees to make avail17 able under clause (i). 

18 (B) PREVIOUSLY PARTICIPATING

19 STATES.— 

20 (i) IN GENERAL.—As part of the ap21 plication submitted by a State under para22 graph (1)(B)(iii), the State shall guar23 antee, with respect to the costs to be in24 curred by the State in carrying out the na25 tionwide program, that the State will make 


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1 available (directly or through donations 

2 from public or private entities) a particular 

3 amount of non-Federal contributions, as a 

4 condition of receiving the Federal match 

5 under clause (ii). 

6 (ii) FEDERAL MATCH.—The payment 

7 amount to each State that the Secretary 

8 enters into an agreement with under para9 graph (1)(B) shall be 3 times the amount 

10 that the State guarantees to make avail11 able under clause (i). 

12 (6) DEFINITIONS.—Under the nationwide pro13 gram: 

14 (A) LONG-TERM CARE FACILITY OR PRO15 VIDER.—The term ‘‘long-term care facility or 

16 provider’’ means the following facilities or pro17 viders which receive payment for services under 

18 title XVIII or XIX of the Social Security Act: 

19 (i) A skilled nursing facility (as de20 fined in section 1819(a) of the Social Secu21 rity Act (42 U.S.C. 1395i–3(a))). 

22 (ii) A nursing facility (as defined in 

23 section 1919(a) of such Act (42 U.S.C. 

24 1396r(a))). 

25 (iii) A home health agency. 


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1 (iv) A provider of hospice care (as de2 fined in section 1861(dd)(1) of such Act 

3 (42 U.S.C. 1395x(dd)(1))). 

4 (v) A long-term care hospital (as de5 scribed in section 1886(d)(1)(B)(iv) of 

6 such Act (42 U.S.C. 

7 1395ww(d)(1)(B)(iv))). 

8 (vi) A provider of personal care serv9 ices. 

10 (vii) A provider of adult day care. 

11 (viii) A residential care provider that 

12 arranges for, or directly provides, long13 term care services, including an assisted 

14 living facility that provides a nursing home 

15 level of care conveyed by State licensure or 

16 State definition. 

17 (ix) An intermediate care facility for 

18 the mentally retarded (as defined in sec19 tion 1905(d) of such Act (42 U.S.C. 

20 1396d(d))). 

21 (x) Any other facility or provider of 

22 long-term care services under such titles as 

23 the participating State determines appro24 priate. 


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1 (B) DIRECT PATIENT ACCESS EM2 PLOYEE.—The term ‘‘direct patient access em3 ployee’’ means any individual who has access to 

4 a patient or resident of a long-term care facility 

5 or provider through employment or through a 

6 contract with such facility or provider and has 

7 duties that involve (or may involve) one-on-one 

8 contact with a patient or resident of the facility 

9 or provider, as determined by the State for pur10 poses of the nationwide program. Such term 

11 does not include a volunteer unless the volun12 teer has duties that are equivalent to the duties 

13 of a direct patient access employee and those 

14 duties involve (or may involve) one-on-one con15 tact with a patient or resident of the long-term 

16 care facility or provider. 

17 (7) EVALUATION AND REPORT.— 

18 (A) EVALUATION.—The Inspector General 

19 of the Department of Health and Human Serv20 ices shall conduct an evaluation of the nation21 wide program. Such evaluation shall include— 

22 (i) a review of the various procedures 

23 implemented by participating States for 

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1 ground checks of direct patient access em2 ployees and identify the most efficient, ef3 fective, and economical procedures for con4 ducting such background checks; 

5 (ii) an assessment of the costs of con6 ducting such background checks (including 

7 start-up and administrative costs); 

8 (iii) a determination of the extent to 

9 which conducting such background checks 

10 leads to any unintended consequences, in11 cluding a reduction in the available work12 force for such facilities or providers; 

13 (iv) an assessment of the impact of 

14 the program on reducing the number of in15 cidents of neglect, abuse, and misappro16 priation of resident property to the extent 

17 practicable; and 

18 (v) an evaluation of other aspects of 

19 the program, as determined appropriate by 

20 the Secretary. 

21 (B) REPORT.—Not later than 180 days 

22 after the completion of the nationwide program, 

23 the Inspector General of the Department of 

24 Health and Human Services shall submit a reVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00839 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 port to Congress containing the results of the 

2 evaluation conducted under subparagraph (A). 

3 (b) FUNDING.— 

4 (1) NOTIFICATION.—The Secretary of Health 

5 and Human Services shall notify the Secretary of 

6 the Treasury of the amount necessary to carry out 

7 the nationwide program under this section, including 

8 costs for the Department of Health and Human 

9 Services to administer and evaluate the program, for 

10 the period of fiscal years 2010 through 2012, except 

11 that in no case shall such amount exceed 

12 $160,000,000. 

13 (2) TRANSFER OF FUNDS.—Out of any funds 

14 in the Treasury not otherwise appropriated, the Sec15 retary of the Treasury shall provide for the transfer 

16 to the Secretary of Health and Human Services of 

17 the amount specified as necessary to carry out the 

18 nationwide program under paragraph (1). Such 

19 amount shall remain available until expended. 

20 PART 2—TARGETING ENFORCEMENT 

21 SEC. 1421. CIVIL MONEY PENALTIES. 

22 (a) SKILLED NURSING FACILITIES.— 

23 (1) IN GENERAL.—Section 1819(h)(2)(B)(ii) of 

24 the Social Security Act (42 U.S.C. 1395i– 

25 3(h)(2)(B)(ii)) is amended to read as follows: 


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1 ‘‘(ii) AUTHORITY WITH RESPECT TO

2 CIVIL MONEY PENALTIES.— 

3 ‘‘(I) AMOUNT.—The Secretary 

4 may impose a civil money penalty in 

5 the applicable per instance or per day 

6 amount (as defined in subclause (II) 

7 and (III)) for each day or instance, 

8 respectively, of noncompliance (as de9 termined appropriate by the Sec10 retary). 

11 ‘‘(II) APPLICABLE PER INSTANCE

12 AMOUNT.—In this clause, the term 

13 ‘applicable per instance amount’ 

14 means— 

15 ‘‘(aa) in the case where the 

16 deficiency is found to be a direct 

17 proximate cause of death of a 

18 resident of the facility, an 

19 amount not to exceed $100,000. 

20 ‘‘(bb) in each case of a defi21 ciency where the facility is cited 

22 for actual harm or immediate 

23 jeopardy, an amount not less 

24 than $3,050 and not more than 

25 $25,000; and 


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1 ‘‘(cc) in each case of any 

2 other deficiency, an amount not 

3 less than $250 and not to exceed 

4 $3050. 

5 ‘‘(III) APPLICABLE PER DAY

6 AMOUNT.—In this clause, the term 

7 ‘applicable per day amount’ means— 

8 ‘‘(aa) in each case of a defi9 ciency where the facility is cited 

10 for actual harm or immediate 

11 jeopardy, an amount not less 

12 than $3,050 and not more than 

13 $25,000 and 

14 ‘‘(bb) in each case of any 

15 other deficiency, an amount not 

16 less than $250 and not to exceed 

17 $3,050. 

18 ‘‘(IV) REDUCTION OF CIVIL

19 MONEY PENALTIES IN CERTAIN CIR20 CUMSTANCES.—Subject to subclauses 

21 (V) and (VI), in the case where a fa22 cility self-reports and promptly cor23 rects a deficiency for which a penalty 

24 was imposed under this clause not 

25 later than 10 calendar days after the 


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1 date of such imposition, the Secretary 

2 may reduce the amount of the penalty 

3 imposed by not more than 50 percent. 

4 ‘‘(V) PROHIBITION ON REDUC5 TION FOR CERTAIN DEFICIENCIES.— 

6 ‘‘(aa) REPEAT DEFI7 CIENCIES.—The Secretary may 

8 not reduce under subclause (IV) 

9 the amount of a penalty if the 

10 deficiency is a repeat deficiency. 

11 ‘‘(bb) CERTAIN OTHER DE12 FICIENCIES.—The Secretary may 

13 not reduce under subclause (IV) 

14 the amount of a penalty if the 

15 penalty is imposed for a defi16 ciency described in subclause 

17 (II)(aa) or (III)(aa) and the ac18 tual harm or widespread harm 

19 immediately jeopardizes the 

20 health or safety of a resident or 

21 residents of the facility, or if the 

22 penalty is imposed for a defi23 ciency described in subclause 

24 (II)(bb). 


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1 ‘‘(VI) LIMITATION ON AGGRE2 GATE REDUCTIONS.—The aggregate 

3 reduction in a penalty under sub4 clause (IV) may not exceed 35 percent 

5 on the basis of self-reporting, on the 

6 basis of a waiver of an appeal (as pro7 vided for under regulations under sec8 tion 488.436 of title 42, Code of Fed9 eral Regulations), or on the basis of 

10 both. 

11 ‘‘(VII) COLLECTION OF CIVIL

12 MONEY PENALTIES.—In the case of a 

13 civil money penalty imposed under 

14 this clause, the Secretary— 

15 ‘‘(aa) subject to item (cc), 

16 shall, not later than 30 days 

17 after the date of imposition of 

18 the penalty, provide the oppor19 tunity for the facility to partici20 pate in an independent informal 

21 dispute resolution process, estab22 lished by the State survey agen23 cy, which generates a written 

24 record prior to the collection of 

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1 tunity shall not affect the respon2 sibility of the State survey agen3 cy for making final recommenda4 tions for such penalties; 

5 ‘‘(bb) in the case where the 

6 penalty is imposed for each day 

7 of noncompliance, shall not im8 pose a penalty for any day during 

9 the period beginning on the ini10 tial day of the imposition of the 

11 penalty and ending on the day on 

12 which the informal dispute reso13 lution process under item (aa) is 

14 completed; 

15 ‘‘(cc) may provide for the 

16 collection of such civil money 

17 penalty and the placement of 

18 such amounts collected in an es19 crow account under the direction 

20 of the Secretary on the earlier of 

21 the date on which the informal 

22 dispute resolution process under 

23 item (aa) is completed or the 

24 date that is 90 days after the 


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1 date of the imposition of the pen2 alty; 

3 ‘‘(dd) may provide that such 

4 amounts collected are kept in 

5 such account pending the resolu6 tion of any subsequent appeals; 

7 ‘‘(ee) in the case where the 

8 facility successfully appeals the 

9 penalty, may provide for the re10 turn of such amounts collected 

11 (plus interest) to the facility; and 

12 ‘‘(ff) in the case where all 

13 such appeals are unsuccessful, 

14 may provide that some portion of 

15 such amounts collected may be 

16 used to support activities that 

17 benefit residents, including as18 sistance to support and protect 

19 residents of a facility that closes 

20 (voluntarily or involuntarily) or is 

21 decertified (including offsetting 

22 costs of relocating residents to 

23 home and community-based set24 tings or another facility), projects 

25 that support resident and family 


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1 councils and other consumer in2 volvement in assuring quality 

3 care in facilities, and facility im4 provement initiatives approved by 

5 the Secretary (including joint 

6 training of facility staff and sur7 veyors, technical assistance for 

8 facilities under quality assurance 

9 programs, the appointment of 

10 temporary management, and 

11 other activities approved by the 

12 Secretary). 

13 ‘‘(VIII) PROCEDURE.—The pro14 visions of section 1128A (other than 

15 subsections (a) and (b) and except to 

16 the extent that such provisions require 

17 a hearing prior to the imposition of a 

18 civil money penalty) shall apply to a 

19 civil money penalty under this clause 

20 in the same manner as such provi21 sions apply to a penalty or proceeding 

22 under section 1128A(a).’’. 

23 (2) CONFORMING AMENDMENT.—The second 

24 sentence of section 1819(h)(5) of the Social Security 


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1 Act (42 U.S.C. 1395i–3(h)(5)) is amended by insert2 ing ‘‘(ii),’’after ‘‘(i),’’. 

3 (b) NURSING FACILITIES.— 

4 (1) PENALTIES IMPOSED BY THE STATE.— 

5 (A) IN GENERAL.—Section 1919(h)(2) of 

6 the Social Security Act (42 U.S.C. 1396r(h)(2)) 

7 is amended— 

8 (i) in subparagraph (A)(ii), by strik9 ing the first sentence and inserting the fol10 lowing: ‘‘A civil money penalty in accord11 ance with subparagraph (G).’’; and 

12 (ii) by adding at the end the following 

13 new subparagraph: 

14 ‘‘(G) CIVIL MONEY PENALTIES.— 

15 ‘‘(i) IN GENERAL.—The State may 

16 impose a civil money penalty under sub17 paragraph (A)(ii) in the applicable per in18 stance or per day amount (as defined in 

19 subclause (II) and (III)) for each day or 

20 instance, respectively, of noncompliance (as 

21 determined appropriate by the Secretary). 

22 ‘‘(ii) APPLICABLE PER INSTANCE

23 AMOUNT.—In this subparagraph, the term 

24 ‘applicable per instance amount’ means— 


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1 ‘‘(I) in the case where the defi2 ciency is found to be a direct proxi3 mate cause of death of a resident of 

4 the facility, an amount not to exceed 

5 $100,000. 

6 ‘‘(II) in each case of a deficiency 

7 where the facility is cited for actual 

8 harm or immediate jeopardy, an 

9 amount not less than $3,050 and not 

10 more than $25,000; and 

11 ‘‘(III) in each case of any other 

12 deficiency, an amount not less than 

13 $250 and not to exceed $3050. 

14 ‘‘(iii) APPLICABLE PER DAY

15 AMOUNT.—In this subparagraph, the term 

16 ‘applicable per day amount’ means— 

17 ‘‘(I) in each case of a deficiency 

18 where the facility is cited for actual 

19 harm or immediate jeopardy, an 

20 amount not less than $3,050 and not 

21 more than $25,000 and 

22 ‘‘(II) in each case of any other 

23 deficiency, an amount not less than 

24 $250 and not to exceed $3,050. 


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1 ‘‘(iv) REDUCTION OF CIVIL MONEY

2 PENALTIES IN CERTAIN CIR3 CUMSTANCES.—Subject to clauses (v) and 

4 (vi), in the case where a facility self-re5 ports and promptly corrects a deficiency 

6 for which a penalty was imposed under 

7 subparagraph (A)(ii) not later than 10 cal8 endar days after the date of such imposi9 tion, the State may reduce the amount of 

10 the penalty imposed by not more than 50 

11 percent. 

12 ‘‘(v) PROHIBITION ON REDUCTION

13 FOR CERTAIN DEFICIENCIES.— 

14 ‘‘(I) REPEAT DEFICIENCIES.— 

15 The State may not reduce under 

16 clause (iv) the amount of a penalty if 

17 the State had reduced a penalty im18 posed on the facility in the preceding 

19 year under such clause with respect to 

20 a repeat deficiency. 

21 ‘‘(II) CERTAIN OTHER DEFI22 CIENCIES.—The State may not reduce 

23 under clause (iv) the amount of a pen24 alty if the penalty is imposed for a de25 ficiency described in clause (ii)(II) or 


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1 (iii)(I) and the actual harm or wide2 spread harm that immediately jeop3 ardizes the health or safety of a resi4 dent or residents of the facility, or if 

5 the penalty is imposed for a deficiency 

6 described in clause (ii)(I). 

7 ‘‘(III) LIMITATION ON AGGRE8 GATE REDUCTIONS.—The aggregate 

9 reduction in a penalty under clause 

10 (iv) may not exceed 35 percent on the 

11 basis of self-reporting, on the basis of 

12 a waiver of an appeal (as provided for 

13 under regulations under section 

14 488.436 of title 42, Code of Federal 

15 Regulations), or on the basis of both. 

16 ‘‘(vi) COLLECTION OF CIVIL MONEY

17 PENALTIES.—In the case of a civil money 

18 penalty imposed under subparagraph 

19 (A)(ii), the State— 

20 ‘‘(I) subject to subclause (III), 

21 shall, not later than 30 days after the 

22 date of imposition of the penalty, pro23 vide the opportunity for the facility to 

24 participate in an independent informal 

25 dispute resolution process, established 


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1 by the State survey agency, which 

2 generates a written record prior to the 

3 collection of such penalty, but such 

4 opportunity shall not affect the re5 sponsibility of the State survey agency 

6 for making final recommendations for 

7 such penalties; 

8 ‘‘(II) in the case where the pen9 alty is imposed for each day of non10 compliance, shall not impose a penalty 

11 for any day during the period begin12 ning on the initial day of the imposi13 tion of the penalty and ending on the 

14 day on which the informal dispute res15 olution process under subclause (I) is 

16 completed; 

17 ‘‘(III) may provide for the collec18 tion of such civil money penalty and 

19 the placement of such amounts col20 lected in an escrow account under the 

21 direction of the State on the earlier of 

22 the date on which the informal dis23 pute resolution process under sub24 clause (I) is completed or the date 


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1 that is 90 days after the date of the 

2 imposition of the penalty; 

3 ‘‘(IV) may provide that such 

4 amounts collected are kept in such ac5 count pending the resolution of any 

6 subsequent appeals; 

7 ‘‘(V) in the case where the facil8 ity successfully appeals the penalty, 

9 may provide for the return of such 

10 amounts collected (plus interest) to 

11 the facility; and 

12 ‘‘(VI) in the case where all such 

13 appeals are unsuccessful, may provide 

14 that such funds collected shall be used 

15 for the purposes described in the sec16 ond sentence of subparagraph 

17 (A)(ii).’’. 

18 (B) CONFORMING AMENDMENT.—The sec19 ond sentence of section 1919(h)(2)(A)(ii) of the 

20 Social Security Act (42 U.S.C. 

21 1396r(h)(2)(A)(ii)) is amended by inserting be22 fore the period at the end the following: ‘‘, and 

23 some portion of such funds may be used to sup24 port activities that benefit residents, including 

25 assistance to support and protect residents of a 


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1 facility that closes (voluntarily or involuntarily) 

2 or is decertified (including offsetting costs of re3 locating residents to home and community4 based settings or another facility), projects that 

5 support resident and family councils and other 

6 consumer involvement in assuring quality care 

7 in facilities, and facility improvement initiatives 

8 approved by the Secretary (including joint 

9 training of facility staff and surveyors, pro10 viding technical assistance to facilities under 

11 quality assurance programs, the appointment of 

12 temporary management, and other activities ap13 proved by the Secretary)’’. 

14 (2) PENALTIES IMPOSED BY THE SEC15 RETARY.— 

16 (A) IN GENERAL.—Section 

17 1919(h)(3)(C)(ii) of the Social Security Act (42 

18 U.S.C. 1396r(h)(3)(C)) is amended to read as 

19 follows: 

20 ‘‘(ii) AUTHORITY WITH RESPECT TO

21 CIVIL MONEY PENALTIES.— 

22 ‘‘(I) AMOUNT.—Subject to sub23 clause (II), the Secretary may impose 

24 a civil money penalty in an amount 

25 not to exceed $10,000 for each day or 


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1 each instance of noncompliance (as 

2 determined appropriate by the Sec3 retary). 

4 ‘‘(II) REDUCTION OF CIVIL

5 MONEY PENALTIES IN CERTAIN CIR6 CUMSTANCES.—Subject to subclause 

7 (III), in the case where a facility self8 reports and promptly corrects a defi9 ciency for which a penalty was im10 posed under this clause not later than 

11 10 calendar days after the date of 

12 such imposition, the Secretary may 

13 reduce the amount of the penalty im14 posed by not more than 50 percent. 

15 ‘‘(III) PROHIBITION ON REDUC16 TION FOR REPEAT DEFICIENCIES.— 

17 The Secretary may not reduce the 

18 amount of a penalty under subclause 

19 (II) if the Secretary had reduced a 

20 penalty imposed on the facility in the 

21 preceding year under such subclause 

22 with respect to a repeat deficiency. 

23 ‘‘(IV) COLLECTION OF CIVIL

24 MONEY PENALTIES.—In the case of a 


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1 civil money penalty imposed under 

2 this clause, the Secretary— 

3 ‘‘(aa) subject to item (bb), 

4 shall, not later than 30 days 

5 after the date of imposition of 

6 the penalty, provide the oppor7 tunity for the facility to partici8 pate in an independent informal 

9 dispute resolution process which 

10 generates a written record prior 

11 to the collection of such penalty; 

12 ‘‘(bb) in the case where the 

13 penalty is imposed for each day 

14 of noncompliance, shall not im15 pose a penalty for any day during 

16 the period beginning on the ini17 tial day of the imposition of the 

18 penalty and ending on the day on 

19 which the informal dispute reso20 lution process under item (aa) is 

21 completed; 

22 ‘‘(cc) may provide for the 

23 collection of such civil money 

24 penalty and the placement of 

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1 crow account under the direction 

2 of the Secretary on the earlier of 

3 the date on which the informal 

4 dispute resolution process under 

5 item (aa) is completed or the 

6 date that is 90 days after the 

7 date of the imposition of the pen8 alty; 

9 ‘‘(dd) may provide that such 

10 amounts collected are kept in 

11 such account pending the resolu12 tion of any subsequent appeals; 

13 ‘‘(ee) in the case where the 

14 facility successfully appeals the 

15 penalty, may provide for the re16 turn of such amounts collected 

17 (plus interest) to the facility; and 

18 ‘‘(ff) in the case where all 

19 such appeals are unsuccessful, 

20 may provide that some portion of 

21 such amounts collected may be 

22 used to support activities that 

23 benefit residents, including as24 sistance to support and protect 

25 residents of a facility that closes 


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1 (voluntarily or involuntarily) or is 

2 decertified (including offsetting 

3 costs of relocating residents to 

4 home and community-based set5 tings or another facility), projects 

6 that support resident and family 

7 councils and other consumer in8 volvement in assuring quality 

9 care in facilities, and facility im10 provement initiatives approved by 

11 the Secretary (including joint 

12 training of facility staff and sur13 veyors, technical assistance for 

14 facilities under quality assurance 

15 programs, the appointment of 

16 temporary management, and 

17 other activities approved by the 

18 Secretary). 

19 ‘‘(V) PROCEDURE.—The provi20 sions of section 1128A (other than 

21 subsections (a) and (b) and except to 

22 the extent that such provisions require 

23 a hearing prior to the imposition of a 

24 civil money penalty) shall apply to a 

25 civil money penalty under this clause 


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1 in the same manner as such provi2 sions apply to a penalty or proceeding 

3 under section 1128A(a).’’. 

4 (B) CONFORMING AMENDMENT.—Section 

5 1919(h)(8) of the Social Security Act (42 

6 U.S.C. 1396r(h)(5)(8)) is amended by inserting 

7 ‘‘and in paragraph (3)(C)(ii)’’ after ‘‘paragraph 

8 (2)(A)’’. 

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

10 this section shall take effect 1 year after the date of the 

11 enactment of this Act. 

12 SEC. 1422. NATIONAL INDEPENDENT MONITOR PILOT PRO13 GRAM. 

14 (a) ESTABLISHMENT.— 

15 (1) IN GENERAL.—The Secretary, in consulta16 tion with the Inspector General of the Department 

17 of Health and Human Services, shall establish a 

18 pilot program (in this section referred to as the 

19 ‘‘pilot program’’) to develop, test, and implement use 

20 of an independent monitor to oversee interstate and 

21 large intrastate chains of skilled nursing facilities 

22 and nursing facilities. 

23 (2) SELECTION.—The Secretary shall select 

24 chains of skilled nursing facilities and nursing facili25 ties described in paragraph (1) to participate in the 


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1 pilot program from among those chains that submit 

2 an application to the Secretary at such time, in such 

3 manner, and containing such information as the Sec4 retary may require. 

5 (3) DURATION.—The Secretary shall conduct 

6 the pilot program for a two-year period. 

7 (4) IMPLEMENTATION.—The Secretary shall 

8 implement the pilot program not later than one year 

9 after the date of the enactment of this Act. 

10 (b) REQUIREMENTS.—The Secretary shall evaluate 

11 chains selected to participate in the pilot program based 

12 on criteria selected by the Secretary, including where evi13 dence suggests that one or more facilities of the chain are 

14 experiencing serious safety and quality of care problems. 

15 Such criteria may include the evaluation of a chain that 

16 includes one or more facilities participating in the ‘‘Special 

17 Focus Facility’’ program (or a successor program) or one 

18 or more facilities with a record of repeated serious safety 

19 and quality of care deficiencies. 

20 (c) RESPONSIBILITIES OF THE INDEPENDENT MON21 ITOR.—An independent monitor that enters into a con22 tract with the Secretary to participate in the conduct of 

23 such program shall— 

24 (1) conduct periodic reviews and prepare root25 cause quality and deficiency analyses of a chain to 


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1 assess if facilities of the chain are in compliance 

2 with State and Federal laws and regulations applica3 ble to the facilities; 

4 (2) undertake sustained oversight of the chain, 

5 whether publicly or privately held, to involve the 

6 owners of the chain and the principal business part7 ners of such owners in facilitating compliance by fa8 cilities of the chain with State and Federal laws and 

9 regulations applicable to the facilities; 

10 (3) analyze the management structure, distribu11 tion of expenditures, and nurse staffing levels of fa12 cilities of the chain in relation to resident census, 

13 staff turnover rates, and tenure; 

14 (4) report findings and recommendations with 

15 respect to such reviews, analyses, and oversight to 

16 the chain and facilities of the chain, to the Secretary 

17 and to relevant States; and 

18 (5) publish the results of such reviews, anal19 yses, and oversight. 

20 (d) IMPLEMENTATION OF RECOMMENDATIONS.— 

21 (1) RECEIPT OF FINDING BY CHAIN.—Not later 

22 than 10 days after receipt of a finding of an inde23 pendent monitor under subsection (c)(4), a chain 

24 participating in the pilot program shall submit to 

25 the independent monitor a report— 


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1 (A) outlining corrective actions the chain 

2 will take to implement the recommendations in 

3 such report; or 

4 (B) indicating that the chain will not im5 plement such recommendations and why it will 

6 not do so. 

7 (2) RECEIPT OF REPORT BY INDEPENDENT

8 MONITOR.—Not later than 10 days after the date of 

9 receipt of a report submitted by a chain under para10 graph (1), an independent monitor shall finalize its 

11 recommendations and submit a report to the chain 

12 and facilities of the chain, the Secretary, and the 

13 State (or States) involved, as appropriate, containing 

14 such final recommendations. 

15 (e) COST OF APPOINTMENT.—A chain shall be re16 sponsible for a portion of the costs associated with the 

17 appointment of independent monitors under the pilot pro18 gram. The chain shall pay such portion to the Secretary 

19 (in an amount and in accordance with procedures estab20 lished by the Secretary). 

21 (f) WAIVER AUTHORITY.—The Secretary may waive 

22 such requirements of titles XVIII and XIX of the Social 

23 Security Act (42 U.S.C. 1395 et seq.; 1396 et seq.) as 

24 may be necessary for the purpose of carrying out the pilot 

25 program. 


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1 (g) AUTHORIZATION OF APPROPRIATIONS.—There 

2 are authorized to be appropriated such sums as may be 

3 necessary to carry out this section. 

4 (h) DEFINITIONS.—In this section: 

5 (1) FACILITY.—The term ‘‘facility’’ means a 

6 skilled nursing facility or a nursing facility. 

7 (2) NURSING FACILITY.—The term ‘‘nursing 

8 facility’’ has the meaning given such term in section 

9 1919(a) of the Social Security Act (42 U.S.C. 

10 1396r(a)). 

11 (3) SECRETARY.—The term ‘‘Secretary’’ means 

12 the Secretary of Health and Human Services, acting 

13 through the Assistant Secretary for Planning and 

14 Evaluation. 

15 (4) SKILLED NURSING FACILITY.—The term 

16 ‘‘skilled nursing facility’’ has the meaning given such 

17 term in section 1819(a) of the Social Security Act 

18 (42 U.S.C. 1395(a)). 

19 (i) EVALUATION AND REPORT.— 

20 (1) EVALUATION.—The Inspector General of 

21 the Department of Health and Human Services shall 

22 evaluate the pilot program. Such evaluation shall— 

23 (A) determine whether the independent 

24 monitor program should be established on a 

25 permanent basis; and 


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1 (B) if the Inspector General determines 

2 that the independent monitor program should 

3 be established on a permanent basis, rec4 ommend appropriate procedures and mecha5 nisms for such establishment. 

6 (2) REPORT.—Not later than 180 days after 

7 the completion of the pilot program, the Inspector 

8 General shall submit to Congress and the Secretary 

9 a report containing the results of the evaluation con10 ducted under paragraph (1), together with rec11 ommendations for such legislation and administra12 tive action as the Inspector General determines ap13 propriate. 

14 SEC. 1423. NOTIFICATION OF FACILITY CLOSURE. 

15 (a) SKILLED NURSING FACILITIES.— 

16 (1) IN GENERAL.—Section 1819(c) of the So17 cial Security Act (42 U.S.C. 1395i–3(c)) is amended 

18 by adding at the end the following new paragraph: 

19 ‘‘(7) NOTIFICATION OF FACILITY CLOSURE.— 

20 ‘‘(A) IN GENERAL.—Any individual who is 

21 the administrator of a skilled nursing facility 

22 must— 

23 ‘‘(i) submit to the Secretary, the State 

24 long-term care ombudsman, residents of 

25 the facility, and the legal representatives of 


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1 such residents or other responsible parties, 

2 written notification of an impending clo3 sure— 

4 ‘‘(I) subject to subclause (II), not 

5 later than the date that is 60 days 

6 prior to the date of such closure; and 

7 ‘‘(II) in the case of a facility 

8 where the Secretary terminates the fa9 cility’s participation under this title, 

10 not later than the date that the Sec11 retary determines appropriate; 

12 ‘‘(ii) ensure that the facility does not 

13 admit any new residents on or after the 

14 date on which such written notification is 

15 submitted; and 

16 ‘‘(iii) include in the notice a plan for 

17 the transfer and adequate relocation of the 

18 residents of the facility by a specified date 

19 prior to closure that has been approved by 

20 the State, including assurances that the 

21 residents will be transferred to the most 

22 appropriate facility or other setting in 

23 terms of quality, services, and location, 

24 taking into consideration the needs and 

25 best interests of each resident. 


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1 ‘‘(B) RELOCATION.— 

2 ‘‘(i) IN GENERAL.—The State shall 

3 ensure that, before a facility closes, all 

4 residents of the facility have been success5 fully relocated to another facility or an al6 ternative home and community-based set7 ting. 

8 ‘‘(ii) CONTINUATION OF PAYMENTS

9 UNTIL RESIDENTS RELOCATED.—The Sec10 retary may, as the Secretary determines 

11 appropriate, continue to make payments 

12 under this title with respect to residents of 

13 a facility that has submitted a notification 

14 under subparagraph (A) during the period 

15 beginning on the date such notification is 

16 submitted and ending on the date on which 

17 the resident is successfully relocated.’’. 

18 (2) CONFORMING AMENDMENTS.—Section 

19 1819(h)(4) of the Social Security Act (42 U.S.C. 

20 1395i–3(h)(4)) is amended— 

21 (A) in the first sentence, by striking ‘‘the 

22 Secretary shall terminate’’ and inserting ‘‘the 

23 Secretary, subject to subsection (c)(7), shall 

24 terminate’’; and 


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1 (B) in the second sentence, by striking 

2 ‘‘subsection (c)(2)’’ and inserting ‘‘paragraphs 

3 (2) and (7) of subsection (c)’’. 

4 (b) NURSING FACILITIES.— 

5 (1) IN GENERAL.—Section 1919(c) of the So6 cial Security Act (42 U.S.C. 1396r(c)) is amended 

7 by adding at the end the following new paragraph: 

8 ‘‘(9) NOTIFICATION OF FACILITY CLOSURE.— 

9 ‘‘(A) IN GENERAL.—Any individual who is 

10 an administrator of a nursing facility must— 

11 ‘‘(i) submit to the Secretary, the State 

12 long-term care ombudsman, residents of 

13 the facility, and the legal representatives of 

14 such residents or other responsible parties, 

15 written notification of an impending clo16 sure— 

17 ‘‘(I) subject to subclause (II), not 

18 later than the date that is 60 days 

19 prior to the date of such closure; and 

20 ‘‘(II) in the case of a facility 

21 where the Secretary terminates the fa22 cility’s participation under this title, 

23 not later than the date that the Sec24 retary determines appropriate; 


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1 ‘‘(ii) ensure that the facility does not 

2 admit any new residents on or after the 

3 date on which such written notification is 

4 submitted; and 

5 ‘‘(iii) include in the notice a plan for 

6 the transfer and adequate relocation of the 

7 residents of the facility by a specified date 

8 prior to closure that has been approved by 

9 the State, including assurances that the 

10 residents will be transferred to the most 

11 appropriate facility or other setting in 

12 terms of quality, services, and location, 

13 taking into consideration the needs and 

14 best interests of each resident. 

15 ‘‘(B) RELOCATION.— 

16 ‘‘(i) IN GENERAL.—The State shall 

17 ensure that, before a facility closes, all 

18 residents of the facility have been success19 fully relocated to another facility or an al20 ternative home and community-based set21 ting. 

22 ‘‘(ii) CONTINUATION OF PAYMENTS

23 UNTIL RESIDENTS RELOCATED.—The Sec24 retary may, as the Secretary determines 

25 appropriate, continue to make payments 


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1 under this title with respect to residents of 

2 a facility that has submitted a notification 

3 under subparagraph (A) during the period 

4 beginning on the date such notification is 

5 submitted and ending on the date on which 

6 the resident is successfully relocated.’’. 

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

8 this section shall take effect 1 year after the date of the 

9 enactment of this Act. 

10 PART 3—IMPROVING STAFF TRAINING 

11 SEC. 1431. DEMENTIA AND ABUSE PREVENTION TRAINING. 

12 (a) SKILLED NURSING FACILITIES.—Section 

13 1819(f)(2)(A)(i)(I) of the Social Security Act (42 U.S.C. 

14 1395i–3(f)(2)(A)(i)(I)) is amended by inserting ‘‘(includ15 ing, in the case of initial training and, if the Secretary 

16 determines appropriate, in the case of ongoing training, 

17 dementia management training and resident abuse preven18 tion training)’’ after ‘‘curriculum’’. 

19 (b) NURSING FACILITIES.—Section 

20 1919(f)(2)(A)(i)(I) of the Social Security Act (42 U.S.C. 

21 1396r(f)(2)(A)(i)(I)) is amended by inserting ‘‘(including, 

22 in the case of initial training and, if the Secretary deter23 mines appropriate, in the case of ongoing training, demen24 tia management training and resident abuse prevention 

25 training)’’ after ‘‘curriculum’’. 


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

2 this section shall take effect 1 year after the date of the 

3 enactment of this Act. 

4 SEC. 1432. STUDY AND REPORT ON TRAINING REQUIRED 

5 FOR CERTIFIED NURSE AIDES AND SUPER6 VISORY STAFF. 

7 (a) STUDY.— 

8 (1) IN GENERAL.—The Secretary shall conduct 

9 a study on the content of training for certified nurse 

10 aides and supervisory staff of skilled nursing facili11 ties and nursing facilities. The study shall include an 

12 analysis of the following: 

13 (A) Whether the number of initial training 

14 hours for certified nurse aides required under 

15 sections 1819(f)(2)(A)(i)(II) and 

16 1919(f)(2)(A)(i)(II) of the Social Security Act 

17 (42 U.S.C. 1395i–3(f)(2)(A)(i)(II); 

18 1396r(f)(2)(A)(i)(II)) should be increased from 

19 75 and, if so, what the required number of ini20 tial training hours should be, including any rec21 ommendations for the content of such training 

22 (including training related to dementia). 

23 (B) Whether requirements for ongoing 

24 training under such sections 

25 1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) 


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1 should be increased from 12 hours per year, in2 cluding any recommendations for the content of 

3 such training. 

4 (2) CONSULTATION.—In conducting the anal5 ysis under paragraph (1)(A), the Secretary shall 

6 consult with States that, as of the date of the enact7 ment of this Act, require more than 75 hours of 

8 training for certified nurse aides. 

9 (3) DEFINITIONS.—In this section: 

10 (A) NURSING FACILITY.—The term ‘‘nurs11 ing facility’’ has the meaning given such term 

12 in section 1919(a) of the Social Security Act 

13 (42 U.S.C. 1396r(a)). 

14 (B) SECRETARY.—The term ‘‘Secretary’’ 

15 means the Secretary of Health and Human 

16 Services, acting through the Assistant Secretary 

17 for Planning and Evaluation. 

18 (C) SKILLED NURSING FACILITY.—The 

19 term ‘‘skilled nursing facility’’ has the meaning 

20 given such term in section 1819(a) of the Social 

21 Security Act (42 U.S.C. 1395(a)). 

22 (b) REPORT.—Not later than 2 years after the date 

23 of the enactment of this Act, the Secretary shall submit 

24 to Congress a report containing the results of the study 

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1 ommendations for such legislation and administrative ac2 tion as the Secretary determines appropriate. 

3 SEC. 1433. QUALIFICATION OF DIRECTOR OF FOOD SERV4 ICES OF A SKILLED NURSING FACILITY OR 

5 NURSING FACILITY. 

6 (a) MEDICARE.—Section 1819(b)(4)(A) of the Social 

7 Security Act (42 U.S.C. 1395i–3(b)(4)(A)) is amended by 

8 adding at the end the following: ‘‘With respect to meeting 

9 the staffing requirement imposed by the Secretary to carry 

10 out clause (iv), the full-time director of food services of 

11 the facility, if not a qualified dietitian (as defined in sec12 tion 483.35(a)(2) of title 42, Code of Federal Regulations, 

13 as in effect as of the date of the enactment of this sen14 tence), shall be a Certified Dietary Manager meeting the 

15 requirements of the Certifying Board for Dietary Man16 agers, or a Dietetic Technician, Registered meeting the 

17 requirements of the Commission on Dietetic Registration 

18 or have equivalent military, academic, or other qualifica19 tions (as specified by the Secretary).’’. 

20 (b) MEDICAID.—Section 1919(b)(4)(A) of the Social 

21 Security Act (42 U.S.C. 1396r(b)(4)(A)) is amended by 

22 adding at the end the following: ‘‘With respect to meeting 

23 the staffing requirement imposed by the Secretary to carry 

24 out clause (iv), the full-time director of food services of 

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1 tion 483.35(a)(2) of title 42, Code of Federal Regulations, 

2 as in effect as of the date of the enactment of this sen3 tence), shall be a Certified Dietary Manager meeting the 

4 requirements of the Certifying Board for Dietary Man5 agers, or a Dietetic Technician, Registered meeting the 

6 requirements of the Commission on Dietetic Registration 

7 or have equivalent military, academic, or other qualifica8 tions (as specified by the Secretary).’’. 

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

10 this section shall take effect on the date that is 180 days 

11 after the date of enactment of this Act. 

12 Subtitle C—Quality Measurements 

13 SEC. 1441. ESTABLISHMENT OF NATIONAL PRIORITIES FOR 

14 QUALITY IMPROVEMENT. 

15 Title XI of the Social Security Act, as amended by 

16 section 1401(a), is further amended by adding at the end 

17 the following new part: 

18 ‘‘PART E—QUALITY IMPROVEMENT

19 ‘‘ESTABLISHMENT OF NATIONAL PRIORITIES FOR

20 PERFORMANCE IMPROVEMENT

21 ‘‘SEC. 1191. (a) ESTABLISHMENT OF NATIONAL PRI22 ORITIES BY THE SECRETARY.—The Secretary shall estab23 lish and periodically update, not less frequently than tri24 ennially, national priorities for performance improvement. 


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1 ‘‘(b) RECOMMENDATIONS FOR NATIONAL PRIOR2 ITIES.—In establishing and updating national priorities 

3 under subsection (a), the Secretary shall solicit and con4 sider recommendations from multiple outside stake5 holders. 

6 ‘‘(c) CONSIDERATIONS IN SETTING NATIONAL PRI7 ORITIES.—With respect to such priorities, the Secretary 

8 shall ensure that priority is given to areas in the delivery 

9 of health care services in the United States that— 

10 ‘‘(1) contribute to a large burden of disease, in11 cluding those that address the health care provided 

12 to patients with prevalent, high-cost chronic dis13 eases; 

14 ‘‘(2) have the greatest potential to decrease 

15 morbidity and mortality in this country, including 

16 those that are designed to eliminate harm to pa17 tients; 

18 ‘‘(3) have the greatest potential for improving 

19 the performance, affordability, and patient20 centeredness of health care, including those due to 

21 variations in care; 

22 ‘‘(4) address health disparities across groups 

23 and areas; and 


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1 ‘‘(5) have the potential for rapid improvement 

2 due to existing evidence, standards of care or other 

3 reasons. 

4 ‘‘(d) DEFINITIONS.—In this part: 

5 ‘‘(1) CONSENSUS-BASED ENTITY.—The term 

6 ‘consensus-based entity’ means an entity with a con7 tract with the Secretary under section 1890. 

8 ‘‘(2) QUALITY MEASURE.—The term ‘quality 

9 measure’ means a national consensus standard for 

10 measuring the performance and improvement of pop11 ulation health, or of institutional providers of serv12 ices, physicians, and other health care practitioners 

13 in the delivery of health care services. 

14 ‘‘(e) FUNDING.— 

15 ‘‘(1) IN GENERAL.—The Secretary shall provide 

16 for the transfer, from the Federal Hospital Insur17 ance Trust Fund under section 1817 and the Fed18 eral Supplementary Medical Insurance Trust Fund 

19 under section 1841 (in such proportion as the Sec20 retary determines appropriate), of $2,000,000, for 

21 the activities under this section for each of the fiscal 

22 years 2010 through 2014. 

23 ‘‘(2) AUTHORIZATION OF APPROPRIATIONS.— 

24 For purposes of carrying out the provisions of this 

25 section, in addition to funds otherwise available, out 


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1 of any funds in the Treasury not otherwise appro2 priated, there are appropriated to the Secretary of 

3 Health and Human Services $2,000,000 for each of 

4 the fiscal years 2010 through 2014.’’. 

5 SEC. 1442. DEVELOPMENT OF NEW QUALITY MEASURES; 

6 GAO EVALUATION OF DATA COLLECTION 

7 PROCESS FOR QUALITY MEASUREMENT. 

8 Part E of title XI of the Social Security Act, as added 

9 by section 1441, is amended by adding at the end the fol10 lowing new sections: 

11 ‘‘SEC. 1192. DEVELOPMENT OF NEW QUALITY MEASURES. 

12 ‘‘(a) AGREEMENTS WITH QUALIFIED ENTITIES.— 

13 ‘‘(1) IN GENERAL.—The Secretary shall enter 

14 into agreements with qualified entities to develop 

15 quality measures for the delivery of health care serv16 ices in the United States. 

17 ‘‘(2) FORM OF AGREEMENTS.—The Secretary 

18 may carry out paragraph (1) by contract, grant, or 

19 otherwise. 

20 ‘‘(3) RECOMMENDATIONS OF CONSENSUS21 BASED ENTITY.—In carrying out this section, the 

22 Secretary shall— 

23 ‘‘(A) seek public input; and 


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1 ‘‘(B) take into consideration recommenda2 tions of the consensus-based entity with a con3 tract with the Secretary under section 1890(a). 

4 ‘‘(b) DETERMINATION OF AREAS WHERE QUALITY

5 MEASURES ARE REQUIRED.—Consistent with the na6 tional priorities established under this part and with the 

7 programs administered by the Centers for Medicare & 

8 Medicaid Services and in consultation with other relevant 

9 Federal agencies, the Secretary shall determine areas in 

10 which quality measures for assessing health care services 

11 in the United States are needed. 

12 ‘‘(c) DEVELOPMENT OF QUALITY MEASURES.— 

13 ‘‘(1) PATIENT-CENTERED AND POPULATION14 BASED MEASURES.—In entering into agreements 

15 under subsection (a), the Secretary shall give pri16 ority to the development of quality measures that 

17 allow the assessment of— 

18 ‘‘(A) health outcomes, presence of impair19 ment, and functional status of patients; 

20 ‘‘(B) the continuity and coordination of 

21 care and care transitions for patients across 

22 providers and health care settings, including 

23 end of life care; 

24 ‘‘(C) patient experience and patient en25 gagement; 


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1 ‘‘(D) the safety, effectiveness, and timeli2 ness of care; 

3 ‘‘(E) health disparities including those as4 sociated with individual race, ethnicity, age, 

5 gender, place of residence or language; and 

6 ‘‘(F) the efficiency and resource use in the 

7 provision of care. 

8 ‘‘(2) USE OF FUNDS.—An entity that enters 

9 into an agreement under subsection (a) shall develop 

10 quality measures that— 

11 ‘‘(A) to the extent feasible, have the ability 

12 to be collected through the use of health infor13 mation technologies supporting better delivery 

14 of health care services; and 

15 ‘‘(B) are available free of charge to users 

16 for the use of such measures. 

17 ‘‘(3) AVAILABILITY OF MEASURES.—The Sec18 retary shall make quality measures developed under 

19 this section available to the public. 

20 ‘‘(4) TESTING OF PROPOSED MEASURES.—The 

21 Secretary may use amounts made available under 

22 subsection (f) to fund the testing of proposed quality 

23 measures by qualified entities. Testing funded under 

24 this paragraph shall include testing of the feasibility 

25 and usability of proposed measures. 


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1 ‘‘(5) UPDATING OF ENDORSED MEASURES.— 

2 The Secretary may use amounts made available 

3 under subsection (f) to fund the updating (and test4 ing, if applicable) by consensus-based entities of 

5 quality measures that have been previously endorsed 

6 by such an entity as new evidence is developed, in 

7 a manner consistent with section 1890(b)(3). 

8 ‘‘(d) QUALIFIED ENTITIES.—Before entering into 

9 agreements with a qualified entity, the Secretary shall en10 sure that the entity is a public, private, or academic insti11 tution with technical expertise in the area of health quality 

12 measurement. 

13 ‘‘(e) APPLICATION FOR GRANT.—A grant may be 

14 made under this section only if an application for the 

15 grant is submitted to the Secretary and the application 

16 is in such form, is made in such manner, and contains 

17 such agreements, assurances, and information as the Sec18 retary determines to be necessary to carry out this section. 

19 ‘‘(f) FUNDING.— 

20 ‘‘(1) IN GENERAL.—The Secretary shall provide 

21 for the transfer, from the Federal Hospital Insur22 ance Trust Fund under section 1817 and the Fed23 eral Supplementary Medical Insurance Trust Fund 

24 under section 1841 (in such proportion as the Sec25 retary determines appropriate), of $25,000,000, to 


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1 the Secretary for purposes of carrying out this sec2 tion for each of the fiscal years 2010 through 2014. 

3 ‘‘(2) AUTHORIZATION OF APPROPRIATIONS.— 

4 For purposes of carrying out the provisions of this 

5 section, in addition to funds otherwise available, out 

6 of any funds in the Treasury not otherwise appro7 priated, there are appropriated to the Secretary of 

8 Health and Human Services $25,000,000 for each 

9 of the fiscal years 2010 through 2014. 

10 ‘‘SEC. 1193. GAO EVALUATION OF DATA COLLECTION PROC11 ESS FOR QUALITY MEASUREMENT. 

12 ‘‘(a) GAO EVALUATIONS.—The Comptroller General 

13 of the United States shall conduct periodic evaluations of 

14 the implementation of the data collection processes for 

15 quality measures used by the Secretary. 

16 ‘‘(b) CONSIDERATIONS.—In carrying out the evalua17 tion under subsection (a), the Comptroller General shall 

18 determine— 

19 ‘‘(1) whether the system for the collection of 

20 data for quality measures provides for validation of 

21 data as relevant and scientifically credible; 

22 ‘‘(2) whether data collection efforts under the 

23 system use the most efficient and cost-effective 

24 means in a manner that minimizes administrative 

25 burden on persons required to collect data and that 


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1 adequately protects the privacy of patients’ personal 

2 health information and provides data security; 

3 ‘‘(3) whether standards under the system pro4 vide for an appropriate opportunity for physicians 

5 and other clinicians and institutional providers of 

6 services to review and correct findings; and 

7 ‘‘(4) the extent to which quality measures are 

8 consistent with section 1192(c)(1) or result in direct 

9 or indirect costs to users of such measures. 

10 ‘‘(c) REPORT.—The Comptroller General shall sub11 mit reports to Congress and to the Secretary containing 

12 a description of the findings and conclusions of the results 

13 of each such evaluation.’’. 

14 SEC. 1443. MULTI-STAKEHOLDER PRE-RULEMAKING INPUT 

15 INTO SELECTION OF QUALITY MEASURES. 

16 Section 1808 of the Social Security Act (42 U.S.C. 

17 1395b–9) is amended by adding at the end the following 

18 new subsection: 

19 ‘‘(d) MULTI-STAKEHOLDER PRE-RULEMAKING INPUT

20 INTO SELECTION OF QUALITY MEASURES.— 

21 ‘‘(1) LIST OF MEASURES.—Not later than De22 cember 1 before each year (beginning with 2011), 

23 the Secretary shall make public a list of measures 

24 being considered for selection for quality measure25 ment by the Secretary in rulemaking with respect to 


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1 payment systems under this title beginning in the 

2 payment year beginning in such year and for pay3 ment systems beginning in the calendar year fol4 lowing such year, as the case may be. 

5 ‘‘(2) CONSULTATION ON SELECTION OF EN6 DORSED QUALITY MEASURES.—A consensus-based 

7 entity that has entered into a contract under section 

8 1890 shall, as part of such contract, convene multi9 stakeholder groups to provide recommendations on 

10 the selection of individual or composite quality meas11 ures, for use in reporting performance information 

12 to the public or for use in public health care pro13 grams. 

14 ‘‘(3) MULTI-STAKEHOLDER INPUT.—Not later 

15 than February 1 of each year (beginning with 

16 2011), the consensus-based entity described in para17 graph (2) shall transmit to the Secretary the rec18 ommendations of multi-stakeholder groups provided 

19 under paragraph (2). Such recommendations shall 

20 be included in the transmissions the consensus-based 

21 entity makes to the Secretary under the contract 

22 provided for under section 1890. 

23 ‘‘(4) REQUIREMENT FOR TRANSPARENCY IN

24 PROCESS.— 


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1 ‘‘(A) IN GENERAL.—In convening multi2 stakeholder groups under paragraph (2) with 

3 respect to the selection of quality measures, the 

4 consensus-based entity described in such para5 graph shall provide for an open and transparent 

6 process for the activities conducted pursuant to 

7 such convening. 

8 ‘‘(B) SELECTION OF ORGANIZATIONS PAR9 TICIPATING IN MULTI-STAKEHOLDER

10 GROUPS.—The process under paragraph (2) 

11 shall ensure that the selection of representatives 

12 of multi-stakeholder groups includes provision 

13 for public nominations for, and the opportunity 

14 for public comment on, such selection. 

15 ‘‘(5) USE OF INPUT.—The respective proposed 

16 rule shall contain a summary of the recommenda17 tions made by the multi-stakeholder groups under 

18 paragraph (2), as well as other comments received 

19 regarding the proposed measures, and the extent to 

20 which such proposed rule follows such recommenda21 tions and the rationale for not following such rec22 ommendations. 

23 ‘‘(6) MULTI-STAKEHOLDER GROUPS.—For pur24 poses of this subsection, the term ‘multi-stakeholder 

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1 voluntary collaborative of organizations representing 

2 persons interested in or affected by the use of such 

3 quality measure, such as the following: 

4 ‘‘(A) Hospitals and other institutional pro5 viders. 

6 ‘‘(B) Physicians. 

7 ‘‘(C) Health care quality alliances. 

8 ‘‘(D) Nurses and other health care practi9 tioners. 

10 ‘‘(E) Health plans. 

11 ‘‘(F) Patient advocates and consumer 

12 groups. 

13 ‘‘(G) Employers. 

14 ‘‘(H) Public and private purchasers of 

15 health care items and services. 

16 ‘‘(I) Labor organizations. 

17 ‘‘(J) Relevant departments or agencies of 

18 the United States. 

19 ‘‘(K) Biopharmaceutical companies and 

20 manufacturers of medical devices. 

21 ‘‘(L) Licensing, credentialing, and accred22 iting bodies. 

23 ‘‘(7) FUNDING.— 

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

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1 pital Insurance Trust Fund under section 1817 

2 and the Federal Supplementary Medical Insur3 ance Trust Fund under section 1841 (in such 

4 proportion as the Secretary determines appro5 priate), of $1,000,000, to the Secretary for pur6 poses of carrying out this subsection for each of 

7 the fiscal years 2010 through 2014. 

8 ‘‘(B) AUTHORIZATION OF APPROPRIA9 TIONS.—For purposes of carrying out the provi10 sions of this subsection, in addition to funds 

11 otherwise available, out of any funds in the 

12 Treasury not otherwise appropriated, there are 

13 appropriated to the Secretary of Health and 

14 Human Services $1,000,000 for each of the fis15 cal years 2010 through 2014.’’. 

16 SEC. 1444. APPLICATION OF QUALITY MEASURES. 

17 (a) INPATIENT HOSPITAL SERVICES.—Section 

18 1886(b)(3)(B) of such Act (42 U.S.C. 1395ww(b)(3)(B)) 

19 is amended by adding at the end the following new clause: 

20 ‘‘(x)(I) Subject to subclause (II), for purposes of re21 porting data on quality measures for inpatient hospital 

22 services furnished during fiscal year 2012 and each subse23 quent fiscal year, the quality measures specified under 

24 clause (viii) shall be measures selected by the Secretary 


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1 from measures that have been endorsed by the entity with 

2 a contract with the Secretary under section 1890(a). 

3 ‘‘(II) In the case of a specified area or medical topic 

4 determined appropriate by the Secretary for which a fea5 sible and practical quality measure has not been endorsed 

6 by the entity with a contract under section 1890(a), the 

7 Secretary may specify a measure that is not so endorsed 

8 as long as due consideration is given to measures that 

9 have been endorsed or adopted by a consensus organiza10 tion identified by the Secretary. The Secretary shall sub11 mit such a non-endorsed measure to the entity for consid12 eration for endorsement. If the entity considers but does 

13 not endorse such a measure and if the Secretary does not 

14 phase-out use of such measure, the Secretary shall include 

15 the rationale for continued use of such a measure in rule16 making.’’. 

17 (b) OUTPATIENT HOSPITAL SERVICES.—Section 

18 1833(t)(17) of such Act (42 U.S.C. 1395l(t)(17)) is 

19 amended by adding at the end the following new subpara20 graph: 

21 ‘‘(F) USE OF ENDORSED QUALITY MEAS22 URES.—The provisions of clause (x) of section 

23 1886(b)(3)(C) shall apply to quality measures 

24 for covered OPD services under this paragraph 

25 in the same manner as such provisions apply to 


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1 quality measures for inpatient hospital serv2 ices.’’. 

3 (c) PHYSICIANS’ SERVICES.—Section 

4 1848(k)(2)(C)(ii) of such Act (42 U.S.C. 1395w5 4(k)(2)(C)(ii)) is amended by adding at the end the fol6 lowing: ‘‘The Secretary shall submit such a non-endorsed 

7 measure to the entity for consideration for endorsement. 

8 If the entity considers but does not endorse such a meas9 ure and if the Secretary does not phase-out use of such 

10 measure, the Secretary shall include the rationale for con11 tinued use of such a measure in rulemaking.’’. 

12 (d) RENAL DIALYSIS SERVICES.—Section 

13 1881(h)(2)(B)(ii) of such Act (42 U.S.C. 

14 1395rr(h)(2)(B)(ii)) is amended by adding at the end the 

15 following: ‘‘The Secretary shall submit such a non-en16 dorsed measure to the entity for consideration for endorse17 ment. If the entity considers but does not endorse such 

18 a measure and if the Secretary does not phase-out use 

19 of such measure, the Secretary shall include the rationale 

20 for continued use of such a measure in rulemaking.’’. 

21 (e) ENDORSEMENT OF STANDARDS.—Section 

22 1890(b)(2) of the Social Security Act (42 U.S.C. 

23 1395aaa(b)(2)) is amended by adding after and below sub24 paragraph (B) the following: 


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1 ‘‘If the entity does not endorse a measure, such enti2 ty shall explain the reasons and provide suggestions 

3 about changes to such measure that might make it 

4 a potentially endorsable measure.’’. 

5 (f) EFFECTIVE DATE.—Except as otherwise pro6 vided, the amendments made by this section shall apply 

7 to quality measures applied for payment years beginning 

8 with 2012 or fiscal year 2012, as the case may be. 

9 SEC. 1445. CONSENSUS-BASED ENTITY FUNDING. 

10 Section 1890(d) of the Social Security Act (42 U.S.C. 

11 1395aaa(d)) is amended by striking ‘‘for each of fiscal 

12 years 2009 through 2012’’ and inserting ‘‘for fiscal year 

13 2009, and $12,000,000 for each of the fiscal years 2010 

14 through 2012’’ 


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1 Subtitle D—Physician Payments 

2 Sunshine Provision 

3 SEC. 1451. REPORTS ON FINANCIAL RELATIONSHIPS BE4 TWEEN MANUFACTURERS AND DISTRIBU5 TORS OF COVERED DRUGS, DEVICES, 

6 BIOLOGICALS, OR MEDICAL SUPPLIES 

7 UNDER MEDICARE, MEDICAID, OR CHIP AND 

8 PHYSICIANS AND OTHER HEALTH CARE ENTI9 TIES AND BETWEEN PHYSICIANS AND OTHER 

10 HEALTH CARE ENTITIES. 

11 (a) IN GENERAL.—Part A of title XI of the Social 

12 Security Act (42 U.S.C. 1301 et seq.), as amended by sec13 tion 1631(a), is further amended by inserting after section 

14 1128G the following new section: 

15 ‘‘SEC. 1128H. FINANCIAL REPORTS ON PHYSICIANS’ FINAN16 CIAL RELATIONSHIPS WITH MANUFACTUR17 ERS AND DISTRIBUTORS OF COVERED 

18 DRUGS, DEVICES, BIOLOGICALS, OR MEDICAL 

19 SUPPLIES UNDER MEDICARE, MEDICAID, OR 

20 CHIP AND WITH ENTITIES THAT BILL FOR 

21 SERVICES UNDER MEDICARE. 

22 ‘‘(a) REPORTING OF PAYMENTS OR OTHER TRANS23 FERS OF VALUE.— 

24 ‘‘(1) IN GENERAL.—Except as provided in this 

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1 nually thereafter, each applicable manufacturer or 

2 distributor that provides a payment or other transfer 

3 of value to a covered recipient, or to an entity or in4 dividual at the request of or designated on behalf of 

5 a covered recipient, shall submit to the Secretary, in 

6 such electronic form as the Secretary shall require, 

7 the following information with respect to the pre8 ceding calendar year: 

9 ‘‘(A) With respect to the covered recipient, 

10 the recipient’s name, business address, physi11 cian specialty, and national provider identifier. 

12 ‘‘(B) With respect to the payment or other 

13 transfer of value, other than a drug sample— 

14 ‘‘(i) its value and date; 

15 ‘‘(ii) the name of the related drug, de16 vice, or supply, if available, to the level of 

17 specificity available; and 

18 ‘‘(iii) a description of its form, indi19 cated (as appropriate for all that apply) 

20 as— 

21 ‘‘(I) cash or a cash equivalent; 

22 ‘‘(II) in-kind items or services; 

23 ‘‘(III) stock, a stock option, or 

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1 dend, profit, or other return on invest2 ment; or 

3 ‘‘(IV) any other form (as defined 

4 by the Secretary). 

5 ‘‘(C) With respect to a drug sample, the 

6 name, number, date, and dosage units of the 

7 sample. 

8 ‘‘(2) AGGREGATE REPORTING.—Information 

9 submitted by an applicable manufacturer or dis10 tributor under paragraph (1) shall include the ag11 gregate amount of all payments or other transfers of 

12 value provided by the manufacturer or distributor to 

13 covered recipients (and to entities or individuals at 

14 the request of or designated on behalf of a covered 

15 recipient) during the year involved, including all pay16 ments and transfers of value regardless of whether 

17 such payments or transfer of value were individually 

18 disclosed. 

19 ‘‘(3) SPECIAL RULE FOR CERTAIN PAYMENTS

20 OR OTHER TRANSFERS OF VALUE.—In the case 

21 where an applicable manufacturer or distributor pro22 vides a payment or other transfer of value to an en23 tity or individual at the request of or designated on 

24 behalf of a covered recipient, the manufacturer or 

25 distributor shall disclose that payment or other 


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1 transfer of value under the name of the covered re2 cipient. 

3 ‘‘(4) DELAYED REPORTING FOR PAYMENTS

4 MADE PURSUANT TO PRODUCT DEVELOPMENT

5 AGREEMENTS.—In the case of a payment or other 

6 transfer of value made to a covered recipient by an 

7 applicable manufacturer or distributor pursuant to a 

8 product development agreement for services fur9 nished in connection with the development of a new 

10 drug, device, biological, or medical supply, the appli11 cable manufacturer or distributor may report the 

12 value and recipient of such payment or other trans13 fer of value in the first reporting period under this 

14 subsection in the next reporting deadline after the 

15 earlier of the following: 

16 ‘‘(A) The date of the approval or clearance 

17 of the covered drug, device, biological, or med18 ical supply by the Food and Drug Administra19 tion. 

20 ‘‘(B) Two calendar years after the date 

21 such payment or other transfer of value was 

22 made. 

23 ‘‘(5) DELAYED REPORTING FOR PAYMENTS

24 MADE PURSUANT TO CLINICAL INVESTIGATIONS.—In 

25 the case of a payment or other transfer of value 


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1 made to a covered recipient by an applicable manu2 facturer or distributor in connection with a clinical 

3 investigation regarding a new drug, device, biologi4 cal, or medical supply, the applicable manufacturer 

5 or distributor may report as required under this sec6 tion in the next reporting period under this sub7 section after the earlier of the following: 

8 ‘‘(A) The date that the clinical investiga9 tion is registered on the website maintained by 

10 the National Institutes of Health pursuant to 

11 section 671 of the Food and Drug Administra12 tion Amendments Act of 2007. 

13 ‘‘(B) Two calendar years after the date 

14 such payment or other transfer of value was 

15 made. 

16 ‘‘(6) CONFIDENTIALITY.—Information de17 scribed in paragraph (4) or (5) shall be considered 

18 confidential and shall not be subject to disclosure 

19 under section 552 of title 5, United States Code, or 

20 any other similar Federal, State, or local law, until 

21 or after the date on which the information is made 

22 available to the public under such paragraph. 

23 ‘‘(7) PHYSICIANS IN SELF-INSURED HEALTH

24 PLANS.—Nothing in this subsection shall be con25 strued to require the disclosure of a payment or 


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1 other transfer of value to a physician by a self-in2 sured health plan. 

3 ‘‘(b) REPORTING OF OWNERSHIP INTEREST BY PHY4 SICIANS.— 

5 ‘‘(1) HOSPITALS AND OTHER ENTITIES THAT

6 BILL MEDICARE.—Not later than March 31 of each 

7 year (beginning with 2011), each hospital or other 

8 health care entity (not including a Medicare Advan9 tage organization) that bills the Secretary under 

10 part A or part B of title XVIII for services shall re11 port on the ownership shares (other than ownership 

12 shares described in section 1877(c)) of each physi13 cian who, directly or indirectly, owns an interest in 

14 the entity. 

15 ‘‘(2) ADDITIONAL PHYSICIAN OWNERSHIP.— 

16 Not later than March 31 of each year (beginning 

17 with 2011), in addition to the requirement under 

18 subsection (a)(1), any applicable manufacturer, ap19 plicable group purchasing organization, or applicable 

20 distributor shall submit to the Secretary, in such 

21 electronic form as the Secretary shall require, the 

22 following information regarding any ownership or in23 vestment interest (other than an ownership or in24 vestment interest in a publicly traded security and 

25 mutual fund, as described in section 1877(c)) held 


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1 by a physician (or an immediate family member of 

2 such physician (as defined for purposes of section 

3 1877(a))) in the applicable manufacturer, applicable 

4 group purchasing organization or applicable dis5 tributor during the preceding year: 

6 ‘‘(A) The dollar amount invested by each 

7 physician holding such an ownership or invest8 ment interest. 

9 ‘‘(B) The value and terms of each such 

10 ownership or investment interest. 

11 ‘‘(C) Any payment or other transfer of 

12 value provided to a physician holding such an 

13 ownership or investment interest (or to an enti14 ty or individual at the request of or designated 

15 on behalf of a physician holding such an owner16 ship or investment interest), including the infor17 mation described in clauses (i) through (iii) of 

18 paragraph (a)(1)(B), and information described 

19 in subsection (f)(8)(A) and (f)(8)(B). 

20 ‘‘(D) Any other information regarding the 

21 ownership or investment interest the Secretary 

22 determines appropriate. 

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


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1 ‘‘(A) PHYSICIAN.—The term ‘physician’ in2 cludes a physician’s immediate family members 

3 (as defined for purposes of section 1877(a)). 

4 ‘‘(B) APPLICABLE GROUP PURCHASING OR5 GANIZATION.—The term ‘applicable group pur6 chasing organization’ means any organization 

7 or other entity (as defined by the Secretary) 

8 that purchases, arranges for, or negotiates the 

9 purchase of a covered drug, device, biological, 

10 or medical supply. 

11 ‘‘(4) STUDY OF PRACTICE PATTERNS IN AD12 VANCED DIAGNOSTIC IMAGING AND RADIATION ON13 COLOGY SERVICES.—The Comptroller General of the 

14 United States shall conduct a study to evaluate the 

15 extent of use of physician self-referral arrangements 

16 and the effects of such arrangements on the cost of 

17 providing advanced diagnostic imaging and radiation 

18 oncology services to Medicare beneficiaries under 

19 title XVIII. The study shall be completed and sub20 mitted to Congress not later than July 1, 2011. 

21 ‘‘(c) PUBLIC AVAILABILITY.— 

22 ‘‘(1) IN GENERAL.—The Secretary shall estab23 lish procedures to ensure that, not later than Sep24 tember 30, 2011, and on June 30 of each year be25 ginning thereafter, the information submitted under 


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1 subsections (a) and (b), other than information re2 gard drug samples, with respect to the preceding 

3 calendar year is made available through an Internet 

4 website that— 

5 ‘‘(A) is searchable and is in a format that 

6 is clear and understandable; 

7 ‘‘(B) contains information that is pre8 sented by the name of the applicable manufac9 turer or distributor, the name of the covered re10 cipient, the business address of the covered re11 cipient, the specialty (if applicable) of the cov12 ered recipient, the value of the payment or 

13 other transfer of value, the date on which the 

14 payment or other transfer of value was provided 

15 to the covered recipient, the form of the pay16 ment or other transfer of value, indicated (as 

17 appropriate) under subsection (a)(1)(B)(ii), the 

18 nature of the payment or other transfer of 

19 value, indicated (as appropriate) under sub20 section (a)(1)(B)(iii), and the name of the cov21 ered drug, device, biological, or medical supply, 

22 as applicable; 

23 ‘‘(C) contains information that is able to 

24 be easily aggregated and downloaded; 


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1 ‘‘(D) contains a description of any enforce2 ment actions taken to carry out this section, in3 cluding any penalties imposed under subsection 

4 (d), during the preceding year; 

5 ‘‘(E) contains background information on 

6 industry-physician relationships; 

7 ‘‘(F) in the case of information submitted 

8 with respect to a payment or other transfer of 

9 value described in subsection (a)(5), lists such 

10 information separately from the other informa11 tion submitted under subsection (a) and des12 ignates such separately listed information as 

13 funding for clinical research; 

14 ‘‘(G) contains any other information the 

15 Secretary determines would be helpful to the 

16 average consumer; and 

17 ‘‘(H) provides the covered recipient an op18 portunity to submit corrections to the informa19 tion made available to the public with respect to 

20 the covered recipient. 

21 ‘‘(2) ACCURACY OF REPORTING.—The accuracy 

22 of the information that is submitted under sub23 sections (a) and (b) and made available under para24 graph (1) shall be the responsibility of the reporting 

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1 plicable. The Secretary shall establish procedures to 

2 ensure that the covered recipient is provided with an 

3 opportunity to submit corrections to the applicable 

4 reporting entity with regard to information made 

5 public with respect to the covered recipient and, 

6 under such procedures, the corrections shall be 

7 transmitted to the Secretary. 

8 ‘‘(3) SPECIAL RULE FOR DRUG SAMPLES.—In9 formation relating to drug samples provided under 

10 subsection (a) shall not be made available to the 

11 public by the Secretary but may be made available 

12 outside the Department of Health and Human Serv13 ices by the Secretary for research or legitimate busi14 ness purposes pursuant to data use agreements. 

15 ‘‘(4) SPECIAL RULE FOR NATIONAL PROVIDER

16 IDENTIFIERS.—Information relating to national pro17 vider identifiers provided under subsection (a) shall 

18 not be made available to the public by the Secretary 

19 but may be made available outside the Department 

20 of Health and Human Services by the Secretary for 

21 research or legitimate business purposes pursuant to 

22 data use agreements. 

23 ‘‘(d) PENALTIES FOR NONCOMPLIANCE.— 

24 ‘‘(1) FAILURE TO REPORT.— 


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1 ‘‘(A) IN GENERAL.—Subject to subpara2 graph (B), except as provided in paragraph (2), 

3 any reporting entity that fails to submit infor4 mation required under subsection (a) or (b), as 

5 applicable, in a timely manner in accordance 

6 with regulations promulgated to carry out such 

7 applicable subsection shall be subject to a civil 

8 money penalty of not less than $1,000, but not 

9 more than $10,000, for each payment or other 

10 transfer of value or ownership or investment in11 terest not reported as required under such sub12 section. Such penalty shall be imposed and col13 lected in the same manner as civil money pen14 alties under subsection (a) of section 1128A are 

15 imposed and collected under that section. 

16 ‘‘(B) LIMITATION.—The total amount of 

17 civil money penalties imposed under subpara18 graph (A), with respect to each annual submis19 sion of information under subsection (a) by a 

20 reporting entity, shall not exceed $150,000. 

21 ‘‘(2) KNOWING FAILURE TO REPORT.— 

22 ‘‘(A) IN GENERAL.—Subject to subpara23 graph (B), any reporting entity that knowingly 

24 fails to submit information required under sub25 section (a) or (b), as applicable, in a timely 


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1 manner in accordance with regulations promul2 gated to carry out such applicable subsection, 

3 shall be subject to a civil money penalty of not 

4 less than $10,000, but not more than 

5 $100,000, for each payment or other transfer of 

6 value or ownership or investment interest not 

7 reported as required under such subsection. 

8 Such penalty shall be imposed and collected in 

9 the same manner as civil money penalties under 

10 subsection (a) of section 1128A are imposed 

11 and collected under that section. 

12 ‘‘(B) LIMITATION.—The total amount of 

13 civil money penalties imposed under subpara14 graph (A) with respect to each annual submis15 sion of information under subsection (a) or (b) 

16 by an applicable reporting entity shall not ex17 ceed $1,000,000, or, if greater, 0.1 percentage 

18 of the total annual revenues of the reporting en19 tity. 

20 ‘‘(3) USE OF FUNDS.—Funds collected by the 

21 Secretary as a result of the imposition of a civil 

22 money penalty under this subsection shall be used to 

23 carry out this section. 

24 ‘‘(4) ENFORCEMENT THROUGH STATE ATTOR25 NEYS GENERAL.—The attorney general of a State, 


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1 after providing notice to the Secretary of an intent 

2 to proceed under this paragraph in a specific case 

3 and providing the Secretary with an opportunity to 

4 bring an action under this subsection and the Sec5 retary declining such opportunity, may proceed 

6 under this subsection against an applicable manufac7 turer or distributor in the State. 

8 ‘‘(e) ANNUAL REPORT TO CONGRESS.—Not later 

9 than April 1 of each year beginning with 2011, the Sec10 retary shall submit to Congress a report that includes the 

11 following: 

12 ‘‘(1) The information submitted under this sec13 tion during the preceding year, aggregated for each 

14 applicable reporting entity that submitted such in15 formation during such year. 

16 ‘‘(2) A description of any enforcement actions 

17 taken to carry out this section, including any pen18 alties imposed under subsection (d), during the pre19 ceding year. 

20 ‘‘(f) DEFINITIONS.—In this section: 

21 ‘‘(1) APPLICABLE DISTRIBUTOR.—The term 

22 ‘applicable distributor’ means— 

23 ‘‘(A) any entity, other than an applicable 

24 group purchasing organization, that buys and 

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1 lar form of payment, from another seller, for 

2 selling or arranging for the sale of a covered 

3 drug, device, biological, or medical supply; or 

4 ‘‘(B) any entity under common ownership 

5 with such an entity described in subparagraph 

6 (A) and which provides assistance or support to 

7 such entity so described with respect to the pro8 duction, preparation, propagation, 

9 compounding, conversion, processing, mar10 keting, or distribution of a covered drug, device, 

11 biological, or medical supply. 

12 Such term does not include a wholesale pharma13 ceutical distributor. 

14 ‘‘(2) APPLICABLE MANUFACTURER.—The term 

15 ‘applicable manufacturer’ means any entity which is 

16 engaged in the production, preparation, propagation, 

17 compounding, conversion, processing, marketing, or 

18 manufacturer-direct distribution of a covered drug, 

19 device, biological, or medical supply (or any entity 

20 under common ownership with such entity and which 

21 provides assistance or support to such entity with re22 spect to the production, preparation, propagation, 

23 compounding, conversion, processing, marketing, or 

24 distribution or a covered drug, device, biological, or 

25 medical supply). For purposes of this section only, 


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1 such term does not include a retail pharmacy li2 censed under State law. 

3 ‘‘(3) CLINICAL INVESTIGATION.—The term 

4 ‘clinical investigation’ means any experiment involv5 ing one or more human subjects, or materials de6 rived from human subjects, in which a drug or de7 vice is administered, dispensed, or used. 

8 ‘‘(4) COVERED DRUG, DEVICE, BIOLOGICAL, OR

9 MEDICAL SUPPLY.—The term ‘covered’ means, with 

10 respect to a drug, device, biological, or medical sup11 ply, such a drug, device, biological, or medical supply 

12 for which payment is available under title XVIII or 

13 a State plan under title XIX or XXI (or a waiver 

14 of such a plan). 

15 ‘‘(5) COVERED RECIPIENT.—The term ‘covered 

16 recipient’ means the following: 

17 ‘‘(A) A physician. 

18 ‘‘(B) A physician group practice. 

19 ‘‘(C) Any other prescriber of a covered 

20 drug, device, biological, or medical supply. 

21 ‘‘(D) A pharmacy or pharmacist. 

22 ‘‘(E) A health insurance issuer, group 

23 health plan, or other entity offering a health 

24 benefits plan, including any employee of such 

25 an issuer, plan, or entity. 


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1 ‘‘(F) A pharmacy benefit manager, includ2 ing any employee of such a manager. 

3 ‘‘(G) A hospital. 

4 ‘‘(H) A medical school. 

5 ‘‘(I) A sponsor of a continuing medical 

6 education program. 

7 ‘‘(J) A patient advocacy or disease specific 

8 group. 

9 ‘‘(K) A organization of health care profes10 sionals. 

11 ‘‘(L) A biomedical researcher. 

12 ‘‘(M) A group purchasing organization. 

13 ‘‘(6) EMPLOYEE.—The term ‘employee’ has the 

14 meaning given such term in section 1877(h)(2). 

15 ‘‘(7) KNOWINGLY.—The term ‘knowingly’ has 

16 the meaning given such term in section 3729(b) of 

17 title 31, United States Code. 

18 ‘‘(8) PAYMENT OR OTHER TRANSFER OF

19 VALUE.— 

20 ‘‘(A) IN GENERAL.—The term ‘payment or 

21 other transfer of value’ means a transfer of 

22 anything of value for or of any of the following: 

23 ‘‘(i) Gift, food, or entertainment. 

24 ‘‘(ii) Travel or trip. 

25 ‘‘(iii) Honoraria. 


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1 ‘‘(iv) Research funding or grant. 

2 ‘‘(v) Education or conference funding. 

3 ‘‘(vi) Consulting fees. 

4 ‘‘(vii) Ownership or investment inter5 est and royalties or license fee. 

6 ‘‘(B) INCLUSIONS.—Subject to subpara7 graph (C), the term ‘payment or other transfer 

8 of value’ includes any compensation, gift, hono9 rarium, speaking fee, consulting fee, travel, 

10 services, dividend, profit distribution, stock or 

11 stock option grant, or any ownership or invest12 ment interest held by a physician in a manufac13 turer (excluding a dividend or other profit dis14 tribution from, or ownership or investment in15 terest in, a publicly traded security or mutual 

16 fund (as described in section 1877(c))). 

17 ‘‘(C) EXCLUSIONS.—The term ‘payment or 

18 other transfer of value’ does not include the fol19 lowing: 

20 ‘‘(i) Any payment or other transfer of 

21 value provided by an applicable manufac22 turer or distributor to a covered recipient 

23 where the amount transferred to, requested 

24 by, or designated on behalf of the covered 

25 recipient does not exceed $5. 


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1 ‘‘(ii) The loan of a covered device for 

2 a short-term trial period, not to exceed 90 

3 days, to permit evaluation of the covered 

4 device by the covered recipient. 

5 ‘‘(iii) Items or services provided under 

6 a contractual warranty, including the re7 placement of a covered device, where the 

8 terms of the warranty are set forth in the 

9 purchase or lease agreement for the cov10 ered device. 

11 ‘‘(iv) A transfer of anything of value 

12 to a covered recipient when the covered re13 cipient is a patient and not acting in the 

14 professional capacity of a covered recipient. 

15 ‘‘(v) In-kind items used for the provi16 sion of charity care. 

17 ‘‘(vi) A dividend or other profit dis18 tribution from, or ownership or investment 

19 interest in, a publicly traded security and 

20 mutual fund (as described in section 

21 1877(c)). 

22 ‘‘(vii) Compensation paid by an appli23 cable manufacturer or distributor to a cov24 ered recipient who is directly employed by 


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1 and works solely for such manufacturer or 

2 distributor. 

3 ‘‘(viii) Payments made to a covered 

4 recipient by an applicable manufacturer or 

5 by a health plan affiliated with an applica6 ble manufacturer for medical care provided 

7 to employees of such manufacturer or their 

8 dependents. 

9 ‘‘(ix) Any discount (including a re10 bate). 

11 ‘‘(x) Any payment or other transfer of 

12 value that is made to a covered recipient 

13 indirectly through an entity other than the 

14 applicable manufacturer in connection with 

15 an activity or service— 

16 ‘‘(I) in which the applicable man17 ufacturer is unaware of the identity of 

18 the covered recipient and is not using 

19 such activity or service to market its 

20 product to the covered recipient; and 

21 ‘‘(II) that is not designed to mar22 ket or promote the product to the cov23 ered recipient. 

24 ‘‘(xi) In the case of an applicable 

25 manufacturer who offers a self-insured 


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1 plan, payments for the provision of health 

2 care to employees under the plan. 

3 ‘‘(9) PHYSICIAN.—The term ‘physician’ has the 

4 meaning given that term in section 1861(r). For 

5 purposes of this section, such term does not include 

6 a physician who is an employee of the applicable 

7 manufacturer that is required to submit information 

8 under subsection (a). 

9 ‘‘(10) REPORTING ENTITY.—The term ‘report10 ing entity’ means— 

11 ‘‘(A) with respect to the reporting require12 ment under subsection (a), an applicable manu13 facturer or distributor of a covered drug, device, 

14 biological, or medical supply required to report 

15 under such subsection; and 

16 ‘‘(B) with respect to the reporting require17 ment under subsection (b), a hospital, other 

18 health care entity, applicable manufacturer, ap19 plicable distributor, or applicable group pur20 chasing organization required to report physi21 cian ownership under such subsection. 

22 ‘‘(g) ANNUAL REPORTS TO STATES.—Not later than 

23 April 1 of each year beginning with 2011, the Secretary 

24 shall submit to States a report that includes a summary 

25 of the information submitted under subsections (a), (b), 


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1 and (e) during the preceding year with respect to covered 

2 recipients or other hospitals and entities in the State. 

3 ‘‘(h) RELATION TO STATE LAWS.— 

4 ‘‘(1) IN GENERAL.—Effective on January 1, 

5 2011, subject to paragraph (2), the provisions of 

6 this section shall preempt any law or regulation of 

7 a State or of a political subdivision of a State that 

8 requires an applicable manufacturer and applicable 

9 distributor (as such terms are defined in subsection 

10 (f)) to disclose or report, in any format, the type of 

11 information (described in subsection (a)) regarding a 

12 payment or other transfer of value provided by the 

13 manufacturer to a covered recipient (as so defined). 

14 ‘‘(2) NO PREEMPTION OF ADDITIONAL RE15 QUIREMENTS.—Paragraph (1) shall not preempt any 

16 statute or regulation of a State or political subdivi17 sion of a State that requires any of the following: 

18 ‘‘(A) The disclosure or reporting of infor19 mation not of the type required to be disclosed 

20 or reported under this section. 

21 ‘‘(B) The disclosure or reporting, in any 

22 format, of information described in subsection 

23 (f)(8)(C), except in the case of information de24 scribed in clause (i) of subsection (f)(8)(C). 


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1 ‘‘(C) The disclosure or reporting, in any 

2 format, of the type of information by any per3 son or entity other than an applicable manufac4 turer (as so defined) or a covered recipient (as 

5 defined in subsection (f)). 

6 ‘‘(D) The disclosure or reporting, in any 

7 format, of the type of information required to 

8 be disclosed or reported under this section to a 

9 Federal, State, or local governmental agency for 

10 public health surveillance, investigation, or 

11 other public health purposes or health oversight 

12 purposes. 

13 Nothing in paragraph (1) shall be construed to limit 

14 the discovery or admissibility of information de15 scribed in this paragraph in a criminal, civil, or ad16 ministrative proceeding.’’. 

17 (b) AVAILABILITY OF INFORMATION FROM THE DIS18 CLOSURE OF FINANCIAL RELATIONSHIP REPORT

19 (DFRR).—The Secretary of Health and Human Services 

20 shall submit to Congress a report on the full results of 

21 the Disclosure of Physician Financial Relationships sur22 veys required pursuant to section 5006 of the Deficit Re23 duction Act of 2005. Such report shall be submitted to 

24 Congress not later than the date that is 6 months after 

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1 licly available on an Internet website of the Department 

2 of Health and Human Services. 

3 (c) GAO REPORT.—Not later than December 31, 

4 2012, the Comptroller General of the United States shall 

5 submit to Congress a report on section 1128H of the So6 cial Security Act, as added by subsection (a). Such report 

7 shall address the extent to which important transfers of 

8 value are being adequately reported under such section 

9 (including unreported transfers required by such section 

10 as well as transfers not required to be reported by such 

11 section), the impact on States of the federal preemption 

12 provision under subsection (h) of such section, whether 

13 changes have occurred in the pattern of payments as a 

14 result of efforts to evade reporting requirements, a de15 scription of the financial relationships subject to delayed 

16 reporting under subsection (a) of such section, and any 

17 recommended improvements to the collection or the anal18 ysis of data reported under such section. 


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1 Subtitle E—Public Reporting on 

2 Health Care-Associated Infections 

3 SEC. 1461. REQUIREMENT FOR PUBLIC REPORTING BY 

4 HOSPITALS AND AMBULATORY SURGICAL 

5 CENTERS ON HEALTH CARE-ASSOCIATED IN6 FECTIONS. 

7 (a) IN GENERAL.—Title XI of the Social Security Act 

8 is amended by inserting after section 1138 the following 

9 section: 

10 ‘‘SEC. 1138A. REQUIREMENT FOR PUBLIC REPORTING BY 

11 HOSPITALS AND AMBULATORY SURGICAL 

12 CENTERS ON HEALTH CARE-ASSOCIATED IN13 FECTIONS. 

14 ‘‘(a) REPORTING REQUIREMENT.— 

15 ‘‘(1) IN GENERAL.—The Secretary shall provide 

16 that a hospital (as defined in subsection (g)) or am17 bulatory surgical center meeting the requirements of 

18 titles XVIII or XIX may participate in the programs 

19 established under such titles only if, in accordance 

20 with this section, the hospital or center reports such 

21 information on health care-associated infections that 

22 develop in the hospital or center (and such demo23 graphic information associated with such infections) 

24 as the Secretary specifies. 


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1 ‘‘(2) REPORTING PROTOCOLS.— Such informa2 tion shall be reported in accordance with reporting 

3 protocols established by the Secretary through the 

4 Director of the Centers for Disease Control and Pre5 vention (in this section referred to as the ‘CDC’) 

6 and to the National Healthcare Safety Network of 

7 the CDC or under such another reporting system of 

8 such Centers as determined appropriate by the Sec9 retary in consultation with such Director. 

10 ‘‘(3) COORDINATION WITH HIT.—The Sec11 retary, through the Director of the CDC and the Of12 fice of the National Coordinator for Health Informa13 tion Technology, shall ensure that the transmission 

14 of information under this subsection is coordinated 

15 with systems established under the HITECH Act, 

16 where appropriate. 

17 ‘‘(4) PROCEDURES TO ENSURE THE VALIDITY

18 OF INFORMATION.—The Secretary shall establish 

19 procedures regarding the validity of the information 

20 submitted under this subsection in order to ensure 

21 that such information is appropriately compared 

22 across hospitals and centers. Such procedures shall 

23 address failures to report as well as errors in report24 ing. 


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1 ‘‘(5) IMPLEMENTATION.—Not later than 1 year 

2 after the date of enactment of this section, the Sec3 retary, through the Director of CDC, shall promul4 gate regulations to carry out this section. 

5 ‘‘(b) PUBLIC POSTING OF INFORMATION.—The Sec6 retary shall promptly post, on the official public Internet 

7 site of the Department of Health and Human Services, 

8 the information reported under subsection (a). Such infor9 mation shall be set forth in a manner that allows for the 

10 comparison of information on health care-associated infec11 tions— 

12 ‘‘(1) among hospitals and ambulatory surgical 

13 centers; and 

14 ‘‘(2) by demographic information. 

15 ‘‘(c) ANNUAL REPORT TO CONGRESS.—On an annual 

16 basis the Secretary shall submit to the Congress a report 

17 that summarizes each of the following: 

18 ‘‘(1) The number and types of health care-asso19 ciated infections reported under subsection (a) in 

20 hospitals and ambulatory surgical centers during 

21 such year. 

22 ‘‘(2) Factors that contribute to the occurrence 

23 of such infections, including health care worker im24 munization rates. 


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1 ‘‘(3) Based on the most recent information 

2 available to the Secretary on the composition of the 

3 professional staff of hospitals and ambulatory sur4 gical centers, the number of certified infection con5 trol professionals on the staff of hospitals and ambu6 latory surgical centers. 

7 ‘‘(4) The total increases or decreases in health 

8 care costs that resulted from increases or decreases 

9 in the rates of occurrence of each such type of infec10 tion during such year. 

11 ‘‘(5) Recommendations, in coordination with the 

12 Center for Quality Improvement established under 

13 section 931 of the Public Health Service Act, for 

14 best practices to eliminate the rates of occurrence of 

15 each such type of infection in hospitals and ambula16 tory surgical centers. 

17 ‘‘(d) NON-PREEMPTION OF STATE LAWS.—Nothing 

18 in this section shall be construed as preempting or other19 wise affecting any provision of State law relating to the 

20 disclosure of information on health care-associated infec21 tions or patient safety procedures for a hospital or ambu22 latory surgical center. 

23 ‘‘(e) HEALTH CARE-ASSOCIATED INFECTION.—For 

24 purposes of this section: 


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1 ‘‘(1) IN GENERAL.—The term ‘health care-asso2 ciated infection’ means an infection that develops in 

3 a patient who has received care in any institutional 

4 setting where health care is delivered and is related 

5 to receiving health care. 

6 ‘‘(2) RELATED TO RECEIVING HEALTH CARE.— 

7 The term ‘related to receiving health care’, with re8 spect to an infection, means that the infection was 

9 not incubating or present at the time health care 

10 was provided. 

11 ‘‘(f) APPLICATION TO CRITICAL ACCESS HOS12 PITALS.—For purposes of this section, the term ‘hospital’ 

13 includes a critical access hospital, as defined in section 

14 1861(mm)(1).’’. 

15 (b) EFFECTIVE DATE.—With respect to section 

16 1138A of the Social Security Act (as inserted by sub17 section (a) of this section), the requirement under such 

18 section that hospitals and ambulatory surgical centers 

19 submit reports takes effect on such date (not later than 

20 2 years after the date of the enactment of this Act) as 

21 the Secretary of Health and Human Services shall specify. 

22 In order to meet such deadline, the Secretary may imple23 ment such section through guidance or other instructions. 

24 (c) GAO REPORT.—Not later than 18 months after 

25 the date of the enactment of this Act, the Comptroller 


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1 General of the United States shall submit to Congress a 

2 report on the program established under section 1138A 

3 of the Social Security Act, as inserted by subsection (a). 

4 Such report shall include an analysis of the appropriate5 ness of the types of information required for submission, 

6 compliance with reporting requirements, the success of the 

7 validity procedures established, and any conflict or overlap 

8 between the reporting required under such section and any 

9 other reporting systems mandated by either the States or 

10 the Federal Government. 

11 (d) REPORT ON ADDITIONAL DATA.—Not later than 

12 18 months after the date of the enactment of this Act, 

13 the Secretary of Health and Human Services shall submit 

14 to the Congress a report on the appropriateness of expand15 ing the requirements under such section to include addi16 tional information (such as health care worker immuniza17 tion rates), in order to improve health care quality and 

18 patient safety. 

19 TITLE V—MEDICARE GRADUATE 

20 MEDICAL EDUCATION 

21 SEC. 1501. DISTRIBUTION OF UNUSED RESIDENCY POSI22 TIONS. 

23 (a) IN GENERAL.—Section 1886(h) of the Social Se24 curity Act (42 U.S.C. 1395ww(h)) is amended— 


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1 (1) in paragraph (4)(F)(i), by striking ‘‘para2 graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 

3 (2) in paragraph (4)(H)(i), by striking ‘‘para4 graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 

5 (3) in paragraph (7)(E), by inserting ‘‘and 

6 paragraph (8)’’ after ‘‘this paragraph’’; and 

7 (4) by adding at the end the following new 

8 paragraph: 

9 ‘‘(8) ADDITIONAL REDISTRIBUTION OF UNUSED

10 RESIDENCY POSITIONS.— 

11 ‘‘(A) REDUCTIONS IN LIMIT BASED ON UN12 USED POSITIONS.— 

13 ‘‘(i) PROGRAMS SUBJECT TO REDUC14 TION.—If a hospital’s reference resident 

15 level (specified in clause (ii)) is less than 

16 the otherwise applicable resident limit (as 

17 defined in subparagraph (C)(ii)), effective 

18 for portions of cost reporting periods oc19 curring on or after July 1, 2011, the oth20 erwise applicable resident limit shall be re21 duced by 90 percent of the difference be22 tween such otherwise applicable resident 

23 limit and such reference resident level. 

24 ‘‘(ii) REFERENCE RESIDENT LEVEL.— 


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1 ‘‘(I) IN GENERAL.—Except as 

2 otherwise provided in a subsequent 

3 subclause, the reference resident level 

4 specified in this clause for a hospital 

5 is the highest resident level for any of 

6 the 3 most recent cost reporting peri7 ods (ending before the date of the en8 actment of this paragraph) of the hos9 pital for which a cost report has been 

10 settled (or, if not, submitted (subject 

11 to audit)), as determined by the Sec12 retary. 

13 ‘‘(II) USE OF MOST RECENT AC14 COUNTING PERIOD TO RECOGNIZE EX15 PANSION OF EXISTING PROGRAMS.—If 

16 a hospital submits a timely request to 

17 increase its resident level due to an 

18 expansion, or planned expansion, of 

19 an existing residency training pro20 gram that is not reflected on the most 

21 recent settled or submitted cost re22 port, after audit and subject to the 

23 discretion of the Secretary, subject to 

24 subclause (IV), the reference resident 

25 level for such hospital is the resident 


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1 level that includes the additional resi2 dents attributable to such expansion 

3 or establishment, as determined by 

4 the Secretary. The Secretary is au5 thorized to determine an alternative 

6 reference resident level for a hospital 

7 that submitted to the Secretary a 

8 timely request, before the start of the 

9 2009–2010 academic year, for an in10 crease in its reference resident level 

11 due to a planned expansion. 

12 ‘‘(III) SPECIAL PROVIDER

13 AGREEMENT.—In the case of a hos14 pital described in paragraph 

15 (4)(H)(v), the reference resident level 

16 specified in this clause is the limita17 tion applicable under subclause (I) of 

18 such paragraph. 

19 ‘‘(IV) PREVIOUS REDISTRIBU20 TION.—The reference resident level 

21 specified in this clause for a hospital 

22 shall be increased to the extent re23 quired to take into account an in24 crease in resident positions made 

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1 graph (7)(B) that are not otherwise 

2 taken into account under a previous 

3 subclause. 

4 ‘‘(iii) AFFILIATION.—The provisions 

5 of clause (i) shall be applied to hospitals 

6 which are members of the same affiliated 

7 group (as defined by the Secretary under 

8 paragraph (4)(H)(ii)) and to the extent the 

9 hospitals can demonstrate that they are 

10 filling any additional resident slots allo11 cated to other hospitals through an affili12 ation agreement, the Secretary shall adjust 

13 the determination of available slots accord14 ingly, or which the Secretary otherwise has 

15 permitted the resident positions (under 

16 section 402 of the Social Security Amend17 ments of 1967) to be aggregated for pur18 poses of applying the resident position lim19 itations under this subsection. 

20 ‘‘(B) REDISTRIBUTION.— 

21 ‘‘(i) IN GENERAL.—The Secretary 

22 shall increase the otherwise applicable resi23 dent limit for each qualifying hospital that 

24 submits an application under this subpara25 graph by such number as the Secretary 


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1 may approve for portions of cost reporting 

2 periods occurring on or after July 1, 2011. 

3 The estimated aggregate number of in4 creases in the otherwise applicable resident 

5 limit under this subparagraph may not ex6 ceed the Secretary’s estimate of the aggre7 gate reduction in such limits attributable 

8 to subparagraph (A). 

9 ‘‘(ii) REQUIREMENTS FOR QUALI10 FYING HOSPITALS.—A hospital is not a 

11 qualifying hospital for purposes of this 

12 paragraph unless the following require13 ments are met: 

14 ‘‘(I) MAINTENANCE OF PRIMARY

15 CARE RESIDENT LEVEL.—The hos16 pital maintains the number of primary 

17 care residents at a level that is not 

18 less than the base level of primary 

19 care residents increased by the num20 ber of additional primary care resi21 dent positions provided to the hospital 

22 under this subparagraph. For pur23 poses of this subparagraph, the ‘base 

24 level of primary care residents’ for a 

25 hospital is the level of such residents 


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1 as of a base period (specified by the 

2 Secretary), determined without regard 

3 to whether such positions were in ex4 cess of the otherwise applicable resi5 dent limit for such period but taking 

6 into account the application of sub7 clauses (II) and (III) of subparagraph 

8 (A)(ii). 

9 ‘‘(II) DEDICATED ASSIGNMENT

10 OF ADDITIONAL RESIDENT POSITIONS

11 TO PRIMARY CARE.—The hospital as12 signs all such additional resident posi13 tions for primary care residents. 

14 ‘‘(III) ACCREDITATION.—The 

15 hospital’s residency programs in pri16 mary care are fully accredited or, in 

17 the case of a residency training pro18 gram not in operation as of the base 

19 year, the hospital is actively applying 

20 for such accreditation for the program 

21 for such additional resident positions 

22 (as determined by the Secretary). 

23 ‘‘(iii) CONSIDERATIONS IN REDIS24 TRIBUTION.—In determining for which 

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1 erwise applicable resident limit is provided 

2 under this subparagraph, the Secretary 

3 shall take into account the demonstrated 

4 likelihood of the hospital filling the posi5 tions within the first 3 cost reporting peri6 ods beginning on or after July 1, 2011, 

7 made available under this subparagraph, 

8 as determined by the Secretary. 

9 ‘‘(iv) PRIORITY FOR CERTAIN HOS10 PITALS.—In determining for which quali11 fying hospitals the increase in the other12 wise applicable resident limit is provided 

13 under this subparagraph, the Secretary 

14 shall distribute the increase to qualifying 

15 hospitals based on the following criteria: 

16 ‘‘(I) The Secretary shall give 

17 preference to hospitals that had a re18 duction in resident training positions 

19 under subparagraph (A). 

20 ‘‘(II) The Secretary shall give 

21 preference to hospitals with 3-year 

22 primary care residency training pro23 grams, such as family practice and 

24 general internal medicine. 


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1 ‘‘(III) The Secretary shall give 

2 preference to hospitals insofar as they 

3 have in effect formal arrangements 

4 (as determined by the Secretary) that 

5 place greater emphasis upon training 

6 in Federally qualified health centers, 

7 rural health clinics, and other nonpro8 vider settings, and to hospitals that 

9 receive additional payments under 

10 subsection (d)(5)(F) and emphasize 

11 training in an outpatient department. 

12 ‘‘(IV) The Secretary shall give 

13 preference to hospitals with a number 

14 of positions (as of July 1, 2009) in 

15 excess of the otherwise applicable resi16 dent limit for such period. 

17 ‘‘(V) The Secretary shall give 

18 preference to hospitals that place 

19 greater emphasis upon training in a 

20 health professional shortage area (des21 ignated under section 332 of the Pub22 lic Health Service Act) or a health 

23 professional needs area (designated 

24 under section 2211 of such Act). 


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1 ‘‘(VI) The Secretary shall give 

2 preference to hospitals in States that 

3 have low resident-to-population ratios 

4 (including a greater preference for 

5 those States with lower resident-to6 population ratios). 

7 ‘‘(v) LIMITATION.—In no case shall 

8 more than 20 full-time equivalent addi9 tional residency positions be made available 

10 under this subparagraph with respect to 

11 any hospital. 

12 ‘‘(vi) APPLICATION OF PER RESIDENT

13 AMOUNTS FOR PRIMARY CARE.—With re14 spect to additional residency positions in a 

15 hospital attributable to the increase pro16 vided under this subparagraph, the ap17 proved FTE resident amounts are deemed 

18 to be equal to the hospital per resident 

19 amounts for primary care and nonprimary 

20 care computed under paragraph (2)(D) for 

21 that hospital. 

22 ‘‘(vii) DISTRIBUTION.—The Secretary 

23 shall distribute the increase in resident 

24 training positions to qualifying hospitals 


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1 under this subparagraph not later than 

2 July 1, 2011. 

3 ‘‘(C) RESIDENT LEVEL AND LIMIT DE4 FINED.—In this paragraph: 

5 ‘‘(i) The term ‘resident level’ has the 

6 meaning given such term in paragraph 

7 (7)(C)(i). 

8 ‘‘(ii) The term ‘otherwise applicable 

9 resident limit’ means, with respect to a 

10 hospital, the limit otherwise applicable 

11 under subparagraphs (F)(i) and (H) of 

12 paragraph (4) on the resident level for the 

13 hospital determined without regard to this 

14 paragraph but taking into account para15 graph (7)(A). 

16 ‘‘(D) MAINTENANCE OF PRIMARY CARE

17 RESIDENT LEVEL.—In carrying out this para18 graph, the Secretary shall require hospitals that 

19 receive additional resident positions under sub20 paragraph (B)— 

21 ‘‘(i) to maintain records, and periodi22 cally report to the Secretary, on the num23 ber of primary care residents in its resi24 dency training programs; and 


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1 ‘‘(ii) as a condition of payment for a 

2 cost reporting period under this subsection 

3 for such positions, to maintain the level of 

4 such positions at not less than the sum 

5 of— 

6 ‘‘(I) the base level of primary 

7 care resident positions (as determined 

8 under subparagraph (B)(ii)(I)) before 

9 receiving such additional positions; 

10 and 

11 ‘‘(II) the number of such addi12 tional positions.’’. 

13 (b) IME.— 

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

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

16 1395ww(d)(5)(B)(v)), in the third sentence, is 

17 amended— 

18 (A) by striking ‘‘subsection (h)(7)’’ and in19 serting ‘‘subsections (h)(7) and (h)(8)’’; and 

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

21 ‘‘they apply’’. 

22 (2) CONFORMING PROVISION.—Section 

23 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

24 1395ww(d)(5)(B)) is amended by adding at the end 

25 the following clause: 


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1 ‘‘(x) For discharges occurring on or after July 1, 

2 2011, insofar as an additional payment amount under this 

3 subparagraph is attributable to resident positions distrib4 uted to a hospital under subsection (h)(8)(B), the indirect 

5 teaching adjustment factor shall be computed in the same 

6 manner as provided under clause (ii) with respect to such 

7 resident positions.’’. 

8 (c) CONFORMING AMENDMENT.—Section 422(b)(2) 

9 of the Medicare Prescription Drug, Improvement, and 

10 Modernization Act of 2003 (Public Law 108–173) is 

11 amended by striking ‘‘section 1886(h)(7)’’ and all that fol12 lows and inserting ‘‘paragraphs (7) and (8) of subsection 

13 (h) of section 1886 of the Social Security Act.’’. 

14 SEC. 1502. INCREASING TRAINING IN NONPROVIDER SET15 TINGS. 

16 (a) DIRECT GME.—Section 1886(h)(4)(E) of the So17 cial Security Act (42 U.S.C. 1395ww(h)) is amended— 

18 (1) by designating the first sentence as a clause 

19 (i) with the heading ‘‘IN GENERAL.—’’ and appro20 priate indentation; 

21 (2) by striking ‘‘shall be counted and that all 

22 the time’’ and inserting ‘‘shall be counted and 

23 that— 


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1 ‘‘(I) effective for cost reporting 

2 periods beginning before July 1, 2009, 

3 all the time’’; 

4 (3) in subclause (I), as inserted by paragraph 

5 (1), by striking the period at the end and inserting 

6 ‘‘; and’’; and 

7 (A) by inserting after subclause (I), as so 

8 inserted, the following: 

9 ‘‘(II) effective for cost reporting 

10 periods beginning on or after July 1, 

11 2009, all the time so spent by a resi12 dent shall be counted towards the de13 termination of full-time equivalency, 

14 without regard to the setting in which 

15 the activities are performed, if the 

16 hospital incurs the costs of the sti17 pends and fringe benefits of the resi18 dent during the time the resident 

19 spends in that setting. 

20 Any hospital claiming under this subpara21 graph for time spent in a nonprovider set22 ting shall maintain and make available to 

23 the Secretary records regarding the 

24 amount of such time and such amount in 

25 comparison with amounts of such time in 


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1 such base year as the Secretary shall speci2 fy.’’. 

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

4 Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amend5 ed— 

6 (1) by striking ‘‘(iv) Effective for discharges oc7 curring on or after October 1, 1997’’ and inserting 

8 ‘‘(iv)(I) Effective for discharges occurring on or 

9 after October 1, 1997, and before July 1, 2009’’; 

10 and 

11 (2) by inserting after subclause (I), as inserted 

12 by paragraph (1), the following new subclause: 

13 ‘‘(II) Effective for discharges occurring on or 

14 after July 1, 2009, all the time spent by an intern 

15 or resident in patient care activities at an entity in 

16 a nonprovider setting shall be counted towards the 

17 determination of full-time equivalency if the hospital 

18 incurs the costs of the stipends and fringe benefits 

19 of the intern or resident during the time the intern 

20 or resident spends in that setting.’’. 

21 (c) OIG STUDY ON IMPACT ON TRAINING.—The In22 spector General of the Department of Health and Human 

23 Services shall analyze the data collected by the Secretary 

24 of Health and Human Services from the records made 

25 available to the Secretary under section 1886(h)(4)(E) of 


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1 the Social Security Act, as amended by subsection (a), in 

2 order to assess the extent to which there is an increase 

3 in time spent by medical residents in training in nonpro4 vider settings as a result of the amendments made by this 

5 section. Not later than 4 years after the date of the enact6 ment of this Act, the Inspector General shall submit a re7 port to Congress on such analysis and assessment. 

8 (d) DEMONSTRATION PROJECT FOR APPROVED

9 TEACHING HEALTH CENTERS.— 

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

11 Human Services shall conduct a demonstration 

12 project under which an approved teaching health 

13 center (as defined in paragraph (3)) would be eligi14 ble for payment under subsections (h) and (k) of 

15 section 1886 of the Social Security Act (42 U.S.C. 

16 1395ww) of amounts for its own direct costs of 

17 graduate medical education activities for primary 

18 care residents, as well as for the direct costs of grad19 uate medical education activities of its contracting 

20 hospital for such residents, in a manner similar to 

21 the manner in which such payments would be made 

22 to a hospital if the hospital were to operate such a 

23 program. 

24 (2) CONDITIONS.—Under the demonstration 

25 project— 


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1 (A) an approved teaching health center 

2 shall contract with an accredited teaching hos3 pital to carry out the inpatient responsibilities 

4 of the primary care residency program of the 

5 hospital involved and is responsible for payment 

6 to the hospital for the hospital’s costs of the 

7 salary and fringe benefits for residents in the 

8 program; 

9 (B) the number of primary care residents 

10 of the center shall not count against the con11 tracting hospital’s resident limit; and 

12 (C) the contracting hospital shall agree not 

13 to diminish the number of residents in its pri14 mary care residency training program. 

15 (3) APPROVED TEACHING HEALTH CENTER DE16 FINED.—In this subsection, the term ‘‘approved 

17 teaching health center’’ means a nonprovider setting, 

18 such as a Federally qualified health center or rural 

19 health clinic (as defined in section 1861(aa) of the 

20 Social Security Act), that develops and operates an 

21 accredited primary care residency program for which 

22 funding would be available if it were operated by a 

23 hospital. 


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1 SEC. 1503. RULES FOR COUNTING RESIDENT TIME FOR DI2 DACTIC AND SCHOLARLY ACTIVITIES AND 

3 OTHER ACTIVITIES. 

4 (a) DIRECT GME.—Section 1886(h) of the Social Se5 curity Act (42 U.S.C. 1395ww(h)) is amended— 

6 (1) in paragraph (4)(E), as amended by section 

7 1502(a)— 

8 (A) in clause (i), by striking ‘‘Such rules’’ 

9 and inserting ‘‘Subject to clause (ii), such 

10 rules’’; and 

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

12 clause: 

13 ‘‘(ii) TREATMENT OF CERTAIN NON14 PROVIDER AND DIDACTIC ACTIVITIES.— 

15 Such rules shall provide that all time spent 

16 by an intern or resident in an approved 

17 medical residency training program in a 

18 nonprovider setting that is primarily en19 gaged in furnishing patient care (as de20 fined in paragraph (5)(K)) in nonpatient 

21 care activities, such as didactic conferences 

22 and seminars, but not including research 

23 not associated with the treatment or diag24 nosis of a particular patient, as such time 

25 and activities are defined by the Secretary, 


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1 shall be counted toward the determination 

2 of full-time equivalency.’’; 

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

4 following new subparagraph: 

5 ‘‘(I) TREATMENT OF CERTAIN TIME IN AP6 PROVED MEDICAL RESIDENCY TRAINING PRO7 GRAMING.—In determining the hospital’s num8 ber of full-time equivalent residents for pur9 poses of this subsection, all the time that is 

10 spent by an intern or resident in an approved 

11 medical residency training program on vacation, 

12 sick leave, or other approved leave, as such time 

13 is defined by the Secretary, and that does not 

14 prolong the total time the resident is partici15 pating in the approved program beyond the nor16 mal duration of the program shall be counted 

17 toward the determination of full-time equiva18 lency.’’; and 

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

20 following new subparagraph: 

21 ‘‘(K) NONPROVIDER SETTING THAT IS PRI22 MARILY ENGAGED IN FURNISHING PATIENT

23 CARE.—The term ‘nonprovider setting that is 

24 primarily engaged in furnishing patient care’ 

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1 mary activity is the care and treatment of pa2 tients, as defined by the Secretary.’’. 

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

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

5 section 1501(b), is amended by adding at the end the fol6 lowing new clause: 

7 ‘‘(xi)(I) The provisions of subparagraph (I) of sub8 section (h)(4) shall apply under this subparagraph in the 

9 same manner as they apply under such subsection. 

10 ‘‘(II) In determining the hospital’s number of full11 time equivalent residents for purposes of this subpara12 graph, all the time spent by an intern or resident in an 

13 approved medical residency training program in non14 patient care activities, such as didactic conferences and 

15 seminars, as such time and activities are defined by the 

16 Secretary, that occurs in the hospital shall be counted to17 ward the determination of full-time equivalency if the hos18 pital— 

19 ‘‘(aa) is recognized as a subsection (d) hospital; 

20 ‘‘(bb) is recognized as a subsection (d) Puerto 

21 Rico hospital; 

22 ‘‘(cc) is reimbursed under a reimbursement sys23 tem authorized under section 1814(b)(3); or 

24 ‘‘(dd) is a provider-based hospital outpatient de25 partment. 


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1 ‘‘(III) In determining the hospital’s number of full2 time equivalent residents for purposes of this subpara3 graph, all the time spent by an intern or resident in an 

4 approved medical residency training program in research 

5 activities that are not associated with the treatment or di6 agnosis of a particular patient, as such time and activities 

7 are defined by the Secretary, shall not be counted toward 

8 the determination of full-time equivalency.’’. 

9 (c) EFFECTIVE DATES; APPLICATION.— 

10 (1) IN GENERAL.—Except as otherwise pro11 vided, the Secretary of Health and Human Services 

12 shall implement the amendments made by this sec13 tion in a manner so as to apply to cost reporting pe14 riods beginning on or after January 1, 1983. 

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

16 the Social Security Act, as added by subsection 

17 (a)(1)(B), shall apply to cost reporting periods be18 ginning on or after July 1, 2008. 

19 (3) IME.—Section 1886(d)(5)(B)(x)(III) of the 

20 Social Security Act, as added by subsection (b), shall 

21 apply to cost reporting periods beginning on or after 

22 October 1, 2001. Such section, as so added, shall 

23 not give rise to any inference on how the law in ef24 fect prior to such date should be interpreted. 


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1 (4) APPLICATION.—The amendments made by 

2 this section shall not be applied in a manner that re3 quires reopening of any settled hospital cost reports 

4 as to which there is not a jurisdictionally proper ap5 peal pending as of the date of the enactment of this 

6 Act on the issue of payment for indirect costs of 

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

8 the Social Security Act or for direct graduate med9 ical education costs under section 1886(h) of such 

10 Act. 

11 SEC. 1504. PRESERVATION OF RESIDENT CAP POSITIONS 

12 FROM CLOSED HOSPITALS. 

13 (a) DIRECT GME.—Section 1886(h)(4)(H) of the So14 cial Security Act (42 U.S.C. Section 1395ww(h)(4)(H)) 

15 is amended by adding at the end the following new clause: 

16 ‘‘(vi) REDISTRIBUTION OF RESIDENCY

17 SLOTS AFTER A HOSPITAL CLOSES.— 

18 ‘‘(I) IN GENERAL.—The Sec19 retary shall, by regulation, establish a 

20 process consistent with subclauses (II) 

21 and (III) under which, in the case 

22 where a hospital (other than a hos23 pital described in clause (v)) with an 

24 approved medical residency program 

25 in a State closes on or after the date 


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1 that is 2 years before the date of the 

2 enactment of this clause, the Sec3 retary shall increase the otherwise ap4 plicable resident limit under this para5 graph for other hospitals in the State 

6 in accordance with this clause. 

7 ‘‘(II) PROCESS FOR HOSPITALS

8 IN CERTAIN AREAS.—In determining 

9 for which hospitals the increase in the 

10 otherwise applicable resident limit de11 scribed in subclause (I) is provided, 

12 the Secretary shall establish a process 

13 to provide for such increase to one or 

14 more hospitals located in the State. 

15 Such process shall take into consider16 ation the recommendations submitted 

17 to the Secretary by the senior health 

18 official (as designated by the chief ex19 ecutive officer of such State) if such 

20 recommendations are submitted not 

21 later than 180 days after the date of 

22 the hospital closure involved (or, in 

23 the case of a hospital that closed after 

24 the date that is 2 years before the 

25 date of the enactment of this clause, 


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1 180 days after such date of enact2 ment). 

3 ‘‘(III) LIMITATION.—The esti4 mated aggregate number of increases 

5 in the otherwise applicable resident 

6 limits for hospitals under this clause 

7 shall be equal to the estimated num8 ber of resident positions in the ap9 proved medical residency programs 

10 that closed on or after the date de11 scribed in subclause (I).’’. 

12 (b) NO EFFECT ON TEMPORARY FTE CAP ADJUST13 MENTS.—The amendments made by this section shall not 

14 effect any temporary adjustment to a hospital’s FTE cap 

15 under section 413.79(h) of title 42, Code of Federal Regu16 lations (as in effect on the date of enactment of this Act) 

17 and shall not affect the application of section 

18 1886(h)(4)(H)(v) of the Social Security Act. 

19 (c) CONFORMING AMENDMENTS.— 

20 (1) Section 422(b)(2) of the Medicare Prescrip21 tion Drug, Improvement, and Modernization Act of 

22 2003 (Public Law 108–173), as amended by section 

23 1501(c), is amended by striking ‘‘(7) and’’ and in24 serting ‘‘(4)(H)(vi), (7), and’’. 


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1 (2) Section 1886(h)(7)(E) of the Social Secu2 rity Act (42 U.S.C. 1395ww(h)(7)(E)) is amended 

3 by inserting ‘‘or under paragraph (4)(H)(vi)’’ after 

4 ‘‘under this paragraph’’. 

5 SEC. 1505. IMPROVING ACCOUNTABILITY FOR APPROVED 

6 MEDICAL RESIDENCY TRAINING. 

7 (a) SPECIFICATION OF GOALS FOR APPROVED MED8 ICAL RESIDENCY TRAINING PROGRAMS.—Section 

9 1886(h)(1) of the Social Security Act (42 U.S.C. 

10 1395ww(h)(1)) is amended— 

11 (1) by designating the matter beginning with 

12 ‘‘Notwithstanding’’ as a subparagraph (A) with the 

13 heading ‘‘IN GENERAL.—’’ and with appropriate in14 dentation; and 

15 (2) by adding at the end the following new sub16 paragraph: 

17 ‘‘(B) GOALS AND ACCOUNTABILITY FOR

18 APPROVED MEDICAL RESIDENCY TRAINING PRO19 GRAMS.—The goals of medical residency train20 ing programs are to foster a physician work21 force so that physicians are trained to be able 

22 to do the following: 

23 ‘‘(i) Work effectively in various health 

24 care delivery settings, such as nonprovider 

25 settings. 


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1 ‘‘(ii) Coordinate patient care within 

2 and across settings relevant to their spe3 cialties. 

4 ‘‘(iii) Understand the relevant cost 

5 and value of various diagnostic and treat6 ment options. 

7 ‘‘(iv) Work in inter-professional teams 

8 and multi-disciplinary team-based models 

9 in provider and nonprovider settings to en10 hance safety and improve quality of patient 

11 care. 

12 ‘‘(v) Be knowledgeable in methods of 

13 identifying systematic errors in health care 

14 delivery and in implementing systematic 

15 solutions in case of such errors, including 

16 experience and participation in continuous 

17 quality improvement projects to improve 

18 health outcomes of the population the phy19 sicians serve. 

20 ‘‘(vi) Be meaningful EHR users (as 

21 determined under section 1848(o)(2)) in 

22 the delivery of care and in improving the 

23 quality of the health of the community and 

24 the individuals that the hospital serves.’’ 


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1 (b) GAO STUDY ON EVALUATION OF TRAINING PRO2 GRAMS.— 

3 (1) IN GENERAL.—The Comptroller General of 

4 the United States shall conduct a study to evaluate 

5 the extent to which medical residency training pro6 grams— 

7 (A) are meeting the goals described in sec8 tion 1886(h)(1)(B) of the Social Security Act, 

9 as added by subsection (a), in a range of resi10 dency programs, including primary care and 

11 other specialties; and 

12 (B) have the appropriate faculty expertise 

13 to teach the topics required to achieve such 

14 goals. 

15 (2) REPORT.—Not later than 18 months after 

16 the date of the enactment of this Act, the Comp17 troller General shall submit to Congress a report on 

18 such study and shall include in such report rec19 ommendations as to how medical residency training 

20 programs could be further encouraged to meet such 

21 goals through means such as— 

22 (A) development of curriculum require23 ments; and 

24 (B) assessment of the accreditation proc25 esses of the Accreditation Council for Graduate 


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1 Medical Education and the American Osteo2 pathic Association and effectiveness of those 

3 processes in accrediting medical residency pro4 grams that meet the goals referred to in para5 graph (1)(A). 

6 TITLE VI—PROGRAM INTEGRITY 

7 Subtitle A—Increased Funding to 

8 Fight Waste, Fraud, and Abuse 

9 SEC. 1601. INCREASED FUNDING AND FLEXIBILITY TO 

10 FIGHT FRAUD AND ABUSE. 

11 (a) IN GENERAL.—Section 1817(k) of the Social Se12 curity Act (42 U.S.C. 1395i(k)) is amended— 

13 (1) by adding at the end the following new 

14 paragraph: 

15 ‘‘(7) ADDITIONAL FUNDING.—In addition to the 

16 funds otherwise appropriated to the Account from 

17 the Trust Fund under paragraphs (3) and (4) and 

18 for purposes described in paragraphs (3)(C) and 

19 (4)(A), there are hereby appropriated an additional 

20 $100,000,000 to such Account from such Trust 

21 Fund for each fiscal year beginning with 2011. The 

22 funds appropriated under this paragraph shall be al23 located in the same proportion as the total funding 

24 appropriated with respect to paragraphs (3)(A) and 

25 (4)(A) was allocated with respect to fiscal year 


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1 2010, and shall be available without further appro2 priation until expended.’’. 

3 (2) in paragraph (4)(A)— 

4 (A) by inserting ‘‘for activities described in 

5 paragraph (3)(C) and’’ after ‘‘necessary’’; and 

6 (B) by inserting ‘‘until expended’’ after 

7 ‘‘appropriation’’. 

8 (b) FLEXIBILITY IN PURSUING FRAUD AND

9 ABUSE.—Section 1893(a) of the Social Security Act (42 

10 U.S.C. 1395ddd(a)) is amended by inserting ‘‘, or other11 wise,’’ after ‘‘entities’’. 

12 Subtitle B—Enhanced Penalties for 

13 Fraud and Abuse 

14 SEC. 1611. ENHANCED PENALTIES FOR FALSE STATEMENTS 

15 ON PROVIDER OR SUPPLIER ENROLLMENT 

16 APPLICATIONS. 

17 (a) IN GENERAL.—Section 1128A(a) of the Social 

18 Security Act (42 U.S.C. 1320a–7a(a)) is amended— 

19 (1) in paragraph (1)(D), by striking all that fol20 lows ‘‘in which the person was excluded’’ and insert21 ing ‘‘under Federal law from the Federal health care 

22 program under which the claim was made, or’’; 

23 (2) by striking ‘‘or’’ at the end of paragraph 

24 (6); 


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1 (3) in paragraph (7), by inserting at the end 

2 ‘‘or’’; 

3 (4) by inserting after paragraph (7) the fol4 lowing new paragraph: 

5 ‘‘(8) knowingly makes or causes to be made any 

6 false statement, omission, or misrepresentation of a 

7 material fact in any application, agreement, bid, or 

8 contract to participate or enroll as a provider of 

9 services or supplier under a Federal health care pro10 gram, including managed care organizations under 

11 title XIX, Medicare Advantage organizations under 

12 part C of title XVIII, prescription drug plan spon13 sors under part D of title XVIII, and entities that 

14 apply to participate as providers of services or sup15 pliers in such managed care organizations and such 

16 plans;’’; 

17 (5) in the matter following paragraph (8), as 

18 inserted by paragraph (4), by striking ‘‘or in cases 

19 under paragraph (7), $50,000 for each such act)’’ 

20 and inserting ‘‘in cases under paragraph (7), 

21 $50,000 for each such act, or in cases under para22 graph (8), $50,000 for each false statement, omis23 sion, or misrepresentation of a material fact)’’; and 

24 (6) in the second sentence, by striking ‘‘for a 

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1 pose, or in cases under paragraph (8), an assess2 ment of not more than 3 times the amount claimed 

3 as the result of the false statement, omission, or 

4 misrepresentation of material fact claimed by a pro5 vider of services or supplier whose application to 

6 participate contained such false statement, omission, 

7 or misrepresentation)’’. 

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

9 subsection (a) shall apply to acts committed on or after 

10 January 1, 2010. 

11 SEC. 1612. ENHANCED PENALTIES FOR SUBMISSION OF 

12 FALSE STATEMENTS MATERIAL TO A FALSE 

13 CLAIM. 

14 (a) IN GENERAL.—Section 1128A(a) of the Social 

15 Security Act (42 U.S.C. 1320a–7a(a)), as amended by sec16 tion 1611, is further amended— 

17 (1) in paragraph (7), by striking ‘‘or’’ at the 

18 end; 

19 (2) in paragraph (8), by inserting ‘‘or’’ at the 

20 end; and 

21 (3) by inserting after paragraph (8), the fol22 lowing new paragraph: 

23 ‘‘(9) knowingly makes, uses, or causes to be 

24 made or used, a false record or statement material 

25 to a false or fraudulent claim for payment for items 


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1 and services furnished under a Federal health care 

2 program;’’; and 

3 (4) in the matter following paragraph (9), as 

4 inserted by paragraph (3)— 

5 (A) by striking ‘‘or in cases under para6 graph (8)’’ and inserting ‘‘in cases under para7 graph (8)’’; and 

8 (B) by striking ‘‘a material fact)’’ and in9 serting ‘‘a material fact, in cases under para10 graph (9), $50,000 for each false record or 

11 statement)’’. 

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

13 subsection (a) shall apply to acts committed on or after 

14 January 1, 2010. 

15 SEC. 1613. ENHANCED PENALTIES FOR DELAYING INSPEC16 TIONS. 

17 (a) IN GENERAL.—Section 1128A(a) of the Social 

18 Security Act (42 U.S.C. 1320a–7a(a)), as amended by sec19 tions 1611 and 1612, is further amended— 

20 (1) in paragraph (8), by striking ‘‘or’’ at the 

21 end; 

22 (2) in paragraph (9), by inserting ‘‘or’’ at the 

23 end; 

24 (3) by inserting after paragraph (9) the fol25 lowing new paragraph: 


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1 ‘‘(10) fails to grant timely access, upon reason2 able request (as defined by the Secretary in regula3 tions), to the Inspector General of the Department 

4 of Health and Human Services, for the purpose of 

5 audits, investigations, evaluations, or other statutory 

6 functions of the Inspector General of the Depart7 ment of Health and Human Services;’’; and 

8 (4) in the matter following paragraph (10), as 

9 inserted by paragraph (3), by inserting ‘‘, or in cases 

10 under paragraph (10), $15,000 for each day of the 

11 failure described in such paragraph’’ after ‘‘false 

12 record or statement’’. 

13 (b) ENSURING TIMELY INSPECTIONS RELATING TO

14 CONTRACTS WITH MA ORGANIZATIONS.—Section 

15 1857(d)(2) of such Act (42 U.S.C. 1395w–27(d)(2)) is 

16 amended— 

17 (1) in subparagraph (A), by inserting ‘‘timely’’ 

18 before ‘‘inspect’’; and 

19 (2) in subparagraph (B), by inserting ‘‘timely’’ 

20 before ‘‘audit and inspect’’. 

21 (c) EFFECTIVE DATE.—The amendments made by 

22 subsection (a) shall apply to violations committed on or 

23 after January 1, 2010. 


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1 SEC. 1614. ENHANCED HOSPICE PROGRAM SAFEGUARDS. 

2 (a) MEDICARE.—Part A of title XVIII of the Social 

3 Security Act is amended by inserting after section 1819 

4 the following new section: 

5 ‘‘SEC. 1819A. ASSURING QUALITY OF CARE IN HOSPICE 

6 CARE. 

7 ‘‘(a) IN GENERAL.—If the Secretary determines on 

8 the basis of a survey or otherwise, that a hospice program 

9 that is certified for participation under this title has dem10 onstrated a substandard quality of care and failed to meet 

11 such other requirements as the Secretary may find nec12 essary in the interest of the health and safety of the indi13 viduals who are provided care and services by the agency 

14 or organization involved and determines— 

15 ‘‘(1) that the deficiencies involved immediately 

16 jeopardize the health and safety of the individuals to 

17 whom the program furnishes items and services, the 

18 Secretary shall take immediate action to remove the 

19 jeopardy and correct the deficiencies through the 

20 remedy specified in subsection (b)(2)(A)(iii) or ter21 minate the certification of the program, and may 

22 provide, in addition, for 1 or more of the other rem23 edies described in subsection (b)(2)(A); or 

24 ‘‘(2) that the deficiencies involved do not imme25 diately jeopardize the health and safety of the indiVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00951 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 viduals to whom the program furnishes items and 

2 services, the Secretary may— 

3 ‘‘(A) impose intermediate sanctions devel4 oped pursuant to subsection (b), in lieu of ter5 minating the certification of the program; and 

6 ‘‘(B) if, after such a period of intermediate 

7 sanctions, the program is still not in compliance 

8 with such requirements, the Secretary shall ter9 minate the certification of the program. 

10 If the Secretary determines that a hospice program 

11 that is certified for participation under this title is 

12 in compliance with such requirements but, as of a 

13 previous period, was not in compliance with such re14 quirements, the Secretary may provide for a civil 

15 money penalty under subsection (b)(2)(A)(i) for the 

16 days in which it finds that the program was not in 

17 compliance with such requirements. 

18 ‘‘(b) INTERMEDIATE SANCTIONS.— 

19 ‘‘(1) DEVELOPMENT AND IMPLEMENTATION.— 

20 The Secretary shall develop and implement, by not 

21 later than July 1, 2012— 

22 ‘‘(A) a range of intermediate sanctions to 

23 apply to hospice programs under the conditions 

24 described in subsection (a), and 


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1 ‘‘(B) appropriate procedures for appealing 

2 determinations relating to the imposition of 

3 such sanctions. 

4 ‘‘(2) SPECIFIED SANCTIONS.— 

5 ‘‘(A) IN GENERAL.—The intermediate 

6 sanctions developed under paragraph (1) may 

7 include— 

8 ‘‘(i) civil money penalties in an 

9 amount not to exceed $10,000 for each day 

10 of noncompliance or, in the case of a per 

11 instance penalty applied by the Secretary, 

12 not to exceed $25,000, 

13 ‘‘(ii) denial of all or part of the pay14 ments to which a hospice program would 

15 otherwise be entitled under this title with 

16 respect to items and services furnished by 

17 a hospice program on or after the date on 

18 which the Secretary determines that inter19 mediate sanctions should be imposed pur20 suant to subsection (a)(2), 

21 ‘‘(iii) the appointment of temporary 

22 management to oversee the operation of 

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1 uals under the care of the program while 

2 improvements are made, 

3 ‘‘(iv) corrective action plans, and 

4 ‘‘(v) in-service training for staff. 

5 The provisions of section 1128A (other than 

6 subsections (a) and (b)) shall apply to a civil 

7 money penalty under clause (i) in the same 

8 manner as such provisions apply to a penalty or 

9 proceeding under section 1128A(a). The tem10 porary management under clause (iii) shall not 

11 be terminated until the Secretary has deter12 mined that the program has the management 

13 capability to ensure continued compliance with 

14 all requirements referred to in that clause. 

15 ‘‘(B) CLARIFICATION.—The sanctions 

16 specified in subparagraph (A) are in addition to 

17 sanctions otherwise available under State or 

18 Federal law and shall not be construed as lim19 iting other remedies, including any remedy 

20 available to an individual at common law. 

21 ‘‘(C) COMMENCEMENT OF PAYMENT.—A 

22 denial of payment under subparagraph (A)(ii) 

23 shall terminate when the Secretary determines 

24 that the hospice program no longer dem25 onstrates a substandard quality of care and 


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1 meets such other requirements as the Secretary 

2 may find necessary in the interest of the health 

3 and safety of the individuals who are provided 

4 care and services by the agency or organization 

5 involved. 

6 ‘‘(3) SECRETARIAL AUTHORITY.—The Secretary 

7 shall develop and implement, by not later than July 

8 1, 2011, specific procedures with respect to the con9 ditions under which each of the intermediate sanc10 tions developed under paragraph (1) is to be applied, 

11 including the amount of any fines and the severity 

12 of each of these sanctions. Such procedures shall be 

13 designed so as to minimize the time between identi14 fication of deficiencies and imposition of these sanc15 tions and shall provide for the imposition of incre16 mentally more severe fines for repeated or uncor17 rected deficiencies.’’. 

18 (b) APPLICATION TO MEDICAID.—Section 1905(o) of 

19 the Social Security Act (42 U.S.C. 1396d(o)) is amended 

20 by adding at the end the following new paragraph: 

21 ‘‘(4) The provisions of section 1819A shall apply to 

22 a hospice program providing hospice care under this title 

23 in the same manner as such provisions apply to a hospice 

24 program providing hospice care under title XVIII.’’. 


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1 (c) APPLICATION TO CHIP.—Title XXI of the Social 

2 Security Act is amended by adding at the end the fol3 lowing new section: 

4 ‘‘SEC. 2114. ASSURING QUALITY OF CARE IN HOSPICE CARE. 

5 ‘‘The provisions of section 1819A shall apply to a 

6 hospice program providing hospice care under this title in 

7 the same manner such provisions apply to a hospice pro8 gram providing hospice care under title XVIII.’’. 

9 SEC. 1615. ENHANCED PENALTIES FOR INDIVIDUALS EX10 CLUDED FROM PROGRAM PARTICIPATION. 

11 (a) IN GENERAL.—Section 1128A(a) of the Social 

12 Security Act (42 U.S.C. 1320a–7a(a)), as amended by the 

13 previous sections, is further amended— 

14 (1) by striking ‘‘or’’ at the end of paragraph 

15 (9); 

16 (2) by inserting ‘‘or’’ at the end of paragraph 

17 (10); 

18 (3) by inserting after paragraph (10) the fol19 lowing new paragraph: 

20 ‘‘(11) orders or prescribes an item or service, 

21 including without limitation home health care, diag22 nostic and clinical lab tests, prescription drugs, du23 rable medical equipment, ambulance services, phys24 ical or occupational therapy, or any other item or 

25 service, during a period when the person has been 


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1 excluded from participation in a Federal health care 

2 program, and the person knows or should know that 

3 a claim for such item or service will be presented to 

4 such a program;’’; and 

5 (4) in the matter following paragraph (11), as 

6 inserted by paragraph (2), by striking ‘‘$15,000 for 

7 each day of the failure described in such paragraph’’ 

8 and inserting ‘‘$15,000 for each day of the failure 

9 described in such paragraph, or in cases under para10 graph (11), $50,000 for each order or prescription 

11 for an item or service by an excluded individual’’. 

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

13 subsection (a) shall apply to violations committed on or 

14 after January 1, 2010. 

15 SEC. 1616. ENHANCED PENALTIES FOR PROVISION OF 

16 FALSE INFORMATION BY MEDICARE ADVAN17 TAGE AND PART D PLANS. 

18 (a) IN GENERAL.—Section 1857(g)(2)(A) of the So19 cial Security Act (42 U.S.C. 1395w—27(g)(2)(A)) is 

20 amended by inserting ‘‘except with respect to a determina21 tion under subparagraph (E), an assessment of not more 

22 than 3 times the amount claimed by such plan or plan 

23 sponsor based upon the misrepresentation or falsified in24 formation involved,’’ after ‘‘for each such determination,’’. 


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

2 subsection (a) shall apply to violations committed on or 

3 after January 1, 2010. 

4 SEC. 1617. ENHANCED PENALTIES FOR MEDICARE ADVAN5 TAGE AND PART D MARKETING VIOLATIONS. 

6 (a) IN GENERAL.—Section 1857(g)(1) of the Social 

7 Security Act (42 U.S.C. 1395w—27(g)(1)), as amended 

8 by section 1221(b), is amended— 

9 (1) in subparagraph (G), by striking ‘‘or’’ at 

10 the end; 

11 (2) by inserting after subparagraph (H) the fol12 lowing new subparagraphs: 

13 ‘‘(I) except as provided under subpara14 graph (C) or (D) of section 1860D–1(b)(1), en15 rolls an individual in any plan under this part 

16 without the prior consent of the individual or 

17 the designee of the individual; 

18 ‘‘(J) transfers an individual enrolled under 

19 this part from one plan to another without the 

20 prior consent of the individual or the designee 

21 of the individual or solely for the purpose of 

22 earning a commission; 

23 ‘‘(K) fails to comply with marketing re24 strictions described in subsections (h) and (j) of 


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1 section 1851 or applicable implementing regula2 tions or guidance; or 

3 ‘‘(L) employs or contracts with any indi4 vidual or entity who engages in the conduct de5 scribed in subparagraphs (A) through (K) of 

6 this paragraph;’’; and 

7 (3) by adding at the end the following new sen8 tence: ‘‘The Secretary may provide, in addition to 

9 any other remedies authorized by law, for any of the 

10 remedies described in paragraph (2), if the Secretary 

11 determines that any employee or agent of such orga12 nization, or any provider or supplier who contracts 

13 with such organization, has engaged in any conduct 

14 described in subparagraphs (A) through (L) of this 

15 paragraph.’’ 

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

17 subsection (a) shall apply to violations committed on or 

18 after January 1, 2010. 

19 SEC. 1618. ENHANCED PENALTIES FOR OBSTRUCTION OF 

20 PROGRAM AUDITS. 

21 (a) IN GENERAL.—Section 1128(b)(2) of the Social 

22 Security Act (42 U.S.C. 1320a–7(b)(2)) is amended— 

23 (1) in the heading, by inserting ‘‘OR AUDIT’’ 

24 after ‘‘INVESTIGATION’’; and 


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1 (2) by striking ‘‘investigation into’’ and all that 

2 follows through the period and inserting ‘‘investiga3 tion or audit related to—’’ 

4 ‘‘(i) any offense described in para5 graph (1) or in subsection (a); or 

6 ‘‘(ii) the use of funds received, directly 

7 or indirectly, from any Federal health care 

8 program (as defined in section 

9 1128B(f)).’’. 

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

11 subsection (a) shall apply to violations committed on or 

12 after January 1, 2010. 

13 SEC. 1619. EXCLUSION OF CERTAIN INDIVIDUALS AND EN14 TITIES FROM PARTICIPATION IN MEDICARE 

15 AND STATE HEALTH CARE PROGRAMS. 

16 (a) IN GENERAL.—Section 1128(c) of the Social Se17 curity Act, as previously amended by this division, is fur18 ther amended— 

19 (1) in the heading, by striking ‘‘AND PERIOD’’ 

20 and inserting ‘‘PERIOD, AND EFFECT’’; and 

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

22 paragraph: 

23 ‘‘(4)(A) For purposes of this Act, subject to subpara24 graph (C), the effect of exclusion is that no payment may 

25 be made by any Federal health care program (as defined 


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1 in section 1128B(f)) with respect to any item or service 

2 furnished— 

3 ‘‘(i) by an excluded individual or entity; or 

4 ‘‘(ii) at the medical direction or on the prescrip5 tion of a physician or other authorized individual 

6 when the person submitting a claim for such item or 

7 service knew or had reason to know of the exclusion 

8 of such individual. 

9 ‘‘(B) For purposes of this section and sections 1128A 

10 and 1128B, subject to subparagraph (C), an item or serv11 ice has been furnished by an individual or entity if the 

12 individual or entity directly or indirectly provided, ordered, 

13 manufactured, distributed, prescribed, or otherwise sup14 plied the item or service regardless of how the item or 

15 service was paid for by a Federal health care program or 

16 to whom such payment was made. 

17 ‘‘(C)(i) Payment may be made under a Federal 

18 health care program for emergency items or services (not 

19 including items or services furnished in an emergency 

20 room of a hospital) furnished by an excluded individual 

21 or entity, or at the medical direction or on the prescription 

22 of an excluded physician or other authorized individual 

23 during the period of such individual’s exclusion. 

24 ‘‘(ii) In the case that an individual eligible for bene25 fits under title XVIII or XIX submits a claim for payment 


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1 for items or services furnished by an excluded individual 

2 or entity, and such individual eligible for such benefits did 

3 not know or have reason to know that such excluded indi4 vidual or entity was so excluded, then, notwithstanding 

5 such exclusion, payment shall be made for such items or 

6 services. In such case the Secretary shall notify such indi7 vidual eligible for such benefits of the exclusion of the indi8 vidual or entity furnishing the items or services. Payment 

9 shall not be made for items or services furnished by an 

10 excluded individual or entity to an individual eligible for 

11 such benefits after a reasonable time (as determined by 

12 the Secretary in regulations) after the Secretary has noti13 fied the individual eligible for such benefits of the exclu14 sion of the individual or entity furnishing the items or 

15 services. 

16 ‘‘(iii) In the case that a claim for payment for items 

17 or services furnished by an excluded individual or entity 

18 is submitted by an individual or entity other than an indi19 vidual eligible for benefits under title XVIII or XIX or 

20 the excluded individual or entity, and the Secretary deter21 mines that the individual or entity that submitted the 

22 claim took reasonable steps to learn of the exclusion and 

23 reasonably relied upon inaccurate or misleading informa24 tion from the relevant Federal health care program or its 

25 contractor, the Secretary may waive repayment of the 


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1 amount paid in violation of the exclusion to the individual 

2 or entity that submitted the claim for the items or services 

3 furnished by the excluded individual or entity. If a Federal 

4 health care program contractor provided inaccurate or 

5 misleading information that resulted in the waiver of an 

6 overpayment under this clause, the Secretary shall take 

7 appropriate action to recover the improperly paid amount 

8 from the contractor.’’. 

9 SEC. 1620. OIG AUTHORITY TO EXCLUDE FROM FEDERAL 

10 HEALTH CARE PROGRAMS OFFICERS AND 

11 OWNERS OF ENTITIES CONVICTED OF FRAUD. 

12 Section 1128(b)(15)(A) of the Social Security Act 

13 (42 U.S.C. 1320a–7(b)(15)(A)) is amended— 

14 (1) in clause (i)— 

15 (A) by striking ‘‘has’’ and inserting ‘‘had’’; 

16 and 

17 (B) by striking ‘‘sanctioned entity and who 

18 knows or should know (as defined in section 

19 1128A(i)(6)) of’’ and inserting ‘‘sanctioned en20 tity at the time of, and who knew or should 

21 have known (as defined in section 1128A(i)(6)) 

22 of,’’ ; and 

23 (2) in clause (ii)— 

24 (A) by striking ‘‘is an officer’’ and insert25 ing ‘‘was an officer’’; and 


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1 (B) by inserting before the period the fol2 lowing: ‘‘at the time of the action constituting 

3 the basis for the conviction or exclusion de4 scribed in subparagraph (B)’’. 

5 SEC. 1621. SELF-REFERRAL DISCLOSURE PROTOCOL. 

6 (a) DEVELOPMENT OF SELF-REFERRAL DISCLOSURE

7 PROTOCOL.— 

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

9 Human Services, in cooperation with the Inspector 

10 General of the Department of Health and Human 

11 Services, shall establish, not later than 6 months 

12 after the date of the enactment of this Act, a pro13 tocol to enable health care providers of services and 

14 suppliers to disclose an actual or potential violation 

15 of section 1877 of the Social Security Act (42 

16 U.S.C. 1395nn) pursuant to a self-referral disclosure 

17 protocol (in this section referred to as an ‘‘SRDP’’). 

18 The SRDP shall include direction to health care pro19 viders of services and suppliers on— 

20 (A) a specific person, official, or office to 

21 whom such disclosures shall be made; and 

22 (B) instruction on the implication of the 

23 SRDP on corporate integrity agreements and 

24 corporate compliance agreements. 


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1 (2) PUBLICATION ON INTERNET WEBSITE OF

2 SRDP INFORMATION.—The Secretary shall post in3 formation on the public Internet website of the Cen4 ters for Medicare & Medicaid Services to inform rel5 evant stakeholders of how to disclose actual or po6 tential violations pursuant to an SRDP. 

7 (3) RELATION TO ADVISORY OPINIONS.—The 

8 SRDP shall be separate from the advisory opinion 

9 process set forth in regulations implementing section 

10 1877(g) of the Social Security Act. 

11 (b) REDUCTION IN AMOUNTS OWED.—The Secretary 

12 is authorized to reduce the amount due and owing for all 

13 violations under section 1877 of the Social Security Act 

14 to an amount less than that specified in subsection (g) 

15 of such section. In establishing such amount for a viola16 tion, the Secretary may consider the following factors: 

17 (1) The nature and extent of the improper or 

18 illegal practice. 

19 (2) The timeliness of such self-disclosure. 

20 (3) The cooperation in providing additional in21 formation related to the disclosure. 

22 (4) Such other factors as the Secretary con23 siders appropriate. 

24 (c) REPORT.—Not later than 18 months after the 

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1 section (a)(1), the Secretary shall submit to Congress a 

2 report on the implementation of this section. Such report 

3 shall include— 

4 (1) the number of health care providers of serv5 ices and suppliers making disclosures pursuant to an 

6 SRDP; 

7 (2) the amounts collected pursuant to the 

8 SRDP; 

9 (3) the types of violations reported under the 

10 SRDP; and 

11 (4) such other information as may be necessary 

12 to evaluate the impact of this section. 

13 (d) RELATION TO OTHER LAW AND REGULATION.— 

14 Nothing in this section shall affect the application of sec15 tion 1128G(c) of the Social Security Act, as added by sec16 tion 1641, except, in the case of a health care provider 

17 of services or supplier who is a person (as defined in para18 graph (4) of such section 1128G(c)) who discloses an over19 payment (as defined in such paragraph) to the Secretary 

20 of Health and Human Services pursuant to a SRDP es21 tablished under this section, the 60-day period described 

22 in paragraph (2) of such section 1128G(c) shall be ex23 tended with respect to the return of an overpayment to 

24 the extent necessary for the Secretary to determine pursu25 ant to the SRDP the amount due and owing. 


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1 Subtitle C—Enhanced Program 

2 and Provider Protections 

3 SEC. 1631. ENHANCED CMS PROGRAM PROTECTION AU4 THORITY. 

5 (a) IN GENERAL.—Title XI of the Social Security Act 

6 (42 U.S.C. 1301 et seq.) is amended by inserting after 

7 section 1128F the following new section: 

8 ‘‘SEC. 1128G. ENHANCED PROGRAM AND PROVIDER PRO9 TECTIONS IN THE MEDICARE, MEDICAID, AND 

10 CHIP PROGRAMS. 

11 ‘‘(a) CERTAIN AUTHORIZED SCREENING, ENHANCED

12 OVERSIGHT PERIODS, AND ENROLLMENT MORATORIA.— 

13 ‘‘(1) IN GENERAL.—For periods beginning after 

14 January 1, 2011, in the case that the Secretary de15 termines there is a significant risk of fraudulent ac16 tivity (as determined by the Secretary based on rel17 evant complaints, reports, referrals by law enforce18 ment or other sources, data analysis, trending infor19 mation, or claims submissions by providers of serv20 ices and suppliers) with respect to a category of pro21 vider of services or supplier of items or services, in22 cluding a category within a geographic area, under 

23 title XVIII, XIX, or XXI, the Secretary may impose 

24 any of the following requirements with respect to a 

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1 vider or supplier is initially enrolling in the program 

2 or is renewing such enrollment): 

3 ‘‘(A) Screening under paragraph (2). 

4 ‘‘(B) Enhanced oversight periods under 

5 paragraph (3). 

6 ‘‘(C) Enrollment moratoria under para7 graph (4). 

8 In applying this subsection for purposes of title XIX 

9 and XXI the Secretary may require a State to carry 

10 out the provisions of this subsection as a require11 ment of the State plan under title XIX or the child 

12 health plan under title XXI. Actions taken and de13 terminations made under this subsection shall not be 

14 subject to review by a judicial tribunal. 

15 ‘‘(2) SCREENING.—For purposes of paragraph 

16 (1), the Secretary shall establish procedures under 

17 which screening is conducted with respect to pro18 viders of services and suppliers described in such 

19 paragraph. Such screening may include— 

20 ‘‘(A) licensing board checks; 

21 ‘‘(B) screening against the list of individ22 uals and entities excluded from the program 

23 under title XVIII, XIX, or XXI; 

24 ‘‘(C) the excluded provider list system; 

25 ‘‘(D) background checks; and 


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1 ‘‘(E) unannounced pre-enrollment or other 

2 site visits. 

3 ‘‘(3) ENHANCED OVERSIGHT PERIOD.—For 

4 purposes of paragraph (1), the Secretary shall estab5 lish procedures to provide for a period of not less 

6 than 30 days and not more than 365 days during 

7 which providers of services and suppliers described 

8 in such paragraph, as the Secretary determines ap9 propriate, would be subject to enhanced oversight, 

10 such as required or unannounced (or required and 

11 unannounced) site visits or inspections, prepayment 

12 review, enhanced review of claims, and such other 

13 actions as specified by the Secretary, under the pro14 grams under titles XVIII, XIX, and XXI. Under 

15 such procedures, the Secretary may extend such pe16 riod for more than 365 days if the Secretary deter17 mines that after the initial period such additional 

18 period of oversight is necessary. 

19 ‘‘(4) MORATORIUM ON ENROLLMENT OF PRO20 VIDERS AND SUPPLIERS.—For purposes of para21 graph (1), the Secretary, based upon a finding of a 

22 risk of serious ongoing fraud within a program 

23 under title XVIII, XIX, or XXI, may impose a mor24 atorium on the enrollment of providers of services 

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1 ices and suppliers (including a category within a spe2 cific geographic area) under such title. Such a mora3 torium may only be imposed if the Secretary makes 

4 a determination that the moratorium would not ad5 versely impact access of individuals to care under 

6 such program. 

7 ‘‘(5) CLARIFICATION.—Nothing in this sub8 section shall be interpreted to preclude or limit the 

9 ability of a State to engage in provider screening or 

10 enhanced provider oversight activities beyond those 

11 required by the Secretary.’’. 

12 (b) CONFORMING AMENDMENTS.— 

13 (1) MEDICAID.—Section 1902(a) of the Social 

14 Security Act (42 U.S.C. 42 U.S.C. 1396a(a)) is 

15 amended— 

16 (A) in paragraph (23), by inserting before 

17 the semicolon at the end the following: ‘‘or by 

18 a person to whom or entity to which a morato19 rium under section 1128G(a)(4) is applied dur20 ing the period of such moratorium’’; 

21 (B) in paragraph (72); by striking at the 

22 end ‘‘and’’; 

23 (C) in paragraph (73), by striking the pe24 riod at the end and inserting ‘‘; and’’; and 


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1 (D) by adding after paragraph (73) the 

2 following new paragraph: 

3 ‘‘(74) provide that the State will enforce any 

4 determination made by the Secretary under sub5 section (a) of section 1128G (relating to a signifi6 cant risk of fraudulent activity with respect to a cat7 egory of provider or supplier described in such sub8 section (a) through use of the appropriate proce9 dures described in such subsection (a)), and that the 

10 State will carry out any activities as required by the 

11 Secretary for purposes of such subsection (a).’’. 

12 (2) CHIP.—Section 2102 of such Act (42 

13 U.S.C. 1397bb) is amended by adding at the end the 

14 following new subsection: 

15 ‘‘(d) PROGRAM INTEGRITY.—A State child health 

16 plan shall include a description of the procedures to be 

17 used by the State— 

18 ‘‘(1) to enforce any determination made by the 

19 Secretary under subsection (a) of section 1128G (re20 lating to a significant risk of fraudulent activity with 

21 respect to a category of provider or supplier de22 scribed in such subsection through use of the appro23 priate procedures described in such subsection); and 

24 ‘‘(2) to carry out any activities as required by 

25 the Secretary for purposes of such subsection.’’. 


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1 (3) MEDICARE.—Section 1866(j) of such Act 

2 (42 U.S.C. 1395cc(j)) is amended by adding at the 

3 end the following new paragraph: 

4 ‘‘(3) PROGRAM INTEGRITY.—The provisions of 

5 section 1128G(a) apply to enrollments and renewals 

6 of enrollments of providers of services and suppliers 

7 under this title.’’. 

8 SEC. 1632. ENHANCED MEDICARE, MEDICAID, AND CHIP 

9 PROGRAM DISCLOSURE REQUIREMENTS RE10 LATING TO PREVIOUS AFFILIATIONS. 

11 (a) IN GENERAL.—Section 1128G of the Social Secu12 rity Act, as inserted by section 1631, is amended by add13 ing at the end the following new subsection: 

14 ‘‘(b) ENHANCED PROGRAM DISCLOSURE REQUIRE15 MENTS.— 

16 ‘‘(1) DISCLOSURE.—A provider of services or 

17 supplier who submits on or after July 1, 2011, an 

18 application for enrollment and renewing enrollment 

19 in a program under title XVIII, XIX, or XXI shall 

20 disclose (in a form and manner determined by the 

21 Secretary) any current affiliation or affiliation with22 in the previous 10-year period with a provider of 

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1 cluded under such program, subject to a payment 

2 suspension, or has had its billing privileges revoked. 

3 ‘‘(2) ENHANCED SAFEGUARDS.—If the Sec4 retary determines that such previous affiliation of 

5 such provider or supplier poses a risk of fraud, 

6 waste, or abuse, the Secretary may apply such en7 hanced safeguards as the Secretary determines nec8 essary to reduce such risk associated with such pro9 vider or supplier enrolling or participating in the 

10 program under title XVIII, XIX, or XXI. Such safe11 guards may include enhanced oversight, such as en12 hanced screening of claims, required or unannounced 

13 (or required and unannounced) site visits or inspec14 tions, additional information reporting requirements, 

15 and conditioning such enrollment on the provision of 

16 a surety bond. 

17 ‘‘(3) AUTHORITY TO DENY PARTICIPATION.—If 

18 the Secretary determines that there has been at 

19 least one such affiliation and that such affiliation or 

20 affiliations, as applicable, of such provider or sup21 plier poses a serious risk of fraud, waste, or abuse, 

22 the Secretary may deny the application of such pro23 vider or supplier.’’. 

24 (b) CONFORMING AMENDMENTS.— 


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1 (1) MEDICAID.—Paragraph (74) of section 

2 1902(a) of such Act (42 U.S.C. 1396a(a)), as added 

3 by section 1631(b)(1), is amended— 

4 (A) by inserting ‘‘or subsection (b) of such 

5 section (relating to disclosure requirements)’’ 

6 before ‘‘, and that the State’’; and 

7 (B) by inserting before the period the fol8 lowing: ‘‘and apply any enhanced safeguards, 

9 with respect to a provider or supplier described 

10 in such subsection (b), as the Secretary deter11 mines necessary under such subsection (b)’’. 

12 (2) CHIP.—Subsection (d) of section 2102 of 

13 such Act (42 U.S.C. 1397bb), as added by section 

14 1631(b)(2), is amended— 

15 (A) in paragraph (1), by striking at the 

16 end ‘‘and’’; 

17 (B) in paragraph (2) by striking the period 

18 at the end and inserting ‘‘; and’ ’’ and 

19 (C) by adding at the end the following new 

20 paragraph: 

21 ‘‘(3) to enforce any determination made by the 

22 Secretary under subsection (b) of section 1128G (re23 lating to disclosure requirements) and to apply any 

24 enhanced safeguards, with respect to a provider or 


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1 supplier described in such subsection, as the Sec2 retary determines necessary under such subsection.’’. 

3 SEC. 1633. REQUIRED INCLUSION OF PAYMENT MODIFIER 

4 FOR CERTAIN EVALUATION AND MANAGE5 MENT SERVICES. 

6 Section 1848 of the Social Security Act (42 U.S.C. 

7 1395w–4), as amended by section 4101 of the HITECH 

8 Act (Public Law 111–5), is amended by adding at the end 

9 the following new subsection: 

10 ‘‘(p) PAYMENT MODIFIER FOR CERTAIN EVALUA11 TION AND MANAGEMENT SERVICES.—The Secretary shall 

12 establish a payment modifier under the fee schedule under 

13 this section for evaluation and management services (as 

14 specified in section 1842(b)(16)(B)(ii)) that result in the 

15 ordering of additional services (such as lab tests), the pre16 scription of drugs, the furnishing or ordering of durable 

17 medical equipment in order to enable better monitoring 

18 of claims for payment for such additional services under 

19 this title, or the ordering, furnishing, or prescribing of 

20 other items and services determined by the Secretary to 

21 pose a high risk of waste, fraud, and abuse. The Secretary 

22 may require providers of services or suppliers to report 

23 such modifier in claims submitted for payment.’’. 


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1 SEC. 1634. EVALUATIONS AND REPORTS REQUIRED UNDER 

2 MEDICARE INTEGRITY PROGRAM. 

3 (a) IN GENERAL.—Section 1893(c) of the Social Se4 curity Act (42 U.S.C. 1395ddd(c)) is amended— 

5 (1) in paragraph (3), by striking at the end 

6 ‘‘and’’; 

7 (2) by redesignating paragraph (4) as para8 graph (5); and 

9 (3) by inserting after paragraph (3) the fol10 lowing new paragraph: 

11 ‘‘(4) for the contract year beginning in 2011 

12 and each subsequent contract year, the entity pro13 vides assurances to the satisfaction of the Secretary 

14 that the entity will conduct periodic evaluations of 

15 the effectiveness of the activities carried out by such 

16 entity under the Program and will submit to the 

17 Secretary an annual report on such activities; and’’. 

18 (b) REFERENCE TO MEDICAID INTEGRITY PRO19 GRAM.—For a similar provision with respect to the Med20 icaid Integrity Program, see section 1752. 

21 SEC. 1635. REQUIRE PROVIDERS AND SUPPLIERS TO 

22 ADOPT PROGRAMS TO REDUCE WASTE, 

23 FRAUD, AND ABUSE. 

24 (a) IN GENERAL.—Section 1866(j) of the Social Se25 curity Act (42 U.S.C. 42 U.S.C. 1395cc(j)), as amended 


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1 by section 1631(d)(3), is further amended by adding at 

2 the end the following new paragraph: 

3 ‘‘(4) COMPLIANCE PROGRAMS FOR PROVIDERS

4 OF SERVICES AND SUPPLIERS.— 

5 ‘‘(A) IN GENERAL.—The Secretary may 

6 not enroll (or renew the enrollment of) a pro7 vider of services or a supplier (other than a 

8 physician or a skilled nursing facility) under 

9 this title if such provider of services or supplier 

10 fails to, subject to subparagraph (E), establish 

11 a compliance program that contains the core 

12 elements established under subparagraph (B) 

13 and certify in a manner determined by the Sec14 retary, that the provider or suppler has estab15 lished such a program. 

16 ‘‘(B) ESTABLISHMENT OF CORE ELE17 MENTS.—The Secretary, in consultation with 

18 the Inspector General of the Department of 

19 Health and Human Services, shall establish 

20 core elements for a compliance program under 

21 subparagraph (A). Such elements may include 

22 written policies, procedures, and standards of 

23 conduct, a designated compliance officer and a 

24 compliance committee; effective training and 

25 education pertaining to fraud, waste, and abuse 


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1 for the organization’s employees, and contrac2 tors; a confidential or anonymous mechanism, 

3 such as a hotline, to receive compliance ques4 tions and reports of fraud, waste, or abuse; dis5 ciplinary guidelines for enforcement of stand6 ards; internal monitoring and auditing proce7 dures, including monitoring and auditing of 

8 contractors; procedures for ensuring prompt re9 sponses to detected offenses and development of 

10 corrective action initiatives, including responses 

11 to potential offenses; and procedures to return 

12 all identified overpayments to the programs 

13 under this title, title XIX, and title XXI. 

14 ‘‘(C) TIMELINE FOR IMPLEMENTATION.— 

15 The Secretary shall determine a timeline for the 

16 establishment of the core elements under sub17 paragraph (B) and the date on which a pro18 vider of services and suppliers (other than phy19 sicians and skilled nursing facilities) shall be re20 quired to have established such a program for 

21 purposes of this subsection. 

22 ‘‘(D) PILOT PROGRAM.—The Secretary 

23 may conduct a pilot program on the application 

24 of this subsection with respect to a category of 

25 providers of services or suppliers (other than 


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1 physicians and skilled nursing facilities) that 

2 the Secretary determines to be a category which 

3 is at high risk for waste, fraud, and abuse be4 fore implementing the requirements of this sub5 section to all providers of services and suppliers 

6 described in subparagraph (C). 

7 ‘‘(E) TREATMENT OF SKILLED NURSING

8 FACILITIES.—For the requirement for skilled 

9 nursing facilities to establish compliance and 

10 ethics programs see section 1819(d)(1)(C). 

11 ‘‘(F) CONSTRUCTION.—Nothing in this 

12 subsection exempts a physician from partici13 pating in a compliance program established by 

14 a health care provider or other entity with 

15 which the physician is employed, under con16 tract, or affiliated if such compliance is re17 quired by such provider or entity.’’. 

18 (b) REFERENCE TO SIMILAR MEDICAID PROVI19 SION.—For a similar provision with respect to the Med20 icaid program under title XIX of the Social Security Act, 

21 see section 1753. 


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1 SEC. 1636. MAXIMUM PERIOD FOR SUBMISSION OF MEDI2 CARE CLAIMS REDUCED TO NOT MORE THAN 

3 12 MONTHS. 

4 (a) PURPOSE.—In general, the 36-month period cur5 rently allowed for claims filing under parts A, B, C, and, 

6 D of title XVIII of the Social Security Act presents oppor7 tunities for fraud schemes in which processing patterns 

8 of the Centers for Medicare & Medicaid Services can be 

9 observed and exploited. Narrowing the window for claims 

10 processing will not overburden providers and will reduce 

11 fraud and abuse. 

12 (b) REDUCING MAXIMUM PERIOD FOR SUBMIS13 SION.— 

14 (1) PART A.—Section 1814(a) of the Social Se15 curity Act (42 U.S.C. 1395f(a)) is amended— 

16 (A) in paragraph (1), by striking ‘‘period 

17 of 3 calendar years’’ and all that follows and in18 serting ‘‘period of 1 calendar year from which 

19 such services are furnished; and’’; and 

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

21 sentence: ‘‘In applying paragraph (1), the Sec22 retary may specify exceptions to the 1 calendar 

23 year period specified in such paragraph.’’. 

24 (2) PART B.—Section 1835(a) of such Act (42 

25 U.S.C. 1395n(a)) is amended— 


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1 (A) in paragraph (1), by striking ‘‘period 

2 of 3 calendar years’’ and all that follows and in3 serting ‘‘period of 1 calendar year from which 

4 such services are furnished; and’’; and 

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

6 sentence: ‘‘In applying paragraph (1), the Sec7 retary may specify exceptions to the 1 calendar 

8 year period specified in such paragraph.’’. 

9 (3) PARTS C AND D.—Section 1857(d) of such 

10 Act is amended by adding at the end the following 

11 new paragraph: 

12 ‘‘(7) PERIOD FOR SUBMISSION OF CLAIMS.— 

13 The contract shall require an MA organization or 

14 PDP sponsor to require any provider of services 

15 under contract with, in partnership with, or affili16 ated with such organization or sponsor to ensure 

17 that, with respect to items and services furnished by 

18 such provider to an enrollee of such organization, 

19 written request, signed by such enrollee, except in 

20 cases in which the Secretary finds it impracticable 

21 for the enrollee to do so, is filed for payment for 

22 such items and services in such form, in such man23 ner, and by such person or persons as the Secretary 

24 may by regulation prescribe, no later than the close 

25 of the 1 calendar year period after such items and 


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1 services are furnished. In applying the previous sen2 tence, the Secretary may specify exceptions to the 1 

3 calendar year period specified.’’. 

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

5 subsection (b) shall be effective for items and services fur6 nished on or after January 1, 2011. 

7 SEC. 1637. PHYSICIANS WHO ORDER DURABLE MEDICAL 

8 EQUIPMENT OR HOME HEALTH SERVICES RE9 QUIRED TO BE MEDICARE ENROLLED PHYSI10 CIANS OR ELIGIBLE PROFESSIONALS. 

11 (a) DME.—Section 1834(a)(11)(B) of the Social Se12 curity Act (42 U.S.C. 1395m(a)(11)(B)) is amended by 

13 striking ‘‘physician’’ and inserting ‘‘physician enrolled 

14 under section 1866(j) or other professional, as determined 

15 by the Secretary’’. 

16 (b) HOME HEALTH SERVICES.— 

17 (1) PART A.—Section 1814(a)(2) of such Act 

18 (42 U.S.C. 1395(a)(2)) is amended in the matter 

19 preceding subparagraph (A) by inserting ‘‘in the 

20 case of services described in subparagraph (C), a 

21 physician enrolled under section 1866(j) or other 

22 professional, as determined by the Secretary,’’ before 

23 ‘‘or, in the case of services’’. 

24 (2) PART B.—Section 1835(a)(2) of such Act 

25 (42 U.S.C. 1395n(a)(2)) is amended in the matter 


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1 preceding subparagraph (A) by inserting ‘‘, or in the 

2 case of services described in subparagraph (A), a 

3 physician enrolled under section 1866(j) or other 

4 professional, as determined by the Secretary,’’ after 

5 ‘‘a physician’’. 

6 (c) DISCRETION TO EXPAND APPLICATION.—The 

7 Secretary may extend the requirement applied by the 

8 amendments made by subsections (a) and (b) to durable 

9 medical equipment and home health services (relating to 

10 requiring certifications and written orders to be made by 

11 enrolled physicians and health professions) to other cat12 egories of items or services under this title, including cov13 ered part D drugs as defined in section 1860D–2(e), if 

14 the Secretary determines that such application would help 

15 to reduce the risk of waste, fraud, and abuse with respect 

16 to such other categories under title XVIII of the Social 

17 Security Act. 

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

19 this section shall apply to written orders and certifications 

20 made on or after July 1, 2010. 


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1 SEC. 1638. REQUIREMENT FOR PHYSICIANS TO PROVIDE 

2 DOCUMENTATION ON REFERRALS TO PRO3 GRAMS AT HIGH RISK OF WASTE AND ABUSE. 

4 (a) PHYSICIANS AND OTHER SUPPLIERS.—Section 

5 1842(h) of the Social Security Act is further amended by 

6 adding at the end the following new paragraph 

7 ‘‘(9) The Secretary may disenroll, for a period of not 

8 more than one year for each act, a physician or supplier 

9 under section 1866(j) if such physician or supplier fails 

10 to maintain and, upon request of the Secretary, provide 

11 access to documentation relating to written orders or re12 quests for payment for durable medical equipment, certifi13 cations for home health services, or referrals for other 

14 items or services written or ordered by such physician or 

15 supplier under this title, as specified by the Secretary.’’. 

16 (b) PROVIDERS OF SERVICES.—Section 1866(a)(1) 

17 of such Act (42 U.S.C. 1395cc), is amended— 

18 (1) in subparagraph (U), by striking at the end 

19 ‘‘and’’; 

20 (2) in subparagraph (V), by striking the period 

21 at the end and adding ‘‘; and’’; and 

22 (3) by adding at the end the following new sub23 paragraph: 

24 ‘‘(W) maintain and, upon request of the 

25 Secretary, provide access to documentation re26 lating to written orders or requests for payment 


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1 for durable medical equipment, certifications for 

2 home health services, or referrals for other 

3 items or services written or ordered by the pro4 vider under this title, as specified by the Sec5 retary.’’. 

6 (c) OIG PERMISSIVE EXCLUSION AUTHORITY.—Sec7 tion 1128(b)(11) of the Social Security Act (42 U.S.C. 

8 1320a–7(b)(11)) is amended by inserting ‘‘, ordering, re9 ferring for furnishing, or certifying the need for’’ after 

10 ‘‘furnishing’’. 

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

12 this section shall apply to orders, certifications, and refer13 rals made on or after January 1, 2010. 

14 SEC. 1639. FACE-TO-FACE ENCOUNTER WITH PATIENT RE15 QUIRED BEFORE ELIGIBILITY CERTIFI16 CATIONS FOR HOME HEALTH SERVICES OR 

17 DURABLE MEDICAL EQUIPMENT. 

18 (a) CONDITION OF PAYMENT FOR HOME HEALTH

19 SERVICES.— 

20 (1) PART A.—Section 1814(a)(2)(C) of such 

21 Act is amended— 

22 (A) by striking ‘‘and such services’’ and in23 serting ‘‘such services’’; and 

24 (B) by inserting after ‘‘care of a physi25 cian’’ the following: ‘‘, and, in the case of a cerVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00985 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 tification or recertification made by a physician 

2 after January 1, 2010, prior to making such 

3 certification the physician must document that 

4 the physician has had a face-to-face encounter 

5 (including through use of telehealth and other 

6 than with respect to encounters that are inci7 dent to services involved) with the individual 

8 during the 6-month period preceding such cer9 tification, or other reasonable timeframe as de10 termined by the Secretary’’. 

11 (2) PART B.—Section 1835(a)(2)(A) of the So12 cial Security Act is amended— 

13 (A) by striking ‘‘and’’ before ‘‘(iii)’’; and 

14 (B) by inserting after ‘‘care of a physi15 cian’’ the following: ‘‘, and (iv) in the case of 

16 a certification or recertification after January 

17 1, 2010, prior to making such certification the 

18 physician must document that the physician has 

19 had a face-to-face encounter (including through 

20 use of telehealth and other than with respect to 

21 encounters that are incident to services in22 volved) with the individual during the 6-month 

23 period preceding such certification or recertifi24 cation, or other reasonable timeframe as deter25 mined by the Secretary’’. 


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1 (b) CONDITION OF PAYMENT FOR DURABLE MED2 ICAL EQUIPMENT.—Section 1834(a)(11)(B) of the Social 

3 Security Act (42 U.S.C. 1395m(a)(11)(B)) is amended by 

4 adding before the period at the end the following: ‘‘and 

5 shall require that any written order required for payment 

6 under this subsection be written only pursuant to the eligi7 ble health care professional authorized to make such writ8 ten order documenting that such professional has had a 

9 face-to-face encounter (including through use of telehealth 

10 and other than with respect to encounters that are inci11 dent to services involved) with the individual involved dur12 ing the 6-month period preceding such written order, or 

13 other reasonable timeframe as determined by the Sec14 retary’’. 

15 (c) APPLICATION TO OTHER AREAS UNDER MEDI16 CARE.—The Secretary may apply a face-to-face encounter 

17 requirement similar to the requirement described in the 

18 amendments made by subsections (a) and (b) to other 

19 items and services for which payment is provided under 

20 title XVIII of the Social Security Act based upon a finding 

21 that such a decision would reduce the risk of waste, fraud, 

22 or abuse. 

23 (d) APPLICATION TO MEDICAID AND CHIP.—The 

24 face-to-face encounter requirements described in the 

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1 panded application of similar requirements pursuant to 

2 subsection (c) shall apply with respect to a certification 

3 or recertification for home health services under title XIX 

4 or XXI of the Social Security Act, a written order for du5 rable medical equipment under such title, and any other 

6 applicable item or service identified pursuant to subsection 

7 (c) for which payment is made under such title, respec8 tively, in the same manner and to the same extent as such 

9 requirements apply in the case of such a certification or 

10 recertification, written order, or other applicable item or 

11 service so identified, respectively, under title XVIII of such 

12 Act. 

13 SEC. 1640. EXTENSION OF TESTIMONIAL SUBPOENA AU14 THORITY TO PROGRAM EXCLUSION INVES15 TIGATIONS. 

16 (a) IN GENERAL.—Section 1128(f) of the Social Se17 curity Act (42 U.S.C. 1320a-7(f)) is amended by adding 

18 at the end the following new paragraph: 

19 ‘‘(4) The provisions of subsections (d) and (e) of sec20 tion 205 shall apply with respect to this section to the 

21 same extent as they are applicable with respect to title 

22 II. The Secretary may delegate the authority granted by 

23 section 205(d) (as made applicable to this section) to the 

24 Inspector General of the Department of Health and 

25 Human Services or the Administrator of the Centers for 


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1 Medicare & Medicaid Services for purposes of any inves2 tigation under this section.’’. 

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

4 subsection (a) shall apply to investigations beginning on 

5 or after January 1, 2010. 

6 SEC. 1641. REQUIRED REPAYMENTS OF MEDICARE AND 

7 MEDICAID OVERPAYMENTS. 

8 Section 1128G of the Social Security Act, as inserted 

9 by section 1631 and amended by section 1632, is further 

10 amended by adding at the end the following new sub11 section: 

12 ‘‘(c) REPORTS ON AND REPAYMENT OF OVERPAY13 MENTS IDENTIFIED THROUGH INTERNAL AUDITS AND

14 REVIEWS.— 

15 ‘‘(1) REPORTING AND RETURNING OVERPAY16 MENTS.—If a person knows of an overpayment, the 

17 person must— 

18 ‘‘(A) report and return the overpayment to 

19 the Secretary, the State, an intermediary, a 

20 carrier, or a contractor, as appropriate, at the 

21 correct address, and 

22 ‘‘(B) notify the Secretary, the State, inter23 mediary, carrier, or contractor to whom the 

24 overpayment was returned in writing of the rea25 son for the overpayment. 


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1 ‘‘(2) TIMING.—Subject to section 1620(d) of 

2 the Affordable Health Care for America Act, an 

3 overpayment must be reported and returned under 

4 paragraph (1)(A) by not later than the date that is 

5 60 days after the date the person knows of the over6 payment. 

7 Any known overpayment retained later than the ap8 plicable date specified in this paragraph creates an 

9 obligation as defined in section 3729(b)(3) of title 

10 31 of the United States Code. 

11 ‘‘(3) CLARIFICATION.—Repayment of any over12 payments (or refunding by withholding of future 

13 payments) by a provider of services or supplier does 

14 not otherwise limit the provider or supplier’s poten15 tial liability for administrative obligations such as 

16 applicable interests, fines, and penalties or civil or 

17 criminal sanctions involving the same claim if it is 

18 determined later that the reason for the overpay19 ment was related to fraud or other intentional con20 duct by the provider or supplier or the employees or 

21 agents of such provider or supplier. 

22 ‘‘(4) DEFINITIONS.—In this subsection: 

23 ‘‘(A) KNOWS.—The term ‘knows’ has the 

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1 ingly’ in section 3729(b) of title 31 of the 

2 United States Code. 

3 ‘‘(B) OVERPAYMENT.—The term ‘‘overpay4 ment’’ means any funds that a person receives 

5 or retains under title XVIII, XIX, or XXI to 

6 which the person, after applicable reconciliation 

7 (pursuant to the applicable existing process 

8 under the respective title), is not entitled under 

9 such title. 

10 ‘‘(C) PERSON.—The term ‘person’ means a 

11 provider of services, supplier, Medicaid man12 aged care organization (as defined in section 

13 1903(m)(1)(A)), Medicare Advantage organiza14 tion (as defined in section 1859(a)(1)), or PDP 

15 sponsor (as defined in section 1860D– 

16 41(a)(13)), but excluding a beneficiary.’’. 

17 SEC. 1642. EXPANDED APPLICATION OF HARDSHIP WAIV18 ERS FOR OIG EXCLUSIONS TO BENE19 FICIARIES OF ANY FEDERAL HEALTH CARE 

20 PROGRAM. 

21 Section 1128(c)(3)(B) of the Social Security Act (42 

22 U.S.C. 1320a–7(c)(3)(B)) is amended by striking ‘‘indi23 viduals entitled to benefits under part A of title XVIII 

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1 ing ‘‘beneficiaries (as defined in section 1128A(i)(5)) of 

2 that program’’. 

3 SEC. 1643. ACCESS TO CERTAIN INFORMATION ON RENAL 

4 DIALYSIS FACILITIES. 

5 Section 1881(b) of the Social Security Act (42 U.S.C. 

6 1395rr(b)) is amended by adding at the end the following 

7 new paragraph: 

8 ‘‘(15) For purposes of evaluating or auditing pay9 ments made to renal dialysis facilities for items and serv10 ices under this section under paragraph (1), each such 

11 renal dialysis facility, upon the request of the Secretary, 

12 shall provide to the Secretary access to information relat13 ing to any ownership or compensation arrangement be14 tween such facility and the medical director of such facility 

15 or between such facility and any physician.’’. 

16 SEC. 1644. BILLING AGENTS, CLEARINGHOUSES, OR OTHER 

17 ALTERNATE PAYEES REQUIRED TO REG18 ISTER UNDER MEDICARE. 

19 (a) MEDICARE.—Section 1866(j)(1) of the Social Se20 curity Act (42 U.S.C. 1395cc(j)(1)) is amended by adding 

21 at the end the following new subparagraph: 

22 ‘‘(D) BILLING AGENTS AND CLEARING23 HOUSES REQUIRED TO BE REGISTERED UNDER

24 MEDICARE.—Any agent, clearinghouse, or other 

25 alternate payee that submits claims on behalf of 


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1 a health care provider must be registered with 

2 the Secretary in a form and manner specified 

3 by the Secretary.’’. 

4 (b) MEDICAID.—For a similar provision with respect 

5 to the Medicaid program under title XIX of the Social Se6 curity Act, see section 1759. 

7 (c) EFFECTIVE DATE.—The amendment made by 

8 subsection (a) shall apply to claims submitted on or after 

9 January 1, 2012. 

10 SEC. 1645. CONFORMING CIVIL MONETARY PENALTIES TO 

11 FALSE CLAIMS ACT AMENDMENTS. 

12 Section 1128A of the Social Security Act, as amended 

13 by sections 1611, 1612, 1613, and 1615, is further 

14 amended— 

15 (1) in subsection (a)— 

16 (A) in paragraph (1), by striking ‘‘to an 

17 officer, employee, or agent of the United States, 

18 or of any department or agency thereof, or of 

19 any State agency (as defined in subsection 

20 (i)(1))’’; 

21 (B) in paragraph (4)— 

22 (i) in the matter preceding subpara23 graph (A), by striking ‘‘participating in a 

24 program under title XVIII or a State 

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1 ticipating in a Federal health care program 

2 (as defined in section 1128B(f))’’; and 

3 (ii) in subparagraph (A), by striking 

4 ‘‘title XVIII or a State health care pro5 gram’’ and inserting ‘‘a Federal health 

6 care program (as defined in section 

7 1128B(f))’’; 

8 (C) by striking ‘‘or’’ at the end of para9 graph (10); 

10 (D) by inserting after paragraph (11) the 

11 following new paragraphs: 

12 ‘‘(12) conspires to commit a violation of this 

13 section; or 

14 ‘‘(13) knowingly makes, uses, or causes to be 

15 made or used, a false record or statement material 

16 to an obligation to pay or transmit money or prop17 erty to a Federal health care program, or knowingly 

18 conceals or knowingly and improperly avoids or de19 creases an obligation to pay or transmit money or 

20 property to a Federal health care program;’’; and 

21 (E) in the matter following paragraph 

22 (13), as inserted by subparagraph (D)— 

23 (i) by striking ‘‘or’’ before ‘‘in cases 

24 under paragraph (11)’’; and 


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1 (ii) by inserting ‘‘, in cases under 

2 paragraph (12), $50,000 for any violation 

3 described in this section committed in fur4 therance of the conspiracy involved; or in 

5 cases under paragraph (13), $50,000 for 

6 each false record or statement, or conceal7 ment, avoidance, or decrease’’ after ‘‘by an 

8 excluded individual’’; and 

9 (F) in the second sentence, by striking 

10 ‘‘such false statement, omission, or misrepre11 sentation)’’ and inserting ‘‘such false statement 

12 or misrepresentation, in cases under paragraph 

13 (12), an assessment of not more than 3 times 

14 the total amount that would otherwise apply for 

15 any violation described in this section com16 mitted in furtherance of the conspiracy in17 volved, or in cases under paragraph (13), an as18 sessment of not more than 3 times the total 

19 amount of the obligation to which the false 

20 record or statement was material or that was 

21 avoided or decreased)’’. 

22 (2) in subsection (c)(1), by striking ‘‘six years’’ 

23 and inserting ‘‘10 years’’; and 

24 (3) in subsection (i)— 


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1 (A) by amending paragraph (2) to read as 

2 follows: 

3 ‘‘(2) The term ‘claim’ means any application, 

4 request, or demand, whether under contract, or oth5 erwise, for money or property for items and services 

6 under a Federal health care program (as defined in 

7 section 1128B(f)), whether or not the United States 

8 or a State agency has title to the money or property, 

9 that— 

10 ‘‘(A) is presented or caused to be pre11 sented to an officer, employee, or agent of the 

12 United States, or of any department or agency 

13 thereof, or of any State agency (as defined in 

14 subsection (i)(1)); or 

15 ‘‘(B) is made to a contractor, grantee, or 

16 other recipient if the money or property is to be 

17 spent or used on the Federal health care pro18 gram’s behalf or to advance a Federal health 

19 care program interest, and if the Federal health 

20 care program— 

21 ‘‘(i) provides or has provided any por22 tion of the money or property requested or 

23 demanded; or 

24 ‘‘(ii) will reimburse such contractor, 

25 grantee, or other recipient for any portion 


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1 of the money or property which is re2 quested or demanded.’’; 

3 (B) by amending paragraph (3) to read as 

4 follows: 

5 ‘‘(3) The term ‘item or service’ means, without 

6 limitation, any medical, social, management, admin7 istrative, or other item or service used in connection 

8 with or directly or indirectly related to a Federal 

9 health care program.’’; 

10 (C) in paragraph (6)— 

11 (i) in subparagraph (C), by striking at 

12 the end ‘‘or’’; 

13 (ii) in the first subparagraph (D), by 

14 striking at the end the period and inserting 

15 ‘‘; or’’; and 

16 (iii) by redesignating the second sub17 paragraph (D) as a subparagraph (E); 

18 (D) by amending paragraph (7) to read as 

19 follows: 

20 ‘‘(7) The terms ‘knowing’, ‘knowingly’, and 

21 ‘should know’ mean that a person, with respect to 

22 information— 

23 ‘‘(A) has actual knowledge of the informa24 tion; 


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1 ‘‘(B) acts in deliberate ignorance of the 

2 truth or falsity of the information; or 

3 ‘‘(C) acts in reckless disregard of the truth 

4 or falsity of the information; 

5 and require no proof of specific intent to defraud.’’; 

6 and 

7 (E) by adding at the end the following new 

8 paragraphs: 

9 ‘‘(8) The term ‘obligation’ means an established 

10 duty, whether or not fixed, arising from an express 

11 or implied contractual, grantor-grantee, or licensor12 licensee relationship, from a fee-based or similar re13 lationship, from statute or regulation, or from the 

14 retention of any overpayment. 

15 ‘‘(9) The term ‘material’ means having a nat16 ural tendency to influence, or be capable of influ17 encing, the payment or receipt of money or prop18 erty.’’. 


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1 SEC. 1646. REQUIRING PROVIDER AND SUPPLIER PAY2 MENTS UNDER MEDICARE TO BE MADE 

3 THROUGH DIRECT DEPOSIT OR ELECTRONIC 

4 FUNDS TRANSFER (EFT) AT INSURED DEPOSI5 TORY INSTITUTIONS. 

6 (a) MEDICARE.—Section 1874 of the Social Security 

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

8 the following new subsection: 

9 ‘‘(e) LIMITATION ON PAYMENT TO PROVIDERS OF

10 SERVICES AND SUPPLIERS.—No payment shall be made 

11 under this title for items and services furnished by a pro12 vider of services or supplier unless each payment to the 

13 provider of services or supplier is in the form of direct 

14 deposit or electronic funds transfer to the provider of serv15 ices’ or supplier’s account, as applicable, at a depository 

16 institution (as defined in section 19(b)(1)(A) of the Fed17 eral Reserve Act.’’. 

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

19 this section shall apply to each payment made to a pro20 vider of services, provider, or supplier on or after such 

21 date (not later than July 1, 2012) as the Secretary of 

22 Health and Human Services shall specify, regardless of 

23 when the items and services for which such payment is 

24 made were furnished. 


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1 SEC. 1647. INSPECTOR GENERAL FOR THE HEALTH 

2 CHOICES ADMINISTRATION. 

3 (a) ESTABLISHMENT; APPOINTMENT.—There is 

4 hereby established an Office of Inspector General for the 

5 Health Choices Administration, to be headed by the In6 spector General for the Health Choices Administration to 

7 be appointed by the President, by and with the advice and 

8 consent of the Senate. 

9 (b) AMENDMENTS TO THE INSPECTOR GENERAL ACT

10 OF 1978.— 

11 (1) APPLICATION TO HEALTH CHOICES ADMIN12 ISTRATION.—Section 12 of the Inspector General 

13 Act of 1978 (5 U.S.C. App.) is amended— 

14 (A) in paragraph (1), by striking ‘‘or the 

15 Federal Cochairpersons of the Commissions es16 tablished under section 15301 of title 40, 

17 United States Code’’ and inserting ‘‘the Federal 

18 Cochairpersons of the Commissions established 

19 under section 15301 of title 40, United States 

20 Code; or the Commissioner of the Health 

21 Choices Administration established under sec22 tion 241 of the Affordable Health Care for 

23 America Act’’; and 

24 (B) in paragraph (2), by striking ‘‘or the 

25 Commissions established under section 15301 

26 of title 40, United States Code’’ and inserting 


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1 ‘‘the Commissions established under section 

2 15301 of title 40, United States Code, or the 

3 Health Choices Administration established 

4 under section 241 of the Affordable Health 

5 Care for America Act’’. 

6 (2) SPECIAL PROVISIONS RELATING TO HEALTH

7 CHOICES ADMINISTRATION AND HHS.—The Inspec8 tor General Act of 1978 (5 U.S.C. App.) is further 

9 amended by inserting after section 8L the following 

10 new section: 

11 ‘‘SEC. 8M SPECIAL PROVISIONS RELATING TO THE HEALTH 

12 CHOICES ADMINISTRATION AND THE DE13 PARTMENT OF HEALTH AND HUMAN SERV14 ICES. 

15 ‘‘(a) The Inspector General of the Health Choices Ad16 ministration shall— 

17 ‘‘(1) have the authority to conduct, supervise, 

18 and coordinate audits, evaluations, and investiga19 tions of the programs and operations of the Health 

20 Choices Administration established under section 

21 241 of the Affordable Health Care for America Act, 

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1 ticipating in the Health Insurance Exchange estab2 lished under section 301 of such Act; 

3 ‘‘(2) have the authority to conduct audits, eval4 uations, and investigations relating to any private 

5 Exchange-participating health benefits plan, as de6 fined in section 201(c) of such Act; 

7 ‘‘(3) have the authority, in consultation with 

8 the Office of Inspector General for the Department 

9 of Health and Human Services and subject to sub10 section (b), to conduct audits, evaluations, and in11 vestigations relating to the public health insurance 

12 option established under section 321 of such Act; 

13 and 

14 ‘‘(4) have access to all relevant records nec15 essary to carry out this section, including records re16 lating to claims paid by Exchange-participating 

17 health benefits plans. 

18 ‘‘(b) Authority granted to the Health Choices Admin19 istration and the Inspector General of the Health Choices 

20 Administration by the Affordable Health Care for America 

21 Act does not limit the duties, authorities, and responsibil22 ities of the Office of Inspector General for the Department 

23 of Health and Human Services, as in existence as of the 

24 date of the enactment of the Affordable Health Care for 

25 America Act , to oversee programs and operations of such 


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1 department. The Office of Inspector General for the De2 partment of Health and Human Services retains primary 

3 jurisdiction over fraud and abuse in connection with pay4 ments made under the public health insurance option es5 tablished under section 321 of such Act and administered 

6 by the Department of Health and Human Services.’’. 

7 (3) APPLICATION OF RULE OF CONSTRUC8 TION.—Section 8J of the Inspector General Act of 

9 1978 (5 U.S.C. App.) is amended by striking ‘‘or 

10 8H’’ and inserting ‘‘, 8H, or 8M’’. 

11 (c) EFFECTIVE DATE.—The provisions of and 

12 amendments made by this section shall take effect on the 

13 date of the enactment of this Act. 

14 Subtitle D—Access to Information 

15 Needed to Prevent Fraud, 

16 Waste, and Abuse 

17 SEC. 1651. ACCESS TO INFORMATION NECESSARY TO IDEN18 TIFY FRAUD, WASTE, AND ABUSE. 

19 (a) GAO ACCESS.—Subchapter II of chapter 7 of 

20 title 31, United States Code, is amended by adding at the 

21 end the following: 

22 ‘‘§ 721. Access to certain information 

23 ‘‘No provision of the Social Security Act shall be con24 strued to limit, amend, or supersede the authority of the 

25 Comptroller General to obtain any information, to inspect 


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1 any record, or to interview any officer or employee under 

2 section 716 of this title, including with respect to any in3 formation disclosed to or obtained by the Secretary of 

4 Health and Human Services under part C or D of title 

5 XVIII of the Social Security Act.’’. 

6 (b) ACCESS TO MEDICARE PART D DATA PROGRAM

7 INTEGRITY PURPOSES.— 

8 (1) PROVISION OF INFORMATION AS CONDITION

9 OF PAYMENT.—Section 1860D–15(d)(2)(B) of the 

10 Social Security Act (42 U.S.C. 1395w– 

11 115(d)(2)(B)) is amended— 

12 (A) by striking ‘‘may be used by officers’’ 

13 and all that follows through the period and in14 serting ‘‘may be used by—’’; and 

15 (B) by adding at the end the following 

16 clauses: 

17 ‘‘(i) officers, employees, and contrac18 tors of the Department of Health and 

19 Human Services only for the purposes of, 

20 and to the extent necessary in, carrying 

21 out this section; and 

22 ‘‘(ii) the Inspector General of the De23 partment of Health and Human Services, 

24 the Administrator of the Centers for Medi25 care & Medicaid Services, and the Attorney 


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1 General only for the purposes of protecting 

2 the integrity of the programs under this 

3 title and title XIX; conducting the activi4 ties described in section 1893 and subpara5 graphs (A) through (E) of section 

6 1128C(a)(1); and for investigation, audit, 

7 evaluation, oversight, and law enforce8 ment purposes to the extent consistent 

9 with applicable law.’’. 

10 (2) GENERAL DISCLOSURE OF INFORMATION.— 

11 Section 1860D–15(f)(2) of the Social Security Act 

12 (42 U.S.C. 1395w–115(f)(2)) is amended— 

13 (A) by striking ‘‘may be used by officers’’ 

14 and all that follows through the period and in15 serting ‘‘may be used by—’’; and 

16 (B) by adding at the end the following sub17 paragraphs: 

18 ‘‘(A) officers, employees, and contractors 

19 of the Department of Health and Human Serv20 ices only for the purposes of, and to the extent 

21 necessary in, carrying out this section; and 

22 ‘‘(B) the Inspector General of the Depart23 ment of Health and Human Services, the Ad24 ministrator of the Centers for Medicare & Med25 icaid Services, and the Attorney General only 


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1 for the purposes of protecting the integrity of 

2 the programs under this title and title XIX; 

3 conducting the activities described in section 

4 1893 and subparagraphs (A) through (E) of 

5 section 1128C(a)(1); and for investigation, 

6 audit, evaluation, oversight, and law enforce7 ment purposes to the extent consistent with ap8 plicable law.’’. 

9 SEC. 1652. ELIMINATION OF DUPLICATION BETWEEN THE 

10 HEALTHCARE INTEGRITY AND PROTECTION 

11 DATA BANK AND THE NATIONAL PRACTI12 TIONER DATA BANK. 

13 (a) IN GENERAL.—To eliminate duplication between 

14 the Healthcare Integrity and Protection Data Bank 

15 (HIPDB) established under section 1128E of the Social 

16 Security Act and the National Practitioner Data Bank 

17 (NPBD) established under the Health Care Quality Im18 provement Act of 1986, section 1128E of the Social Secu19 rity Act (42 U.S.C. 1320a-7e) is amended— 

20 (1) in subsection (a), by striking ‘‘Not later 

21 than’’ and inserting ‘‘Subject to subsection (h), not 

22 later than’’; 

23 (2) in the first sentence of subsection (d)(2), by 

24 striking ‘‘(other than with respect to requests by 

25 Federal agencies)’’; and 


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1 (3) by adding at the end the following new sub2 section: 

3 ‘‘(h) SUNSET OF THE HEALTHCARE INTEGRITY AND

4 PROTECTION DATA BANK; TRANSITION PROCESS.—Ef5 fective upon the enactment of this subsection, the Sec6 retary shall implement a process to eliminate duplication 

7 between the Healthcare Integrity and Protection Data 

8 Bank (in this subsection referred to as the ‘HIPDB’ es9 tablished pursuant to subsection (a) and the National 

10 Practitioner Data Bank (in this subsection referred to as 

11 the ‘NPDB’) as implemented under the Health Care Qual12 ity Improvement Act of 1986 and section 1921 of this Act, 

13 including systems testing necessary to ensure that infor14 mation formerly collected in the HIPDB will be accessible 

15 through the NPDB, and other activities necessary to 

16 eliminate duplication between the two data banks. Upon 

17 the completion of such process, notwithstanding any other 

18 provision of law, the Secretary shall cease the operation 

19 of the HIPDB and shall collect information required to 

20 be reported under the preceding provisions of this section 

21 in the NPDB. Except as otherwise provided in this sub22 section, the provisions of subsections (a) through (g) shall 

23 continue to apply with respect to the reporting of (or fail24 ure to report), access to, and other treatment of the infor25 mation specified in this section.’’. 


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1 (b) ELIMINATION OF THE RESPONSIBILITY OF THE

2 HHS OFFICE OF THE INSPECTOR GENERAL.—Section 

3 1128C(a)(1) of the Social Security Act (42 U.S.C. 1320a4 7c(a)(1)) is amended— 

5 (1) in subparagraph (C), by adding at the end 

6 ‘‘and’’; 

7 (2) in subparagraph (D), by striking at the end 

8 ‘‘, and’’ and inserting a period; and 

9 (3) by striking subparagraph (E). 

10 (c) SPECIAL PROVISION FOR ACCESS TO THE NA11 TIONAL PRACTITIONER DATA BANK BY THE DEPART12 MENT OF VETERANS AFFAIRS.— 

13 (1) IN GENERAL.—Notwithstanding any other 

14 provision of law, during the one year period that be15 gins on the effective date specified in subsection 

16 (e)(1), the information described in paragraph (2) 

17 shall be available from the National Practitioner 

18 Data Bank (described in section 1921 of the Social 

19 Security Act) to the Secretary of Veterans Affairs 

20 without charge. 

21 (2) INFORMATION DESCRIBED.—For purposes 

22 of paragraph (1), the information described in this 

23 paragraph is the information that would, but for the 

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1 able to the Secretary of Veterans Affairs from the 

2 Healthcare Integrity and Protection Data Bank. 

3 (d) FUNDING.—Notwithstanding any provisions of 

4 this Act, sections 1128E(d)(2) and 1817(k)(3) of the So5 cial Security Act, or any other provision of law, there shall 

6 be available for carrying out the transition process under 

7 section 1128E(h) of the Social Security Act over the pe8 riod required to complete such process, and for operation 

9 of the National Practitioner Data Bank until such process 

10 is completed, without fiscal year limitation— 

11 (1) any fees collected pursuant to section 

12 1128E(d)(2) of such Act; and 

13 (2) such additional amounts as necessary, from 

14 appropriations available to the Secretary and to the 

15 Office of the Inspector General of the Department of 

16 Health and Human Services under clauses (i) and 

17 (ii), respectively, of section 1817(k)(3)(A) of such 

18 Act, for costs of such activities during the first 12 

19 months following the date of the enactment of this 

20 Act. 

21 (e) EFFECTIVE DATE.—The amendments made— 

22 (1) by subsection (a)(2) shall take effect on the 

23 first day after the Secretary of Health and Human 

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1 suant to section 1128E(h) of the Social Security Act 

2 (as added by subsection (a)(3)) is complete; and 

3 (2) by subsection (b) shall take effect on the 

4 earlier of the date specified in paragraph (1) or the 

5 first day of the second succeeding fiscal year after 

6 the fiscal year during which this Act is enacted. 

7 SEC. 1653. COMPLIANCE WITH HIPAA PRIVACY AND SECU8 RITY STANDARDS. 

9 The provisions of sections 262(a) and 264 of the 

10 Health Insurance Portability and Accountability Act of 

11 1996 (and standards promulgated pursuant to such sec12 tions) and the Privacy Act of 1974 shall apply with respect 

13 to the provisions of this subtitle and amendments made 

14 by this subtitle. 

15 TITLE VII—MEDICAID AND CHIP 

16 SEC. 1. TABLE OF CONTENTS øTEMPORARY¿. 

Sec. 1. Table of contents øTemporary¿. 

Subtitle A—Medicaid and Health Reform 

Sec. 1701. Eligibility for individuals with income below 150 percent of the Federal poverty level. 

Sec. 1702. Requirements and special rules for certain Medicaid eligible individuals. 

Sec. 1703. CHIP and Medicaid maintenance of eligibility. 

Sec. 1704. Reduction in Medicaid DSH. 

Sec. 1705. Expanded outstationing. 

Subtitle B—Prevention 

Sec. 1711. Required coverage of preventive services. 

Sec. 1712. Tobacco cessation. 

Sec. 1713. Optional coverage of nurse home visitation services. 

Sec. 1714. State eligibility option for family planning services. 

Subtitle C—Access 


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Sec. 1721. Payments to primary care practitioners. 

Sec. 1722. Medical home pilot program. 

Sec. 1723. Translation or interpretation services. 

Sec. 1724. Optional coverage for freestanding birth center services. 

Sec. 1725. Inclusion of public health clinics under the vaccines for children program. 

Sec. 1726. Requiring coverage of services of podiatrists. 

Sec. 1726A. Requiring coverage of services of optometrists. 

Sec. 1727. Therapeutic foster care. 

Sec. 1728. Assuring adequate payment levels for services. 

Sec. 1729. Preserving Medicaid coverage for youths upon release from public 

institutions. 

Sec. 1730. Quality measures for maternity and adult health services under 

Medicaid and CHIP. 

Sec. 1730A. Accountable care organization pilot program. 

Sec. 1730B. FQHC coverage. 

Subtitle D—Coverage 

Sec. 1731. Optional Medicaid coverage of low-income HIV-infected individuals. 

Sec. 1732. Extending transitional Medicaid Assistance (TMA). 

Sec. 1733. Requirement of 12-month continuous coverage under certain CHIP 

programs. 

Sec. 1734. Preventing the application under CHIP of coverage waiting periods 

for certain children. 

Sec. 1735. Adult day health care services. 

Sec. 1736. Medicaid coverage for citizens of Freely Associated States. 

Sec. 1737. Continuing requirement of Medicaid coverage of nonemergency 

transportation to medically necessary services. 

Sec. 1738. State option to disregard certain income in providing continued 

Medicaid coverage for certain individuals with extremely high 

prescription costs. 

Sec. 1739. Provisions relating to community living assistance services and supports (CLASS). 

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. 


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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. 

1 Subtitle A—Medicaid and Health 

2 Reform 

3 SEC. 1701. ELIGIBILITY FOR INDIVIDUALS WITH INCOME 

4 BELOW 150 PERCENT OF THE FEDERAL POV5 ERTY LEVEL. 

6 (a) ELIGIBILITY FOR NON-TRADITIONAL INDIVID7 UALS WITH INCOME BELOW 150 PERCENT OF THE FED8 ERAL POVERTY LEVEL.— 

9 (1) FULL MEDICAID BENEFITS FOR NON-MEDI10 CARE ELIGIBLE INDIVIDUALS.—Section 


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1 1902(a)(10)(A)(i) of the Social Security Act (42 

2 U.S.C. 1396b(a)(10)(A)(i)) is amended— 

3 (A) by striking ‘‘or’’ at the end of sub4 clause (VI); 

5 (B) by adding ‘‘or’’ at the end of subclause 

6 (VII); and 

7 (C) by adding at the end the following new 

8 subclause: 

9 ‘‘(VIII) who are under 65 years 

10 of age, who are not described in a pre11 vious subclause of this clause, who are 

12 not entitled to hospital insurance ben13 efits under part A of title XVIII, and 

14 whose family income (determined 

15 using methodologies and procedures 

16 specified by the Secretary in consulta17 tion with the Health Choices Commis18 sioner) does not exceed 150 percent of 

19 the income official poverty line (as de20 fined by the Office of Management 

21 and Budget, and revised annually in 

22 accordance with section 673(2) of the 

23 Omnibus Budget Reconciliation Act of 

24 1981) applicable to a family of the 

25 size involved;’’. 


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1 (2) MEDICARE COST SHARING ASSISTANCE FOR

2 MEDICARE-ELIGIBLE INDIVIDUALS.—Section 

3 1902(a)(10)(E) of such Act (42 U.S.C. 

4 1396b(a)(10)(E)) is amended— 

5 (A) in clause (iii), by striking ‘‘and’’ at the 

6 end; 

7 (B) in clause (iv), by adding ‘‘and’’ at the 

8 end; and 

9 (C) by adding at the end the following new 

10 clause: 

11 ‘‘(v) for making medical assistance avail12 able for medicare cost-sharing described in sub13 paragraphs (B) and (C) of section 1905(p)(3), 

14 for individuals under 65 years of age who would 

15 be qualified medicare beneficiaries described in 

16 section 1905(p)(1) but for the fact that their 

17 income exceeds the income level established by 

18 the State under section 1905(p)(2) but is less 

19 than 150 percent of the official poverty line (re20 ferred to in such section) for a family of the 

21 size involved; and’’. 

22 (3) INCREASED FMAP FOR NON-TRADITIONAL

23 FULL MEDICAID ELIGIBLE INDIVIDUALS.—Section 

24 1905 of such Act (42 U.S.C. 1396d) is amended— 


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1 (A) in the first sentence of subsection (b), 

2 by striking ‘‘and’’ before ‘‘(4)’’ and by inserting 

3 before the period at the end the following: ‘‘, 

4 and (5) 100 percent (for periods before 2015 

5 and 91 percent for periods beginning with 

6 2015) with respect to amounts described in 

7 subsection (y)’’; and 

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

9 subsection: 

10 ‘‘(y) ADDITIONAL EXPENDITURES SUBJECT TO IN11 CREASED FMAP.—For purposes of section 1905(b)(5), 

12 the amounts described in this subsection are the following: 

13 ‘‘(1) Amounts expended for medical assistance 

14 for individuals described in subclause (VIII) of sec15 tion 1902(a)(10)(A)(i).’’. 

16 (4) CONSTRUCTION.—Nothing in this sub17 section shall be construed as not providing for cov18 erage under subparagraph (A)(i)(VIII) or (E)(v) of 

19 section 1902(a)(10) of the Social Security Act, as 

20 added by paragraphs (1) and (2), or an increased 

21 FMAP under the amendments made by paragraph 

22 (3), for an individual who has been provided medical 

23 assistance under title XIX of the Act under a dem24 onstration waiver approved under section 1115 of 

25 such Act or with State funds. 


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1 (5) CONFORMING AMENDMENTS.— 

2 (A) Section 1903(f)(4) of the Social Secu3 rity Act (42 U.S.C. 1396b(f)(4)) is amended— 

4 (i) by inserting 

5 ‘‘1902(a)(10)(A)(i)(VIII),’’ after 

6 ‘‘1902(a)(10)(A)(i)(VII),’’; and 

7 (ii) by inserting ‘‘1902(a)(10)(E)(v),’’ 

8 before ‘‘1905(p)(1)’’. 

9 (B) Section 1905(a) of such Act (42 

10 U.S.C. 1396d(a)), as amended by sections 

11 1714(a)(4) and 1731(c), is further amended, in 

12 the matter preceding paragraph (1)— 

13 (i) by striking ‘‘or’’ at the end of 

14 clause (xiv); 

15 (ii) by adding ‘‘or’’ at the end of 

16 clause (xv); and 

17 (iii) by inserting after clause (xv) the 

18 following: 

19 ‘‘(xvi) individuals described in section 

20 1902(a)(10)(A)(i)(VIII),’’. 

21 (b) ELIGIBILITY FOR TRADITIONAL MEDICAID ELI22 GIBLE INDIVIDUALS WITH INCOME NOT EXCEEDING 150 

23 PERCENT OF THE FEDERAL POVERTY LEVEL .— 

24 (1) IN GENERAL.—Section 1902(a)(10)(A)(i) of 

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


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1 1396b(a)(10)(A)(i)), as amended by subsection (a), 

2 is amended— 

3 (A) by striking ‘‘or’’ at the end of sub4 clause (VII); and 

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

6 subclause: 

7 ‘‘(IX) who are over 18, and 

8 under 65 years of age, who would be 

9 eligible for medical assistance under 

10 the State plan under subclause (I) or 

11 section 1931 (based on the income 

12 standards, methodologies, and proce13 dures in effect as of June 16, 2009) 

14 but for income, who are in families 

15 whose income does not exceed 150 

16 percent of the income official poverty 

17 line (as defined by the Office of Man18 agement and Budget, and revised an19 nually in accordance with section 

20 673(2) of the Omnibus Budget Rec21 onciliation Act of 1981) applicable to 

22 a family of the size involved; or 

23 ‘‘(X) beginning with 2014, who 

24 are over 5, and under 19, years of 

25 age, who would be eligible for medical 


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1 assistance under the State plan under 

2 subclause (I) or (VII) (based on the 

3 income standards, methodologies, and 

4 procedures in effect as of June 16, 

5 2009) but for income, who are in fam6 ilies whose income does not exceed 

7 150 percent of the income official pov8 erty line (as defined by the Office of 

9 Management and Budget, and revised 

10 annually in accordance with section 

11 673(2) of the Omnibus Budget Rec12 onciliation Act of 1981) applicable to 

13 a family of the size involved; or 

14 ‘‘(XI) beginning with 2014, who 

15 are under 19 years of age, who are 

16 not described in subclause (X), and 

17 who would be eligible for child health 

18 assistance under a State child health 

19 plan insofar as such plan provides 

20 benefits under this title (as described 

21 in section 2101(a)(2)) based on such 

22 plan as in effect as of June 16, 2009; 

23 or’’. 

24 (2) INCREASED FMAP FOR CERTAIN TRADI25 TIONAL MEDICAID ELIGIBLE INDIVIDUALS.— 


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1 (A) INCREASED FMAP FOR ADULTS.—Sec2 tion 1905(y) of such Act (42 U.S.C. 1396d(y)), 

3 as added by subsection (a)(2)(B), is amended 

4 by inserting ‘‘or (IX)’’ after ‘‘(VIII)’’. 

5 (B) ENHANCED FMAP FOR CHILDREN.— 

6 Section 1905(b)(4) of such Act is amended by 

7 inserting ‘‘1902(a)(10)(A)(i)(X), 

8 1902(a)(10)(A)(i)(XI), or’’ after ‘‘on the basis 

9 of section’’. 

10 (3) CONSTRUCTION.—Nothing in this sub11 section shall be construed as not providing for cov12 erage under subclause (IX), (X), or (XI) of section 

13 1902(a)(10)(A)(i) of the Social Security Act, as 

14 added by paragraph (1), or an increased or en15 hanced FMAP under the amendments made by 

16 paragraph (2), for an individual who has been pro17 vided medical assistance under title XIX of the Act 

18 under a demonstration waiver approved under sec19 tion 1115 of such Act or with State funds. 

20 (4) CONFORMING AMENDMENT.—Section 

21 1903(f)(4) of the Social Security Act (42 U.S.C. 

22 1396b(f)(4)), as amended by subsection (a)(4), is 

23 amended by inserting ‘‘1902(a)(10)(A)(i)(IX), 

24 1902(a)(10)(A)(i)(X), 1902(a)(10)(A)(i)(XI),’’ after 

25 ‘‘1902(a)(10)(A)(i)(VIII),’’. 


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1 (c) INCREASED MATCHING RATE FOR TEMPORARY

2 COVERAGE OF CERTAIN NEWBORNS.—Section 1905(y) of 

3 such Act, as added by subsection (a)(3)(B), is amended 

4 by adding at the end the following: 

5 ‘‘(2) Amounts expended for medical assistance 

6 for children described in section 305(d)(1) of the Af7 fordable Health Care for America Act during the 

8 time period specified in such section.’’. 

9 (d) NETWORK ADEQUACY.—Section 1932(a)(2) of 

10 the Social Security Act (42 U.S.C. 1396u–2(a)(2)) is 

11 amended by adding at the end the following new subpara12 graph: 

13 ‘‘(D) ENROLLMENT OF NON-TRADITIONAL

14 MEDICAID ELIGIBLES.—A State may not re15 quire under paragraph (1) the enrollment in a 

16 managed care entity of an individual described 

17 in section 1902(a)(10)(A)(i)(VIII) unless the 

18 State demonstrates, to the satisfaction of the 

19 Secretary, that the entity, through its provider 

20 network and other arrangements, has the ca21 pacity to meet the health, mental health, and 

22 substance abuse needs of such individuals.’’. 

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

24 this section shall take effect on the first day of Y1, and 


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1 shall apply with respect to items and services furnished 

2 on or after such date. 

3 SEC. 1702. REQUIREMENTS AND SPECIAL RULES FOR CER4 TAIN MEDICAID ELIGIBLE INDIVIDUALS. 

5 (a) IN GENERAL.—Title XIX of the Social Security 

6 Act is amended by adding at the end the following new 

7 section: 

8 ‘‘ REQUIREMENTS AND SPECIAL RULES FOR CERTAIN

9 MEDICAID ELIGIBLE INDIVIDUALS

10 ‘‘SEC. 1943. (a) COORDINATION WITH NHI EX11 CHANGE THROUGH MEMORANDUM OF UNDER12 STANDING.— 

13 ‘‘(1) IN GENERAL.—The State shall enter into 

14 a Medicaid memorandum of understanding described 

15 in section 305(e)(2) of the Affordable Health Care 

16 for America Act with the Health Choices Commis17 sioner, acting in consultation with the Secretary, 

18 with respect to coordinating the implementation of 

19 the provisions of division A of such Act with the 

20 State plan under this title in order to ensure the en21 rollment of Medicaid eligible individuals in accept22 able coverage. Nothing in this section shall be con23 strued as permitting such memorandum to modify or 

24 vitiate any requirement of a State plan under this 

25 title. 


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1 ‘‘(2) ENROLLMENT OF EXCHANGE-REFERRED

2 INDIVIDUALS.— 

3 ‘‘(A) NON-TRADITIONAL INDIVIDUALS.— 

4 Pursuant to such memorandum the State shall 

5 accept without further determination the enroll6 ment under this title of an individual deter7 mined by the Commissioner to be a non-tradi8 tional Medicaid eligible individual. The State 

9 shall not do any redeterminations of eligibility 

10 for such individuals unless the periodicity of 

11 such redeterminations is consistent with the pe12 riodicity for redeterminations by the Commis13 sioner of eligibility for affordability credits 

14 under subtitle C of title II of division A of the 

15 Affordable Health Care for America Act, as 

16 specified under such memorandum. 

17 ‘‘(B) TRADITIONAL INDIVIDUALS.—Pursu18 ant to such memorandum, the State shall ac19 cept without further determination the enroll20 ment under this title of an individual deter21 mined by the Commissioner to be a traditional 

22 Medicaid eligible individual. The State may do 

23 redeterminations of eligibility of such individual 

24 consistent with such section and the memo25 randum. 


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1 ‘‘(3) DETERMINATIONS OF ELIGIBILITY FOR

2 AFFORDABILITY CREDITS.—If the Commissioner de3 termines that a State Medicaid agency has the ca4 pacity to make determinations of eligibility for af5 fordability credits under subtitle C of title II of divi6 sion A of the Affordable Health Care for America 

7 Act, under such memorandum— 

8 ‘‘(A) the State Medicaid agency shall con9 duct such determinations for any Exchange-eli10 gible individual who requests such a determina11 tion; 

12 ‘‘(B) in the case that a State Medicaid 

13 agency determines that an Exchange-eligible in14 dividual is not eligible for affordability credits, 

15 the agency shall forward the information on the 

16 basis of which such determination was made to 

17 the Commissioner; and 

18 ‘‘(C) the Commissioner shall reimburse the 

19 State Medicaid agency for the costs of con20 ducting such determinations. 

21 ‘‘(4) REFERRALS UNDER MEMORANDUM.—Pur22 suant to such memorandum, if an individual applies 

23 to the State for assistance in obtaining health cov24 erage and the State determines that the individual 

25 is not eligible for medical assistance under this title 


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1 and is not authorized under such memorandum to 

2 make an determination with respect to eligibility for 

3 coverage and affordability credits through the 

4 Health Insurance Exchange, the State shall refer 

5 the individual to the Commissioner for a determina6 tion of such eligibility and, with the individual’s au7 thorization, provide to the Commissioner information 

8 obtained by the State as part of the application 

9 process. 

10 ‘‘(5) ADDITIONAL TERMS.—Such memorandum 

11 shall include such additional provisions as are nec12 essary to implement efficiently the provisions of this 

13 section and title II of division A of the Affordable 

14 Health Care for America Act. 

15 ‘‘(b) TREATMENT OF CERTAIN NEWBORNS.— 

16 ‘‘(1) IN GENERAL.—In the case of a child who 

17 is deemed under section 305(d) of the Affordable 

18 Health Care for America Act to be a Medicaid eligi19 ble individual and enrolled under this title pursuant 

20 to such section, the State shall provide for a deter21 mination, by not later than the end of the period re22 ferred to in paragraph (2) of such section, of the 

23 child’s eligibility for medical assistance under this 

24 title. 


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1 ‘‘(2) EXTENDED TREATMENT AS TRADITIONAL

2 MEDICAID ELIGIBLE INDIVIDUAL.—In accordance 

3 with paragraph (2) of section 305(d) of the Afford4 able Health Care for America Act, in the case of a 

5 child described in paragraph (1) of such section who 

6 at the end of the period referred to in such para7 graph is not otherwise covered under acceptable cov8 erage, the child shall be deemed (until such time as 

9 the child obtains such coverage or the State other10 wise makes a determination of the child’s eligibility 

11 for medical assistance under its plan under this title 

12 pursuant to paragraph (1)) to be a Medicaid eligible 

13 individual described in section 1902(l)(1)(B). 

14 ‘‘(c) DEFINITIONS.—In this section: 

15 ‘‘(1) MEDICAID ELIGIBLE INDIVIDUAL.—The 

16 term ‘Medicaid eligible individual’ means an indi17 vidual who is eligible for medical assistance under 

18 Medicaid. 

19 ‘‘(2) TRADITIONAL MEDICAID ELIGIBLE INDI20 VIDUAL.—The term ‘traditional Medicaid eligible in21 dividual’ means a Medicaid eligible individual other 

22 than an individual who is— 

23 ‘‘(A) a Medicaid eligible individual by rea24 son of the application of subclause (VIII) of 


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1 section 1902(a)(10)(A)(i) of the Social Security 

2 Act; or 

3 ‘‘(B) a childless adult not described in sec4 tion 1902(a)(10)(A) or (C) of such Act (as in 

5 effect as of the day before the date of the en6 actment of this Act). 

7 ‘‘(3) NON-TRADITIONAL MEDICAID ELIGIBLE

8 INDIVIDUAL.—The term ‘non-traditional Medicaid 

9 eligible individual’ means a Medicaid eligible indi10 vidual who is not a traditional Medicaid eligible indi11 vidual. 

12 ‘‘(4) MEMORANDUM.—The term ‘memorandum’ 

13 means a Medicaid memorandum of understanding 

14 under section 305(e)(2) of the Affordable Health 

15 Care for America Act. 

16 ‘‘(5) Y1.—The term ‘Y1’ has the meaning given 

17 such term in section 100(c) of the Affordable Health 

18 Care for America Act.’’. 

19 (b) CONFORMING AMENDMENTS TO ERROR RATE.— 

20 (1) Section 1903(u)(1)(D) of the Social Secu21 rity Act (42 U.S.C. 1396b(u)(1)(D)) is amended by 

22 adding at the end the following new clause: 

23 ‘‘(vi) In determining the amount of erroneous excess 

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1 bility determination under subtitle C of title II of division 

2 A of the Affordable Health Care for America Act.’’. 

3 (2) Section 2105(c)(11) of such Act (42 U.S.C. 

4 1397ee(c)(11)) is amended by adding at the end the 

5 following new sentence: ‘‘Clause (vi) of section 

6 1903(u)(1)(D) shall apply with respect to the appli7 cation of such requirements under this title and title 

8 XIX.’’. 

9 SEC. 1703. CHIP AND MEDICAID MAINTENANCE OF ELIGI10 BILITY. 

11 (a) CHIP MAINTENANCE OF ELIGIBILITY.—Section 

12 1902 of the Social Security Act (42 U.S.C. 1396a) is 

13 amended— 

14 (1) in subsection (a), as amended by section 

15 1631(b)(1)(D)— 

16 (A) by striking ‘‘and’’ at the end of para17 graph (73); 

18 (B) by striking the period at the end of 

19 paragraph (74) and inserting ‘‘; and’’; and 

20 (C) by inserting after paragraph (74) the 

21 following new paragraph: 

22 ‘‘(75) provide for maintenance of effort under 

23 the State child health plan under title XXI in ac24 cordance with subsection (gg).’’; and 


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1 (2) by adding at the end the following new sub2 section: 

3 ‘‘(gg) CHIP MAINTENANCE OF ELIGIBILITY RE4 QUIREMENT.— 

5 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

6 as a condition of its State plan under this title under 

7 subsection (a)(75) and receipt of any Federal finan8 cial assistance under section 1903(a) for calendar 

9 quarters beginning after the date of the enactment 

10 of this subsection and before CHIP MOE termi11 nation date specified in paragraph (3), a State shall 

12 not have in effect eligibility standards, methodolo13 gies, or procedures under its State child health plan 

14 under title XXI (including any waiver under such 

15 title or demonstration project under section 1115) 

16 that are more restrictive than the eligibility stand17 ards, methodologies, or procedures, respectively, 

18 under such plan (or waiver) as in effect on June 16, 

19 2009. 

20 ‘‘(2) LIMITATION.—Paragraph (1) shall not be 

21 construed as preventing a State from imposing a 

22 limitation described in section 2110(b)(5)(C)(i)(II) 

23 for a fiscal year in order to limit expenditures under 

24 its State child health plan under title XXI to those 


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1 for which Federal financial participation is available 

2 under section 2105 for the fiscal year. 

3 ‘‘(3) CHIP MOE TERMINATION DATE.—In para4 graph (1), the ‘CHIP MOE termination date’ for a 

5 State is the date that is the last day of Y1 (as de6 fined in section 100(c) of the Affordable Health 

7 Care for America Act). 

8 ‘‘(4) CHIP TRANSITION REPORT.—Not later 

9 than December 31, 2011, the Secretary shall submit 

10 to Congress a report— 

11 ‘‘(A) that compares the benefits packages 

12 offered under an average State child health 

13 plan under title XXI in 2011 and to the benefit 

14 standards initially adopted under section 224(b) 

15 of the Affordable Health Care for America Act 

16 and for affordability credits under subtitle C of 

17 title II of division C of such Act; and 

18 ‘‘(B) that includes such recommendations 

19 as may be necessary to ensure that— 

20 ‘‘(i) such coverage is at least com21 parable to the coverage provided to chil22 dren under such an average State child 

23 health plan; and 

24 ‘‘(ii) there are procedures in effect for 

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1 ing CHIP-eligible pregnant women) at the 

2 end of Y1 under this title, into a qualified 

3 health benefits plan offered through the 

4 Health Insurance Exchange, or into other 

5 acceptable coverage (as defined for pur6 poses of such Act) without interruption of 

7 coverage or a written plan of treatment.’’. 

8 (b) MEDICAID MAINTENANCE OF EFFORT; SIMPLI9 FYING AND COORDINATING ELIGIBILITY RULES BE10 TWEEN EXCHANGE AND MEDICAID.— 

11 (1) IN GENERAL.—Section 1903 of such Act 

12 (42 U.S.C. 1396b) is amended by adding at the end 

13 the following new subsection: 

14 ‘‘(aa) MAINTENANCE OF MEDICAID EFFORT; SIMPLI15 FYING AND COORDINATING ELIGIBILITY RULES BE16 TWEEN HEALTH INSURANCE EXCHANGE AND MED17 ICAID.— 

18 ‘‘(1) MAINTENANCE OF EFFORT.— 

19 ‘‘(A) IN GENERAL.—Subject to subpara20 graph (B), a State is not eligible for payment 

21 under subsection (a) for a calendar quarter be22 ginning after the date of the enactment of this 

23 subsection if eligibility standards, methodolo24 gies, or procedures under its plan under this 

25 title (including any waiver under this title or 


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1 demonstration project under section 1115) that 

2 are more restrictive than the eligibility stand3 ards, methodologies, or procedures, respectively, 

4 under such plan (or waiver) as in effect on 

5 June 16, 2009. The Secretary shall extend such 

6 a waiver (including the availability of Federal 

7 financial participation under such waiver) for 

8 such period as may be required for a State to 

9 meet the requirement of the previous sentence. 

10 ‘‘(B) EXCEPTION FOR CERTAIN DEM11 ONSTRATION PROJECTS.—In the case of a State 

12 demonstration project under section 1115 in ef13 fect on June 16, 2009, that permits individuals 

14 to be eligible solely to receive a premium or 

15 cost-sharing subsidy for individual or group 

16 health insurance coverage, effective for coverage 

17 provided in Y1— 

18 ‘‘(i) the Secretary shall permit the 

19 State to amend such waiver to apply more 

20 restrictive eligibility standards, methodolo21 gies, or procedures with respect to such in22 dividuals under such waiver; and 

23 ‘‘(ii) the application of such more re24 strictive, standards, methodologies, or pro25 cedures under such an amendment shall 


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1 not be considered in violation of the re2 quirement of subparagraph (A). 

3 ‘‘(2) REMOVAL OF ASSET TEST FOR CERTAIN

4 ELIGIBILITY CATEGORIES.— 

5 ‘‘(A) IN GENERAL.—A State is not eligible 

6 for payment under subsection (a) for a calendar 

7 quarter beginning on or after the first day of 

8 Y1 (as defined in section 100(c) of the Afford9 able Health Care for America Act), if the State 

10 applies any asset or resource test in deter11 mining (or redetermining) eligibility of any indi12 vidual on or after such first day under any of 

13 the following: 

14 ‘‘(i) Subclause (I), (III), (IV), (VI), 

15 (VIII), (IX), (X), or (XI) of section 

16 1902(a)(10)(A)(i). 

17 ‘‘(ii) Subclause (II), (IX), (XIV) or 

18 (XVII) of section 1902(a)(10)(A)(ii). 

19 ‘‘(iii) Section 1931(b). 

20 ‘‘(B) OVERRIDING CONTRARY PROVISIONS; 

21 REFERENCES.—The provisions of this title that 

22 prevent the waiver of an asset or resource test 

23 described in subparagraph (A) are hereby 

24 waived. 


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1 ‘‘(C) REFERENCES.—Any reference to a 

2 provision described in a provision in subpara3 graph (A) shall be deemed to be a reference to 

4 such provision as modified through the applica5 tion of subparagraphs (A) and (B).’’. 

6 (2) CONFORMING AMENDMENTS.—(A) Section 

7 1902(a)(10)(A) of such Act (42 U.S.C. 

8 1396a(a)(10)(A)) is amended, in the matter before 

9 clause (i), by inserting ‘‘subject to section 

10 1903(aa)(2),’’ after ‘‘(A)’’. 

11 (B) Section 1931(b)(1) of such Act (42 U.S.C. 

12 1396u–1(b)(1)) is amended by inserting ‘‘and sec13 tion 1903(aa)(2)’’ after ‘‘and (3)’’. 

14 (c) STANDARDS FOR BENCHMARK PACKAGES.—Sec15 tion 1937(b) of such Act (42 U.S.C. 1396u–7(b)) is 

16 amended— 

17 (1) in each of paragraphs (1) and (2), by in18 serting ‘‘subject to paragraph (5),’’ after ‘‘subsection 

19 (a)(1),’’; and 

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

21 paragraph: 

22 ‘‘(5) MINIMUM STANDARDS.—Effective January 

23 1, 2013, any benchmark benefit package (or bench24 mark equivalent coverage under paragraph (2)) 

25 must meet the minimum benefits and cost-sharing 


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1 standards of a basic plan offered through the Health 

2 Insurance Exchange.’’. 

3 (d) REPEAL OF CHIP.—Section 2104(a) of the So4 cial Security Act is amended by inserting at the end the 

5 following: 

6 ‘‘No funds shall be appropriated or authorized to be 

7 appropriated under this section for fiscal year 2014 

8 and subsequent years.’’. 

9 SEC. 1704. REDUCTION IN MEDICAID DSH. 

10 (a) REPORT.— 

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

12 2016, the Secretary of Health and Human Services 

13 (in this title referred to as the ‘‘Secretary’’) shall 

14 submit to Congress a report concerning the extent to 

15 which, based upon the impact of the health care re16 forms carried out under division A in reducing the 

17 number of uninsured individuals, there is a contin18 ued role for Medicaid DSH. In preparing the report, 

19 the Secretary shall consult with community-based 

20 health care networks serving low-income bene21 ficiaries. 

22 (2) MATTERS TO BE INCLUDED.—The report 

23 shall include the following: 

24 (A) RECOMMENDATIONS.—Recommenda25 tions regarding— 


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1 (i) the appropriate targeting of Med2 icaid DSH within States; and 

3 (ii) the distribution of Medicaid DSH 

4 among the States, taking into account the 

5 ratio of the amount of DSH funds allo6 cated to a State to the number of unin7 sured individuals in such State. 

8 (B) SPECIFICATION OF DSH HEALTH RE9 FORM METHODOLOGY.—The DSH Health Re10 form methodology described in paragraph (2) of 

11 subsection (b) for purposes of implementing the 

12 requirements of such subsection. 

13 (3) COORDINATION WITH MEDICARE DSH RE14 PORT.—The Secretary shall coordinate the report 

15 under this subsection with the report on Medicare 

16 DSH under section 1112. 

17 (4) MEDICAID DSH.—In this section, the term 

18 ‘‘Medicaid DSH’’ means adjustments in payments 

19 under section 1923 of the Social Security Act for in20 patient hospital services furnished by dispropor21 tionate share hospitals. 

22 (b) MEDICAID DSH REDUCTIONS.— 

23 (1) REDUCTIONS.— 


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1 (A) IN GENERAL.—For each of fiscal years 

2 2017 through 2019 the Secretary shall effect 

3 the following reductions: 

4 (i) REDUCTION DSH ALLOTMENTS.— 

5 The Secretary shall reduce DSH allot6 ments to States in the amount specified 

7 under the DSH health reform methodology 

8 under paragraph (2) for the State for the 

9 fiscal year. 

10 (ii) REDUCTIONS IN PAYMENTS.—The 

11 Secretary shall reduce payments to States 

12 under section 1903(a) of the Social Secu13 rity Act (42 U.S.C. 1396b(a)) for each cal14 endar quarter in the fiscal year, in the 

15 manner specified in subparagraph (C), in 

an amount equal to 1 16 ⁄4 of the DSH allot17 ment reduction under clause (i) for the 

18 State for the fiscal year. 

19 (B) AGGREGATE REDUCTIONS.—The ag20 gregate reductions in DSH allotments for all 

21 States under subparagraph (A)(i) shall be equal 

22 to— 

23 (i) $1,500,000,000 for fiscal year 

24 2017; 


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1 (ii) $2,500,000,000 for fiscal year 

2 2018; and 

3 (iii) $6,000,000,000 for fiscal year 

4 2019. 

5 The Secretary shall distribute such aggregate 

6 reduction among States in accordance with 

7 paragraph (2). 

8 (C) MANNER OF PAYMENT REDUCTION.— 

9 The amount of the payment reduction under 

10 subparagraph (A)(ii) for a State for a quarter 

11 shall be deemed an overpayment to the State 

12 under title XIX of the Social Security Act to be 

13 disallowed against the State’s regular quarterly 

14 draw for all Medicaid spending under section 

15 1903(d)(2) of such Act (42 U.S.C. 

16 1396b(d)(2)). Such a disallowance is not sub17 ject to a reconsideration under 1116(d) of such 

18 Act (42 U.S.C. 1316(d)). 

19 (D) DEFINITIONS.—In this section: 

20 (i) STATE.—The term ‘‘State’’ means 

21 the 50 States and the District of Colum22 bia. 

23 (ii) DSH ALLOTMENT.—The term 

24 ‘‘DSH allotment’’ means, with respect to a 

25 State for a fiscal year, the allotment made 


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1 under section 1923(f) of the Social Secu2 rity Act (42 U.S.C. 1396r–4(f)) to the 

3 State for the fiscal year. 

4 (2) DSH HEALTH REFORM METHODOLOGY.— 

5 The Secretary shall carry out paragraph (1) through 

6 use of a DSH Health Reform methodology issued by 

7 the Secretary that imposes the largest percentage re8 ductions on the States that— 

9 (A) have the lowest percentages of unin10 sured individuals (determined on the basis of 

11 audited hospital cost reports) during the most 

12 recent year for which such data are available; 

13 or 

14 (B) do not target their DSH payments 

15 on— 

16 (i) hospitals with high volumes of 

17 Medicaid inpatients (as defined in section 

18 1923(b)(1)(A) of the Social Security Act 

19 (42 U.S.C. 1396r–4(b)(1)(A)); and 

20 (ii) hospitals that have high levels of 

21 uncompensated care (excluding bad debt). 

22 (3) DSH ALLOTMENT PUBLICATIONS.— 

23 (A) IN GENERAL.—Not later than the pub24 lication deadline specified in subparagraph (B), 

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1 ister a notice specifying the DSH allotment to 

2 each State under 1923(f) of the Social Security 

3 Act for the respective fiscal year specified in 

4 such subparagraph, consistent with the applica5 tion of the DSH Health Reform methodology 

6 described in paragraph (2). 

7 (B) PUBLICATION DEADLINE.—The publi8 cation deadline specified in this subparagraph 

9 is— 

10 (i) January 1, 2016, with respect to 

11 DSH allotments described in subparagraph 

12 (A) for fiscal year 2017; 

13 (ii) January 1, 2017, with respect to 

14 DSH allotments described in subparagraph 

15 (A) for fiscal year 2018; and 

16 (iii) January 1, 2018, with respect to 

17 DSH allotments described in subparagraph 

18 (A) for fiscal year 2019. 

19 (c) CONFORMING AMENDMENTS.— 

20 (1) Section 1923(f) of the Social Security Act 

21 (42 U.S.C. 1396r–4(f)) is amended— 

22 (A) by redesignating paragraph (7) as 

23 paragraph (8); and 

24 (B) by inserting after paragraph (6) the 

25 following new paragraph: 


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1 ‘‘(7) SPECIAL RULE FOR FISCAL YEARS 2017, 

2 2018, AND 2019.—For each of fiscal years 2017, 

3 2018, and 2018, the DSH allotments under this 

4 subsection are subject to reduction under section 

5 1704(b) of the Affordable Health Care for America 

6 Act.’’. 

7 (2) The second sentence of section 1923(b)(4) 

8 of such Act (42 U.S.C. 1396r–4(b)(4)) is amended 

9 by inserting before the period the following: ‘‘or to 

10 affect the authority of the Secretary to issue and im11 plement the DSH Health Reform methodology under 

12 section 1704(b)(2) of the Affordable Health Care for 

13 America Act’’. 

14 (d) DISPROPORTIONATE SHARE HOSPITALS (DSH) 

15 AND ESSENTIAL ACCESS HOSPITAL (EAH) NON-DIS16 CRIMINATION.— 

17 (1) IN GENERAL.—Section 1923(d) of the So18 cial Security Act (42 U.S.C. 1396r-4) is amended by 

19 adding at the end the following new paragraph: 

20 ‘‘(4) No hospital may be defined or deemed as 

21 a disproportionate share hospital, or as an essential 

22 access hospital (for purposes of subsection 

23 (f)(6)(A)(iv)), under a State plan under this title or 

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1 onstration project under section 1115) unless the 

2 hospital— 

3 ‘‘(A) provides services to beneficiaries 

4 under this title without discrimination on the 

5 ground of race, color, national origin, creed, 

6 source of payment, status as a beneficiary 

7 under this title, or any other ground unrelated 

8 to such beneficiary’s need for the services or the 

9 availability of the needed services in the hos10 pital; and 

11 ‘‘(B) makes arrangements for, and accepts, 

12 reimbursement under this title for services pro13 vided to eligible beneficiaries under this title.’’. 

14 (2) EFFECTIVE DATE.—The amendment made 

15 by paragraph (1) shall apply to expenditures made 

16 on or after July 1, 2010. 

17 SEC. 1705. EXPANDED OUTSTATIONING. 

18 (a) IN GENERAL.—Section 1902(a)(55) of the Social 

19 Security Act (42 U.S.C. 1396a(a)(55)) is amended by 

20 striking ‘‘under subsection (a)(10)(A)(i)(IV), 

21 (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or 

22 (a)(10)(A)(ii)(IX)’’ and inserting ‘‘(including receipt and 

23 processing of applications of individuals for affordability 

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1 icaid memorandum of understanding under section 

2 1943(a)(1))’’. 

3 (b) EFFECTIVE DATE.—Except as provided in sec4 tion 1790, the amendment made by subsection (a) shall 

5 apply to services furnished on or after July 1, 2010, with6 out regard to whether or not final regulations to carry out 

7 such amendment have been promulgated by such date. 

8 Subtitle B—Prevention 

9 SEC. 1711. REQUIRED COVERAGE OF PREVENTIVE SERV10 ICES. 

11 (a) COVERAGE.—Section 1905 of the Social Security 

12 Act (42 U.S.C. 1396d), as amended by section 

13 1701(a)(3)(B), is amended— 

14 (1) in subsection (a)(4)— 

15 (A) by striking ‘‘and’’ before ‘‘(C)’’; and 

16 (B) by inserting before the semicolon at 

17 the end the following: ‘‘; and (D) preventive 

18 services described in subsection (z)’’; and 

19 (2) by adding at the end the following new sub20 section: 

21 ‘‘(z) PREVENTIVE SERVICES.—The preventive serv22 ices described in this subsection are services not otherwise 

23 described in subsection (a) or (r) that the Secretary deter24 mines are— 


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1 ‘‘(1)(A) recommended with a grade of A or B 

2 by the Task Force for Clinical Preventive Services; 

3 or 

4 ‘‘(B) vaccines recommended for use as appro5 priate by the Director of the Centers for Disease 

6 Control and Prevention; and 

7 ‘‘(2) appropriate for individuals entitled to med8 ical assistance under this title.’’. 

9 (b) ELIMINATION OF COST-SHARING.— 

10 (1) Subsections (a)(2)(D) and (b)(2)(D) of sec11 tion 1916 of such Act (42 U.S.C. 1396o) are each 

12 amended by inserting ‘‘preventive services described 

13 in section 1905(z),’’ after ‘‘emergency services (as 

14 defined by the Secretary),’’. 

15 (2) Section 1916A(a)(1) of such Act (42 U.S.C. 

16 1396o–1 (a)(1)) is amended by inserting ‘‘, preven17 tive services described in section 1905(z),’’ after 

18 ‘‘subsection (c)’’. 

19 (c) CONFORMING AMENDMENT.—Section 1928 of 

20 such Act (42 U.S.C. 1396s) is amended— 

21 (1) in subsection (c)(2)(B)(i), by striking ‘‘the 

22 advisory committee referred to in subsection (e)’’ 

23 and inserting ‘‘the Director of the Centers for Dis24 ease Control and Prevention’’; 


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1 (2) in subsection (e), by striking ‘‘Advisory 

2 Committee’’ and all that follows and inserting ‘‘Di3 rector of the Centers for Disease Control and Pre4 vention.’’; and 

5 (3) by striking subsection (g). 

6 (d) EFFECTIVE DATE.—Except as provided in sec7 tion 1790, the amendments made by this section shall 

8 apply to services furnished on or after July 1, 2010, with9 out regard to whether or not final regulations to carry out 

10 such amendments have been promulgated by such date. 

11 SEC. 1712. TOBACCO CESSATION. 

12 (a) DROPPING TOBACCO CESSATION EXCLUSION

13 FROM COVERED OUTPATIENT DRUGS.—Section 

14 1927(d)(2) of the Social Security Act (42 U.S.C. 1396r– 

15 8(d)(2)) is amended— 

16 (1) by striking subparagraph (E); 

17 (2) in subparagraph (G), by inserting before the 

18 period at the end the following: ‘‘, except agents ap19 proved by the Food and Drug Administration for 

20 purposes of promoting, and when used to promote, 

21 tobacco cessation’’; and 

22 (3) by redesignating subparagraphs (F) 

23 through (K) as subparagraphs (E) through (J), re24 spectively. 


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

2 this section shall apply to drugs and services furnished 

3 on or after January 1, 2010. 

4 SEC. 1713. OPTIONAL COVERAGE OF NURSE HOME VISITA5 TION SERVICES. 

6 (a) IN GENERAL.—Section 1905 of the Social Secu7 rity Act (42 U.S.C. 1396d), as amended by sections 

8 1701(a)(3)(B) and 1711(a), is amended— 

9 (1) in subsection (a)— 

10 (A) in paragraph (27), by striking ‘‘and’’ 

11 at the end; 

12 (B) by redesignating paragraph (28) as 

13 paragraph (29); and 

14 (C) by inserting after paragraph (27) the 

15 following new paragraph: 

16 ‘‘(28) nurse home visitation services (as defined 

17 in subsection (aa)); and’’; and 

18 (2) by adding at the end the following new sub19 section: 

20 ‘‘(aa) The term ‘nurse home visitation services’ 

21 means home visits by trained nurses to families with a 

22 first-time pregnant woman, or a child (under 2 years of 

23 age), who is eligible for medical assistance under this title, 

24 but only, to the extent determined by the Secretary based 


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1 upon evidence, that such services are effective in one or 

2 more of the following: 

3 ‘‘(1) Improving maternal or child health and 

4 pregnancy outcomes or increasing birth intervals be5 tween pregnancies. 

6 ‘‘(2) Reducing the incidence of child abuse, ne7 glect, and injury, improving family stability (includ8 ing reduction in the incidence of intimate partner vi9 olence), or reducing maternal and child involvement 

10 in the criminal justice system. 

11 ‘‘(3) Increasing economic self-sufficiency, em12 ployment advancement, school-readiness, and edu13 cational achievement, or reducing dependence on 

14 public assistance.’’. 

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

16 this section shall apply to services furnished on or after 

17 January 1, 2010. 

18 (c) CONSTRUCTION.—Nothing in the amendments 

19 made by this section shall be construed as affecting the 

20 ability of a State under title XIX or XXI of the Social 

21 Security Act to provide nurse home visitation services as 

22 part of another class of items and services falling within 

23 the definition of medical assistance or child health assist24 ance under the respective title, or as an administrative ex25 penditure for which payment is made under section 


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1 1903(a) or 2105(a) of such Act, respectively, on or after 

2 the date of the enactment of this Act. 

3 SEC. 1714. STATE ELIGIBILITY OPTION FOR FAMILY PLAN4 NING SERVICES. 

5 (a) COVERAGE AS OPTIONAL CATEGORICALLY

6 NEEDY GROUP.— 

7 (1) IN GENERAL.—Section 1902(a)(10)(A)(ii) 

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

9 1396a(a)(10)(A)(ii)) is amended— 

10 (A) in subclause (XVIII), by striking ‘‘or’’ 

11 at the end; 

12 (B) in subclause (XIX), by adding ‘‘or’’ at 

13 the end; and 

14 (C) by adding at the end the following new 

15 subclause: 

16 ‘‘(XX) who are described in sub17 section (hh) (relating to individuals 

18 who meet certain income standards);’’. 

19 (2) GROUP DESCRIBED.—Section 1902 of such 

20 Act (42 U.S.C. 1396a), as amended by section 1703, 

21 is amended by adding at the end the following new 

22 subsection: 

23 ‘‘(hh)(1) Individuals described in this subsection are 

24 individuals— 


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1 ‘‘(A) whose income does not exceed an in2 come eligibility level established by the State 

3 that does not exceed the highest income eligi4 bility level established under the State plan 

5 under this title (or under its State child health 

6 plan under title XXI) for pregnant women; and 

7 ‘‘(B) who are not pregnant. 

8 ‘‘(2) At the option of a State, individuals described 

9 in this subsection may include individuals who, had indi10 viduals applied on or before January 1, 2007, would have 

11 been made eligible pursuant to the standards and proc12 esses imposed by that State for benefits described in 

13 clause (XV) of the matter following subparagraph (G) of 

14 section subsection (a)(10) pursuant to a demonstration 

15 project waiver granted under section 1115. 

16 ‘‘(3) At the option of a State, for purposes of sub17 section (a)(17)(B), in determining eligibility for services 

18 under this subsection, the State may consider only the in19 come of the applicant or recipient.’’. 

20 (3) LIMITATION ON BENEFITS.—Section 

21 1902(a)(10) of such Act (42 U.S.C. 1396a(a)(10)) 

22 is amended in the matter following subparagraph 

23 (G)— 

24 (A) by striking ‘‘and (XIV)’’ and inserting 

25 ‘‘(XIV)’’; and 


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1 (B) by inserting ‘‘, and (XV) the medical 

2 assistance made available to an individual de3 scribed in subsection (hh) shall be limited to 

4 family planning services and supplies described 

5 in section 1905(a)(4)(C) including medical di6 agnosis and treatment services that are pro7 vided pursuant to a family planning service in 

8 a family planning setting’’ after ‘‘cervical can9 cer’’. 

10 (4) CONFORMING AMENDMENTS.—Section 

11 1905(a) of such Act (42 U.S.C. 1396d(a)), as 

12 amended by section 1731(c), is amended in the mat13 ter preceding paragraph (1)— 

14 (A) in clause (xiii), by striking ‘‘or’’ at the 

15 end; 

16 (B) in clause (xiv), by adding ‘‘or’’ at the 

17 end; and 

18 (C) by inserting after clause (xiv) the fol19 lowing: 

20 ‘‘(xv) individuals described in section 

21 1902(hh),’’. 

22 (b) PRESUMPTIVE ELIGIBILITY.— 

23 (1) IN GENERAL.—Title XIX of the Social Se24 curity Act (42 U.S.C. 1396 et seq.) is amended by 

25 inserting after section 1920B the following: 


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1 ‘‘PRESUMPTIVE ELIGIBILITY FOR FAMILY PLANNING

2 SERVICES

3 ‘‘SEC. 1920C. (a) STATE OPTION.—State plan ap4 proved under section 1902 may provide for making med5 ical assistance available to an individual described in sec6 tion 1902(hh) (relating to individuals who meet certain 

7 income eligibility standard) during a presumptive eligi8 bility period. In the case of an individual described in sec9 tion 1902(hh), such medical assistance shall be limited to 

10 family planning services and supplies described in 

11 1905(a)(4)(C) and, at the State’s option, medical diag12 nosis and treatment services that are provided in conjunc13 tion with a family planning service in a family planning 

14 setting. 

15 ‘‘(b) DEFINITIONS.—For purposes of this section: 

16 ‘‘(1) PRESUMPTIVE ELIGIBILITY PERIOD.—The 

17 term ‘presumptive eligibility period’ means, with re18 spect to an individual described in subsection (a), 

19 the period that— 

20 ‘‘(A) begins with the date on which a 

21 qualified entity determines, on the basis of pre22 liminary information, that the individual is de23 scribed in section 1902(hh); and 

24 ‘‘(B) ends with (and includes) the earlier 

25 of— 


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1 ‘‘(i) the day on which a determination 

2 is made with respect to the eligibility of 

3 such individual for services under the State 

4 plan; or 

5 ‘‘(ii) in the case of such an individual 

6 who does not file an application by the last 

7 day of the month following the month dur8 ing which the entity makes the determina9 tion referred to in subparagraph (A), such 

10 last day. 

11 ‘‘(2) QUALIFIED ENTITY.— 

12 ‘‘(A) IN GENERAL.—Subject to subpara13 graph (B), the term ‘qualified entity’ means 

14 any entity that— 

15 ‘‘(i) is eligible for payments under a 

16 State plan approved under this title; and 

17 ‘‘(ii) is determined by the State agen18 cy to be capable of making determinations 

19 of the type described in paragraph (1)(A). 

20 ‘‘(B) RULE OF CONSTRUCTION.—Nothing 

21 in this paragraph shall be construed as pre22 venting a State from limiting the classes of en23 tities that may become qualified entities in 

24 order to prevent fraud and abuse. 

25 ‘‘(c) ADMINISTRATION.— 


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1 ‘‘(1) IN GENERAL.—The State agency shall pro2 vide qualified entities with— 

3 ‘‘(A) such forms as are necessary for an 

4 application to be made by an individual de5 scribed in subsection (a) for medical assistance 

6 under the State plan; and 

7 ‘‘(B) information on how to assist such in8 dividuals in completing and filing such forms. 

9 ‘‘(2) NOTIFICATION REQUIREMENTS.—A quali10 fied entity that determines under subsection 

11 (b)(1)(A) that an individual described in subsection 

12 (a) is presumptively eligible for medical assistance 

13 under a State plan shall— 

14 ‘‘(A) notify the State agency of the deter15 mination within 5 working days after the date 

16 on which determination is made; and 

17 ‘‘(B) inform such individual at the time 

18 the determination is made that an application 

19 for medical assistance is required to be made by 

20 not later than the last day of the month fol21 lowing the month during which the determina22 tion is made. 

23 ‘‘(3) APPLICATION FOR MEDICAL ASSIST24 ANCE.—In the case of an individual described in 

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1 ty to be presumptively eligible for medical assistance 

2 under a State plan, the individual shall apply for 

3 medical assistance by not later than the last day of 

4 the month following the month during which the de5 termination is made. 

6 ‘‘(d) PAYMENT.—Notwithstanding any other provi7 sion of law, medical assistance that— 

8 ‘‘(1) is furnished to an individual described in 

9 subsection (a)— 

10 ‘‘(A) during a presumptive eligibility pe11 riod; 

12 ‘‘(B) by a entity that is eligible for pay13 ments under the State plan; and 

14 ‘‘(2) is included in the care and services covered 

15 by the State plan, 

16 shall be treated as medical assistance provided by such 

17 plan for purposes of clause (4) of the first sentence of 

18 section 1905(b).’’. 

19 (2) CONFORMING AMENDMENTS.— 

20 (A) Section 1902(a)(47) of the Social Se21 curity Act (42 U.S.C. 1396a(a)(47)) is amend22 ed by inserting before the semicolon at the end 

23 the following: ‘‘and provide for making medical 

24 assistance available to individuals described in 

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1 sumptive eligibility period in accordance with 

2 such section’’. 

3 (B) Section 1903(u)(1)(D)(v) of such Act 

4 (42 U.S.C. 1396b(u)(1)(D)(v)) is amended— 

5 (i) by striking ‘‘or for’’ and inserting 

6 ‘‘for’’; and 

7 (ii) by inserting before the period the 

8 following: ‘‘, or for medical assistance pro9 vided to an individual described in sub10 section (a) of section 1920C during a pre11 sumptive eligibility period under such sec12 tion’’. 

13 (c) CLARIFICATION OF COVERAGE OF FAMILY PLAN14 NING SERVICES AND SUPPLIES.—Section 1937(b) of the 

15 Social Security Act (42 U.S.C. 1396u–7(b)), as amended 

16 by section 1703(c)(2), is amended by adding at the end 

17 the following: 

18 ‘‘(6) COVERAGE OF FAMILY PLANNING SERV19 ICES AND SUPPLIES.—Notwithstanding the previous 

20 provisions of this section, a State may not provide 

21 for medical assistance through enrollment of an indi22 vidual with benchmark coverage or benchmark-equiv23 alent coverage under this section unless such cov24 erage includes for any individual described in section 

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1 ning services and supplies in accordance with such 

2 section.’’. 

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

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

5 this Act and shall apply to items and services furnished 

6 on or after such date. 

7 Subtitle C—Access 

8 SEC. 1721. PAYMENTS TO PRIMARY CARE PRACTITIONERS. 

9 (a) IN GENERAL.— 

10 (1) FEE-FOR-SERVICE PAYMENTS.—Section 

11 1902 of the Social Security Act (42 U.S.C. 1396b)as 

12 amended by sections 1703(a), 1714(a), 1731(a), and 

13 1746, is amended— 

14 (A) in subsection (a)(13)— 

15 (i) by striking ‘‘and’’ at the end of 

16 subparagraph (A); 

17 (ii) by adding ‘‘and’’ at the end of 

18 subparagraph (B); and 

19 (iii) by adding at the end the fol20 lowing new subparagraph: 

21 ‘‘(C) payment for primary care services (as 

22 defined in subsection (kk)(1)) furnished by phy23 sicians (or for services furnished by other 

24 health care professionals that would be primary 

25 care services under such section if furnished by 


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1 a physician) at a rate not less than 80 percent 

2 of the payment rate that would be applicable if 

3 the adjustment described in subsection (kk)(2) 

4 were to apply to such services and physicians or 

5 professionals (as the case may be) under part 

6 B of title XVIII for services furnished in 2010, 

7 90 percent of such adjusted payment rate for 

8 services and physicians (or professionals) fur9 nished in 2011, or 100 percent of such adjusted 

10 payment rate for services and physicians (or 

11 professionals) furnished in 2012 and each sub12 sequent year;’’; and 

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

14 subsection: 

15 ‘‘(kk) INCREASED PAYMENT FOR PRIMARY CARE

16 SERVICES.—For purposes of subsection (a)(13)(C): 

17 ‘‘(1) PRIMARY CARE SERVICES DEFINED.—The 

18 term ‘primary care services’ means evaluation and 

19 management services, without regard to the specialty 

20 of the physician furnishing the services, that are 

21 procedure codes (for services covered under title 

22 XVIII) for services in the category designated Eval23 uation and Management in the Health Care Com24 mon Procedure Coding System (established by the 

25 Secretary under section 1848(c)(5) as of December 


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1 31, 2009, and as subsequently modified by the Sec2 retary). 

3 ‘‘(2) ADJUSTMENT.—The adjustment described 

4 in this paragraph is the substitution of 1.25 percent 

5 for the update otherwise provided under section 

6 1848(d)(4) for each year beginning with 2010.’’. 

7 (2) UNDER MEDICAID MANAGED CARE

8 PLANS.—Section 1932(f) of such Act (42 U.S.C. 

9 1396u–2(f)) is amended— 

10 (A) in the heading, by adding at the end 

11 the following: ‘‘; ADEQUACY OF PAYMENT FOR

12 PRIMARY CARE SERVICES’’; and 

13 (B) by inserting before the period at the 

14 end the following: ‘‘and, in the case of primary 

15 care services described in section 

16 1902(a)(13)(C), consistent with the minimum 

17 payment rates specified in such section (regard18 less of the manner in which such payments are 

19 made, including in the form of capitation or 

20 partial capitation)’’. 

21 (b) INCREASE IN PAYMENT USING INCREASED

22 FMAP.—Section 1905(y) of the Social Security Act, as 

23 added by section 1701(a)(3)(B) and as amended by sec24 tion 1701(c)(2), is amended by adding at the end the fol25 lowing: 


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1 ‘‘(3)(A) The portion of the amounts expended 

2 for medical assistance for services described in sec3 tion 1902(a)(13)(C) furnished on or after January 

4 1, 2010, that is attributable to the amount by which 

5 the minimum payment rate required under such sec6 tion (or, by application, section 1932(f)) exceeds the 

7 payment rate applicable to such services under the 

8 State plan as of June 16, 2009. 

9 ‘‘(B) Subparagraph (A) shall not be construed 

10 as preventing the payment of Federal financial par11 ticipation based on the Federal medical assistance 

12 percentage for amounts in excess of those specified 

13 under such subparagraph.’’. 

14 (c) EFFECTIVE DATE.—The amendments made by 

15 this section shall apply to services furnished on or after 

16 January 1, 2010. 

17 SEC. 1722. MEDICAL HOME PILOT PROGRAM. 

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

19 Human Services shall establish under this section a med20 ical home pilot program under which a State may apply 

21 to the Secretary for approval of a medical home pilot 

22 project described in subsection (b) (in this section referred 

23 to as a ‘‘pilot project’’) for the application of the medical 

24 home concept under title XIX of the Social Security Act. 


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1 The pilot program shall operate for a period of up to 5 

2 years. 

3 (b) PILOT PROJECT DESCRIBED.— 

4 (1) IN GENERAL.—A pilot project is a project 

5 that applies one or more of the medical home models 

6 described in section 1866F(a)(3) of the Social Secu7 rity Act (as inserted by section 1302(a)) or such 

8 other model as the Secretary may approve, to indi9 viduals (including medically fragile children and 

10 high-risk pregnant women) who are eligible for med11 ical assistance under title XIX of the Social Security 

12 Act. The Secretary shall provide for appropriate co13 ordination of the pilot program under this section 

14 with the medical home pilot program under section 

15 1866F of such Act. 

16 (2) LIMITATION.—A pilot project shall be for a 

17 duration of not more than 5 years. 

18 (3) CONSIDERATION FOR CERTAIN TECH19 NOLOGIES.—In considering applications for pilots 

20 projects under this section, the Secretary may ap21 prove a project which tests the effectiveness of appli22 cations and devices, such as wireless patient man23 agement technologies, that are approved by the Food 

24 and Drug Administration and enable providers and 


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1 practitioners to communicate directly with their pa2 tients in managing chronic illness. 

3 (c) ADDITIONAL INCENTIVES.—In the case of a pilot 

4 project, the Secretary may— 

5 (1) waive the requirements of section 

6 1902(a)(1) of the Social Security Act (relating to 

7 statewideness) and section 1902(a)(10)(B) of such 

8 Act (relating to comparability); and 

9 (2) increase to up to 90 percent (for the first 

10 2 years of the pilot program) or 75 percent (for the 

11 next 3 years) the matching percentage for adminis12 trative expenditures (such as those for community 

13 care workers). 

14 (d) MEDICALLY FRAGILE CHILDREN.—In the case of 

15 a model involving medically fragile children, the model 

16 shall ensure that the patient-centered medical home serv17 ices received by each child, in addition to fulfilling the re18 quirements under 1866F(b)(1) of the Social Security Act, 

19 provide for continuous involvement and education of the 

20 parent or caregiver and for assistance to the child in ob21 taining necessary transitional care if a child’s enrollment 

22 ceases for any reason. 

23 (e) EVALUATION; REPORT.— 

24 (1) EVALUATION.—The Secretary, using the 

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1 cial Security Act (as inserted by section 1123), shall 

2 conduct an evaluation of the pilot program under 

3 this section. 

4 (2) REPORT.—Not later than 60 days after the 

5 date of completion of the evaluation under para6 graph (1), the Secretary shall submit to Congress 

7 and make available to the public a report on the 

8 findings of the evaluation under such paragraph. 

9 (f) FUNDING.—The additional Federal financial par10 ticipation resulting from the implementation of the pilot 

11 program under this section may not exceed in the aggre12 gate $1,235,000,000 over the 5-year period of the pro13 gram. 

14 SEC. 1723. TRANSLATION OR INTERPRETATION SERVICES. 

15 (a) IN GENERAL.—Section 1903(a)(2)(E) of the So16 cial Security Act (42 U.S.C. 1396b(a)(2)), as added by 

17 section 201(b)(2)(A) of the Children’s Health Insurance 

18 Program Reauthorization Act of 2009 (Public Law 111– 

19 3), is amended by inserting ‘‘and other individuals’’ after 

20 ‘‘children of families’’. 

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

22 subsection (a) shall apply to payment for translation or 

23 interpretation services furnished on or after January 1, 

24 2010. 


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1 SEC. 1724. OPTIONAL COVERAGE FOR FREESTANDING 

2 BIRTH CENTER SERVICES. 

3 (a) IN GENERAL.—Section 1905 of the Social Secu4 rity Act (42 U.S.C. 1396d), as amended by section 

5 1713(a), is amended— 

6 (1) in subsection (a)— 

7 (A) by redesignating paragraph (29) as 

8 paragraph (30); 

9 (B) in paragraph (28), by striking at the 

10 end ‘‘and’’; and 

11 (C) by inserting after paragraph (28) the 

12 following new paragraph: 

13 ‘‘(29) freestanding birth center services (as de14 fined in subsection (l)(3)(A)) and other ambulatory 

15 services that are offered by a freestanding birth cen16 ter (as defined in subsection (l)(3)(B)) and that are 

17 otherwise included in the plan; and’’; and 

18 (2) in subsection (l), by adding at the end the 

19 following new paragraph: 

20 ‘‘(3)(A) The term ‘freestanding birth center services’ 

21 means services furnished to an individual at a freestanding 

22 birth center (as defined in subparagraph (B)), including 

23 by a licensed birth attendant (as defined in subparagraph 

24 (C)) at such center. 

25 ‘‘(B) The term ‘freestanding birth center’ means a 

26 health facility— 


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1 ‘‘(i) that is not a hospital; and 

2 ‘‘(ii) where childbirth is planned to occur away 

3 from the pregnant woman’s residence. 

4 ‘‘(C) The term ‘licensed birth attendant’ means an 

5 individual who is licensed or registered by the State in6 volved to provide health care at childbirth and who pro7 vides such care within the scope of practice under which 

8 the individual is legally authorized to perform such care 

9 under State law (or the State regulatory mechanism pro10 vided by State law), regardless of whether the individual 

11 is under the supervision of, or associated with, a physician 

12 or other health care provider. Nothing in this subpara13 graph shall be construed as changing State law require14 ments applicable to a licensed birth attendant.’’. 

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

16 this section shall apply to items and services furnished on 

17 or after the date of the enactment of this Act. 

18 SEC. 1725. INCLUSION OF PUBLIC HEALTH CLINICS UNDER 

19 THE VACCINES FOR CHILDREN PROGRAM. 

20 Section 1928(b)(2)(A)(iii)(I) of the Social Security 

21 Act (42 U.S.C. 1396s(b)(2)(A)(iii)(I)) is amended— 

22 (1) by striking ‘‘or a rural health clinic’’ and in23 serting ‘‘, a rural health clinic’’; and 

24 (2) by inserting ‘‘or a public health clinic,’’ 

25 after ‘‘‘1905(l)(1)),’’. 


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1 SEC. 1726. REQUIRING COVERAGE OF SERVICES OF PODIA2 TRISTS. 

3 (a) IN GENERAL.—Section 1905(a)(5)(A) of the So4 cial Security Act (42 U.S.C. 1396d(a)(5)(A)) is amended 

5 by striking ‘‘section 1861(r)(1)’’ and inserting ‘‘para6 graphs (1) and (3) of section 1861(r)’’. 

7 (b) EFFECTIVE DATE.—Except as provided in sec8 tion 1790, the amendment made by subsection (a) shall 

9 apply to services furnished on or after January 1, 2010. 

10 SEC. 1726A. REQUIRING COVERAGE OF SERVICES OF OP11 TOMETRISTS. 

12 (a) IN GENERAL.—Section 1905(a)(5) of the Social 

13 Security Act (42 U.S.C. 1396d(a)(5)) is amended— 

14 (1) by striking ‘‘and’’ before ‘‘(B)’’; and 

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

16 the following: ‘‘, and (C) medical and other health 

17 services (as defined in section 1861(s)) as authorized 

18 by State law, furnished by an optometrist (described 

19 in section 1861(r)(4)) to the extent such services 

20 may be performed under State law’’. 

21 (b) EFFECTIVE DATE.—Except as provided in sec22 tion 1790, the amendments made by subsection (a) shall 

23 take effect 90 days after the date of the enactment of this 

24 Act and shall apply to services furnished or other actions 

25 required on or after such date. 


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1 SEC. 1727. THERAPEUTIC FOSTER CARE. 

2 (a) RULE OF CONSTRUCTION.—Nothing in this title 

3 shall prevent or limit a State from covering therapeutic 

4 foster care for eligible children in out-of-home placements 

5 under section 1905(a) of the Social Security Act (42 

6 U.S.C. 1396d(a)). 

7 (b) THERAPEUTIC FOSTER CARE DEFINED.—For 

8 purposes of this section, the term ‘‘therapeutic foster 

9 care’’ means a foster care program that provides— 

10 (1) to the child— 

11 (A) structured daily activities that develop, 

12 improve, monitor, and reinforce age-appropriate 

13 social, communications, and behavioral skills; 

14 (B) crisis intervention and crisis support 

15 services; 

16 (C) medication monitoring; 

17 (D) counseling; and 

18 (E) case management services; and 

19 (2) specialized training for the foster parent 

20 and consultation with the foster parent on the man21 agement of children with mental illnesses and re22 lated health and developmental conditions. 


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1 SEC. 1728. ASSURING ADEQUATE PAYMENT LEVELS FOR 

2 SERVICES. 

3 (a) IN GENERAL.—Title XIX of the Social Security 

4 Act is amended by inserting after section 1925 the fol5 lowing new section: 

6 ‘‘ASSURING ADEQUATE PAYMENT LEVELS FOR SERVICES

7 ‘‘SEC. 1926. (a) IN GENERAL.—A State plan under 

8 this title shall not be considered to meet the requirement 

9 of section 1902(a)(30)(A) for a year (beginning with 

10 2011) unless, by not later than April 1 before the begin11 ning of such year, the State submits to the Secretary an 

12 amendment to the plan that specifies the payment rates 

13 to be used for such services under the plan in such year 

14 and includes in such submission such additional data as 

15 will assist the Secretary in evaluating the State’s compli16 ance with such requirement, including data relating to how 

17 rates established for payments to medicaid managed care 

18 organizations under sections 1903(m) and 1932 take into 

19 account such payment rates. 

20 ‘‘(b) SECRETARIAL REVIEW.—The Secretary, by not 

21 later than 90 days after the date of submission of a plan 

22 amendment under subsection (a), shall— 

23 ‘‘(1) review each such amendment for compli24 ance with the requirement of section 

25 1902(a)(30)(A); and 


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1 ‘‘(2) approve or disapprove each such amend2 ment. 

3 If the Secretary disapproves such an amendment, the 

4 State shall immediately submit a revised amendment that 

5 meets such requirement.’’. 

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

7 subsection (a) shall take effect on the date of the enact8 ment of this Act. 

9 SEC. 1729. PRESERVING MEDICAID COVERAGE FOR 

10 YOUTHS UPON RELEASE FROM PUBLIC INSTI11 TUTIONS. 

12 Section 1902(a) of the Social Security Act (42 U.S.C. 

13 1396a), as amended by section 1631(b) and 1703(a), is 

14 amended— 

15 (1) by striking ‘‘and’’ at the end of paragraph 

16 (74); 

17 (2) by striking the period at the end of para18 graph (75) and inserting ‘‘; and’’; and 

19 (3) by inserting after paragraph (75) the fol20 lowing new paragraph: 

21 ‘‘(76) provide that in the case of any youth who 

22 is 18 years of age or younger, was enrolled for med23 ical assistance under the State plan immediately be24 fore becoming an inmate of a public institution, is 

25 18 years of age or younger upon release from such 


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1 institution, and is eligible for such medical assist2 ance under the State plan at the time of release 

3 from such institution— 

4 ‘‘(A) during the period such youth is incar5 cerated in a public institution, the State shall 

6 not terminate eligibility for medical assistance 

7 under the State plan for such youth; 

8 ‘‘(B) during the period such youth is incar9 cerated in a public institution, the State shall 

10 establish a process that ensures— 

11 ‘‘(i) that the State does not claim fed12 eral financial participation for services that 

13 are provided to such youth and that are 

14 excluded under subsection 1905(a)(28)(A); 

15 and 

16 ‘‘(ii) that the youth receives medical 

17 assistance for which federal participation is 

18 available under this title; 

19 ‘‘(C) on or before the date such youth is 

20 released from such institution, the State shall 

21 ensure that such youth is enrolled for medical 

22 assistance under this title, unless and until 

23 there is a determination that the individual is 

24 no longer eligible to be so enrolled; and 


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1 ‘‘(D) the State shall ensure that enroll2 ment under subparagraph (C) will be completed 

3 before such date so that the youth can access 

4 medical assistance under this title immediately 

5 upon leaving the institution.’’ 

6 SEC. 1730. QUALITY MEASURES FOR MATERNITY AND 

7 ADULT HEALTH SERVICES UNDER MEDICAID 

8 AND CHIP. 

9 Title XI of the Social Security Act (42 U.S.C. 1301 

10 et seq.) is amended by inserting after section 1139A the 

11 following new section: 

12 ‘‘SEC. 1139B. QUALITY MEASURES FOR MATERNITY AND 

13 ADULT HEALTH SERVICES UNDER MEDICAID 

14 AND CHIP. 

15 ‘‘(a) MATERNITY CARE QUALITY MEASURES UNDER

16 MEDICAID AND CHIP.— 

17 ‘‘(1) DEVELOPMENT OF MEASURES.—No later 

18 than January 1, 2011, the Secretary shall develop 

19 and publish for comment a proposed set of measures 

20 that accurately describe the quality of maternity 

21 care provided under State plans under titles XIX 

22 and XXI. The Secretary shall publish a final rec23 ommended set of such measures no later than July 

24 1, 2011. 


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1 ‘‘(2) STANDARDIZED REPORTING FORMAT.—No 

2 later than January 1, 2012, the Secretary shall de3 velop and publish a standardized reporting format 

4 for maternity care quality measures for use by State 

5 programs under titles XIX and XXI to collect data 

6 from managed care entities and providers and prac7 titioners that participate in such programs and to 

8 report maternity care quality measures to the Sec9 retary. 

10 ‘‘(b) OTHER ADULT HEALTH QUALITY MEASURES

11 UNDER MEDICAID.— 

12 ‘‘(1) DEVELOPMENT OF MEASURES.—The Sec13 retary shall develop quality measures that are not 

14 otherwise developed under section 1192 for services 

15 received under State plans under title XIX by indi16 viduals who are 21 years of age or older but have 

17 not attained age 65. The Secretary shall publish 

18 such quality measures through notice and comment 

19 rulemaking. 

20 ‘‘(2) STANDARDIZED REPORTING FORMAT.— 

21 The Secretary shall develop and publish a standard22 ized reporting format for quality measures developed 

23 under paragraph (1) and section 1192 for services 

24 furnished under State plans under title XIX to indi25 viduals who are 21 years of age or older but have 


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1 not attained age 65 for use under such plans and 

2 State plans under title XXI. The format shall enable 

3 State agencies administering such plans to collect 

4 data from managed care entities and providers and 

5 practitioners that participate in such plans and to 

6 report quality measures to the Secretary. 

7 ‘‘(c) DEVELOPMENT PROCESS.—With respect to the 

8 development of quality measures under subsections (a) 

9 and (b)— 

10 ‘‘(1) USE OF QUALIFIED ENTITIES.—The Sec11 retary may enter into agreements with public, non12 profit, or academic institutions with technical exper13 tise in the area of health quality measurement to as14 sist in such development. The Secretary may carry 

15 out these agreements by contract, grant, or other16 wise. 

17 ‘‘(2) MULTI-STAKEHOLDER PRE-RULEMAKING

18 INPUT.—The Secretary shall obtain the input of 

19 stakeholders with respect to such quality measures 

20 using a process similar to that described in section 

21 1808(d). 

22 ‘‘(3) COORDINATION.—The Secretary shall co23 ordinate the development of such measures under 

24 such subsections and with the development of child 

25 health quality measures under section 1139A. 


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1 ‘‘(d) ANNUAL REPORT TO CONGRESS.—No later than 

2 January 1, 2013, and annually thereafter, the Secretary 

3 shall report to the Committee on Energy and Commerce 

4 of the House of Representatives the Committee on Fi5 nance of the Senate regarding— 

6 ‘‘(1) the availability of reliable data relating to 

7 the quality of maternity care furnished under State 

8 plans under titles XIX and XXI; 

9 ‘‘(2) the availability of reliable data relating to 

10 the quality of services furnished under State plans 

11 under title XIX to adults who are 21 years of age 

12 or older but have not attained age 65; and 

13 ‘‘(3) recommendations for improving the quality 

14 of such care and services furnished under such State 

15 plans. 

16 ‘‘(e) RULE OF CONSTRUCTION.—Notwithstanding 

17 any other provision in this section, no quality measure de18 veloped, published, or used as a basis of measurement or 

19 reporting under this section may be used to establish an 

20 irrebuttable presumption regarding either the medical ne21 cessity of care or the maximum permissible coverage for 

22 any individual who receives medical assistance under title 

23 XIX or child health assistance under title XXI. 

24 ‘‘(f) APPROPRIATION.—For purposes of carrying out 

25 this section, in addition to funds otherwise available, out 


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1 of any funds in the Treasury not otherwise appropriated, 

2 there are appropriated $40,000,000 for the 5-fiscal-year 

3 period beginning with fiscal year 2010. Funds appro4 priated under this subsection shall remain available until 

5 expended.’’. 

6 SEC. 1730A. ACCOUNTABLE CARE ORGANIZATION PILOT 

7 PROGRAM. 

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

9 Human Services shall establish under this section an ac10 countable care program under which a State may apply 

11 to the Secretary for approval of an accountable care orga12 nization pilot program described in subsection (b) (in this 

13 section referred to as a ‘‘pilot program’’) for the applica14 tion of the accountable care organization concept under 

15 title XIX of the Social Security Act. 

16 (b) PILOT PROGRAM DESCRIBED.— 

17 (1) IN GENERAL.—The pilot program described 

18 in this subsection is a program that applies one or 

19 more of the accountable care organization models 

20 described in section 1866E of the Social Security 

21 Act, as added by section 1301 of this Act. 

22 (2) LIMITATION.—The pilot program shall op23 erate for a period of not more than 5 years. 

24 (c) ADDITIONAL INCENTIVES.—In the case of the 

25 pilot program under this section, the Secretary may— 


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1 (1) waive the requirements of— 

2 (A) section 1902(a)(1) of the Social Secu3 rity Act (relating to statewideness); 

4 (B) section 1902(a)(10)(B) of such Act 

5 (relating to comparability); and 

6 (2) increase the matching percentage for ad7 ministrative expenditures up to— 

8 (A) 90 percent (for the first 2 years of the 

9 pilot program); and 

10 (B) 75 percent (for the next 3 years). 

11 (d) EVALUATION; REPORT.— 

12 (1) EVALUATION.—The Secretary shall conduct 

13 an evaluation of the pilot program under this sec14 tion. In conducting such evaluation, the Secretary 

15 shall use the criteria used under subsection (g)(1) of 

16 section 1866E of the Social Security Act (as in17 serted by section 1301 of this Act) to evaluate pilot 

18 programs under such section. 

19 (2) REPORT.—Not later than 60 days after the 

20 date of completion of the evaluation under para21 graph (1), the Secretary shall submit to Congress 

22 and make available to the public a report on the 

23 findings of the evaluation under such paragraph. 


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1 SEC. 1730B. FQHC COVERAGE. 

2 Section 1905(l)(2)(B) of the Social Security Act (42 

3 U.S.C. 1396d(l)(2)(B)) is amended— 

4 (1) by striking ‘‘or’’ at the end of clause (iii); 

5 (2) by striking the semicolon at the end of 

6 clause (iv) and inserting ‘‘, and’’; and 

7 (3) by inserting after clause (iv) the following 

8 new clause: 

9 ‘‘(v) is receiving a grant under section 399Z–1 

10 of the Public Health Service Act;’’. 

11 Subtitle D—Coverage 

12 SEC. 1731. OPTIONAL MEDICAID COVERAGE OF LOW-IN13 COME HIV-INFECTED INDIVIDUALS. 

14 (a) IN GENERAL.— Section 1902 of the Social Secu15 rity Act (42 U.S.C. 1396a), as amended by section 

16 1714(a)(1), is amended— 

17 (1) in subsection (a)(10)(A)(ii)— 

18 (A) by striking ‘‘or’’ at the end of sub19 clause (XIX); 

20 (B) by adding ‘‘or’’ at the end of subclause 

21 (XX); and 

22 (C) by adding at the end the following: 

23 ‘‘(XXI) who are described in sub24 section (ii) (relating to HIV-infected 

25 individuals);’’; and 


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1 (2) by adding at the end, as amended by sec2 tions 1703 and 1714(a), the following: 

3 ‘‘(ii) Individuals described in this subsection are indi4 viduals not described in subsection (a)(10)(A)(i)— 

5 ‘‘(1) who have HIV infection; 

6 ‘‘(2) whose income (as determined under the 

7 State plan under this title with respect to disabled 

8 individuals) does not exceed the maximum amount 

9 of income a disabled individual described in sub10 section (a)(10)(A)(i) may have and obtain medical 

11 assistance under the plan; and 

12 ‘‘(3) whose resources (as determined under the 

13 State plan under this title with respect to disabled 

14 individuals) do not exceed the maximum amount of 

15 resources a disabled individual described in sub16 section (a)(10)(A)(i) may have and obtain medical 

17 assistance under the plan.’’. 

18 (b) ENHANCED MATCH.—The first sentence of sec19 tion 1905(b) of such Act (42 U.S.C. 1396d(b)) is amended 

20 by striking ‘‘section 1902(a)(10)(A)(ii)(XVIII)’’ and in21 serting ‘‘subclause (XVIII) or (XXI) of section 

22 1902(a)(10)(A)(ii)’’. 

23 (c) CONFORMING AMENDMENTS.—Section 1905(a) of 

24 such Act (42 U.S.C. 1396d(a)) is amended, in the matter 

25 preceding paragraph (1)— 


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1 (1) by striking ‘‘or’’ at the end of clause (xii); 

2 (2) by adding ‘‘or’’ at the end of clause (xiii); 

3 and 

4 (3) by inserting after clause (xiii) the following: 

5 ‘‘(xiv) individuals described in section 

6 1902(ii),’’. 

7 (d) EXEMPTION FROM FUNDING LIMITATION FOR

8 TERRITORIES.—Section 1108(g) of the Social Security 

9 Act (42 U.S.C. 1308(g)) is amended by adding at the end 

10 the following: 

11 ‘‘(5) DISREGARDING MEDICAL ASSISTANCE FOR

12 OPTIONAL LOW-INCOME HIV-INFECTED INDIVID13 UALS.—The limitations under subsection (f) and the 

14 previous provisions of this subsection shall not apply 

15 to amounts expended for medical assistance for indi16 viduals described in section 1902(ii) who are only el17 igible for such assistance on the basis of section 

18 1902(a)(10)(A)(ii)(XXI).’’. 

19 (e) EFFECTIVE DATE; SUNSET.—The amendments 

20 made by this section shall apply to expenditures for cal21 endar quarters beginning on or after the date of the enact22 ment of this Act, and before January 1, 2013, without 

23 regard to whether or not final regulations to carry out 

24 such amendments have been promulgated by such date. 


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1 SEC. 1732. EXTENDING TRANSITIONAL MEDICAID ASSIST2 ANCE (TMA). 

3 Sections 1902(e)(1)(B) and 1925(f) of the Social Se4 curity Act (42 U.S.C. 1396a(e)(1)(B), 1396r–6(f)), as 

5 amended by section 5004(a)(1) of the American Recovery 

6 and Reinvestment Act of 2009 (Public Law 111–5), are 

7 each amended by striking ‘‘December 31, 2010’’ and in8 serting ‘‘December 31, 2012’’. 

9 SEC. 1733. REQUIREMENT OF 12-MONTH CONTINUOUS COV10 ERAGE UNDER CERTAIN CHIP PROGRAMS. 

11 (a) IN GENERAL.—Section 2102(b) of the Social Se12 curity Act (42 U.S.C. 1397bb(b)) is amended by adding 

13 at the end the following new paragraph: 

14 ‘‘(6) REQUIREMENT FOR 12-MONTH CONTIN15 UOUS ELIGIBILITY.—In the case of a State child 

16 health plan that provides child health assistance 

17 under this title through a means other than de18 scribed in section 2101(a)(2), the plan shall provide 

19 for implementation under this title of the 12-month 

20 continuous eligibility option described in section 

21 1902(e)(12) for targeted low-income children whose 

22 family income is below 200 percent of the poverty 

23 line.’’. 

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

25 subsection (a) shall apply to determinations (and redeter26 minations) of eligibility made on or after January 1, 2010. 


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1 SEC. 1734. PREVENTING THE APPLICATION UNDER CHIP OF 

2 COVERAGE WAITING PERIODS FOR CERTAIN 

3 CHILDREN. 

4 (a) IN GENERAL.—Section 2102(b)(1) of the Social 

5 Security Act (42 U.S.C. 1397bb(b)(1)) is amended— 

6 (1) in subparagraph (B)— 

7 (A) in clause (iii), by striking ‘‘and’’ at the 

8 end; 

9 (B) in clause (iv), by striking the period at 

10 the end and inserting ‘‘; and’’; and 

11 (C) by adding at the end the following new 

12 clause: 

13 ‘‘(v) may not apply a waiting period 

14 (including a waiting period to carry out 

15 paragraph (3)(C)) in the case of a child 

16 described in subparagraph (C).’’; and 

17 (2) by adding at the end the following new sub18 paragraph: 

19 ‘‘(C) DESCRIPTION OF CHILDREN NOT

20 SUBJECT TO WAITING PERIOD.—For purposes 

21 of this paragraph, a child described in this sub22 paragraph is a child who, on the date an appli23 cation is submitted for such child for child 

24 health assistance under this title, meets any of 

25 the following requirements: 


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1 ‘‘(i) INFANTS AND TODDLERS.—The 

2 child is under two years of age. 

3 ‘‘(ii) LOSS OF GROUP HEALTH PLAN

4 COVERAGE.—The child previously had pri5 vate health insurance coverage through a 

6 group health plan or health insurance cov7 erage offered through an employer and lost 

8 such coverage due to— 

9 ‘‘(I) termination of an individ10 ual’s employment; 

11 ‘‘(II) a reduction in hours that 

12 an individual works for an employer; 

13 ‘‘(III) elimination of an individ14 ual’s retiree health benefits; or 

15 ‘‘(IV) termination of an individ16 ual’s group health plan or health in17 surance coverage offered through an 

18 employer. 

19 ‘‘(iii) UNAFFORDABLE PRIVATE COV20 ERAGE.— 

21 ‘‘(I) IN GENERAL.—The family of 

22 the child demonstrates that the cost 

23 of health insurance coverage (includ24 ing the cost of premiums, co-pay25 ments, deductibles, and other cost 


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1 sharing) for such family exceeds 10 

2 percent of the income of such family. 

3 ‘‘(II) DETERMINATION OF FAM4 ILY INCOME.—For purposes of sub5 clause (I), family income shall be de6 termined in the same manner speci7 fied by the State for purposes of de8 termining a child’s eligibility for child 

9 health assistance under this title.’’. 

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

11 this section shall take effect as of the date that is 90 days 

12 after the date of the enactment of this Act. 

13 SEC. 1735. ADULT DAY HEALTH CARE SERVICES. 

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

15 Human Services shall not— 

16 (1) withhold, suspend, disallow, or otherwise 

17 deny Federal financial participation under section 

18 1903(a) of the Social Security Act (42 U.S.C. 

19 1396b(a)) for the provision of adult day health care 

20 services, day activity and health services, or adult 

21 medical day care services, as defined under a State 

22 Medicaid plan approved during or before 1994, dur23 ing such period if such services are provided con24 sistent with such definition and the requirements of 

25 such plan; or 


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1 (2) withdraw Federal approval of any such 

2 State plan or part thereof regarding the provision of 

3 such services (by regulation or otherwise). 

4 (b) EFFECTIVE DATE.—Subsection (a) shall apply 

5 with respect to services provided on or after October 1, 

6 2008. 

7 SEC. 1736. MEDICAID COVERAGE FOR CITIZENS OF FREELY 

8 ASSOCIATED STATES. 

9 (a) IN GENERAL.—Section 402(b)(2) of the Personal 

10 Responsibility and Work Opportunity Reconciliation Act 

11 of 1996 (8 U.S.C. 1612(b)(2)) is amended by adding at 

12 the end the following: 

13 ‘‘(G) MEDICAID EXCEPTION FOR CITIZENS

14 OF FREELY ASSOCIATED STATES.—With respect 

15 to eligibility for benefits for the designated Fed16 eral program defined in paragraph (3)(C) (re17 lating to the Medicaid program), section 401(a) 

18 and paragraph (1) shall not apply to any indi19 vidual who lawfully resides in 1 of the 50 States 

20 or the District of Columbia in accordance with 

21 the Compacts of Free Association between the 

22 Government of the United States and the Gov23 ernments of the Federated States of Micro24 nesia, the Republic of the Marshall Islands, and 

25 the Republic of Palau.’’. 


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1 (b) EXCEPTION TO 5-YEAR LIMITED ELIGIBILITY.— 

2 Section 403(d) of such Act (8 U.S.C. 1613(d)) is amend3 ed— 

4 (1) in paragraph (1), by striking ‘‘or’’ at the 

5 end; 

6 (2) in paragraph (2), by striking the period at 

7 the end and inserting ‘‘; or’’; and 

8 (3) by adding at the end the following: 

9 ‘‘(3) an individual described in section 

10 402(b)(2)(G), but only with respect to the des11 ignated Federal program defined in section 

12 402(b)(3)(C).’’. 

13 (c) DEFINITION OF QUALIFIED ALIEN.—Section 

14 431(b) of such Act (8 U.S.C. 1641(b)) is amended— 

15 (1) in paragraph (6), by striking ‘‘; or’’ at the 

16 end and inserting a comma; 

17 (2) in paragraph (7), by striking the period at 

18 the end and inserting ‘‘, or’’; and 

19 (3) by adding at the end the following: 

20 ‘‘(8) an individual who lawfully resides in the 

21 United States in accordance with a Compact of Free 

22 Association referred to in section 402(b)(2)(G), but 

23 only with respect to the designated Federal program 

24 defined in section 402(b)(3)(C) (relating to the Med25 icaid program).’’. 


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1 SEC. 1737. CONTINUING REQUIREMENT OF MEDICAID COV2 ERAGE OF NONEMERGENCY TRANSPOR3 TATION TO MEDICALLY NECESSARY SERV4 ICES. 

5 (a) REQUIREMENT.—Section 1902(a)(10) of the So6 cial Security Act (42 U.S.C. 1396a(a)(10)) is amended— 

7 (1) in subparagraph (A), in the matter pre8 ceding clause (i), by striking ‘‘and (21)’’ and insert9 ing ‘‘, (21), and (30)’’; and 

10 (2) in subparagraph (C)(iv), by striking ‘‘and 

11 (17)’’ and inserting ‘‘, (17), and (30)’’. 

12 (b) DESCRIPTION OF SERVICES.—Section 1905(a) of 

13 such Act (42 U.S.C. 1395d(a)), as amended by sections 

14 1713(a)(1) and 1724(a)(1), is amended— 

15 (1) in paragraph (29), by striking ‘‘and’’ at the 

16 end; 

17 (2) by redesignating paragraph (30) as para18 graph (31) and by striking the comma at the end 

19 and inserting a semicolon; and 

20 (3) by inserting after paragraph (29) the fol21 lowing new paragraph: 

22 ‘‘(30) nonemergency transportation to medically 

23 necessary services, consistent with the requirement 

24 of section 431.53 of title 42, Code of Federal Regu25 lations, as in effect as of June 1, 2008; and’’. 


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

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

3 of this Act and shall apply to transportation on or after 

4 such date. 

5 SEC. 1738. STATE OPTION TO DISREGARD CERTAIN INCOME 

6 IN PROVIDING CONTINUED MEDICAID COV7 ERAGE FOR CERTAIN INDIVIDUALS WITH EX8 TREMELY HIGH PRESCRIPTION COSTS. 

9 Section 1902(e) of the Social Security Act (42 U.S.C. 

10 1396b(e)), as amended by section 203(a) of the Children’s 

11 Health Insurance Program Reauthorization Act of 2009 

12 (Public Law 111–3), is amended by adding at the end the 

13 following new paragraph: 

14 ‘‘(14)(A) At the option of the State, in the case of 

15 an individual with extremely high prescription drug costs 

16 described in subparagraph (B) who has been determined 

17 (without the application of this paragraph) to be eligible 

18 for medical assistance under this title, the State may, in 

19 redetermining the individual’s eligibility for medical assist20 ance under this title, disregard any family income of the 

21 individual to the extent such income is less than an 

22 amount that is specified by the State and does not exceed 

23 the amount specified in subparagraph (C), or, if greater, 

24 income equal to the cost of the orphan drugs described 

25 in subparagraph (B)(iii). 


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1 ‘‘(B) An individual with extremely high prescription 

2 drug costs described in this subparagraph for a 12-month 

3 period is an individual— 

4 ‘‘(i) who is covered under health insurance or a 

5 health benefits plan that has a maximum lifetime 

6 limit of not less than $1,000,000 which includes all 

7 prescription drug coverage; 

8 ‘‘(ii) who has exhausted all available prescrip9 tion drug coverage under the plan as of the begin10 ning of such period; 

11 ‘‘(iii) who incurs (or is reasonably expected to 

12 incur) on an annual basis during the period costs for 

13 orphan drugs in excess of the amount specified in 

14 subparagraph (C) for the period; and 

15 ‘‘(iv) whose annual family income (determined 

16 without regard to this paragraph) as of the begin17 ning of the period does not exceed 75 percent of the 

18 amount incurred for such drugs (as described in 

19 clause (iii)). 

20 ‘‘(C) The amount specified in this subparagraph for 

21 a 12-month period beginning in— 

22 ‘‘(i) 2009 or 2010, is $200,000; or 

23 ‘‘(ii) a subsequent year, is the amount specified 

24 in clause (i) (or this subparagraph) for the previous 

25 year increased by the annual rate of increase in the 


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1 medical care component of the consumer price index 

2 (U.S. city average) for the 12-month period ending 

3 in August of the previous year. 

4 Any amount computed under clause (ii) that is not a mul5 tiple of $1,000 shall be rounded to the nearest multiple 

6 of $1,000. 

7 ‘‘(D) In applying this paragraph, amounts incurred 

8 for prescription drugs for cosmetic purposes shall not be 

9 taken into account. 

10 ‘‘(E) With respect to an individual described in sub11 paragraph (A), notwithstanding section 1916, the State 

12 plan— 

13 ‘‘(i) shall provide for the application of cost14 sharing that is at least nominal as determined under 

15 section 1916; and 

16 ‘‘(ii) may provide, consistent with section 

17 1916A, for such additional cost-sharing as does not 

18 exceed a maximum level of cost-sharing that is speci19 fied by the Secretary and is adjusted by the Sec20 retary on an annual basis. 

21 ‘‘(F) A State electing the option under this para22 graph shall provide for a determination on an individual’s 

23 application for continued medical assistance under this 

24 title within 30 days of the date the application if filed with 

25 the State. 


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1 ‘‘(G) In this paragraph: 

2 ‘‘(i) The term ‘orphan drugs’ means prescrip3 tion drugs designated under section 526 of the Fed4 eral Food, Drug, and Cosmetic Act (21 U.S.C. 

5 360bb) as a drug for a rare disease or condition. 

6 ‘‘(ii) The term ‘health benefits plan’ includes 

7 coverage under a plan offered under a State high 

8 risk pool.’’. 

9 SEC. 1739. PROVISIONS RELATING TO COMMUNITY LIVING 

10 ASSISTANCE SERVICES AND SUPPORTS 

11 (CLASS). 

12 (a) COORDINATION WITH CLASS PROVISIONS.— 

13 Section 1902(a) of the Social Security Act (42 U.S.C. 

14 1396a(a)), as amended by sections 1631(b), 1703(a), 

15 1729, 1753, 1757(a), 1759(a), 1783(a), and 1907(b), is 

16 amended— 

17 (1) in paragraph (80), by striking ‘‘and’’ at the 

18 end; 

19 (2) in paragraph (81), by striking the period 

20 and inserting ‘‘; and’’; and 

21 (3) by inserting after paragraph (81) the fol22 lowing: 

23 ‘‘(82) provide that the State will comply with 

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1 viduals who are eligible for medical assistance under 

2 this title and are eligible beneficiaries under the 

3 CLASS program established under title XXXII of 

4 the Public Health Service Act as the Secretary shall 

5 establish.’’. 

6 (b) ASSURANCE OF ADEQUATE INFRASTRUCTURE

7 FOR THE PROVISION OF PERSONAL CARE ATTENDANT

8 WORKERS.—Section 1902(a) of such Act (42 U.S.C. 

9 1396a(a)), as amended by subsection (a), is amended— 

10 (1) in paragraph (81), by striking ‘‘and’’ at the 

11 end; 

12 (2) in paragraph (82), by striking the period at 

13 the end and inserting ‘‘; and’’; and 

14 (3) by inserting after paragraph (82), the fol15 lowing: 

16 ‘‘(83) provide that, not later than 2 years after 

17 the date of enactment of this paragraph, each State 

18 shall— 

19 ‘‘(A) assess the extent to which entities 

20 such as providers of home care, home health 

21 services, home and community service providers, 

22 public authorities created to provide personal 

23 care services to individuals eligible for medical 

24 assistance under the State plan, and nonprofit 

25 organizations, are serving or have the capacity 


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1 to serve as fiscal agents for, employers of, and 

2 providers of employment-related benefits for, 

3 personal care attendant workers who provide 

4 personal care services to individuals receiving 

5 benefits under the CLASS program established 

6 under title XXXII of the Public Health Service 

7 Act, including in rural and underserved areas; 

8 ‘‘(B) designate or create such entities to 

9 serve as fiscal agents for, employers of, and 

10 providers of employment-related benefits for, 

11 such workers to ensure an adequate supply of 

12 the workers for individuals receiving benefits 

13 under the CLASS program, including in rural 

14 and underserved areas; and 

15 ‘‘(C) ensure that the designation or cre16 ation of such entities will not negatively alter or 

17 impede existing programs, models, methods, or 

18 administration of service delivery that provide 

19 for consumer controlled or self-directed home 

20 and community services and further ensure that 

21 such entities will not impede the ability of indi22 viduals to direct and control their home and 

23 community services, including the ability to se24 lect, manage, dismiss, co-employ, or employ 

25 such workers or inhibit such individuals from 


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1 relying on family members for the provision of 

2 personal care services.’’. 

3 (c) INCLUSION OF INFORMATION ON SUPPLEMENTAL

4 COVERAGE IN THE NATIONAL CLEARINGHOUSE FOR

5 LONG-TERM CARE INFORMATION; EXTENSION OF FUND6 ING.—Section 6021(d) of the Deficit Reduction Act of 

7 2005 (42 U.S.C. 1396p note) is amended— 

8 (1) in paragraph (2)(A)— 

9 (A) in clause (ii), by striking ‘‘and’’ at the 

10 end; 

11 (B) in clause (iii), by striking the period at 

12 the end and inserting ‘‘; and’’; and 

13 (C) by adding at the end the following: 

14 ‘‘(iv) include information regarding 

15 the CLASS program established under 

16 title XXXII of the Public Health Service 

17 Act.’’; and 

18 (2) in paragraph (3)— 

19 (A) by striking ‘‘2010’’ and inserting 

20 ‘‘2015’’; and 

21 (B) by adding at the end the following: ‘‘In 

22 addition to the amount appropriated under the 

23 previous sentence, there are authorized to be 

24 appropriated to carry out this subsection, 


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1 $7,000,000 for each of fiscal years 2011, 2012, 

2 and 2013.’’. 

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

4 this section take effect on January 1, 2011. 

5 Subtitle E—Financing 

6 SEC. 1741. PAYMENTS TO PHARMACISTS. 

7 (a) PHARMACY REIMBURSEMENT LIMITS.— 

8 (1) IN GENERAL.—Section 1927(e) of the So9 cial Security Act (42 U.S.C. 1396r–8(e)) is amend10 ed— 

11 (A) by striking paragraph (5) and insert12 ing the following: 

13 ‘‘(5) USE OF AMP IN UPPER PAYMENT LIM14 ITS.—The Secretary shall calculate the Federal 

15 upper reimbursement limit established under para16 graph (4) as 130 percent of the weighted average 

17 (determined on the basis of manufacturer utiliza18 tion) of monthly average manufacturer prices. Noth19 ing in the previous sentence shall be construed as 

20 preventing the Secretary from performing such cal21 culation using a smoothing process in order to re22 duce significant variations from month to month as 

23 a result of rebates, discounts, and other pricing 

24 practices, such as in the manner such a process is 

25 used by the Secretary in determining the average 


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1 sales price of a drug or biological under section 

2 1847A.’’ 

3 (2) DEFINITION OF AMP.—Section 

4 1927(k)(1)(B) of such Act (42 U.S.C. 1396r– 

5 8(k)(1)(B)) is amended— 

6 (B) in the heading, by striking ‘‘EX7 TENDED TO WHOLESALERS’’ and inserting 

8 ‘‘AND OTHER PAYMENTS’’; and 

9 (C) by striking ‘‘regard to’’ and all that 

10 follows through the period and inserting the fol11 lowing: ‘‘regard to— 

12 ‘‘(i) customary prompt pay discounts 

13 extended to wholesalers; 

14 ‘‘(ii) bona fide service fees paid by 

15 manufacturers; 

16 ‘‘(iii) reimbursement by manufactur17 ers for recalled, damaged, expired, or oth18 erwise unsalable returned goods, including 

19 reimbursement for the cost of the goods 

20 and any reimbursement of costs associated 

21 with return goods handling and processing, 

22 reverse logistics, and drug destruction; 

23 ‘‘(iv) sales directly to, or rebates, dis24 counts, or other price concessions provided 

25 to, pharmacy benefit managers, managed 


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1 care organizations, health maintenance or2 ganizations, insurers, mail order phar3 macies that are not open to all members of 

4 the public, or long term care providers, 

5 provided that these rebates, discounts, or 

6 price concessions are not passed through to 

7 retail pharmacies; 

8 ‘‘(v) sales directly to, or rebates, dis9 counts, or other price concessions provided 

10 to, hospitals, clinics, and physicians, unless 

11 the drug is an inhalation, infusion, or 

12 injectable drug, or unless the Secretary de13 termines, as allowed for in Agency admin14 istrative procedures, that it is necessary to 

15 include such sales, rebates, discounts, and 

16 price concessions in order to obtain an ac17 curate AMP for the drug. Such a deter18 mination shall not be subject to judicial re19 view; or 

20 ‘‘(vi) rebates, discounts, and other 

21 price concessions required to be provided 

22 under agreements under subsections (f) 

23 and (g) of section 1860D–2(f).’’. 


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1 (3) MANUFACTURER REPORTING REQUIRE2 MENTS.—Section 1927(b)(3)(A) of such Act (42 

3 U.S.C. 1396r–8(b)(3)(A)) is amended— 

4 (A) in clause (ii), by striking ‘‘and’’ at the 

5 end; 

6 (B) by striking the period at the end of 

7 clause (iii) and inserting ‘‘; and’’; and 

8 (C) by inserting after clause (iii) the fol9 lowing new clause: 

10 ‘‘(iv) not later than 30 days after the 

11 last day of each month of a rebate period 

12 under the agreement, on the manufactur13 er’s total number of units that are used to 

14 calculate the monthly average manufac15 turer price for each covered outpatient 

16 drug.’’. 

17 (4) AUTHORITY TO PROMULGATE REGULA18 TION.—The Secretary of Health and Human Serv19 ices may promulgate regulations to clarify the re20 quirements for upper payment limits and for the de21 termination of the average manufacturer price in an 

22 expedited manner. Such regulations may become ef23 fective on an interim final basis, pending oppor24 tunity for public comment. 


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1 (5) PHARMACY REIMBURSEMENTS THROUGH

2 DECEMBER 31, 2010.—The specific upper limit under 

3 section 447.332 of title 42, Code of Federal Regula4 tions (as in effect on December 31, 2006) applicable 

5 to payments made by a State for multiple source 

6 drugs under a State Medicaid plan shall continue to 

7 apply through December 31, 2010, for purposes of 

8 the availability of Federal financial participation for 

9 such payments. 

10 (b) DISCLOSURE OF PRICE INFORMATION TO THE

11 PUBLIC.—Section 1927(b)(3) of such Act (42 U.S.C. 

12 1396r–8(b)(3)) is amended— 

13 (1) in subparagraph (A)— 

14 (A) in clause (i), in the matter preceding 

15 subclause (I), by inserting ‘‘month of a’’ after 

16 ‘‘each’’; and 

17 (B) in the last sentence, by striking ‘‘and 

18 shall,’’ and all that follows up to the period; 

19 and 

20 (2) in subparagraph (D)(v), by inserting 

21 ‘‘weighted’’ before ‘‘average manufacturer prices’’. 

22 SEC. 1742. PRESCRIPTION DRUG REBATES. 

23 (a) ADDITIONAL REBATE FOR NEW FORMULATIONS

24 OF EXISTING DRUGS.— 


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1 (1) IN GENERAL.—Section 1927(c)(2) of the 

2 Social Security Act (42 U.S.C. 1396r–8(c)(2)) is 

3 amended by adding at the end the following new 

4 subparagraph: 

5 ‘‘(C) TREATMENT OF NEW FORMULA6 TIONS.—In the case of a drug that is a line ex7 tension of a single source drug or an innovator 

8 multiple source drug that is an oral solid dos9 age form, the rebate obligation with respect to 

10 such drug under this section shall be the 

11 amount computed under this section for such 

12 new drug or, if greater, the product of— 

13 ‘‘(i) the average manufacturer price of 

14 the line extension of a single source drug 

15 or an innovator multiple source drug that 

16 is an oral solid dosage form; 

17 ‘‘(ii) the highest additional rebate 

18 (calculated as a percentage of average 

19 manufacturer price) under this section for 

20 any strength of the original single source 

21 drug or innovator multiple source drug; 

22 and 

23 ‘‘(iii) the total number of units of 

24 each dosage form and strength of the line 

25 extension product paid for under the State 


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1 plan in the rebate period (as reported by 

2 the State). 

3 In this subparagraph, the term ‘line extension’ 

4 means, with respect to a drug, a new formula5 tion of the drug, such as an extended release 

6 formulation.’’. 

7 (2) EFFECTIVE DATE.—The amendment made 

8 by paragraph (1) shall apply to drugs dispensed 

9 after December 31, 2009. 

10 (b) INCREASE MINIMUM REBATE PERCENTAGE FOR

11 SINGLE SOURCE DRUGS.— 

12 (1) IN GENERAL.—Section 1927(c)(1)(B)(i) of 

13 the Social Security Act (42 U.S.C. 1396r– 

14 8(c)(1)(B)(i)) is amended— 

15 (A) in subclause (IV), by striking ‘‘and’’ at 

16 the end; 

17 (B) in subclause (V)— 

18 (i) by inserting ‘‘and before January 

19 1, 2010’’ after ‘‘December 31, 1995,’’; and 

20 (ii) by striking the period at the end 

21 and inserting ‘‘; and’’; and 

22 (C) by adding at the end the following new 

23 subclause: 

24 ‘‘(VI) after December 31, 2009, 

25 is 23.1 percent.’’. 


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1 (2) RECAPTURE OF TOTAL SAVINGS DUE TO IN2 CREASE.—Section 1927(b)(1) of such Act is amend3 ed by adding at the end the following new subpara4 graph: 

5 ‘‘(C) SPECIAL RULE FOR INCREASED MIN6 IMUM REBATE PERCENTAGE.— 

7 ‘‘(i) IN GENERAL.—In addition to the 

8 amounts applied as a reduction under sub9 paragraph (B), for rebate periods begin10 ning on or after January 1, 2010, during 

11 a fiscal year, the Secretary shall reduce 

12 payments to a State under section 1903(a) 

13 in the manner specified in clause (ii), in an 

14 amount equal to the product of— 

15 ‘‘(I) 100 percent minus the Fed16 eral medical assistance percentage ap17 plicable to the rebate period for the 

18 State; and 

19 ‘‘(II) the amounts received by the 

20 State under such subparagraph that 

21 are attributable (as estimated by the 

22 Secretary based on utilization and 

23 other data) to the increase in the min24 imum rebate percentage effected by 

25 the amendments made by section 


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1 1742(b)(1) of the Affordable Health 

2 Care for America Act, taking into ac3 count the additional drugs included 

4 under the amendments made by sec5 tion 1743 of such Act. 

6 The Secretary shall adjust such payment 

7 reduction for a calendar quarter to the ex8 tent the Secretary determines, based upon 

9 subsequent utilization and other data, that 

10 the reduction for such quarter was greater 

11 or less than the amount of payment reduc12 tion that should have been made. 

13 ‘‘(ii) MANNER OF PAYMENT REDUC14 TION.—The amount of the payment reduc15 tion under clause (i) for a State for a 

16 quarter shall be deemed an overpayment to 

17 the State under this title to be disallowed 

18 against the State’s regular quarterly draw 

19 for all Medicaid spending under section 

20 1903(d)(2). Such a disallowance is not 

21 subject to a reconsideration under 

22 1116(d).’’. 


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1 SEC. 1743. EXTENSION OF PRESCRIPTION DRUG DIS2 COUNTS TO ENROLLEES OF MEDICAID MAN3 AGED CARE ORGANIZATIONS. 

4 (a) IN GENERAL.—Section 1903(m)(2)(A) of the So5 cial Security Act (42 U.S.C. 1396b(m)(2)(A)) is amend6 ed— 

7 (1) in clause (xi), by striking ‘‘and’’ at the end; 

8 (2) in clause (xii), by striking the period at the 

9 end and inserting ‘‘; and’’; and 

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

11 ‘‘(xiii) such contract provides that the entity 

12 shall report to the State such information, on such 

13 timely and periodic basis as specified by the Sec14 retary, as the State may require in order to include, 

15 in the information submitted by the State to a man16 ufacturer under section 1927(b)(2)(A) and to the 

17 Secretary under section 1927(b)(2)(C), information 

18 on covered outpatient drugs dispensed to individuals 

19 eligible for medical assistance who are enrolled with 

20 the entity and for which the entity is responsible for 

21 coverage of such drugs under this subsection.’’. 

22 (b) CONFORMING AMENDMENTS.—Section 1927 of 

23 such Act (42 U.S.C. 1396r-8) is amended—— 

24 (1) in the first sentence of subsection (b)(1)(A), 

25 by inserting before the period at the end the fol26 lowing: ‘‘, including such drugs dispensed to individVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01101 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 uals enrolled with a medicaid managed care organi2 zation if the organization is responsible for coverage 

3 of such drugs’’; 

4 (2) in subsection (b)(2), by adding at the end 

5 the following new subparagraph: 

6 ‘‘(C) REPORTING ON MMCO DRUGS.—On a 

7 quarterly basis, each State shall report to the 

8 Secretary the total amount of rebates in dollars 

9 received from pharmacy manufacturers for 

10 drugs provided to individuals enrolled with 

11 Medicaid managed care organizations that con12 tract under section 1903(m) and such other in13 formation as the Secretary may require to carry 

14 out paragraph (1)(C) with respect to such re15 bates.’’; and 

16 (3) in subsection (j)— 

17 (A) in the heading by striking ‘‘EXEMP18 TION’’ and inserting ‘‘SPECIAL RULES’’; and 

19 (B) in paragraph (1), by striking ‘‘are not 

20 subject to the requirements of this section’’ and 

21 inserting ‘‘are subject to the requirements of 

22 this section unless such drugs are subject to 

23 discounts under section 340B of the Public 

24 Health Service Act’’. 


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

2 this section take effect on January 1, 2010, and shall 

3 apply to drugs dispensed on or after such date, without 

4 regard to whether or not final regulations to carry out 

5 such amendments have been promulgated by such date. 

6 SEC. 1744. PAYMENTS FOR GRADUATE MEDICAL EDU7 CATION. 

8 (a) IN GENERAL.—Section 1905 of the Social Secu9 rity Act (42 U.S.C. 1396d), as amended by sections 

10 1701(a)(3)(B), 1711(a), and 1713(a), is amended by add11 ing at the end the following new subsection: 

12 ‘‘(bb) PAYMENT FOR GRADUATE MEDICAL EDU13 CATION.— 

14 ‘‘(1) IN GENERAL.—The term ‘medical assist15 ance’ includes payment for costs of graduate medical 

16 education consistent with this subsection, whether 

17 provided in or outside of a hospital. 

18 ‘‘(2) SUBMISSION OF INFORMATION.—For pur19 poses of paragraph (1) and section 

20 1902(a)(13)(A)(v), payment for such costs is not 

21 consistent with this subsection unless— 

22 ‘‘(A) the State submits to the Secretary, in 

23 a timely manner and on an annual basis speci24 fied by the Secretary, information on total pay25 ments for graduate medical education and how 


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1 such payments are being used for graduate 

2 medical education, including— 

3 ‘‘(i) the institutions and programs eli4 gible for receiving the funding; 

5 ‘‘(ii) the manner in which such pay6 ments are calculated; 

7 ‘‘(iii) the types and fields of education 

8 being supported; 

9 ‘‘(iv) the workforce or other goals to 

10 which the funding is being applied; 

11 ‘‘(v) State progress in meeting such 

12 goals; and 

13 ‘‘(vi) such other information as the 

14 Secretary determines will assist in carrying 

15 out paragraphs (3) and (4); and 

16 ‘‘(B) such expenditures are made con17 sistent with such goals and requirements as are 

18 established under paragraph (4). 

19 ‘‘(3) REVIEW OF INFORMATION.—The Secretary 

20 shall make the information submitted under para21 graph (2) available to the Advisory Committee on 

22 Health Workforce Evaluation and Assessment (es23 tablished under section 2261 of the Public Health 

24 Service Act). The Secretary and the Advisory Com25 mittee shall independently review the information 


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1 submitted under paragraph (2), taking into account 

2 State and local workforce needs. 

3 ‘‘(4) SPECIFICATION OF GOALS AND REQUIRE4 MENTS.—The Secretary shall specify by rule, ini5 tially published by not later than December 31, 

6 2011— 

7 ‘‘(A) program goals for the use of funds 

8 described in paragraph (1), taking into account 

9 recommendations of the such Advisory Com10 mittee and the goals for approved medical resi11 dency training programs described in section 

12 1886(h)(1)(B); and 

13 ‘‘(B) requirements for use of such funds 

14 consistent with such goals. 

15 Such rule may be effective on an interim basis pend16 ing revision after an opportunity for public com17 ment.’’. 

18 (b) CONFORMING AMENDMENT.—Section 

19 1902(a)(13)(A) of such Act (42 U.S.C. 1396a(a)(13)(A)), 

20 as amended by section 1721(a)(1)(A), is amended— 

21 (1) by striking ‘‘and’’ at the end of clause (iii); 

22 (2) by striking the semicolon in clause (iv) and 

23 inserting ‘‘, and’’; and 

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

25 clause: 


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1 ‘‘(v) in the case of hospitals and at 

2 the option of a State, such rates may in3 clude, to the extent consistent with section 

4 1905(bb), payment for graduate medical 

5 education; and’’. 

6 (c) EFFECTIVE DATE.—The amendments made by 

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

8 of this Act. Nothing in this section shall be construed as 

9 affecting payments made before such date under a State 

10 plan under title XIX of the Social Security Act for grad11 uate medical education. 

12 SEC. 1745. NURSING FACILITY SUPPLEMENTAL PAYMENT 

13 PROGRAM. 

14 (a) TOTAL AMOUNT AVAILABLE FOR PAYMENTS.— 

15 (1) IN GENERAL.—Out of any funds in the 

16 Treasury not otherwise appropriated, there are ap17 propriated to the Secretary of Health and Human 

18 Services (in this section referred to as the ‘‘Sec19 retary’’) to carry out this section $6,000,000,000, of 

20 which the following amounts shall be available for 

21 obligation in the following years: 

22 (A) $1,500,000,000 shall be available be23 ginning in 2010. 

24 (B) $1,500,000,000 shall be available be25 ginning in 2011. 


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1 (C) $1,500,000,000 shall be available be2 ginning in 2012. 

3 (D) $1,500,000,000 shall be available be4 ginning in 2013. 

5 (2) AVAILABILITY.—Funds appropriated under 

6 paragraph (1) shall remain available until all eligible 

7 dually-certified facilities (as defined in subsection 

8 (b)(3)) have been reimbursed for underpayments 

9 under this section during cost reporting periods end10 ing during calendar years 2010 through 2013. 

11 (3) LIMITATION OF AUTHORITY.—The Sec12 retary may not may payments under this section 

13 that exceed the funds appropriated under paragraph 

14 (1). 

15 (4) DISPOSITION OF REMAINING FUNDS INTO

16 MIF.—Any funds appropriated under paragraph (1) 

17 which remain available after the application of para18 graph (2) shall be deposited into the Medicaid Im19 provement Fund under section 1941 of the Social 

20 Security Act. 

21 (b) USE OF FUNDS.— 

22 (1) AUTHORITY TO MAKE PAYMENTS.—From 

23 the amounts available for obligation in a year under 

24 subsection (a), the Secretary, acting through the Ad25 ministrator of the Centers for Medicare & Medicaid 


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1 Services, shall pay the amount determined under 

2 paragraph (2) directly to an eligible dually-certified 

3 facility for the purpose of providing funding to reim4 burse such facility for furnishing quality care to 

5 Medicaid-eligible individuals. 

6 (2) DETERMINATION OF PAYMENT AMOUNTS.— 

7 (A) IN GENERAL.—Subject to subpara8 graphs (B) and (C), the payment amount deter9 mined under this paragraph for a year for an 

10 eligible dually-certified facility shall be an 

11 amount determined by the Secretary as re12 ported on the facility’s latest available Medicare 

13 cost report. 

14 (B) LIMITATION ON PAYMENT AMOUNT.— 

15 In no case shall the payment amount for an eli16 gible dually-certified facility for a year under 

17 subparagraph (A) be more than the payment 

18 deficit described in paragraph (3)(D) for such 

19 facility as reported on the facility’s latest avail20 able Medicare cost report. 

21 (C) PRO-RATA REDUCTION.—If the 

22 amount available for obligation under sub23 section (a) for a year (as reduced by allowable 

24 administrative costs under this section) is insuf25 ficient to ensure that each eligible dually-cerVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01108 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 tified facility receives the amount of payment 

2 calculated under subparagraph (A), the Sec3 retary shall reduce that amount of payment 

4 with respect to each such facility in a pro-rata 

5 manner to ensure that the entire amount avail6 able for such payments for the year be paid. 

7 (D) NO REQUIRED MATCH.—The Secretary 

8 may not require that a State provide matching 

9 funds for any payment made under this sub10 section. 

11 (3) ELIGIBLE DUALLY-CERTIFIED FACILITY DE12 FINED.—For purposes of this section, the term ‘‘eli13 gible dually-certified facility’’ means, for a cost re14 porting period ending during a year (beginning no 

15 earlier than 2010) that is covered by the latest avail16 able Medicare cost report, a nursing facility that 

17 meets all of the following requirements: 

18 (A) The facility is participating as a nurs19 ing facility under title XIX of the Social Secu20 rity Act and as a skilled nursing facility under 

21 title XVIII of such Act during the entire year. 

22 (B) The base Medicaid payment rate (ex23 cluding any supplemental payments) to the fa24 cility is not less than the base Medicaid payVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01109 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 ment rate (excluding any supplemental pay2 ments) to such facility as of June 16, 2009. 

3 (C) As reported on the facility’s latest 

4 Medicare cost report— 

5 (i) the Medicaid share of patient days 

6 for such facility is not less than 60 percent 

7 of the combined Medicare and Medicaid 

8 share of resident days for such facility; and 

9 (ii) the combined Medicare and Med10 icaid share of resident days for such facil11 ity, as reported on the facility’s latest 

12 available Medicare cost report, is not less 

13 than 75 percent of the total resident days 

14 for such facility. 

15 (D) The facility has received Medicaid re16 imbursement (including any supplemental pay17 ments) for the provision of covered services to 

18 Medicaid eligible individuals, as reported on the 

19 facility’s latest available Medicare cost report, 

20 that is significantly less (as determined by the 

21 Secretary) than the allowable costs (as deter22 mined by the Secretary) incurred by the facility 

23 in providing such services. 

24 (E) The facility is not in the highest quar25 tile of costs costs per day, as determined by the 


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1 Secretary and as adjusted for case mix, wages, 

2 and type of facility. 

3 (F) The facility provides quality care, as 

4 determined by the Secretary, to— 

5 (i) Medicaid eligible individuals; and 

6 (ii) individuals who are entitled to 

7 items and services under part A of title 

8 XVIII of the Social Security Act. 

9 (G) In the most recent standard survey 

10 available, the facility was not cited for any im11 mediate jeopardy deficiencies as defined by the 

12 Secretary. 

13 (H) In the most recent standard survey 

14 available, the facility maintains an appropriate 

15 staffing level to attain or maintain the highest 

16 practicable well-being of each resident as de17 fined by the Secretary 

18 (I) The facility complies with all the re19 quirements, as determined by the Secretary, 

20 contained in sections 1411 through 1416 and 

21 the amendments made by such sections. 

22 (J) The facility was not listed as a Centers 

23 for Medicare & Medicaid Services Special Focus 

24 Facility (SFF) nor as a SFF on a State-based 

25 list. 


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1 (4) FREQUENCY OF PAYMENT.—Payment of an 

2 amount under this subsection to an eligible dually3 certified facility shall be made for a year in a lump 

4 sum or in such periodic payments in such frequency 

5 as the Secretary determines appropriate. 

6 (5) DIRECT PAYMENTS.—Such payment— 

7 (A) shall be made directly by the Secretary 

8 to an eligible dually-certified facility or a con9 tractor designated by such facility; and 

10 (B) shall not be made through a State. 

11 (c) ADMINISTRATION.— 

12 (1) ANNUAL APPLICATIONS; DEADLINES.—The 

13 Secretary shall establish a process, including dead14 lines, under which facilities may apply on an annual 

15 basis to qualify as eligible dually-certified facilities 

16 for payment under subsection (b). 

17 (2) CONTRACTING AUTHORITY.—The Secretary 

18 may enter into one or more contracts with entities 

19 for the purpose of implementation of this section. 

20 (3) LIMITATION.—The Secretary may not 

21 spend more than 0.75 percent of the amount made 

22 available under subsection (a) in any year on the 

23 costs of administering the program of payments 

24 under this section for the year. 


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1 (4) IMPLEMENTATION.—Notwithstanding any 

2 other provision of law, the Secretary may implement, 

3 by program instruction or otherwise, the provisions 

4 of this section. 

5 (5) LIMITATIONS ON REVIEW.—There shall be 

6 no administrative or judicial review of— 

7 (A) the determination of the eligibility of a 

8 facility for payments under subsection (b); or 

9 (B) the determination of the amount of 

10 any payment made to a facility under such sub11 section. 

12 (d) ANNUAL REPORTS.—The Secretary shall submit 

13 an annual report to the committees with jurisdiction in 

14 the Congress on payments made under subsection (b). 

15 Each such report shall include information on— 

16 (1) the facilities receiving such payments; 

17 (2) the amount of such payments to such facili18 ties; and 

19 (3) the basis for selecting such facilities and the 

20 amount of such payments. 

21 (e) REFERENCE TO REPORT.—For report by the 

22 Medicaid and CHIP Payment and Access Commission on 

23 the adequacy of payments to nursing facilities under the 

24 Medicaid program, see section 1900(b)(2)(B) of the Social 

25 Security Act, as amended by section 1784. 


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1 (f) DEFINITIONS.—For purposes of this section: 

2 (1) DUALLY-CERTIFIED FACILITY.—The term 

3 ‘‘dually-certified facility’’ means a facility that is 

4 participating as a nursing facility under title XIX of 

5 the Social Security Act and as a skilled nursing fa6 cility under title XVIII of such Act. 

7 (2) MEDICAID ELIGIBLE INDIVIDUAL.—The 

8 term ‘‘Medicaid eligible individual’’ means an indi9 vidual who is eligible for medical assistance, with re10 spect to nursing facility services (as defined in sec11 tion 1905(f) of the Social Security Act), under title 

12 XIX of the such Act. 

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

14 States and the District of Columbia. 

15 SEC. 1746. REPORT ON MEDICAID PAYMENTS. 

16 Section 1902 of the Social Security Act (42 U.S.C. 

17 1396), as amended by sections 1703(a), 1714(a), and 

18 1731(a), is amended by adding at the end the following 

19 new subsection: 

20 ‘‘(jj) REPORT ON MEDICAID PAYMENTS.—Each year, 

21 on or before a date determined by the Secretary, a State 

22 participating in the Medicaid program under this title 

23 shall submit to the Administrator of the Centers for Medi24 care & Medicaid Services— 


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1 ‘‘(1) information on the determination of rates 

2 of payment to providers for covered services under 

3 the State plan, including— 

4 ‘‘(A) the final rates; 

5 ‘‘(B) the methodologies used to determine 

6 such rates; and 

7 ‘‘(C) justifications for the rates; and 

8 ‘‘(2) an explanation of the process used by the 

9 State to allow providers, beneficiaries and their rep10 resentatives, and other concerned State residents a 

11 reasonable opportunity to review and comment on 

12 such rates, methodologies, and justifications before 

13 the State made such rates final.’’. 

14 SEC. 1747. REVIEWS OF MEDICAID. 

15 (a) GAO STUDY ON FMAP.—. 

16 (1) STUDY.—The Comptroller General of the 

17 United States shall conduct a study regarding fed18 eral payments made to the State Medicaid programs 

19 under title XIX of the Social Security Act for the 

20 purposes of making recommendations to Congress. 

21 (2) REPORT.—Not later than February 15, 

22 2011, the Comptroller General shall submit to the 

23 appropriate committees of Congress a report on the 

24 study conducted under paragraph (1) and the effect 


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1 on the federal government, States, providers, and 

2 beneficiaries of— 

3 (A) removing the 50 percent floor, or 83 

4 percent ceiling, or both, in the Federal medical 

5 assistance percentage under section 1905(b)(1) 

6 of the Social Security Act; and 

7 (B) revising the current formula for such 

8 Federal medical assistance percentage to better 

9 reflect State fiscal capacity and State effort to 

10 pay for health and long-term care services and 

11 to better adjust for national or regional eco12 nomic downturns. 

13 (b) GAO STUDY ON MEDICAID ADMINISTRATIVE

14 COSTS..— 

15 (1) STUDY.—The Comptroller General of the 

16 United States shall conduct a study of the adminis17 tration of the Medicaid program by the Department 

18 of Health and Human Services, State Medicaid 

19 agencies, and local government agencies. The report 

20 shall address the following issues: 

21 (A) The extent to which federal funds for 

22 each administrative function, such as survey 

23 and certification and claims processing, are 

24 being used effectively and efficiently. 


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1 (B) The administrative functions on which 

2 federal Medicaid funds are expended and the 

3 amounts of such expenditures (whether spent 

4 directly or by contract). 

5 (2) REPORT.—Not later than February 15, 

6 2011, the Comptroller General shall submit to the 

7 appropriate committees of Congress a report on the 

8 study conducted under paragraph (1). 

9 SEC. 1748. EXTENSION OF DELAY IN MANAGED CARE ORGA10 NIZATION PROVIDER TAX ELIMINATION. 

11 Effective as if included in the enactment of section 

12 6051 of the Deficit Reduction Act of 2005 (Public Law 

13 109–171), subsection (b)(2)(A) of such section is amended 

14 by striking ‘‘October 1, 2009’’ and inserting ‘‘October 1, 

15 2010’’. 

16 SEC. 1749. EXTENSION OF ARRA INCREASE IN FMAP. 

17 Section 5001 of the American Recovery and Reinvest18 ment Act of 2009 (Public Law 111–5) is amended— 

19 (1) in subsection (a)(3), by striking ‘‘first cal20 endar quarter’’ and inserting ‘‘first 3 calendar quar21 ters’’; 

22 (2) in subsection (b)(2), by inserting before the 

23 period at the end the following: ‘‘and such para24 graph shall not apply to calendar quarters beginning 

25 on or after October 1, 2010’’; 


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1 (3) in subsection (c)(4)(C)(ii), by striking ‘‘De2 cember 2009’’ and ‘‘January 2010’’ and inserting 

3 ‘‘June 2010’’ and ‘‘July 2010’’, respectively; 

4 (4) in subsection (d), by inserting ‘‘ending be5 fore October 1, 2010’’ after ‘‘entire fiscal years’’ and 

6 after ‘‘with respect to fiscal years’’; 

7 (5) in subsection (g)(1), by striking ‘‘September 

8 30, 2011’’ and inserting ‘‘December 31, 2011’’; and 

9 (6) in subsection (h)(3), by striking ‘‘December 

10 31, 2010’’ and inserting ‘‘June 30, 2011’’. 

11 Subtitle F—Waste, Fraud, and 

12 Abuse 

13 SEC. 1751. HEALTH CARE ACQUIRED CONDITIONS. 

14 (a) MEDICAID NON-PAYMENT FOR CERTAIN HEALTH

15 CARE-ACQUIRED CONDITIONS.—Section 1903(i) of the 

16 Social Security Act (42 U.S.C. 1396b(i)) is amended— 

17 (1) by striking ‘‘or’’ at the end of paragraph 

18 (23); 

19 (2) by striking the period at the end of para20 graph (24) and inserting ‘‘; or’’; and 

21 (3) by inserting after paragraph (24) the fol22 lowing new paragraph: 

23 ‘‘(25) with respect to amounts expended for 

24 services related to the presence of a condition that 

25 could be identified by a secondary diagnostic code 


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1 described in section 1886(d)(4)(D)(iv) and for any 

2 health care acquired condition determined as a non3 covered service under title XVIII.’’. 

4 (b) APPLICATION TO CHIP.—Section 2107(e)(1)(G) 

5 of such Act (42 U.S.C. 1397gg(e)(1)(G)) is amended by 

6 striking ‘‘and (17)’’ and inserting ‘‘(17), and (25)’’. 

7 (c) PERMISSION TO INCLUDE ADDITIONAL HEALTH

8 CARE-ACQUIRED CONDITIONS.—Nothing in this section 

9 shall prevent a State from including additional health 

10 care-acquired conditions for non-payment in its Medicaid 

11 program under title XIX of the Social Security Act. 

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

13 this section shall apply to discharges occurring on or after 

14 January 1, 2010. 

15 SEC. 1752. EVALUATIONS AND REPORTS REQUIRED UNDER 

16 MEDICAID INTEGRITY PROGRAM. 

17 Section 1936(c)(2)) of the Social Security Act (42 

18 U.S.C. 1396u–7(c)(2)) is amended— 

19 (1) by redesignating subparagraph (D) as sub20 paragraph (E); and 

21 (2) by inserting after subparagraph (C) the fol22 lowing new subparagraph: 

23 ‘‘(D) For the contract year beginning in 

24 2011 and each subsequent contract year, the 

25 entity provides assurances to the satisfaction of 


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1 the Secretary that the entity will conduct peri2 odic evaluations of the effectiveness of the ac3 tivities carried out by such entity under the 

4 Program and will submit to the Secretary an 

5 annual report on such activities.’’. 

6 SEC. 1753. REQUIRE PROVIDERS AND SUPPLIERS TO 

7 ADOPT PROGRAMS TO REDUCE WASTE, 

8 FRAUD, AND ABUSE. 

9 Section 1902(a) of such Act (42 U.S.C. 42 U.S.C. 

10 1396a(a)), as amended by sections 1631(b)(1), 1703, and 

11 1729, is further amended— 

12 (1) in paragraph (75), by striking at the end 

13 ‘‘and’’; 

14 (2) in paragraph (76), by striking at the end 

15 the period and inserting ‘‘; and’’; and 

16 (3) by inserting after paragraph (76) the fol17 lowing new paragraph: 

18 ‘‘(77) provide that any provider or supplier 

19 (other than a physician or nursing facility) providing 

20 services under such plan shall, subject to paragraph 

21 (5) of section 1874(d), establish a compliance pro22 gram described in paragraph (1) of such section in 

23 accordance with such section.’’. 


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1 SEC. 1754. OVERPAYMENTS. 

2 (a) IN GENERAL.—Section 1903(d)(2)(C) of the So3 cial Security Act (42 U.S.C. 1396b(d)(2)(C)) is amend4 ed— 

5 (1) in the first sentence, by inserting ‘‘(or of 1 

6 year in the case of overpayments due to fraud)’’ 

7 after ‘‘60 days’’; and 

8 (2) in the second sentence, by striking ‘‘the 60 

9 days’’ and inserting ‘‘such period’’. 

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

11 subsection (a) shall apply in the case of overpayments dis12 covered on or after the date of the enactment of this Act. 

13 SEC. 1755. MANAGED CARE ORGANIZATIONS. 

14 (a) MINIMUM MEDICAL LOSS RATIO.— 

15 (1) MEDICAID.—Section 1903(m)(2)(A) of the 

16 Social Security Act (42 U.S.C. 1396b(m)(2)(A)), as 

17 amended by section 1743(a)(3), is amended— 

18 (A) by striking ‘‘and’’ at the end of clause 

19 (xii); 

20 (B) by striking the period at the end of 

21 clause (xiii) and inserting ‘‘; and’’; and 

22 (C) by adding at the end the following new 

23 clause: 

24 ‘‘(xiv) such contract has a medical loss ratio, as 

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1 fied by the Secretary that is a percentage (not less 

2 than 85 percent) as specified by the Secretary.’’. 

3 (2) CHIP.—Section 2107(e)(1) of such Act (42 

4 U.S.C. 1397gg(e)(1)) is amended— 

5 (A) by redesignating subparagraphs (H) 

6 through (L) as subparagraphs (I) through (M); 

7 and 

8 (B) by inserting after subparagraph (G) 

9 the following new subparagraph: 

10 ‘‘(H) Section 1903(m)(2)(A)(xiv) (relating 

11 to application of minimum loss ratios), with re12 spect to comparable contracts under this title.’’. 

13 (3) EFFECTIVE DATE.—The amendments made 

14 by this subsection shall apply to contracts entered 

15 into or renewed on or after July 1, 2010. 

16 (b) PATIENT ENCOUNTER DATA.— 

17 (1) IN GENERAL.—Section 1903(m)(2)(A)(xi) 

18 of the Social Security Act (42 U.S.C. 

19 1396b(m)(2)(A)(xi)) is amended by inserting ‘‘and 

20 for the provision of such data to the State at a fre21 quency and level of detail to be specified by the Sec22 retary’’ after ‘‘patients’’. 

23 (2) EFFECTIVE DATE.—The amendment made 

24 by paragraph (1) shall apply with respect to contract 

25 years beginning on or after January 1, 2010. 


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1 SEC. 1756. TERMINATION OF PROVIDER PARTICIPATION 

2 UNDER MEDICAID AND CHIP IF TERMINATED 

3 UNDER MEDICARE OR OTHER STATE PLAN 

4 OR CHILD HEALTH PLAN. 

5 (a) STATE PLAN REQUIREMENT.—Section 

6 1902(a)(39) of the Social Security Act (42 U.S.C. 42 

7 U.S.C. 1396a(a)) is amended by inserting after ‘‘1128A,’’ 

8 the following: ‘‘terminate the participation of any indi9 vidual or entity in such program if (subject to such excep10 tions are permitted with respect to exclusion under sec11 tions 1128(b)(3)(C) and 1128(d)(3)(B)) participation of 

12 such individual or entity is terminated under title XVIII, 

13 any other State plan under this title, or any child health 

14 plan under title XXI,’’. 

15 (b) APPLICATION TO CHIP.—Section 2107(e)(1)(A) 

16 of such Act (42 U.S.C. 1397gg(e)(1)(A)) is amended by 

17 inserting before the period at the end the following: ‘‘and 

18 section 1902(a)(39) (relating to exclusion and termination 

19 of participation)’’. 

20 (c) EFFECTIVE DATE.—Except as provided in section 

21 1790, the amendments made by this section shall apply 

22 to services furnished on or after January 1, 2011, without 

23 regard to whether or not final regulations to carry out 

24 such amendments have been promulgated by such date. 


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1 SEC. 1757. MEDICAID AND CHIP EXCLUSION FROM PARTICI2 PATION RELATING TO CERTAIN OWNERSHIP, 

3 CONTROL, AND MANAGEMENT AFFILIATIONS. 

4 (a) STATE PLAN REQUIREMENT.—Section 1902(a) 

5 of the Social Security Act (42 U.S.C. 1396a(a)), as 

6 amended by sections 1631(b)(1), 1703(a), 1729, and 

7 1753, is further amended— 

8 (1) in paragraph (76), by striking at the end 

9 ‘‘and’’; 

10 (2) in paragraph (77), by striking at the end 

11 the period and inserting ‘‘; and’’; and 

12 (3) by inserting after paragraph (77) the fol13 lowing new paragraph: 

14 ‘‘(78) provide that the State agency described 

15 in paragraph (9) exclude, with respect to a period, 

16 any individual or entity from participation in the 

17 program under the State plan if such individual or 

18 entity owns, controls, or manages an entity that (or 

19 if such entity is owned, controlled, or managed by an 

20 individual or entity that)— 

21 ‘‘(A) has unpaid overpayments under this 

22 title during such period determined by the Sec23 retary or the State agency to be delinquent; 

24 ‘‘(B) is suspended or excluded from par25 ticipation under or whose participation is termi26 nated under this title during such period; or 


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1 ‘‘(C) is affiliated with an individual or enti2 ty that has been suspended or excluded from 

3 participation under this title or whose participa4 tion is terminated under this title during such 

5 period.’’. 

6 (b) CHILD HEALTH PLAN REQUIREMENT.—Section 

7 2107(e)(1)(A) of such Act (42 U.S.C. 1397gg(e)(1)(A)), 

8 as amended by section 1756(b), is amended by striking 

9 ‘‘section 1902(a)(39)’’ and inserting ‘‘sections 

10 1902(a)(39) and 1902(a)(78)’’. 

11 (c) EFFECTIVE DATE.—Except as provided in section 

12 1790, the amendments made by this section shall apply 

13 to services furnished on or after January 1, 2011, without 

14 regard to whether or not final regulations to carry out 

15 such amendments have been promulgated by such date. 

16 SEC. 1758. REQUIREMENT TO REPORT EXPANDED SET OF 

17 DATA ELEMENTS UNDER MMIS TO DETECT 

18 FRAUD AND ABUSE. 

19 Section 1903(r)(1)(F) of the Social Security Act (42 

20 U.S.C. 1396b(r)(1)(F)) is amended by inserting after 

21 ‘‘necessary’’ the following: ‘‘and including, for data sub22 mitted to the Secretary on or after July 1, 2010, data 

23 elements from the automated data system that the Sec24 retary determines to be necessary for detection of waste, 

25 fraud, and abuse’’. 


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1 SEC. 1759. BILLING AGENTS, CLEARINGHOUSES, OR OTHER 

2 ALTERNATE PAYEES REQUIRED TO REG3 ISTER UNDER MEDICAID. 

4 (a) IN GENERAL.—Section 1902(a) of the Social Se5 curity Act (42 U.S.C. 42 U.S.C. 1396a(a)), as amended 

6 by sections 1631(b), 1703(a), 1729, 1753, and 1757(a), 

7 is further amended— 

8 (1) in paragraph (77); by striking at the end 

9 ‘‘and’’; 

10 (2) in paragraph (78), by striking the period at 

11 the end and inserting ‘‘and’’; and 

12 (3) by inserting after paragraph (78) the fol13 lowing new paragraph: 

14 ‘‘(79) provide that any agent, clearinghouse, or 

15 other alternate payee that submits claims on behalf 

16 of a health care provider must register with the 

17 State and the Secretary in a form and manner speci18 fied by the Secretary under section 1866(j)(1)(D).’’. 

19 (b) DENIAL OF PAYMENT.—Section 1903(i) of such 

20 Act (42 U.S.C. 1396b(i)), as amended by section 1751, 

21 is amended— 

22 (1) by striking ‘‘or’’ at the end of paragraph 

23 (24); 

24 (2) by striking the period at the end of para25 graph (25) and inserting ‘‘; or’’; and 


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1 (3) by inserting after paragraph (25) the fol2 lowing new paragraph: 

3 ‘‘(26) with respect to any amount paid to a bill4 ing agent, clearinghouse, or other alternate payee 

5 that is not registered with the State and the Sec6 retary as required under section 1902(a)(79).’’. 

7 (c) EFFECTIVE DATE.—Except as provided in section 

8 1790, the amendments made by this section shall apply 

9 to claims submitted on or after January 1, 2012, without 

10 regard to whether or not final regulations to carry out 

11 such amendments have been promulgated by such date. 

12 SEC. 1760. DENIAL OF PAYMENTS FOR LITIGATION-RE13 LATED MISCONDUCT. 

14 (a) IN GENERAL.—Section 1903(i) of the Social Se15 curity Act (42 U.S.C. 1396b(i)), as amended by sections 

16 1751(a) and 1759(b), is amended— 

17 (1) by striking ‘‘or’’ at the end of paragraph 

18 (25); 

19 (2) by striking the period at the end of para20 graph (26) and inserting ‘‘; or’’; and 

21 (3) by inserting after paragraph (26) the fol22 lowing new paragraph: 

23 ‘‘(27) with respect to any amount expended— 


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1 ‘‘(A) on litigation in which a court imposes 

2 sanctions on the State, its employees, or its 

3 counsel for litigation-related misconduct; or 

4 ‘‘(B) to reimburse (or otherwise com5 pensate) a managed care entity for payment of 

6 legal expenses associated with any action in 

7 which a court imposes sanctions on the man8 aged care entity for litigation-related mis9 conduct.’’. 

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

11 subsection (a) shall apply to amounts expended on or after 

12 January 1, 2010. 

13 SEC. 1761. MANDATORY STATE USE OF NATIONAL CORRECT 

14 CODING INITIATIVE. 

15 Section 1903(r) of the Social Security Act (42 U.S.C. 

16 1396b(r)) is amended— 

17 (1) in paragraph (1)(B)— 

18 (A) in clause (ii), by striking ‘‘and’’ at the 

19 end; 

20 (B) in clause (iii), by adding ‘‘and’’ at the 

21 end; and 

22 (C) by adding at the end the following new 

23 clause: 

24 ‘‘(iv) effective for claims filed on or 

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1 ible methodologies of the National Correct 

2 Coding Initiative administered by the Sec3 retary (or any successor initiative to pro4 mote correct coding and to control im5 proper coding leading to inappropriate pay6 ment) and such other methodologies of 

7 that Initiative (or such other national cor8 rect coding methodologies) as the Sec9 retary identifies in accordance with para10 graph (4);’’; and 

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

12 paragraph: 

13 ‘‘(4) Not later than September 1, 2010, the Secretary 

14 shall do the following: 

15 ‘‘(A) Identify those methodologies of the Na16 tional Correct Coding Initiative administered by the 

17 Secretary (or any successor initiative to promote cor18 rect coding and to control improper coding leading 

19 to inappropriate payment) which are compatible to 

20 claims filed under this title. 

21 ‘‘(B) Identify those methodologies of such Ini22 tiative (or such other national correct coding meth23 odologies) that should be incorporated into claims 

24 filed under this title with respect to items or services 

25 for which States provide medical assistance under 


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1 this title and no national correct coding methodolo2 gies have been established under such Initiative with 

3 respect to title XVIII. 

4 ‘‘(C) Notify States of— 

5 ‘‘(i) the methodologies identified under 

6 subparagraphs (A) and (B) (and of any other 

7 national correct coding methodologies identified 

8 under subparagraph (B)); and 

9 ‘‘(ii) how States are to incorporate such 

10 methodologies into claims filed under this title. 

11 ‘‘(D) Submit a report to Congress that includes 

12 the notice to States under subparagraph (C) and an 

13 analysis supporting the identification of the meth14 odologies made under subparagraphs (A) and (B).’’. 

15 Subtitle G—Payments to the 

16 Territories 

17 SEC. 1771. PAYMENT TO TERRITORIES. 

18 (a) INCREASE IN CAP.—Section 1108 of the Social 

19 Security Act (42 U.S.C. 1308) is amended— 

20 (1) in subsection (f), by striking ‘‘subsection 

21 (g)’’ and inserting ‘‘subsections (g) and (h)’’; 

22 (2) in subsection (g)(1), by striking ‘‘With re23 spect to’’ and inserting ‘‘Subject to subsection (h), 

24 with respect to’’; and 


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1 (3) by adding at the end the following new sub2 section: 

3 ‘‘(h) ADDITIONAL INCREASE FOR FISCAL YEARS

4 2011 THROUGH 2019.—Subject to section 347(b)(1) of 

5 the Affordable Health Care for America Act, with respect 

6 to fiscal years 2011 through 2019, the amounts otherwise 

7 determined under subsections (f) and (g) for Puerto Rico, 

8 the Virgin Islands, Guam, the Northern Mariana Islands 

9 and American Samoa shall be increased by the following 

10 amounts: 

11 ‘‘(1) For Puerto Rico, for fiscal year 2011, 

12 $727,600,000; for fiscal year 2012, $775,000,000; 

13 for fiscal year 2013, $850,000,000; for fiscal year 

14 2014, $925,000,000; for fiscal year 2015, 

15 $1,000,000,000; for fiscal year 2016, 

16 $1,075,000,000; for fiscal year 2017, 

17 $1,150,000,000; for fiscal year 2018, 

18 $1,225,000,000; and for fiscal year 2019, 

19 $1,396,400,000. 

20 ‘‘(2) For the Virgin Islands, for fiscal year 

21 2011, $34,000,000; for fiscal year 2012, 

22 $37,000,000; for fiscal year 2013, $40,000,000; for 

23 fiscal year 2014, $43,000,000; for fiscal year 2015, 

24 $46,000,000; for fiscal year 2016, $49,000,000; for 


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1 fiscal year 2017, $52,000,000; for fiscal year 2018, 

2 $55,000,000; and for fiscal year 2019, $58,000,000. 

3 ‘‘(3) For Guam, for fiscal year 2011, 

4 $34,000,000; for fiscal year 2012, $37,000,000; for 

5 fiscal year 2013, $40,000,000; for fiscal year 2014, 

6 $43,000,000; for fiscal year 2015, $46,000,000; for 

7 fiscal year 2016, $49,000,000; for fiscal year 2017, 

8 $52,000,000; for fiscal year 2018, $55,000,000; and 

9 for fiscal year 2019, $58,000,000. 

10 ‘‘(4) For the Northern Mariana Islands, for fis11 cal year 2011, $13,500,000; fiscal year 2012, 

12 $14,500,000; for fiscal year 2013, $15,500,000; for 

13 fiscal year 2014, $16,500,000; for fiscal year 2015, 

14 $17,500,000; for fiscal year 2016, $18,500,000; for 

15 fiscal year 2017, $19,500,000; for fiscal year 2018, 

16 $21,000,000; and for fiscal year 2019, $22,000,000. 

17 ‘‘(5) For American Samoa, fiscal year 2011, 

18 $22,000,000; fiscal year 2012, $23,687,500; for fis19 cal year 2013, $24,687,500; for fiscal year 2014, 

20 $25,687,500; for fiscal year 2015, $26,687,500; for 

21 fiscal year 2016, $27,687,500; for fiscal year 2017, 

22 $28,687,500; for fiscal year 2018, $29,687,500; and 

23 for fiscal year 2019, $30,687,500.’’. 

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1 (1) IN GENERAL.—Not later than October 1, 

2 2013, the Secretary of Health and Human Services 

3 shall submit to Congress a report that details a plan 

4 for the transition of each territory to full parity in 

5 Medicaid with the 50 States and the District of Co6 lumbia in fiscal year 2020 by modifying their exist7 ing Medicaid programs and outlining actions the 

8 Secretary and the governments of each territory 

9 must take by fiscal year 2020 to ensure parity in fi10 nancing. Such report shall include what the Federal 

11 medical assistance percentages would be for each 

12 territory if the formula applicable to the 50 States 

13 were applied. Such report shall also include any rec14 ommendations that the Secretary may have as to 

15 whether the mandatory ceiling amounts for each ter16 ritory provided for in section 1108 of the Social Se17 curity Act (42 U.S.C. 1308) should be increased any 

18 time before fiscal year 2020 due to any factors that 

19 the Secretary deems relevant. 

20 (2) PER CAPITA DATA.—As part of such report 

21 the Secretary shall include information about per 

22 capita income data that could be used to calculate 

23 Federal medical assistance percentages under section 

24 1905(b) of the Social Security Act, under section 

25 1108(a)(8)(B) of such Act, for each territory on how 


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1 such data differ from the per capita income data 

2 used to promulgate Federal medical assistance per3 centages for the 50 States. The report under this 

4 subsection shall include recommendations on how 

5 the Federal medical assistance percentages can be 

6 calculated for the territories beginning in fiscal year 

7 2020 to ensure parity with the 50 States. 

8 (3) SUBSEQUENT REPORTS.—The Secretary 

9 shall submit subsequent reports to Congress in 

10 2015, 2017, and 2019 detailing the progress that 

11 the Secretary and the governments of each territory 

12 have made in fulfilling the actions outlined in the 

13 plan submitted under paragraph (1). 

14 (c) APPLICATION OF FMAP FOR ADDITIONAL

15 FUNDS.—Section 1905(b) of such Act (42 U.S.C. 

16 1396d(b)) is amended by adding at the end the following 

17 sentence: ‘‘Notwithstanding the first sentence of this sub18 section and any other provision of law, for fiscal years 

19 2011 through 2019, the Federal medical assistance per20 centage for Puerto Rico, the Virgin Islands, Guam, the 

21 Northern Mariana Islands, and American Samoa shall be 

22 the highest Federal medical assistance percentage applica23 ble to any of the 50 States or the District of Columbia 

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1 vision B of the American Recovery and Reinvestment Act 

2 of 2009 (Public Law 111–5) to such States and the Dis3 trict for calendar quarters during such fiscal years for 

4 which such subsections apply.’’. 

5 (d) WAIVERS.— 

6 (1) IN GENERAL.—Section 1902(j) of the Social 

7 Security Act (42 U.S.C. 1396a(j)) is amended— 

8 (A) by striking ‘‘American Samoa and the 

9 Northern Mariana Islands’’ and inserting 

10 ‘‘Puerto Rico, the Virgin Islands, Guam, the 

11 Northern Mariana Islands, and American 

12 Samoa’’; and 

13 (B) by striking ‘‘American Samoa or the 

14 Northern Mariana Islands’’ and inserting 

15 ‘‘Puerto Rico, the Virgin Islands, Guam, the 

16 Northern Mariana Islands, or American 

17 Samoa’’. 

18 (2) EFFECTIVE DATE.—The amendments made 

19 by paragraph (1) shall apply beginning with fiscal 

20 year 2011. 

21 (e) TECHNICAL ASSISTANCE.—The Secretary shall 

22 provide nonmonetary technical assistance to the govern23 ments of Puerto Rico, the Virgin Islands, Guam, the 

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1 pate meeting reporting requirements necessary to imple2 ment the plan contained in the report under subsection 

3 (b)(1). 

4 Subtitle H—Miscellaneous 

5 SEC. 1781. TECHNICAL CORRECTIONS. 

6 (a) TECHNICAL CORRECTION TO SECTION 1144 OF

7 THE SOCIAL SECURITY ACT.—The first sentence of sec8 tion 1144(c)(3) of the Social Security Act (42 U.S.C. 

9 1320b—14(c)(3)) is amended— 

10 (1) by striking ‘‘transmittal’’; and 

11 (2) by inserting before the period the following: 

12 ‘‘as specified in section 1935(a)(4)’’. 

13 (b) CLARIFYING AMENDMENT TO SECTION 1935 OF

14 THE SOCIAL SECURITY ACT.—Section 1935(a)(4) of the 

15 Social Security Act (42 U.S.C. 1396u—5(a)(4)), as 

16 amended by section 113(b) of Public Law 110–275, is 

17 amended— 

18 (1) by striking the second sentence; 

19 (2) by redesignating the first sentence as a sub20 paragraph (A) with appropriate indentation and 

21 with the following heading: ‘‘IN GENERAL.—’’; 

22 (3) by adding at the end the following subpara23 graphs: 

24 ‘‘(B) FURNISHING MEDICAL ASSISTANCE

25 WITH REASONABLE PROMPTNESS.—For the 


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1 purpose of a State’s obligation under section 

2 1902(a)(8) to furnish medical assistance with 

3 reasonable promptness, the date of the elec4 tronic transmission of low-income subsidy pro5 gram data, as described in section 1144(c), 

6 from the Commissioner of Social Security to the 

7 State Medicaid Agency, shall constitute the date 

8 of filing of such application for benefits under 

9 the Medicare Savings Program. 

10 ‘‘(C) DETERMINING AVAILABILITY OF

11 MEDICAL ASSISTANCE.—For the purpose of de12 termining when medical assistance will be made 

13 available, the State shall consider the date of 

14 the individual’s application for the low income 

15 subsidy program to constitute the date of filing 

16 for benefits under the Medicare Savings Pro17 gram.’’. 

18 (c) EFFECTIVE DATE RELATING TO MEDICAID

19 AGENCY CONSIDERATION OF LOW-INCOME SUBSIDY AP20 PLICATION AND DATA TRANSMITTAL.—The amendments 

21 made by subsections (a) and (b) shall be effective as if 

22 included in the enactment of section 113(b) of Public Law 

23 110–275. 

24 (d) TECHNICAL CORRECTION TO SECTION 605 OF

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1 ance Program Reauthorization Act of 2009 (Public Law 

2 111–3) is amended by striking ‘‘legal residents’’ and in3 serting ‘‘lawfully residing in the United States’’. 

4 (e) TECHNICAL CORRECTION TO SECTION 1905 OF

5 THE SOCIAL SECURITY ACT.—Section 1905(a) of the So6 cial Security Act (42 U.S.C. 1396d(a)) is amended by in7 serting ‘‘or the care and services themselves, or both’’ be8 fore ‘‘(if provided in or after’’. 

9 (f) CLARIFYING AMENDMENT TO SECTION 1115 OF

10 THE SOCIAL SECURITY ACT.—Section 1115(a) of the So11 cial Security Act (42 U.S.C. 1315(a)) is amended by add12 ing at the end the following: ‘‘If an experimental, pilot, 

13 or demonstration project that relates to title XIX is ap14 proved pursuant to any part of this subsection, such 

15 project shall be treated as part of the State plan, all med16 ical assistance provided on behalf of any individuals af17 fected by such project shall be medical assistance provided 

18 under the State plan, and all provisions of this Act not 

19 explicitly waived in approving such project shall remain 

20 fully applicable to all individuals receiving benefits under 

21 the State plan.’’. 

22 SEC. 1782. EXTENSION OF QI PROGRAM. 

23 (a) IN GENERAL.—Section 1902(a)(10)(E)(iv) of the 

24 Social Security Act (42 U.S.C. 1396b(a)(10)(E)(iv)) is 

25 amended— 


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1 (1) by striking ‘‘sections 1933 and’’ and by in2 serting ‘‘section’’; and 

3 (2) by striking ‘‘December 2010’’ and inserting 

4 ‘‘December 2012’’. 

5 (b) ELIMINATION OF FUNDING LIMITATION.— 

6 (1) IN GENERAL.—Section 1933 of such Act 

7 (42 U.S.C. 1396u–3) is amended— 

8 (A) in subsection (a), by striking ‘‘who are 

9 selected to receive such assistance under sub10 section (b)’’; 

11 (B) by striking subsections (b), (c), (e), 

12 and (g); 

13 (C) in subsection (d), by striking ‘‘fur14 nished in a State’’ and all that follows and in15 serting ‘‘the Federal medical assistance percent16 age shall be equal to 100 percent.’’; and 

17 (D) by redesignating subsections (d) and 

18 (f) as subsections (b) and (c), respectively. 

19 (2) CONFORMING AMENDMENT.—Section 

20 1905(b) of such Act (42 U.S.C. 1396d(b)) is amend21 ed by striking ‘‘1933(d)’’ and inserting ‘‘1933(b)’’. 

22 (3) EFFECTIVE DATE.—The amendments made 

23 by paragraph (1) shall take effect on January 1, 

24 2011. 


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1 SEC. 1783. ASSURING TRANSPARENCY OF INFORMATION. 

2 (a) IN GENERAL.—Section 1902(a) of the Social Se3 curity Act (42 U.S.C. 1396a(a)), as amended by sections 

4 1631(b), 1703(a), 1729, 1753, 1757(a), 1759(a), and 

5 1907(b), is amended— 

6 (1) by striking ‘‘and’’ at the end of paragraph 

7 (79); 

8 (2) by striking the period at the end of para9 graph (80) and inserting ‘‘; and’’; and 

10 (3) by inserting after paragraph (80) the fol11 lowing new paragraph: 

12 ‘‘(81) provide that the State will establish and 

13 maintain laws, in accordance with the requirements 

14 of section 1921A, to require disclosure of informa15 tion on hospital charges and quality and to make 

16 such information available to the public and the Sec17 retary.’’; and 

18 (4) by inserting after section 1921 the following 

19 new section: 

20 ‘‘HOSPITAL PRICE TRANSPARENCY

21 ‘‘SEC. 1921A. (a) IN GENERAL.—The requirements 

22 referred to in section 1902(a)(81) are that the laws of a 

23 State must— 

24 ‘‘(1) require reporting to the State (or its 

25 agent) by each hospital located therein, of informa26 tion on,— 


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1 ‘‘(A) the charges for the most common in2 patient and outpatient hospital services; 

3 ‘‘(B) the Medicare and Medicaid reim4 bursement amount for such services; and 

5 ‘‘(C) if the hospitals allows for or provides 

6 reduced charges for individuals based on finan7 cial need, the factors considered in making de8 terminations for reductions in charges, includ9 ing any formula for such determination and the 

10 contact information for the specific department 

11 of a hospital that responds to such inquiries; 

12 ‘‘(2) provide for notice to individuals seeking or 

13 requiring such services of the availability of informa14 tion on charges described in paragraph (1); 

15 ‘‘(3) provide for timely access to such informa16 tion, including at least through an Internet website, 

17 by individuals seeking or requiring such services; 

18 and 

19 ‘‘(4) provide for timely access to information re20 garding the quality of care at each hospital made 

21 publicly available in accordance with section 501 of 

22 the Medicare Prescription Drug, Improvement, and 

23 Modernization Act of 2003 (Public Law 108–173), 

24 section 1139A, or section 1139B. 


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1 The Secretary shall consult with stakeholders (including 

2 those entities in section 1808(d)(6) and the National Gov3 ernors Association) through a formal process to obtain 

4 guidance prior to issuing implementing policies under this 

5 section. 

6 ‘‘(b) HOSPITAL DEFINED.—For purposes of this sec7 tion, the term ‘hospital’ means an institution that meets 

8 the requirements of paragraphs (1) and (7) of section 

9 1861(e) and includes those to which section 1820(c) ap10 plies.’’. 

11 (b) EFFECTIVE DATE; ADMINISTRATION.— 

12 (1) IN GENERAL.—Except as provided in para13 graphs (2)(B) and section 1790, the amendments 

14 made by subsection (a) shall take effect on October 

15 1, 2010. 

16 (2) EXISTING PROGRAMS.— 

17 (A) IN GENERAL.—The Secretary of 

18 Health and Human Services shall establish a 

19 process by which a State with an existing pro20 gram may certify to the Secretary that its pro21 gram satisfies the requirements of section 

22 1921A of the Social Security Act, as inserted 

23 by subsection (a). 

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1 actment of this Act, administer hospital price 

2 transparency policies that do not meet such re3 quirements shall have 2 years from such date to 

4 make necessary modifications to come into com5 pliance and shall not be regarded as failing to 

6 comply with such requirements during such 2- 

7 year period. 

8 SEC. 1784. MEDICAID AND CHIP PAYMENT AND ACCESS 

9 COMMISSION. 

10 (a) REPORT ON NURSING FACILITY PAYMENT POLI11 CIES.—Section 1900(b) of the Social Security Act (42 

12 U.S.C. 1396(b)) is amended by adding at the end the fol13 lowing new paragraph: 

14 ‘‘(10) REPORTS ON SPECIAL TOPICS ON PAY15 MENT POLICIES.— 

16 ‘‘(A) NURSING FACILITY PAYMENT POLI17 CIES.—Not later than January 1, 2012, the 

18 Commission shall submit to Congress a report 

19 on nursing facility payment policies under Med20 icaid that includes— 

21 ‘‘(i) information on the difference be22 tween the amount paid by each State to 

23 nursing facilities in such State under the 

24 Medicaid program under this title and the 

25 cost to such facilities of providing efficient 


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1 quality care to Medicaid eligible individ2 uals; 

3 ‘‘(ii) an evaluation of patient out4 comes and quality as a result of the sup5 plemental payments under section 1745(b) 

6 of the Affordable Health Care for America 

7 Act; and 

8 ‘‘(iii) whether adjustments should be 

9 made under the Medicaid program to the 

10 rates that States pay skilled nursing facili11 ties to ensure that such rates are sufficient 

12 to provide efficient quality care to Med13 icaid eligible individuals.’’. 

14 (b) PEDIATRIC SUBSPECIALIST PAYMENT POLI15 CIES.—Section 1900(b)(10) of the Social Security Act, as 

16 added by subsection (a) is amended by adding at the end 

17 the following new subparagraph: 

18 ‘‘(B) PEDIATRIC SUBSPECIALIST PAYMENT

19 POLICIES.—Not later than January 1, 2011, 

20 the Commission shall submit to Congress a re21 port on payment policies for pediatric sub22 specialist services under Medicaid that in23 cludes— 

24 ‘‘(i) a comprehensive review of each 

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1 tient and outpatient pediatric speciality 

2 services; 

3 ‘‘(ii) a comparison, on a State-by4 State basis, of the rates under clause (i) to 

5 Medicare payments for similar services; 

6 ‘‘(iii) information on any limitations 

7 in patient access to pediatric speciality 

8 care, such as delays in receiving care or 

9 wait times for receiving care; 

10 ‘‘(iv) an analysis of the extent to 

11 which low Medicaid payment rates in any 

12 State contributes to limits in access to pe13 diatric subspecialty services in such State; 

14 and 

15 ‘‘(v) recommendations to ameliorate 

16 any problems found with such payment 

17 rates or with access to such services.’’. 

18 (c) ADDITIONAL AMENDMENTS.— 

19 (1) COMMISSION STATUS.—Section 1900(a) of 

20 the Social Security Act is amended by inserting ‘‘as 

21 an agency of Congress’’ after ‘‘established’’. 

22 (2) EXPANSION OF SCOPE.—Section 

23 1900(b)(1)(A) of the Social Security Act is amended 

24 by striking ‘‘children’s access’’ and inserting ‘‘access 


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1 by low-income children and other eligible individ2 uals’’. 

3 (3) CHANGE IN REPORT DEADLINES.—Subpara4 graphs (C) and (D) of section 1900(b)(1) of such 

5 Act are amended by striking ‘‘2010’’ and inserting 

6 ‘‘2011’’ each place it appears. 

7 (4) REPORT IN HEALTH REFORM.—Section 

8 1900(b)(2) of such Act is amended— 

9 (A) in subparagraph (A)(i), by striking 

10 ‘‘skilled’’; 

11 (B) by striking subparagraph (B); 

12 (C) by redesignating subparagraph (C) as 

13 subparagraph (B); and 

14 (D) by adding at the end the following new 

15 subparagraph: 

16 ‘‘(C) IMPLEMENTATION OF HEALTH RE17 FORM.—The implementation of the provisions 

18 of the Affordable Health Care for America Act 

19 that relate to Medicaid or CHIP by the Sec20 retary, the Health Choices Commissioner, and 

21 the States, including the effect of such imple22 mentation on the access to needed health care 

23 items and services by low-income individuals 

24 and families.’’. 


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1 (5) CLARIFICATION OF MEMBERSHIP.—Section 

2 1900(c)(2)(B) of such Act is amended by striking 

3 ‘‘consumers’’ and inserting ‘‘individuals’’. 

4 (6) AUTHORIZATION OF APPROPRIATIONS.— 

5 (A) CURRENT AUTHORIZATION.—Section 

6 1900(f)(2) of such Act is amended— 

7 (i) in the heading, by inserting ‘‘OF

8 APPROPRIATIONS PRIOR TO 2010’’ after 

9 ‘‘AUTHORIZATION’’; and 

10 (ii) by striking ‘‘There are’’ and in11 serting ‘‘Prior to January 1, 2010, there 

12 are’’ 

13 (B) FUTURE AUTHORIZATION.—Section 

14 1900(f) of such Act is further amended by add15 ing at the end the following new paragraph: 

16 after the period the following: 

17 ‘‘(3) AUTHORIZATION OF APPROPRIATIONS FOR

18 2010.—Beginning on January 1, 2010, there is au19 thorized to be appropriated $11,800,000 to carry 

20 out the provisions of this section. Such funds shall 

21 remain available until expended.’’. 

22 SEC. 1785. OUTREACH AND ENROLLMENT OF MEDICAID 

23 AND CHIP ELIGIBLE INDIVIDUALS. 

24 (a) IN GENERAL.—Not later than 12 months after 

25 date of enactment of this Act, the Secretary of Health and 


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1 Human Services shall issue guidance regarding standards 

2 and best practices for conducting outreach to inform eligi3 ble individuals about healthcare coverage under Medicaid 

4 under title XIX of the Social Security Act or for child 

5 health assistance under CHIP under title XXI of such 

6 Act, providing assistance to such individuals for enroll7 ment in applicable programs, and establishing methods or 

8 procedures for eliminating application and enrollment bar9 riers. Such guidance shall include provisions to ensure 

10 that outreach, enrollment assistance, and administrative 

11 simplification efforts are targeted specifically to vulnerable 

12 populations such as children, unaccompanied homeless 

13 youth, victims of abuse or trauma, individuals with mental 

14 health or substance related disorders, and individuals with 

15 HIV/AIDS. Guidance issued pursuant to this section re16 lating to methods to increase outreach and enrollment pro17 vided for under titles XIX and XXI of the Social Security 

18 Act shall specifically target such vulnerable and under19 served populations and shall include, but not be limited 

20 to, guidance on outstationing of eligibility workers, express 

21 lane eligibility, residence requirements, documentation of 

22 income and assets, presumptive eligibility, continuous eli23 gibility, and automatic renewal. 

24 (b) IMPLEMENTATION.—In implementing the re25 quirements under subsection (a), the Secretary may use 


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1 such authorities as are available under law and may work 

2 with such entities as the Secretary deems appropriate to 

3 facilitate effective implementation of such programs. Not 

4 later than 2 years after the enactment of this Act and 

5 annually thereafter, the Secretary shall review and report 

6 to Congress on progress in implementing targeted out7 reach, application and enrollment assistance, and adminis8 trative simplification methods for such vulnerable and un9 derserved populations as are specified in subsection (a). 

10 SEC. 1786. PROHIBITIONS ON FEDERAL MEDICAID AND 

11 CHIP PAYMENT FOR UNDOCUMENTED 

12 ALIENS. 

13 Nothing in this title shall change current prohibitions 

14 against Federal Medicaid and CHIP payments under titles 

15 XIX and XXI of the Social Security Act on behalf of indi16 viduals who are not lawfully present in the United States. 

17 SEC. 1787. DEMONSTRATION PROJECT FOR STABILIZATION 

18 OF EMERGENCY MEDICAL CONDITIONS BY 

19 INSTITUTIONS FOR MENTAL DISEASES. 

20 (a) AUTHORITY TO CONDUCT DEMONSTRATION

21 PROJECT.—The Secretary of Health and Human Services 

22 (in this section referred to as the ‘‘Secretary’’) shall estab23 lish a demonstration project under which an eligible State 

24 (as described in subsection (c)) shall provide reimburse25 ment under the State Medicaid plan under title XIX of 


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1 the Social Security Act to an institution for mental dis2 eases that is subject to the requirements of section 1867 

3 of the Social Security Act (42 U.S.C. 1395dd) for the pro4 vision of medical assistance available under such plan to 

5 an individual who— 

6 (1) has attained age 21, but has not attained 

7 age 65; 

8 (2) is eligible for medical assistance under such 

9 plan; and 

10 (3) requires such medical assistance to stabilize 

11 an emergency medical condition. 

12 (b) IN-STAY REVIEW.—The Secretary shall establish 

13 a mechanism for in-stay review to determine whether or 

14 not the patient has been stabilized (as defined in sub15 section (h)(5)). This mechanism shall commence before 

16 the third day of the inpatient stay. States participating 

17 in the demonstration project may manage the provision 

18 of these benefits under the project through utilization re19 view, authorization, or management practices, or the ap20 plication of medical necessity and appropriateness criteria 

21 applicable to behavioral health. 

22 (c) ELIGIBLE STATE DEFINED.— 

23 (1) APPLICATION.—Upon approval of an appli24 cation submitted by a State described in paragraph 

25 (2), the State shall be an eligible State for purposes 


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1 of conducting a demonstration project under this 

2 section. 

3 (2) STATE DESCRIBED.—States shall be se4 lected by the Secretary in a manner so as to provide 

5 geographic diversity on the basis of the application 

6 to conduct a demonstration project under this sec7 tion submitted by such States. 

8 (d) LENGTH OF DEMONSTRATION PROJECT.—The 

9 demonstration project established under this section shall 

10 be conducted for a period of 3 consecutive years. 

11 (e) LIMITATIONS ON FEDERAL FUNDING.— 

12 (1) APPROPRIATION.— 

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

14 Treasury not otherwise appropriated, there is 

15 appropriated to carry out this section, 

16 $75,000,000 for fiscal year 2010. 

17 (B) BUDGET AUTHORITY.—Subparagraph 

18 (A) constitutes budget authority in advance of 

19 appropriations Act and represents the obliga20 tion of the Federal Government to provide for 

21 the payment of the amounts appropriated under 

22 that subparagraph. 

23 (2) 3-YEAR AVAILABILITY.—Funds appro24 priated under paragraph (1) shall remain available 

25 for obligation through December 31, 2012. 


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1 (3) LIMITATION ON PAYMENTS.—In no case 

2 may— 

3 (A) the aggregate amount of payments 

4 made by the Secretary to eligible States under 

5 this section exceed $75,000,000; or 

6 (B) payments be provided by the Secretary 

7 under this section after December 31, 2012. 

8 (4) FUNDS ALLOCATED TO STATES.—The Sec9 retary shall allocate funds to eligible States based on 

10 their applications and the availability of funds. 

11 (5) PAYMENTS TO STATES.—The Secretary 

12 shall pay to each eligible State, from its allocation 

13 under paragraph (4), an amount each quarter equal 

14 to the Federal medical assistance percentage of ex15 penditures in the quarter for medical assistance de16 scribed in subsection (a). 

17 (f) REPORTS.— 

18 (1) ANNUAL PROGRESS REPORTS.—The Sec19 retary shall submit annual reports to Congress on 

20 the progress of the demonstration project conducted 

21 under this section. 

22 (2) FINAL REPORT AND RECOMMENDATION.— 

23 An evaluation shall be conducted of the demonstra24 tion project’s impact on the functioning of the health 

25 and mental health service system and on individuals 


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1 enrolled in the Medicaid program. This evaluation 

2 shall include collection of baseline data for one-year 

3 prior to the initiation of the demonstration project 

4 as well as collection of data from matched compari5 son states not participating in the demonstration. 

6 The evaluation measures shall include the following: 

7 (A) A determination, by State, as to 

8 whether the demonstration project resulted in 

9 increased access to inpatient mental health 

10 services under the Medicaid program and 

11 whether average length of stays were longer (or 

12 shorter) for individuals admitted under the 

13 demonstration project compared with individ14 uals otherwise admitted in comparison sites. 

15 (B) An analysis, by State, regarding 

16 whether the demonstration project produced a 

17 significant reduction in emergency room visits 

18 for individuals eligible for assistance under the 

19 Medicaid program or in the duration of emer20 gency room lengths of stay. 

21 (C) An assessment of discharge planning 

22 by participating hospitals that ensures access to 

23 further (non-emergency) inpatient or residential 

24 care as well as continuity of care for those dis25 charged to outpatient care. 


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1 (D) An assessment of the impact of the 

2 demonstration project on the costs of the full 

3 range of mental health services (including inpa4 tient, emergency and ambulatory care) under 

5 the plan as contrasted with the comparison 

6 areas. 

7 (E) Data on the percentage of consumers 

8 with Medicaid coverage who are admitted to in9 patient facilities as a result of the demonstra10 tion project as compared to those admitted to 

11 these same facilities through other means. 

12 (F) A recommendation regarding whether 

13 the demonstration project should be continued 

14 after December 31, 2012, and expanded on a 

15 national basis. 

16 (g) WAIVER AUTHORITY.— 

17 (1) IN GENERAL.—The Secretary shall waive 

18 the limitation of subdivision (B) following paragraph 

19 (28) of section 1905(a) of the Social Security Act 

20 (42 U.S.C. 1396d(a)) (relating to limitations on pay21 ments for care or services for individuals under 65 

22 years of age who are patients in an institution for 

23 mental diseases) for purposes of carrying out the 

24 demonstration project under this section. 


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1 (2) LIMITED OTHER WAIVER AUTHORITY.—The 

2 Secretary may waive other requirements of title XIX 

3 of the Social Security Act (including the require4 ments of sections 1902(a)(1) (relating to 

5 statewideness) and 1902(1)(10)(B) (relating to com6 parability)) only to extent necessary to carry out the 

7 demonstration project under this section. 

8 (h) DEFINITIONS.—In this section: 

9 (1) EMERGENCY MEDICAL CONDITION.—The 

10 term ‘‘emergency medical condition’’ means, with re11 spect to an individual, an individual who expresses 

12 suicidal or homicidal thoughts or gestures, if deter13 mined dangerous to self or others. 

14 (2) FEDERAL MEDICAL ASSISTANCE PERCENT15 AGE.—The term ‘‘Federal medical assistance per16 centage’’ has the meaning given that term with re17 spect to a State under section 1905(b) of the Social 

18 Security Act (42 U.S.C. 1396d(b)). 

19 (3) INSTITUTION FOR MENTAL DISEASES.—The 

20 term ‘‘institution for mental diseases’’ has the mean21 ing given to that term in section 1905(i) of the So22 cial Security Act (42 U.S.C. 1396d(i)). 

23 (4) MEDICAL ASSISTANCE.—The term ‘‘medical 

24 assistance’’ has the meaning given to that term in 


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1 section 1905(a) of the Social Security Act (42 

2 U.S.C. 1396d(a)). 

3 (5) STABILIZED.—The term ‘‘stabilized’’ 

4 means, with respect to an individual, that the emer5 gency medical condition no longer exists with respect 

6 to the individual and the individual is no longer dan7 gerous to self or others. 

8 (6) STATE.—The term ‘‘State’’ has the mean9 ing given that term for purposes of title XIX of the 

10 Social Security Act (42 U.S.C. 1396 et seq.). 

11 SEC. 1788. APPLICATION OF MEDICAID IMPROVEMENT 

12 FUND. 

13 Section 1941(b)(1) of the Social Security Act (42 

14 U.S.C. 1396w–1(b)(1)) is amended by striking ‘‘from the 

15 Fund’’ and all that follows and inserting ‘‘from the Fund, 

16 only such amounts as may be appropriated or otherwise 

17 made available by law.’’. 

18 SEC. 1789. TREATMENT OF CERTAIN MEDICAID BROKERS. 

19 Section 1903(b)(4) of the Social Security Act (42 

20 U.S.C. 1396b(b)(4)) is amended— 

21 (1) in the matter before subparagraph (A), by 

22 inserting after ‘‘respect to the broker’’ the following: 

23 ‘‘(or, in the case of subparagraph (A) and subpara24 graph (B)(i), if the Inspector General of Department 

25 of Health and Human Services finds that the broker 


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1 has established and maintains procedures to ensure 

2 the independence of its enrollment activities from 

3 the interests of any managed care entity or pro4 vider)’’; and 

5 (2) in subparagraph (B)— 

6 (A) by inserting ‘‘(i)’’ after ‘‘either’’; and 

7 (B) by inserting ‘‘(ii)’’ after ‘‘health care 

8 provider or’’. 

9 SEC. 1790. RULE FOR CHANGES REQUIRING STATE LEGIS10 LATION. 

11 In the case of a State plan for medical assistance 

12 under title XIX of the Social Security Act which the Sec13 retary of Health and Human Services determines requires 

14 State legislation (other than legislation appropriating 

15 funds) in order for the plan to meet an additional require16 ment imposed by an amendment made by this title, the 

17 State plan shall not be regarded as failing to comply with 

18 the requirements of such title XIX solely on the basis of 

19 its failure to meet this additional requirement before the 

20 first day of the first calendar quarter beginning after the 

21 close of the first regular session of the State legislature 

22 that begins after the date of the enactment of this Act. 

23 For purposes of the previous sentence, in the case of a 

24 State that has a 2-year legislative session, each year of 


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1 such session shall be deemed to be a separate regular ses2 sion of the State legislature. 

3 TITLE VIII—REVENUE-RELATED 

4 PROVISIONS 

5 SEC. 1801. DISCLOSURES TO FACILITATE IDENTIFICATION 

6 OF INDIVIDUALS LIKELY TO BE INELIGIBLE 

7 FOR THE LOW-INCOME ASSISTANCE UNDER 

8 THE MEDICARE PRESCRIPTION DRUG PRO9 GRAM TO ASSIST SOCIAL SECURITY ADMINIS10 TRATION’S OUTREACH TO ELIGIBLE INDIVID11 UALS. 

12 (a) IN GENERAL.—Paragraph (19) of section 6103(l) 

13 of the Internal Revenue Code of 1986 is amended to read 

14 as follows: 

15 ‘‘(19) DISCLOSURES TO FACILITATE IDENTI16 FICATION OF INDIVIDUALS LIKELY TO BE INELI17 GIBLE FOR LOW-INCOME SUBSIDIES UNDER MEDI18 CARE PRESCRIPTION DRUG PROGRAM TO ASSIST SO19 CIAL SECURITY ADMINISTRATION’S OUTREACH TO

20 ELIGIBLE INDIVIDUALS.— 

21 ‘‘(A) IN GENERAL.—Upon written request 

22 from the Commissioner of Social Security, the 

23 following return information (including such in24 formation disclosed to the Social Security Ad25 ministration under paragraph (1) or (5)) shall 


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1 be disclosed to officers and employees of the So2 cial Security Administration, with respect to 

3 any taxpayer identified by the Commissioner of 

4 Social Security— 

5 ‘‘(i) return information for the appli6 cable year from returns with respect to 

7 wages (as defined in section 3121(a) or 

8 3401(a)) and payments of retirement in9 come (as described in paragraph (1) of this 

10 subsection), 

11 ‘‘(ii) unearned income information 

12 and income information of the taxpayer 

13 from partnerships, trusts, estates, and sub14 chapter S corporations for the applicable 

15 year, 

16 ‘‘(iii) if the individual filed an income 

17 tax return for the applicable year, the fil18 ing status, number of dependents, income 

19 from farming, and income from self-em20 ployment, on such return, 

21 ‘‘(iv) if the individual is a married in22 dividual filing a separate return for the ap23 plicable year, the social security number (if 

24 reasonably available) of the spouse on such 

25 return, 


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1 ‘‘(v) if the individual files a joint re2 turn for the applicable year, the social se3 curity number, unearned income informa4 tion, and income information from partner5 ships, trusts, estates, and subchapter S 

6 corporations of the individual’s spouse on 

7 such return, and 

8 ‘‘(vi) such other return information 

9 relating to the individual (or the individ10 ual’s spouse in the case of a joint return) 

11 as is prescribed by the Secretary by regula12 tion as might indicate that the individual 

13 is likely to be ineligible for a low-income 

14 prescription drug subsidy under section 

15 1860D–14 of the Social Security Act. 

16 ‘‘(B) APPLICABLE YEAR.—For the pur17 poses of this paragraph, the term ‘applicable 

18 year’ means the most recent taxable year for 

19 which information is available in the Internal 

20 Revenue Service’s taxpayer information records. 

21 ‘‘(C) RESTRICTION ON INDIVIDUALS FOR

22 WHOM DISCLOSURE MAY BE REQUESTED.—The 

23 Commissioner of Social Security shall request 

24 information under this paragraph only with re25 spect to— 


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1 ‘‘(i) individuals the Social Security 

2 Administration has identified, using all 

3 other reasonably available information, as 

4 likely to be eligible for a low-income pre5 scription drug subsidy under section 

6 1860D–14 of the Social Security Act and 

7 who have not applied for such subsidy, and 

8 ‘‘(ii) any individual the Social Security 

9 Administration has identified as a spouse 

10 of an individual described in clause (i). 

11 ‘‘(D) RESTRICTION ON USE OF DISCLOSED

12 INFORMATION.—Return information disclosed 

13 under this paragraph may be used only by offi14 cers and employees of the Social Security Ad15 ministration solely for purposes of identifying 

16 individuals likely to be ineligible for a low-in17 come prescription drug subsidy under section 

18 1860D–14 of the Social Security Act for use in 

19 outreach efforts under section 1144 of the So20 cial Security Act.’’. 

21 (b) SAFEGUARDS.—Paragraph (4) of section 6103(p) 

22 of such Code is amended— 

23 (1) by striking ‘‘(19),’’ each place it appears, 

24 and 


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1 (2) by striking ‘‘or (17)’’ each place it appears 

2 and inserting ‘‘(17), or (19)’’. 

3 (c) CONFORMING AMENDMENT.—Paragraph (3) of 

4 section 6103(a) of such Code is amended by striking 

5 ‘‘(19),’’. 

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

7 this section shall apply to disclosures made after the date 

8 which is 12 months after the date of the enactment of 

9 this Act. 

10 SEC. 1802. COMPARATIVE EFFECTIVENESS RESEARCH 

11 TRUST FUND; FINANCING FOR TRUST FUND. 

12 (a) ESTABLISHMENT OF TRUST FUND.— 

13 (1) IN GENERAL.—Subchapter A of chapter 98 

14 of the Internal Revenue Code of 1986 (relating to 

15 trust fund code) is amended by adding at the end 

16 the following new section: 

17 ‘‘SEC. 9511. HEALTH CARE COMPARATIVE EFFECTIVENESS 

18 RESEARCH TRUST FUND. 

19 ‘‘(a) CREATION OF TRUST FUND.—There is estab20 lished in the Treasury of the United States a trust fund 

21 to be known as the ‘Health Care Comparative Effective22 ness Research Trust Fund’ (hereinafter in this section re23 ferred to as the ‘CERTF’), consisting of such amounts 

24 as may be appropriated or credited to such Trust Fund 

25 as provided in this section and section 9602(b). 


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1 ‘‘(b) TRANSFERS TO FUND.— 

2 ‘‘(1) IN GENERAL.—There are hereby appro3 priated to the Trust Fund the following: 

4 ‘‘(A) For fiscal year 2010, $90,000,000. 

5 ‘‘(B) For fiscal year 2011, $100,000,000. 

6 ‘‘(C) For fiscal year 2012, $110,000,000. 

7 ‘‘(D) For each fiscal year beginning with 

8 fiscal year 2013— 

9 ‘‘(i) an amount equivalent to the net 

10 revenues received in the Treasury from the 

11 fees imposed under subchapter B of chap12 ter 34 (relating to fees on health insurance 

13 and self-insured plans) for such fiscal year; 

14 and 

15 ‘‘(ii) subject to subsection (c)(2), 

16 amounts determined by the Secretary of 

17 Health and Human Services to be equiva18 lent to the fair share per capita amount 

19 computed under subsection (c)(1) for the 

20 fiscal year multiplied by the average num21 ber of individuals entitled to benefits under 

22 part A, or enrolled under part B, of title 

23 XVIII of the Social Security Act during 

24 such fiscal year. 

25 ‘‘(2) ADMINISTRATIVE PROVISIONS.— 


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1 ‘‘(A) TRANSFERS FROM OTHER TRUST

2 FUNDS.—The amounts appropriated by sub3 paragraphs (A), (B), (C), and (D)(ii) of para4 graph (1) shall be transferred from the Federal 

5 Hospital Insurance Trust Fund and from the 

6 Federal Supplementary Medical Insurance 

7 Trust Fund (established under section 1841 of 

8 such Act), and from the Medicare Prescription 

9 Drug Account within such Trust Fund, in pro10 portion (as estimated by the Secretary) to the 

11 total expenditures during such fiscal year that 

12 are made under title XVIII of such Act from 

13 the respective trust fund or account. 

14 ‘‘(B) APPROPRIATIONS NOT SUBJECT TO

15 FISCAL YEAR LIMITATION.—The amounts ap16 propriated by paragraph (1) shall not be sub17 ject to any fiscal year limitation. 

18 ‘‘(C) PERIODIC TRANSFERS, ESTIMATES, 

19 AND ADJUSTMENTS.—Except as provided in 

20 subparagraph (A), the provisions of section 

21 9601 shall apply to the amounts appropriated 

22 by paragraph (1). 

23 ‘‘(c) FAIR SHARE PER CAPITA AMOUNT.— 

24 ‘‘(1) COMPUTATION.— 


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1 ‘‘(A) IN GENERAL.—Subject to subpara2 graph (B), the fair share per capita amount 

3 under this paragraph for a fiscal year (begin4 ning with fiscal year 2013) is an amount com5 puted by the Secretary of Health and Human 

6 Services for such fiscal year that, when applied 

7 under this section and subchapter B of chapter 

8 34 of the Internal Revenue Code of 1986, will 

9 result in revenues to the CERTF of 

10 $375,000,000 for the fiscal year. 

11 ‘‘(B) ALTERNATIVE COMPUTATION.— 

12 ‘‘(i) IN GENERAL.—If the Secretary is 

13 unable to compute the fair share per capita 

14 amount under subparagraph (A) for a fis15 cal year, the fair share per capita amount 

16 under this paragraph for the fiscal year 

17 shall be the default amount determined 

18 under clause (ii) for the fiscal year. 

19 ‘‘(ii) DEFAULT AMOUNT.—The default 

20 amount under this clause for— 

21 ‘‘(I) fiscal year 2013 is equal to 

22 $2; or 

23 ‘‘(II) a subsequent year is equal 

24 to the default amount under this 

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1 creased by the annual percentage in2 crease in the medical care component 

3 of the consumer price index (United 

4 States city average) for the 12-month 

5 period ending with April of the pre6 ceding fiscal year. 

7 Any amount determined under subclause 

8 (II) shall be rounded to the nearest penny. 

9 ‘‘(2) LIMITATION ON MEDICARE FUNDING.—In 

10 no case shall the amount transferred under sub11 section (b)(4)(B) for any fiscal year exceed 

12 $90,000,000. 

13 ‘‘(d) EXPENDITURES FROM FUND.— 

14 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

15 amounts in the CERTF are available, without the 

16 need for further appropriations and without fiscal 

17 year limitation, to the Secretary of Health and 

18 Human Services to carry out section 1181 of the So19 cial Security Act. 

20 ‘‘(2) ALLOCATION FOR COMMISSION.—The fol21 lowing amounts in the CERTF shall be available, 

22 without the need for further appropriations and 

23 without fiscal year limitation, to the Commission to 

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1 ness Research Commission established under section 

2 1181(b) of the Social Security Act: 

3 ‘‘(A) For fiscal year 2010, $7,000,000. 

4 ‘‘(B) For fiscal year 2011, $9,000,000. 

5 ‘‘(C) For each fiscal year beginning with 

6 2012, 2.6 percent of the total amount appro7 priated to the CERTF under subsection (b) for 

8 the fiscal year. 

9 ‘‘(e) NET REVENUES.—For purposes of this section, 

10 the term ‘net revenues’ means the amount estimated by 

11 the Secretary based on the excess of— 

12 ‘‘(1) the fees received in the Treasury under 

13 subchapter B of chapter 34, over 

14 ‘‘(2) the decrease in the tax imposed by chapter 

15 1 resulting from the fees imposed by such sub16 chapter.’’. 

17 (2) CLERICAL AMENDMENT.—The table of sec18 tions for such subchapter A is amended by adding 

19 at the end thereof the following new item: 

‘‘Sec. 9511. Health Care Comparative Effectiveness Research Trust Fund.’’. 

20 (b) FINANCING FOR FUND FROM FEES ON INSURED

21 AND SELF-INSURED HEALTH PLANS.— 

22 (1) GENERAL RULE.—Chapter 34 of the Inter23 nal Revenue Code of 1986 is amended by adding at 

24 the end the following new subchapter: 


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1 ‘‘Subchapter B—Insured and Self-Insured 

2 Health Plans 

‘‘Sec. 4375. Health insurance. 

‘‘Sec. 4376. Self-insured health plans. 

‘‘Sec. 4377. Definitions and special rules. 

3 ‘‘SEC. 4375. HEALTH INSURANCE. 

4 ‘‘(a) IMPOSITION OF FEE.—There is hereby imposed 

5 on each specified health insurance policy for each policy 

6 year a fee equal to the fair share per capita amount deter7 mined under section 9511(c)(1) multiplied by the average 

8 number of lives covered under the policy. 

9 ‘‘(b) LIABILITY FOR FEE.—The fee imposed by sub10 section (a) shall be paid by the issuer of the policy. 

11 ‘‘(c) SPECIFIED HEALTH INSURANCE POLICY.—For 

12 purposes of this section: 

13 ‘‘(1) IN GENERAL.—Except as otherwise pro14 vided in this section, the term ‘specified health in15 surance policy’ means any accident or health insur16 ance policy issued with respect to individuals resid17 ing in the United States. 

18 ‘‘(2) EXEMPTION FOR CERTAIN POLICIES.—The 

19 term ‘specified health insurance policy’ does not in20 clude any insurance if substantially all of its cov21 erage is of excepted benefits described in section 

22 9832(c). 

23 ‘‘(3) TREATMENT OF PREPAID HEALTH COV24 ERAGE ARRANGEMENTS.— 


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1 ‘‘(A) IN GENERAL.—In the case of any ar2 rangement described in subparagraph (B)— 

3 ‘‘(i) such arrangement shall be treated 

4 as a specified health insurance policy, and 

5 ‘‘(ii) the person referred to in such 

6 subparagraph shall be treated as the 

7 issuer. 

8 ‘‘(B) DESCRIPTION OF ARRANGEMENTS.— 

9 An arrangement is described in this subpara10 graph if under such arrangement fixed pay11 ments or premiums are received as consider12 ation for any person’s agreement to provide or 

13 arrange for the provision of accident or health 

14 coverage to residents of the United States, re15 gardless of how such coverage is provided or ar16 ranged to be provided. 

17 ‘‘SEC. 4376. SELF-INSURED HEALTH PLANS. 

18 ‘‘(a) IMPOSITION OF FEE.—In the case of any appli19 cable self-insured health plan for each plan year, there is 

20 hereby imposed a fee equal to the fair share per capita 

21 amount determined under section 9511(c)(1) multiplied by 

22 the average number of lives covered under the plan. 

23 ‘‘(b) LIABILITY FOR FEE.— 

24 ‘‘(1) IN GENERAL.—The fee imposed by sub25 section (a) shall be paid by the plan sponsor. 


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1 ‘‘(2) PLAN SPONSOR.—For purposes of para2 graph (1) the term ‘plan sponsor’ means— 

3 ‘‘(A) the employer in the case of a plan es4 tablished or maintained by a single employer, 

5 ‘‘(B) the employee organization in the case 

6 of a plan established or maintained by an em7 ployee organization, 

8 ‘‘(C) in the case of— 

9 ‘‘(i) a plan established or maintained 

10 by 2 or more employers or jointly by 1 or 

11 more employers and 1 or more employee 

12 organizations, 

13 ‘‘(ii) a multiple employer welfare ar14 rangement, or 

15 ‘‘(iii) a voluntary employees’ bene16 ficiary association described in section 

17 501(c)(9), 

18 the association, committee, joint board of trust19 ees, or other similar group of representatives of 

20 the parties who establish or maintain the plan, 

21 or 

22 ‘‘(D) the cooperative or association de23 scribed in subsection (c)(2)(F) in the case of a 

24 plan established or maintained by such a coop25 erative or association. 


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1 ‘‘(c) APPLICABLE SELF-INSURED HEALTH PLAN.— 

2 For purposes of this section, the term ‘applicable self-in3 sured health plan’ means any plan for providing accident 

4 or health coverage if— 

5 ‘‘(1) any portion of such coverage is provided 

6 other than through an insurance policy, and 

7 ‘‘(2) such plan is established or maintained— 

8 ‘‘(A) by one or more employers for the 

9 benefit of their employees or former employees, 

10 ‘‘(B) by one or more employee organiza11 tions for the benefit of their members or former 

12 members, 

13 ‘‘(C) jointly by 1 or more employers and 1 

14 or more employee organizations for the benefit 

15 of employees or former employees, 

16 ‘‘(D) by a voluntary employees’ beneficiary 

17 association described in section 501(c)(9), 

18 ‘‘(E) by any organization described in sec19 tion 501(c)(6), or 

20 ‘‘(F) in the case of a plan not described in 

21 the preceding subparagraphs, by a multiple em22 ployer welfare arrangement (as defined in sec23 tion 3(40) of Employee Retirement Income Se24 curity Act of 1974), a rural electric cooperative 

25 (as defined in section 3(40)(B)(iv) of such Act), 


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1 or a rural telephone cooperative association (as 

2 defined in section 3(40)(B)(v) of such Act). 

3 ‘‘SEC. 4377. DEFINITIONS AND SPECIAL RULES. 

4 ‘‘(a) DEFINITIONS.—For purposes of this sub5 chapter— 

6 ‘‘(1) ACCIDENT AND HEALTH COVERAGE.—The 

7 term ‘accident and health coverage’ means any cov8 erage which, if provided by an insurance policy, 

9 would cause such policy to be a specified health in10 surance policy (as defined in section 4375(c)). 

11 ‘‘(2) INSURANCE POLICY.—The term ‘insurance 

12 policy’ means any policy or other instrument where13 by a contract of insurance is issued, renewed, or ex14 tended. 

15 ‘‘(3) UNITED STATES.—The term ‘United 

16 States’ includes any possession of the United States. 

17 ‘‘(b) TREATMENT OF GOVERNMENTAL ENTITIES.— 

18 ‘‘(1) IN GENERAL.—For purposes of this sub19 chapter— 

20 ‘‘(A) the term ‘person’ includes any gov21 ernmental entity, and 

22 ‘‘(B) notwithstanding any other law or rule 

23 of law, governmental entities shall not be ex24 empt from the fees imposed by this subchapter 

25 except as provided in paragraph (2). 


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1 ‘‘(2) TREATMENT OF EXEMPT GOVERNMENTAL

2 PROGRAMS.—In the case of an exempt governmental 

3 program, no fee shall be imposed under section 4375 

4 or section 4376 on any covered life under such pro5 gram. 

6 ‘‘(3) EXEMPT GOVERNMENTAL PROGRAM DE7 FINED.—For purposes of this subchapter, the term 

8 ‘exempt governmental program’ means— 

9 ‘‘(A) any insurance program established 

10 under title XVIII of the Social Security Act, 

11 ‘‘(B) the medical assistance program es12 tablished by title XIX or XXI of the Social Se13 curity Act, 

14 ‘‘(C) any program established by Federal 

15 law for providing medical care (other than 

16 through insurance policies) to individuals (or 

17 the spouses and dependents thereof) by reason 

18 of such individuals being— 

19 ‘‘(i) members of the Armed Forces of 

20 the United States, or 

21 ‘‘(ii) veterans, and 

22 ‘‘(D) any program established by Federal 

23 law for providing medical care (other than 

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1 dian tribes (as defined in section 4(d) of the In2 dian Health Care Improvement Act). 

3 ‘‘(c) TREATMENT AS TAX.—For purposes of subtitle 

4 F, the fees imposed by this subchapter shall be treated 

5 as if they were taxes. 

6 ‘‘(d) NO COVER OVER TO POSSESSIONS.—Notwith7 standing any other provision of law, no amount collected 

8 under this subchapter shall be covered over to any posses9 sion of the United States.’’. 

10 (2) CLERICAL AMENDMENTS.— 

11 (A) Chapter 34 of such Code is amended 

12 by striking the chapter heading and inserting 

13 the following: 

14 ‘‘CHAPTER 34—TAXES ON CERTAIN 

15 INSURANCE POLICIES 

‘‘SUBCHAPTER A. POLICIES ISSUED BY FOREIGN INSURERS

‘‘SUBCHAPTER B. INSURED AND SELF-INSURED HEALTH PLANS

16 ‘‘Subchapter A—Policies Issued By Foreign 

17 Insurers’’. 

18 (B) The table of chapters for subtitle D of 

19 such Code is amended by striking the item re20 lating to chapter 34 and inserting the following 

21 new item: 

‘‘CHAPTER 34—TAXES ON CERTAIN INSURANCE POLICIES’’. 

22 (3) EFFECTIVE DATE.—The amendments made 

23 by this subsection shall apply with respect to policies 


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1 and plans for portions of policy or plan years begin2 ning on or after October 1, 2012. 

3 TITLE IX—MISCELLANEOUS 

4 PROVISIONS 

5 SEC. 1901. REPEAL OF TRIGGER PROVISION. 

6 Subtitle A of title VIII of the Medicare Prescription 

7 Drug, Improvement, and Modernization Act of 2003 (Pub8 lic Law 108–173) is repealed and the provisions of law 

9 amended by such subtitle are restored as if such subtitle 

10 had never been enacted. 

11 SEC. 1902. REPEAL OF COMPARATIVE COST ADJUSTMENT 

12 (CCA) PROGRAM. 

13 Section 1860C–1 of the Social Security Act (42 

14 U.S.C. 1395w–29), as added by section 241(a) of the 

15 Medicare Prescription Drug, Improvement, and Mod16 ernization Act of 2003 (Public Law 108–173), is repealed. 

17 SEC. 1903. EXTENSION OF GAINSHARING DEMONSTRATION. 

18 (a) IN GENERAL.—Subsection (d)(3) of section 5007 

19 of the Deficit Reduction Act of 2005 (Public Law 109– 

20 171) is amended by inserting ‘‘(or September 30, 2011, 

21 in the case of a demonstration project in operation as of 

22 October 1, 2008)’’ after ‘‘December 31, 2009’’. 

23 (b) FUNDING.— 


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1 (1) IN GENERAL.—Subsection (f)(1) of such 

2 section is amended by inserting ‘‘and for fiscal year 

3 2010, $1,600,000,’’ after ‘‘$6,000,000,’’. 

4 (2) AVAILABILITY.—Subsection (f)(2) of such 

5 section is amended by striking ‘‘2010’’ and inserting 

6 ‘‘2014 or until expended’’. 

7 (c) REPORTS.— 

8 (1) QUALITY IMPROVEMENT AND SAVINGS.— 

9 Subsection (e)(3) of such section is amended by 

10 striking ‘‘December 1, 2008’’ and inserting ‘‘March 

11 31, 2011’’. 

12 (2) FINAL REPORT.—Subsection (e)(4) of such 

13 section is amended by striking ‘‘May 1, 2010’’ and 

14 inserting ‘‘March 31, 2013’’. 

15 SEC. 1904. GRANTS TO STATES FOR QUALITY HOME VISITA16 TION PROGRAMS FOR FAMILIES WITH YOUNG 

17 CHILDREN AND FAMILIES EXPECTING CHIL18 DREN. 

19 Part B of title IV of the Social Security Act (42 

20 U.S.C. 621–629i) is amended by adding at the end the 

21 following: 


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1 ‘‘Subpart 3—Support for Quality Home Visitation 

2 Programs 

3 ‘‘SEC. 440. HOME VISITATION PROGRAMS FOR FAMILIES 

4 WITH YOUNG CHILDREN AND FAMILIES EX5 PECTING CHILDREN. 

6 ‘‘(a) PURPOSE.—The purpose of this section is to im7 prove the well-being, health, and development of children 

8 by enabling the establishment and expansion of high qual9 ity programs providing voluntary home visitation for fami10 lies with young children and families expecting children. 

11 ‘‘(b) GRANT APPLICATION.—A State that desires to 

12 receive a grant under this section shall submit to the Sec13 retary for approval, at such time and in such manner as 

14 the Secretary may require, an application for the grant 

15 that includes the following: 

16 ‘‘(1) DESCRIPTION OF HOME VISITATION PRO17 GRAMS.—A description of the high quality programs 

18 of home visitation for families with young children 

19 and families expecting children that will be sup20 ported by a grant made to the State under this sec21 tion, the outcomes the programs are intended to 

22 achieve, and the evidence supporting the effective23 ness of the programs. 

24 ‘‘(2) RESULTS OF NEEDS ASSESSMENT.—The 

25 results of a statewide needs assessment that de26 scribes— 


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1 ‘‘(A) the number, quality, and capacity of 

2 home visitation programs for families with 

3 young children and families expecting children 

4 in the State; 

5 ‘‘(B) the number and types of families who 

6 are receiving services under the programs; 

7 ‘‘(C) the sources and amount of funding 

8 provided to the programs; 

9 ‘‘(D) the gaps in home visitation in the 

10 State, including identification of communities 

11 that are in high need of the services; and 

12 ‘‘(E) training and technical assistance ac13 tivities designed to achieve or support the goals 

14 of the programs. 

15 ‘‘(3) ASSURANCES.—Assurances from the State 

16 that— 

17 ‘‘(A) in supporting home visitation pro18 grams using funds provided under this section, 

19 the State shall identify and prioritize serving 

20 communities that are in high need of such serv21 ices, especially communities with a high propor22 tion of low-income families or a high incidence 

23 of child maltreatment; 

24 ‘‘(B) the State will reserve 5 percent of the 

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1 ance to the home visitation programs using 

2 such funds; 

3 ‘‘(C) in supporting home visitation pro4 grams using funds provided under this section, 

5 the State will promote coordination and collabo6 ration with other home visitation programs (in7 cluding programs funded under title XIX) and 

8 with other child and family services, health 

9 services, income supports, and other related as10 sistance; 

11 ‘‘(D) home visitation programs supported 

12 using such funds will, when appropriate, pro13 vide referrals to other programs serving chil14 dren and families; and 

15 ‘‘(E) the State will comply with subsection 

16 (i), and cooperate with any evaluation con17 ducted under subsection (j). 

18 ‘‘(4) OTHER INFORMATION.—Such other infor19 mation as the Secretary may require. 

20 ‘‘(c) ALLOTMENTS.— 

21 ‘‘(1) INDIAN TRIBES.—From the amount re22 served under subsection (l)(2) for a fiscal year, the 

23 Secretary shall allot to each Indian tribe that meets 

24 the requirement of subsection (d), if applicable, for 

25 the fiscal year the amount that bears the same ratio 


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1 to the amount so reserved as the number of children 

2 in the Indian tribe whose families have income that 

3 does not exceed 200 percent of the poverty line bears 

4 to the total number of children in such Indian tribes 

5 whose families have income that does not exceed 200 

6 percent of the poverty line. 

7 ‘‘(2) STATES AND TERRITORIES.—From the 

8 amount appropriated under subsection (m) for a fis9 cal year that remains after making the reservations 

10 required by subsection (l), the Secretary shall allot 

11 to each State that is not an Indian tribe and that 

12 meets the requirement of subsection (d), if applica13 ble, for the fiscal year the amount that bears the 

14 same ratio to the remainder of the amount so appro15 priated as the number of children in the State whose 

16 families have income that does not exceed 200 per17 cent of the poverty line bears to the total number of 

18 children in such States whose families have income 

19 that does not exceed 200 percent of the poverty line. 

20 ‘‘(3) REALLOTMENTS.—The amount of any al21 lotment to a State under a paragraph of this sub22 section for any fiscal year that the State certifies to 

23 the Secretary will not be expended by the State pur24 suant to this section shall be available for reallot25 ment using the allotment methodology specified in 


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1 that paragraph. Any amount so reallotted to a State 

2 is deemed part of the allotment of the State under 

3 this subsection. 

4 ‘‘(d) MAINTENANCE OF EFFORT.—Beginning with 

5 fiscal year 2011, a State meets the requirement of this 

6 subsection for a fiscal year if the Secretary finds that the 

7 aggregate expenditures by the State from State and local 

8 sources for programs of home visitation for families with 

9 young children and families expecting children for the then 

10 preceding fiscal year was not less than 100 percent of such 

11 aggregate expenditures for the then 2nd preceding fiscal 

12 year. 

13 ‘‘(e) PAYMENT OF GRANT.— 

14 ‘‘(1) IN GENERAL.—The Secretary shall make a 

15 grant to each State that meets the requirements of 

16 subsections (b) and (d), if applicable, for a fiscal 

17 year for which funds are appropriated under sub18 section (m), in an amount equal to the reimbursable 

19 percentage of the eligible expenditures of the State 

20 for the fiscal year, but not more than the amount 

21 allotted to the State under subsection (c) for the fis22 cal year. 

23 ‘‘(2) REIMBURSABLE PERCENTAGE DEFINED.— 

24 In paragraph (1), the term ‘reimbursable percent25 age’ means, with respect to a fiscal year— 


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1 ‘‘(A) 85 percent, in the case of fiscal year 

2 2010; 

3 ‘‘(B) 80 percent, in the case of fiscal year 

4 2011; or 

5 ‘‘(C) 75 percent, in the case of fiscal year 

6 2012 and any succeeding fiscal year. 

7 ‘‘(f) ELIGIBLE EXPENDITURES.— 

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

9 ‘eligible expenditures’— 

10 ‘‘(A) means expenditures to provide vol11 untary home visitation for as many families 

12 with young children (under the age of school 

13 entry) and families expecting children as prac14 ticable, through the implementation or expan15 sion of high quality home visitation programs 

16 that— 

17 ‘‘(i) adhere to clear evidence-based 

18 models of home visitation that have dem19 onstrated positive effects on important pro20 gram-determined child and parenting out21 comes, such as reducing abuse and neglect 

22 and improving child health and develop23 ment; 

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1 vision, provide for ongoing training and 

2 professional development, and show strong 

3 organizational capacity to implement such 

4 a program; 

5 ‘‘(iii) establish appropriate linkages 

6 and referrals to other community resources 

7 and supports; 

8 ‘‘(iv) monitor fidelity of program im9 plementation to ensure that services are 

10 delivered according to the specified model; 

11 and 

12 ‘‘(v) provide parents with— 

13 ‘‘(I) knowledge of age-appro14 priate child development in cognitive, 

15 language, social, emotional, and motor 

16 domains (including knowledge of sec17 ond language acquisition, in the case 

18 of English language learners); 

19 ‘‘(II) knowledge of realistic ex20 pectations of age-appropriate child be21 haviors; 

22 ‘‘(III) knowledge of health and 

23 wellness issues for children and par24 ents; 


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1 ‘‘(IV) modeling, consulting, and 

2 coaching on parenting practices; 

3 ‘‘(V) skills to interact with their 

4 child to enhance age-appropriate de5 velopment; 

6 ‘‘(VI) skills to recognize and seek 

7 help for issues related to health, devel8 opmental delays, and social, emo9 tional, and behavioral skills; and 

10 ‘‘(VII) activities designed to help 

11 parents become full partners in the 

12 education of their children; 

13 ‘‘(B) includes expenditures for training, 

14 technical assistance, and evaluations related to 

15 the programs; and 

16 ‘‘(C) does not include any expenditure with 

17 respect to which a State has submitted a claim 

18 for payment under any other provision of Fed19 eral law. 

20 ‘‘(2) PRIORITY FUNDING FOR PROGRAMS WITH

21 STRONGEST EVIDENCE.— 

22 ‘‘(A) IN GENERAL.—The expenditures, de23 scribed in paragraph (1), of a State for a fiscal 

24 year that are attributable to the cost of pro25 grams that do not adhere to a model of home 


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1 visitation with the strongest evidence of effec2 tiveness shall not be considered eligible expendi3 tures for the fiscal year to the extent that the 

4 total of the expenditures exceeds the applicable 

5 percentage for the fiscal year of the allotment 

6 of the State under subsection (c) for the fiscal 

7 year. 

8 ‘‘(B) APPLICABLE PERCENTAGE DE9 FINED.—In subparagraph (A), the term ‘appli10 cable percentage’ means, with respect to a fiscal 

11 year— 

12 ‘‘(i) 60 percent for fiscal year 2010; 

13 ‘‘(ii) 55 percent for fiscal year 2011; 

14 ‘‘(iii) 50 percent for fiscal year 2012; 

15 ‘‘(iv) 45 percent for fiscal year 2013; 

16 or 

17 ‘‘(v) 40 percent for fiscal year 2014. 

18 ‘‘(g) NO USE OF OTHER FEDERAL FUNDS FOR

19 STATE MATCH.—A State to which a grant is made under 

20 this section may not expend any Federal funds to meet 

21 the State share of the cost of an eligible expenditure for 

22 which the State receives a payment under this section. 

23 ‘‘(h) WAIVER AUTHORITY.— 

24 ‘‘(1) IN GENERAL.—The Secretary may waive 

25 or modify the application of any provision of this 


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1 section, other than subsection (b) or (f), to an In2 dian tribe if the failure to do so would impose an 

3 undue burden on the Indian tribe. 

4 ‘‘(2) SPECIAL RULE.—An Indian tribe is 

5 deemed to meet the requirement of subsection (d) 

6 for purposes of subsections (c) and (e) if— 

7 ‘‘(A) the Secretary waives the requirement; 

8 or 

9 ‘‘(B) the Secretary modifies the require10 ment, and the Indian tribe meets the modified 

11 requirement. 

12 ‘‘(i) STATE REPORTS.—Each State to which a grant 

13 is made under this section shall submit to the Secretary 

14 an annual report on the progress made by the State in 

15 addressing the purposes of this section. Each such report 

16 shall include a description of— 

17 ‘‘(1) the services delivered by the programs that 

18 received funds from the grant; 

19 ‘‘(2) the characteristics of each such program, 

20 including information on the service model used by 

21 the program and the performance of the program; 

22 ‘‘(3) the characteristics of the providers of serv23 ices through the program, including staff qualifica24 tions, work experience, and demographic characteris25 tics; 


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1 ‘‘(4) the characteristics of the recipients of serv2 ices provided through the program, including the 

3 number of the recipients, the demographic charac4 teristics of the recipients, and family retention; 

5 ‘‘(5) the annual cost of implementing the pro6 gram, including the cost per family served under the 

7 program; 

8 ‘‘(6) the outcomes experienced by recipients of 

9 services through the program; 

10 ‘‘(7) the training and technical assistance pro11 vided to aid implementation of the program, and 

12 how the training and technical assistance contrib13 uted to the outcomes achieved through the program; 

14 ‘‘(8) the indicators and methods used to mon15 itor whether the program is being implemented as 

16 designed; and 

17 ‘‘(9) other information as determined necessary 

18 by the Secretary. 

19 ‘‘(j) EVALUATION.— 

20 ‘‘(1) IN GENERAL.—The Secretary shall, by 

21 grant or contract, provide for the conduct of an 

22 independent evaluation of the effectiveness of home 

23 visitation programs receiving funds provided under 

24 this section, which shall examine the following: 


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1 ‘‘(A) The effect of home visitation pro2 grams on child and parent outcomes, including 

3 child maltreatment, child health and develop4 ment, school readiness, and links to community 

5 services. 

6 ‘‘(B) The effectiveness of home visitation 

7 programs on different populations, including 

8 the extent to which the ability of programs to 

9 improve outcomes varies across programs and 

10 populations. 

11 ‘‘(2) REPORTS TO THE CONGRESS.— 

12 ‘‘(A) INTERIM REPORT.—Within 3 years 

13 after the date of the enactment of this section, 

14 the Secretary shall submit to the Congress an 

15 interim report on the evaluation conducted pur16 suant to paragraph (1). 

17 ‘‘(B) FINAL REPORT.—Within 5 years 

18 after the date of the enactment of this section, 

19 the Secretary shall submit to the Congress a 

20 final report on the evaluation conducted pursu21 ant to paragraph (1). 

22 ‘‘(k) ANNUAL REPORTS TO THE CONGRESS.—The 

23 Secretary shall submit annually to the Congress a report 

24 on the activities carried out using funds made available 


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1 under this section, which shall include a description of the 

2 following: 

3 ‘‘(1) The high need communities targeted by 

4 States for programs carried out under this section. 

5 ‘‘(2) The service delivery models used in the 

6 programs receiving funds provided under this sec7 tion. 

8 ‘‘(3) The characteristics of the programs, in9 cluding— 

10 ‘‘(A) the qualifications and demographic 

11 characteristics of program staff; and 

12 ‘‘(B) recipient characteristics including the 

13 number of families served, the demographic 

14 characteristics of the families served, and fam15 ily retention and duration of services. 

16 ‘‘(4) The outcomes reported by the programs. 

17 ‘‘(5) The research-based instruction, materials, 

18 and activities being used in the activities funded 

19 under the grant. 

20 ‘‘(6) The training and technical activities, in21 cluding on-going professional development, provided 

22 to the programs. 

23 ‘‘(7) The annual costs of implementing the pro24 grams, including the cost per family served under 

25 the programs. 


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1 ‘‘(8) The indicators and methods used by States 

2 to monitor whether the programs are being been im3 plemented as designed. 

4 ‘‘(l) RESERVATIONS OF FUNDS.—From the amounts 

5 appropriated for a fiscal year under subsection (m), the 

6 Secretary shall reserve— 

7 ‘‘(1) an amount equal to 5 percent of the 

8 amounts to pay the cost of the evaluation provided 

9 for in subsection (j), and the provision to States of 

10 training and technical assistance, including the dis11 semination of best practices in early childhood home 

12 visitation; and 

13 ‘‘(2) after making the reservation required by 

14 paragraph (1), an amount equal to 3 percent of the 

15 amount so appropriated, to pay for grants to Indian 

16 tribes under this section. 

17 ‘‘(m) APPROPRIATIONS.—Out of any money in the 

18 Treasury of the United States not otherwise appropriated, 

19 there is appropriated to the Secretary to carry out this 

20 section— 

21 ‘‘(1) $50,000,000 for fiscal year 2010; 

22 ‘‘(2) $100,000,000 for fiscal year 2011; 

23 ‘‘(3) $150,000,000 for fiscal year 2012; 

24 ‘‘(4) $200,000,000 for fiscal year 2013; and 

25 ‘‘(5) $250,000,000 for fiscal year 2014. 


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1 ‘‘(n) INDIAN TRIBES TREATED AS STATES.—In this 

2 section, paragraphs (4), (5), and (6) of section 431(a) 

3 shall apply.’’. 

4 SEC. 1905. IMPROVED COORDINATION AND PROTECTION 

5 FOR DUAL ELIGIBLES. 

6 Title XI of the Social Security Act is amended by 

7 inserting after section 1150 the following new section: 

8 ‘‘IMPROVED COORDINATION AND PROTECTION FOR DUAL

9 ELIGIBLES

10 ‘‘SEC. 1150A. (a) IN GENERAL.—The Secretary shall 

11 provide, through an identifiable office or program within 

12 the Centers for Medicare & Medicaid Services, for a fo13 cused effort to provide for improved coordination between 

14 Medicare and Medicaid and protection in the case of dual 

15 eligibles (as defined in subsection (g)). The office or pro16 gram shall— 

17 ‘‘(1) review Medicare and Medicaid policies re18 lated to enrollment, benefits, service delivery, pay19 ment, and grievance and appeals processes under 

20 parts A and B of title XVIII, under the Medicare 

21 Advantage program under part C of such title, and 

22 under title XIX; 

23 ‘‘(2) identify areas of such policies where better 

24 coordination and protection could improve care and 

25 costs; and 


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1 ‘‘(3) issue guidance to States regarding improv2 ing such coordination and protection. 

3 ‘‘(b) ELEMENTS.—The improved coordination and 

4 protection under this section shall include efforts— 

5 ‘‘(1) to simplify access of dual eligibles to bene6 fits and services under Medicare and Medicaid; 

7 ‘‘(2) to improve care continuity for dual eligi8 bles and ensure safe and effective care transitions; 

9 ‘‘(3) to harmonize regulatory conflicts between 

10 Medicare and Medicaid rules with regard to dual eli11 gibles; and 

12 ‘‘(4) to improve total cost and quality perform13 ance under Medicare and Medicaid for dual eligibles. 

14 ‘‘(c) RESPONSIBILITIES.—In carrying out this sec15 tion, the Secretary shall provide for the following: 

16 ‘‘(1) An examination of Medicare and Medicaid 

17 payment systems to develop strategies to foster more 

18 integrated and higher quality care. 

19 ‘‘(2) Development of methods to facilitate ac20 cess to post-acute and community-based services and 

21 to identify actions that could lead to better coordina22 tion of community-based care. 

23 ‘‘(3) A study of enrollment of dual eligibles in 

24 the Medicare Savings Program (as defined in section 

25 1144(c)(7)), under Medicaid, and in the low-income 


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1 subsidy program under section 1860D–14 to identify 

2 methods to more efficiently and effectively reach and 

3 enroll dual eligibles. 

4 ‘‘(4) An assessment of communication strate5 gies for dual eligibles to determine whether addi6 tional informational materials or outreach is needed, 

7 including an assessment of the Medicare website, 1– 

8 800–MEDICARE, and the Medicare handbook. 

9 ‘‘(5) Research and evaluation of areas where 

10 service utilization, quality, and access to cost sharing 

11 protection could be improved and an assessment of 

12 factors related to enrollee satisfaction with services 

13 and care delivery. 

14 ‘‘(6) Collection (and making available to the 

15 public) of data and a database that describe the eli16 gibility, benefit and cost-sharing assistance available 

17 to dual eligibles by State. 

18 ‘‘(7) Support for coordination of State and Fed19 eral contracting and oversight for dual coordination 

20 programs supportive of the goals described in sub21 section (b). 

22 ‘‘(8) Support for State Medicaid agencies 

23 through the provision of technical assistance for 

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1 signed to improve acute and long-term care for dual 

2 eligibles. 

3 ‘‘(9) Monitoring total combined Medicare and 

4 Medicaid program costs in serving dual eligibles and 

5 making recommendations for optimizing total quality 

6 and cost performance across both programs. 

7 ‘‘(10) Coordination of activities relating to 

8 Medicare Advantage plans under 1859(b)(6)(B)(ii) 

9 and Medicaid. 

10 ‘‘(d) REPORTING.—The Office or program shall work 

11 with relevant State agencies and any appropriate quality 

12 measurement entities to improve and coordinate reporting 

13 requirements for Medicare and Medicaid. In addition, the 

14 Office or program shall seek to minimize duplication in 

15 reporting requirements, where appropriate, and to identify 

16 opportunities to combine assessment requirements, where 

17 appropriate. The Office or program shall seek to identify 

18 quality metrics and assessment requirements that facili19 tate comparisons of the quality of care received by bene20 ficiaries enrolled in or entitled to benefits under fee-for21 service Medicare, the Medicare Advantage program, fee22 for-service Medicaid, and Medicaid managed care, and 

23 combinations thereof (including integrated Medicare-Med24 icaid programs for dual eligibles). 


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1 ‘‘(e) ENDORSEMENT.—The Secretary shall seek en2 dorsement by the entity with a contract under section 

3 1890(a) of quality measures and benchmarks developed 

4 under this section. 

5 ‘‘(f) CONSULTATION WITH STAKEHOLDERS.—The 

6 Office or program shall consult with relevant stakeholders, 

7 including dual eligible beneficiaries representatives for 

8 dual eligible beneficiaries, health plans, providers, and rel9 evant State agencies, in the development of policies related 

10 to integrated Medicare-Medicaid programs for dual eligi11 bles. 

12 ‘‘(g) PERIODIC REPORTS.—Not later than 1 year 

13 after the date of the enactment of this section and every 

14 3 years thereafter the Secretary shall submit to Congress 

15 a report on progress in activities conducted under this sec16 tion. 

17 ‘‘(h) DEFINITIONS.—In this section: 

18 ‘‘(1) DUAL ELIGIBLE.—The term ‘dual eligible’ 

19 means an individual who is dually eligible for bene20 fits under title XVIII, and medical assistance under 

21 title XIX, including such individuals who are eligible 

22 for benefits under the Medicare Savings Program 

23 (as defined in section 1144(c)(7)). 


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1 ‘‘(2) MEDICARE; MEDICAID.—The terms ‘Medi2 care’ and ‘Medicaid’ mean the programs under titles 

3 XVIII and XIX, respectively.’’. 

4 SEC. 1906. ASSESSMENT OF MEDICARE COST-INTENSIVE 

5 DISEASES AND CONDITIONS. 

6 (a) INITIAL ASSESSMENT.— 

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

8 Human Services shall conduct an assessment of the 

9 diseases and conditions that are the most cost-inten10 sive for the Medicare program and, to the extent 

11 possible, assess the diseases and conditions that 

12 could become cost-intensive for Medicare in the fu13 ture. In conducting the assessment, the Secretary 

14 shall include the input of relevant research agencies, 

15 including the National Institutes of Health, the 

16 Agency for Healthcare Research and Quality, the 

17 Food and Drug Administration, and the Centers for 

18 Medicare & Medicaid Services. 

19 (2) REPORT.—Not later than January 1, 2011, 

20 the Secretary shall transmit a report to the Commit21 tees on Energy and Commerce, Ways and Means, 

22 and Appropriations of the House of Representatives 

23 and the Committees on Health, Education, Labor 

24 and Pensions, Finance, and Appropriations of the 


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1 Senate on the assessment conducted under para2 graph (1). Such report shall— 

3 (A) include the assessment of current and 

4 future trends of cost-intensive diseases and con5 ditions described in such paragraph; 

6 (B) address whether current research pri7 orities are appropriately addressing current and 

8 future cost-intensive conditions so identified; 

9 and 

10 (C) include recommendations concerning 

11 research in the Department of Health and 

12 Human Services that should be funded to im13 prove the prevention, treatment, or cure of such 

14 cost-intensive diseases and conditions. 

15 (b) UPDATES OF ASSESSMENT.—Not later than Jan16 uary 1, 2013, and biennially thereafter, the Secretary 

17 shall— 

18 (1) review and update the assessment and rec19 ommendations described in subsection (a)(1); and 

20 (2) submit a report described in subsection 

21 (a)(2) to the Committees specified in subsection 

22 (a)(2) on such updated assessment and rec23 ommendations. 


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1 SEC. 1907. ESTABLISHMENT OF CENTER FOR MEDICARE 

2 AND MEDICAID INNOVATION WITHIN CMS. 

3 (a) IN GENERAL.—Title XI of the Social Security Act 

4 is amended by inserting after section 1115 the following 

5 new section: 

6 ‘‘CENTER FOR MEDICARE AND MEDICAID INNOVATION

7 ‘‘SEC. 1115A. (a) CENTER FOR MEDICARE AND

8 MEDICAID INNOVATION ESTABLISHED.— 

9 ‘‘(1) IN GENERAL.—There is created within the 

10 Centers for Medicare & Medicaid Services a Center 

11 for Medicare and Medicaid Innovation (in this sec12 tion referred to as the ‘CMI’) to carry out the duties 

13 described in this section. The purpose of the CMI is 

14 to test innovative payment and service delivery mod15 els to improve the coordination, quality, and effi16 ciency of health care services provided to applicable 

17 individuals defined in paragraph (4)(A). 

18 ‘‘(2) DEADLINE.—The Secretary shall ensure 

19 that the CMI is carrying out the duties described in 

20 this section by not later than January 1, 2011. 

21 ‘‘(3) CONSULTATION.—In carrying out the du22 ties under this section, the CMI shall consult rep23 resentatives of relevant Federal agencies, clinical 

24 and analytical experts with expertise in medicine and 

25 health care management, and States. The CMI shall 


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1 use open door forums or other mechanisms to seek 

2 input from interested parties. 

3 ‘‘(4) DEFINITIONS.—In this section: 

4 ‘‘(A) APPLICABLE INDIVIDUAL.—The term 

5 ‘applicable individual’ means— 

6 ‘‘(i) an individual who is enrolled 

7 under part B and entitled to benefits 

8 under part A of title XVIII; 

9 ‘‘(ii) an individual who is eligible for 

10 medical assistance under title XIX; or 

11 ‘‘(iii) an individual who meets the cri12 teria of both clauses (i) and (ii). 

13 ‘‘(B) APPLICABLE TITLE.—The term ‘ap14 plicable title’ means title XVIII, title XIX, or 

15 both. 

16 ‘‘(b) TESTING OF MODELS (PHASE I).— 

17 ‘‘(1) IN GENERAL.—The CMI shall test pay18 ment and service delivery models in accordance with 

19 selection criteria under paragraph (2) to determine 

20 the effect of applying such models under the applica21 ble title (as defined in subsection (a)(4)(B)) on pro22 gram expenditures under such titles and the quality 

23 of care received by individuals receiving benefits 

24 under such title. 

25 ‘‘(2) SELECTION OF MODELS TO BE TESTED.— 


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

2 give preference to testing models for which, as 

3 determined by the Administrator of the Centers 

4 for Medicare & Medicaid Services and using 

5 such input from outside the Centers as the Ad6 ministrator determines appropriate, there is evi7 dence that the model addresses a defined popu8 lation for which there are deficits in care lead9 ing to poor clinical outcomes or potentially 

10 avoidable expenditures. The Administrator shall 

11 focus on models expected to reduce program 

12 costs under the applicable title while preserving 

13 or enhancing the quality of care received by in14 dividuals receiving benefits under such title. 

15 ‘‘(B) APPLICATION TO OTHER DEM16 ONSTRATIONS.—The Secretary shall operate the 

17 demonstration programs under sections 1222 

18 and 1236 of the Affordable Health Care for 

19 America Act through the CMI in accordance 

20 with the rules applicable under this section, in21 cluding those relating to evaluations, termi22 nations, and expansions. 

23 ‘‘(3) BUDGET NEUTRALITY.— 

24 ‘‘(A) INITIAL PERIOD.—The Secretary 

25 shall not require, as a condition for testing a 


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1 model under paragraph (1), that the design of 

2 such model ensure that such model is budget 

3 neutral initially with respect to expenditures 

4 under the applicable title. 

5 ‘‘(B) TERMINATION.—The Secretary shall 

6 terminate or modify the design and implemen7 tation of a model unless the Secretary deter8 mines (and the Chief Actuary of the Centers for 

9 Medicare & Medicaid Services, with respect to 

10 spending under the applicable title, certifies), 

11 after testing has begun, that the model is ex12 pected to— 

13 ‘‘(i) improve the quality of care (as 

14 determined by the Administrator of the 

15 Centers for Medicare & Medicaid Services) 

16 without increasing spending under such 

17 title; 

18 ‘‘(ii) reduce spending under such titles 

19 without reducing the quality of care; or 

20 ‘‘(iii) do both. 

21 Such termination may occur at any time after 

22 such testing has begun and before completion of 

23 the testing. 

24 ‘‘(4) EVALUATION.— 


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

2 conduct an evaluation of each model tested 

3 under this subsection. Such evaluation shall in4 clude an analysis of— 

5 ‘‘(i) the quality of care furnished 

6 under the model, including through the use 

7 of patient-level outcomes measures; and 

8 ‘‘(ii) the changes in spending under 

9 the applicable titles by reason of the 

10 model. 

11 The Secretary shall make the results of each 

12 evaluation under this paragraph available to the 

13 public in a timely fashion. 

14 ‘‘(B) MEASURE SELECTION.—To the ex15 tent feasible, the Secretary shall select meas16 ures under this paragraph that reflect national 

17 priorities for quality improvement and patient18 centered care consistent with the measures de19 veloped under section 1192(c)(1). 

20 ‘‘(5) TESTING PERIOD.—In no case shall a 

21 model be tested under this subsection for more than 

22 a 7-year period. 

23 ‘‘(c) EXPANSION OF MODELS (PHASE II).—The Sec24 retary may expand the duration and the scope of a model 


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1 that is being tested under subsection (b) (including imple2 mentation on a nationwide basis), to the extent deter3 mined appropriate by the Secretary, if— 

4 ‘‘(1) the Secretary determines that such expan5 sion is expected— 

6 ‘‘(A) to improve the quality of patient care 

7 without increasing spending under the applica8 ble titles; 

9 ‘‘(B) to reduce spending under applicable 

10 titles without reducing the quality of care; or 

11 ‘‘(C) to do both; 

12 ‘‘(2) the Chief Actuary of the Centers for Medi13 care & Medicaid Services certifies that such expan14 sion would reduce (or not result in any increase in) 

15 net program spending under applicable titles; and 

16 ‘‘(3) the Secretary determines that such expan17 sion would not deny or limit the coverage or provi18 sion of benefits under the applicable title for applica19 ble individuals. 

20 ‘‘(d) IMPLEMENTATION.— 

21 ‘‘(1) WAIVER AUTHORITY.—The Secretary may 

22 waive such requirements of titles XI and XVIII and 

23 of sections 1902 and 1903(m) as may be necessary 

24 solely for purposes of carrying out this section with 

25 respect to testing models described in subsection (b). 


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1 ‘‘(2) LIMITATIONS ON REVIEW.—There shall be 

2 no administrative or judicial review under section 

3 1869, section 1878, or otherwise of— 

4 ‘‘(A) the selection of models for testing or 

5 expansion under this section; 

6 ‘‘(B) the elements, parameters, scope, and 

7 duration of such models for testing or dissemi8 nation; 

9 ‘‘(C) the termination or modification of the 

10 design and implementation of a model under 

11 subsection (b)(3)(B); and 

12 ‘‘(D) determinations about expansion of 

13 the duration and scope of a model under sub14 section (c) including the determination that a 

15 model is not expected to meet criteria described 

16 in paragraphs (1) or (2) of such subsection. 

17 ‘‘(3) ADMINISTRATION.—Chapter 35 of title 44, 

18 United States Code shall not apply to the testing 

19 and evaluation of models or expansion of such mod20 els under this section. 

21 ‘‘(4) FUNDING FOR TESTING ITEMS AND SERV22 ICES AND ADMINISTRATIVE COSTS.— 

23 ‘‘(A) ADDITIONAL BENEFITS.—There shall 

24 be available until expended, equally divided 

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1 surance Trust Fund and Federal Supple2 mentary Medical Insurance Trust Fund for 

3 payments for additional benefits for items and 

4 services under models tested under subsection 

5 (b) not otherwise covered under this title and 

6 applicable to benefits under this title, and for 

7 researching, designing, implementing, and eval8 uating such models, $350,000,000 for fiscal 

9 year 2010, $440,000,000 for fiscal year 2011, 

10 $550,000,000 for fiscal year 2012, and, for a 

11 subsequent fiscal year, the amount determined 

12 under this subparagraph for the preceding fis13 cal year increased by the annual percentage 

14 rate of increase in total expenditures under this 

15 title for the subsequent fiscal year as estimated 

16 in the latest available Annual Report of the 

17 Board of Trustees as described in section 

18 1841(b)(2). 

19 ‘‘(B) MEDICAID.—For administrative costs 

20 of the Centers for Medicare & Medicaid Serv21 ices for administering this section with respect 

22 to title XIX, from any amounts in the Treasury 

23 not otherwise appropriated there are appro24 priated to the Secretary for the Centers for 

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1 agement Account $25,000,000 for each fiscal 

2 year beginning with fiscal year 2010. Amounts 

3 appropriated under this subparagraph for a fis4 cal year shall be available until expended. 

5 ‘‘(e) REPORT TO CONGRESS.—Beginning in 2012, 

6 and not less than once every other year thereafter, the 

7 Secretary shall submit to Congress a report on activities 

8 under this section. Each such report shall describe the 

9 payment models tested under subsection (b), including the 

10 number of individuals described in subsection (a)(4)(A)(i) 

11 and of individuals described in subsection (a)(4)(A)(ii) 

12 participating in such models and payments made under 

13 applicable titles for services on behalf of such individuals, 

14 any models chosen for expansion under subsection (c), and 

15 the results from evaluations under subsection (b)(4). In 

16 addition, each such report shall provide such recommenda17 tions as the Secretary believes are appropriate for legisla18 tive action to facilitate the development and expansion of 

19 successful payment models.’’. 

20 (b) MEDICAID CONFORMING AMENDMENT.—Section 

21 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), 

22 as amended by sections 1631(b), 1703(a), 1729, 1753, 

23 1757(a), and 1759(a), is amended— 

24 (1) in paragraph (78), by striking ‘‘and’’ at the 

25 end; 


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1 (2) in paragraph (79), by striking the period at 

2 the end and inserting ‘‘; and’’; and 

3 (3) by inserting after paragraph (79) the fol4 lowing new paragraph: 

5 ‘‘(80) provide for implementation of the pay6 ment models specified by the Secretary under section 

7 1115A(c) for implementation on a nationwide basis 

8 unless the State demonstrates to the satisfaction of 

9 the Secretary that implementation would not be ad10 ministratively feasible or appropriate to the health 

11 care delivery system of the State.’’. 

12 SEC. 1908. APPLICATION OF EMERGENCY SERVICES LAWS. 

13 Nothing in this Act shall be construed to relieve any 

14 health care provider from providing emergency services as 

15 required by State or Federal law, including section 1867 

16 of the Social Security Act (popularly known as 

17 ′′EMTALA′′). 

18 SEC. 1909. DISREGARD UNDER THE SUPPLEMENTAL SECU19 RITY INCOME PROGRAM OF COMPENSATION 

20 FOR PARTICIPATION IN CLINICAL TRIALS 

21 FOR RARE DISEASES OR CONDITIONS. 

22 (a) INCOME DISREGARD.—Section 1612(b) of the So23 cial Security Act (42 U.S.C. 1382a(b)) is amended— 

24 (1) by striking ‘‘and’’ at the end of paragraph 

25 (24); 


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1 (2) by striking the period at the end of para2 graph (25) and inserting ‘‘; and’’; and 

3 (3) by adding at the end the following: 

4 ‘‘(26) The first $2,000 per year received by 

5 such individual (or such spouse) for participation in 

6 a clinical trial to test a treatment for a rare disease 

7 or condition (within the meaning of section 5(b)(2) 

8 of the Orphan Drug Act (Public Law 97–414)), 

9 that— 

10 ‘‘(A) has been reviewed and approved by 

11 an institutional review board that— 

12 ‘‘(i) is established to protect the rights 

13 and welfare of human subjects partici14 pating in research; and 

15 ‘‘(ii) meet the standards for such bod16 ies set forth in part 46 of title 45, Code of 

17 Federal Regulations; and 

18 ‘‘(B) meets the standards for protection of 

19 human subjects for clinical research (as set 

20 forth in such part).’’. 

21 (b) RESOURCE DISREGARD.—Section 1613(a) of 

22 such Act (42 U.S.C. 1382b(a)) is amended— 

23 (1) by striking ‘‘and’’ at the end of paragraph 

24 (15); 


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1 (2) by striking the period at the end of para2 graph (16) and inserting ‘‘; and’’; and 

3 (3) by inserting after paragraph (16) the fol4 lowing: 

5 ‘‘(17) the first $2,000 per year received by such 

6 individual (or such spouse) for participation in a 

7 clinical trial, as described in section 1612(b)(26).’’. 

8 (c) EFFECTIVE DATE.—The amendments made by 

9 this section shall apply to benefits payable for calendar 

10 months beginning after the earlier of— 

11 (1) the date the Commissioner of Social Secu12 rity promulgates regulations to carry out the amend13 ments; or 

14 (2) the 180-day period that begins with the 

15 date of the enactment of this Act. 

16 DIVISION C—PUBLIC HEALTH 

17 AND WORKFORCE DEVELOP18 MENT 

19 SEC. 2001. TABLE OF CONTENTS; REFERENCES. 

20 (a) TABLE OF CONTENTS.—The table of contents of 

21 this division is as follows: 

Sec. 2001. Table of contents; references. 

Sec. 2002. Public Health Investment Fund. 

Sec. 2003. Deficit neutrality. 

TITLE I—COMMUNITY HEALTH CENTERS 

Sec. 2101. Increased funding. 

TITLE II—WORKFORCE 


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Subtitle A—Primary Care Workforce 

PART 1—NATIONAL HEALTH SERVICE CORPS

Sec. 2201. National Health Service Corps. 

Sec. 2202. Authorizations of appropriations. 

PART 2—PROMOTION OF PRIMARY CARE AND DENTISTRY

Sec. 2211. Frontline health providers. 

‘‘SUBPART XI—HEALTH PROFESSIONAL NEEDS AREAS

‘‘Sec. 340H. In general. 

‘‘Sec. 340I. Loan repayments. 

‘‘Sec. 340J. Report. 

‘‘Sec. 340K. Allocation. 

Sec. 2212. Primary care student loan funds. 

Sec. 2213. Training in family medicine, general internal medicine, general pediatrics, geriatrics, and physician assistants. 

Sec. 2214. Training of medical residents in community-based settings. 

Sec. 2215. Training for general, pediatric, and public health dentists and dental 

hygienists. 

Sec. 2216. Authorization of appropriations. 

Sec. 2217. Study on effectiveness of scholarships and loan repayments. 

Subtitle B—Nursing Workforce 

Sec. 2221. Amendments to Public Health Service Act. 

Subtitle C—Public Health Workforce 

Sec. 2231. Public Health Workforce Corps. 

‘‘SUBPART XII—PUBLIC HEALTH WORKFORCE

‘‘Sec. 340L. Public Health Workforce Corps. 

‘‘Sec. 340M. Public Health Workforce Scholarship Program. 

‘‘Sec. 340N. Public Health Workforce Loan Repayment Program. 

Sec. 2232. Enhancing the public health workforce. 

Sec. 2233. Public health training centers. 

Sec. 2234. Preventive medicine and public health training grant program. 

Sec. 2235. Authorization of appropriations. 

Subtitle D—Adapting Workforce to Evolving Health System Needs 

PART 1—HEALTH PROFESSIONS TRAINING FOR DIVERSITY

Sec. 2241. Scholarships for disadvantaged students, loan repayments and fellowships regarding faculty positions, and educational assistance 

in the health professions regarding individuals from disadvantaged backgrounds. 

Sec. 2242. Nursing workforce diversity grants. 

Sec. 2243. Coordination of diversity and cultural competency programs. 

PART 2—INTERDISCIPLINARY TRAINING PROGRAMS

Sec. 2251. Cultural and linguistic competency training for health professionals. 

Sec. 2252. Innovations in interdisciplinary care training. 


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PART 3—ADVISORY COMMITTEE ON HEALTH WORKFORCE EVALUATION AND

ASSESSMENT

Sec. 2261. Health workforce evaluation and assessment. 

PART 4—HEALTH WORKFORCE ASSESSMENT

Sec. 2271. Health workforce assessment. 

PART 5—AUTHORIZATION OF APPROPRIATIONS

Sec. 2281. Authorization of appropriations. 

TITLE III—PREVENTION AND WELLNESS 

Sec. 2301. Prevention and wellness. 

‘‘TITLE XXXI—PREVENTION AND WELLNESS 

‘‘Subtitle A—Prevention and Wellness Trust 

‘‘Sec. 3111. Prevention and Wellness Trust. 

‘‘Subtitle B—National Prevention and Wellness Strategy 

‘‘Sec. 3121. National Prevention and Wellness Strategy. 

‘‘Subtitle C—Prevention Task Forces 

‘‘Sec. 3131. Task Force on Clinical Preventive Services. 

‘‘Sec. 3132. Task Force on Community Preventive Services. 

‘‘Subtitle D—Prevention and Wellness Research 

‘‘Sec. 3141. Prevention and wellness research activity coordination. 

‘‘Sec. 3142. Community prevention and wellness research grants. 

‘‘Sec. 3143. Research on subsidies and rewards to encourage wellness and 

healthy behaviors. 

‘‘Subtitle E—Delivery of Community Prevention and Wellness Services 

‘‘Sec. 3151. Community prevention and wellness services grants. 

‘‘Subtitle F—Core Public Health Infrastructure 

‘‘Sec. 3161. Core public health infrastructure for State, local, and tribal 

health departments. 

‘‘Sec. 3162. Core public health infrastructure and activities for CDC. 

‘‘Subtitle G—General Provisions 

‘‘Sec. 3171. Definitions. 

TITLE IV—QUALITY AND SURVEILLANCE 

Sec. 2401. Implementation of best practices in the delivery of health care. 

Sec. 2402. Assistant Secretary for Health Information. 

Sec. 2403. Authorization of appropriations. 

TITLE V—OTHER PROVISIONS 


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

Integrity 

Sec. 2501. Expanded participation in 340B program. 

Sec. 2502. Improvements to 340B program integrity. 

Sec. 2503. Effective date. 

Subtitle B—Programs 

PART 1—GRANTS FOR CLINICS AND CENTERS

Sec. 2511. School-based health clinics. 

Sec. 2512. Nurse-Managed health centers. 

Sec. 2513. Federally qualified behavioral health centers. 

PART 2—OTHER GRANT PROGRAMS

Sec. 2521. Comprehensive programs to provide education to nurses and create 

a pipeline to nursing. 

Sec. 2522. Mental and behavioral health training. 

Sec. 2523. Reauthorization of telehealth and telemedicine grant programs. 

Sec. 2524. No child left unimmunized against influenza: demonstration program using elementary and secondary schools as influenza vaccination centers. 

Sec. 2525. Extension of Wisewoman Program. 

Sec. 2526. Healthy teen initiative to prevent teen pregnancy. 

Sec. 2527. National training initiatives on autism spectrum disorders. 

Sec. 2528. Implementation of medication management services in treatment of 

chronic diseases. 

Sec. 2529. Postpartum depression. 

Sec. 2530. Grants to promote positive health behaviors and outcomes. 

Sec. 2531. Medical liability alternatives. 

Sec. 2532. Infant mortality pilot programs. 

Sec. 2533. Secondary school health sciences training program. 

Sec. 2534. Community-based collaborative care networks. 

Sec. 2535. Community-based overweight and obesity prevention program. 

Sec. 2536. Reducing student-to-school nurse ratios. 

Sec. 2537. Medical-legal partnerships. 

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 


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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. 

1 (b) REFERENCES.—Except as otherwise specified, 

2 whenever in this division an amendment is expressed in 

3 terms of an amendment to a section or other provision, 

4 the reference shall be considered to be made to a section 


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1 or other provision of the Public Health Service Act (42 

2 U.S.C. 201 et seq.). 

3 SEC. 2002. PUBLIC HEALTH INVESTMENT FUND. 

4 (a) ESTABLISHMENT OF FUNDS.— 

5 (1) IN GENERAL.—Subject to section 2003, 

6 there is hereby established in the Treasury a sepa7 rate account to be known as the ‘‘Public Health In8 vestment Fund’’ (referred to in this section and sec9 tion 2003 as the ‘‘Fund’’). 

10 (2) FUNDING.— 

11 (A) There shall be deposited into the 

12 Fund— 

13 (i) for fiscal year 2011, 

14 $4,600,000,000; 

15 (ii) for fiscal year 2012, 

16 $5,600,000,000; 

17 (iii) for fiscal year 2013, 

18 $6,900,000,000; 

19 (iv) for fiscal year 2014, 

20 $7,800,000,000; and 

21 (v) for fiscal year 2015, 

22 $9,000,000,000. 

23 (B) Amounts deposited into the Fund shall 

24 be derived from general revenues of the Treas25 ury only for the fiscal years set forth in this 


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1 section, and amounts appropriated from the 

2 Fund shall remain available until expended. 

3 (b) AUTHORIZATION OF APPROPRIATIONS FROM THE

4 FUND.— 

5 (1) NEW FUNDING.— 

6 (A) IN GENERAL.—Subject to section 

7 2003, amounts in the Fund are authorized to 

8 be appropriated for carrying out activities 

9 under designated public health provisions. 

10 (B) DESIGNATED PROVISIONS.—For pur11 poses of this paragraph, the term ‘‘designated 

12 public health provisions’’ means the provisions 

13 for which amounts are authorized to be appro14 priated under section 330(s), 338(c), 338H–1, 

15 799C, 872, or 3111 of the Public Health Serv16 ice Act, as added by this division. 

17 (2) BASELINE FUNDING.— 

18 (A) IN GENERAL.—Amounts in the Fund 

19 are authorized to be appropriated (as described 

20 in paragraph (1)) for a fiscal year only if (ex21 cluding any amounts in or appropriated from 

22 the Fund)— 

23 (i) the amounts specified in subpara24 graph (B) for the fiscal year involved are 

25 equal to or greater than the amounts specVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01215 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 ified in subparagraph (B) for fiscal year 

2 2008; and 

3 (ii) the amounts appropriated, out of 

4 the general fund of the Treasury, to the 

5 Prevention and Wellness Trust under sec6 tion 3111(a)(1) of the Public Health Serv7 ice Act, as added by this division, for the 

8 fiscal year involved are equal to or greater 

9 than the funds— 

10 (I) appropriated under the head11 ing ‘‘Prevention and Wellness Fund’’ 

12 in title VIII of division A of the Amer13 ican Recovery and Reinvestment Act 

14 of 2009 (Public Law 111–5); and 

15 (II) allocated by the second pro16 viso under such heading for evidence17 based clinical and community-based 

18 prevention and wellness strategies. 

19 (B) AMOUNTS SPECIFIED.—The amounts 

20 specified in this subparagraph, with respect to 

21 a fiscal year, are the amounts appropriated for 

22 the following: 

23 (i) Community health centers (includ24 ing funds appropriated under the authority 


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1 of section 330 of the Public Health Service 

2 Act (42 U.S.C. 254b)). 

3 (ii) The National Health Service 

4 Corps Program (including funds appro5 priated under the authority of section 338 

6 of such Act (42 U.S.C. 254k)). 

7 (iii) The National Health Service 

8 Corps Scholarship and Loan Repayment 

9 Programs (including funds appropriated 

10 under the authority of section 338H of 

11 such Act (42 U.S.C. 254q)). 

12 (iv) Primary care education programs 

13 (including funds appropriated under the 

14 authority of sections 736, 740, 741, and 

15 747 of such Act (42 U.S.C. 293, 293d, 

16 and 293k)). 

17 (v) Sections 761 and 770 of such Act 

18 (42 U.S.C. 294n and 295e). 

19 (vi) Nursing workforce development 

20 (including funds appropriated under the 

21 authority of title VIII of such Act (42 

22 U.S.C. 296 et seq.)). 

23 (vii) The National Center for Health 

24 Statistics (including funds appropriated 

25 under the authority of sections 304, 306, 


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1 307, and 308 of such Act (42 U.S.C. 

2 242b, 242k, 242l, and 242m)). 

3 (viii) The Agency for Healthcare Re4 search and Quality (including funds appro5 priated under the authority of title IX of 

6 such Act (42 U.S.C. 299 et seq.)). 

7 SEC. 2003. DEFICIT NEUTRALITY. 

8 (a) AVAILABILITY.—Funds appropriated or made 

9 available pursuant to sections 330(s), 338(c), 338H–1, 

10 799C, 872, or 3111 of the Public Health Service Act, as 

11 added by this division, are only available for the purposes 

12 set forth in this Act. Appropriations shall not be available 

13 and are precluded from obligation for any other purpose. 

14 (b) ESTIMATION OF BUDGETARY IMPACT.—For the 

15 purposes of estimating the spending effects of this Act, 

16 the authorization of appropriations from the Fund, to the 

17 extent amounts in the Fund are derived from the general 

18 revenues of the Treasury, shall be treated as new direct 

19 spending and attributed to this Act. 

20 (c) BUDGETARY TREATMENT.—For the purposes of 

21 section 257 of the Balanced Budget and Emergency Def22 icit Control Act of 1985, the Fund, to the extent amounts 

23 in the Fund are derived from the general revenues of the 

24 Treasury, and not in excess of amounts subsequently ap25 propriated from the Fund, shall be deemed to be included 


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1 on the list of appropriations referenced under section 

2 250(c)(17) of that Act. 

3 TITLE I—COMMUNITY HEALTH 

4 CENTERS 

5 SEC. 2101. INCREASED FUNDING. 

6 Section 330 of the Public Health Service Act (42 

7 U.S.C. 254b) is amended— 

8 (1) in subsection (r)(1)— 

9 (A) in subparagraph (D), by striking 

10 ‘‘and’’ at the end; 

11 (B) in subparagraph (E), by striking the 

12 period at the end and inserting ‘‘; and’’; and 

13 (C) by inserting at the end the following: 

14 ‘‘(F) such sums as may be necessary for 

15 each of fiscal years 2013 through 2015.’’; and 

16 (2) by inserting after subsection (r) the fol17 lowing: 

18 ‘‘(s) ADDITIONAL FUNDING.—For the purpose of 

19 carrying out this section, in addition to any other amounts 

20 authorized to be appropriated for such purpose, there are 

21 authorized to be appropriated, out of any monies in the 

22 Public Health Investment Fund, the following: 

23 ‘‘(1) For fiscal year 2011, $1,000,000,000. 

24 ‘‘(2) For fiscal year 2012, $1,500,000,000. 

25 ‘‘(3) For fiscal year 2013, $2,500,000,000. 


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1 ‘‘(4) For fiscal year 2014, $3,000,000,000. 

2 ‘‘(5) For fiscal year 2015, $4,000,000,000.’’. 

3 TITLE II—WORKFORCE 

4 Subtitle A—Primary Care 

5 Workforce 

6 PART 1—NATIONAL HEALTH SERVICE CORPS 

7 SEC. 2201. NATIONAL HEALTH SERVICE CORPS. 

8 (a) FULFILLMENT OF OBLIGATED SERVICE RE9 QUIREMENT THROUGH HALF-TIME SERVICE.— 

10 (1) WAIVERS.—Subsection (i) of section 331 

11 (42 U.S.C. 254d) is amended— 

12 (A) in paragraph (1), by striking ‘‘In car13 rying out subpart III’’ and all that follows 

14 through the period and inserting ‘‘In carrying 

15 out subpart III, the Secretary may, in accord16 ance with this subsection, issue waivers to indi17 viduals who have entered into a contract for ob18 ligated service under the Scholarship Program 

19 or the Loan Repayment Program under which 

20 the individuals are authorized to satisfy the re21 quirement of obligated service through pro22 viding clinical practice that is half-time.’’; 

23 (B) in paragraph (2)— 


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1 (i) in subparagraphs (A)(ii) and (B), 

2 by striking ‘‘less than full time’’ each place 

3 it appears and inserting ‘‘half time’’; 

4 (ii) in subparagraphs (C) and (F), by 

5 striking ‘‘less than full-time service’’ each 

6 place it appears and inserting ‘‘half-time 

7 service’’; and 

8 (iii) by amending subparagraphs (D) 

9 and (E) to read as follows: 

10 ‘‘(D) the entity and the Corps member agree in 

11 writing that the Corps member will perform half12 time clinical practice; 

13 ‘‘(E) the Corps member agrees in writing to 

14 fulfill all of the service obligations under section 

15 338C through half-time clinical practice and ei16 ther— 

17 ‘‘(i) double the period of obligated service 

18 that would otherwise be required; or 

19 ‘‘(ii) in the case of contracts entered into 

20 under section 338B, accept a minimum service 

21 obligation of 2 years with an award amount 

22 equal to 50 percent of the amount that would 

23 otherwise be payable for full-time service; and’’; 

24 and 


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1 (C) in paragraph (3), by striking ‘‘In eval2 uating a demonstration project described in 

3 paragraph (1)’’ and inserting ‘‘In evaluating 

4 waivers issued under paragraph (1)’’. 

5 (2) DEFINITIONS.—Subsection (j) of section 

6 331 (42 U.S.C. 254d) is amended by adding at the 

7 end the following: 

8 ‘‘(5) The terms ‘full time’ and ‘full-time’ mean 

9 a minimum of 40 hours per week in a clinical prac10 tice, for a minimum of 45 weeks per year. 

11 ‘‘(6) The terms ‘half time’ and ‘half-time’ mean 

12 a minimum of 20 hours per week (not to exceed 39 

13 hours per week) in a clinical practice, for a min14 imum of 45 weeks per year.’’. 

15 (b) REAPPOINTMENT TO NATIONAL ADVISORY COUN16 CIL.—Section 337(b)(1) (42 U.S.C. 254j(b)(1)) is amend17 ed by striking ‘‘Members may not be reappointed to the 

18 Council.’’. 

19 (c) LOAN REPAYMENT AMOUNT.—Section 

20 338B(g)(2)(A) (42 U.S.C. 254l–1(g)(2)(A)) is amended 

21 by striking ‘‘$35,000’’ and inserting ‘‘$50,000, plus, be22 ginning with fiscal year 2012, an amount determined by 

23 the Secretary on an annual basis to reflect inflation,’’. 

24 (d) TREATMENT OF TEACHING AS OBLIGATED SERV25 ICE.—Subsection (a) of section 338C (42 U.S.C. 254m) 


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1 is amended by adding at the end the following: ‘‘The Sec2 retary may treat teaching as clinical practice for up to 

3 20 percent of such period of obligated service.’’. 

4 SEC. 2202. AUTHORIZATIONS OF APPROPRIATIONS. 

5 (a) NATIONAL HEALTH SERVICE CORPS PRO6 GRAM.—Section 338 (42 U.S.C. 254k) is amended— 

7 (1) in subsection (a), by striking ‘‘2012’’ and 

8 inserting ‘‘2015’’; and 

9 (2) by adding at the end the following: 

10 ‘‘(c) For the purpose of carrying out this subpart, 

11 in addition to any other amounts authorized to be appro12 priated for such purpose, there are authorized to be appro13 priated, out of any monies in the Public Health Invest14 ment Fund, the following: 

15 ‘‘(1) $63,000,000 for fiscal year 2011. 

16 ‘‘(2) $66,000,000 for fiscal year 2012. 

17 ‘‘(3) $70,000,000 for fiscal year 2013. 

18 ‘‘(4) $73,000,000 for fiscal year 2014. 

19 ‘‘(5) $77,000,000 for fiscal year 2015.’’. 

20 (b) SCHOLARSHIP AND LOAN REPAYMENT PRO21 GRAMS.—Subpart III of part D of title III of the Public 

22 Health Service Act (42 U.S.C. 254l et seq.) is amended— 

23 (1) in section 338H(a)— 

24 (A) in paragraph (4), by striking ‘‘and’’ at 

25 the end; 


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1 (B) in paragraph (5), by striking the pe2 riod at the end and inserting ‘‘; and’’; and 

3 (C) by adding at the end the following: 

4 ‘‘(6) for each of fiscal years 2013 through 

5 2015, such sums as may be necessary.’’; and 

6 (2) by inserting after section 338H the fol7 lowing: 

8 ‘‘SEC. 338H–1. ADDITIONAL FUNDING. 

9 ‘‘For the purpose of carrying out this subpart, in ad10 dition to any other amounts authorized to be appropriated 

11 for such purpose, there are authorized to be appropriated, 

12 out of any monies in the Public Health Investment Fund, 

13 the following: 

14 ‘‘(1) $254,000,000 for fiscal year 2011. 

15 ‘‘(2) $266,000,000 for fiscal year 2012. 

16 ‘‘(3) $278,000,000 for fiscal year 2013. 

17 ‘‘(4) $292,000,000 for fiscal year 2014. 

18 ‘‘(5) $306,000,000 for fiscal year 2015.’’. 

19 PART 2—PROMOTION OF PRIMARY CARE AND 

20 DENTISTRY 

21 SEC. 2211. FRONTLINE HEALTH PROVIDERS. 

22 Part D of title III (42 U.S.C. 254b et seq.) is amend23 ed by adding at the end the following: 


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1 ‘‘Subpart XI—Health Professional Needs Areas 

2 ‘‘SEC. 340H. IN GENERAL. 

3 ‘‘(a) PROGRAM.—The Secretary, acting through the 

4 Administrator of the Health Resources and Services Ad5 ministration, shall establish a program, to be known as 

6 the Frontline Health Providers Loan Repayment Pro7 gram, to address unmet health care needs in health profes8 sional needs areas through loan repayments under section 

9 340I. 

10 ‘‘(b) DESIGNATION OF HEALTH PROFESSIONAL

11 NEEDS AREAS.— 

12 ‘‘(1) IN GENERAL.—In this subpart, the term 

13 ‘health professional needs area’ means an area, pop14 ulation, or facility that is designated by the Sec15 retary in accordance with paragraph (2). 

16 ‘‘(2) DESIGNATION.—To be designated by the 

17 Secretary as a health professional needs area under 

18 this subpart: 

19 ‘‘(A) In the case of an area, the area must 

20 be a rational area for the delivery of health 

21 services. 

22 ‘‘(B) The area, population, or facility must 

23 have, in one or more health disciplines, special24 ties, or subspecialties for the population served, 

25 as determined by the Secretary— 


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1 ‘‘(i) insufficient capacity of health 

2 professionals; or 

3 ‘‘(ii) high needs for health services, in4 cluding services to address health dispari5 ties. 

6 ‘‘(C) With respect to the delivery of pri7 mary health services, the area, population, or 

8 facility must not include a health professional 

9 shortage area (as designated under section 

10 332), except that the area, population, or facil11 ity may include such a health professional 

12 shortage area in which there is an unmet need 

13 for such services. 

14 ‘‘(c) ELIGIBILITY.—To be eligible to participate in 

15 the Program, an individual shall— 

16 ‘‘(1) hold a degree in a course of study or pro17 gram (approved by the Secretary) from a school de18 fined in section 799B(1)(A) (other than a school of 

19 public health); 

20 ‘‘(2) hold a degree in a course of study or pro21 gram (approved by the Secretary) from a school or 

22 program defined in subparagraph (C), (D), or 

23 (E)(4) of section 799B(1), as designated by the Sec24 retary; 

25 ‘‘(3) be enrolled as a full-time student— 


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1 ‘‘(A) in a school or program defined in 

2 subparagraph (C), (D), or (E)(4) of section 

3 799B(1), as designated by the Secretary, or a 

4 school described in paragraph (1); and 

5 ‘‘(B) in the final year of a course of study 

6 or program, offered by such school or program 

7 and approved by the Secretary, leading to a de8 gree in a discipline referred to in subparagraph 

9 (A) (other than a graduate degree in public 

10 health), (C), (D), or (E)(4) of section 799B(1); 

11 ‘‘(4) be a practitioner described in section 

12 1842(b)(18)(C) or 1848(k)(3)(B)(iii) or (iv) of the 

13 Social Security Act; or 

14 ‘‘(5) be a practitioner in the field of respiratory 

15 therapy, medical technology, or radiologic tech16 nology. 

17 ‘‘(d) DEFINITIONS.—In this subpart: 

18 ‘‘(1) The term ‘health disparities’ has the 

19 meaning given to the term in section 3171. 

20 ‘‘(2) The term ‘primary health services’ has the 

21 meaning given to such term in section 331(a)(3)(D). 

22 ‘‘SEC. 340I. LOAN REPAYMENTS. 

23 ‘‘(a) LOAN REPAYMENTS.—The Secretary, acting 

24 through the Administrator of the Health Resources and 


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1 Services Administration, shall enter into contracts with in2 dividuals under which— 

3 ‘‘(1) the individual agrees— 

4 ‘‘(A) to serve as a full-time primary health 

5 services provider or as a full-time or part-time 

6 provider of other health services for a period of 

7 time equal to 2 years or such longer period as 

8 the individual may agree to; 

9 ‘‘(B) to serve in a health professional 

10 needs area in a health discipline, specialty, or a 

11 subspecialty for which the area, population, or 

12 facility is designated as a health professional 

13 needs area under section 340H; and 

14 ‘‘(C) in the case of an individual described 

15 in section 340H(c)(3) who is in the final year 

16 of study and who has accepted employment as 

17 a primary health services provider or provider 

18 of other health services in accordance with sub19 paragraphs (A) and (B), to complete the edu20 cation or training and maintain an acceptable 

21 level of academic standing (as determined by 

22 the educational institution offering the course 

23 of study or training); and 

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

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1 terest of the undergraduate or graduate educational 

2 loans (or both) of the individual that is not more 

3 than 50 percent of the average award made under 

4 the National Health Service Corps Loan Repayment 

5 Program under subpart III in that year. 

6 ‘‘(b) PRACTICE SETTING.—A contract entered into 

7 under this section shall allow the individual receiving the 

8 loan repayment to satisfy the service requirement de9 scribed in subsection (a)(1) through employment in a solo 

10 or group practice, a clinic, an accredited public or private 

11 nonprofit hospital, or any other health care entity, as 

12 deemed appropriate by the Secretary. 

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

14 provisions of subpart III of part D shall, except as incon15 sistent with this section, apply to the loan repayment pro16 gram under this subpart in the same manner and to the 

17 same extent as such provisions apply to the National 

18 Health Service Corps Loan Repayment Program estab19 lished under section 338B. 

20 ‘‘(d) INSUFFICIENT NUMBER OF APPLICANTS.—If 

21 there are an insufficient number of applicants for loan re22 payments under this section to obligate all appropriated 

23 funds, the Secretary shall transfer the unobligated funds 

24 to the National Health Service Corps for the purpose of 

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1 viduals so as to ensure a sufficient number of participants 

2 in the National Health Service Corps for the following 

3 year. 

4 ‘‘SEC. 340J. REPORT. 

5 ‘‘The Secretary shall submit to the Congress an an6 nual report on the program carried out under this subpart. 

7 ‘‘SEC. 340K. ALLOCATION. 

8 ‘‘Of the amount of funds obligated under this subpart 

9 each fiscal year for loan repayments— 

10 ‘‘(1) 90 percent shall be for physicians and 

11 other health professionals providing primary health 

12 services; and 

13 ‘‘(2) 10 percent shall be for health professionals 

14 not described in paragraph (1).’’. 

15 SEC. 2212. PRIMARY CARE STUDENT LOAN FUNDS. 

16 (a) IN GENERAL.—Section 735 (42 U.S.C. 292y) is 

17 amended— 

18 (1) by redesignating subsection (f) as sub19 section (g); and 

20 (2) by inserting after subsection (e) the fol21 lowing: 

22 ‘‘(f) DETERMINATION OF FINANCIAL NEED.—The 

23 Secretary— 

24 ‘‘(1) may require, or authorize a school or other 

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1 mation to determine the financial resources available 

2 to any individual seeking assistance under this sub3 part; and 

4 ‘‘(2) shall take into account the extent to which 

5 such individual is financially independent in deter6 mining whether to require or authorize the submis7 sion of such information regarding such individual’s 

8 family members.’’. 

9 (b) REVISED GUIDELINES.—The Secretary of Health 

10 and Human Services shall— 

11 (1) strike the second sentence of section 

12 57.206(b)(1) of title 42, Code of Federal Regula13 tions; and 

14 (2) make such other revisions to guidelines and 

15 regulations in effect as of the date of the enactment 

16 of this Act as may be necessary for consistency with 

17 the amendments made by paragraph (1). 

18 SEC. 2213. TRAINING IN FAMILY MEDICINE, GENERAL IN19 TERNAL MEDICINE, GENERAL PEDIATRICS, 

20 GERIATRICS, AND PHYSICIAN ASSISTANTS. 

21 Section 747 (42 U.S.C. 293k) is amended— 

22 (1) by amending the section heading to read as 

23 follows: ‘‘PRIMARY CARE TRAINING AND EN24 HANCEMENT’’; 


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1 (2) by redesignating subsection (e) as sub2 section (g); and 

3 (3) by striking subsections (a) through (d) and 

4 inserting the following: 

5 ‘‘(a) PROGRAM.—The Secretary shall establish a pri6 mary care training and capacity building program con7 sisting of awarding grants and contracts under sub8 sections (b) and (c). 

9 ‘‘(b) SUPPORT AND DEVELOPMENT OF PRIMARY

10 CARE TRAINING PROGRAMS.— 

11 ‘‘(1) IN GENERAL.—The Secretary shall make 

12 grants to, or enter into contracts with, eligible enti13 ties— 

14 ‘‘(A) to plan, develop, operate, or partici15 pate in an accredited professional training pro16 gram, including an accredited residency or in17 ternship program, in the field of family medi18 cine, general internal medicine, general pediat19 rics, or geriatrics for medical students, interns, 

20 residents, or practicing physicians; 

21 ‘‘(B) to provide financial assistance in the 

22 form of traineeships and fellowships to medical 

23 students, interns, residents, or practicing physi24 cians, who are participants in any such pro25 gram, and who plan to specialize or work in 


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1 family medicine, general internal medicine, gen2 eral pediatrics, or geriatrics; 

3 ‘‘(C) to plan, develop, operate, or partici4 pate in an accredited program for the training 

5 of physicians who plan to teach in family medi6 cine, general internal medicine, general pediat7 rics, or geriatrics training programs including 

8 in community-based settings; 

9 ‘‘(D) to provide financial assistance in the 

10 form of traineeships and fellowships to prac11 ticing physicians who are participants in any 

12 such programs and who plan to teach in a fam13 ily medicine, general internal medicine, general 

14 pediatrics, or geriatrics training program; and 

15 ‘‘(E) to plan, develop, operate, or partici16 pate in an accredited program for physician as17 sistant education, and for the training of indi18 viduals who plan to teach in programs to pro19 vide such training. 

20 ‘‘(2) ELIGIBILITY.—To be eligible for a grant 

21 or contract under paragraph (1), an entity shall 

22 be— 

23 ‘‘(A) an accredited school of medicine or 

24 osteopathic medicine, public or nonprofit private 


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1 hospital, or physician assistant training pro2 gram; 

3 ‘‘(B) a public or private nonprofit entity; 

4 or 

5 ‘‘(C) a consortium of 2 or more entities de6 scribed in subparagraphs (A) and (B). 

7 ‘‘(c) CAPACITY BUILDING IN PRIMARY CARE.— 

8 ‘‘(1) IN GENERAL.—The Secretary shall make 

9 grants to or enter into contracts with eligible entities 

10 to establish, maintain, or improve— 

11 ‘‘(A) academic administrative units (in12 cluding departments, divisions, or other appro13 priate units) in the specialties of family medi14 cine, general internal medicine, general pediat15 rics, or geriatrics; or 

16 ‘‘(B) programs that improve clinical teach17 ing in such specialties. 

18 ‘‘(2) ELIGIBILITY.—To be eligible for a grant 

19 or contract under paragraph (1), an entity shall be 

20 an accredited school of medicine or osteopathic med21 icine. 

22 ‘‘(d) PREFERENCE.—In awarding grants or contracts 

23 under this section, the Secretary shall give preference to 

24 entities that have a demonstrated record of at least one 

25 of the following: 


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1 ‘‘(1) Training a high or significantly improved 

2 percentage of health professionals who provide pri3 mary care. 

4 ‘‘(2) Training individuals who are from dis5 advantaged backgrounds (including racial and ethnic 

6 minorities underrepresented among primary care 

7 professionals). 

8 ‘‘(3) A high rate of placing graduates in prac9 tice settings having the principal focus of serving in 

10 underserved areas or populations experiencing health 

11 disparities (including serving patients eligible for 

12 medical assistance under title XIX of the Social Se13 curity Act or for child health assistance under title 

14 XXI of such Act or those with special health care 

15 needs). 

16 ‘‘(4) Supporting teaching programs that ad17 dress the health care needs of vulnerable popu18 lations. 

19 ‘‘(e) REPORT.—The Secretary shall submit to the 

20 Congress an annual report on the program carried out 

21 under this section. 

22 ‘‘(f) DEFINITION.—In this section, the term ‘health 

23 disparities’ has the meaning given the term in section 

24 3171.’’. 


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1 SEC. 2214. TRAINING OF MEDICAL RESIDENTS IN COMMU2 NITY-BASED SETTINGS. 

3 Title VII (42 U.S.C. 292 et seq.) is amended— 

4 (1) by redesignating section 748 as 749A; and 

5 (2) by inserting after section 747 the following: 

6 ‘‘SEC. 748. TRAINING OF MEDICAL RESIDENTS IN COMMU7 NITY-BASED SETTINGS. 

8 ‘‘(a) PROGRAM.—The Secretary shall establish a pro9 gram for the training of medical residents in community10 based settings consisting of awarding grants and contracts 

11 under this section. 

12 ‘‘(b) DEVELOPMENT AND OPERATION OF COMMU13 NITY-BASED PROGRAMS.—The Secretary shall make 

14 grants to, or enter into contracts with, eligible entities— 

15 ‘‘(1) to plan and develop a new primary care 

16 residency training program, which may include— 

17 ‘‘(A) planning and developing curricula; 

18 ‘‘(B) recruiting and training residents and 

19 faculty; and 

20 ‘‘(C) other activities designated to result in 

21 accreditation of such a program; or 

22 ‘‘(2) to operate or participate in an established 

23 primary care residency training program, which may 

24 include— 

25 ‘‘(A) planning and developing curricula; 


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1 ‘‘(B) recruitment and training of residents; 

2 and 

3 ‘‘(C) retention of faculty. 

4 ‘‘(c) ELIGIBLE ENTITY.—To be eligible to receive a 

5 grant or contract under subsection (b), an entity shall— 

6 ‘‘(1) be designated as a recipient of payment 

7 for the direct costs of medical education under sec8 tion 1886(k) of the Social Security Act; 

9 ‘‘(2) be designated as an approved teaching 

10 health center under section 1502(d) of the Afford11 able Health Care for America Act and continuing to 

12 participate in the demonstration project under such 

13 section; 

14 ‘‘(3) be an applicant for designation described 

15 in paragraph (1) or (2) and have demonstrated to 

16 the Secretary appropriate involvement of an accred17 ited teaching hospital to carry out the inpatient re18 sponsibilities associated with a primary care resi19 dency training program; or 

20 ‘‘(4) be eligible to be designated as described in 

21 paragraph (1) or (2), not be an applicant as de22 scribed in paragraph (3), and have demonstrated ap23 propriate involvement of an accredited teaching hos24 pital to carry out the inpatient responsibilities assoVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01237 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 ciated with a primary care residency training pro2 gram. 

3 ‘‘(d) PREFERENCES.—In awarding grants and con4 tracts under paragraph (1) or (2) of subsection (b), the 

5 Secretary shall give preference to entities that— 

6 ‘‘(1) support teaching programs that address 

7 the health care needs of vulnerable populations; or 

8 ‘‘(2) are a Federally qualified health center (as 

9 defined in section 1861(aa)(4) of the Social Security 

10 Act) or a rural health clinic (as defined in section 

11 1861(aa)(2) of such Act). 

12 ‘‘(e) ADDITIONAL PREFERENCES FOR ESTABLISHED

13 PROGRAMS.—In awarding grants and contracts under 

14 subsection (b)(2), the Secretary shall give preference to 

15 entities that have a demonstrated record of training— 

16 ‘‘(1) a high or significantly improved percentage 

17 of health professionals who provide primary care; 

18 ‘‘(2) individuals who are from disadvantaged 

19 backgrounds (including racial and ethnic minorities 

20 underrepresented among primary care professionals); 

21 or 

22 ‘‘(3) individuals who practice in settings having 

23 the principal focus of serving underserved areas or 

24 populations experiencing health disparities (including 

25 serving patients eligible for medical assistance under 


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1 title XIX of the Social Security Act or for child 

2 health assistance under title XXI of such Act or 

3 those with special health care needs). 

4 ‘‘(f) PERIOD OF AWARDS.— 

5 ‘‘(1) IN GENERAL.—The period of a grant or 

6 contract under this section— 

7 ‘‘(A) shall not exceed 3 years for awards 

8 under subsection (b)(1); and 

9 ‘‘(B) shall not exceed 5 years for awards 

10 under subsection (b)(2). 

11 ‘‘(2) SPECIAL RULES.— 

12 ‘‘(A) An award of a grant or contract 

13 under subsection (b)(1) shall not be renewed. 

14 ‘‘(B) The period of a grant or contract 

15 awarded to an entity under subsection (b)(2) 

16 shall not overlap with the period of any grant 

17 or contact awarded to the same entity under 

18 subsection (b)(1). 

19 ‘‘(g) REPORT.—The Secretary shall submit to the 

20 Congress an annual report on the program carried out 

21 under this section. 

22 ‘‘(h) DEFINITIONS.—In this section: 

23 ‘‘(1) HEALTH DISPARITIES.—The term ‘health 

24 disparities’ has the meaning given the term in sec25 tion 3171. 


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1 ‘‘(2) PRIMARY CARE RESIDENT.—The term ‘pri2 mary care resident’ has the meaning given the term 

3 in section 1886(h)(5)(H) of the Social Security Act. 

4 ‘‘(3) PRIMARY CARE RESIDENCY TRAINING PRO5 GRAM.—The term ‘primary care residency training 

6 program’ means an approved medical residency 

7 training program described in section 1886(h)(5)(A) 

8 of the Social Security Act for primary care residents 

9 that is— 

10 ‘‘(A) in the case of entities seeking awards 

11 under subsection (b)(1), actively applying to be 

12 accredited by the Accreditation Council for 

13 Graduate Medical Education or the American 

14 Osteopathic Association; or 

15 ‘‘(B) in the case of entities seeking awards 

16 under subsection (b)(2), so accredited. 

17 ‘‘(i) ALLOCATION OF FUNDS.—Of the amount appro18 priated pursuant to section 799C(a) for a fiscal year, not 

19 more than 17 percent of such amount shall be made avail20 able to carry out this section.’’. 

21 SEC. 2215. TRAINING FOR GENERAL, PEDIATRIC, AND PUB22 LIC HEALTH DENTISTS AND DENTAL HYGIEN23 ISTS. 

24 Title VII (42 U.S.C. 292 et seq.) is amended— 


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1 (1) in section 791(a)(1), by striking ‘‘747 and 

2 750’’ and inserting ‘‘747, 749, and 750’’; and 

3 (2) by inserting after section 748, as added, the 

4 following: 

5 ‘‘SEC. 749. TRAINING FOR GENERAL, PEDIATRIC, AND PUB6 LIC HEALTH DENTISTS AND DENTAL HYGIEN7 ISTS. 

8 ‘‘(a) PROGRAM.—The Secretary shall establish a 

9 training program for oral health professionals consisting 

10 of awarding grants and contracts under this section. 

11 ‘‘(b) SUPPORT AND DEVELOPMENT OF ORAL

12 HEALTH TRAINING PROGRAMS.—The Secretary shall 

13 make grants to, or enter into contracts with, eligible enti14 ties— 

15 ‘‘(1) to plan, develop, operate, or participate in 

16 an accredited professional training program for oral 

17 health professionals; 

18 ‘‘(2) to provide financial assistance to oral 

19 health professionals who are in need thereof, who 

20 are participants in any such program, and who plan 

21 to work in general, pediatric, or public health den22 tistry, or dental hygiene; 

23 ‘‘(3) to plan, develop, operate, or participate in 

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1 sionals who plan to teach in general, pediatric, or 

2 public health dentistry, or dental hygiene; 

3 ‘‘(4) to provide financial assistance in the form 

4 of traineeships and fellowships to oral health profes5 sionals who plan to teach in general, pediatric, or 

6 public health dentistry or dental hygiene; 

7 ‘‘(5) to establish, maintain, or improve— 

8 ‘‘(A) academic administrative units (in9 cluding departments, divisions, or other appro10 priate units) in the specialties of general, pedi11 atric, or public health dentistry; or 

12 ‘‘(B) programs that improve clinical teach13 ing in such specialties; 

14 ‘‘(6) to plan, develop, operate, or participate in 

15 predoctoral and postdoctoral training in general, pe16 diatric, or public health dentistry programs; 

17 ‘‘(7) to plan, develop, operate, or participate in 

18 a loan repayment program for full-time faculty in a 

19 program of general, pediatric, or public health den20 tistry; and 

21 ‘‘(8) to provide technical assistance to pediatric 

22 dental training programs in developing and imple23 menting instruction regarding the oral health status, 

24 dental care needs, and risk-based clinical disease 


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1 management of all pediatric populations with an em2 phasis on underserved children. 

3 ‘‘(c) ELIGIBILITY.—To be eligible for a grant or con4 tract under this section, an entity shall be— 

5 ‘‘(1) an accredited school of dentistry, training 

6 program in dental hygiene, or public or nonprofit 

7 private hospital; 

8 ‘‘(2) a training program in dental hygiene at an 

9 accredited institution of higher education; 

10 ‘‘(3) a public or private nonprofit entity; or 

11 ‘‘(4) a consortium of— 

12 ‘‘(A) 1 or more of the entities described in 

13 paragraphs (1) through (3); and 

14 ‘‘(B) an accredited school of public health. 

15 ‘‘(d) PREFERENCE.—In awarding grants or contracts 

16 under this section, the Secretary shall give preference to 

17 entities that have a demonstrated record of at least one 

18 of the following: 

19 ‘‘(1) Training a high or significantly improved 

20 percentage of oral health professionals who practice 

21 general, pediatric, or public health dentistry. 

22 ‘‘(2) Training individuals who are from dis23 advantaged backgrounds (including racial and ethnic 

24 minorities underrepresented among oral health pro25 fessionals). 


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1 ‘‘(3) A high rate of placing graduates in prac2 tice settings having the principal focus of serving in 

3 underserved areas or populations experiencing health 

4 disparities (including serving patients eligible for 

5 medical assistance under title XIX of the Social Se6 curity Act or for child health assistance under title 

7 XXI of such Act or those with special health care 

8 needs). 

9 ‘‘(4) Supporting teaching programs that ad10 dress the oral health needs of vulnerable popu11 lations. 

12 ‘‘(5) Providing instruction regarding the oral 

13 health status, oral health care needs, and risk-based 

14 clinical disease management of all pediatric popu15 lations with an emphasis on underserved children. 

16 ‘‘(e) REPORT.—The Secretary shall submit to the 

17 Congress an annual report on the program carried out 

18 under this section. 

19 ‘‘(f) DEFINITIONS.—In this section: 

20 ‘‘(1) The term ‘health disparities’ has the 

21 meaning given the term in section 3171. 

22 ‘‘(2) The term ‘oral health professional’ means 

23 an individual training or practicing— 


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1 ‘‘(A) in general dentistry, pediatric den2 tistry, public health dentistry, or dental hy3 giene; or 

4 ‘‘(B) another oral health specialty, as 

5 deemed appropriate by the Secretary.’’. 

6 SEC. 2216. AUTHORIZATION OF APPROPRIATIONS. 

7 (a) IN GENERAL.—Part F of title VII (42 U.S.C. 

8 295j et seq.) is amended by adding at the end the fol9 lowing: 

10 ‘‘SEC. 799C. FUNDING THROUGH PUBLIC HEALTH INVEST11 MENT FUND. 

12 ‘‘(a) PROMOTION OF PRIMARY CARE AND DEN13 TISTRY.—For the purpose of carrying out subpart XI of 

14 part D of title III and sections 747, 748, and 749, in addi15 tion to any other amounts authorized to be appropriated 

16 for such purpose, there are authorized to be appropriated, 

17 out of any monies in the Public Health Investment Fund, 

18 the following: 

19 ‘‘(1) $240,000,000 for fiscal year 2011. 

20 ‘‘(2) $253,000,000 for fiscal year 2012. 

21 ‘‘(3) $265,000,000 for fiscal year 2013. 

22 ‘‘(4) $278,000,000 for fiscal year 2014. 

23 ‘‘(5) $292,000,000 for fiscal year 2015.’’. 

24 (b) EXISTING AUTHORIZATION OF APPROPRIA25 TIONS.—Subsection (g)(1), as so redesignated, of section 


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1 747 (42 U.S.C. 293k) is amended by striking ‘‘2002’’ and 

2 inserting ‘‘2015’’. 

3 SEC. 2217. STUDY ON EFFECTIVENESS OF SCHOLARSHIPS 

4 AND LOAN REPAYMENTS. 

5 (a) STUDY.—The Comptroller General of the United 

6 States shall conduct a study to determine the effectiveness 

7 of scholarship and loan repayment programs under sub8 parts III and XI of part D of title III of the Public Health 

9 Service Act, as amended or added by sections 2201 and 

10 2211, including whether scholarships or loan repayments 

11 are more effective in— 

12 (1) incentivizing physicians, and other pro13 viders, to pursue careers in primary care specialties; 

14 (2) retaining such primary care providers; and 

15 (3) encouraging such primary care providers to 

16 practice in underserved areas. 

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

18 date of the enactment of this Act, the Comptroller General 

19 shall submit to the Congress a report on the results of 

20 the study under subsection (a). 

21 Subtitle B—Nursing Workforce 

22 SEC. 2221. AMENDMENTS TO PUBLIC HEALTH SERVICE ACT. 

23 (a) DEFINITIONS.—Section 801 (42 U.S.C. 296 et 

24 seq.) is amended— 


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1 (1) in paragraph (1), by inserting ‘‘nurse-man2 aged health centers,’’ after ‘‘nursing centers,’’; and 

3 (2) by adding at the end the following: 

4 ‘‘(16) NURSE-MANAGED HEALTH CENTER.— 

5 The term ‘nurse-managed health center’— 

6 ‘‘(A) means a nurse-practice arrangement, 

7 managed by one or more advanced practice 

8 nurses, that provides primary care or wellness 

9 services to underserved or vulnerable popu10 lations and is associated with an accredited 

11 school of nursing, Federally qualified health 

12 center, or independent nonprofit health or social 

13 services agency; and 

14 ‘‘(B) shall not be construed as changing 

15 State law requirements applicable to an ad16 vanced practice nurse or the authorized scope of 

17 practice of such a nurse.’’. 

18 (b) GRANTS FOR HEALTH PROFESSIONS EDU19 CATION.—Title VIII (42 U.S.C. 296 et seq.) is amended 

20 by striking section 807. 

21 (c) REPORTS.—Part A of title VIII (42 U.S.C. 296 

22 et seq.) is amended by adding at the end the following: 


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1 ‘‘SEC. 809. REPORTS. 

2 ‘‘The Secretary shall submit to the Congress a sepa3 rate annual report on the activities carried out under each 

4 of sections 811, 821, 836, 846A, and 861.’’. 

5 (d) ADVANCED EDUCATION NURSING GRANTS.—Sec6 tion 811(f) (42 U.S.C. 296j(f)) is amended— 

7 (1) by striking paragraph (2); 

8 (2) by redesignating paragraph (3) as para9 graph (2); and 

10 (3) in paragraph (2), as so redesignated, by 

11 striking ‘‘that agrees’’ and all that follows through 

12 the end and inserting: ‘‘that agrees to expend the 

13 award— 

14 ‘‘(A) to train advanced education nurses 

15 who will practice in health professional shortage 

16 areas designated under section 332; or 

17 ‘‘(B) to increase diversity among advanced 

18 education nurses.’’. 

19 (e) NURSE EDUCATION, PRACTICE, AND RETENTION

20 GRANTS.—Section 831 (42 U.S.C. 296p) is amended— 

21 (1) in subsection (b), by amending paragraph 

22 (3) to read as follows: 

23 ‘‘(3) providing coordinated care, quality care, 

24 and other skills needed to practice nursing; or’’; and 


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1 (2) by striking subsection (e) and redesignating 

2 subsections (f) through (h) as subsections (e) 

3 through (g), respectively. 

4 (f) STUDENT LOANS.—Subsection (a) of section 836 

5 (42 U.S.C. 297b) is amended— 

6 (1) by striking ‘‘$2,500’’ and inserting 

7 ‘‘$3,300’’; 

8 (2) by striking ‘‘$4,000’’ and inserting 

9 ‘‘$5,200’’; 

10 (3) by striking ‘‘$13,000’’ and inserting 

11 ‘‘$17,000’’; and 

12 (4) by adding at the end the following: ‘‘Begin13 ning with fiscal year 2012, the dollar amounts speci14 fied in this subsection shall be adjusted by an 

15 amount determined by the Secretary on an annual 

16 basis to reflect inflation.’’. 

17 (g) LOAN REPAYMENT.—Section 846 (42 U.S.C. 

18 297n) is amended— 

19 (1) in subsection (a), by amending paragraph 

20 (3) to read as follows: 

21 ‘‘(3) who enters into an agreement with the 

22 Secretary to serve for a period of not less than 2 

23 years— 

24 ‘‘(A) as a nurse at a health care facility 

25 with a critical shortage of nurses; or 


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1 ‘‘(B) as a faculty member at an accredited 

2 school of nursing;’’; and 

3 (2) in subsection (g)(1), by striking ‘‘to provide 

4 health services’’ each place it appears and inserting 

5 ‘‘to provide health services or serve as a faculty 

6 member’’. 

7 (h) NURSE FACULTY LOAN PROGRAM.—Paragraph 

8 (2) of section 846A(c) (42 U.S.C. 297n–1(c)) is amended 

9 by striking ‘‘$30,000’’ and all that follows through the 

10 semicolon and inserting ‘‘$35,000, plus, beginning with 

11 fiscal year 2012, an amount determined by the Secretary 

12 on an annual basis to reflect inflation;’’. 

13 (i) PUBLIC SERVICE ANNOUNCEMENTS.—Title VIII 

14 (42 U.S.C. 296 et seq.) is amended by striking part H. 

15 (j) TECHNICAL AND CONFORMING AMENDMENTS.— 

16 Title VIII (42 U.S.C. 296 et seq.) is amended— 

17 (1) by moving section 810 (relating to prohibi18 tion against discrimination by schools on the basis of 

19 sex) so that it follows section 809, as added by sub20 section (c); 

21 (2) in sections 835, 836, 838, 840, and 842, by 

22 striking the term ‘‘this subpart’’ each place it ap23 pears and inserting ‘‘this part’’; 

24 (3) in section 836(h), by striking the last sen25 tence; 


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1 (4) in section 836, by redesignating subsection 

2 (l) as subsection (k); 

3 (5) in section 839, by striking ‘‘839’’ and all 

4 that follows through ‘‘(a)’’ and inserting ‘‘839. (a)’’; 

5 (6) in section 835(b), by striking ‘‘841’’ each 

6 place it appears and inserting ‘‘871’’; 

7 (7) by redesignating section 841 as section 871, 

8 moving part F to the end of the title, and redesig9 nating such part as part H; 

10 (8) in part G— 

11 (A) by redesignating section 845 as section 

12 851; and 

13 (B) by redesignating part G as part F; and 

14 (9) in part I— 

15 (A) by redesignating section 855 as section 

16 861; and 

17 (B) by redesignating part I as part G. 

18 (k) FUNDING.— 

19 (1) IN GENERAL.—Part H, as redesignated, of 

20 title VIII is amended by adding at the end the fol21 lowing: 

22 ‘‘SEC. 872. FUNDING THROUGH PUBLIC HEALTH INVEST23 MENT FUND. 

24 ‘‘For the purpose of carrying out this title, in addi25 tion to any other amounts authorized to be appropriated 


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1 for such purpose, there are authorized to be appropriated, 

2 out of any monies in the Public Health Investment Fund, 

3 the following: 

4 ‘‘(1) $115,000,000 for fiscal year 2011. 

5 ‘‘(2) $122,000,000 for fiscal year 2012. 

6 ‘‘(3) $127,000,000 for fiscal year 2013. 

7 ‘‘(4) $134,000,000 for fiscal year 2014. 

8 ‘‘(5) $140,000,000 for fiscal year 2015.’’. 

9 (2) EXISTING AUTHORIZATIONS OF APPROPRIA10 TIONS.— 

11 (A) SECTIONS 831, 846, 846A, AND 861.— 

12 Sections 831(g) (as so redesignated), 846(i)(1) 

13 (42 U.S.C. 297n(i)(1)), 846A(f) (42 U.S.C. 

14 297n–1(f)), and 861(e) (as so redesignated) are 

15 amended by striking ‘‘2007’’ each place it ap16 pears and inserting ‘‘2015’’. 

17 (B) SECTION 871.—Section 871, as so re18 designated by subsection (j), is amended to read 

19 as follows: 

20 ‘‘SEC. 871. FUNDING. 

21 ‘‘For the purpose of carrying out parts B, C, and D 

22 (subject to section 851(g)), there are authorized to be ap23 propriated such sums as may be necessary for each fiscal 

24 year through fiscal year 2015.’’. 


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1 Subtitle C—Public Health 

2 Workforce 

3 SEC. 2231. PUBLIC HEALTH WORKFORCE CORPS. 

4 Part D of title III (42 U.S.C. 254b et seq.), as 

5 amended by section 2211, is amended by adding at the 

6 end the following: 

7 ‘‘Subpart XII—Public Health Workforce 

8 ‘‘SEC. 340L. PUBLIC HEALTH WORKFORCE CORPS. 

9 ‘‘(a) ESTABLISHMENT.—There is established, within 

10 the Service, the Public Health Workforce Corps (in this 

11 subpart referred to as the ‘Corps’), for the purpose of en12 suring an adequate supply of public health professionals 

13 throughout the Nation. The Corps shall consist of— 

14 ‘‘(1) such officers of the Regular and Reserve 

15 Corps of the Service as the Secretary may designate; 

16 ‘‘(2) such civilian employees of the United 

17 States as the Secretary may appoint; and 

18 ‘‘(3) such other individuals who are not employ19 ees of the United States. 

20 ‘‘(b) ADMINISTRATION.—Except as provided in sub21 section (c), the Secretary shall carry out this subpart act22 ing through the Administrator of the Health Resources 

23 and Services Administration. 

24 ‘‘(c) PLACEMENT AND ASSIGNMENT.—The Secretary, 

25 acting through the Director of the Centers for Disease 


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1 Control and Prevention, shall develop a methodology for 

2 placing and assigning Corps participants as public health 

3 professionals. Such methodology may allow for placing and 

4 assigning such participants in State, local, and tribal 

5 health departments and Federally qualified health centers 

6 (as defined in section 1861(aa)(4) of the Social Security 

7 Act). 

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

9 provisions of subpart II shall, except as inconsistent with 

10 this subpart, apply to the Public Health Workforce Corps 

11 in the same manner and to the same extent as such provi12 sions apply to the National Health Service Corps estab13 lished under section 331. 

14 ‘‘(e) REPORT.—The Secretary shall submit to the 

15 Congress an annual report on the programs carried out 

16 under this subpart. 

17 ‘‘SEC. 340M. PUBLIC HEALTH WORKFORCE SCHOLARSHIP 

18 PROGRAM. 

19 ‘‘(a) ESTABLISHMENT.—The Secretary shall estab20 lish the Public Health Workforce Scholarship Program 

21 (referred to in this section as the ‘Program’) for the pur22 pose described in section 340L(a). 

23 ‘‘(b) ELIGIBILITY.—To be eligible to participate in 

24 the Program, an individual shall— 


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1 ‘‘(1)(A) be accepted for enrollment, or be en2 rolled, as a full-time or part-time student in a course 

3 of study or program (approved by the Secretary) at 

4 an accredited graduate school or program of public 

5 health; or 

6 ‘‘(B) have demonstrated expertise in public 

7 health and be accepted for enrollment, or be en8 rolled, as a full-time or part-time student in a course 

9 of study or program (approved by the Secretary) 

10 at— 

11 ‘‘(i) an accredited graduate school or pro12 gram of nursing; health administration, man13 agement, or policy; preventive medicine; labora14 tory science; veterinary medicine; or dental 

15 medicine; or 

16 ‘‘(ii) another accredited graduate school or 

17 program, as deemed appropriate by the Sec18 retary; 

19 ‘‘(2) be eligible for, or hold, an appointment as 

20 a commissioned officer in the Regular or Reserve 

21 Corps of the Service or be eligible for selection for 

22 civilian service in the Corps; and 

23 ‘‘(3) sign and submit to the Secretary a written 

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1 pletion of the course of study or program involved, 

2 for the period of obligated service described in sub3 section (c)(2)(E). 

4 ‘‘(c) CONTRACT.—The written contract between the 

5 Secretary and an individual under subsection (b)(3) shall 

6 contain— 

7 ‘‘(1) an agreement on the part of the Secretary 

8 that the Secretary will— 

9 ‘‘(A) provide the individual with a scholar10 ship for a period of years (not to exceed 4 aca11 demic years) during which the individual shall 

12 pursue an approved course of study or program 

13 to prepare the individual to serve in the public 

14 health workforce; and 

15 ‘‘(B) accept (subject to the availability of 

16 appropriated funds) the individual into the 

17 Corps; 

18 ‘‘(2) an agreement on the part of the individual 

19 that the individual will— 

20 ‘‘(A) accept provision of such scholarship 

21 to the individual; 

22 ‘‘(B) maintain full-time or part-time enroll23 ment in the approved course of study or pro24 gram described in subsection (b)(1) until the inVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01256 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 dividual completes that course of study or pro2 gram; 

3 ‘‘(C) while enrolled in the approved course 

4 of study or program, maintain an acceptable 

5 level of academic standing (as determined by 

6 the educational institution offering such course 

7 of study or program); 

8 ‘‘(D) if applicable, complete a residency or 

9 internship; and 

10 ‘‘(E) serve full-time as a public health pro11 fessional for a period of time equal to the great12 er of— 

13 ‘‘(i) 1 year for each academic year for 

14 which the individual was provided a schol15 arship under the Program; or 

16 ‘‘(ii) 2 years; and 

17 ‘‘(3) an agreement by both parties as to the na18 ture and extent of the scholarship assistance, which 

19 may include— 

20 ‘‘(A) payment of reasonable educational ex21 penses of the individual, including tuition, fees, 

22 books, equipment, and laboratory expenses; and 

23 ‘‘(B) payment of a stipend of not more 

24 than $1,269 (plus, beginning with fiscal year 

25 2012, an amount determined by the Secretary 


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1 on an annual basis to reflect inflation) per 

2 month for each month of the academic year in3 volved, with the dollar amount of such a stipend 

4 determined by the Secretary taking into consid5 eration whether the individual is enrolled full6 time or part-time. 

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

8 provisions of subpart III shall, except as inconsistent with 

9 this subpart, apply to the scholarship program under this 

10 section in the same manner and to the same extent as 

11 such provisions apply to the National Health Service 

12 Corps Scholarship Program established under section 

13 338A. 

14 ‘‘SEC. 340N. PUBLIC HEALTH WORKFORCE LOAN REPAY15 MENT PROGRAM. 

16 ‘‘(a) ESTABLISHMENT.—The Secretary shall estab17 lish the Public Health Workforce Loan Repayment Pro18 gram (referred to in this section as the ‘Program’) for the 

19 purpose described in section 340L(a). 

20 ‘‘(b) ELIGIBILITY.—To be eligible to participate in 

21 the Program, an individual shall— 

22 ‘‘(1)(A) have a graduate degree from an accred23 ited school or program of public health; 

24 ‘‘(B) have demonstrated expertise in public 

25 health and have a graduate degree in a course of 


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1 study or program (approved by the Secretary) 

2 from— 

3 ‘‘(i) an accredited school or program of 

4 nursing; health administration, management, or 

5 policy; preventive medicine; laboratory science; 

6 veterinary medicine; or dental medicine; or 

7 ‘‘(ii) another accredited school or program 

8 approved by the Secretary; or 

9 ‘‘(C) be enrolled as a full-time or part-time stu10 dent in the final year of a course of study or pro11 gram (approved by the Secretary) offered by a 

12 school or program described in subparagraph (A) or 

13 (B), leading to a graduate degree; 

14 ‘‘(2) be eligible for, or hold, an appointment as 

15 a commissioned officer in the Regular or Reserve 

16 Corps of the Service or be eligible for selection for 

17 civilian service in the Corps; 

18 ‘‘(3) if applicable, complete a residency or in19 ternship; and 

20 ‘‘(4) sign and submit to the Secretary a written 

21 contract (described in subsection (c)) to serve full22 time as a public health professional for the period of 

23 obligated service described in subsection (c)(2). 


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1 ‘‘(c) CONTRACT.—The written contract between the 

2 Secretary and an individual under subsection (b)(4) shall 

3 contain— 

4 ‘‘(1) an agreement by the Secretary to repay on 

5 behalf of the individual loans incurred by the indi6 vidual in the pursuit of the relevant public health 

7 workforce educational degree in accordance with the 

8 terms of the contract; 

9 ‘‘(2) an agreement by the individual to serve 

10 full-time as a public health professional for a period 

11 of time equal to 2 years or such longer period as the 

12 individual may agree to; and 

13 ‘‘(3) in the case of an individual described in 

14 subsection (b)(1)(C) who is in the final year of study 

15 and who has accepted employment as a public health 

16 professional, in accordance with section 340L(c), an 

17 agreement on the part of the individual to complete 

18 the education or training, maintain an acceptable 

19 level of academic standing (as determined by the 

20 educational institution offering the course of study 

21 or training), and serve the period of obligated service 

22 described in paragraph (2). 

23 ‘‘(d) PAYMENTS.— 

24 ‘‘(1) IN GENERAL.—A loan repayment provided 

25 for an individual under a written contract under the 


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1 Program shall consist of payment, in accordance 

2 with paragraph (2), on behalf of the individual of 

3 the principal, interest, and related expenses on gov4 ernment and commercial loans received by the indi5 vidual regarding the undergraduate or graduate edu6 cation of the individual (or both), which loans were 

7 made for reasonable educational expenses, including 

8 tuition, fees, books, equipment, and laboratory ex9 penses, incurred by the individual. 

10 ‘‘(2) PAYMENTS FOR YEARS SERVED.— 

11 ‘‘(A) IN GENERAL.—For each year of obli12 gated service that an individual contracts to 

13 serve under subsection (c), the Secretary may 

14 pay up to $35,000 (plus, beginning with fiscal 

15 year 2012, an amount determined by the Sec16 retary on an annual basis to reflect inflation) 

17 on behalf of the individual for loans described 

18 in paragraph (1). 

19 ‘‘(B) REPAYMENT SCHEDULE.—Any ar20 rangement made by the Secretary for the mak21 ing of loan repayments in accordance with this 

22 subsection shall provide that any repayments 

23 for a year of obligated service shall be made no 

24 later than the end of the fiscal year in which 

25 the individual completes such year of service. 


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1 ‘‘(e) APPLICATION OF CERTAIN PROVISIONS.—The 

2 provisions of subpart III shall, except as inconsistent with 

3 this subpart, apply to the loan repayment program under 

4 this section in the same manner and to the same extent 

5 as such provisions apply to the National Health Service 

6 Corps Loan Repayment Program established under sec7 tion 338B.’’. 

8 SEC. 2232. ENHANCING THE PUBLIC HEALTH WORKFORCE. 

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

10 follows: 

11 ‘‘SEC. 765. ENHANCING THE PUBLIC HEALTH WORKFORCE. 

12 ‘‘(a) PROGRAM.—The Secretary, acting through the 

13 Administrator of the Health Resources and Services Ad14 ministration and in consultation with the Director of the 

15 Centers for Disease Control and Prevention, shall estab16 lish a public health workforce training and enhancement 

17 program consisting of awarding grants and contracts 

18 under subsection (b). 

19 ‘‘(b) GRANTS AND CONTRACTS.—The Secretary shall 

20 award grants to, or enter into contracts with, eligible enti21 ties— 

22 ‘‘(1) to plan, develop, operate, or participate in, 

23 an accredited professional training program in the 

24 field of public health (including such a program in 

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1 icy; preventive medicine; laboratory science; veteri2 nary medicine; or dental medicine) for members of 

3 the public health workforce, including midcareer pro4 fessionals; 

5 ‘‘(2) to provide financial assistance in the form 

6 of traineeships and fellowships to students who are 

7 participants in any such program and who plan to 

8 specialize or work in the field of public health; 

9 ‘‘(3) to plan, develop, operate, or participate in 

10 a program for the training of public health profes11 sionals who plan to teach in any program described 

12 in paragraph (1); and 

13 ‘‘(4) to provide financial assistance in the form 

14 of traineeships and fellowships to public health pro15 fessionals who are participants in any program de16 scribed in paragraph (1) and who plan to teach in 

17 the field of public health, including nursing; health 

18 administration, management, or policy; preventive 

19 medicine; laboratory science; veterinary medicine; or 

20 dental medicine. 

21 ‘‘(c) ELIGIBILITY.—To be eligible for a grant or con22 tract under this section, an entity shall be— 

23 ‘‘(1) an accredited health professions school, in24 cluding an accredited school or program of public 

25 health; nursing; health administration, management, 


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1 or policy; preventive medicine; laboratory science; 

2 veterinary medicine; or dental medicine; 

3 ‘‘(2) a State, local, or tribal health department; 

4 ‘‘(3) a public or private nonprofit entity; or 

5 ‘‘(4) a consortium of 2 or more entities de6 scribed in paragraphs (1) through (3). 

7 ‘‘(d) PREFERENCE.—In awarding grants or contracts 

8 under this section, the Secretary shall give preference to 

9 entities that have a demonstrated record of at least one 

10 of the following: 

11 ‘‘(1) Training a high or significantly improved 

12 percentage of public health professionals who serve 

13 in underserved communities. 

14 ‘‘(2) Training individuals who are from dis15 advantaged backgrounds (including racial and ethnic 

16 minorities underrepresented among public health 

17 professionals). 

18 ‘‘(3) Training individuals in public health spe19 cialties experiencing a significant shortage of public 

20 health professionals (as determined by the Sec21 retary). 

22 ‘‘(4) Training a high or significantly improved 

23 percentage of public health professionals serving in 

24 the Federal Government or a State, local, or tribal 

25 government. 


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1 ‘‘(e) REPORT.—The Secretary shall submit to the 

2 Congress an annual report on the program carried out 

3 under this section.’’. 

4 SEC. 2233. PUBLIC HEALTH TRAINING CENTERS. 

5 Section 766 (42 U.S.C. 295a) is amended— 

6 (1) in subsection (b)(1), by striking ‘‘in further7 ance of the goals established by the Secretary for 

8 the year 2000’’ and inserting ‘‘in furtherance of the 

9 goals established by the Secretary in the national 

10 prevention and wellness strategy under section 

11 3121’’; and 

12 (2) by adding at the end the following: 

13 ‘‘(d) REPORT.—The Secretary shall submit to the 

14 Congress an annual report on the program carried out 

15 under this section.’’. 

16 SEC. 2234. PREVENTIVE MEDICINE AND PUBLIC HEALTH 

17 TRAINING GRANT PROGRAM. 

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

19 follows: 

20 ‘‘SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH 

21 TRAINING GRANT PROGRAM. 

22 ‘‘(a) GRANTS.—The Secretary, acting through the 

23 Administrator of the Health Resources and Services Ad24 ministration and in consultation with the Director of the 

25 Centers for Disease Control and Prevention, shall award 


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1 grants to, or enter into contracts with, eligible entities to 

2 provide training to graduate medical residents in preven3 tive medicine specialties. 

4 ‘‘(b) ELIGIBILITY.—To be eligible for a grant or con5 tract under subsection (a), an entity shall be— 

6 ‘‘(1) an accredited school of public health or 

7 school of medicine or osteopathic medicine; 

8 ‘‘(2) an accredited public or private nonprofit 

9 hospital; 

10 ‘‘(3) a State, local, or tribal health department; 

11 or 

12 ‘‘(4) a consortium of 2 or more entities de13 scribed in paragraphs (1) through (3). 

14 ‘‘(c) USE OF FUNDS.—Amounts received under a 

15 grant or contract under this section shall be used to— 

16 ‘‘(1) plan, develop (including the development of 

17 curricula), operate, or participate in an accredited 

18 residency or internship program in preventive medi19 cine or public health; 

20 ‘‘(2) defray the costs of practicum experiences, 

21 as required in such a program; and 

22 ‘‘(3) establish, maintain, or improve— 

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1 priate units) in preventive medicine and public 

2 health; or 

3 ‘‘(B) programs that improve clinical teach4 ing in preventive medicine and public health. 

5 ‘‘(d) REPORT.—The Secretary shall submit to the 

6 Congress an annual report on the program carried out 

7 under this section.’’. 

8 SEC. 2235. AUTHORIZATION OF APPROPRIATIONS. 

9 (a) IN GENERAL.—Section 799C, as added by section 

10 2216 of this Act, is amended by adding at the end the 

11 following: 

12 ‘‘(b) PUBLIC HEALTH WORKFORCE.—For the pur13 pose of carrying out subpart XII of part D of title III 

14 and sections 765, 766, and 768, in addition to any other 

15 amounts authorized to be appropriated for such purpose, 

16 there are authorized to be appropriated, out of any monies 

17 in the Public Health Investment Fund, the following: 

18 ‘‘(1) $51,000,000 for fiscal year 2011. 

19 ‘‘(2) $54,000,000 for fiscal year 2012. 

20 ‘‘(3) $57,000,000 for fiscal year 2013. 

21 ‘‘(4) $59,000,000 for fiscal year 2014. 

22 ‘‘(5) $62,000,000 for fiscal year 2015.’’. 

23 (b) EXISTING AUTHORIZATION OF APPROPRIA24 TIONS.—Subsection (a) of section 770 (42 U.S.C. 295e) 

25 is amended by striking ‘‘2002’’ and inserting ‘‘2015’’. 


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1 Subtitle D—Adapting Workforce to 

2 Evolving Health System Needs 

3 PART 1—HEALTH PROFESSIONS TRAINING FOR 

4 DIVERSITY 

5 SEC. 2241. SCHOLARSHIPS FOR DISADVANTAGED STU6 DENTS, LOAN REPAYMENTS AND FELLOW7 SHIPS REGARDING FACULTY POSITIONS, AND 

8 EDUCATIONAL ASSISTANCE IN THE HEALTH 

9 PROFESSIONS REGARDING INDIVIDUALS 

10 FROM DISADVANTAGED BACKGROUNDS. 

11 Paragraph (1) of section 738(a) (42 U.S.C. 293b(a)) 

12 is amended by striking ‘‘not more than $20,000’’ and all 

13 that follows through the end of the paragraph and insert14 ing: ‘‘not more than $35,000 (plus, beginning with fiscal 

15 year 2012, an amount determined by the Secretary on an 

16 annual basis to reflect inflation) of the principal and inter17 est of the educational loans of such individuals.’’. 

18 SEC. 2242. NURSING WORKFORCE DIVERSITY GRANTS. 

19 Subsection (b) of section 821 (42 U.S.C. 296m) is 

20 amended— 

21 (1) in the heading, by striking ‘‘GUIDANCE’’ 

22 and inserting ‘‘CONSULTATION’’; and 

23 (2) by striking ‘‘shall take into consideration’’ 

24 and all that follows through ‘‘consult with nursing 


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1 associations’’ and inserting ‘‘shall, as appropriate, 

2 consult with nursing associations’’. 

3 SEC. 2243. COORDINATION OF DIVERSITY AND CULTURAL 

4 COMPETENCY PROGRAMS. 

5 (a) IN GENERAL.—Title VII (42 U.S.C. 292 et seq.) 

6 is amended by inserting after section 739 the following: 

7 ‘‘SEC. 739A. COORDINATION OF DIVERSITY AND CULTURAL 

8 COMPETENCY PROGRAMS. 

9 ‘‘The Secretary shall, to the extent practicable, co10 ordinate the activities carried out under this part and sec11 tion 821 in order to enhance the effectiveness of such ac12 tivities and avoid duplication of effort.’’. 

13 (b) REPORT.—Section 736 (42 U.S.C. 293) is 

14 amended— 

15 (1) by redesignating subsection (h) as sub16 section (i); and 

17 (2) by inserting after subsection (g) the fol18 lowing: 

19 ‘‘(h) REPORT.—The Secretary shall submit to the 

20 Congress an annual report on the activities carried out 

21 under this section.’’. 


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1 PART 2—INTERDISCIPLINARY TRAINING 

2 PROGRAMS 

3 SEC. 2251. CULTURAL AND LINGUISTIC COMPETENCY 

4 TRAINING FOR HEALTH PROFESSIONALS. 

5 Section 741 (42 U.S.C. 293e) is amended— 

6 (1) in the section heading, by striking 

7 ‘‘GRANTS FOR HEALTH PROFESSIONS EDU8 CATION’’ and inserting ‘‘CULTURAL AND LIN9 GUISTIC COMPETENCY TRAINING FOR HEALTH

10 PROFESSIONALS’’; 

11 (2) by redesignating subsection (b) as sub12 section (h); and 

13 (3) by striking subsection (a) and inserting the 

14 following: 

15 ‘‘(a) PROGRAM.—The Secretary shall establish a cul16 tural and linguistic competency training program for 

17 health professionals, including nurse professionals, con18 sisting of awarding grants and contracts under subsection 

19 (b). 

20 ‘‘(b) CULTURAL AND LINGUISTIC COMPETENCY

21 TRAINING.—The Secretary shall award grants to, or enter 

22 into contracts with, eligible entities— 

23 ‘‘(1) to test, develop, and evaluate models of 

24 cultural and linguistic competency training (includ25 ing continuing education) for health professionals; 

26 and 


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1 ‘‘(2) to implement cultural and linguistic com2 petency training programs for health professionals 

3 developed under paragraph (1) or otherwise. 

4 ‘‘(c) ELIGIBILITY.—To be eligible for a grant or con5 tract under subsection (b), an entity shall be— 

6 ‘‘(1) an accredited health professions school or 

7 program; 

8 ‘‘(2) an academic health center; 

9 ‘‘(3) a public or private nonprofit entity; or 

10 ‘‘(4) a consortium of 2 or more entities de11 scribed in paragraphs (1) through (3). 

12 ‘‘(d) PREFERENCE.—In awarding grants and con13 tracts under this section, the Secretary shall give pref14 erence to entities that have a demonstrated record of at 

15 least one of the following: 

16 ‘‘(1) Addressing, or partnering with an entity 

17 with experience addressing, the cultural and lin18 guistic competency needs of the population to be 

19 served through the grant or contract. 

20 ‘‘(2) Addressing health disparities. 

21 ‘‘(3) Placing health professionals in regions ex22 periencing significant changes in the cultural and 

23 linguistic demographics of populations, including 

24 communities along the United States-Mexico border. 


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1 ‘‘(4) Carrying out activities described in sub2 section (b) with respect to more than one health pro3 fession discipline, specialty, or subspecialty. 

4 ‘‘(e) CONSULTATION.—The Secretary shall carry out 

5 this section in consultation with the heads of appropriate 

6 health agencies and offices in the Department of Health 

7 and Human Services, including the Office of Minority 

8 Health and the National Center on Minority Health and 

9 Health Disparities. 

10 ‘‘(f) DEFINITION.—In this section, the term ‘health 

11 disparities’ has the meaning given to the term in section 

12 3171. 

13 ‘‘(g) REPORT.—The Secretary shall submit to the 

14 Congress an annual report on the program carried out 

15 under this section.’’. 

16 SEC. 2252. INNOVATIONS IN INTERDISCIPLINARY CARE 

17 TRAINING. 

18 Part D of title VII (42 U.S.C. 294 et seq.) is amend19 ed by adding at the end the following: 

20 ‘‘SEC. 759. INNOVATIONS IN INTERDISCIPLINARY CARE 

21 TRAINING. 

22 ‘‘(a) PROGRAM.—The Secretary shall establish an in23 novations in interdisciplinary care training program con24 sisting of awarding grants and contracts under subsection 

25 (b). 


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1 ‘‘(b) TRAINING PROGRAMS.—The Secretary shall 

2 award grants to, or enter into contracts with, eligible enti3 ties— 

4 ‘‘(1) to test, develop, and evaluate health pro5 fessional training programs (including continuing 

6 education) designed to promote— 

7 ‘‘(A) the delivery of health services through 

8 interdisciplinary and team-based models, which 

9 may include patient-centered medical home 

10 models, medication therapy management mod11 els, and models integrating physical, mental, or 

12 oral health services; and 

13 ‘‘(B) coordination of the delivery of health 

14 care within and across settings, including health 

15 care institutions, community-based settings, 

16 and the patient’s home; and 

17 ‘‘(2) to implement such training programs de18 veloped under paragraph (1) or otherwise. 

19 ‘‘(c) ELIGIBILITY.—To be eligible for a grant or con20 tract under subsection (b), an entity shall be— 

21 ‘‘(1) an accredited health professions school or 

22 program; 

23 ‘‘(2) an academic health center; 


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1 ‘‘(3) a public or private nonprofit entity (includ2 ing an area health education center or a geriatric 

3 education center); or 

4 ‘‘(4) a consortium of 2 or more entities de5 scribed in paragraphs (1) through (3). 

6 ‘‘(d) PREFERENCES.—In awarding grants and con7 tracts under this section, the Secretary shall give pref8 erence to entities that have a demonstrated record of at 

9 least one of the following: 

10 ‘‘(1) Training a high or significantly improved 

11 percentage of health professionals who serve in un12 derserved communities. 

13 ‘‘(2) Broad interdisciplinary team-based collabo14 rations. 

15 ‘‘(3) Addressing health disparities. 

16 ‘‘(e) REPORT.—The Secretary shall submit to the 

17 Congress an annual report on the program carried out 

18 under this section. 

19 ‘‘(f) DEFINITIONS.—In this section: 

20 ‘‘(1) The term ‘health disparities’ has the 

21 meaning given the term in section 3171. 

22 ‘‘(2) The term ‘interdisciplinary’ means collabo23 ration across health professions and specialties, 

24 which may include public health, nursing, allied 


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1 health, dietetics or nutrition, and appropriate health 

2 specialties.’’. 

3 PART 3—ADVISORY COMMITTEE ON HEALTH 

4 WORKFORCE EVALUATION AND ASSESSMENT 

5 SEC. 2261. HEALTH WORKFORCE EVALUATION AND ASSESS6 MENT. 

7 Subpart 1 of part E of title VII (42 U.S.C. 294n 

8 et seq.) is amended by adding at the end the following: 

9 ‘‘SEC. 764. HEALTH WORKFORCE EVALUATION AND ASSESS10 MENT. 

11 ‘‘(a) ADVISORY COMMITTEE.—The Secretary, acting 

12 through the Assistant Secretary for Health, shall establish 

13 a permanent advisory committee to be known as the Advi14 sory Committee on Health Workforce Evaluation and As15 sessment (referred to in this section as the ‘Advisory Com16 mittee’) to develop and implement an integrated, coordi17 nated, and strategic national health workforce policy re18 flective of current and evolving health workforce needs. 

19 ‘‘(b) RESPONSIBILITIES.—The Advisory Committee 

20 shall— 

21 ‘‘(1) not later than 1 year after the date of the 

22 establishment of the Advisory Committee, submit 

23 recommendations to the Secretary on— 


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1 ‘‘(A) classifications of the health workforce 

2 to ensure consistency of data collection on the 

3 health workforce; and 

4 ‘‘(B) based on such classifications, stand5 ardized methodologies and procedures to enu6 merate the health workforce; 

7 ‘‘(2) not later than 2 years after the date of the 

8 establishment of the Advisory Committee, submit 

9 recommendations to the Secretary on— 

10 ‘‘(A) the supply, diversity, and geographic 

11 distribution of the health workforce; 

12 ‘‘(B) the retention and expansion of the 

13 health workforce (on a short- and long-term 

14 basis) to ensure quality and adequacy of such 

15 workforce; and 

16 ‘‘(C) policies to carry out the recommenda17 tions made pursuant to subparagraphs (A) and 

18 (B); and 

19 ‘‘(3) not later than 4 years after the date of the 

20 establishment of the Advisory Committee, and every 

21 2 years thereafter, submit updated recommendations 

22 to the Secretary under paragraphs (1) and (2). 

23 ‘‘(c) ROLE OF AGENCY.—The Secretary shall provide 

24 ongoing administrative, research, and technical support 

25 for the operations of the Advisory Committee, including 


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1 coordinating and supporting the dissemination of the rec2 ommendations of the Advisory Committee. 

3 ‘‘(d) MEMBERSHIP.— 

4 ‘‘(1) NUMBER; APPOINTMENT.—The Secretary 

5 shall appoint 15 members to serve on the Advisory 

6 Committee. 

7 ‘‘(2) TERMS.— 

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

9 appoint members of the Advisory Committee for 

10 a term of 3 years and may reappoint such 

11 members, but the Secretary may not appoint 

12 any member to serve more than a total of 6 

13 years. 

14 ‘‘(B) STAGGERED TERMS.—Notwith15 standing subparagraph (A), of the members 

16 first appointed to the Advisory Committee 

17 under paragraph (1)— 

18 ‘‘(i) 5 shall be appointed for a term of 

19 1 year; 

20 ‘‘(ii) 5 shall be appointed for a term 

21 of 2 years; and 

22 ‘‘(iii) 5 shall be appointed for a term 

23 of 3 years. 

24 ‘‘(3) QUALIFICATIONS.—Members of the Advi25 sory Committee shall be appointed from among indiVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01277 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 viduals who possess expertise in at least one of the 

2 following areas: 

3 ‘‘(A) Conducting and interpreting health 

4 workforce market analysis, including health 

5 care labor workforce analysis. 

6 ‘‘(B) Conducting and interpreting health 

7 finance and economics research. 

8 ‘‘(C) Delivering and administering health 

9 care services. 

10 ‘‘(D) Delivering and administering health 

11 workforce education and training. 

12 ‘‘(4) REPRESENTATION.—In appointing mem13 bers of the Advisory Committee, the Secretary 

14 shall— 

15 ‘‘(A) include no less than one representa16 tive of each of— 

17 ‘‘(i) health professionals within the 

18 health workforce; 

19 ‘‘(ii) health care patients and con20 sumers; 

21 ‘‘(iii) employers; 

22 ‘‘(iv) labor unions; and 

23 ‘‘(v) third-party health payors; and 

24 ‘‘(B) ensure that— 


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1 ‘‘(i) all areas of expertise described in 

2 paragraph (3) are represented; 

3 ‘‘(ii) the members of the Advisory 

4 Committee include members who, collec5 tively, have significant experience working 

6 with— 

7 ‘‘(I) populations in urban and 

8 federally designated rural and non9 metropolitan areas; and 

10 ‘‘(II) populations who are under11 represented in the health professions, 

12 including underrepresented minority 

13 groups; and 

14 ‘‘(iii) individuals who are directly in15 volved in health professions education or 

16 practice do not constitute a majority of the 

17 members of the Advisory Committee. 

18 ‘‘(5) DISCLOSURE AND CONFLICTS OF INTER19 EST.—Members of the Advisory Committee shall not 

20 be considered employees of the Federal Government 

21 by reason of service on the Advisory Committee, ex22 cept members of the Advisory Committee shall be 

23 considered to be special Government employees with24 in the meaning of section 107 of the Ethics in Gov25 ernment Act of 1978 (5 U.S.C. App.) and section 


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1 208 of title 18, United States Code, for the purposes 

2 of disclosure and management of conflicts of interest 

3 under those sections. 

4 ‘‘(6) NO PAY; RECEIPT OF TRAVEL EX5 PENSES.—Members of the Advisory Committee shall 

6 not receive any pay for service on the Committee, 

7 but may receive travel expenses, including a per 

8 diem, in accordance with applicable provisions of 

9 subchapter I of chapter 57 of title 5, United States 

10 Code. 

11 ‘‘(e) CONSULTATION.—In carrying out this section, 

12 the Secretary shall consult with the Secretary of Edu13 cation and the Secretary of Labor. 

14 ‘‘(f) COLLABORATION.—The Advisory Committee 

15 shall collaborate with the advisory bodies at the Health 

16 Resources and Services Administration, the National Ad17 visory Council (as authorized in section 337), the Advisory 

18 Committee on Training in Primary Care Medicine and 

19 Dentistry (as authorized in section 749A), the Advisory 

20 Committee on Interdisciplinary, Community-Based Link21 ages (as authorized in section 756), the Advisory Council 

22 on Graduate Medical Education (as authorized in section 

23 762), and the National Advisory Council on Nurse Edu24 cation and Practice (as authorized in section 851). 


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1 ‘‘(g) FACA.—The Federal Advisory Committee Act 

2 (5 U.S.C. App.) except for section 14 of such Act shall 

3 apply to the Advisory Committee under this section only 

4 to the extent that the provisions of such Act do not conflict 

5 with the requirements of this section. 

6 ‘‘(h) REPORT.—The Secretary shall submit to the 

7 Congress an annual report on the activities of the Advisory 

8 Committee. 

9 ‘‘(i) DEFINITION.—In this section, the term ‘health 

10 workforce’ includes all health care providers with direct 

11 patient care and support responsibilities, including physi12 cians, nurses, physician assistants, pharmacists, oral 

13 health professionals (as defined in section 749(f)(2)), al14 lied health professionals, mental and behavioral health 

15 professionals (as defined in section 775(f)(2)), and public 

16 health professionals (including veterinarians engaged in 

17 public health practice).’’. 

18 PART 4—HEALTH WORKFORCE ASSESSMENT 

19 SEC. 2271. HEALTH WORKFORCE ASSESSMENT. 

20 (a) IN GENERAL.—Section 761 (42 U.S.C. 294n) is 

21 amended— 

22 (1) by redesignating subsection (c) as sub23 section (e); and 

24 (2) by striking subsections (a) and (b) and in25 serting the following: 


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1 ‘‘(a) IN GENERAL.—The Secretary shall, based upon 

2 the classifications and standardized methodologies and 

3 procedures developed by the Advisory Committee on 

4 Health Workforce Evaluation and Assessment under sec5 tion 764(b)— 

6 ‘‘(1) collect data on the health workforce (as 

7 defined in section 764(i)), disaggregated by field, 

8 discipline, and specialty, with respect to— 

9 ‘‘(A) the supply (including retention) of 

10 health professionals relative to the demand for 

11 such professionals; 

12 ‘‘(B) the diversity of health professionals 

13 (including with respect to race, ethnic back14 ground, and sex); and 

15 ‘‘(C) the geographic distribution of health 

16 professionals; and 

17 ‘‘(2) collect such data on individuals partici18 pating in the programs authorized by subtitles A, B, 

19 and C and part 1 of subtitle D of title II of division 

20 C of the Affordable Health Care for America Act. 

21 ‘‘(b) GRANTS AND CONTRACTS FOR HEALTH WORK22 FORCE ANALYSIS.— 

23 ‘‘(1) IN GENERAL.—The Secretary may award 

24 grants to, or enter into contracts with, eligible enti25 ties to carry out subsection (a). 


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1 ‘‘(2) ELIGIBILITY.—To be eligible for a grant 

2 or contract under this subsection, an entity shall 

3 be— 

4 ‘‘(A) an accredited health professions 

5 school or program; 

6 ‘‘(B) an academic health center; 

7 ‘‘(C) a State, local, or tribal government; 

8 ‘‘(D) a public or private entity; or 

9 ‘‘(E) a consortium of 2 or more entities de10 scribed in subparagraphs (A) through (D). 

11 ‘‘(c) COLLABORATION AND DATA SHARING.—The 

12 Secretary shall collaborate with Federal departments and 

13 agencies, health professions organizations (including 

14 health professions education organizations), and profes15 sional medical societies for the purpose of carrying out 

16 subsection (a). 

17 ‘‘(d) REPORT.—The Secretary shall submit to the 

18 Congress an annual report on the data collected under 

19 subsection (a).’’. 

20 (b) PERIOD BEFORE COMPLETION OF NATIONAL

21 STRATEGY.—Pending completion of the classifications and 

22 standardized methodologies and procedures developed by 

23 the Advisory Committee on Health Workforce Evaluation 

24 and Assessment under section 764(b) of the Public Health 

25 Service Act, as added by section 2261, the Secretary of 


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1 Health and Human Services, acting through the Adminis2 trator of the Health Resources and Services Administra3 tion and in consultation with such Advisory Committee, 

4 may make a judgment about the classifications, meth5 odologies, and procedures to be used for collection of data 

6 under section 761(a) of the Public Health Service Act, as 

7 amended by this section. 

8 PART 5—AUTHORIZATION OF APPROPRIATIONS 

9 SEC. 2281. AUTHORIZATION OF APPROPRIATIONS. 

10 (a) IN GENERAL.—Section 799C, as added and 

11 amended, is further amended by adding at the end the 

12 following: 

13 ‘‘(c) HEALTH PROFESSIONS TRAINING FOR DIVER14 SITY.—For the purpose of carrying out sections 736, 737, 

15 738, 739, and 739A, in addition to any other amounts 

16 authorized to be appropriated for such purpose, there are 

17 authorized to be appropriated, out of any monies in the 

18 Public Health Investment Fund, the following: 

19 ‘‘(1) $90,000,000 for fiscal year 2011. 

20 ‘‘(2) $97,000,000 for fiscal year 2012. 

21 ‘‘(3) $100,000,000 for fiscal year 2013. 

22 ‘‘(4) $104,000,000 for fiscal year 2014. 

23 ‘‘(5) $110,000,000 for fiscal year 2015. 

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1 TION AND ASSESSMENT, AND HEALTH WORKFORCE AS2 SESSMENT.—For the purpose of carrying out sections 

3 741, 759, 761, and 764, in addition to any other amounts 

4 authorized to be appropriated for such purpose, there are 

5 authorized to be appropriated, out of any monies in the 

6 Public Health Investment Fund, the following: 

7 ‘‘(1) $87,000,000 for fiscal year 2011. 

8 ‘‘(2) $97,000,000 for fiscal year 2012. 

9 ‘‘(3) $103,000,000 for fiscal year 2013. 

10 ‘‘(4) $105,000,000 for fiscal year 2014. 

11 ‘‘(5) $113,000,000 for fiscal year 2015.’’. 

12 (b) EXISTING AUTHORIZATIONS OF APPROPRIA13 TIONS.— 

14 (1) SECTION 736.—Paragraph (1) of section 

15 736(i) (42 U.S.C. 293(h)), as redesignated, is 

16 amended by striking ‘‘2002’’ and inserting ‘‘2015’’. 

17 (2) SECTIONS 737, 738, AND 739.—Subsections 

18 (a), (b), and (c) of section 740 are amended by 

19 striking ‘‘2002’’ each place it appears and inserting 

20 ‘‘2015’’. 

21 (3) SECTION 741.—Subsection (h), as so redes22 ignated, of section 741 is amended— 

23 (A) by striking ‘‘and’’ after ‘‘fiscal year 

24 2003,’’; and 


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1 (B) by inserting ‘‘, and such sums as may 

2 be necessary for each subsequent fiscal year 

3 through the end of fiscal year 2015’’ before the 

4 period at the end. 

5 (4) SECTION 761.—Subsection (e)(1), as so re6 designated, of section 761 is amended by striking 

7 ‘‘2002’’ and inserting ‘‘2015’’. 

8 TITLE III—PREVENTION AND 

9 WELLNESS 

10 SEC. 2301. PREVENTION AND WELLNESS. 

11 (a) IN GENERAL.—The Public Health Service Act 

12 (42 U.S.C. 201 et seq.) is amended by inserting after title 

13 XXX the following: 

14 ‘‘TITLE XXXI—PREVENTION AND 

15 WELLNESS 

16 ‘‘Subtitle A—Prevention and 

17 Wellness Trust 

18 ‘‘SEC. 3111. PREVENTION AND WELLNESS TRUST. 

19 ‘‘(a) DEPOSITS INTO TRUST.—There is established 

20 a Prevention and Wellness Trust. There are authorized 

21 to be appropriated to the Trust— 

22 ‘‘(1) out of the general fund of the Treasury, 

23 amounts described in section 2002(b)(2)(A)(ii) of 

24 the Affordable Health Care for America Act for each 

25 fiscal year; and 


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1 ‘‘(2) in addition, out of any monies in the Pub2 lic Health Investment Fund— 

3 ‘‘(A) for fiscal year 2011, $2,400,000,000; 

4 ‘‘(B) for fiscal year 2012, $2,845,000,000; 

5 ‘‘(C) for fiscal year 2013, $3,100,000,000; 

6 ‘‘(D) for fiscal year 2014, $3,455,000,000; 

7 and 

8 ‘‘(E) for fiscal year 2015, $3,600,000,000. 

9 ‘‘(b) AVAILABILITY OF FUNDS.—Amounts in the Pre10 vention and Wellness Trust shall be available, as provided 

11 in advance in appropriation Acts, for carrying out this 

12 title. 

13 ‘‘(c) ALLOCATION.—Of the amounts authorized to be 

14 appropriated in subsection (a)(2), there are authorized to 

15 be appropriated— 

16 ‘‘(1) for carrying out subtitle C (Prevention 

17 Task Forces), $30,000,000 for each of fiscal years 

18 2011 through 2015; 

19 ‘‘(2) for carrying out subtitle D (Prevention 

20 and Wellness Research)— 

21 ‘‘(A) for fiscal year 2011, $155,000,000; 

22 ‘‘(B) for fiscal year 2012, $205,000,000; 

23 ‘‘(C) for fiscal year 2013, $255,000,000; 

24 ‘‘(D) for fiscal year 2014, $305,000,000; 

25 and 


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1 ‘‘(E) for fiscal year 2015, $355,000,000; 

2 ‘‘(3) for carrying out subtitle E (Delivery of 

3 Community Preventive and Wellness Services)— 

4 ‘‘(A) for fiscal year 2011, $1,065,000,000; 

5 ‘‘(B) for fiscal year 2012, $1,260,000,000; 

6 ‘‘(C) for fiscal year 2013, $1,365,000,000; 

7 ‘‘(D) for fiscal year 2014, $1,570,000,000; 

8 and 

9 ‘‘(E) for fiscal year 2015, $1,600,000,000; 

10 ‘‘(4) for carrying out section 3161 (Core Public 

11 Health Infrastructure for State, Local, and Tribal 

12 Health Departments)— 

13 ‘‘(A) for fiscal year 2011, $800,000,000; 

14 ‘‘(B) for fiscal year 2012, $1,000,000,000; 

15 ‘‘(C) for fiscal year 2013, $1,100,000,000; 

16 ‘‘(D) for fiscal year 2014, $1,200,000,000; 

17 and 

18 ‘‘(E) for fiscal year 2015, $1,265,000,000; 

19 and 

20 ‘‘(5) for carrying out section 3162 (Core Public 

21 Health Infrastructure and Activities for CDC), 

22 $350,000,000 for each of fiscal years 2011 through 

23 2015. 


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1 ‘‘Subtitle B—National Prevention 

2 and Wellness Strategy 

3 ‘‘SEC. 3121. NATIONAL PREVENTION AND WELLNESS STRAT4 EGY. 

5 ‘‘(a) IN GENERAL.—The Secretary shall submit to 

6 the Congress within one year after the date of the enact7 ment of this section, and at least every 2 years thereafter, 

8 a national strategy that is designed to improve the Na9 tion’s health through evidence-based clinical and commu10 nity prevention and wellness activities (in this section re11 ferred to as ‘prevention and wellness activities’), including 

12 core public health infrastructure improvement activities. 

13 ‘‘(b) CONTENTS.—The strategy under subsection (a) 

14 shall include each of the following: 

15 ‘‘(1) Identification of specific national goals and 

16 objectives in prevention and wellness activities that 

17 take into account appropriate public health measures 

18 and standards, including departmental measures and 

19 standards (including Healthy People and National 

20 Public Health Performance Standards). 

21 ‘‘(2) Establishment of national priorities for 

22 prevention and wellness, taking into account unmet 

23 prevention and wellness needs. 

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1 count unanswered research questions on prevention 

2 and wellness. 

3 ‘‘(4) Identification of health disparities in pre4 vention and wellness. 

5 ‘‘(5) Review of prevention payment incentives, 

6 the prevention workforce, and prevention delivery 

7 system capacity. 

8 ‘‘(6) A plan for addressing and implementing 

9 paragraphs (1) through (5). 

10 ‘‘(c) CONSULTATION.—In developing or revising the 

11 strategy under subsection (a), the Secretary shall consult 

12 with the following: 

13 ‘‘(1) The heads of appropriate health agencies 

14 and offices in the Department, including the Office 

15 of the Surgeon General of the Public Health Service, 

16 the Office of Minority Health, the Office on Wom17 en’s Health, and the Substance Abuse and Mental 

18 Health Services Administration. 

19 ‘‘(2) As appropriate, the heads of other Federal 

20 departments and agencies whose programs have a 

21 significant impact upon health (as determined by the 

22 Secretary). 

23 ‘‘(3) As appropriate, nonprofit and for-profit 

24 entities. 


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1 ‘‘(4) The Association of State and Territorial 

2 Health Officials and the National Association of 

3 County and City Health Officials. 

4 ‘‘(5) The Task Force on Community Preventive 

5 Services and the Task Force on Clinical Preventive 

6 Services. 

7 ‘‘Subtitle C—Prevention Task 

8 Forces 

9 ‘‘SEC. 3131. TASK FORCE ON CLINICAL PREVENTIVE SERV10 ICES. 

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

12 the Director of the Agency for Healthcare Research and 

13 Quality, shall establish a permanent task force to be 

14 known as the Task Force on Clinical Preventive Services 

15 (in this section referred to as the ‘Task Force’). 

16 ‘‘(b) RESPONSIBILITIES.—The Task Force shall— 

17 ‘‘(1) identify clinical preventive services for re18 view; 

19 ‘‘(2) review the scientific evidence related to the 

20 benefits, effectiveness, appropriateness, and costs of 

21 clinical preventive services identified under para22 graph (1) for the purpose of developing, updating, 

23 publishing, and disseminating evidence-based rec24 ommendations on the use of such services; 


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1 ‘‘(3) as appropriate, take into account health 

2 disparities in developing, updating, publishing, and 

3 disseminating evidence-based recommendations on 

4 the use of such services; 

5 ‘‘(4) identify gaps in clinical preventive services 

6 research and evaluation and recommend priority 

7 areas for such research and evaluation; 

8 ‘‘(5) pursuant to section 3143(c), determine 

9 whether subsidies and rewards meet the Task 

10 Force’s standards for a grade of A or B; 

11 ‘‘(6) as appropriate, consult with the clinical 

12 prevention stakeholders board in accordance with 

13 subsection (f); 

14 ‘‘(7) consult with the Task Force on Commu15 nity Preventive Services established under section 

16 3132; and 

17 ‘‘(8) as appropriate, in carrying out this sec18 tion, consider the national strategy under section 

19 3121. 

20 ‘‘(c) ROLE OF AGENCY.—The Secretary shall provide 

21 ongoing administrative, research, and technical support 

22 for the operations of the Task Force, including coordi23 nating and supporting the dissemination of the rec24 ommendations of the Task Force. 

25 ‘‘(d) MEMBERSHIP.— 


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1 ‘‘(1) NUMBER; APPOINTMENT.—The Task 

2 Force shall be composed of 30 members, appointed 

3 by the Secretary. 

4 ‘‘(2) TERMS.— 

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

6 appoint members of the Task Force for a term 

7 of 6 years and may reappoint such members, 

8 but the Secretary may not appoint any member 

9 to serve more than a total of 12 years. 

10 ‘‘(B) STAGGERED TERMS.—Notwith11 standing subparagraph (A), of the members 

12 first appointed to serve on the Task Force after 

13 the enactment of this title— 

14 ‘‘(i) 10 shall be appointed for a term 

15 of 2 years; 

16 ‘‘(ii) 10 shall be appointed for a term 

17 of 4 years; and 

18 ‘‘(iii) 10 shall be appointed for a term 

19 of 6 years. 

20 ‘‘(3) QUALIFICATIONS.—Members of the Task 

21 Force shall be appointed from among individuals 

22 who possess expertise in at least one of the following 

23 areas: 

24 ‘‘(A) Health promotion and disease preven25 tion. 


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1 ‘‘(B) Evaluation of research and system2 atic evidence reviews. 

3 ‘‘(C) Application of systematic evidence re4 views to clinical decisionmaking or health pol5 icy. 

6 ‘‘(D) Clinical primary care in child and ad7 olescent health. 

8 ‘‘(E) Clinical primary care in adult health, 

9 including women’s health. 

10 ‘‘(F) Clinical primary care in geriatrics. 

11 ‘‘(G) Clinical counseling and behavioral 

12 services for primary care patients. 

13 ‘‘(4) REPRESENTATION.—In appointing mem14 bers of the Task Force, the Secretary shall ensure 

15 that— 

16 ‘‘(A) all areas of expertise described in 

17 paragraph (3) are represented; and 

18 ‘‘(B) the members of the Task Force in19 clude individuals with expertise in health dis20 parities. 

21 ‘‘(e) SUBGROUPS.—As appropriate to maximize effi22 ciency, the Task Force may delegate authority for con23 ducting reviews and making recommendations to sub24 groups consisting of Task Force members, subject to final 

25 approval by the Task Force. 


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1 ‘‘(f) CLINICAL PREVENTION STAKEHOLDERS

2 BOARD.— 

3 ‘‘(1) IN GENERAL.—The Task Force shall con4 vene a clinical prevention stakeholders board com5 posed of representatives of appropriate public and 

6 private entities with an interest in clinical preventive 

7 services to advise the Task Force on developing, up8 dating, publishing, and disseminating evidence-based 

9 recommendations on the use of clinical preventive 

10 services. 

11 ‘‘(2) MEMBERSHIP.—The members of the clin12 ical prevention stakeholders board shall include rep13 resentatives of the following: 

14 ‘‘(A) Health care consumers and patient 

15 groups. 

16 ‘‘(B) Providers of clinical preventive serv17 ices, including community-based providers. 

18 ‘‘(C) Federal departments and agencies, 

19 including— 

20 ‘‘(i) appropriate health agencies and 

21 offices in the Department, including the 

22 Office of the Surgeon General of the Pub23 lic Health Service, the Office of Minority 

24 Health, the National Center on Minority 


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1 Health and Health Disparities, and the Of2 fice on Women’s Health; and 

3 ‘‘(ii) as appropriate, other Federal de4 partments and agencies whose programs 

5 have a significant impact upon health (as 

6 determined by the Secretary). 

7 ‘‘(D) Private health care payors. 

8 ‘‘(3) RESPONSIBILITIES.—In accordance with 

9 subsection (b)(6), the clinical prevention stake10 holders board shall— 

11 ‘‘(A) recommend clinical preventive serv12 ices for review by the Task Force; 

13 ‘‘(B) suggest scientific evidence for consid14 eration by the Task Force related to reviews 

15 undertaken by the Task Force; 

16 ‘‘(C) provide feedback regarding draft rec17 ommendations by the Task Force; and 

18 ‘‘(D) assist with efforts regarding dissemi19 nation of recommendations by the Director of 

20 the Agency for Healthcare Research and Qual21 ity. 

22 ‘‘(g) DISCLOSURE AND CONFLICTS OF INTEREST.— 

23 Members of the Task Force or the clinical prevention 

24 stakeholders board shall not be considered employees of 

25 the Federal Government by reason of service on the Task 


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1 Force or the clinical prevention stakeholders board, except 

2 members of the Task Force or the clinical prevention 

3 stakeholders board shall be considered to be special Gov4 ernment employees within the meaning of section 107 of 

5 the Ethics in Government Act of 1978 (5 U.S.C. App.) 

6 and section 208 of title 18, United States Code, for the 

7 purposes of disclosure and management of conflicts of in8 terest under those sections. 

9 ‘‘(h) NO PAY; RECEIPT OF TRAVEL EXPENSES.— 

10 Members of the Task Force or the clinical prevention 

11 stakeholders board shall not receive any pay for service 

12 on the Task Force, but may receive travel expenses, in13 cluding a per diem, in accordance with applicable provi14 sions of subchapter I of chapter 57 of title 5, United 

15 States Code. 

16 ‘‘(i) APPLICATION OF FACA.—The Federal Advisory 

17 Committee Act (5 U.S.C. App.) except for section 14 of 

18 such Act shall apply to the Task Force to the extent that 

19 the provisions of such Act do not conflict with the provi20 sions of this title. 

21 ‘‘(j) REPORT.—The Secretary shall submit to the 

22 Congress an annual report on the Task Force, including 

23 with respect to gaps identified and recommendations made 

24 under subsection (b)(4). 


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1 ‘‘SEC. 3132. TASK FORCE ON COMMUNITY PREVENTIVE 

2 SERVICES. 

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

4 the Director of the Centers for Disease Control and Pre5 vention, shall establish a permanent task force to be 

6 known as the Task Force on Community Preventive Serv7 ices (in this section referred to as the ‘Task Force’). 

8 ‘‘(b) RESPONSIBILITIES.—The Task Force shall— 

9 ‘‘(1) identify community preventive services for 

10 review; 

11 ‘‘(2) review the scientific evidence related to the 

12 benefits, effectiveness, appropriateness, and costs of 

13 community preventive services identified under para14 graph (1) for the purpose of developing, updating, 

15 publishing, and disseminating evidence-based rec16 ommendations on the use of such services; 

17 ‘‘(3) as appropriate, take into account health 

18 disparities in developing, updating, publishing, and 

19 disseminating evidence-based recommendations on 

20 the use of such services; 

21 ‘‘(4) identify gaps in community preventive 

22 services research and evaluation and recommend pri23 ority areas for such research and evaluation; 

24 ‘‘(5) pursuant to section 3143(d), determine 

25 whether subsidies and rewards are effective; 


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1 ‘‘(6) as appropriate, consult with the commu2 nity prevention stakeholders board in accordance 

3 with subsection (f); 

4 ‘‘(7) consult with the Task Force on Clinical 

5 Preventive Services established under section 3131; 

6 and 

7 ‘‘(8) as appropriate, in carrying out this sec8 tion, consider the national strategy under section 

9 3121. 

10 ‘‘(c) ROLE OF AGENCY.—The Secretary shall provide 

11 ongoing administrative, research, and technical support 

12 for the operations of the Task Force, including coordi13 nating and supporting the dissemination of the rec14 ommendations of the Task Force. 

15 ‘‘(d) MEMBERSHIP.— 

16 ‘‘(1) NUMBER; APPOINTMENT.—The Task 

17 Force shall be composed of 30 members, appointed 

18 by the Secretary. 

19 ‘‘(2) TERMS.— 

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

21 appoint members of the Task Force for a term 

22 of 6 years and may reappoint such members, 

23 but the Secretary may not appoint any member 

24 to serve more than a total of 12 years. 


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1 ‘‘(B) STAGGERED TERMS.—Notwith2 standing subparagraph (A), of the members 

3 first appointed to serve on the Task Force after 

4 the enactment of this section— 

5 ‘‘(i) 10 shall be appointed for a term 

6 of 2 years; 

7 ‘‘(ii) 10 shall be appointed for a term 

8 of 4 years; and 

9 ‘‘(iii) 10 shall be appointed for a term 

10 of 6 years. 

11 ‘‘(3) QUALIFICATIONS.—Members of the Task 

12 Force shall be appointed from among individuals 

13 who possess expertise in at least one of the following 

14 areas: 

15 ‘‘(A) Public health. 

16 ‘‘(B) Evaluation of research and system17 atic evidence reviews. 

18 ‘‘(C) Disciplines relevant to community 

19 preventive services, including health promotion; 

20 disease prevention; chronic disease; worksite 

21 health; school-site health; qualitative and quan22 titative analysis; and health economics, policy, 

23 law, and statistics. 

24 ‘‘(4) REPRESENTATION.—In appointing mem25 bers of the Task Force, the Secretary— 


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1 ‘‘(A) shall ensure that all areas of exper2 tise described in paragraph (3) are represented; 

3 ‘‘(B) shall ensure that such members in4 clude sufficient representatives of each of— 

5 ‘‘(i) State health officers; 

6 ‘‘(ii) local health officers; 

7 ‘‘(iii) health care practitioners; and 

8 ‘‘(iv) public health practitioners; and 

9 ‘‘(C) shall appoint individuals who have ex10 pertise in health disparities. 

11 ‘‘(e) SUBGROUPS.—As appropriate to maximize effi12 ciency, the Task Force may delegate authority for con13 ducting reviews and making recommendations to sub14 groups consisting of Task Force members, subject to final 

15 approval by the Task Force. 

16 ‘‘(f) COMMUNITY PREVENTION STAKEHOLDERS

17 BOARD.— 

18 ‘‘(1) IN GENERAL.—The Task Force shall con19 vene a community prevention stakeholders board 

20 composed of representatives of appropriate public 

21 and private entities with an interest in community 

22 preventive services to advise the Task Force on de23 veloping, updating, publishing, and disseminating 

24 evidence-based recommendations on the use of com25 munity preventive services. 


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1 ‘‘(2) MEMBERSHIP.—The members of the com2 munity prevention stakeholders board shall include 

3 representatives of the following: 

4 ‘‘(A) Health care consumers and patient 

5 groups. 

6 ‘‘(B) Providers of community preventive 

7 services, including community-based providers. 

8 ‘‘(C) Federal departments and agencies, 

9 including— 

10 ‘‘(i) appropriate health agencies and 

11 offices in the Department, including the 

12 Office of the Surgeon General of the Pub13 lic Health Service, the Office of Minority 

14 Health, the National Center on Minority 

15 Health and Health Disparities, and the Of16 fice on Women’s Health; and 

17 ‘‘(ii) as appropriate, other Federal de18 partments and agencies whose programs 

19 have a significant impact upon health (as 

20 determined by the Secretary). 

21 ‘‘(D) Private health care payors. 

22 ‘‘(3) RESPONSIBILITIES.—In accordance with 

23 subsection (b)(6), the community prevention stake24 holders board shall— 


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1 ‘‘(A) recommend community preventive 

2 services for review by the Task Force; 

3 ‘‘(B) suggest scientific evidence for consid4 eration by the Task Force related to reviews 

5 undertaken by the Task Force; 

6 ‘‘(C) provide feedback regarding draft rec7 ommendations by the Task Force; and 

8 ‘‘(D) assist with efforts regarding dissemi9 nation of recommendations by the Director of 

10 the Centers for Disease Control and Prevention. 

11 ‘‘(g) DISCLOSURE AND CONFLICTS OF INTEREST.— 

12 Members of the Task Force or the community prevention 

13 stakeholders board shall not be considered employees of 

14 the Federal Government by reason of service on the Task 

15 Force or the community prevention stakeholders board, 

16 except members of the Task Force or the community pre17 vention stakeholders board shall be considered to be spe18 cial Government employees within the meaning of section 

19 107 of the Ethics in Government Act of 1978 (5 U.S.C. 

20 App.) and section 208 of title 18, United States Code, for 

21 the purposes of disclosure and management of conflicts 

22 of interest under those sections. 

23 ‘‘(h) NO PAY; RECEIPT OF TRAVEL EXPENSES.— 

24 Members of the Task Force or the community prevention 

25 stakeholders board shall not receive any pay for service 


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1 on the Task Force, but may receive travel expenses, in2 cluding a per diem, in accordance with applicable provi3 sions of subchapter I of chapter 57 of title 5, United 

4 States Code. 

5 ‘‘(i) APPLICATION OF FACA.—The Federal Advisory 

6 Committee Act (5 U.S.C. App.) except for section 14 of 

7 such Act shall apply to the Task Force to the extent that 

8 the provisions of such Act do not conflict with the provi9 sions of this title. 

10 ‘‘(j) REPORT.—The Secretary shall submit to the 

11 Congress an annual report on the Task Force, including 

12 with respect to gaps identified and recommendations made 

13 under subsection (b)(4). 

14 ‘‘Subtitle D—Prevention and 

15 Wellness Research 

16 ‘‘SEC. 3141. PREVENTION AND WELLNESS RESEARCH ACTIV17 ITY COORDINATION. 

18 ‘‘In conducting or supporting research on prevention 

19 and wellness, the Director of the Centers for Disease Con20 trol and Prevention, the Director of the National Insti21 tutes of Health, and the heads of other agencies within 

22 the Department of Health and Human Services con23 ducting or supporting such research, shall take into con24 sideration the national strategy under section 3121 and 

25 the recommendations of the Task Force on Clinical PreVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01304 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 ventive Services under section 3131 and the Task Force 

2 on Community Preventive Services under section 3132. 

3 ‘‘SEC. 3142. COMMUNITY PREVENTION AND WELLNESS RE4 SEARCH GRANTS. 

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

6 the Director of the Centers for Disease Control and Pre7 vention, shall conduct, or award grants to eligible entities 

8 to conduct, research in priority areas identified by the Sec9 retary in the national strategy under section 3121 or by 

10 the Task Force on Community Preventive Services as re11 quired by section 3132. 

12 ‘‘(b) ELIGIBILITY.—To be eligible for a grant under 

13 this section, an entity shall be— 

14 ‘‘(1) a State, local, or tribal department of 

15 health; 

16 ‘‘(2) a public or private nonprofit entity; or 

17 ‘‘(3) a consortium of 2 or more entities de18 scribed in paragraphs (1) and (2). 

19 ‘‘(c) REPORT.—The Secretary shall submit to the 

20 Congress an annual report on the program of research 

21 under this section. 

22 ‘‘SEC. 3143. RESEARCH ON SUBSIDIES AND REWARDS TO 

23 ENCOURAGE WELLNESS AND HEALTHY BE24 HAVIORS. 

25 ‘‘(a) RESEARCH AND DEMONSTRATION PROJECTS.— 


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1 ‘‘(1) IN GENERAL.—The Secretary shall con2 duct, or award grants to public or nonprofit private 

3 entities to conduct, research and demonstration 

4 projects on the use of financial and in-kind subsidies 

5 and rewards to encourage individuals and commu6 nities to promote wellness, adopt healthy behaviors, 

7 and use evidence-based preventive health services. 

8 ‘‘(2) FOCUS.—Research and demonstration 

9 projects under paragraph (1) shall focus on— 

10 ‘‘(A) tobacco use, obesity, and other pre11 vention and wellness priorities identified by the 

12 Secretary in the national strategy under section 

13 3121; 

14 ‘‘(B) the initiation, maintenance, and long15 term sustainability of wellness promotion; adop16 tion of healthy behaviors; and use of evidence17 based preventive health services; and 

18 ‘‘(C) populations at high risk of prevent19 able diseases and conditions. 

20 ‘‘(b) FINDINGS; REPORT.— 

21 ‘‘(1) SUBMISSION OF FINDINGS.—The Secretary 

22 shall submit the findings of research and demonstra23 tion projects under subsection (a) to— 

24 ‘‘(A) the Task Force on Clinical Preventive 

25 Services established under section 3131 or the 


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1 Task Force on Community Preventive Services 

2 established under section 3132, as appropriate; 

3 and 

4 ‘‘(B) the Health Benefits Advisory Com5 mittee established by section 223 of the Afford6 able Health Care for America Act. 

7 ‘‘(2) REPORT TO CONGRESS.—Not later than 

8 18 months after the initiation of research and dem9 onstration projects under subsection (a), the Sec10 retary shall submit a report to the Congress on the 

11 progress of such research and projects, including 

12 any preliminary findings. 

13 ‘‘(c) INCLUSION IN ESSENTIAL BENEFITS PACK14 AGE.—If, on the basis of the findings of research and dem15 onstration projects under subsection (a) or other sources 

16 consistent with section 3131, the Task Force on Clinical 

17 Preventive Services determines that a subsidy or reward 

18 meets the Task Force’s standards for a grade A or B, 

19 the Secretary shall ensure that the subsidy or reward is 

20 included in the essential benefits package under section 

21 222. 

22 ‘‘(d) INCLUSION AS ALLOWABLE USE OF COMMUNITY

23 PREVENTION AND WELLNESS SERVICES GRANTS.—If, on 

24 the basis of the findings of research and demonstration 

25 projects under subsection (a) or other sources consistent 


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1 with section 3132, the Task Force on Community Preven2 tive Services determines that a subsidy or reward is effec3 tive, the Secretary shall ensure that the subsidy or reward 

4 becomes an allowable use of grant funds under section 

5 3151. 

6 ‘‘(e) NONDISCRIMINATION; NO TIE TO PREMIUM OR

7 COST SHARING.—In carrying out this section, the Sec8 retary shall ensure that any subsidy or reward— 

9 ‘‘(1) does not have a discriminatory effect on 

10 the basis of any personal characteristic extraneous 

11 to the provision of high-quality health care or related 

12 services; and 

13 ‘‘(2) is not tied to the premium or cost sharing 

14 of an individual under any qualified health benefits 

15 plan (as defined in section 100(c)). 

16 ‘‘Subtitle E—Delivery of Commu17 nity Prevention and Wellness 

18 Services 

19 ‘‘SEC. 3151. COMMUNITY PREVENTION AND WELLNESS 

20 SERVICES GRANTS. 

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

22 the Director of the Centers for Disease Control and Pre23 vention, shall establish a program for the delivery of com24 munity prevention and wellness services consisting of 

25 awarding grants to eligible entities— 


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1 ‘‘(1) to provide evidence-based, community pre2 vention and wellness services in priority areas identi3 fied by the Secretary in the national strategy under 

4 section 3121; or 

5 ‘‘(2) to plan such services. 

6 ‘‘(b) ELIGIBILITY.— 

7 ‘‘(1) DEFINITION.—To be eligible for a grant 

8 under this section, an entity shall be— 

9 ‘‘(A) a State, local, or tribal department of 

10 health; 

11 ‘‘(B) a public or private entity; or 

12 ‘‘(C) a consortium that— 

13 ‘‘(i) consists of 2 or more entities de14 scribed in subparagraph (A) or (B); and 

15 ‘‘(ii) may be a community partnership 

16 representing a Health Empowerment Zone. 

17 ‘‘(2) HEALTH EMPOWERMENT ZONE.—In this 

18 subsection, the term ‘Health Empowerment Zone’ 

19 means an area— 

20 ‘‘(A) in which multiple community preven21 tion and wellness services are implemented in 

22 order to address one or more health disparities, 

23 including those identified by the Secretary in 

24 the national strategy under section 3121; and 


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1 ‘‘(B) which is represented by a community 

2 partnership that demonstrates community sup3 port and coordination with State, local, or tribal 

4 health departments and includes— 

5 ‘‘(i) a broad cross section of stake6 holders; 

7 ‘‘(ii) residents of the community; and 

8 ‘‘(iii) representatives of entities that 

9 have a history of working within and serv10 ing the community. 

11 ‘‘(c) PREFERENCES.—In awarding grants under this 

12 section, the Secretary shall give preference to entities 

13 that— 

14 ‘‘(1) will address one or more goals or objec15 tives identified by the Secretary in the national 

16 strategy under section 3121; 

17 ‘‘(2) will address significant health disparities, 

18 including those identified by the Secretary in the na19 tional strategy under section 3121; 

20 ‘‘(3) will address unmet community prevention 

21 and wellness needs and avoid duplication of effort; 

22 ‘‘(4) have been demonstrated to be effective in 

23 communities comparable to the proposed target com24 munity; 


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1 ‘‘(5) will contribute to the evidence base for 

2 community prevention and wellness services; 

3 ‘‘(6) demonstrate that the community preven4 tion and wellness services to be funded will be sus5 tainable; and 

6 ‘‘(7) demonstrate coordination or collaboration 

7 across governmental and nongovernmental partners. 

8 ‘‘(d) HEALTH DISPARITIES.—Of the funds awarded 

9 under this section for a fiscal year, the Secretary shall 

10 award not less than 50 percent for planning or imple11 menting community prevention and wellness services 

12 whose primary purpose is to achieve a measurable reduc13 tion in one or more health disparities, including those 

14 identified by the Secretary in the national strategy under 

15 section 3121. 

16 ‘‘(e) EMPHASIS ON RECOMMENDED SERVICES.—For 

17 fiscal year 2014 and subsequent fiscal years, the Secretary 

18 shall award grants under this section only for planning 

19 or implementing services recommended by the Task Force 

20 on Community Preventive Services under section 3132 or 

21 deemed effective based on a review of comparable rigor 

22 (as determined by the Director of the Centers for Disease 

23 Control and Prevention). 


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1 ‘‘(f) PROHIBITED USES OF FUNDS.—An entity that 

2 receives a grant under this section may not use funds pro3 vided through the grant— 

4 ‘‘(1) to build or acquire real property or for 

5 construction; or 

6 ‘‘(2) for services or planning to the extent that 

7 payment has been made, or can reasonably be ex8 pected to be made— 

9 ‘‘(A) under any insurance policy; 

10 ‘‘(B) under any Federal or State health 

11 benefits program (including titles XIX and XXI 

12 of the Social Security Act); or 

13 ‘‘(C) by an entity which provides health 

14 services on a prepaid basis. 

15 ‘‘(g) REPORT.—The Secretary shall submit to the 

16 Congress an annual report on the program of grants 

17 awarded under this section. 

18 ‘‘(h) DEFINITIONS.—In this section, the term ‘evi19 dence-based’ means that methodologically sound research 

20 has demonstrated a beneficial health effect, in the judg21 ment of the Director of the Centers for Disease Control 

22 and Prevention. 


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1 ‘‘Subtitle F—Core Public Health 

2 Infrastructure 

3 ‘‘SEC. 3161. CORE PUBLIC HEALTH INFRASTRUCTURE FOR 

4 STATE, LOCAL, AND TRIBAL HEALTH DEPART5 MENTS. 

6 ‘‘(a) PROGRAM.—The Secretary, acting through the 

7 Director of the Centers for Disease Control and Preven8 tion, shall establish a core public health infrastructure 

9 program consisting of awarding grants under subsection 

10 (b). 

11 ‘‘(b) GRANTS.— 

12 ‘‘(1) AWARD.—For the purpose of addressing 

13 core public health infrastructure needs, the Sec14 retary— 

15 ‘‘(A) shall award a grant to each State 

16 health department; and 

17 ‘‘(B) may award grants on a competitive 

18 basis to State, local, or tribal health depart19 ments. 

20 ‘‘(2) ALLOCATION.—Of the total amount of 

21 funds awarded as grants under this subsection for a 

22 fiscal year— 

23 ‘‘(A) not less than 50 percent shall be for 

24 grants to State health departments under para25 graph (1)(A); and 


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1 ‘‘(B) not less than 30 percent shall be for 

2 grants to State, local, or tribal health depart3 ments under paragraph (1)(B). 

4 ‘‘(c) USE OF FUNDS.—The Secretary may award a 

5 grant to an entity under subsection (b)(1) only if the enti6 ty agrees to use the grant to address core public health 

7 infrastructure needs, including those identified in the ac8 creditation process under subsection (g). 

9 ‘‘(d) FORMULA GRANTS TO STATE HEALTH DEPART10 MENTS.—In making grants under subsection (b)(1)(A), 

11 the Secretary shall award funds to each State health de12 partment in accordance with— 

13 ‘‘(1) a formula based on population size; burden 

14 of preventable disease and disability; and core public 

15 health infrastructure gaps, including those identified 

16 in the accreditation process under subsection (g); 

17 and 

18 ‘‘(2) application requirements established by the 

19 Secretary, including a requirement that the State 

20 submit a plan that demonstrates to the satisfaction 

21 of the Secretary that the State’s health department 

22 will— 

23 ‘‘(A) address its highest priority core pub24 lic health infrastructure needs; and 


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1 ‘‘(B) as appropriate, allocate funds to local 

2 health departments within the State. 

3 ‘‘(e) COMPETITIVE GRANTS TO STATE, LOCAL, AND

4 TRIBAL HEALTH DEPARTMENTS.—In making grants 

5 under subsection (b)(1)(B), the Secretary shall give pri6 ority to applicants demonstrating core public health infra7 structure needs identified in the accreditation process 

8 under subsection (g). 

9 ‘‘(f) MAINTENANCE OF EFFORT.—The Secretary 

10 may award a grant to an entity under subsection (b) only 

11 if the entity demonstrates to the satisfaction of the Sec12 retary that— 

13 ‘‘(1) funds received through the grant will be 

14 expended only to supplement, and not supplant, non15 Federal and Federal funds otherwise available to the 

16 entity for the purpose of addressing core public 

17 health infrastructure needs; and 

18 ‘‘(2) with respect to activities for which the 

19 grant is awarded, the entity will maintain expendi20 tures of non-Federal amounts for such activities at 

21 a level not less than the level of such expenditures 

22 maintained by the entity for the fiscal year pre23 ceding the fiscal year for which the entity receives 

24 the grant. 


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1 ‘‘(g) ESTABLISHMENT OF A PUBLIC HEALTH AC2 CREDITATION PROGRAM.— 

3 ‘‘(1) IN GENERAL.—The Secretary, acting 

4 through the Director of the Centers for Disease 

5 Control and Prevention, shall— 

6 ‘‘(A) develop, and periodically review and 

7 update, standards for voluntary accreditation of 

8 State, local, or tribal health departments and 

9 public health laboratories for the purpose of ad10 vancing the quality and performance of such de11 partments and laboratories; and 

12 ‘‘(B) implement a program to accredit 

13 such health departments and laboratories in ac14 cordance with such standards. 

15 ‘‘(2) COOPERATIVE AGREEMENT.—The Sec16 retary may enter into a cooperative agreement with 

17 a private nonprofit entity to carry out paragraph 

18 (1). 

19 ‘‘(h) REPORT.—The Secretary shall submit to the 

20 Congress an annual report on progress being made to ac21 credit entities under subsection (g), including— 

22 ‘‘(1) a strategy, including goals and objectives, 

23 for accrediting entities under subsection (g) and 

24 achieving the purpose described in subsection (g)(1); 

25 and 


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1 ‘‘(2) identification of gaps in research related to 

2 core public health infrastructure and recommenda3 tions of priority areas for such research. 

4 ‘‘SEC. 3162. CORE PUBLIC HEALTH INFRASTRUCTURE AND 

5 ACTIVITIES FOR CDC. 

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

7 the Director of the Centers for Disease Control and Pre8 vention, shall expand and improve the core public health 

9 infrastructure and activities of the Centers for Disease 

10 Control and Prevention to address unmet and emerging 

11 public health needs. 

12 ‘‘(b) REPORT.—The Secretary shall submit to the 

13 Congress an annual report on the activities funded 

14 through this section. 

15 ‘‘Subtitle G—General Provisions 

16 ‘‘SEC. 3171. DEFINITIONS. 

17 ‘‘In this title: 

18 ‘‘(1) The term ‘core public health infrastruc19 ture’ includes workforce capacity and competency; 

20 laboratory systems; health information, health infor21 mation systems, and health information analysis; 

22 communications; financing; other relevant compo23 nents of organizational capacity; and other related 

24 activities. 


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1 ‘‘(2) The terms ‘Department’ and ‘depart2 mental’ refer to the Department of Health and 

3 Human Services. 

4 ‘‘(3) The term ‘health disparities’ includes 

5 health and health care disparities and means popu6 lation-specific differences in the presence of disease, 

7 health outcomes, or access to health care. For pur8 poses of the preceding sentence, a population may be 

9 delineated by race, ethnicity, primary language, sex, 

10 sexual orientation, gender identity, disability, socio11 economic status, or rural, urban, or other geographic 

12 setting, and any other population or subpopulation 

13 determined by the Secretary to experience significant 

14 gaps in disease, health outcomes, or access to health 

15 care. 

16 ‘‘(4) The term ‘tribal’ refers to an Indian tribe, 

17 a Tribal organization, or an Urban Indian organiza18 tion, as such terms are defined in section 4 of the 

19 Indian Health Care Improvement Act.’’. 

20 (b) TRANSITION PROVISIONS APPLICABLE TO TASK

21 FORCES.— 

22 (1) FUNCTIONS, PERSONNEL, ASSETS, LIABIL23 ITIES, AND ADMINISTRATIVE ACTIONS.—All func24 tions, personnel, assets, and liabilities of, and ad25 ministrative actions applicable to, the Preventive 


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1 Services Task Force convened under section 915(a) 

2 of the Public Health Service Act and the Task Force 

3 on Community Preventive Services (as such section 

4 and Task Forces were in existence on the day before 

5 the date of the enactment of this Act) shall be trans6 ferred to the Task Force on Clinical Preventive 

7 Services and the Task Force on Community Preven8 tive Services, respectively, established under sections 

9 3131 and 3132 of the Public Health Service Act, as 

10 added by subsection (a). 

11 (2) RECOMMENDATIONS.—All recommendations 

12 of the Preventive Services Task Force and the Task 

13 Force on Community Preventive Services, as in ex14 istence on the day before the date of the enactment 

15 of this Act, shall be considered to be recommenda16 tions of the Task Force on Clinical Preventive Serv17 ices and the Task Force on Community Preventive 

18 Services, respectively, established under sections 

19 3131 and 3132 of the Public Health Service Act, as 

20 added by subsection (a). 

21 (3) MEMBERS ALREADY SERVING.— 

22 (A) INITIAL MEMBERS.—The Secretary of 

23 Health and Human Services may select those 

24 individuals already serving on the Preventive 

25 Services Task Force and the Task Force on 


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1 Community Preventive Services, as in existence 

2 on the day before the date of the enactment of 

3 this Act, to be among the first members ap4 pointed to the Task Force on Clinical Preven5 tive Services and the Task Force on Commu6 nity Preventive Services, respectively, under sec7 tions 3131 and 3132 of the Public Health Serv8 ice Act, as added by subsection (a). 

9 (B) CALCULATION OF TOTAL SERVICE.—In 

10 calculating the total years of service of a mem11 ber of a task force for purposes of section 

12 3131(d)(2)(A) or 3132(d)(2)(A) of the Public 

13 Health Service Act, as added by subsection (a), 

14 the Secretary of Health and Human Services 

15 shall not include any period of service by the 

16 member on the Preventive Services Task Force 

17 or the Task Force on Community Preventive 

18 Services, respectively, as in existence on the day 

19 before the date of the enactment of this Act. 

20 (c) PERIOD BEFORE COMPLETION OF NATIONAL

21 STRATEGY.—Pending completion of the national strategy 

22 under section 3121 of the Public Health Service Act, as 

23 added by subsection (a), the Secretary of Health and 

24 Human Services, acting through the relevant agency head, 

25 may make a judgment about how the strategy will address 


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1 an issue and rely on such judgment in carrying out any 

2 provision of subtitle C, D, E, or F of title XXXI of such 

3 Act, as added by subsection (a), that requires the Sec4 retary— 

5 (1) to take into consideration such strategy; 

6 (2) to conduct or support research or provide 

7 services in priority areas identified in such strategy; 

8 or 

9 (3) to take any other action in reliance on such 

10 strategy. 

11 (d) CONFORMING AMENDMENTS.— 

12 (1) Paragraph (61) of section 3(b) of the In13 dian Health Care Improvement Act (25 U.S.C. 

14 1602) is amended by striking ‘‘United States Pre15 ventive Services Task Force’’ and inserting ‘‘Task 

16 Force on Clinical Preventive Services’’. 

17 (2) Section 126 of the Medicare, Medicaid, and 

18 SCHIP Benefits Improvement and Protection Act of 

19 2000 (Appendix F of Public Law 106–554) is 

20 amended by striking ‘‘United States Preventive 

21 Services Task Force’’ each place it appears and in22 serting ‘‘Task Force on Clinical Preventive Serv23 ices’’. 

24 (3) Paragraph (7) of section 317D(a) of the 

25 Public Health Service Act (42 U.S.C. 247b–5(a)) is 


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1 amended by striking ‘‘United States Preventive 

2 Services Task Force’’ and inserting ‘‘Task Force on 

3 Clinical Preventive Services’’. 

4 (4) Section 915 of the Public Health Service 

5 Act (42 U.S.C. 299b–4) is amended by striking sub6 section (a). 

7 (5) Subsections (s)(2)(AA)(iii)(II), (xx)(1), and 

8 (ddd)(1)(B) of section 1861 of the Social Security 

9 Act (42 U.S.C. 1395x) are amended by striking 

10 ‘‘United States Preventive Services Task Force’’ 

11 each place it appears and inserting ‘‘Task Force on 

12 Clinical Preventive Services’’. 

13 TITLE IV—QUALITY AND 

14 SURVEILLANCE 

15 SEC. 2401. IMPLEMENTATION OF BEST PRACTICES IN THE 

16 DELIVERY OF HEALTH CARE. 

17 (a) IN GENERAL.—Title IX of the Public Health 

18 Service Act (42 U.S.C. 299 et seq.) is amended— 

19 (1) by redesignating part D as part E; 

20 (2) by redesignating sections 931 through 938 

21 as sections 941 through 948, respectively; 

22 (3) in section 948(1), as redesignated, by strik23 ing ‘‘931’’ and inserting ‘‘941’’; and 

24 (4) by inserting after part C the following: 


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1 ‘‘PART D—IMPLEMENTATION OF BEST 

2 PRACTICES IN THE DELIVERY OF HEALTH CARE 

3 ‘‘SEC. 931. CENTER FOR QUALITY IMPROVEMENT. 

4 ‘‘(a) IN GENERAL.—There is established the Center 

5 for Quality Improvement (referred to in this part as the 

6 ‘Center’), to be headed by the Director. 

7 ‘‘(b) PRIORITIZATION.— 

8 ‘‘(1) IN GENERAL.—The Director shall 

9 prioritize areas for the identification, development, 

10 evaluation, and implementation of best practices (in11 cluding innovative methodologies and strategies) for 

12 quality improvement activities in the delivery of 

13 health care services (in this section referred to as 

14 ‘best practices’). 

15 ‘‘(2) CONSIDERATIONS.—In prioritizing areas 

16 under paragraph (1), the Director shall consider— 

17 ‘‘(A) the priorities established under sec18 tion 1191 of the Social Security Act; and 

19 ‘‘(B) the key health indicators identified by 

20 the Assistant Secretary for Health Information 

21 under section 1709. 

22 ‘‘(3) LIMITATIONS.—In conducting its duties 

23 under this subsection, the Center for Quality Im24 provement shall not develop quality-adjusted life 

25 year measures or any other methodologies that can 

26 be used to deny benefits to a beneficiary against the 


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1 beneficiary’s wishes on the basis of the beneficiary’s 

2 age, life expectancy, present or predicted disability, 

3 or expected quality of life. 

4 ‘‘(c) OTHER RESPONSIBILITIES.—The Director, act5 ing directly or by awarding a grant or contract to an eligi6 ble entity, shall— 

7 ‘‘(1) identify existing best practices under sub8 section (e); 

9 ‘‘(2) develop new best practices under sub10 section (f); 

11 ‘‘(3) evaluate best practices under subsection 

12 (g); 

13 ‘‘(4) implement best practices under subsection 

14 (h); 

15 ‘‘(5) ensure that best practices are identified, 

16 developed, evaluated, and implemented under this 

17 section consistent with standards adopted by the 

18 Secretary under section 3004 for health information 

19 technology used in the collection and reporting of 

20 quality information (including for purposes of the 

21 demonstration of meaningful use of certified elec22 tronic health record (EHR) technology by physicians 

23 and hospitals under the Medicare program (under 

24 sections 1848(o)(2) and 1886(n)(3), respectively, of 

25 the Social Security Act)); and 


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1 ‘‘(6) provide for dissemination of information 

2 and reporting under subsections (i) and (j). 

3 ‘‘(d) ELIGIBILITY.—To be eligible for a grant or con4 tract under subsection (c), an entity shall— 

5 ‘‘(1) be a nonprofit entity; 

6 ‘‘(2) agree to work with a variety of institu7 tional health care providers, physicians, nurses, and 

8 other health care practitioners; and 

9 ‘‘(3) if the entity is not the organization holding 

10 a contract under section 1153 of the Social Security 

11 Act for the area to be served, agree to cooperate 

12 with and avoid duplication of the activities of such 

13 organization. 

14 ‘‘(e) IDENTIFYING EXISTING BEST PRACTICES.—The 

15 Director shall identify best practices that are— 

16 ‘‘(1) currently utilized by health care providers 

17 (including hospitals, physician and other clinician 

18 practices, community cooperatives, and other health 

19 care entities) that deliver consistently high-quality, 

20 efficient health care services; and 

21 ‘‘(2) easily adapted for use by other health care 

22 providers and for use across a variety of health care 

23 settings. 

24 ‘‘(f) DEVELOPING NEW BEST PRACTICES.—The Di25 rector shall develop best practices that are— 


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1 ‘‘(1) based on a review of existing scientific evi2 dence; 

3 ‘‘(2) sufficiently detailed for implementation 

4 and incorporation into the workflow of health care 

5 providers; and 

6 ‘‘(3) designed to be easily adapted for use by 

7 health care providers across a variety of health care 

8 settings. 

9 ‘‘(g) EVALUATION OF BEST PRACTICES.—The Direc10 tor shall evaluate best practices identified or developed 

11 under this section. Such evaluation— 

12 ‘‘(1) shall include determinations of which best 

13 practices— 

14 ‘‘(A) most reliably and effectively achieve 

15 significant progress in improving the quality of 

16 patient care; and 

17 ‘‘(B) are easily adapted for use by health 

18 care providers across a variety of health care 

19 settings; 

20 ‘‘(2) shall include regular review, updating, and 

21 improvement of such best practices; and 

22 ‘‘(3) may include in-depth case studies or em23 pirical assessments of health care providers (includ24 ing hospitals, physician and other clinician practices, 

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1 ties) and simulations of such best practices for de2 terminations under paragraph (1). 

3 ‘‘(h) IMPLEMENTATION OF BEST PRACTICES.— 

4 ‘‘(1) IN GENERAL.—The Director shall enter 

5 into arrangements with entities in a State or region 

6 to implement best practices identified or developed 

7 under this section. Such implementation— 

8 ‘‘(A) may include forming collaborative 

9 multi-institutional teams; and 

10 ‘‘(B) shall include an evaluation of the best 

11 practices being implemented, including the 

12 measurement of patient outcomes before, dur13 ing, and after implementation of such best 

14 practices. 

15 ‘‘(2) PREFERENCES.—In carrying out this sub16 section, the Director shall give priority to health 

17 care providers implementing best practices that— 

18 ‘‘(A) have the greatest impact on patient 

19 outcomes and satisfaction; 

20 ‘‘(B) are the most easily adapted for use 

21 by health care providers across a variety of 

22 health care settings; 

23 ‘‘(C) promote coordination of health care 

24 practitioners across the continuum of care; and 


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1 ‘‘(D) engage patients and their families in 

2 improving patient care and outcomes. 

3 ‘‘(i) PUBLIC DISSEMINATION OF INFORMATION.— 

4 The Director shall provide for the public dissemination of 

5 information with respect to best practices and activities 

6 under this section. Such information shall be made avail7 able in appropriate formats and languages to reflect the 

8 varying needs of consumers and diverse levels of health 

9 literacy. 

10 ‘‘(j) REPORT.— 

11 ‘‘(1) IN GENERAL.—The Director shall submit 

12 an annual report to the Congress and the Secretary 

13 on activities under this section. 

14 ‘‘(2) CONTENT.—Each report under paragraph 

15 (1) shall include— 

16 ‘‘(A) information on activities conducted 

17 pursuant to grants and contracts awarded; 

18 ‘‘(B) summary data on patient outcomes 

19 before, during, and after implementation of best 

20 practices; and 

21 ‘‘(C) recommendations on the adaptability 

22 of best practices for use by health providers.’’. 

23 (b) INITIAL QUALITY IMPROVEMENT ACTIVITIES AND

24 INITIATIVES TO BE IMPLEMENTED.—Until the Director 

25 of the Agency for Healthcare Research and Quality has 


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1 established initial priorities under section 931(b) of the 

2 Public Health Service Act, as added by subsection (a), the 

3 Director shall, for purposes of such section, prioritize the 

4 following: 

5 (1) HEALTH CARE-ASSOCIATED INFECTIONS.— 

6 Reducing health care-associated infections, including 

7 infections in nursing homes and outpatient settings. 

8 (2) SURGERY.—Increasing hospital and out9 patient perioperative patient safety, including reduc10 ing surgical-site infections and surgical errors (such 

11 as wrong-site surgery and retained foreign bodies). 

12 (3) EMERGENCY ROOM.—Improving care in 

13 hospital emergency rooms, including through the use 

14 of principles of efficiency of design and delivery to 

15 improve patient flow. 

16 (4) OBSTETRICS.—Improving the provision of 

17 obstetrical and neonatal care, including the identi18 fication of interventions that are effective in reduc19 ing the risk of preterm and premature labor and the 

20 implementation of best practices for labor and deliv21 ery care. 

22 (5) PEDIATRICS.—Improving the provision of 

23 preventive and developmental child health services, 

24 including interventions that can reduce child health 

25 disparities (as defined in section 3171 of the Public 


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1 Health Service Act, as added by section 2301) and 

2 reduce the risk of developing chronic health-threat3 ening conditions that affect an individual’s life 

4 course development. 

5 (c) REPORT.—Not later than 18 months after the 

6 date of the enactment of this Act, the Director of the 

7 Agency for Healthcare Research and Quality shall submit 

8 a report to the Congress on the impact of the nurse-to9 patient ratio on the quality of care and patient outcomes, 

10 including recommendations for further integration into 

11 quality measurement and quality improvement activities. 

12 SEC. 2402. ASSISTANT SECRETARY FOR HEALTH INFORMA13 TION. 

14 (a) ESTABLISHMENT.—Title XVII (42 U.S.C. 300u 

15 et seq.) is amended— 

16 (1) by redesignating sections 1709 and 1710 as 

17 sections 1710 and 1711, respectively; and 

18 (2) by inserting after section 1708 the fol19 lowing: 

20 ‘‘SEC. 1709. ASSISTANT SECRETARY FOR HEALTH INFORMA21 TION. 

22 ‘‘(a) IN GENERAL.—There is established within the 

23 Department an Assistant Secretary for Health Informa24 tion (in this section referred to as the ‘Assistant Sec25 retary’), to be appointed by the Secretary. 


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1 ‘‘(b) RESPONSIBILITIES.—The Assistant Secretary 

2 shall— 

3 ‘‘(1) ensure the collection, collation, reporting, 

4 and publishing of information (including full and 

5 complete statistics) on key health indicators regard6 ing the Nation’s health and the performance of the 

7 Nation’s health care; 

8 ‘‘(2) facilitate and coordinate the collection, col9 lation, reporting, and publishing of information re10 garding the Nation’s health and the performance of 

11 the Nation’s health care (other than information de12 scribed in paragraph (1)); 

13 ‘‘(3)(A) develop standards for the collection of 

14 data regarding the Nation’s health and the perform15 ance of the Nation’s health care; and 

16 ‘‘(B) in carrying out subparagraph (A)— 

17 ‘‘(i) ensure appropriate specificity and 

18 standardization for data collection at the na19 tional, regional, State, and local levels; 

20 ‘‘(ii) include standards, as appropriate, for 

21 the collection of accurate data on health dis22 parities; 

23 ‘‘(iii) ensure, with respect to data on race 

24 and ethnicity, consistency with the 1997 Office 

25 of Management and Budget Standards for 


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1 Maintaining, Collecting and Presenting Federal 

2 Data on Race and Ethnicity (or any successor 

3 standards); and 

4 ‘‘(iv) in consultation with the Director of 

5 the Office of Minority Health, and the Director 

6 of the Office of Civil Rights of the Department, 

7 develop standards for the collection of data on 

8 health and health care with respect to primary 

9 language; 

10 ‘‘(4) provide support to Federal departments 

11 and agencies whose programs have a significant im12 pact upon health (as determined by the Secretary) 

13 for the collection and collation of information de14 scribed in paragraphs (1) and (2); 

15 ‘‘(5) ensure the sharing of information de16 scribed in paragraphs (1) and (2) among the agen17 cies of the Department; 

18 ‘‘(6) facilitate the sharing of information de19 scribed in paragraphs (1) and (2) by Federal depart20 ments and agencies whose programs have a signifi21 cant impact upon health (as determined by the Sec22 retary); 

23 ‘‘(7) identify gaps in information described in 

24 paragraphs (1) and (2) and the appropriate agency 

25 or entity to address such gaps; 


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1 ‘‘(8) facilitate and coordinate identification and 

2 monitoring of health disparities by the agencies of 

3 the Department to inform program and policy ef4 forts to reduce such disparities, including facilitating 

5 and funding analyses conducted in cooperation with 

6 the Social Security Administration, the Bureau of 

7 the Census, and other appropriate agencies and enti8 ties; 

9 ‘‘(9) consistent with privacy, proprietary, and 

10 other appropriate safeguards, facilitate public acces11 sibility of datasets (such as de-identified Medicare 

12 datasets or publicly available data on key health in13 dicators) by means of the Internet; and 

14 ‘‘(10) award grants or contracts for the collec15 tion and collation of information described in para16 graphs (1) and (2) (including through statewide sur17 veys that provide standardized information). 

18 ‘‘(c) KEY HEALTH INDICATORS.— 

19 ‘‘(1) IN GENERAL.—In carrying out subsection 

20 (b)(1), the Assistant Secretary shall— 

21 ‘‘(A) identify, and reassess at least once 

22 every 3 years, key health indicators described in 

23 such subsection; 

24 ‘‘(B) publish statistics on such key health 

25 indicators for the public— 


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1 ‘‘(i) not less than annually; and 

2 ‘‘(ii) on a supplemental basis when3 ever warranted by— 

4 ‘‘(I) the rate of change for a key 

5 health indicator; or 

6 ‘‘(II) the need to inform policy 

7 regarding the Nation’s health and the 

8 performance of the Nation’s health 

9 care; and 

10 ‘‘(C) ensure consistency with the national 

11 strategy developed by the Secretary under sec12 tion 3121 and consideration of the indicators 

13 specified in the reports under sections 308, 

14 903(a)(6), and 913(b)(2). 

15 ‘‘(2) RELEASE OF KEY HEALTH INDICATORS.— 

16 The regulations, rules, processes, and procedures of 

17 the Office of Management and Budget governing the 

18 review, release, and dissemination of key health indi19 cators shall be the same as the regulations, rules, 

20 processes, and procedures of the Office of Manage21 ment and Budget governing the review, release, and 

22 dissemination of Principal Federal Economic Indica23 tors (or equivalent statistical data) by the Bureau of 

24 Labor Statistics. 


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1 ‘‘(d) COORDINATION.—In carrying out this section, 

2 the Assistant Secretary shall coordinate with— 

3 ‘‘(1) public and private entities that collect and 

4 disseminate information on health and health care, 

5 including foundations; and 

6 ‘‘(2) the head of the Office of the National Co7 ordinator for Health Information Technology to en8 sure optimal use of health information technology. 

9 ‘‘(e) REQUEST FOR INFORMATION FROM DEPART10 MENTS AND AGENCIES.—Consistent with applicable law, 

11 the Assistant Secretary may secure directly from any Fed12 eral department or agency information necessary to enable 

13 the Assistant Secretary to carry out this section. 

14 ‘‘(f) REPORT.— 

15 ‘‘(1) SUBMISSION.—The Assistant Secretary 

16 shall submit to the Secretary and the Congress an 

17 annual report containing— 

18 ‘‘(A) a description of national, regional, or 

19 State changes in health or health care, as re20 flected by the key health indicators identified 

21 under subsection (c)(1); 

22 ‘‘(B) a description of gaps in the collection, 

23 collation, reporting, and publishing of informa24 tion regarding the Nation’s health and the per25 formance of the Nation’s health care; 


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1 ‘‘(C) recommendations for addressing such 

2 gaps and identification of the appropriate agen3 cy within the Department or other entity to ad4 dress such gaps; 

5 ‘‘(D) a description of analyses of health 

6 disparities, including the results of completed 

7 analyses, the status of ongoing longitudinal 

8 studies, and proposed or planned research; and 

9 ‘‘(E) a plan for actions to be taken by the 

10 Assistant Secretary to address gaps described 

11 in subparagraph (B). 

12 ‘‘(2) CONSIDERATION.—In preparing a report 

13 under paragraph (1), the Assistant Secretary shall 

14 take into consideration the findings and conclusions 

15 in the reports under sections 308, 903(a)(6), and 

16 913(b)(2). 

17 ‘‘(g) PROPRIETARY AND PRIVACY PROTECTIONS.— 

18 Nothing in this section shall be construed to affect appli19 cable proprietary or privacy protections. 

20 ‘‘(h) CONSULTATION.—In carrying out this section, 

21 the Assistant Secretary shall consult with— 

22 ‘‘(1) the heads of appropriate health agencies 

23 and offices in the Department, including the Office 

24 of the Surgeon General of the Public Health Service, 


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1 the Office of Minority Health, and the Office on 

2 Women’s Health; and 

3 ‘‘(2) as appropriate, the heads of other Federal 

4 departments and agencies whose programs have a 

5 significant impact upon health (as determined by the 

6 Secretary). 

7 ‘‘(i) DEFINITION.—In this section: 

8 ‘‘(1) The terms ‘agency’ and ‘agencies’ include 

9 an epidemiology center established under section 214 

10 of the Indian Health Care Improvement Act. 

11 ‘‘(2) The term ‘Department’ means the Depart12 ment of Health and Human Services. 

13 ‘‘(3) The term ‘health disparities’ has the 

14 meaning given to such term in section 3171.’’. 

15 (b) OTHER COORDINATION RESPONSIBILITIES.— 

16 Title III (42 U.S.C. 241 et seq.) is amended— 

17 (1) in paragraphs (1) and (2) of section 304(c) 

18 (42 U.S.C. 242b(c)), by inserting ‘‘, acting through 

19 the Assistant Secretary for Health Information,’’ 

20 after ‘‘The Secretary’’ each place it appears; and 

21 (2) in section 306(j) (42 U.S.C. 242k(j)), by in22 serting ‘‘, acting through the Assistant Secretary for 

23 Health Information,’’ after ‘‘of this section, the Sec24 retary’’. 


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1 SEC. 2403. AUTHORIZATION OF APPROPRIATIONS. 

2 Section 799C, as added and amended, is further 

3 amended by adding at the end the following: 

4 ‘‘(e) QUALITY AND SURVEILLANCE.—For the pur5 pose of carrying out part D of title IX and section 1709, 

6 in addition to any other amounts authorized to be appro7 priated for such purpose, there are authorized to be appro8 priated, out of any monies in the Public Health Invest9 ment Fund, $300,000,000 for each of fiscal years 2011 

10 through 2015.’’. 

11 TITLE V—OTHER PROVISIONS 

12 Subtitle A—Drug Discount for 

13 Rural and Other Hospitals; 340B 

14 Program Integrity 

15 SEC. 2501. EXPANDED PARTICIPATION IN 340B PROGRAM. 

16 (a) EXPANSION OF COVERED ENTITIES RECEIVING

17 DISCOUNTED PRICES.—Section 340B(a)(4) (42 U.S.C. 

18 256b(a)(4)) is amended by adding at the end the fol19 lowing: 

20 ‘‘(M) A children’s hospital excluded from 

21 the Medicare prospective payment system pur22 suant to section 1886(d)(1)(B)(iii) of the Social 

23 Security Act, or a free-standing cancer hospital 

24 excluded from the Medicare prospective pay25 ment system pursuant to section 

26 1886(d)(1)(B)(v) of the Social Security Act 


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1 that would meet the requirements of subpara2 graph (L), including the disproportionate share 

3 adjustment percentage requirement under 

4 clause (ii) of such subparagraph, if the hospital 

5 were a subsection (d) hospital as defined by sec6 tion 1886(d)(1)(B) of the Social Security Act. 

7 ‘‘(N) An entity that is a critical access hos8 pital (as determined under section 1820(c)(2) 

9 of the Social Security Act). 

10 ‘‘(O) An entity receiving funds under title 

11 V of the Social Security Act (relating to mater12 nal and child health) for the provision of health 

13 services. 

14 ‘‘(P) An entity receiving funds under sub15 part I of part B of title XIX of the Public 

16 Health Service Act (relating to comprehensive 

17 mental health services) for the provision of com18 munity mental health services. 

19 ‘‘(Q) An entity receiving funds under sub20 part II of such part B (relating to the preven21 tion and treatment of substance abuse) for the 

22 provision of treatment services for substance 

23 abuse. 


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1 ‘‘(R) An entity that is a Medicare-depend2 ent, small rural hospital (as defined in section 

3 1886(d)(5)(G)(iv) of the Social Security Act). 

4 ‘‘(S) An entity that is a sole community 

5 hospital (as defined in section 

6 1886(d)(5)(D)(iii) of the Social Security Act). 

7 ‘‘(T) An entity that is classified as a rural 

8 referral center under section 1886(d)(5)(C) of 

9 the Social Security Act.’’. 

10 (b) PROHIBITION ON GROUP PURCHASING ARRANGE11 MENTS.—Section 340B(a) (42 U.S.C. 256b(a)) is amend12 ed— 

13 (1) in paragraph (4)(L)— 

14 (A) by adding ‘‘and’’ at the end of clause 

15 (i); 

16 (B) by striking ‘‘; and’’ at the end of 

17 clause (ii) and inserting a period; and 

18 (C) by striking clause (iii); and 

19 (2) in paragraph (5), by redesignating subpara20 graphs (C) and (D) as subparagraphs (D) and (E), 

21 respectively, and by inserting after subparagraph 

22 (B) the following: 

23 ‘‘(C) PROHIBITING USE OF GROUP PUR24 CHASING ARRANGEMENTS.—A hospital de25 scribed in subparagraph (L), (M), (N), (R), 


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1 (S), or (T) of paragraph (4) shall not obtain 

2 covered outpatient drugs through a group pur3 chasing organization or other group purchasing 

4 arrangement.’’. 

5 SEC. 2502. IMPROVEMENTS TO 340B PROGRAM INTEGRITY. 

6 (a) INTEGRITY IMPROVEMENTS.—Section 340B (42 

7 U.S.C. 256b) is amended— 

8 (1) by striking subsections (c) and (d); and 

9 (2) by inserting after subsection (b) the fol10 lowing: 

11 ‘‘(c) IMPROVEMENTS IN PROGRAM INTEGRITY.— 

12 ‘‘(1) MANUFACTURER COMPLIANCE.— 

13 ‘‘(A) IN GENERAL.—From amounts appro14 priated under paragraph (4), the Secretary 

15 shall provide for improvements in compliance by 

16 manufacturers with the requirements of this 

17 section in order to prevent overcharges and 

18 other violations of the discounted pricing re19 quirements specified in this section. 

20 ‘‘(B) IMPROVEMENTS.—The improvements 

21 described in subparagraph (A) shall include the 

22 following: 

23 ‘‘(i) The establishment of a process to 

24 enable the Secretary to verify the accuracy 

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1 ers under subsection (a)(1) and charged to 

2 covered entities, which shall include the 

3 following: 

4 ‘‘(I) Developing and publishing, 

5 through an appropriate policy or regu6 latory issuance, standards and meth7 odology for the calculation of ceiling 

8 prices under such subsection. 

9 ‘‘(II) Comparing regularly the 

10 ceiling prices calculated by the Sec11 retary with the quarterly pricing data 

12 that is reported by manufacturers to 

13 the Secretary. 

14 ‘‘(III) Conducting periodic moni15 toring of sales transactions to covered 

16 entities. 

17 ‘‘(IV) Inquiring into any discrep18 ancies between ceiling prices and 

19 manufacturer pricing data that may 

20 be identified and taking, or requiring 

21 manufacturers to take, corrective ac22 tion in response to such discrepancies, 

23 including the issuance of refunds pur24 suant to the procedures set forth in 

25 clause (ii). 


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1 ‘‘(ii) The establishment of procedures 

2 for the issuance of refunds to covered enti3 ties by manufacturers in the event that the 

4 Secretary finds there has been an over5 charge, including the following: 

6 ‘‘(I) Submission to the Secretary 

7 by manufacturers of an explanation of 

8 why and how the overcharge occurred, 

9 how the refunds will be calculated, 

10 and to whom the refunds will be 

11 issued. 

12 ‘‘(II) Oversight by the Secretary 

13 to ensure that the refunds are issued 

14 accurately and within a reasonable pe15 riod of time. 

16 ‘‘(iii) Notwithstanding any other pro17 vision of law prohibiting the disclosure of 

18 ceiling prices or data used to calculate the 

19 ceiling price, the provision of access to cov20 ered entities and State Medicaid agencies 

21 through an Internet website of the Depart22 ment of Health and Human Services or 

23 contractor to the applicable ceiling prices 

24 for covered drugs as calculated and verified 

25 by the Secretary in a manner that ensures 


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1 protection of privileged pricing data from 

2 unauthorized disclosure. 

3 ‘‘(iv) The development of a mecha4 nism by which— 

5 ‘‘(I) rebates, discounts, or other 

6 price concessions provided by manu7 facturers to other purchasers subse8 quent to the sale of covered drugs to 

9 covered entities are reported to the 

10 Secretary; and 

11 ‘‘(II) appropriate credits and re12 funds are issued to covered entities if 

13 such rebates, discounts, or other price 

14 concessions have the effect of lowering 

15 the applicable ceiling price for the rel16 evant quarter for the drugs involved. 

17 ‘‘(v) In addition to authorities under 

18 section 1927(b)(3) of the Social Security 

19 Act, the Secretary may conduct audits of 

20 manufacturers and wholesalers to ensure 

21 the integrity of the program under this 

22 section, including audits on the market 

23 price of covered drugs. 

24 ‘‘(vi) The establishment of a require25 ment that manufacturers and wholesalers 


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1 use the identification system developed by 

2 the Secretary for purposes of facilitating 

3 the ordering, purchasing, and delivery of 

4 covered drugs under this section, including 

5 the processing of chargebacks for such 

6 drugs. 

7 ‘‘(vii) The imposition of sanctions in 

8 the form of civil monetary penalties, 

9 which— 

10 ‘‘(I) shall be assessed according 

11 to standards and procedures estab12 lished in regulations to be promul13 gated by the Secretary within one 

14 year of the date of the enactment of 

15 the Affordable Health Care for Amer16 ica Act; and 

17 ‘‘(II) shall apply to any manufac18 turer with an agreement under this 

19 section and shall not exceed $100,000 

20 for each instance where a manufac21 turer knowingly charges a covered en22 tity a price for purchase of a drug 

23 that exceeds the maximum applicable 

24 price under subsection (a)(1) or that 

25 knowingly violates any other provision 


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1 of this section, or withholds or pro2 vides false information to the Sec3 retary or to covered entities under 

4 this section. 

5 ‘‘(2) COVERED ENTITY COMPLIANCE.— 

6 ‘‘(A) IN GENERAL.—From amounts appro7 priated under paragraph (4), the Secretary 

8 shall provide for improvements in compliance by 

9 covered entities with the requirements of this 

10 section in order to prevent diversion and viola11 tions of the duplicate discount provision and 

12 other requirements under subsection (a)(5). 

13 ‘‘(B) IMPROVEMENTS.—The improvements 

14 described in subparagraph (A) shall include the 

15 following: 

16 ‘‘(i) The development of procedures to 

17 enable and require covered entities to up18 date at least annually the information on 

19 the Internet Web site of the Department of 

20 Health and Human Services relating to 

21 this section. 

22 ‘‘(ii) The development of procedures 

23 for the Secretary to verify the accuracy of 

24 information regarding covered entities that 


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1 is listed on the Web site described in 

2 clause (i). 

3 ‘‘(iii) The development of more de4 tailed guidance describing methodologies 

5 and options available to covered entities for 

6 billing covered drugs to State Medicaid 

7 agencies in a manner that avoids duplicate 

8 discounts pursuant to subsection (a)(5)(A). 

9 ‘‘(iv) The establishment of a single, 

10 universal, and standardized identification 

11 system by which each covered entity site 

12 can be identified by manufacturers, dis13 tributors, covered entities, and the Sec14 retary for purposes of facilitating the or15 dering, purchasing, and delivery of covered 

16 drugs under this section, including the 

17 processing of chargebacks for such drugs. 

18 ‘‘(v) The imposition of sanctions in 

19 the form of civil monetary penalties, 

20 which— 

21 ‘‘(I) shall be assessed according 

22 to standards and procedures estab23 lished in regulations promulgated by 

24 the Secretary; 


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1 ‘‘(II) shall not exceed $5,000 for 

2 each violation; and 

3 ‘‘(III) shall apply to any covered 

4 entity that knowingly violates sub5 paragraph (a)(5)(B) or knowingly vio6 lates any other provision of this sec7 tion. 

8 ‘‘(vi) The exclusion of a covered entity 

9 from participation in the program under 

10 this section, for a period of time to be de11 termined by the Secretary, in cases in 

12 which the Secretary determines, in accord13 ance with standards and procedures estab14 lished in regulations, that— 

15 ‘‘(I) a violation of a requirement 

16 of this section was repeated and 

17 knowing; and 

18 ‘‘(II) imposition of a monetary 

19 penalty would be insufficient to rea20 sonably ensure compliance. 

21 ‘‘(vii) The referral of matters as ap22 propriate to the Food and Drug Adminis23 tration, the Office of Inspector General of 

24 Department of Health and Human Serv25 ices, or other Federal agencies. 


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1 ‘‘(3) ADMINISTRATIVE DISPUTE RESOLUTION

2 PROCESS.—From amounts appropriated under para3 graph (4), the Secretary may establish and imple4 ment an administrative process for the resolution of 

5 the following: 

6 ‘‘(A) Claims by covered entities that manu7 facturers have violated the terms of their agree8 ment with the Secretary under subsection 

9 (a)(1). 

10 ‘‘(B) Claims by manufacturers that cov11 ered entities have violated subsection (a)(5)(A) 

12 or (a)(5)(B). 

13 ‘‘(4) AUTHORIZATION OF APPROPRIATIONS.— 

14 There are authorized to be appropriated to carry out 

15 this subsection, such sums as may be necessary for 

16 fiscal year 2011 and each succeeding fiscal year.’’. 

17 (b) CONFORMING AMENDMENTS.— 

18 (1) Section 340B(a) (42 U.S.C. 256b(a)) is 

19 amended— 

20 (A) by adding at the end of paragraph (1) 

21 the following: ‘‘Such agreement shall require 

22 that the manufacturer offer each covered entity 

23 covered drugs for purchase at or below the ap24 plicable ceiling price if such drug is made avail25 able to any other purchaser at any price. Such 


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1 agreement shall require that, if the supply of a 

2 covered drug is insufficient to meet demand, 

3 then the manufacturer may utilize an allocation 

4 method that is reported in writing to the Sec5 retary and does not discriminate on the basis of 

6 the price paid by covered entities or on any 

7 other basis related to an entity’s participation 

8 in the program under this section. Notwith9 standing any other provision of law, if the Sec10 retary requests a manufacturer to enter into a 

11 new or amended agreement under this section 

12 that complies with current law and if the manu13 facturer opts not to sign the new or amended 

14 agreement, then any existing agreement be15 tween the manufacturer and the Secretary 

16 under this section is deemed to no longer meet 

17 the requirements of this section for purposes of 

18 this section and section 1927 of the Social Se19 curity Act.’’; and 

20 (B) by adding at the end the following 

21 paragraph: 

22 ‘‘(11) QUARTERLY REPORTS.—An agreement 

23 described in paragraph (1) shall require that the 

24 manufacturer furnish the Secretary with reports on 


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1 a quarterly basis that include the following informa2 tion: 

3 ‘‘(A) The price for each covered drug sub4 ject to the agreement that, according to the 

5 manufacturer, represents the maximum price 

6 that covered entities may permissibly be re7 quired to pay for the drug (referred to in this 

8 section as the ‘ceiling price’). 

9 ‘‘(B) The component information used to 

10 calculate the ceiling price as determined nec11 essary to administer the requirements of the 

12 program under this section. 

13 ‘‘(C) Rebates, discounts, and other price 

14 concessions provided by manufacturers to other 

15 purchasers subsequent to the sale of covered 

16 drugs to covered entities.’’. 

17 (2) Section 1927(a)(5) of the Social Security 

18 Act (42 U.S.C. 1396r–8(a)(5)) is amended by strik19 ing subparagraph (D). 

20 SEC. 2503. EFFECTIVE DATE. 

21 (a) IN GENERAL.—The amendments made by this 

22 subtitle shall take effect on the date of the enactment of 

23 this Act, and sections 2501, 2502(a)(1), and 2502(b)(2) 

24 shall apply to drugs dispensed on or after such date. 


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1 (b) EFFECTIVENESS.—The amendments made by 

2 this subtitle shall be effective, and shall be taken into ac3 count in determining whether a manufacturer is deemed 

4 to meet the requirements of section 340B(a) of the Public 

5 Health Service Act (42 U.S.C. 256b(a)), and of section 

6 1927(a)(5) of the Social Security Act (42 U.S.C. 1396r– 

7 8(a)(5)), notwithstanding any other provision of law. 

8 Subtitle B—Programs 

9 PART 1—GRANTS FOR CLINICS AND CENTERS 

10 SEC. 2511. SCHOOL-BASED HEALTH CLINICS. 

11 (a) IN GENERAL.—Part Q of title III (42 U.S.C. 

12 280h et seq.) is amended by adding at the end the fol13 lowing: 

14 ‘‘SEC. 399Z–1. SCHOOL-BASED HEALTH CLINICS. 

15 ‘‘(a) PROGRAM.—The Secretary shall establish a 

16 school-based health clinic program consisting of awarding 

17 grants to eligible entities to support the operation of 

18 school-based health clinics (referred to in this section as 

19 ‘SBHCs’). 

20 ‘‘(b) ELIGIBILITY.—To be eligible for a grant under 

21 this section, an entity shall— 

22 ‘‘(1) be an SBHC (as defined in subsection 

23 (l)(3)); and 

24 ‘‘(2) submit an application at such time, in 

25 such manner, and containing such information as 


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1 the Secretary may require, including at a min2 imum— 

3 ‘‘(A) evidence that the applicant meets all 

4 criteria necessary to be designated as an 

5 SBHC; 

6 ‘‘(B) evidence of local need for the services 

7 to be provided by the SBHC; 

8 ‘‘(C) an assurance that— 

9 ‘‘(i) SBHC services will be provided in 

10 accordance with Federal, State, and local 

11 laws; 

12 ‘‘(ii) the SBHC has established and 

13 maintains collaborative relationships with 

14 other health care providers in the 

15 catchment area of the SBHC; 

16 ‘‘(iii) the SBHC will provide onsite ac17 cess during the academic day when school 

18 is in session and has an established net19 work of support and access to services with 

20 backup health providers when the school or 

21 SBHC is closed; 

22 ‘‘(iv) the SBHC will be integrated into 

23 the school environment and will coordinate 

24 health services with appropriate school perVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01353 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 sonnel and other community providers co2 located at the school; and 

3 ‘‘(v) the SBHC sponsoring facility as4 sumes all responsibility for the SBHC ad5 ministration, operations, and oversight; 

6 and 

7 ‘‘(D) such other information as the Sec8 retary may require. 

9 ‘‘(c) USE OF FUNDS.—Funds awarded under a grant 

10 under this section— 

11 ‘‘(1) may be used for— 

12 ‘‘(A) providing training related to the pro13 vision of comprehensive primary health services 

14 and additional health services; 

15 ‘‘(B) the management and operation of 

16 SBHC programs, including through sub17 contracts; and 

18 ‘‘(C) the payment of salaries for health 

19 professionals and other appropriate SBHC per20 sonnel; and 

21 ‘‘(2) may not be used to provide abortions. 

22 ‘‘(d) CONSIDERATION OF NEED.—In determining the 

23 amount of a grant under this section, the Secretary shall 

24 take into consideration— 

25 ‘‘(1) the financial need of the SBHC; 


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1 ‘‘(2) State, local, or other sources of funding 

2 provided to the SBHC; and 

3 ‘‘(3) other factors as determined appropriate by 

4 the Secretary. 

5 ‘‘(e) PREFERENCES.—In awarding grants under this 

6 section, the Secretary shall give preference to SBHCs that 

7 have a demonstrated record of service to at least one of 

8 the following: 

9 ‘‘(1) A high percentage of medically under10 served children and adolescents. 

11 ‘‘(2) Communities or populations in which chil12 dren and adolescents have difficulty accessing health 

13 and mental health services. 

14 ‘‘(3) Communities with high percentages of chil15 dren and adolescents who are uninsured, under16 insured, or eligible for medical assistance under Fed17 eral or State health benefits programs (including ti18 tles XIX and XXI of the Social Security Act). 

19 ‘‘(f) MATCHING REQUIREMENT.—The Secretary may 

20 award a grant to an SBHC under this section only if the 

21 SBHC agrees to provide, from non-Federal sources, an 

22 amount equal to 20 percent of the amount of the grant 

23 (which may be provided in cash or in kind) to carry out 

24 the activities supported by the grant. 


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1 ‘‘(g) SUPPLEMENT, NOT SUPPLANT.—The Secretary 

2 may award a grant to an SBHC under this section only 

3 if the SBHC demonstrates to the satisfaction of the Sec4 retary that funds received through the grant will be ex5 pended only to supplement, and not supplant, non-Federal 

6 and Federal funds otherwise available to the SBHC for 

7 operation of the SBHC (including each activity described 

8 in paragraph (1) or (2) of subsection (c)). 

9 ‘‘(h) PAYOR OF LAST RESORT.—The Secretary may 

10 award a grant to an SBHC under this section only if the 

11 SBHC demonstrates to the satisfaction of the Secretary 

12 that funds received through the grant will not be expended 

13 for any activity to the extent that payment has been made, 

14 or can reasonably be expected to be made— 

15 ‘‘(1) under any insurance policy; 

16 ‘‘(2) under any Federal or State health benefits 

17 program (including titles XIX and XXI of the Social 

18 Security Act); or 

19 ‘‘(3) by an entity which provides health services 

20 on a prepaid basis. 

21 ‘‘(i) REGULATIONS REGARDING REIMBURSEMENT

22 FOR HEALTH SERVICES.—The Secretary shall issue regu23 lations regarding the reimbursement for health services 

24 provided by SBHCs to individuals eligible to receive such 

25 services through the program under this section, including 


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1 reimbursement under any insurance policy or any Federal 

2 or State health benefits program (including titles XIX and 

3 XXI of the Social Security Act). 

4 ‘‘(j) TECHNICAL ASSISTANCE.—The Secretary shall 

5 provide (either directly or by grant or contract) technical 

6 and other assistance to SBHCs to assist such SBHCs to 

7 meet the requirements of this section. Such assistance 

8 may include fiscal and program management assistance, 

9 training in fiscal and program management, operational 

10 and administrative support, and the provision of informa11 tion to the SBHCs of the variety of resources available 

12 under this title and how those resources can be best used 

13 to meet the health needs of the communities served by 

14 the SBHCs. 

15 ‘‘(k) EVALUATION; REPORT.—The Secretary shall— 

16 ‘‘(1) develop and implement a plan for evalu17 ating SBHCs and monitoring quality performances 

18 under the awards made under this section; and 

19 ‘‘(2) submit to the Congress on an annual basis 

20 a report on the program under this section. 

21 ‘‘(l) DEFINITIONS.—In this section: 

22 ‘‘(1) COMPREHENSIVE PRIMARY HEALTH SERV23 ICES.—The term ‘comprehensive primary health 

24 services’ means the core services offered by SBHCs, 

25 which— 


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1 ‘‘(A) shall include— 

2 ‘‘(i) comprehensive health assess3 ments, diagnosis, and treatment of minor, 

4 acute, and chronic medical conditions and 

5 referrals to, and followup for, specialty 

6 care; and 

7 ‘‘(ii) mental health assessments, crisis 

8 intervention, counseling, treatment, and re9 ferral to a continuum of services including 

10 emergency psychiatric care, community 

11 support programs, inpatient care, and out12 patient programs; and 

13 ‘‘(B) may include additional services, such 

14 as oral health, social, and age-appropriate 

15 health education services, including nutritional 

16 counseling. 

17 ‘‘(2) MEDICALLY UNDERSERVED CHILDREN

18 AND ADOLESCENTS.—The term ‘medically under19 served children and adolescents’ means a population 

20 of children and adolescents who are residents of an 

21 area designated by the Secretary as an area with a 

22 shortage of personal health services and health in23 frastructure for such children and adolescents. 


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1 ‘‘(3) SCHOOL-BASED HEALTH CLINIC.—The 

2 term ‘school-based health clinic’ means a health clin3 ic that— 

4 ‘‘(A) is located in, or is adjacent to, a 

5 school facility of a local educational agency; 

6 ‘‘(B) is organized through school, commu7 nity, and health provider relationships; 

8 ‘‘(C) is administered by a sponsoring facil9 ity; 

10 ‘‘(D) provides comprehensive primary 

11 health services during school hours to children 

12 and adolescents by health professionals in ac13 cordance with State and local laws and regula14 tions, established standards, and community 

15 practice; and 

16 ‘‘(E) does not perform abortion services. 

17 ‘‘(4) SPONSORING FACILITY.—The term ‘spon18 soring facility’ is— 

19 ‘‘(A) a hospital; 

20 ‘‘(B) a public health department; 

21 ‘‘(C) a community health center; 

22 ‘‘(D) a nonprofit health care entity whose 

23 mission is to provide access to comprehensive 

24 primary health care services; 

25 ‘‘(E) a local educational agency; or 


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1 ‘‘(F) a program administered by the In2 dian Health Service or the Bureau of Indian 

3 Affairs or operated by an Indian tribe or a trib4 al organization under the Indian Self-Deter5 mination and Education Assistance Act, a Na6 tive Hawaiian entity, or an urban Indian pro7 gram under title V of the Indian Health Care 

8 Improvement Act. 

9 ‘‘(m) AUTHORIZATION OF APPROPRIATIONS.—For 

10 purposes of carrying out this section, there are authorized 

11 to be appropriated $50,000,000 for fiscal year 2011 and 

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

13 2012 through 2015.’’. 

14 (b) EFFECTIVE DATE.—The Secretary of Health and 

15 Human Services shall begin awarding grants under section 

16 399Z–1 of the Public Health Service Act, as added by sub17 section (a), not later than July 1, 2010, without regard 

18 to whether or not final regulations have been issued under 

19 section 399Z–1(i) of such Act. 

20 (c) TERMINATION OF STUDY.—Section 2(b) of the 

21 Health Care Safety Net Act of 2008 (42 U.S.C. 254b 

22 note) is amended by striking paragraph (2) (relating to 

23 a school-based health center study). 


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1 SEC. 2512. NURSE-MANAGED HEALTH CENTERS. 

2 Title III (42 U.S.C. 241 et seq.) is amended by add3 ing at the end the following: 

4 ‘‘PART S—NURSE-MANAGED HEALTH CENTERS 

5 ‘‘SEC. 399FF. NURSE-MANAGED HEALTH CENTERS. 

6 ‘‘(a) PROGRAM.—The Secretary, acting through the 

7 Administrator of the Health Resources and Services Ad8 ministration, shall establish a nurse-managed health cen9 ter program consisting of awarding grants to entities 

10 under subsection (b). 

11 ‘‘(b) GRANT.—The Secretary shall award grants to 

12 entities— 

13 ‘‘(1) to plan and develop a nurse-managed 

14 health center; or 

15 ‘‘(2) to operate a nurse-managed health center. 

16 ‘‘(c) USE OF FUNDS.—Amounts received as a grant 

17 under subsection (b) may be used for activities including 

18 the following: 

19 ‘‘(1) Purchasing or leasing equipment. 

20 ‘‘(2) Training and technical assistance related 

21 to the provision of comprehensive primary care serv22 ices and wellness services. 

23 ‘‘(3) Other activities for planning, developing, 

24 or operating, as applicable, a nurse-managed health 

25 center. 


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1 ‘‘(d) ASSURANCES APPLICABLE TO BOTH PLANNING

2 AND OPERATION GRANTS.— 

3 ‘‘(1) IN GENERAL.—The Secretary may award 

4 a grant under this section to an entity only if the 

5 entity demonstrates to the Secretary’s satisfaction 

6 that— 

7 ‘‘(A) nurses, in addition to managing the 

8 center, will be adequately represented as pro9 viders at the center; and 

10 ‘‘(B) not later than 90 days after receiving 

11 the grant, the entity will establish a community 

12 advisory committee composed of individuals, a 

13 majority of whom are being served by the cen14 ter, to provide input into the nurse-managed 

15 health center’s operations. 

16 ‘‘(2) MATCHING REQUIREMENT.—The Sec17 retary may award a grant under this section to an 

18 entity only if the entity agrees to provide, from non19 Federal sources, an amount equal to 20 percent of 

20 the amount of the grant (which may be provided in 

21 cash or in kind) to carry out the activities supported 

22 by the grant. 

23 ‘‘(3) PAYOR OF LAST RESORT.—The Secretary 

24 may award a grant under this section to an entity 

25 only if the entity demonstrates to the satisfaction of 


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1 the Secretary that funds received through the grant 

2 will not be expended for any activity to the extent 

3 that payment has been made, or can reasonably be 

4 expected to be made— 

5 ‘‘(A) under any insurance policy; 

6 ‘‘(B) under any Federal or State health 

7 benefits program (including titles XIX and XXI 

8 of the Social Security Act); or 

9 ‘‘(C) by an entity which provides health 

10 services on a prepaid basis. 

11 ‘‘(4) MAINTENANCE OF EFFORT.—The Sec12 retary may award a grant under this section to an 

13 entity only if the entity demonstrates to the satisfac14 tion of the Secretary that— 

15 ‘‘(A) funds received through the grant will 

16 be expended only to supplement, and not sup17 plant, non-Federal and Federal funds otherwise 

18 available to the entity for the activities to be 

19 funded through the grant; and 

20 ‘‘(B) with respect to such activities, the en21 tity will maintain expenditures of non-Federal 

22 amounts for such activities at a level not less 

23 than the lesser of such expenditures maintained 

24 by the entity for the fiscal year preceding the 


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1 fiscal year for which the entity receives the 

2 grant. 

3 ‘‘(e) ADDITIONAL ASSURANCE FOR PLANNING

4 GRANTS.—The Secretary may award a grant under sub5 section (b)(1) to an entity only if the entity agrees— 

6 ‘‘(1) to assess the needs of the medically under7 served populations proposed to be served by the 

8 nurse-managed health center; and 

9 ‘‘(2) to design services and operations of the 

10 nurse-managed health center for such populations 

11 based on such assessment. 

12 ‘‘(f) ADDITIONAL ASSURANCE FOR OPERATION

13 GRANTS.—The Secretary may award a grant under sub14 section (b)(2) to an entity only if the entity assures that 

15 the nurse-managed health center will provide— 

16 ‘‘(1) comprehensive primary care services, 

17 wellness services, and other health care services 

18 deemed appropriate by the Secretary; 

19 ‘‘(2) care without respect to insurance status or 

20 income of the patient; and 

21 ‘‘(3) direct access to client-centered services of22 fered by advanced practice nurses, other nurses, 

23 physicians, physician assistants, or other qualified 

24 health professionals. 


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1 ‘‘(g) TECHNICAL ASSISTANCE.—The Secretary shall 

2 provide (either directly or by grant or contract) technical 

3 and other assistance to nurse-managed health centers to 

4 assist such centers in meeting the requirements of this 

5 section. Such assistance may include fiscal and program 

6 management assistance, training in fiscal and program 

7 management, operational and administrative support, and 

8 the provision of information to nurse-managed health cen9 ters regarding the various resources available under this 

10 section and how those resources can best be used to meet 

11 the health needs of the communities served by nurse-man12 aged health centers. 

13 ‘‘(h) REPORT.—The Secretary shall submit to the 

14 Congress an annual report on the program under this sec15 tion. 

16 ‘‘(i) DEFINITIONS.—In this section: 

17 ‘‘(1) COMPREHENSIVE PRIMARY CARE SERV18 ICES.—The term ‘comprehensive primary care serv19 ices’ has the meaning given to the term ‘required 

20 primary health services’ in section 330(b)(1). 

21 ‘‘(2) MEDICALLY UNDERSERVED POPU22 LATION.—The term ‘medically underserved popu23 lation’ has the meaning given to such term in section 

24 330(b)(3). 


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1 ‘‘(3) NURSE-MANAGED HEALTH CENTER.—The 

2 term ‘nurse-managed health center’ has the meaning 

3 given to such term in section 801. 

4 ‘‘(4) WELLNESS SERVICES.—The term ‘wellness 

5 services’ means any health-related service or inter6 vention, not including primary care, which is de7 signed to reduce identifiable health risks and in8 crease healthy behaviors intended to prevent the 

9 onset of disease or lessen the impact of existing 

10 chronic conditions by teaching more effective man11 agement techniques that focus on individual self-care 

12 and patient-driven decisionmaking. 

13 ‘‘(j) AUTHORIZATION OF APPROPRIATIONS.—To 

14 carry out this section, there are authorized to be appro15 priated such sums as may be necessary for each of fiscal 

16 years 2011 through 2015.’’. 

17 SEC. 2513. FEDERALLY QUALIFIED BEHAVIORAL HEALTH 

18 CENTERS. 

19 Section 1913 (42 U.S.C. 300x–3) is amended— 

20 (1) in subsection (a)(2)(A), by striking ‘‘com21 munity mental health services’’ and inserting ‘‘be22 havioral health services (of the type offered by feder23 ally qualified behavioral health centers consistent 

24 with subsection (c)(3))’’; 

25 (2) in subsection (b)— 


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1 (A) by striking paragraph (1) and insert2 ing the following: 

3 ‘‘(1) services under the plan will be provided 

4 only through appropriate, qualified community pro5 grams (which may include federally qualified behav6 ioral health centers, child mental health programs, 

7 psychosocial rehabilitation programs, mental health 

8 peer-support programs, and mental health primary 

9 consumer-directed programs); and’’; and 

10 (B) in paragraph (2), by striking ‘‘commu11 nity mental health centers’’ and inserting ‘‘fed12 erally qualified behavioral health centers’’; and 

13 (3) by striking subsection (c) and inserting the 

14 following: 

15 ‘‘(c) CRITERIA FOR FEDERALLY QUALIFIED BEHAV16 IORAL HEALTH CENTERS.— 

17 ‘‘(1) IN GENERAL.—The Administrator shall 

18 certify, and recertify at least every 5 years, federally 

19 qualified behavioral health centers as meeting the 

20 criteria specified in this subsection. 

21 ‘‘(2) REGULATIONS.—Not later than 18 months 

22 after the date of the enactment of the Affordable 

23 Health Care for America Act, the Administrator 

24 shall issue final regulations for certifying centers 

25 under paragraph (1). 


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1 ‘‘(3) CRITERIA.—The criteria referred to in 

2 subsection (b)(2) are that the center performs each 

3 of the following: 

4 ‘‘(A) Provide services in locations that en5 sure services will be available and accessible 

6 promptly and in a manner which preserves 

7 human dignity and assures continuity of care. 

8 ‘‘(B) Provide services in a mode of service 

9 delivery appropriate for the target population. 

10 ‘‘(C) Provide individuals with a choice of 

11 service options where there is more than one ef12 ficacious treatment. 

13 ‘‘(D) Employ a core staff of clinical staff 

14 that is multidisciplinary and culturally and lin15 guistically competent. 

16 ‘‘(E) Provide services, within the limits of 

17 the capacities of the center, to any individual 

18 residing or employed in the service area of the 

19 center. 

20 ‘‘(F) Provide, directly or through contract, 

21 to the extent covered for adults in the State 

22 Medicaid plan and for children in accordance 

23 with section 1905(r) of the Social Security Act 

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1 nosis, and treatment, each of the following serv2 ices: 

3 ‘‘(i) Screening, assessment, and diag4 nosis, including risk assessment. 

5 ‘‘(ii) Person-centered treatment plan6 ning or similar processes, including risk as7 sessment and crisis planning. 

8 ‘‘(iii) Outpatient clinic mental health 

9 services, including screening, assessment, 

10 diagnosis, psychotherapy, substance abuse 

11 counseling, medication management, and 

12 integrated treatment for mental illness and 

13 substance abuse which shall be evidence14 based (including cognitive behavioral ther15 apy, dialectical behavioral therapy, motiva16 tional interviewing, and other such thera17 pies which are evidence-based). 

18 ‘‘(iv) Outpatient clinic primary care 

19 services, including screening and moni20 toring of key health indicators and health 

21 risk (including screening for diabetes, hy22 pertension, and cardiovascular disease and 

23 monitoring of weight, height, body mass 

24 index (BMI), blood pressure, blood glucose 

25 or HbA1C, and lipid profile). 


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1 ‘‘(v) Crisis mental health services, in2 cluding 24-hour mobile crisis teams, emer3 gency crisis intervention services, and cri4 sis stabilization. 

5 ‘‘(vi) Targeted case management 

6 (services to assist individuals gaining ac7 cess to needed medical, social, educational, 

8 and other services and applying for income 

9 security and other benefits to which they 

10 may be entitled). 

11 ‘‘(vii) Psychiatric rehabilitation serv12 ices including skills training, assertive com13 munity treatment, family psychoeducation, 

14 disability self-management, supported em15 ployment, supported housing services, 

16 therapeutic foster care services, multisys17 temic therapy, and such other evidence18 based practices as the Secretary may re19 quire. 

20 ‘‘(viii) Peer support and counselor 

21 services and family supports. 

22 ‘‘(G) Maintain linkages, and where possible 

23 enter into formal contracts with, inpatient psy24 chiatric facilities and substance abuse detoxi25 fication and residential programs. 


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1 ‘‘(H) Make available to individuals served 

2 by the center, directly, through contract, or 

3 through linkages with other programs, each of 

4 the following: 

5 ‘‘(i) Adult and youth peer support and 

6 counselor services. 

7 ‘‘(ii) Family support services for fami8 lies of children with serious mental dis9 orders. 

10 ‘‘(iii) Other community or regional 

11 services, supports, and providers, including 

12 schools, child welfare agencies, juvenile and 

13 criminal justice agencies and facilities, 

14 housing agencies and programs, employers, 

15 and other social services. 

16 ‘‘(iv) Onsite or offsite access to pri17 mary care services. 

18 ‘‘(v) Enabling services, including out19 reach, transportation, and translation. 

20 ‘‘(vi) Health and wellness services, in21 cluding services for tobacco cessation.’’. 


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1 PART 2—OTHER GRANT PROGRAMS 

2 SEC. 2521. COMPREHENSIVE PROGRAMS TO PROVIDE EDU3 CATION TO NURSES AND CREATE A PIPELINE 

4 TO NURSING. 

5 (a) PURPOSES.—It is the purpose of this section to 

6 authorize grants to— 

7 (1) address the projected shortage of nurses by 

8 funding comprehensive programs to create a career 

9 ladder to nursing (including certified nurse assist10 ants, licensed practical nurses, licensed vocational 

11 nurses, and registered nurses) for incumbent ancil12 lary health care workers; 

13 (2) increase the capacity for educating nurses 

14 by increasing both nurse faculty and clinical oppor15 tunities through collaborative programs between 

16 staff nurse organizations, health care providers, and 

17 accredited schools of nursing; and 

18 (3) provide training programs through edu19 cation and training organizations jointly adminis20 tered by health care providers and health care labor 

21 organizations or other organizations representing 

22 staff nurses and frontline health care workers, work23 ing in collaboration with accredited schools of nurs24 ing and academic institutions. 

25 (b) GRANTS.—Not later than 6 months after the date 

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1 ferred to in this section as the ‘‘Secretary’’) shall establish 

2 a partnership grant program to award grants to eligible 

3 entities to carry out comprehensive programs to provide 

4 education to nurses and create a pipeline to nursing for 

5 incumbent ancillary health care workers who wish to ad6 vance their careers, and to otherwise carry out the pur7 poses of this section. 

8 (c) ELIGIBILITY.—To be eligible for a grant under 

9 this section, an entity shall be— 

10 (1) a health care entity that is jointly adminis11 tered by a health care employer and a labor union 

12 representing the health care employees of the em13 ployer and that carries out activities using labor14 management training funds as provided for under 

15 section 302(c)(6) of the Labor Management Rela16 tions Act, 1947 (29 U.S.C. 186(c)(6)); 

17 (2) an entity that operates a training program 

18 that is jointly administered by— 

19 (A) one or more health care providers or 

20 facilities, or a trade association of health care 

21 providers; and 

22 (B) one or more organizations which rep23 resent the interests of direct care health care 

24 workers or staff nurses and in which the direct 

25 care health care workers or staff nurses have 


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1 direct input as to the leadership of the organi2 zation; 

3 (3) a State training partnership program that 

4 consists of nonprofit organizations that include equal 

5 participation from industry, including public or pri6 vate employers, and labor organizations including 

7 joint labor-management training programs, and 

8 which may include representatives from local govern9 ments, worker investment agency one-stop career 

10 centers, community-based organizations, community 

11 colleges, and accredited schools of nursing; or 

12 (4) a school of nursing (as defined in section 

13 801 of the Public Health Service Act (42 U.S.C. 

14 296)). 

15 (d) ADDITIONAL REQUIREMENTS FOR HEALTH CARE

16 EMPLOYER DESCRIBED IN SUBSECTION (c).—To be eligi17 ble for a grant under this section, a health care employer 

18 described in subsection (c) shall demonstrate that it— 

19 (1) has an established program within its facil20 ity to encourage the retention of existing nurses; 

21 (2) provides wages and benefits to its nurses 

22 that are competitive for its market or that have been 

23 collectively bargained with a labor organization; and 

24 (3) supports programs funded under this sec25 tion through 1 or more of the following: 


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1 (A) The provision of paid leave time and 

2 continued health coverage to incumbent health 

3 care workers to allow their participation in 

4 nursing career ladder programs, including cer5 tified nurse assistants, licensed practical nurses, 

6 licensed vocational nurses, and registered 

7 nurses. 

8 (B) Contributions to a joint labor-manage9 ment training fund which administers the pro10 gram involved. 

11 (C) The provision of paid release time, in12 centive compensation, or continued health cov13 erage to staff nurses who desire to work full- or 

14 part-time in a faculty position. 

15 (D) The provision of paid release time for 

16 staff nurses to enable them to obtain a bachelor 

17 of science in nursing degree, other advanced 

18 nursing degrees, specialty training, or certifi19 cation program. 

20 (E) The payment of tuition assistance 

21 which is managed by a joint labor-management 

22 training fund or other jointly administered pro23 gram. 

24 (e) OTHER REQUIREMENTS.— 

25 (1) MATCHING REQUIREMENT.— 


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1 (A) IN GENERAL.—The Secretary may not 

2 make a grant under this section unless the ap3 plicant involved agrees, with respect to the costs 

4 to be incurred by the applicant in carrying out 

5 the program under the grant, to make available 

6 non-Federal contributions (in cash or in kind 

7 under subparagraph (B)) toward such costs in 

8 an amount equal to not less than $1 for each 

9 $1 of Federal funds provided in the grant. Such 

10 contributions may be made directly or through 

11 donations from public or private entities, or 

12 may be provided through the cash equivalent of 

13 paid release time provided to incumbent worker 

14 students. 

15 (B) DETERMINATION OF AMOUNT OF NON16 FEDERAL CONTRIBUTION.—Non-Federal con17 tributions required in subparagraph (A) may be 

18 in cash or in kind (including paid release time), 

19 fairly evaluated, including equipment or services 

20 (and excluding indirect or overhead costs). 

21 Amounts provided by the Federal Government, 

22 or services assisted or subsidized to any signifi23 cant extent by the Federal Government, may 

24 not be included in determining the amount of 

25 such non-Federal contributions. 


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1 (2) REQUIRED COLLABORATION.—Entities car2 rying out or overseeing programs carried out with 

3 assistance provided under this section shall dem4 onstrate collaboration with accredited schools of 

5 nursing which may include community colleges and 

6 other academic institutions providing associate’s, 

7 bachelor’s, or advanced nursing degree programs or 

8 specialty training or certification programs. 

9 (f) USE OF FUNDS.—Amounts awarded to an entity 

10 under a grant under this section shall be used for the fol11 lowing: 

12 (1) To carry out programs that provide edu13 cation and training to establish nursing career lad14 ders to educate incumbent health care workers to be15 come nurses (including certified nurse assistants, li16 censed practical nurses, licensed vocational nurses, 

17 and registered nurses). Such programs shall include 

18 one or more of the following: 

19 (A) Preparing incumbent workers to return 

20 to the classroom through English-as-a-second21 language education, GED education, precollege 

22 counseling, college preparation classes, and sup23 port with entry level college classes that are a 

24 prerequisite to nursing. 


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1 (B) Providing tuition assistance with pref2 erence for dedicated cohort classes in commu3 nity colleges, universities, and accredited 

4 schools of nursing with supportive services in5 cluding tutoring and counseling. 

6 (C) Providing assistance in preparing for 

7 and meeting all nursing licensure tests and re8 quirements. 

9 (D) Carrying out orientation and 

10 mentorship programs that assist newly grad11 uated nurses in adjusting to working at the 

12 bedside to ensure their retention 

13 postgraduation, and ongoing programs to sup14 port nurse retention. 

15 (E) Providing stipends for release time and 

16 continued health care coverage to enable incum17 bent health care workers to participate in these 

18 programs. 

19 (2) To carry out programs that assist nurses in 

20 obtaining advanced degrees and completing specialty 

21 training or certification programs and to establish 

22 incentives for nurses to assume nurse faculty posi23 tions on a part-time or full-time basis. Such pro24 grams shall include one or more of the following: 


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1 (A) Increasing the pool of nurses with ad2 vanced degrees who are interested in teaching 

3 by funding programs that enable incumbent 

4 nurses to return to school. 

5 (B) Establishing incentives for advanced 

6 degree bedside nurses who wish to teach in 

7 nursing programs so they can obtain a leave 

8 from their bedside position to assume a full- or 

9 part-time position as adjunct or full-time fac10 ulty without the loss of salary or benefits. 

11 (C) Collaboration with accredited schools 

12 of nursing which may include community col13 leges and other academic institutions providing 

14 associate’s, bachelor’s, or advanced nursing de15 gree programs, or specialty training or certifi16 cation programs, for nurses to carry out innova17 tive nursing programs which meet the needs of 

18 bedside nursing and health care providers. 

19 (g) PREFERENCE.—In awarding grants under this 

20 section the Secretary shall give preference to programs 

21 that— 

22 (1) provide for improving nurse retention; 

23 (2) provide for improving the diversity of the 

24 new nurse graduates to reflect changes in the demo25 graphics of the patient population; 


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1 (3) provide for improving the quality of nursing 

2 education to improve patient care and safety; 

3 (4) have demonstrated success in upgrading in4 cumbent health care workers to become nurses or 

5 which have established effective programs or pilots 

6 to increase nurse faculty; or 

7 (5) are modeled after or affiliated with such 

8 programs described in paragraph (4). 

9 (h) EVALUATION.— 

10 (1) PROGRAM EVALUATIONS.—An entity that 

11 receives a grant under this section shall annually 

12 evaluate, and submit to the Secretary a report on, 

13 the activities carried out under the grant and the 

14 outcomes of such activities. Such outcomes may in15 clude— 

16 (A) an increased number of incumbent 

17 workers entering an accredited school of nurs18 ing and in the pipeline for nursing programs; 

19 (B) an increasing number of graduating 

20 nurses and improved nurse graduation and li21 censure rates; 

22 (C) improved nurse retention; 

23 (D) an increase in the number of staff 

24 nurses at the health care facility involved; 


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1 (E) an increase in the number of nurses 

2 with advanced degrees in nursing; 

3 (F) an increase in the number of nurse 

4 faculty; 

5 (G) improved measures of patient quality 

6 (which may include staffing ratios of nurses, 

7 patient satisfaction rates, and patient safety 

8 measures); and 

9 (H) an increase in the diversity of new 

10 nurse graduates relative to the patient popu11 lation. 

12 (2) GENERAL REPORT.—Not later than 2 years 

13 after the date of the enactment of this Act, and an14 nually thereafter, the Secretary of Labor shall, using 

15 data and information from the reports received 

16 under paragraph (1), submit to the Congress a re17 port concerning the overall effectiveness of the grant 

18 program carried out under this section. 

19 (i) AUTHORIZATION OF APPROPRIATIONS.—There 

20 are authorized to be appropriated to carry out this section 

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

22 2011 through 2015. 

23 SEC. 2522. MENTAL AND BEHAVIORAL HEALTH TRAINING. 

24 Part E of title VII (42 U.S.C. 294n et seq.) is amend25 ed by adding at the end the following: 


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1 ‘‘Subpart 3—Mental and Behavioral Health Training 

2 ‘‘SEC. 775. MENTAL AND BEHAVIORAL HEALTH TRAINING 

3 PROGRAM. 

4 ‘‘(a) PROGRAM.—The Secretary, acting through the 

5 Administrator of the Health Resources and Services Ad6 ministration and in consultation with the Administrator 

7 of the Substance Abuse and Mental Health Services Ad8 ministration, shall establish an interdisciplinary mental 

9 and behavioral health training program consisting of 

10 awarding grants and contracts under subsection (b). 

11 ‘‘(b) SUPPORT AND DEVELOPMENT OF MENTAL AND

12 BEHAVIORAL HEALTH TRAINING PROGRAMS.—The Sec13 retary shall make grants to, or enter into contracts with, 

14 eligible entities— 

15 ‘‘(1) to plan, develop, operate, or participate in 

16 an accredited professional training program for men17 tal and behavioral health professionals to promote— 

18 ‘‘(A) interdisciplinary training; and 

19 ‘‘(B) coordination of the delivery of health 

20 care within and across settings, including health 

21 care institutions, community-based settings, 

22 and the patient’s home; 

23 ‘‘(2) to provide financial assistance to mental 

24 and behavioral health professionals, who are partici25 pants in any such program, and who plan to work 

26 in the field of mental and behavioral health; 


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1 ‘‘(3) to plan, develop, operate, or participate in 

2 an accredited program for the training of mental 

3 and behavioral health professionals who plan to 

4 teach in the field of mental and behavioral health; 

5 and 

6 ‘‘(4) to provide financial assistance in the form 

7 of traineeships and fellowships to mental and behav8 ioral health professionals who are participants in any 

9 such program and who plan to teach in the field of 

10 mental and behavioral health. 

11 ‘‘(c) ELIGIBILITY.—To be eligible for a grant or con12 tract under subsection (b), an entity shall be— 

13 ‘‘(1) an accredited health professions school, in14 cluding an accredited school or program of psy15 chology, psychiatry, social work, marriage and family 

16 therapy, professional mental health or substance 

17 abuse counseling, or addiction medicine; 

18 ‘‘(2) an accredited public or nonprofit private 

19 hospital; 

20 ‘‘(3) a public or private nonprofit entity; or 

21 ‘‘(4) a consortium of 2 or more entities de22 scribed in paragraphs (1) through (3). 

23 ‘‘(d) PREFERENCE.—In awarding grants or contracts 

24 under this section, the Secretary shall give preference to 


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1 entities that have a demonstrated record of at least one 

2 of the following: 

3 ‘‘(1) Training a high or significantly improved 

4 percentage of health professionals who serve in un5 derserved communities. 

6 ‘‘(2) Supporting teaching programs that ad7 dress the health care needs of vulnerable popu8 lations. 

9 ‘‘(3) Training individuals who are from dis10 advantaged backgrounds (including racial and ethnic 

11 minorities underrepresented among mental and be12 havioral health professionals). 

13 ‘‘(4) Training individuals who serve geriatric 

14 populations with an emphasis on underserved elder15 ly. 

16 ‘‘(5) Training individuals who serve pediatric 

17 populations with an emphasis on underserved chil18 dren. 

19 ‘‘(e) REPORT.—The Secretary shall submit to the 

20 Congress an annual report on the program under this sec21 tion. 

22 ‘‘(f) DEFINITION.—In this section: 

23 ‘‘(1) The term ‘interdisciplinary’ means collabo24 ration across health professions, specialties, and sub25 specialties, which may include public health, nursing, 


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1 allied health, dietetics or nutrition, and appropriate 

2 health specialties. 

3 ‘‘(2) The term ‘mental and behavioral health 

4 professional’ means an individual training or prac5 ticing— 

6 ‘‘(A) in psychology; general, geriatric, child 

7 or adolescent psychiatry; social work; marriage 

8 and family therapy; professional mental health 

9 or substance abuse counseling; or addiction 

10 medicine; or 

11 ‘‘(B) another mental and behavioral health 

12 specialty, as deemed appropriate by the Sec13 retary. 

14 ‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—To 

15 carry out this section, there is authorized to be appro16 priated $60,000,000 for each of fiscal years 2011 through 

17 2015. Of the amounts appropriated to carry out this sec18 tion for a fiscal year, not less than 15 percent shall be 

19 used for training programs in psychology.’’. 

20 SEC. 2523. REAUTHORIZATION OF TELEHEALTH AND TELE21 MEDICINE GRANT PROGRAMS. 

22 (a) TELEHEALTH NETWORK AND TELEHEALTH RE23 SOURCE CENTERS GRANT PROGRAMS.—Section 330I (42 

24 U.S.C. 254c–14) is amended— 

25 (1) in subsection (a)— 


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1 (A) by striking paragraph (3) (relating to 

2 frontier communities); and 

3 (B) by inserting after paragraph (2) the 

4 following: 

5 ‘‘(3) HEALTH DISPARITIES.—The term ‘health 

6 disparities’ has the meaning given such term in sec7 tion 3171.’’; 

8 (2) in subsection (d)(1)— 

9 (A) in subparagraph (B), by striking 

10 ‘‘and’’ at the end; 

11 (B) in subparagraph (C), by striking the 

12 period at the end and inserting ‘‘; and’’; and 

13 (C) by adding at the end the following: 

14 ‘‘(D) reduce health disparities.’’; 

15 (3) in subsection (f)(1)(B)(iii)— 

16 (A) in subclause (VII), by inserting ‘‘, in17 cluding skilled nursing facilities’’ before the pe18 riod at the end; 

19 (B) in subclause (IX), by inserting ‘‘, in20 cluding county mental health and public mental 

21 health facilities’’ before the period at the end; 

22 and 

23 (C) by adding at the end the following: 

24 ‘‘(XIII) Renal dialysis facilities.’’; 


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1 (4) by amending subsection (i) to read as fol2 lows: 

3 ‘‘(i) PREFERENCES.— 

4 ‘‘(1) TELEHEALTH NETWORKS.—In awarding 

5 grants under subsection (d)(1) for projects involving 

6 telehealth networks, the Secretary shall give pref7 erence to eligible entities meeting at least one of the 

8 following: 

9 ‘‘(A) NETWORK.—The eligible entity is a 

10 health care provider in, or proposing to form, a 

11 health care network that furnishes services in a 

12 medically underserved area or a health profes13 sional shortage area. 

14 ‘‘(B) BROAD GEOGRAPHIC COVERAGE.— 

15 The eligible entity demonstrates broad geo16 graphic coverage in the rural or medically un17 derserved areas of the State or States in which 

18 the entity is located. 

19 ‘‘(C) HEALTH DISPARITIES.—The eligible 

20 entity demonstrates how the project to be fund21 ed through the grant will address health dis22 parities. 

23 ‘‘(D) LINKAGES.—The eligible entity 

24 agrees to use the grant to establish or develop 

25 plans for telehealth systems that will link rural 


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1 hospitals and rural health care providers to 

2 other hospitals, health care providers, and pa3 tients. 

4 ‘‘(E) EFFICIENCY.—The eligible entity 

5 agrees to use the grant to promote greater effi6 ciency in the use of health care resources. 

7 ‘‘(F) VIABILITY.—The eligible entity dem8 onstrates the long-term viability of projects 

9 through— 

10 ‘‘(i) availability of non-Federal fund11 ing sources; or 

12 ‘‘(ii) institutional and community sup13 port for the telehealth network. 

14 ‘‘(G) SERVICES.—The eligible entity pro15 vides a plan for coordinating system use by eli16 gible entities and prioritizes use of grant funds 

17 for health care services over nonclinical uses. 

18 ‘‘(2) TELEHEALTH RESOURCE CENTERS.—In 

19 awarding grants under subsection (d)(2) for projects 

20 involving telehealth resource centers, the Secretary 

21 shall give preference to eligible entities meeting at 

22 least one of the following: 

23 ‘‘(A) PROVISION OF A BROAD RANGE OF

24 SERVICES.—The eligible entity has a record of 

25 success in the provision of a broad range of 


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1 telehealth services to medically underserved 

2 areas or populations. 

3 ‘‘(B) PROVISION OF TELEHEALTH TECH4 NICAL ASSISTANCE.—The eligible entity has a 

5 record of success in the provision of technical 

6 assistance to providers serving medically under7 served communities or populations in the estab8 lishment and implementation of telehealth serv9 ices. 

10 ‘‘(C) COLLABORATION AND SHARING OF

11 EXPERTISE.—The eligible entity has a dem12 onstrated record of collaborating and sharing 

13 expertise with providers of telehealth services at 

14 the national, regional, State, and local levels.’’; 

15 (5) in subsection (j)(2)(B), by striking ‘‘such 

16 projects for fiscal year 2001’’ and all that follows 

17 through the period and inserting ‘‘such projects for 

18 fiscal year 2010.’’; 

19 (6) in subsection (k)(1)— 

20 (A) in subparagraph (E)(i), by striking 

21 ‘‘transmission of medical data’’ and inserting 

22 ‘‘transmission and electronic archival of medical 

23 data’’; and 

24 (B) by amending subparagraph (F) to read 

25 as follows: 


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1 ‘‘(F) developing projects to use telehealth 

2 technology to— 

3 ‘‘(i) facilitate collaboration between 

4 health care providers; 

5 ‘‘(ii) promote telenursing services; or 

6 ‘‘(iii) promote patient understanding 

7 and adherence to national guidelines for 

8 chronic disease and self-management of 

9 such conditions;’’; 

10 (7) in subsection (q), by striking ‘‘Not later 

11 than September 30, 2005’’ and inserting ‘‘Not later 

12 than 1 year after the date of the enactment of the 

13 Affordable Health Care for America Act, and annu14 ally thereafter’’; 

15 (8) by striking subsection (r); 

16 (9) by redesignating subsection (s) as sub17 section (r); and 

18 (10) in subsection (r) (as so redesignated)— 

19 (A) in paragraph (1)— 

20 (i) by striking ‘‘and’’ before ‘‘such 

21 sums’’; and 

22 (ii) by inserting ‘‘, $10,000,000 for 

23 fiscal year 2011, and such sums as may be 

24 necessary for each of fiscal years 2012 

25 through 2015’’ before the semicolon; and 


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1 (B) in paragraph (2)— 

2 (i) by striking ‘‘and’’ before ‘‘such 

3 sums’’; and 

4 (ii) by inserting ‘‘, $10,000,000 for 

5 fiscal year 2011, and such sums as may be 

6 necessary for each of fiscal years 2012 

7 through 2015’’ before the period. 

8 (b) TELEMEDICINE; INCENTIVE GRANTS REGARDING

9 COORDINATION AMONG STATES.—Subsection (b) of sec10 tion 330L (42 U.S.C. 254c–18) is amended by inserting 

11 ‘‘, $10,000,000 for fiscal year 2011, and such sums as 

12 may be necessary for each of fiscal years 2012 through 

13 2015’’ before the period at the end. 

14 SEC. 2524. NO CHILD LEFT UNIMMUNIZED AGAINST INFLU15 ENZA: DEMONSTRATION PROGRAM USING EL16 EMENTARY AND SECONDARY SCHOOLS AS IN17 FLUENZA VACCINATION CENTERS. 

18 (a) PURPOSE.—The Secretary of Health and Human 

19 Services in consultation with the Secretary of Education, 

20 shall award grants to eligible partnerships to carry out 

21 demonstration programs designed to test the feasibility of 

22 using the Nation’s elementary schools and secondary 

23 schools as influenza vaccination centers. 

24 (b) IN GENERAL.—The Secretary shall coordinate 

25 with the Secretary of Labor, the Secretary of Education, 


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1 State Medicaid agencies, State insurance agencies, and 

2 private insurers to carry out a program consisting of 

3 awarding grants under subsection (c) to ensure that chil4 dren have coverage for all reasonable and customary ex5 penses related to influenza vaccinations, including the 

6 costs of purchasing and administering the vaccine in7 curred when influenza vaccine is administered outside of 

8 the physician’s office in a school or other related setting. 

9 (c) PROGRAM DESCRIPTION.— 

10 (1) GRANTS.—From amounts appropriated pur11 suant to subsection (l), the Secretary shall award 

12 grants to eligible partnerships to be used to provide 

13 influenza vaccinations to children in elementary and 

14 secondary schools, in coordination with school 

15 nurses, school health care programs, community 

16 health care providers, State insurance agencies, or 

17 private insurers. 

18 (2) ACIP RECOMMENDATIONS.—The program 

19 under this section shall be designed to administer 

20 vaccines consistent with the recommendations of the 

21 Centers for Disease Control and Prevention’s Advi22 sory Committee on Immunization Practices (ACIP) 

23 for the annual vaccination of all children 5 through 

24 19 years of age. 


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1 (3) PARTICIPATION VOLUNTARY.—Participation 

2 by a school or an individual shall be voluntary. 

3 (d) USE OF FUNDS.—Eligible partnerships receiving 

4 a grant under this section shall ensure the maximum num5 ber of children access influenza vaccinations as follows: 

6 (1) COVERED CHILDREN.—To the extent to 

7 which payment of the costs of purchasing or admin8 istering the influenza vaccine for children is not cov9 ered through other federally funded programs or 

10 through private insurance, eligible partnerships re11 ceiving a grant shall use funds to purchase and ad12 minister influenza vaccinations. 

13 (2) CHILDREN COVERED BY OTHER FEDERAL

14 PROGRAMS.—For children who are eligible under 

15 other federally funded programs for payment of the 

16 costs of purchasing or administering the influenza 

17 vaccine, eligible partnerships receiving a grant shall 

18 not use funds provided under this section for such 

19 costs. 

20 (3) CHILDREN COVERED BY PRIVATE HEALTH

21 INSURANCE.—For children who have private insur22 ance, eligible partnerships receiving a grant shall 

23 offer assistance in accessing coverage for vaccina24 tions administered through the program under this 

25 section. 


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1 (e) PRIVACY.—The Secretary shall ensure that the 

2 program under this section adheres to confidentiality and 

3 privacy requirements of section 264 of the Health Insur4 ance Portability and Accountability Act of 1996 (42 

5 U.S.C. 1320d–2 note) and section 444 of the General 

6 Education Provisions Act (20 U.S.C. 1232g; commonly re7 ferred to as the ‘‘Family Educational Rights and Privacy 

8 Act of 1974’’). 

9 (f) APPLICATION.—An eligible partnership desiring a 

10 grant under this section shall submit an application to the 

11 Secretary at such time, in such manner, and containing 

12 such information as the Secretary may require. 

13 (g) DURATION.—Eligible partnerships receiving a 

14 grant shall administer a demonstration program funded 

15 through this section over a period of 2 consecutive school 

16 years. 

17 (h) CHOICE OF VACCINE.—The program under this 

18 section shall not restrict the discretion of a health care 

19 provider to administer any influenza vaccine approved by 

20 the Food and Drug Administration for use in pediatric 

21 populations. 

22 (i) AWARDS.—The Secretary shall award— 

23 (1) a minimum of 10 grants in 10 different 

24 States to eligible partnerships that each include one 


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1 or more public schools serving primarily low-income 

2 students; and 

3 (2) a minimum of 5 grants in 5 different States 

4 to eligible partnerships that each include one or 

5 more public schools located in a rural local edu6 cational agency. 

7 (j) REPORT.—Not later than 90 days following the 

8 completion of the program under this section, the Sec9 retary shall submit to the Committees on Education and 

10 Labor, Energy and Commerce, and Appropriations of the 

11 House of Representatives and to the Committees on 

12 Health, Education, Labor, and Pensions and Appropria13 tions of the Senate a report on the results of the program. 

14 The report shall include— 

15 (1) an assessment of the influenza vaccination 

16 rates of school-age children in localities where the 

17 program is implemented, compared to the national 

18 average influenza vaccination rates for school-aged 

19 children, including whether school-based vaccination 

20 assists in achieving the recommendations of the Ad21 visory Committee on Immunization Practices; 

22 (2) an assessment of the utility of employing el23 ementary schools and secondary schools as a part of 

24 a multistate, community-based pandemic response 


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1 program that is consistent with existing Federal and 

2 State pandemic response plans; 

3 (3) an assessment of the feasibility of using ex4 isting Federal and private insurance funding in es5 tablishing a multistate, school-based vaccination pro6 gram for seasonal influenza vaccination; 

7 (4) an assessment of the number of education 

8 days gained by students as a result of seasonal vac9 cinations based on absenteeism rates; 

10 (5) a determination of whether the program 

11 under this section— 

12 (A) increased vaccination rates in the par13 ticipating localities; and 

14 (B) was implemented for sufficient time 

15 for gathering enough valid data; and 

16 (6) a recommendation on whether the program 

17 should be continued, expanded, or terminated. 

18 (k) DEFINITIONS.—In this section: 

19 (1) ELIGIBLE PARTNERSHIP.—The term ‘‘eligi20 ble partnership’’ means a local public health depart21 ment, or another health organization defined by the 

22 Secretary as eligible to submit an application, and 

23 one or more elementary and secondary schools. 

24 (2) ELEMENTARY SCHOOL.—The terms ‘‘ele25 mentary school’’ and ‘‘secondary school’’ have the 


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1 meanings given such terms in section 9101 of the 

2 Elementary and Secondary Education Act of 1965 

3 (20 U.S.C. 7801). 

4 (3) LOW-INCOME.—The term ‘‘low-income’’ 

5 means a student, age 5 through 19, eligible for free 

6 or reduced-price lunch under the National School 

7 Lunch Act (42 U.S.C. 1751 et seq.). 

8 (4) RURAL LOCAL EDUCATIONAL AGENCY.— 

9 The term ‘‘rural local educational agency’’ means an 

10 eligible local educational agency described in section 

11 6211(b)(1) of the Elementary and Secondary Edu12 cation Act of 1965 (20 U.S.C. 7345(b)(1)). 

13 (5) SECRETARY.—Except as otherwise speci14 fied, the term ‘‘Secretary’’ means the Secretary of 

15 Health and Human Services. 

16 (l) AUTHORIZATION OF APPROPRIATIONS.—To carry 

17 out this section, there are authorized to be appropriated 

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

19 2011 through 2015. 

20 SEC. 2525. EXTENSION OF WISEWOMAN PROGRAM. 

21 Section 1509 of the Public Health Service Act (42 

22 U.S.C. 300n–4a) is amended— 

23 (1) in subsection (a)— 

24 (A) by striking the heading and inserting 

25 ‘‘IN GENERAL.—’’; and 


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1 (B) in the matter preceding paragraph (1), 

2 by striking ‘‘may make grants’’ and all that fol3 lows through ‘‘purpose’’ and inserting the fol4 lowing: ‘‘may make grants to such States for 

5 the purpose’’; and 

6 (2) in subsection (d)(1), by striking ‘‘there are 

7 authorized’’ and all that follows through the period 

8 and inserting ‘‘there are authorized to be appro9 priated $70,000,000 for fiscal year 2011, 

10 $73,500,000 for fiscal year 2012, $77,000,000 for 

11 fiscal year 2013, $81,000,000 for fiscal year 2014, 

12 and $85,000,000 for fiscal year 2015.’’. 

13 SEC. 2526. HEALTHY TEEN INITIATIVE TO PREVENT TEEN 

14 PREGNANCY. 

15 Part B of title III (42 U.S.C. 243 et seq.) is amended 

16 by inserting after section 317T the following: 

17 ‘‘SEC. 317U. HEALTHY TEEN INITIATIVE TO PREVENT TEEN 

18 PREGNANCY. 

19 ‘‘(a) PROGRAM.—To the extent and in the amount 

20 of appropriations made in advance in appropriations Acts, 

21 the Secretary, acting through the Director of the Centers 

22 for Disease Control and Prevention, shall establish a pro23 gram consisting of making grants, in amounts determined 

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1 cation in accordance with subsection (d) for an evidence2 based education program described in subsection (b). 

3 ‘‘(b) USE OF FUNDS.—Amounts received by a State 

4 under this section shall be used to conduct or support evi5 dence-based education programs (directly or through 

6 grants or contracts to public or private nonprofit entities, 

7 including schools and community-based and faith-based 

8 organizations) to reduce teen pregnancy or sexually trans9 mitted diseases. 

10 ‘‘(c) DISTRIBUTION OF FUNDS.—The Director shall, 

11 for fiscal year 2011 and each subsequent fiscal year, make 

12 a grant to each State described in subsection (a) in an 

13 amount equal to the product of— 

14 ‘‘(1) the amount appropriated to carry out this 

15 section for the fiscal year; and 

16 ‘‘(2) the percentage determined for the State 

17 under section 502(c)(1)(B)(ii) of the Social Security 

18 Act. 

19 ‘‘(d) APPLICATION.—To seek a grant under this sec20 tion, a State shall submit an application at such time, in 

21 such manner, and containing such information and assur22 ance of compliance with this section as the Secretary may 

23 require. At a minimum, an application shall to the satis24 faction of the Secretary— 


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1 ‘‘(1) describe how the State’s proposal will ad2 dress the needs of at-risk teens in the State; 

3 ‘‘(2) identify the evidence-based education pro4 gram or programs selected from the registry devel5 oped under subsection (g) that will be used to ad6 dress risks in priority populations; 

7 ‘‘(3) describe how the program or programs will 

8 be implemented and any adaptations to the evidence9 based model that will be made; 

10 ‘‘(4) list any private and public entities with 

11 whom the State proposes to work, including schools 

12 and community-based and faith-based organizations, 

13 and demonstrate their capacity to implement the 

14 proposed program or programs; and 

15 ‘‘(5) identify an independent entity that will 

16 evaluate the impact of the program or programs. 

17 ‘‘(e) EVALUATION.— 

18 ‘‘(1) REQUIREMENT.—As a condition on receipt 

19 of a grant under this section, a State shall agree— 

20 ‘‘(A) to arrange for an independent evalua21 tion of the impact of the programs to be con22 ducted or supported through the grant; and 

23 ‘‘(B) submit reports to the Secretary on 

24 such programs and the results of evaluation of 

25 such programs. 


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1 ‘‘(2) FUNDING LIMITATION.—Of the amounts 

2 made available to a State through a grant under this 

3 section for any fiscal year, not more than 10 percent 

4 may be used for such evaluation. 

5 ‘‘(f) RULE OF CONSTRUCTION.—This section shall 

6 not be construed to preempt or limit any State law regard7 ing parental involvement and decisionmaking in children’s 

8 education. 

9 ‘‘(g) REGISTRY OF ELIGIBLE PROGRAMS.—The Sec10 retary shall develop not later than 180 days after the date 

11 of the enactment of the Affordable Health Care for Amer12 ica Act, and periodically update thereafter, a publicly 

13 available registry of programs described in subsection (b) 

14 that, as determined by the Secretary— 

15 ‘‘(1) meet the definition of the term ‘evidence16 based’ in subsection (i); 

17 ‘‘(2) are medically and scientifically accurate; 

18 and 

19 ‘‘(3) provide age-appropriate information. 

20 ‘‘(h) MATCHING FUNDS.—The Secretary may award 

21 a grant to a State under this section for a fiscal year only 

22 if the State agrees to provide, from non-Federal sources, 

23 an amount equal to $1 (in cash or in kind) for each $4 

24 provided through the grant to carry out the activities sup25 ported by the grant. 


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1 ‘‘(i) DEFINITION.—In this section, the term ‘evi2 dence-based’ means based on a model that has been found, 

3 in methodologically sound research— 

4 ‘‘(1) to delay initiation of sex; 

5 ‘‘(2) to decrease number of partners; 

6 ‘‘(3) to reduce teen pregnancy; 

7 ‘‘(4) to reduce sexually transmitted infection 

8 rates; or 

9 ‘‘(5) to improve rates of contraceptive use. 

10 ‘‘(j) AUTHORIZATION OF APPROPRIATIONS.—To 

11 carry out this section, there is authorized to be appro12 priated $50,000,000 for each of fiscal years 2011 through 

13 2015.’’. 

14 SEC. 2527. NATIONAL TRAINING INITIATIVES ON AUTISM 

15 SPECTRUM DISORDERS. 

16 Title I of the Developmental Disabilities Assistance 

17 and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) 

18 is amended by adding at the end the following: 

19 ‘‘Subtitle F—National Training Ini20 tiative on Autism Spectrum Dis21 orders 

22 ‘‘SEC. 171. NATIONAL TRAINING INITIATIVE. 

23 ‘‘(a) GRANTS AND TECHNICAL ASSISTANCE.— 

24 ‘‘(1) GRANTS.— 


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1 ‘‘(A) IN GENERAL.—The Secretary, in con2 sultation with the Interagency Autism Coordi3 nating Committee, shall award multiyear grants 

4 to eligible entities to provide individuals (includ5 ing parents and health, allied health, vocational, 

6 and educational professionals) with interdiscipli7 nary training, continuing education, technical 

8 assistance, and information for the purpose of 

9 improving services rendered to children and 

10 adults with autism, and their families, to ad11 dress unmet needs related to autism. 

12 ‘‘(B) ELIGIBLE ENTITY.—To be eligible to 

13 receive a grant under this subsection, an entity 

14 shall be— 

15 ‘‘(i) a University Center for Excel16 lence in Developmental Disabilities Edu17 cation, Research, and Service; or 

18 ‘‘(ii) a comparable interdisciplinary 

19 education, research, and service entity. 

20 ‘‘(C) APPLICATION REQUIREMENTS.—An 

21 entity that desires to receive a grant for a pro22 gram under this paragraph shall submit to the 

23 Secretary an application— 

24 ‘‘(i) demonstrating that the entity has 

25 capacity to— 


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1 ‘‘(I) provide training and tech2 nical assistance in evidence-based 

3 practices to evaluate, and provide ef4 fective interventions, services, treat5 ments, and supports to, children and 

6 adults with autism and their families; 

7 ‘‘(II) include individuals with au8 tism and their families as part of the 

9 program to ensure that an individual10 and family-centered approach is used; 

11 ‘‘(III) share and disseminate ma12 terials and practices that are devel13 oped for, and evaluated to be effective 

14 in, the provision of training and tech15 nical assistance; and 

16 ‘‘(IV) provide training, technical 

17 assistance, interventions, services, 

18 treatments, and supports under this 

19 subsection statewide. 

20 ‘‘(ii) providing assurances that the en21 tity will— 

22 ‘‘(I) provide trainees under this 

23 subsection with an appropriate bal24 ance of interdisciplinary academic and 

25 community-based experiences; and 


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1 ‘‘(II) provide to the Secretary, in 

2 the manner prescribed by the Sec3 retary, data regarding the number of 

4 individuals who have benefitted from, 

5 and outcomes of, the provision of 

6 training and technical assistance 

7 under this subsection; 

8 ‘‘(iii) providing assurances that train9 ing, technical assistance, dissemination of 

10 information, and services under this sub11 section will be— 

12 ‘‘(I) consistent with the goals of 

13 this Act, the Americans with Disabil14 ities Act of 1990, the Individuals with 

15 Disabilities Education Act, and the 

16 Elementary and Secondary Education 

17 Act of 1965; and 

18 ‘‘(II) conducted in coordination 

19 with relevant State agencies, institu20 tions of higher education, and service 

21 providers; and 

22 ‘‘(iv) containing such other informa23 tion and assurances as the Secretary may 

24 require. 


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1 ‘‘(D) USE OF FUNDS.—A grant received 

2 under this subsection shall be used to provide 

3 individuals (including parents and health, allied 

4 health, vocational, and educational profes5 sionals) with interdisciplinary training, con6 tinuing education, technical assistance, and in7 formation for the purpose of improving services 

8 rendered to children and adults with autism, 

9 and their families, to address unmet needs re10 lated to autism. Such training, education, as11 sistance, and information shall include each of 

12 the following: 

13 ‘‘(i) Training health, allied health, vo14 cational, and educational professionals to 

15 identify, evaluate the needs of, and develop 

16 interventions, services, treatments, and 

17 supports for, children and adults with au18 tism. 

19 ‘‘(ii) Developing model services and 

20 supports that demonstrate evidence-based 

21 practices. 

22 ‘‘(iii) Developing systems and prod23 ucts that allow for the interventions, serv24 ices, treatments, and supports to be evalu25 ated for fidelity of implementation. 


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1 ‘‘(iv) Working to expand the avail2 ability of evidence-based, lifelong interven3 tions; educational, employment, and transi4 tion services; and community supports. 

5 ‘‘(v) Providing statewide technical as6 sistance in collaboration with relevant 

7 State agencies, institutions of higher edu8 cation, autism advocacy groups, and com9 munity-based service providers. 

10 ‘‘(vi) Working to develop comprehen11 sive systems of supports and services for 

12 individuals with autism and their families, 

13 including seamless transitions between 

14 education and health systems across the 

15 lifespan. 

16 ‘‘(vii) Promoting training, technical 

17 assistance, dissemination of information, 

18 supports, and services. 

19 ‘‘(viii) Developing mechanisms to pro20 vide training and technical assistance, in21 cluding for-credit courses, intensive sum22 mer institutes, continuing education pro23 grams, distance based programs, and Web24 based information dissemination strategies. 


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1 ‘‘(ix) Promoting activities that sup2 port community-based family and indi3 vidual services and enable individuals with 

4 autism and related developmental disabil5 ities to fully participate in society and 

6 achieve good quality-of-life outcomes. 

7 ‘‘(x) Collecting data on the outcomes 

8 of training and technical assistance pro9 grams to meet statewide needs for the ex10 pansion of services to children and adults 

11 with autism. 

12 ‘‘(E) AMOUNT OF GRANTS.—The amount 

13 of a grant to any entity for a fiscal year under 

14 this section shall be not less than $250,000. 

15 ‘‘(2) TECHNICAL ASSISTANCE.—The Secretary 

16 shall reserve 2 percent of the amount appropriated 

17 to carry out this subsection for a fiscal year to make 

18 a grant to a national organization with dem19 onstrated capacity for providing training and tech20 nical assistance to— 

21 ‘‘(A) assist in national dissemination of 

22 specific information, including evidence-based 

23 best practices, from interdisciplinary training 

24 programs, and when appropriate, other entities 


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1 whose findings would inform the work per2 formed by entities awarded grants; 

3 ‘‘(B) compile and disseminate strategies 

4 and materials that prove to be effective in the 

5 provision of training and technical assistance so 

6 that the entire network can benefit from the 

7 models, materials, and practices developed in 

8 individual centers; 

9 ‘‘(C) assist in the coordination of activities 

10 of grantees under this subsection; 

11 ‘‘(D) develop a Web portal that will pro12 vide linkages to each of the individual training 

13 initiatives and provide access to training mod14 ules, promising training, and technical assist15 ance practices and other materials developed by 

16 grantees; 

17 ‘‘(E) serve as a research-based resource for 

18 Federal and State policymakers on information 

19 concerning the provision of training and tech20 nical assistance for the assessment, and provi21 sion of supports and services for, children and 

22 adults with autism; 

23 ‘‘(F) convene experts from multiple inter24 disciplinary training programs, individuals with 

25 autism, and the families of such individuals to 


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1 discuss and make recommendations with regard 

2 to training issues related to assessment, inter3 ventions, services, treatment, and supports for 

4 children and adults with autism; and 

5 ‘‘(H) undertake any other functions that 

6 the Secretary determines to be appropriate. 

7 ‘‘(3) AUTHORIZATION OF APPROPRIATIONS.— 

8 To carry out this subsection, there are authorized to 

9 be appropriated $17,000,000 for fiscal year 2011 

10 and such sums as may be necessary for each of fis11 cal years 2012 through 2015. 

12 ‘‘(b) EXPANSION OF THE NUMBER OF UNIVERSITY

13 CENTERS FOR EXCELLENCE IN DEVELOPMENTAL DIS14 ABILITIES EDUCATION, RESEARCH, AND SERVICE.— 

15 ‘‘(1) GRANTS.—To provide for the establish16 ment of up to 4 new University Centers for Excel17 lence in Developmental Disabilities Education, Re18 search, and Service, the Secretary shall award up to 

19 4 grants to institutions of higher education. 

20 ‘‘(2) APPLICABLE PROVISIONS.—Except for 

21 subsection (a)(3), the provisions of subsection (a) 

22 shall apply with respect to grants under this sub23 section to the same extent and in the same manner 

24 as such provisions apply with respect to grants 

25 under subsection (a). 


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1 ‘‘(3) PRIORITY.—In awarding grants under this 

2 subsection, the Secretary shall give priority to appli3 cants that— 

4 ‘‘(A) are minority institutions that have 

5 demonstrated capacity to meet the requirements 

6 of this section and provide services to individ7 uals with autism and their families; or 

8 ‘‘(B) are located in a State with one or 

9 more underserved populations. 

10 ‘‘(4) AUTHORIZATION OF APPROPRIATIONS.— 

11 To carry out this subsection, there is authorized to 

12 be appropriated $2,000,000 for each of fiscal years 

13 2011 through 2015. 

14 ‘‘(c) DEFINITIONS.—In this section: 

15 ‘‘(1) The term ‘autism’ means an autism spec16 trum disorder or a related developmental disability. 

17 ‘‘(2) The term ‘interventions’ means edu18 cational methods and positive behavioral support 

19 strategies designed to improve or ameliorate symp20 toms associated with autism. 

21 ‘‘(3) The term ‘minority institution’ has the 

22 meaning given to such term in section 365 of the 

23 Higher Education Act of 1965. 


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1 ‘‘(4) The term ‘services’ means services to as2 sist individuals with autism to live more independ3 ently in their communities. 

4 ‘‘(5) The term ‘treatments’ means health serv5 ices, including mental health services, designed to 

6 improve or ameliorate symptoms associated with au7 tism. 

8 ‘‘(6) The term ‘University Center for Excellence 

9 in Developmental Disabilities Education, Research, 

10 and Service’ means a University Center for Excel11 lence in Development Disabilities Education, Re12 search, and Service that has been or is funded 

13 through subtitle D or subsection (b).’’. 

14 SEC. 2528. IMPLEMENTATION OF MEDICATION MANAGE15 MENT SERVICES IN TREATMENT OF CHRONIC 

16 DISEASES. 

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

18 Human Services (referred to in this section as the ‘‘Sec19 retary’’), acting through the Director of the Agency for 

20 Health Care Research and Quality, shall establish a pro21 gram to provide grants to eligible entities to implement 

22 medication management services (referred to in this sec23 tion as ‘‘MTM services’’) provided by licensed phar24 macists, as a part of a collaborative, multidisciplinary, 

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1 eases for targeted individuals, to improve the quality of 

2 care and reduce overall cost in the treatment of such dis3 eases. The Secretary shall commence the grant program 

4 not later than May 1, 2011. 

5 (b) ELIGIBLE ENTITIES.—To be eligible to receive a 

6 grant under subsection (a), an entity shall— 

7 (1) provide a setting appropriate for MTM serv8 ices, as recommended by the experts described in 

9 subsection (e); 

10 (2) submit to the Secretary a plan for achieving 

11 long-term financial sustainability; 

12 (3) where applicable, submit a plan for coordi13 nating MTM services with other local providers and 

14 where applicable, through or in collaboration with 

15 the Medicare Medical Home Pilot program as estab16 lished by section 1866F of the Social Security Act, 

17 as added by section 1302(a) of this Act; 

18 (4) submit a plan for meeting the requirements 

19 under subsection (c); and 

20 (5) submit to the Secretary such other informa21 tion as the Secretary may require. 

22 (c) MTM SERVICES TO TARGETED INDIVIDUALS.— 

23 The MTM services provided with the assistance of a grant 

24 awarded under subsection (a) shall, as allowed by State 


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1 law (including applicable collaborative pharmacy practice 

2 agreements), include— 

3 (1) performing or obtaining necessary assess4 ments of the health and functional status of each 

5 patient receiving such MTM services; 

6 (2) formulating a medication treatment plan ac7 cording to therapeutic goals agreed upon by the pre8 scriber and the patient or caregiver or authorized 

9 representative of the patient; 

10 (3) selecting, initiating, modifying, recom11 mending changes to, or administering medication 

12 therapy; 

13 (4) monitoring, which may include access to, or14 dering, or performing laboratory assessments, and 

15 evaluating the response of the patient to therapy, in16 cluding safety and effectiveness; 

17 (5) performing an initial comprehensive medica18 tion review to identify, resolve, and prevent medica19 tion-related problems, including adverse drug events, 

20 quarterly targeted medication reviews for ongoing 

21 monitoring, and additional followup interventions on 

22 a schedule developed collaboratively with the pre23 scriber; 

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1 cluding a summary of the medication review) and 

2 the recommendations of the pharmacist to other ap3 propriate health care providers of the patient in a 

4 timely fashion; 

5 (7) providing education and training designed 

6 to enhance the understanding and appropriate use of 

7 the medications by the patient, caregiver, and other 

8 authorized representative; 

9 (8) providing information, support services, and 

10 resources and strategies designed to enhance patient 

11 adherence with therapeutic regimens; 

12 (9) coordinating and integrating MTM services 

13 within the broader health care management services 

14 provided to the patient; and 

15 (10) such other patient care services as are al16 lowed under the scopes of practice for pharmacists 

17 for purposes of other Federal programs. 

18 (d) TARGETED INDIVIDUALS.—MTM services pro19 vided by licensed pharmacists under a grant awarded 

20 under subsection (a) shall be offered to targeted individ21 uals who— 

22 (1) take 4 or more prescribed medications (in23 cluding over-the-counter and dietary supplements); 

24 (2) take any high-risk medications; 


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1 (3) have 2 or more chronic diseases, as identi2 fied by the Secretary; or 

3 (4) have undergone a transition of care, or 

4 other factors, as determined by the Secretary, that 

5 are likely to create a high risk of medication-related 

6 problems. 

7 (e) CONSULTATION WITH EXPERTS.—In designing 

8 and implementing MTM services provided under grants 

9 awarded under subsection (a), the Secretary shall consult 

10 with Federal, State, private, public-private, and academic 

11 entities, pharmacy and pharmacist organizations, health 

12 care organizations, consumer advocates, chronic disease 

13 groups, and other stakeholders involved with the research, 

14 dissemination, and implementation of pharmacist-deliv15 ered MTM services, as the Secretary determines appro16 priate. The Secretary, in collaboration with this group, 

17 shall determine whether it is possible to incorporate rapid 

18 cycle process improvement concepts in use in other Fed19 eral programs that have implemented MTM services. 

20 (f) REPORTING TO THE SECRETARY.—An entity that 

21 receives a grant under subsection (a) shall submit to the 

22 Secretary a report that describes and evaluates, as re23 quested by the Secretary, the activities carried out under 

24 subsection (c), including quality measures, as determined 

25 by the Secretary. 


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1 (g) EVALUATION AND REPORT.—The Secretary shall 

2 submit to the relevant committees of Congress a report 

3 which shall— 

4 (1) assess the clinical effectiveness of phar5 macist-provided services under the MTM services 

6 program, as compared to usual care, including an 

7 evaluation of whether enrollees maintained better 

8 health with fewer hospitalizations and emergency 

9 room visits than similar patients not enrolled in the 

10 program; 

11 (2) assess changes in overall health care re12 source of targeted individuals; 

13 (3) assess patient and prescriber satisfaction 

14 with MTM services; 

15 (4) assess the impact of patient-cost-sharing re16 quirements on medication adherence and rec17 ommendations for modifications; 

18 (5) identify and evaluate other factors that may 

19 impact clinical and economic outcomes, including de20 mographic characteristics, clinical characteristics, 

21 and health services use of the patient, as well as 

22 characteristics of the regimen, pharmacy benefit, 

23 and MTM services provided; and 

24 (6) evaluate the extent to which participating 

25 pharmacists who maintain a dispensing role have a 


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1 conflict of interest in the provision of MTM services, 

2 and if such conflict is found, provide recommenda3 tions on how such a conflict might be appropriately 

4 addressed. 

5 (h) GRANT TO FUND DEVELOPMENT OF PERFORM6 ANCE MEASURES.—The Secretary may award grants or 

7 contracts to eligible entities for the purpose of funding the 

8 development of performance measures that assess the use 

9 and effectiveness of medication therapy management serv10 ices. 

11 SEC. 2529. POSTPARTUM DEPRESSION. 

12 (a) EXPANSION AND INTENSIFICATION OF ACTIVI13 TIES.— 

14 (1) CONTINUATION OF ACTIVITIES.—The Sec15 retary is encouraged to expand and intensify activi16 ties on postpartum conditions. 

17 (2) PROGRAMS FOR POSTPARTUM CONDI18 TIONS.—In carrying out paragraph (1), the Sec19 retary is encouraged to continue research to expand 

20 the understanding of the causes of, and treatments 

21 for, postpartum conditions, including conducting and 

22 supporting the following: 

23 (A) Basic research concerning the etiology 

24 and causes of the conditions. 


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1 (B) Epidemiological studies to address the 

2 frequency and natural history of the conditions 

3 and the differences among racial and ethnic 

4 groups with respect to the conditions. 

5 (C) The development of improved screen6 ing and diagnostic techniques. 

7 (D) Clinical research for the development 

8 and evaluation of new treatments. 

9 (E) Information and education programs 

10 for health professionals and the public, which 

11 may include a coordinated national campaign 

12 that— 

13 (i) is designed to increase the aware14 ness and knowledge of postpartum condi15 tions; 

16 (ii) may include public service an17 nouncements through television, radio, and 

18 other means; and 

19 (iii) may focus on— 

20 (I) raising awareness about 

21 screening; 

22 (II) educating new mothers and 

23 their families about postpartum condi24 tions to promote earlier diagnosis and 

25 treatment; and 


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1 (III) ensuring that such edu2 cation includes complete information 

3 concerning postpartum conditions, in4 cluding its symptoms, methods of cop5 ing with the illness, and treatment re6 sources. 

7 (b) REPORT BY THE SECRETARY.— 

8 (1) STUDY.—The Secretary shall conduct a 

9 study on the benefits of screening for postpartum 

10 conditions. 

11 (2) REPORT.—Not later than 2 years after the 

12 date of the enactment of this Act, the Secretary 

13 shall complete the study required by paragraph (1) 

14 and submit a report to the Congress on the results 

15 of such study. 

16 (c) SENSE OF CONGRESS REGARDING LONGITU17 DINAL STUDY OF RELATIVE MENTAL HEALTH CON18 SEQUENCES FOR WOMEN OF RESOLVING A PREG19 NANCY.— 

20 (1) SENSE OF CONGRESS.—It is the sense of 

21 the Congress that the Director of the National Insti22 tute of Mental Health may conduct a nationally rep23 resentative longitudinal study (during the period of 

24 fiscal years 2011 through 2020) on the relative men25 tal health consequences for women of resolving a 


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1 pregnancy (intended and unintended) in various 

2 ways, including carrying the pregnancy to term and 

3 parenting the child, carrying the pregnancy to term 

4 and placing the child for adoption, miscarriage, and 

5 having an abortion. This study may assess the inci6 dence, timing, magnitude, and duration of the imme7 diate and long-term mental health consequences 

8 (positive or negative) of these pregnancy outcomes. 

9 (2) REPORT.—Beginning not later than 3 years 

10 after the date of the enactment of this Act, and peri11 odically thereafter for the duration of the study, 

12 such Director may prepare and submit to the Con13 gress reports on the findings of the study. 

14 (d) DEFINITIONS.—In this section: 

15 (1) The term ‘‘postpartum condition’’ means 

16 postpartum depression or postpartum psychosis. 

17 (2) The term ‘‘Secretary’’ means the Secretary 

18 of Health and Human Services. 

19 (e) AUTHORIZATION OF APPROPRIATIONS.—For the 

20 purpose of carrying out this section, in addition to any 

21 other amounts authorized to be appropriated for such pur22 pose, there are authorized to be appropriated such sums 

23 as may be necessary for each of fiscal years 2011 through 

24 2013. 


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1 SEC. 2530. GRANTS TO PROMOTE POSITIVE HEALTH BEHAV2 IORS AND OUTCOMES. 

3 Part P of title III (42 U.S.C. 280g et seq.) is amend4 ed by adding at the end the following: 

5 ‘‘SEC. 399V. GRANTS TO PROMOTE POSITIVE HEALTH BE6 HAVIORS AND OUTCOMES. 

7 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, in col8 laboration with the Director of the Centers for Disease 

9 Control and Prevention and other Federal officials deter10 mined appropriate by the Secretary, is authorized to 

11 award grants to eligible entities to promote positive health 

12 behaviors for populations in medically underserved com13 munities through the use of community health workers. 

14 ‘‘(b) USE OF FUNDS.—Grants awarded under sub15 section (a) shall be used to support community health 

16 workers— 

17 ‘‘(1) to educate, guide, and provide outreach in 

18 a community setting regarding health problems prev19 alent in medically underserved communities, espe20 cially racial and ethnic minority populations; 

21 ‘‘(2) to educate, guide, and provide experiential 

22 learning opportunities that target behavioral risk 

23 factors including— 

24 ‘‘(A) poor nutrition; 

25 ‘‘(B) physical inactivity; 

26 ‘‘(C) being overweight or obese; 


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1 ‘‘(D) tobacco use; 

2 ‘‘(E) alcohol and substance use; 

3 ‘‘(F) injury and violence; 

4 ‘‘(G) risky sexual behavior; 

5 ‘‘(H) untreated mental health problems; 

6 ‘‘(I) untreated dental and oral health prob7 lems; and 

8 ‘‘(J) understanding informed consent; 

9 ‘‘(3) to educate and provide guidance regarding 

10 effective strategies to promote positive health behav11 iors within the family; 

12 ‘‘(4) to educate and provide outreach regarding 

13 enrollment in health insurance including the State 

14 Children’s Health Insurance Program under title 

15 XXI of the Social Security Act, Medicare under title 

16 XVIII of such Act, and Medicaid under title XIX of 

17 such Act; 

18 ‘‘(5) to educate and refer underserved popu19 lations to appropriate health care agencies and com20 munity-based programs and organizations in order 

21 to increase access to quality health care services, in22 cluding preventive health services, and to eliminate 

23 duplicative care; or 


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1 ‘‘(6) to educate, guide, and provide home visita2 tion services regarding maternal health and prenatal 

3 care. 

4 ‘‘(c) APPLICATION.— 

5 ‘‘(1) IN GENERAL.—Each eligible entity that 

6 desires to receive a grant under subsection (a) shall 

7 submit an application to the Secretary, at such time, 

8 in such manner, and accompanied by such informa9 tion as the Secretary may require. 

10 ‘‘(2) CONTENTS.—Each application submitted 

11 pursuant to paragraph (1) shall— 

12 ‘‘(A) describe the activities for which as13 sistance is sought under this section; 

14 ‘‘(B) contain an assurance that, with re15 spect to each community health worker pro16 gram receiving funds under the grant, such pro17 gram will provide training and supervision to 

18 community health workers to enable such work19 ers to provide authorized program services; 

20 ‘‘(C) contain an assurance that the appli21 cant will evaluate the effectiveness of commu22 nity health worker programs receiving funds 

23 under the grant; 

24 ‘‘(D) contain an assurance that each com25 munity health worker program receiving funds 


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1 under the grant will provide services in the cul2 tural context most appropriate for the individ3 uals served by the program; 

4 ‘‘(E) contain a plan to document and dis5 seminate project descriptions and results to 

6 other States and organizations as identified by 

7 the Secretary; and 

8 ‘‘(F) describe plans to enhance the capac9 ity of individuals to utilize health services and 

10 health-related social services under Federal, 

11 State, and local programs by— 

12 ‘‘(i) assisting individuals in estab13 lishing eligibility under the programs and 

14 in receiving the services or other benefits 

15 of the programs; and 

16 ‘‘(ii) providing other services as the 

17 Secretary determines to be appropriate, 

18 that may include transportation and trans19 lation services. 

20 ‘‘(d) PRIORITY.—In awarding grants under sub21 section (a), the Secretary shall give priority to applicants 

22 that— 

23 ‘‘(1) propose to target geographic areas— 


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1 ‘‘(A) with a high percentage of residents 

2 who are eligible for health insurance but are 

3 uninsured or underinsured; 

4 ‘‘(B) with a high percentage of residents 

5 who suffer from chronic diseases including pul6 monary conditions, hypertension, heart disease, 

7 mental disorders, diabetes, and asthma; and 

8 ‘‘(C) with a high infant mortality rate; 

9 ‘‘(2) have experience in providing health or 

10 health-related social services to individuals who are 

11 underserved with respect to such services; and 

12 ‘‘(3) have documented community activity and 

13 experience with community health workers. 

14 ‘‘(e) COLLABORATION WITH ACADEMIC INSTITU15 TIONS.—The Secretary shall encourage community health 

16 worker programs receiving funds under this section to col17 laborate with academic institutions, especially those that 

18 graduate a disproportionate number of health and health 

19 care students from underrepresented racial and ethnic mi20 nority backgrounds. Nothing in this section shall be con21 strued to require such collaboration. 

22 ‘‘(f) EVIDENCE-BASED INTERVENTIONS.—The Sec23 retary shall encourage community health worker programs 

24 receiving funding under this section to implement an out25 come-based payment system that rewards community 


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1 health workers for connecting underserved populations 

2 with the most appropriate services at the most appropriate 

3 time. Nothing in this section shall be construed to require 

4 such payment. 

5 ‘‘(g) QUALITY ASSURANCE AND COST EFFECTIVE6 NESS.—The Secretary shall establish guidelines for assur7 ing the quality of the training and supervision of commu8 nity health workers under the programs funded under this 

9 section and for assuring the cost-effectiveness of such pro10 grams. 

11 ‘‘(h) MONITORING.—The Secretary shall monitor 

12 community health worker programs identified in approved 

13 applications under this section and shall determine wheth14 er such programs are in compliance with the guidelines 

15 established under subsection (g). 

16 ‘‘(i) TECHNICAL ASSISTANCE.—The Secretary may 

17 provide technical assistance to community health worker 

18 programs identified in approved applications under this 

19 section with respect to planning, developing, and operating 

20 programs under the grant. 

21 ‘‘(j) REPORT TO CONGRESS.— 

22 ‘‘(1) IN GENERAL.—Not later than 4 years 

23 after the date on which the Secretary first awards 

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1 mit to Congress a report regarding the grant 

2 project. 

3 ‘‘(2) CONTENTS.—The report required under 

4 paragraph (1) shall include the following: 

5 ‘‘(A) A description of the programs for 

6 which grant funds were used. 

7 ‘‘(B) The number of individuals served 

8 under such programs. 

9 ‘‘(C) An evaluation of— 

10 ‘‘(i) the effectiveness of such pro11 grams; 

12 ‘‘(ii) the cost of such programs; and 

13 ‘‘(iii) the impact of the programs on 

14 the health outcomes of the community resi15 dents. 

16 ‘‘(D) Recommendations for sustaining the 

17 community health worker programs developed 

18 or assisted under this section. 

19 ‘‘(E) Recommendations regarding training 

20 to enhance career opportunities for community 

21 health workers. 

22 ‘‘(k) DEFINITIONS.—In this section: 

23 ‘‘(1) COMMUNITY HEALTH WORKER.—The term 

24 ‘community health worker’ means an individual who 


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1 promotes health or nutrition within the community 

2 in which the individual resides— 

3 ‘‘(A) by serving as a liaison between com4 munities and health care agencies; 

5 ‘‘(B) by providing guidance and social as6 sistance to community residents; 

7 ‘‘(C) by enhancing community residents’ 

8 ability to effectively communicate with health 

9 care providers; 

10 ‘‘(D) by providing culturally and linguis11 tically appropriate health or nutrition edu12 cation; 

13 ‘‘(E) by advocating for individual and com14 munity health, including oral and mental, or 

15 nutrition needs; and 

16 ‘‘(F) by providing referral and followup 

17 services or otherwise coordinating care. 

18 ‘‘(2) COMMUNITY SETTING.—The term ‘commu19 nity setting’ means a home or a community organi20 zation located in the neighborhood in which a partic21 ipant resides. 

22 ‘‘(3) MEDICALLY UNDERSERVED COMMUNITY.— 

23 The term ‘medically underserved community’ means 

24 a community identified by a State, United States 


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1 territory or possession, or federally recognized In2 dian tribe— 

3 ‘‘(A) that has a substantial number of in4 dividuals who are members of a medically un5 derserved population, as defined by section 

6 330(b)(3); and 

7 ‘‘(B) a significant portion of which is a 

8 health professional shortage area as designated 

9 under section 332. 

10 ‘‘(4) SUPPORT.—The term ‘support’ means the 

11 provision of training, supervision, and materials 

12 needed to effectively deliver the services described in 

13 subsection (b), reimbursement for services, and 

14 other benefits. 

15 ‘‘(5) ELIGIBLE ENTITY.—The term ‘eligible en16 tity’ means a public or private nonprofit entity (in17 cluding a State or public subdivision of a State, a 

18 public health department, or a federally qualified 

19 health center), or a consortium of any of such enti20 ties, located in the United States or territory there21 of. 

22 ‘‘(l) AUTHORIZATION OF APPROPRIATIONS.—There is 

23 authorized to be appropriated to carry out this section 

24 $30,000,000 for each of fiscal years 2011 through 2015.’’. 


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1 SEC. 2531. MEDICAL LIABILITY ALTERNATIVES. 

2 (a) INCENTIVE PAYMENTS FOR MEDICAL LIABILITY

3 REFORM.— 

4 (1) IN GENERAL.—To the extent and in the 

5 amounts made available in advance in appropriations 

6 Acts, the Secretary shall make an incentive payment, 

7 in an amount determined by the Secretary, to each 

8 State that has an alternative medical liability law in 

9 compliance with this section. 

10 (2) DETERMINATION BY SECRETARY.—The 

11 Secretary shall determine that a State has an alter12 native medical liability law in compliance with this 

13 section if the Secretary is satisfied that— 

14 (A) the State enacted the law after the 

15 date of the enactment of this Act and is imple16 menting the law; 

17 (B) the law is effective; and 

18 (C) the contents of the law are in accord19 ance with paragraph (4). 

20 (3) CONSIDERATIONS FOR DETERMINING EF21 FECTIVENESS.—In determining whether an alter22 native medical liability law is effective under para23 graph (2)(B), the Secretary shall consider whether 

24 the law— 


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1 (A) makes the medical liability system 

2 more reliable through prevention of, or prompt 

3 and fair resolution of, disputes; 

4 (B) encourages the disclosure of health 

5 care errors; and 

6 (C) maintains access to affordable liability 

7 insurance. 

8 (4) CONTENTS OF ALTERNATIVE MEDICAL LI9 ABILITY LAW.—The contents of an alternative liabil10 ity law are in accordance with this paragraph if— 

11 (A) the litigation alternatives contained in 

12 the law consist of certificate of merit, early 

13 offer, or both; and 

14 (B) the law does not limit attorneys’ fees 

15 or impose caps on damages. 

16 (b) USE OF INCENTIVE PAYMENTS.—Amounts re17 ceived by a State as an incentive payment under this sec18 tion shall be used to improve health care in that State. 

19 (c) TECHNICAL ASSISTANCE.—The Secretary may 

20 provide technical assistance to the States applying for or 

21 receiving an incentive payment under this section. 

22 (d) REPORTS.—Beginning not later than one year 

23 after the date of the enactment of this Act, the Secretary 

24 shall submit to the Congress an annual report on the 

25 progress States have made in enacting and implementing 


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1 alternative medical liability laws in compliance with this 

2 section. Such reports shall contain sufficient documenta3 tion regarding the effectiveness of such laws to enable an 

4 objective comparative analysis of such laws. 

5 (e) DEFINITION.—In this section— 

6 (1) the term ‘‘Secretary’’ means the Secretary 

7 of Health and Human Services; and 

8 (2) the term ‘‘State’’ includes the several 

9 States, District of Columbia, the Commonwealth of 

10 Puerto Rico, and each other territory or possession 

11 of the United States. 

12 (f) AUTHORIZATION OF APPROPRIATIONS.—There 

13 are authorized to be appropriated to carry out this section 

14 such sums as may be necessary, to remain available until 

15 expended. 

16 SEC. 2532. INFANT MORTALITY PILOT PROGRAMS. 

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

18 Human Services (in this section referred to as the ‘‘Sec19 retary’’), acting through the Director, shall award grants 

20 to eligible entities to create, implement, and oversee infant 

21 mortality pilot programs. 

22 (b) PERIOD OF A GRANT.—The period of a grant 

23 under this section shall be 5 consecutive fiscal years. 

24 (c) PREFERENCE.—In awarding grants under this 

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1 ties proposing to serve any of the 15 counties or groups 

2 of counties with the highest rates of infant mortality in 

3 the United States in the past 3 years. 

4 (d) USE OF FUNDS.—Any infant mortality pilot pro5 gram funded under this section may— 

6 (1) include the development of a plan that iden7 tifies the individual needs of each community to be 

8 served and strategies to address those needs; 

9 (2) provide outreach to at-risk mothers through 

10 programs deemed appropriate by the Director; 

11 (3) develop and implement standardized sys12 tems for improved access, utilization, and quality of 

13 social, educational, and clinical services to promote 

14 healthy pregnancies, full term births, and healthy in15 fancies delivered to women and their infants, such 

16 as— 

17 (A) counseling on infant care, feeding, and 

18 parenting; 

19 (B) postpartum care; 

20 (C) prevention of premature delivery; and 

21 (D) additional counseling for at-risk moth22 ers, including smoking cessation programs, 

23 drug treatment programs, alcohol treatment 

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1 lence programs, social and psychological serv2 ices, dental care, and parenting programs; 

3 (4) establish a rural outreach program to pro4 vide care to at-risk mothers in rural areas; 

5 (5) establish a regional public education cam6 paign, including a campaign to— 

7 (A) prevent preterm births; and 

8 (B) educate the public about infant mor9 tality; and 

10 (6) provide for any other activities, programs, 

11 or strategies as identified by the community plan. 

12 (e) LIMITATION.—Of the funds received through a 

13 grant under this section for a fiscal year, an eligible entity 

14 shall not use more than 10 percent for program evalua15 tion. 

16 (f) REPORTS ON PILOT PROGRAMS.— 

17 (1) IN GENERAL.—Not later than 1 year after 

18 receiving a grant, and annually thereafter for the 

19 duration of the grant period, each entity that re20 ceives a grant under subsection (a) shall submit a 

21 report to the Secretary detailing its infant mortality 

22 pilot program. 

23 (2) CONTENTS OF REPORT.—The reports re24 quired under paragraph (1) shall include informa25 tion such as the methodology of, and outcomes and 


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1 statistics from, the grantee’s infant mortality pilot 

2 program. 

3 (3) EVALUATION.—The Secretary shall use the 

4 reports required under paragraph (1) to evaluate, 

5 and conduct statistical research on, infant mortality 

6 pilot programs funded through this section. 

7 (g) DEFINITIONS.—For the purposes of this section: 

8 (1) DIRECTOR.—The term ‘‘Director’’ means 

9 the Director of the Centers for Disease Control and 

10 Prevention. 

11 (2) ELIGIBLE ENTITY.—The term ‘‘eligible enti12 ty’’ means a State, county, city, territorial, or tribal 

13 health department that has submitted a proposal to 

14 the Secretary that the Secretary deems likely to re15 duce infant mortality rates within the standard met16 ropolitan statistical area involved. 

17 (3) TRIBAL.—The term ‘‘tribal’’ refers to an 

18 Indian tribe, a Tribal organization, or an Urban In19 dian organization, as such terms are defined in sec20 tion 4 of the Indian Health Care Improvement Act. 

21 (h) AUTHORIZATION OF APPROPRIATIONS.—To carry 

22 out this section, there are authorized to be appropriated 

23 $10,000,000 for each of fiscal years 2011 through 2015. 


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1 SEC. 2533. SECONDARY SCHOOL HEALTH SCIENCES TRAIN2 ING PROGRAM. 

3 (a) PROGRAM.—The Secretary of Health and Human 

4 Services, acting through the Administrator of the Health 

5 Resources and Services Administration, and in consulta6 tion with the Secretary of Education, may establish a 

7 health sciences training program consisting of awarding 

8 grants and contracts under subsection (b) to prepare sec9 ondary school students for careers in health professions. 

10 (b) DEVELOPMENT AND IMPLEMENTATION OF

11 HEALTH SCIENCES CURRICULA.—The Secretary may 

12 make grants to, or enter into contracts with, eligible enti13 ties— 

14 (1) to plan, develop, or implement secondary 

15 school health sciences curricula, including curricula 

16 in biology, chemistry, physiology, mathematics, nu17 trition, and other courses deemed appropriate by the 

18 Secretary to prepare students for associate’s or 

19 bachelor’s degree programs in health professions or 

20 bachelor’s degree programs in health professions-re21 lated majors; and 

22 (2) to increase the interest of secondary school 

23 students in applying to, and enrolling in, accredited 

24 associate’s or bachelor’s degree programs in health 

25 professions or bachelor’s degree programs in health 

26 professions-related majors, including through— 


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1 (A) work-study programs; 

2 (B) programs to increase awareness of ca3 reers in health professions; and 

4 (C) other activities to increase such inter5 est. 

6 (c) ELIGIBILITY.—To be eligible for a grant or con7 tract under subsection (b), an entity shall— 

8 (1) be a local educational agency; and 

9 (2) provide assurances that activities under the 

10 grant or contract will be carried out in partnership 

11 with an accredited health professions school or pro12 gram, public or private nonprofit hospital, or public 

13 or private nonprofit entity. 

14 (d) PREFERENCE.—In awarding grants and con15 tracts under subsection (b), the Secretary shall give pref16 erence to entities that have a demonstrated record of at 

17 least one of the following: 

18 (1) Graduating a high or significantly improved 

19 percentage of students who have exhibited mastery 

20 in secondary school State science standards. 

21 (2) Graduating students from disadvantaged 

22 backgrounds, including racial and ethnic minorities 

23 who are underrepresented in— 

24 (A) associate’s or bachelor’s degree pro25 grams in health professions or bachelor’s degree 


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1 programs in health professions-related majors; 

2 or 

3 (B) health professions. 

4 (e) REPORT.—The Secretary shall submit to the Con5 gress an annual report on the program carried out under 

6 this section. 

7 (f) DEFINITIONS.—In this section: 

8 (1) The term ‘‘health profession’’ means the 

9 profession of any member of the health workforce, 

10 as defined in section 764(i) of the Public Health 

11 Service Act, as added by section 2261. 

12 (2) The term ‘‘local educational agency’’ has 

13 the meaning given to the term in section 9101 of the 

14 Elementary and Secondary Education Act of 1965 

15 (20 U.S.C. 7801). 

16 (3) The term ‘‘secondary school’’— 

17 (A) means a secondary school, as defined 

18 in section 9101 of the Elementary and Sec19 ondary Education Act of 1965 (20 U.S.C. 

20 7801); and 

21 (B) includes any such school that is a mid22 dle school. 

23 (4) The term ‘‘Secretary’’ means the Secretary 

24 of Health and Human Services except as otherwise 

25 specified. 


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1 (g) AUTHORIZATION OF APPROPRIATIONS.—To carry 

2 out this section, there are authorized to be appropriated 

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

4 2011 through 2015. 

5 SEC. 2534. COMMUNITY-BASED COLLABORATIVE CARE NET6 WORKS. 

7 (a) PURPOSE.—The purpose of this subtitle is to es8 tablish and provide assistance to community-based col9 laborative care networks— 

10 (1) to develop or strengthen coordination of 

11 services to allow all individuals, including the unin12 sured and low-income, to receive efficient and higher 

13 quality care and to gain entry into and receive serv14 ices from a comprehensive system of care; 

15 (2) to develop efficient and sustainable infra16 structure for a health care delivery system charac17 terized by effective collaboration, information shar18 ing, and clinical and financial coordination among 

19 providers of care in the community; 

20 (3) to develop or strengthen activities related to 

21 providing coordinated care for individuals with 

22 chronic conditions; and 

23 (4) to reduce the use of emergency depart24 ments, inpatient and other expensive resources of 

25 hospitals and other providers. 


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1 (b) CREATION OF THE COMMUNITY-BASED COL2 LABORATIVE CARE NETWORK PROGRAM.—Part D of title 

3 III (42 U.S.C. 254b et seq.), as amended, is further 

4 amended by inserting after subpart XII the following new 

5 subpart: 

6 ‘‘Subpart XIII—Community-Based Collaborative Care 

7 Network Program 

8 ‘‘SEC. 340O. COMMUNITY-BASED COLLABORATIVE CARE 

9 NETWORK PROGRAM. 

10 ‘‘(a) IN GENERAL.—The Secretary may award grants 

11 to eligible entities for the purpose of establishing model 

12 projects to accomplish the following goals: 

13 ‘‘(1) To reduce unnecessary use of items and 

14 services furnished in emergency departments of hos15 pitals (especially to ensure that individuals without 

16 health insurance coverage or with inadequate health 

17 insurance coverage do not use the services of such 

18 department instead of the services of a primary care 

19 provider) through methods such as— 

20 ‘‘(A) screening individuals who seek emer21 gency department services for possible eligibility 

22 under relevant governmental health programs 

23 or for subsidies under such programs; and 

24 ‘‘(B) providing such individuals referrals 

25 for followup care and chronic condition care. 


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1 ‘‘(2) To manage chronic conditions to reduce 

2 their severity, negative health outcomes, and ex3 pense. 

4 ‘‘(3) To encourage health care providers to co5 ordinate their efforts so that the most vulnerable pa6 tient populations seek and obtain primary care. 

7 ‘‘(4) To provide more comprehensive and co8 ordinated care to vulnerable low-income individuals 

9 and individuals without health insurance coverage or 

10 with inadequate coverage. 

11 ‘‘(5) To provide mechanisms for improving both 

12 quality and efficiency of care for low-income individ13 uals and families, with an emphasis on those most 

14 likely to remain uninsured despite the existence of 

15 government programs to make health insurance 

16 more affordable. 

17 ‘‘(6) To increase preventive services, including 

18 screening and counseling, to those who would other19 wise not receive such screening, in order to improve 

20 health status and reduce long-term complications 

21 and costs. 

22 ‘‘(7) To ensure the availability of community23 wide safety net services, including emergency and 

24 trauma care. 

25 ‘‘(b) ELIGIBILITY AND GRANTEE SELECTION.— 


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1 ‘‘(1) APPLICATION.—A community-based col2 laborative care network described in subsection (d) 

3 shall submit to the Secretary an application in such 

4 form and manner and containing such information 

5 as specified by the Secretary. Such information shall 

6 at least— 

7 ‘‘(A) identify the health care providers par8 ticipating in the community-based collaborative 

9 care network proposed by the applicant and, if 

10 a provider designated in paragraph (d)(1)(B) is 

11 not included, the reason such provider is not so 

12 included; 

13 ‘‘(B) include a description of how the pro14 viders plan to collaborate to provide comprehen15 sive and integrated care for low-income individ16 uals, including uninsured and underinsured in17 dividuals; 

18 ‘‘(C) include a description of the organiza19 tional and joint governance structure of the 

20 community-based collaborative care network in 

21 a manner so that it is clear how decisions will 

22 be made, and how the decisionmaking process 

23 of the network will include appropriate rep24 resentation of the participating entities; 


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1 ‘‘(D) define the geographic areas and pop2 ulations that the network intends to serve; 

3 ‘‘(E) define the scope of services that the 

4 network intends to provide and identify any 

5 reasons why such services would not include a 

6 suggested core service identified by the Sec7 retary under paragraph (3); 

8 ‘‘(F) demonstrate the network’s ability to 

9 meet the requirements of this section; and 

10 ‘‘(G) provide assurances that grant funds 

11 received shall be used to support the entire 

12 community-based collaborative care network. 

13 ‘‘(2) SELECTION OF GRANTEES.— 

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

15 select community-based collaborative care net16 works to receive grants from applications sub17 mitted under paragraph (1) on the basis of 

18 quality of the proposal involved, geographic di19 versity (including different States and regions 

20 served and urban and rural diversity), and the 

21 number of low-income and uninsured individ22 uals that the proposal intends to serve. 

23 ‘‘(B) PRIORITY.—The Secretary shall give 

24 priority to proposals from community-based col25 laborative care networks that— 


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1 ‘‘(i) include the capability to provide 

2 the broadest range of services to low-in3 come individuals; and 

4 ‘‘(ii) include providers that currently 

5 serve a high volume of low-income individ6 uals. 

7 ‘‘(C) RENEWAL.—In subsequent years, 

8 based on the performance of grantees, the Sec9 retary may provide renewal grants to prior year 

10 grant recipients. 

11 ‘‘(3) SUGGESTED CORE SERVICES.—For pur12 poses of paragraph (1)(E), the Secretary shall de13 velop a list of suggested core patient and core net14 work services to be provided by a community-based 

15 collaborative care network. The Secretary may select 

16 a community-based collaborative care network under 

17 paragraph (2), the application of which does not in18 clude all such services, if such application provides 

19 a reasonable explanation why such services are not 

20 proposed to be included, and the Secretary deter21 mines that the application is otherwise high quality. 

22 ‘‘(4) TERMINATION AUTHORITY.—The Sec23 retary may terminate selection of a community24 based collaborative care network under this section 


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1 for good cause. Such good cause shall include a de2 termination that the network— 

3 ‘‘(A) has failed to provide a comprehensive 

4 range of coordinated and integrated health care 

5 services as required under subsection (d)(2); 

6 ‘‘(B) has failed to meet reasonable quality 

7 standards; 

8 ‘‘(C) has misappropriated funds provided 

9 under this section; or 

10 ‘‘(D) has failed to make progress toward 

11 accomplishing goals set out in subsection (a). 

12 ‘‘(c) USE OF FUNDS.— 

13 ‘‘(1) USE BY GRANTEES.—Grant funds are pro14 vided to community-based collaborative care net15 works to carry out the following activities: 

16 ‘‘(A) Assist low-income individuals without 

17 adequate health care coverage to— 

18 ‘‘(i) access and appropriately use 

19 health services; 

20 ‘‘(ii) enroll in applicable public or pri21 vate health insurance programs; 

22 ‘‘(iii) obtain referrals to and see a pri23 mary care provider in case such an indi24 vidual does not have a primary care pro25 vider; and 


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1 ‘‘(iv) obtain appropriate care for 

2 chronic conditions. 

3 ‘‘(B) Improve heath care by providing case 

4 management, application assistance, and appro5 priate referrals such as through methods to— 

6 ‘‘(i) create and meaningfully use a 

7 health information technology network to 

8 track patients across collaborative pro9 viders; 

10 ‘‘(ii) perform health outreach, such as 

11 by using neighborhood health workers who 

12 may inform individuals about the avail13 ability of safety net and primary care pro14 viders available through the community15 based collaborative care network; 

16 ‘‘(iii) provide for followup outreach to 

17 remind patients of appointments or follow18 up care instructions; 

19 ‘‘(iv) provide transportation to individ20 uals to and from the site of care; 

21 ‘‘(v) expand the capacity to provide 

22 care at any provider participating in the 

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1 cess to services after-hours, on weekends, 

2 or otherwise providing an urgent care al3 ternative to an emergency department; and 

4 ‘‘(vi) provide a primary care provider 

5 or medical home for each network patient. 

6 ‘‘(C) Provide direct patient care services as 

7 described in their application and approved by 

8 the Secretary. 

9 ‘‘(2) GRANT FUNDS TO HRSA GRANTEES.—The 

10 Secretary may limit the percent of grant funding 

11 that may be spent on direct care services provided 

12 by grantees of programs administered by the Health 

13 Resources and Services Administration (in this sec14 tion referred to as ‘HRSA’) or impose other require15 ments on HRSA grantees participating in a commu16 nity-based collaborative care network as may be nec17 essary for consistency with the requirements of such 

18 programs. 

19 ‘‘(3) RESERVATION OF FUNDS FOR NATIONAL

20 PROGRAM PURPOSES.—The Secretary may use not 

21 more than 7 percent of funds appropriated to carry 

22 out this section for providing technical assistance to 

23 grantees, obtaining assistance of experts and con24 sultants, holding meetings, developing of tools, dis25 seminating of information, and evaluation. 


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1 ‘‘(d) COMMUNITY-BASED COLLABORATIVE CARE

2 NETWORKS.— 

3 ‘‘(1) IN GENERAL.— 

4 ‘‘(A) DESCRIPTION.—A community-based 

5 collaborative care network described in this sub6 section is a consortium of health care providers 

7 with a joint governance structure that provides 

8 a comprehensive range of coordinated and inte9 grated health care services for low-income pa10 tient populations or medically underserved com11 munities (whether or not such individuals re12 ceive benefits under title XVIII, XIX, or XXI 

13 of the Social Security Act, private or other 

14 health insurance or are uninsured or under15 insured) and that complies with any applicable 

16 minimum eligibility requirements that the Sec17 retary may determine appropriate. 

18 ‘‘(B) REQUIRED INCLUSION.—Each such 

19 network shall include the following providers 

20 that serve the community (unless such provider 

21 does not exist within the community, declines or 

22 refuses to participate, or places unreasonable 

23 conditions on their participation)— 

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1 come patients, as demonstrated by meeting 

2 the criteria in section 1923(b)(1) of the 

3 Social Security Act, or other similar cri4 teria determined by the Secretary; and 

5 ‘‘(ii) All Federally qualified health 

6 centers (as defined in section 1861(aa) of 

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

8 1395x(aa))) located in the geographic area 

9 served by the Coordinated Care Network; 

10 ‘‘(C) ADDITIONAL INCLUSIONS.—Each 

11 such network may include any of the following 

12 additional providers: 

13 ‘‘(i) A hospital, including a critical ac14 cess hospital (as defined in section 

15 1820(c)(2) of the Social Security Act (42 

16 U.S.C. 1395i–4(c)(2))). 

17 ‘‘(ii) A county or municipal depart18 ment of health. 

19 ‘‘(iii) A rural health clinic or a rural 

20 health network (as defined in sections 

21 1861(aa) and 1820(d) of the Social Secu22 rity Act, respectively (42 U.S.C. 

23 1395x(aa), 1395i–4(d))). 


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1 ‘‘(iv) A community clinic, including a 

2 mental health clinic, substance abuse clin3 ic, or a reproductive health clinic. 

4 ‘‘(v) A health center controlled net5 work as defined by section 330(e)(1)(C) of 

6 the Public Health Service Act 

7 ‘‘(vi) A private practice physician or 

8 group practice. 

9 ‘‘(vii) A nurse or physician assistant 

10 or group practice. 

11 ‘‘(viii) An adult day care center. 

12 ‘‘(ix) A home health provider. 

13 ‘‘(x) Any other type of provider speci14 fied by the Secretary, which has a desire to 

15 serve low-income and uninsured patients. 

16 ‘‘(D) CONSTRUCTION.— 

17 ‘‘(i) Nothing in this section shall pro18 hibit a single entity from qualifying as 

19 community-based collaborative care net20 work so long as such single entity meets 

21 the criteria of a community-based collabo22 rative care network. If the network does 

23 not include the providers referenced in 

24 clauses (i) and (ii) of subparagraph (B) of 

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1 plain the reason pursuant to subsection 

2 (b)(1)(A). 

3 ‘‘(ii) Participation in a community4 based collaborative care network shall not 

5 affect Federally qualified health centers’ 

6 obligation to comply with the governance 

7 requirements under section 330 of the 

8 Public Health Service Act (42 U.S.C. 

9 254b). 

10 ‘‘(iii) Federally qualified health cen11 ters participating in a community-based 

12 collaborative care network may not be re13 quired to provide services beyond their 

14 Federal Health Center scope of project ap15 proved by HRSA. 

16 ‘‘(iv) Nothing in this section shall be 

17 construed to expand medical malpractice li18 ability protection under the Federal Tort 

19 Claims Act for Section 330-funded Feder20 ally qualified health centers. 

21 ‘‘(2) COMPREHENSIVE RANGE OF COORDINATED

22 AND INTEGRATED HEALTH CARE SERVICES.—The 

23 Secretary shall define criteria for evaluating whether 

24 the services offered by a community-based collabo25 rative care network qualify as a comprehensive range 


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1 of coordinated and integrated health care services. 

2 Such criteria may vary based on the needs of the ge3 ographic areas and populations to be served by the 

4 network and may include the following: 

5 ‘‘(A) Requiring community-based collabo6 rative care networks to include at least the sug7 gested core services identified under subsection 

8 (b)(3), or whichever subset of the suggested 

9 core services is applicable to a particular net10 work. 

11 ‘‘(B) Requiring such networks to assign 

12 each patient of the network to a primary care 

13 provider responsible for managing that patient’s 

14 care. 

15 ‘‘(C) Requiring the services provided by a 

16 community-based collaborative care network to 

17 include support services appropriate to meet the 

18 health needs of low-income populations in the 

19 network’s community, which may include chron20 ic care management, nutritional counseling, 

21 transportation, language services, enrollment 

22 counselors, social services and other services as 

23 proposed by the network. 

24 ‘‘(D) Providing that the services provided 

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1 work may also include long-term care services 

2 and other services not specified in this sub3 section. 

4 ‘‘(E) Providing for the approval by the 

5 Secretary of a scope of community-based col6 laborative care network services for each net7 work that addresses an appropriate minimum 

8 scope of work consistent with the setting of the 

9 network and the health professionals available 

10 in the community the network serves. 

11 ‘‘(3) CLARIFICATION.—Participation in a com12 munity-based collaborative care network shall not 

13 disqualify a health care provider from reimburse14 ment under title XVIII, XIX, or XXI of the Social 

15 Security Act with respect to services otherwise reim16 bursable under such title. Nothing in this section 

17 shall prevent a community-based collaborative care 

18 network that is otherwise eligible to contract with 

19 Medicare, a private health insurer, or any other ap20 propriate entity to provide care under Medicare, 

21 under health insurance coverage offered by the in22 surer, or otherwise. 

23 ‘‘(e) EVALUATIONS.— 

24 ‘‘(1) GRANTEE REPORTS.—Beginning in the 

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1 nity-based collaborative care network shall submit to 

2 the Secretary, with respect to each year the grantee 

3 has received a grant, an evaluation on the activities 

4 carried out by the community-based collaborative 

5 care network under the community-based collabo6 rative care network program and shall include— 

7 ‘‘(A) the number of people served; 

8 ‘‘(B) the most common health problems 

9 treated; 

10 ‘‘(C) any reductions in emergency depart11 ment use; 

12 ‘‘(D) any improvements in access to pri13 mary care; 

14 ‘‘(E) an accounting of how amounts re15 ceived were used, including identification of 

16 amounts used for patient care services as may 

17 be required for HRSA grantees; and 

18 ‘‘(F) to the extent requested by the Sec19 retary, any quality measures or any other meas20 ures specified by the Secretary. 

21 ‘‘(2) PROGRAM REPORTS.—The Secretary shall 

22 submit to Congress an annual evaluation (beginning 

23 not later than 6 months after the first reports under 

24 paragraph (1) are submitted) on the extent to which 

25 emergency department use was reduced as a result 


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1 of the activities carried out by the community-based 

2 collaborative care network under the program. Each 

3 such evaluation shall also include information on— 

4 ‘‘(A) the prevalence of certain chronic con5 ditions in various populations, including a com6 parison of such prevalence in the general popu7 lation versus in the population of individuals 

8 with inadequate health insurance coverage; 

9 ‘‘(B) demographic characteristics of the 

10 population of uninsured and underinsured indi11 viduals served by the community-based collabo12 rative care network involved; and 

13 ‘‘(C) the conditions of such individuals for 

14 whom services were requested at such emer15 gency departments of participating hospitals. 

16 ‘‘(3) AUDIT AUTHORITY.—The Secretary may 

17 conduct periodic audits and request periodic spend18 ing reports of community-based collaborative care 

19 networks under the community-based collaborative 

20 care network program. 

21 ‘‘(f) CLARIFICATION.—Nothing in this section re22 quires a provider to report individually identifiable infor23 mation of an individual to government agencies, unless the 

24 individual consents, consistent with HIPAA privacy and 

25 security law, as defined in section 3009(a)(2). 


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1 ‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—There 

2 are authorized to be appropriated to carry out this section 

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

4 2011 through 2015.’’. 

5 SEC. 2535. COMMUNITY-BASED OVERWEIGHT AND OBESITY 

6 PREVENTION PROGRAM. 

7 Part Q of title III (42 U.S.C. 280h et seq.) is amend8 ed by inserting after section 399W the following: 

9 ‘‘SEC. 399W–1. COMMUNITY-BASED OVERWEIGHT AND OBE10 SITY PREVENTION PROGRAM. 

11 ‘‘(a) PROGRAM.—The Secretary shall establish a 

12 community-based overweight and obesity prevention pro13 gram consisting of awarding grants and contracts under 

14 subsection (b). 

15 ‘‘(b) GRANTS.—The Secretary shall award grants to, 

16 or enter into contracts with, eligible entities— 

17 ‘‘(1) to plan evidence-based programs for the 

18 prevention of overweight and obesity among children 

19 and their families through improved nutrition and 

20 increased physical activity; or 

21 ‘‘(2) to implement such programs. 

22 ‘‘(c) ELIGIBILITY.—To be eligible for a grant or con23 tract under subsection (b), an entity shall be a community 

24 partnership that demonstrates community support and in25 cludes— 


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1 ‘‘(1) a broad cross section of stakeholders, such 

2 as— 

3 ‘‘(A) hospitals, health care systems, com4 munity health centers, or other health care pro5 viders; 

6 ‘‘(B) universities, local educational agen7 cies, or childcare providers; 

8 ‘‘(C) State, local, and tribal health depart9 ments; 

10 ‘‘(D) State, local, and tribal park and 

11 recreation departments; 

12 ‘‘(E) employers; and 

13 ‘‘(F) health insurance companies; 

14 ‘‘(2) residents of the community; and 

15 ‘‘(3) representatives of public and private enti16 ties that have a history of working within and serv17 ing the community. 

18 ‘‘(d) PERIOD OF AWARDS.— 

19 ‘‘(1) IN GENERAL.—The period of a grant or 

20 contract under this section shall be 5 years, subject 

21 to renewal under paragraph (2). 

22 ‘‘(2) RENEWAL.—At the end of each fiscal year, 

23 the Secretary may renew a grant or contract award 

24 under this section only if the grant or contract re25 cipient demonstrates to the Secretary’s satisfaction 


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1 that the recipient has made appropriate, measurable 

2 progress in preventing overweight and obesity. 

3 ‘‘(e) REQUIREMENTS.— 

4 ‘‘(1) IN GENERAL.—The Secretary may award 

5 a grant or contract under this section to an entity 

6 only if the entity demonstrates to the Secretary’s 

7 satisfaction that— 

8 ‘‘(A) not later than 90 days after receiving 

9 the grant or contract, the entity will establish 

10 a steering committee to provide input on the as11 sessment of, and recommendations on improve12 ments to, the entity’s program funded through 

13 the grant or contract; and 

14 ‘‘(B) the entity has conducted or will con15 duct an assessment of the overweight and obe16 sity problem in its community, including the ex17 tent of the problem and factors contributing to 

18 the problem. 

19 ‘‘(2) MATCHING REQUIREMENT.—The Sec20 retary may award a grant or contract to an eligible 

21 entity under this section only if the entity agrees to 

22 provide, from non-Federal sources, an amount equal 

23 to $1 (in cash or in kind) for each $9 provided 

24 through the grant or contract to carry out the activi25 ties supported by the grant or contract. 


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1 ‘‘(3) PAYOR OF LAST RESORT.—The Secretary 

2 may award a grant or contract under this section to 

3 an entity only if the entity demonstrates to the satis4 faction of the Secretary that funds received through 

5 the grant or contract will not be expended for any 

6 activity to the extent that payment has been made, 

7 or can reasonably be expected to be made— 

8 ‘‘(A) under any insurance policy; 

9 ‘‘(B) under any Federal or State health 

10 benefits program (including titles XIX and XXI 

11 of the Social Security Act); or 

12 ‘‘(C) by an entity which provides health 

13 services on a prepaid basis. 

14 ‘‘(4) MAINTENANCE OF EFFORT.—The Sec15 retary may award a grant or contract under this sec16 tion to an entity only if the entity demonstrates to 

17 the satisfaction of the Secretary that— 

18 ‘‘(A) funds received through the grant or 

19 contract will be expended only to supplement, 

20 and not supplant, non-Federal and Federal 

21 funds otherwise available to the entity for the 

22 activities to be funded through the grant or 

23 contract; and 

24 ‘‘(B) with respect to such activities, the en25 tity will maintain expenditures of non-Federal 


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1 amounts for such activities at a level not less 

2 than the lesser of such expenditures maintained 

3 by the entity for the fiscal year preceding the 

4 fiscal year for which the entity receives the 

5 grant or contract. 

6 ‘‘(f) PREFERENCES.—In awarding grants and con7 tracts under this section, the Secretary shall give pref8 erence to eligible entities that— 

9 ‘‘(1) will serve communities with high levels of 

10 overweight and obesity and related chronic diseases; 

11 or 

12 ‘‘(2) will plan or implement activities for the 

13 prevention of overweight and obesity in school or 

14 workplace settings. 

15 ‘‘(g) REPORT.—The Secretary shall submit to the 

16 Congress an annual report on the program of grants and 

17 contracts awarded under this section. 

18 ‘‘(h) DEFINITIONS.—In this section: 

19 ‘‘(1) The term ‘evidence-based’ means that 

20 methodologically sound research has demonstrated a 

21 beneficial health effect in the judgment of the Sec22 retary and includes the Ways to Enhance Children’s 

23 Activity and Nutrition (We Can) program and cur24 riculum of the National Institutes of Health. 


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1 ‘‘(2) The term ‘local educational agency’ has 

2 the meaning given to the term in section 9101 of the 

3 Elementary and Secondary Education Act of 1965. 

4 ‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—To 

5 carry out this section, there are authorized to be appro6 priated $10,000,000 for fiscal year 2011 and such sums 

7 as may be necessary for each of fiscal years 2012 through 

8 2015.’’. 

9 SEC. 2536. REDUCING STUDENT-TO-SCHOOL NURSE RATIOS. 

10 (a) DEMONSTRATION GRANTS.— 

11 (1) IN GENERAL.—The Secretary of Education, 

12 in consultation with the Secretary of Health and 

13 Human Services and the Director of the Centers for 

14 Disease Control and Prevention, may make dem15 onstration grants to eligible local educational agen16 cies for the purpose of reducing the student-to17 school nurse ratio in public elementary and sec18 ondary schools. 

19 (2) SPECIAL CONSIDERATION.—In awarding 

20 grants under this section, the Secretary of Edu21 cation shall give special consideration to applications 

22 submitted by high-need local educational agencies 

23 that demonstrate the greatest need for new or addi24 tional nursing services among children in the public 

25 elementary and secondary schools served by the 


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1 agency, in part by providing information on current 

2 ratios of students to school nurses. 

3 (3) MATCHING FUNDS.—The Secretary of Edu4 cation may require recipients of grants under this 

5 subsection to provide matching funds from non-Fed6 eral sources, and shall permit the recipients to 

7 match funds in whole or in part with in-kind con8 tributions. 

9 (b) REPORT.—Not later than 24 months after the 

10 date on which assistance is first made available to local 

11 educational agencies under this section, the Secretary of 

12 Education shall submit to the Congress a report on the 

13 results of the demonstration grant program carried out 

14 under this section, including an evaluation of the effective15 ness of the program in improving the student-to-school 

16 nurse ratios described in subsection (a) and an evaluation 

17 of the impact of any resulting enhanced health of students 

18 on learning. 

19 (c) DEFINITIONS.—For purposes of this section: 

20 (1) The terms ‘‘elementary school’’, ‘‘local edu21 cational agency’’, and ‘‘secondary school’’ have the 

22 meanings given to those terms in section 9101 of the 

23 Elementary and Secondary Education Act of 1965 

24 (20 U.S.C. 7801). 


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1 (2) The term ‘‘eligible local educational agency’’ 

2 means a local educational agency in which the stu3 dent-to-school nurse ratio in the public elementary 

4 and secondary schools served by the agency is 750 

5 or more students to every school nurse. 

6 (3) The term ‘‘high-need local educational agen7 cy’’ means a local educational agency— 

8 (A) that serves not fewer than 10,000 chil9 dren from families with incomes below the pov10 erty line; or 

11 (B) for which not less than 20 percent of 

12 the children served by the agency are from fam13 ilies with incomes below the poverty line. 

14 (4) The term ‘‘nurse’’ means a licensed nurse, 

15 as defined under State law. 

16 (d) AUTHORIZATION OF APPROPRIATIONS.—To carry 

17 out this section, there are authorized to be appropriated 

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

19 2011 through 2015. 

20 SEC. 2537. MEDICAL-LEGAL PARTNERSHIPS. 

21 (a) IN GENERAL.—The Secretary shall establish a 

22 nationwide demonstration project consisting of— 

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1 tients and their families to navigate health-related 

2 programs and activities; and 

3 (2) evaluating the effectiveness of such partner4 ships. 

5 (b) USE OF FUNDS.—Amounts received as a grant 

6 or contract under this section shall be used to assist pa7 tients and their families to navigate health care-related 

8 programs and activities and thereby achieve one or more 

9 of the following goals: 

10 (1) Enhancing access to health care services. 

11 (2) Improving health outcomes for low-income 

12 individuals. 

13 (3) Reducing health disparities. 

14 (4) Enhancing wellness and prevention of 

15 chronic conditions. 

16 (c) PROHIBITION.—No funds under this section may 

17 be used— 

18 (1) for any medical malpractice or other civil 

19 action or proceeding; or 

20 (2) to assist individuals who are not lawfully 

21 present in the United States. 

22 (d) REPORT.—Not later than 5 years after the date 

23 of the enactment of this Act, the Secretary shall submit 

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1 tion project under this section. Such report shall include 

2 the following: 

3 (1) A description of the extent to which med4 ical-legal partnerships funded through this section 

5 achieved the goals described in subsection (b). 

6 (2) Recommendations on the possibility of ex7 tending or expanding the demonstration project. 

8 (e) DEFINITIONS.—In this section: 

9 (1) The term ‘‘health disparities’’ has the 

10 meaning given to the term in section 3171 of the 

11 Public Health Service Act, as added by section 

12 2301. 

13 (2) The term ‘‘medical-legal partnership’’ 

14 means an entity— 

15 (A) that is a collaboration between— 

16 (i) a community health center, public 

17 hospital, children’s hospital, or other pro18 vider of health care services to a signifi19 cant number of low-income beneficiaries; 

20 and 

21 (ii) one or more attorneys; and 

22 (B) whose primary mission is to assist pa23 tients and their families navigate health care-re24 lated programs and activities. 


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1 (3) The term ‘‘Secretary’’ means the Secretary 

2 of Health and Human Services. 

3 (f) AUTHORIZATION OF APPROPRIATIONS.—To carry 

4 out this section, there are authorized to be appropriated 

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

6 2011 through 2015. 

7 PART 3—EMERGENCY CARE-RELATED 

8 PROGRAMS 

9 SEC. 2551. TRAUMA CARE CENTERS. 

10 (a) GRANTS FOR TRAUMA CARE CENTERS.—Section 

11 1241 (42 U.S.C. 300d–41) is amended to read as follows: 

12 ‘‘SEC. 1241. GRANTS FOR CERTAIN TRAUMA CENTERS. 

13 ‘‘(a) IN GENERAL.—The Secretary shall establish a 

14 trauma center program consisting of awarding grants 

15 under section (b). 

16 ‘‘(b) GRANTS.—The Secretary shall award grants as 

17 follows: 

18 ‘‘(1) EXISTING CENTERS.—Grants to public, 

19 private nonprofit, Indian Health Service, Indian 

20 tribal, and urban Indian trauma centers— 

21 ‘‘(A) to further the core missions of such 

22 centers; or 

23 ‘‘(B) to provide emergency relief to ensure 

24 the continued and future availability of trauma 

25 services by trauma centers— 


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1 ‘‘(i) at risk of closing or operating in 

2 an area where a closing has occurred with3 in their primary service area; or 

4 ‘‘(ii) in need of financial assistance 

5 following a natural disaster or other cata6 strophic event, such as a terrorist attack. 

7 ‘‘(2) NEW CENTERS.—Grants to local govern8 ments and public or private nonprofit entities to es9 tablish new trauma centers in urban areas with a 

10 substantial degree of trauma resulting from violent 

11 crimes. 

12 ‘‘(c) MINIMUM QUALIFICATIONS OF TRAUMA CEN13 TERS.— 

14 ‘‘(1) PARTICIPATION IN TRAUMA CARE SYSTEM

15 OPERATING UNDER CERTAIN PROFESSIONAL GUIDE16 LINES.— 

17 ‘‘(A) LIMITATION.—Subject to subpara18 graph (B), the Secretary may not award a 

19 grant to an existing trauma center under this 

20 section unless the center is a participant in a 

21 trauma care system that substantially complies 

22 with section 1213. 

23 ‘‘(B) EXEMPTION.—Subparagraph (A) 

24 shall not apply to trauma centers that are loVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01468 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 cated in States with no existing trauma care 

2 system. 

3 ‘‘(2) DESIGNATION.—The Secretary may not 

4 award a grant under this section to an existing trau5 ma center unless the center is— 

6 ‘‘(A) verified as a trauma center by the 

7 American College of Surgeons; or 

8 ‘‘(B) designated as a trauma center by the 

9 applicable State health or emergency medical 

10 services authority.’’. 

11 (b) CONSIDERATIONS IN MAKING GRANTS.—Section 

12 1242 (42 U.S.C. 300d–42) is amended to read as follows: 

13 ‘‘SEC. 1242. CONSIDERATIONS IN MAKING GRANTS. 

14 ‘‘(a) CORE MISSION AWARDS.— 

15 ‘‘(1) IN GENERAL.—In awarding grants under 

16 section 1241(b)(1)(A), the Secretary shall— 

17 ‘‘(A) reserve a minimum of 25 percent of 

18 the amount allocated for such grants for level 

19 III and level IV trauma centers in rural or un20 derserved areas; 

21 ‘‘(B) reserve a minimum of 25 percent of 

22 the amount allocated for such grants for level 

23 I and level II trauma centers in urban areas; 

24 and 


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1 ‘‘(C) give preference to any application 

2 made by a trauma center— 

3 ‘‘(i) in a geographic area where 

4 growth in demand for trauma services ex5 ceeds capacity; 

6 ‘‘(ii) that demonstrates the financial 

7 support of the State or political subdivision 

8 involved; 

9 ‘‘(iii) that has at least 1 graduate 

10 medical education fellowship in trauma or 

11 trauma-related specialties, including neuro12 logical surgery, surgical critical care, vas13 cular surgery, and spinal cord injury, for 

14 which demand is exceeding supply; or 

15 ‘‘(iv) that demonstrates a substantial 

16 commitment to serving vulnerable popu17 lations. 

18 ‘‘(2) FINANCIAL SUPPORT.—For purposes of 

19 paragraph (1)(C)(ii), financial support may be dem20 onstrated by State or political subdivision funding 

21 for the trauma center’s capital or operating expenses 

22 (including through State trauma regional advisory 

23 coordination activities, Medicaid funding designated 

24 for trauma services, or other governmental funding). 

25 State funding derived from Federal support shall 


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1 not constitute State or local financial support for 

2 purposes of preferential treatment under this sub3 section. 

4 ‘‘(3) USE OF FUNDS.—The recipient of a grant 

5 under section 1241(b)(1)(A) shall carry out, con6 sistent with furthering the core missions of the cen7 ter, one or more of the following activities: 

8 ‘‘(A) Providing 24-hour-a-day, 7-day-a9 week trauma care availability. 

10 ‘‘(B) Reducing overcrowding related to 

11 throughput of trauma patients. 

12 ‘‘(C) Enhancing trauma surge capacity. 

13 ‘‘(D) Ensuring physician and essential per14 sonnel availability. 

15 ‘‘(E) Trauma education and outreach. 

16 ‘‘(F) Coordination with local and regional 

17 trauma care systems. 

18 ‘‘(G) Such other activities as the Secretary 

19 may deem appropriate. 

20 ‘‘(b) EMERGENCY AWARDS; NEW CENTERS.—In 

21 awarding grants under paragraphs (1)(B) and (2) of sec22 tion 1241(b), the Secretary shall— 

23 ‘‘(1) give preference to any application sub24 mitted by an applicant that demonstrates the finan25 cial support (in accordance with subsection (a)(2)) 


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1 of the State or political subdivision involved for the 

2 activities to be funded through the grant for each 

3 fiscal year during which payments are made to the 

4 center under the grant; and 

5 ‘‘(2) give preference to any application sub6 mitted for a trauma center that— 

7 ‘‘(A) is providing or will provide trauma 

8 care in a geographic area in which the avail9 ability of trauma care has either significantly 

10 decreased as a result of a trauma center in the 

11 area permanently ceasing participation in a sys12 tem described in section 1241(c)(1) as of a date 

13 occurring during the 2-year period preceding 

14 the fiscal year for which the trauma center is 

15 applying to receive a grant, or in geographic 

16 areas where growth in demand for trauma serv17 ices exceeds capacity; 

18 ‘‘(B) will, in providing trauma care during 

19 the 1-year period beginning on the date on 

20 which the application for the grant is sub21 mitted, incur substantial uncompensated care 

22 costs in an amount that renders the center un23 able to continue participation in such system 

24 and results in a significant decrease in the 


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1 availability of trauma care in the geographic 

2 area; 

3 ‘‘(C) operates or will operate in rural areas 

4 where trauma care availability will significantly 

5 decrease if the center is forced to close or down6 grade service and substantial costs are contrib7 uting to a likelihood of such closure or 

8 downgradation; 

9 ‘‘(D) is in a geographic location substan10 tially affected by a natural disaster or other 

11 catastrophic event such as a terrorist attack; or 

12 ‘‘(E) will establish a new trauma service in 

13 an urban area with a substantial degree of 

14 trauma resulting from violent crimes. 

15 ‘‘(c) DESIGNATIONS OF LEVELS OF TRAUMA CEN16 TERS IN CERTAIN STATES.—In the case of a State which 

17 has not designated 4 levels of trauma centers, any ref18 erence in this section to— 

19 ‘‘(1) a level I or level II trauma center is 

20 deemed to be a reference to a trauma center within 

21 the highest 2 levels of trauma centers designated 

22 under State guidelines; and 

23 ‘‘(2) a level III or IV trauma center is deemed 

24 to be a reference to a trauma center not within such 

25 highest 2 levels.’’. 


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1 (c) CERTAIN AGREEMENTS.—Section 1243 (42 

2 U.S.C. 300d–43) is amended to read as follows: 

3 ‘‘SEC. 1243. CERTAIN AGREEMENTS. 

4 ‘‘(a) COMMITMENT REGARDING CONTINUED PAR5 TICIPATION IN TRAUMA CARE SYSTEM.—The Secretary 

6 may not award a grant to an applicant under section 

7 1241(b) unless the applicant agrees that— 

8 ‘‘(1) the trauma center involved will continue 

9 participation, or in the case of a new center will par10 ticipate, in the system described in section 

11 1241(c)(1), except as provided in section 

12 1241(c)(1)(B), throughout the grant period begin13 ning on the date that the center first receives pay14 ments under the grant; and 

15 ‘‘(2) if the agreement made pursuant to para16 graph (1) is violated by the center, the center will 

17 be liable to the United States for an amount equal 

18 to the sum of— 

19 ‘‘(A) the amount of assistance provided to 

20 the center under section 1241; and 

21 ‘‘(B) an amount representing interest on 

22 the amount specified in subparagraph (A). 

23 ‘‘(b) MAINTENANCE OF FINANCIAL SUPPORT.—With 

24 respect to activities for which funds awarded through a 

25 grant under section 1241 are authorized to be expended, 


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1 the Secretary may not award such a grant unless the ap2 plicant agrees that, during the period in which the trauma 

3 center involved is receiving payments under the grant, the 

4 center will maintain access to trauma services at levels not 

5 less than the levels for the prior year, taking into ac6 count— 

7 ‘‘(1) reasonable volume fluctuation that is not 

8 caused by intentional trauma boundary reduction; 

9 ‘‘(2) downgrading of the level of services; and 

10 ‘‘(3) whether such center diverts its incoming 

11 patients away from such center 5 percent or more 

12 of the time during which the center is in operation 

13 over the course of the year. 

14 ‘‘(c) TRAUMA CARE REGISTRY.—The Secretary may 

15 not award a grant to a trauma center under section 

16 1241(b)(1) unless the center agrees that— 

17 ‘‘(1) not later than 6 months after the date on 

18 which the center submits a grant application to the 

19 Secretary, the center will establish and operate a 

20 registry of trauma cases in accordance with guide21 lines developed by the American College of Surgeons; 

22 and 

23 ‘‘(2) in carrying out paragraph (1), the center 

24 will maintain information on the number of trauma 

25 cases treated by the center and, for each such case, 


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1 the extent to which the center incurs uncompensated 

2 costs in providing trauma care.’’. 

3 (d) GENERAL PROVISIONS.—Section 1244 (42 

4 U.S.C. 300d–44) is amended to read as follows: 

5 ‘‘SEC. 1244. GENERAL PROVISIONS. 

6 ‘‘(a) LIMITATION ON DURATION OF SUPPORT.—The 

7 period during which a trauma center receives payments 

8 under a grant under section 1241(b)(1) shall be for 3 fis9 cal years, except that the Secretary may waive such re10 quirement for the center and authorize the center to re11 ceive such payments for 1 additional fiscal year. 

12 ‘‘(b) ELIGIBILITY.—The acquisition of, or eligibility 

13 for, a grant under section 1241(b) shall not preclude a 

14 trauma center’s eligibility for another grant described in 

15 such section. 

16 ‘‘(c) FUNDING DISTRIBUTION.—Of the total amount 

17 appropriated for a fiscal year under section 1245— 

18 ‘‘(1) 90 percent shall be used for grants under 

19 paragraph (1)(A) of section 1241(b); and 

20 ‘‘(2) 10 percent shall be used for grants under 

21 paragraphs (1)(B) and (2) of section 1241(b). 

22 ‘‘(d) REPORT.—Beginning 2 years after the date of 

23 the enactment of the Affordable Health Care for America 

24 Act, and every 2 years thereafter, the Secretary shall bien25 nially— 


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1 ‘‘(1) report to Congress on the status of the 

2 grants made pursuant to section 1241; 

3 ‘‘(2) evaluate and report to Congress on the 

4 overall financial stability of trauma centers in the 

5 United States; 

6 ‘‘(3) report on the populations using trauma 

7 care centers and include aggregate patient data on 

8 income, race, ethnicity, and geography; and 

9 ‘‘(4) evaluate the effectiveness and efficiency of 

10 trauma care center activities using standard public 

11 health measures and evaluation methodologies.’’. 

12 (e) AUTHORIZATION OF APPROPRIATIONS.—Section 

13 1245 (42 U.S.C. 300d–45) is amended to read as follows: 

14 ‘‘SEC. 1245. AUTHORIZATION OF APPROPRIATIONS. 

15 ‘‘(a) IN GENERAL.—For the purpose of carrying out 

16 this part, there are authorized to be appropriated 

17 $100,000,000 for fiscal year 2011, and such sums as may 

18 be necessary for each of fiscal years 2012 through 2015. 

19 Such authorization of appropriations is in addition to any 

20 other authorization of appropriations or amounts that are 

21 available for such purpose. 

22 ‘‘(b) REALLOCATION.—The Secretary shall reallocate 

23 for grants under section 1241(b)(1)(A) any funds appro24 priated for grants under paragraph (1)(B) or (2) of secVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01477 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 tion 1241(b), but not obligated due to insufficient applica2 tions eligible for funding.’’. 

3 SEC. 2552. EMERGENCY CARE COORDINATION. 

4 (a) IN GENERAL.—Subtitle B of title XXVIII (42 

5 U.S.C. 300hh–10 et seq.) is amended by adding at the 

6 end the following: 

7 ‘‘SEC. 2816. EMERGENCY CARE COORDINATION. 

8 ‘‘(a) EMERGENCY CARE COORDINATION CENTER.— 

9 ‘‘(1) ESTABLISHMENT.—The Secretary shall es10 tablish, within the Office of the Assistant Secretary 

11 for Preparedness and Response, an Emergency Care 

12 Coordination Center (in this section referred to as 

13 the ‘Center’), to be headed by a director. 

14 ‘‘(2) DUTIES.—The Secretary, acting through 

15 the Director of the Center, in coordination with the 

16 Federal Interagency Committee on Emergency Med17 ical Services, shall— 

18 ‘‘(A) promote and fund research in emer19 gency medicine and trauma health care; 

20 ‘‘(B) promote regional partnerships and 

21 more effective emergency medical systems in 

22 order to enhance appropriate triage, distribu23 tion, and care of routine community patients; 

24 and 


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1 ‘‘(C) promote local, regional, and State 

2 emergency medical systems’ preparedness for 

3 and response to public health events. 

4 ‘‘(b) COUNCIL OF EMERGENCY CARE.— 

5 ‘‘(1) ESTABLISHMENT.—The Secretary, acting 

6 through the Director of the Center, shall establish a 

7 Council of Emergency Care to provide advice and 

8 recommendations to the Director on carrying out 

9 this section. 

10 ‘‘(2) COMPOSITION.—The Council shall be com11 prised of employees of the departments and agencies 

12 of the Federal Government who are experts in emer13 gency care and management. 

14 ‘‘(c) REPORT.— 

15 ‘‘(1) SUBMISSION.—Not later than 12 months 

16 after the date of the enactment of the Affordable 

17 Health Care for America Act, the Secretary shall 

18 submit to the Congress an annual report on the ac19 tivities carried out under this section. 

20 ‘‘(2) CONSIDERATIONS.—In preparing a report 

21 under paragraph (1), the Secretary shall consider 

22 factors including— 

23 ‘‘(A) emergency department crowding and 

24 boarding; and 

25 ‘‘(B) delays in care following presentation. 


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1 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—To 

2 carry out this section, there are authorized to be appro3 priated such sums as may be necessary for each of fiscal 

4 years 2011 through 2015.’’. 

5 (b) FUNCTIONS, PERSONNEL, ASSETS, LIABILITIES, 

6 AND ADMINISTRATIVE ACTIONS.—All functions, per7 sonnel, assets, and liabilities of, and administrative actions 

8 applicable to, the Emergency Care Coordination Center, 

9 as in existence on the day before the date of the enactment 

10 of this Act, shall be transferred to the Emergency Care 

11 Coordination Center established under section 2816(a) of 

12 the Public Health Service Act, as added by subsection (a). 

13 SEC. 2553. PILOT PROGRAMS TO IMPROVE EMERGENCY 

14 MEDICAL CARE. 

15 Part B of title III (42 U.S.C. 243 et seq.) is amended 

16 by inserting after section 314 the following: 

17 ‘‘SEC. 315. REGIONALIZED COMMUNICATION SYSTEMS FOR 

18 EMERGENCY CARE RESPONSE. 

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

20 the Assistant Secretary for Preparedness and Response, 

21 shall award not fewer than 4 multiyear contracts or com22 petitive grants to eligible entities to support demonstration 

23 programs that design, implement, and evaluate innovative 

24 models of regionalized, comprehensive, and accountable 

25 emergency care systems. 


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1 ‘‘(b) ELIGIBLE ENTITY; REGION.— 

2 ‘‘(1) ELIGIBLE ENTITY.—In this section, the 

3 term ‘eligible entity’ means a State or a partnership 

4 of 1 or more States and 1 or more local govern5 ments. 

6 ‘‘(2) REGION.—In this section, the term ‘re7 gion’ means an area within a State, an area that lies 

8 within multiple States, or a similar area (such as a 

9 multicounty area), as determined by the Secretary. 

10 ‘‘(c) DEMONSTRATION PROGRAM.—The Secretary 

11 shall award a contract or grant under subsection (a) to 

12 an eligible entity that proposes a demonstration program 

13 to design, implement, and evaluate an emergency medical 

14 system that— 

15 ‘‘(1) coordinates with public safety services, 

16 public health services, emergency medical services, 

17 medical facilities, and other entities within a region; 

18 ‘‘(2) coordinates an approach to emergency 

19 medical system access throughout the region, includ20 ing 9–1–1 public safety answering points and emer21 gency medical dispatch; 

22 ‘‘(3) includes a mechanism, such as a regional 

23 medical direction or transport communications sys24 tem, that operates throughout the region to ensure 

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1 propriate facility (whether an initial facility or a 

2 higher level facility) in a timely fashion; 

3 ‘‘(4) allows for the tracking of prehospital and 

4 hospital resources, including inpatient bed capacity, 

5 emergency department capacity, on-call specialist 

6 coverage, ambulance diversion status, and the co7 ordination of such tracking with regional commu8 nications and hospital destination decisions; and 

9 ‘‘(5) includes a consistent regionwide 

10 prehospital, hospital, and interfacility data manage11 ment system that— 

12 ‘‘(A) complies with the National EMS In13 formation System, the National Trauma Data 

14 Bank, and others; 

15 ‘‘(B) reports data to appropriate Federal 

16 and State databanks and registries; and 

17 ‘‘(C) contains information sufficient to 

18 evaluate key elements of prehospital care, hos19 pital destination decisions, including initial hos20 pital and interfacility decisions, and relevant 

21 outcomes of hospital care. 

22 ‘‘(d) APPLICATION.— 

23 ‘‘(1) IN GENERAL.—An eligible entity that 

24 seeks a contract or grant described in subsection (a) 

25 shall submit to the Secretary an application at such 


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1 time and in such manner as the Secretary may re2 quire. 

3 ‘‘(2) APPLICATION INFORMATION.—Each appli4 cation shall include— 

5 ‘‘(A) an assurance from the eligible entity 

6 that the proposed system— 

7 ‘‘(i) has been coordinated with the ap8 plicable State office of emergency medical 

9 services (or equivalent State office); 

10 ‘‘(ii) is compatible with the applicable 

11 State emergency medical services system; 

12 ‘‘(iii) includes consistent indirect and 

13 direct medical oversight of prehospital, 

14 hospital, and interfacility transport 

15 throughout the region; 

16 ‘‘(iv) coordinates prehospital treat17 ment and triage, hospital destination, and 

18 interfacility transport throughout the re19 gion; 

20 ‘‘(v) includes a categorization or des21 ignation system for special medical facili22 ties throughout the region that is— 

23 ‘‘(I) consistent with State laws 

24 and regulations; and 


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1 ‘‘(II) integrated with the proto2 cols for transport and destination 

3 throughout the region; and 

4 ‘‘(vi) includes a regional medical di5 rection system, a patient tracking system, 

6 and a resource allocation system that— 

7 ‘‘(I) support day-to-day emer8 gency care system operation; 

9 ‘‘(II) can manage surge capacity 

10 during a major event or disaster; and 

11 ‘‘(III) are integrated with other 

12 components of the national and State 

13 emergency preparedness system; 

14 ‘‘(B) an agreement to make available non15 Federal contributions in accordance with sub16 section (e); and 

17 ‘‘(C) such other information as the Sec18 retary may require. 

19 ‘‘(e) MATCHING FUNDS.— 

20 ‘‘(1) IN GENERAL.—With respect to the costs of 

21 the activities to be carried out each year with a con22 tract or grant under subsection (a), a condition for 

23 the receipt of the contract or grant is that the eligi24 ble entity involved agrees to make available (directly 

25 or through donations from public or private entities) 


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1 non-Federal contributions toward such costs in an 

2 amount that is not less than 25 percent of such 

3 costs. 

4 ‘‘(2) DETERMINATION OF AMOUNT CONTRIB5 UTED.—Non-Federal contributions required in para6 graph (1) may be in cash or in kind, fairly evalu7 ated, including plant, equipment, or services. 

8 Amounts provided by the Federal Government, or 

9 services assisted or subsidized to any significant ex10 tent by the Federal Government, may not be in11 cluded in determining the amount of such non-Fed12 eral contributions. 

13 ‘‘(f) PRIORITY.—The Secretary shall give priority for 

14 the award of the contracts or grants described in sub15 section (a) to any eligible entity that serves a medically 

16 underserved population (as defined in section 330(b)(3)). 

17 ‘‘(g) REPORT.—Not later than 90 days after the com18 pletion of a demonstration program under subsection (a), 

19 the recipient of such contract or grant described in such 

20 subsection shall submit to the Secretary a report con21 taining the results of an evaluation of the program, includ22 ing an identification of— 

23 ‘‘(1) the impact of the regional, accountable 

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1 ious critical care categories, such as trauma, stroke, 

2 cardiac emergencies, and pediatric emergencies; 

3 ‘‘(2) the system characteristics that contribute 

4 to the effectiveness and efficiency of the program (or 

5 lack thereof); 

6 ‘‘(3) methods of assuring the long-term finan7 cial sustainability of the emergency care system; 

8 ‘‘(4) the State and local legislation necessary to 

9 implement and to maintain the system; and 

10 ‘‘(5) the barriers to developing regionalized, ac11 countable emergency care systems, as well as the 

12 methods to overcome such barriers. 

13 ‘‘(h) EVALUATION.—The Secretary, acting through 

14 the Assistant Secretary for Preparedness and Response, 

15 shall enter into a contract with an academic institution 

16 or other entity to conduct an independent evaluation of 

17 the demonstration programs funded under subsection (a), 

18 including an evaluation of— 

19 ‘‘(1) the performance of the eligible entities re20 ceiving the funds; and 

21 ‘‘(2) the impact of the demonstration programs. 

22 ‘‘(i) DISSEMINATION OF FINDINGS.—The Secretary 

23 shall, as appropriate, disseminate to the public and to the 

24 appropriate committees of the Congress, the information 

25 contained in a report made under subsection (h). 


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1 ‘‘(j) AUTHORIZATION OF APPROPRIATIONS.— 

2 ‘‘(1) IN GENERAL.—There is authorized to be 

3 appropriated to carry out this section $12,000,000 

4 for each of fiscal years 2011 through 2015. 

5 ‘‘(2) RESERVATION.—Of the amount appro6 priated to carry out this section for a fiscal year, the 

7 Secretary shall reserve 3 percent of such amount to 

8 carry out subsection (h) (relating to an independent 

9 evaluation).’’. 

10 SEC. 2554. ASSISTING VETERANS WITH MILITARY EMER11 GENCY MEDICAL TRAINING TO BECOME 

12 STATE-LICENSED OR CERTIFIED EMERGENCY 

13 MEDICAL TECHNICIANS (EMTS). 

14 (a) IN GENERAL.—Part B of title III (42 U.S.C. 243 

15 et seq.), as amended, is amended by inserting after section 

16 315 the following: 

17 ‘‘SEC. 315A. ASSISTING VETERANS WITH MILITARY EMER18 GENCY MEDICAL TRAINING TO BECOME 

19 STATE-LICENSED OR CERTIFIED EMERGENCY 

20 MEDICAL TECHNICIANS (EMTS). 

21 ‘‘(a) PROGRAM.—The Secretary shall establish a pro22 gram consisting of awarding grants to States to assist vet23 erans who received and completed military emergency 

24 medical training while serving in the Armed Forces of the 

25 United States to become, upon their discharge or release 


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1 from active duty service, State-licensed or certified emer2 gency medical technicians. 

3 ‘‘(b) USE OF FUNDS.—Amounts received as a grant 

4 under this section may be used to assist veterans described 

5 in subsection (a) to become State-licensed or certified 

6 emergency medical technicians as follows: 

7 ‘‘(1) Providing training. 

8 ‘‘(2) Providing reimbursement for costs associ9 ated with— 

10 ‘‘(A) training; or 

11 ‘‘(B) applying for licensure or certification. 

12 ‘‘(3) Expediting the licensing or certification 

13 process. 

14 ‘‘(c) ELIGIBILITY.—To be eligible for a grant under 

15 this section, a State shall demonstrate to the Secretary’s 

16 satisfaction that the State has a shortage of emergency 

17 medical technicians. 

18 ‘‘(d) REPORT.—The Secretary shall submit to the 

19 Congress an annual report on the program under this sec20 tion. 

21 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—To 

22 carry out this section, there are authorized to be appro23 priated such sums as may be necessary for each of fiscal 

24 years 2011 through 2015.’’. 


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1 (b) GAO STUDY AND REPORT.—The Comptroller 

2 General of the United States shall— 

3 (1) conduct a study on the barriers experienced 

4 by veterans who received training as medical per5 sonnel while serving in the Armed Forces of the 

6 United States and, upon their discharge or release 

7 from active duty service, seek to become licensed or 

8 certified in a State as civilian health professionals; 

9 and 

10 (2) not later than 2 years after the date of the 

11 enactment of this Act, submit to the Congress a re12 port on the results of such study, including rec13 ommendations on whether the program established 

14 under section 315A of the Public Health Service 

15 Act, as added by subsection (a), should be expanded 

16 to assist veterans seeking to become licensed or cer17 tified in a State as health providers other than emer18 gency medical technicians. 

19 SEC. 2555. DENTAL EMERGENCY RESPONDERS: PUBLIC 

20 HEALTH AND MEDICAL RESPONSE. 

21 (a) NATIONAL HEALTH SECURITY STRATEGY.—Sec22 tion 2802(b)(3) (42 U.S.C. 300hh–1(b)(3)) is amended— 

23 (1) in the matter preceding subparagraph (A), 

24 by inserting ‘‘dental and’’ before ‘‘mental health fa25 cilities’’; and 


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1 (2) in subparagraph (D), by inserting ‘‘and 

2 dental’’ after ‘‘medical’’. 

3 (b) ALL-HAZARDS PUBLIC HEALTH AND MEDICAL

4 RESPONSE CURRICULA AND TRAINING.—Section 

5 319F(a)(5)(B) (42 U.S.C. 247d–6(a)(5)(B)) is amended 

6 by striking ‘‘public health or medical’’ and inserting ‘‘pub7 lic health, medical, or dental’’. 

8 SEC. 2556. DENTAL EMERGENCY RESPONDERS: HOMELAND 

9 SECURITY. 

10 (a) NATIONAL RESPONSE FRAMEWORK.—Paragraph 

11 (6) of section 2 of the Homeland Security Act of 2002 

12 (6 U.S.C. 101) is amended by inserting ‘‘and dental’’ after 

13 ‘‘emergency medical’’. 

14 (b) NATIONAL PREPAREDNESS SYSTEM.—Subpara15 graph (B) of section 653(b)(4) of the Post-Katrina Emer16 gency Management Reform Act of 2006 (6 U.S.C. 

17 753(b)(4)) is amended by striking ‘‘public health and med18 ical’’ and inserting ‘‘public health, medical, and dental’’. 

19 (c) CHIEF MEDICAL OFFICER.—Paragraph (5) of 

20 section 516(c) of the Homeland Security Act of 2002 (6 

21 U.S.C. 321e(c)) is amended by striking ‘‘medical commu22 nity’’ and inserting ‘‘medical and dental communities’’. 


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1 PART 4—PAIN CARE AND MANAGEMENT 

2 PROGRAMS 

3 SEC. 2561. INSTITUTE OF MEDICINE CONFERENCE ON PAIN. 

4 (a) CONVENING.—Not later than June 30, 2011, the 

5 Secretary of Health and Human Services shall seek to 

6 enter into an agreement with the Institute of Medicine of 

7 the National Academies to convene a Conference on Pain 

8 (in this section referred to as ‘‘the Conference’’). 

9 (b) PURPOSES.—The purposes of the Conference 

10 shall be to— 

11 (1) increase the recognition of pain as a signifi12 cant public health problem in the United States; 

13 (2) evaluate the adequacy of assessment, diag14 nosis, treatment, and management of acute and 

15 chronic pain in the general population, and in identi16 fied racial, ethnic, gender, age, and other demo17 graphic groups that may be disproportionately af18 fected by inadequacies in the assessment, diagnosis, 

19 treatment, and management of pain; 

20 (3) identify barriers to appropriate pain care, 

21 including— 

22 (A) lack of understanding and education 

23 among employers, patients, health care pro24 viders, regulators, and third-party payors; 


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1 (B) barriers to access to care at the pri2 mary, specialty, and tertiary care levels, includ3 ing barriers— 

4 (i) specific to those populations that 

5 are disproportionately undertreated for 

6 pain; 

7 (ii) related to physician concerns over 

8 regulatory and law enforcement policies 

9 applicable to some pain therapies; and 

10 (iii) attributable to benefit, coverage, 

11 and payment policies in both the public 

12 and private sectors; and 

13 (C) gaps in basic and clinical research on 

14 the symptoms and causes of pain, and potential 

15 assessment methods and new treatments to im16 prove pain care; and 

17 (4) establish an agenda for action in both the 

18 public and private sectors that will reduce such bar19 riers and significantly improve the state of pain care 

20 research, education, and clinical care in the United 

21 States. 

22 (c) OTHER APPROPRIATE ENTITY.—If the Institute 

23 of Medicine declines to enter into an agreement under sub24 section (a), the Secretary of Health and Human Services 


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1 may enter into such agreement with another appropriate 

2 entity. 

3 (d) REPORT.—A report summarizing the Con4 ference’s findings and recommendations shall be sub5 mitted to the Congress not later than June 30, 2012. 

6 (e) AUTHORIZATION OF APPROPRIATIONS.—For the 

7 purpose of carrying out this section, there is authorized 

8 to be appropriated $500,000 for each of fiscal years 2011 

9 and 2012. 

10 SEC. 2562. PAIN RESEARCH AT NATIONAL INSTITUTES OF 

11 HEALTH. 

12 Part B of title IV (42 U.S.C. 284 et seq.) is amended 

13 by adding at the end the following: 

14 ‘‘SEC. 409J. PAIN RESEARCH. 

15 ‘‘(a) RESEARCH INITIATIVES.— 

16 ‘‘(1) IN GENERAL.—The Director of NIH is en17 couraged to continue and expand, through the Pain 

18 Consortium, an aggressive program of basic and 

19 clinical research on the causes of and potential treat20 ments for pain. 

21 ‘‘(2) ANNUAL RECOMMENDATIONS.—Not less 

22 than annually, the Pain Consortium, in consultation 

23 with the Division of Program Coordination, Plan24 ning, and Strategic Initiatives, shall develop and 

25 submit to the Director of NIH recommendations on 


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1 appropriate pain research initiatives that could be 

2 undertaken with funds reserved under section 

3 402A(c)(1) for the Common Fund or otherwise 

4 available for such initiatives. 

5 ‘‘(3) DEFINITION.—In this subsection, the term 

6 ‘Pain Consortium’ means the Pain Consortium of 

7 the National Institutes of Health or a similar trans8 National Institutes of Health coordinating entity 

9 designated by the Secretary for purposes of this sub10 section. 

11 ‘‘(b) INTERAGENCY PAIN RESEARCH COORDINATING

12 COMMITTEE.— 

13 ‘‘(1) ESTABLISHMENT.—The Secretary shall es14 tablish not later than 1 year after the date of the 

15 enactment of this section and as necessary maintain 

16 a committee, to be known as the Interagency Pain 

17 Research Coordinating Committee (in this section 

18 referred to as the ‘Committee’), to coordinate all ef19 forts within the Department of Health and Human 

20 Services and other Federal agencies that relate to 

21 pain research. 

22 ‘‘(2) MEMBERSHIP.— 

23 ‘‘(A) IN GENERAL.—The Committee shall 

24 be composed of the following voting members: 


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1 ‘‘(i) Not more than 7 voting Federal 

2 representatives as follows: 

3 ‘‘(I) The Director of the Centers 

4 for Disease Control and Prevention. 

5 ‘‘(II) The Director of the Na6 tional Institutes of Health and the di7 rectors of such national research insti8 tutes and national centers as the Sec9 retary determines appropriate. 

10 ‘‘(III) The heads of such other 

11 agencies of the Department of Health 

12 and Human Services as the Secretary 

13 determines appropriate. 

14 ‘‘(IV) Representatives of other 

15 Federal agencies that conduct or sup16 port pain care research and treat17 ment, including the Department of 

18 Defense and the Department of Vet19 erans Affairs. 

20 ‘‘(ii) Twelve additional voting mem21 bers appointed under subparagraph (B). 

22 ‘‘(B) ADDITIONAL MEMBERS.—The Com23 mittee shall include additional voting members 

24 appointed by the Secretary as follows: 


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1 ‘‘(i) Six members shall be appointed 

2 from among scientists, physicians, and 

3 other health professionals, who— 

4 ‘‘(I) are not officers or employees 

5 of the United States; 

6 ‘‘(II) represent multiple dis7 ciplines, including clinical, basic, and 

8 public health sciences; 

9 ‘‘(III) represent different geo10 graphical regions of the United 

11 States; and 

12 ‘‘(IV) are from practice settings, 

13 academia, manufacturers, or other re14 search settings. 

15 ‘‘(ii) Six members shall be appointed 

16 from members of the general public, who 

17 are representatives of leading research, ad18 vocacy, and service organizations for indi19 viduals with pain-related conditions. 

20 ‘‘(C) NONVOTING MEMBERS.—The Com21 mittee shall include such nonvoting members as 

22 the Secretary determines to be appropriate. 

23 ‘‘(3) CHAIRPERSON.—The voting members of 

24 the Committee shall select a chairperson from 

25 among such members. The selection of a chairperson 


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1 shall be subject to the approval of the Director of 

2 NIH. 

3 ‘‘(4) MEETINGS.—The Committee shall meet at 

4 the call of the chairperson of the Committee or upon 

5 the request of the Director of NIH, but in no case 

6 less often than once each year. 

7 ‘‘(5) DUTIES.—The Committee shall— 

8 ‘‘(A) develop a summary of advances in 

9 pain care research supported or conducted by 

10 the Federal agencies relevant to the diagnosis, 

11 prevention, and treatment of pain and diseases 

12 and disorders associated with pain; 

13 ‘‘(B) identify critical gaps in basic and 

14 clinical research on the symptoms and causes of 

15 pain; 

16 ‘‘(C) make recommendations to ensure that 

17 the activities of the National Institutes of 

18 Health and other Federal agencies, including 

19 the Department of Defense and the Department 

20 of Veteran Affairs, are free of unnecessary du21 plication of effort; 

22 ‘‘(D) make recommendations on how best 

23 to disseminate information on pain care; and 

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1 cluding Federal agencies, and private entities to 

2 expand collaborative, crosscutting research. 

3 ‘‘(6) REVIEW.—The Secretary shall review the 

4 necessity of the Committee at least once every 2 

5 years.’’. 

6 SEC. 2563. PUBLIC AWARENESS CAMPAIGN ON PAIN MAN7 AGEMENT. 

8 Part B of title II (42 U.S.C. 238 et seq.) is amended 

9 by adding at the end the following: 

10 ‘‘SEC. 249. NATIONAL EDUCATION OUTREACH AND AWARE11 NESS CAMPAIGN ON PAIN MANAGEMENT. 

12 ‘‘(a) ESTABLISHMENT.—Not later than 12 months 

13 after the date of the enactment of this section, the Sec14 retary shall establish and implement a national pain care 

15 education outreach and awareness campaign described in 

16 subsection (b). 

17 ‘‘(b) REQUIREMENTS.—The Secretary shall design 

18 the public awareness campaign under this section to edu19 cate consumers, patients, their families, and other care20 givers with respect to— 

21 ‘‘(1) the incidence and importance of pain as a 

22 national public health problem; 

23 ‘‘(2) the adverse physical, psychological, emo24 tional, societal, and financial consequences that can 


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1 result if pain is not appropriately assessed, diag2 nosed, treated, or managed; 

3 ‘‘(3) the availability, benefits, and risks of all 

4 pain treatment and management options; 

5 ‘‘(4) having pain promptly assessed, appro6 priately diagnosed, treated, and managed, and regu7 larly reassessed with treatment adjusted as needed; 

8 ‘‘(5) the role of credentialed pain management 

9 specialists and subspecialists, and of comprehensive 

10 interdisciplinary centers of treatment expertise; 

11 ‘‘(6) the availability in the public, nonprofit, 

12 and private sectors of pain management-related in13 formation, services, and resources for consumers, 

14 employers, third-party payors, patients, their fami15 lies, and caregivers, including information on— 

16 ‘‘(A) appropriate assessment, diagnosis, 

17 treatment, and management options for all 

18 types of pain and pain-related symptoms; and 

19 ‘‘(B) conditions for which no treatment op20 tions are yet recognized; and 

21 ‘‘(7) other issues the Secretary deems appro22 priate. 

23 ‘‘(c) CONSULTATION.—In designing and imple24 menting the public awareness campaign required by this 

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1 resenting patients in pain and other consumers, employ2 ers, physicians including physicians specializing in pain 

3 care, other pain management professionals, medical device 

4 manufacturers, and pharmaceutical companies. 

5 ‘‘(d) COORDINATION.— 

6 ‘‘(1) LEAD OFFICIAL.—The Secretary shall des7 ignate one official in the Department of Health and 

8 Human Services to oversee the campaign established 

9 under this section. 

10 ‘‘(2) AGENCY COORDINATION.—The Secretary 

11 shall ensure the involvement in the public awareness 

12 campaign under this section of the Surgeon General 

13 of the Public Health Service, the Director of the 

14 Centers for Disease Control and Prevention, and 

15 such other representatives of offices and agencies of 

16 the Department of Health and Human Services as 

17 the Secretary determines appropriate. 

18 ‘‘(e) UNDERSERVED AREAS AND POPULATIONS.—In 

19 designing the public awareness campaign under this sec20 tion, the Secretary shall— 

21 ‘‘(1) take into account the special needs of geo22 graphic areas and racial, ethnic, gender, age, and 

23 other demographic groups that are currently under24 served; and 


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1 ‘‘(2) provide resources that will reduce dispari2 ties in access to appropriate diagnosis, assessment, 

3 and treatment. 

4 ‘‘(f) GRANTS AND CONTRACTS.—The Secretary may 

5 make awards of grants, cooperative agreements, and con6 tracts to public agencies and private nonprofit organiza7 tions to assist with the development and implementation 

8 of the public awareness campaign under this section. 

9 ‘‘(g) EVALUATION AND REPORT.—Not later than the 

10 end of fiscal year 2012, the Secretary shall prepare and 

11 submit to the Congress a report evaluating the effective12 ness of the public awareness campaign under this section 

13 in educating the general public with respect to the matters 

14 described in subsection (b). 

15 ‘‘(h) AUTHORIZATION OF APPROPRIATIONS.—For 

16 purposes of carrying out this section, there are authorized 

17 to be appropriated $2,000,000 for fiscal year 2011 and 

18 $4,000,000 for each of fiscal years 2012 and 2015.’’. 

19 Subtitle C—Food and Drug 

20 Administration 

21 PART 1—IN GENERAL 

22 SEC. 2571. NATIONAL MEDICAL DEVICE REGISTRY. 

23 (a) REGISTRY.— 


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1 (1) IN GENERAL.—Section 519 of the Federal 

2 Food, Drug, and Cosmetic Act (21 U.S.C. 360i) is 

3 amended— 

4 (A) by redesignating subsection (g) as sub5 section (h); and 

6 (B) by inserting after subsection (f) the 

7 following: 

8 ‘‘National Medical Device Registry 

9 ‘‘(g)(1)(A) The Secretary shall establish a national 

10 medical device registry (in this subsection referred to as 

11 the ‘registry’) to facilitate analysis of postmarket safety 

12 and outcomes data on each covered device. 

13 ‘‘(B) In this subsection, the term ‘covered device’— 

14 ‘‘(i) shall include each class III device; and 

15 ‘‘(ii) may include, as the Secretary determines 

16 appropriate and specifies in regulation, a class II de17 vice that is life-supporting or life-sustaining. 

18 ‘‘(C) Notwithstanding subparagraph (B)(i), the Sec19 retary may by order exempt a class III device from the 

20 provisions of this subsection if the Secretary concludes 

21 that inclusion of information on the device in the registry 

22 will not provide useful information on safety or effective23 ness. 

24 ‘‘(2) In developing the registry, the Secretary shall, 

25 in consultation with the Commissioner of Food and Drugs, 


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1 the Administrator of the Centers for Medicare & Medicaid 

2 Services, the Administrator of the Agency for Healthcare 

3 Research and Quality, the head of the Office of the Na4 tional Coordinator for Health Information Technology, 

5 and the Secretary of Veterans Affairs, determine the best 

6 methods for— 

7 ‘‘(A) including in the registry, in a manner con8 sistent with subsection (f), appropriate information 

9 to identify each covered device by type, model, and 

10 serial number or other unique identifier; 

11 ‘‘(B) validating methods for analyzing patient 

12 safety and outcomes data from multiple sources and 

13 for linking such data with the information included 

14 in the registry as described in subparagraph (A), in15 cluding, to the extent feasible, use of— 

16 ‘‘(i) data provided to the Secretary under 

17 other provisions of this chapter; and 

18 ‘‘(ii) information from public and private 

19 sources identified under paragraph (3); 

20 ‘‘(C) integrating the activities described in this 

21 subsection (so as to avoid duplication) with— 

22 ‘‘(i) activities under paragraph (3) of sec23 tion 505(k) (relating to active postmarket risk 

24 identification); 


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1 ‘‘(ii) activities under paragraph (4) of sec2 tion 505(k) (relating to advanced analysis of 

3 drug safety data); 

4 ‘‘(iii) other postmarket device surveillance 

5 activities of the Secretary authorized by this 

6 chapter; and 

7 ‘‘(iv) registries carried out by or for the 

8 Agency for Healthcare Research and Quality; 

9 and 

10 ‘‘(D) providing public access to the data and 

11 analysis collected or developed through the registry 

12 in a manner and form that protects patient privacy 

13 and proprietary information and is comprehensive, 

14 useful, and not misleading to patients, physicians, 

15 and scientists. 

16 ‘‘(3)(A) To facilitate analyses of postmarket safety 

17 and patient outcomes for covered devices, the Secretary 

18 shall, in collaboration with public, academic, and private 

19 entities, develop methods to— 

20 ‘‘(i) obtain access to disparate sources of 

21 patient safety and outcomes data, including— 

22 ‘‘(I) Federal health-related electronic 

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1 rity Act or from the health systems of the 

2 Department of Veterans Affairs); 

3 ‘‘(II) private sector health-related 

4 electronic data (such as pharmaceutical 

5 purchase data and health insurance claims 

6 data); and 

7 ‘‘(III) other data as the Secretary 

8 deems necessary to permit postmarket as9 sessment of device safety and effectiveness; 

10 and 

11 ‘‘(ii) link data obtained under clause (i) 

12 with information in the registry. 

13 ‘‘(B) In this paragraph, the term ‘data’ refers to in14 formation respecting a covered device, including claims 

15 data, patient survey data, standardized analytic files that 

16 allow for the pooling and analysis of data from disparate 

17 data environments, electronic health records, and any 

18 other data deemed appropriate by the Secretary. 

19 ‘‘(4) The Secretary shall promulgate regulations for 

20 establishment and operation of the registry under para21 graph (1). Such regulations— 

22 ‘‘(A)(i) in the case of covered devices that are 

23 sold on or after the date of the enactment of this 

24 subsection, shall require manufacturers of such de25 vices to submit information to the registry, includVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01505 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 ing, for each such device, the type, model, and serial 

2 number or, if required under subsection (f), other 

3 unique device identifier; and 

4 ‘‘(ii) in the case of covered devices that are sold 

5 before such date, may require manufacturers of such 

6 devices to submit such information to the registry, 

7 if deemed necessary by the Secretary to protect the 

8 public health; 

9 ‘‘(B) shall establish procedures— 

10 ‘‘(i) to permit linkage of information sub11 mitted pursuant to subparagraph (A) with pa12 tient safety and outcomes data obtained under 

13 paragraph (3); and 

14 ‘‘(ii) to permit analyses of linked data; 

15 ‘‘(C) may require covered device manufacturers 

16 to submit such other information as is necessary to 

17 facilitate postmarket assessments of device safety 

18 and effectiveness and notification of device risks; 

19 ‘‘(D) shall establish requirements for regular 

20 and timely reports to the Secretary, which shall be 

21 included in the registry, concerning adverse event 

22 trends, adverse event patterns, incidence and preva23 lence of adverse events, and other information the 

24 Secretary determines appropriate, which may include 


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1 data on comparative safety and outcomes trends; 

2 and 

3 ‘‘(E) shall establish procedures to permit public 

4 access to the information in the registry in a manner 

5 and form that protects patient privacy and propri6 etary information and is comprehensive, useful, and 

7 not misleading to patients, physicians, and sci8 entists. 

9 ‘‘(5)(A) The Secretary shall promulgate final regula10 tions under paragraph (4) not later than 36 months after 

11 the date of the enactment of this subsection. 

12 ‘‘(B) Before issuing the notice of proposed rule13 making preceding the final regulations described in sub14 paragraph (A), the Secretary shall hold a public hearing 

15 before an advisory committee on the issue of which class 

16 II devices to include in the definition of covered devices. 

17 ‘‘(C) The Secretary shall include in any regulation 

18 under this subsection an explanation demonstrating that 

19 the requirements of such regulation— 

20 ‘‘(i) do not duplicate other Federal require21 ments; and 

22 ‘‘(ii) do not impose an undue burden on device 

23 manufacturers. 

24 ‘‘(6) With respect to any entity that submits or is 

25 required to submit a safety report or other information 


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1 in connection with the safety of a device under this section 

2 (and any release by the Secretary of that report or infor3 mation), such report or information shall not be construed 

4 to reflect necessarily a conclusion by the entity or the Sec5 retary that the report or information constitutes an admis6 sion that the product involved malfunctioned, caused or 

7 contributed to an adverse experience, or otherwise caused 

8 or contributed to a death, serious injury, or serious illness. 

9 Such an entity need not admit, and may deny, that the 

10 report or information submitted by the entity constitutes 

11 an admission that the product involved malfunctioned, 

12 caused or contributed to an adverse experience, or caused 

13 or contributed to a death, serious injury, or serious illness. 

14 ‘‘(7) To carry out this subsection, there are author15 ized to be appropriated such sums as may be necessary 

16 for each of fiscal years 2011 and 2012.’’. 

17 (2) EFFECTIVE DATE.—The Secretary of 

18 Health and Human Services shall establish and 

19 begin implementation of the registry under section 

20 519(g) of the Federal Food, Drug, and Cosmetic 

21 Act, as added by paragraph (1), by not later than 

22 the date that is 36 months after the date of the en23 actment of this Act, without regard to whether or 

24 not final regulations to establish and operate the 

25 registry have been promulgated by such date. 


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1 (3) CONFORMING AMENDMENT.—Section 

2 303(f)(1)(B)(ii) of the Federal Food, Drug, and 

3 Cosmetic Act (21 U.S.C. 333(f)(1)(B)(ii)) is amend4 ed by striking ‘‘519(g)’’ and inserting ‘‘519(h)’’. 

5 (b) ELECTRONIC EXCHANGE AND USE IN CERTIFIED

6 ELECTRONIC HEALTH RECORDS OF UNIQUE DEVICE

7 IDENTIFIERS.— 

8 (1) RECOMMENDATIONS.—The HIT Policy 

9 Committee established under section 3002 of the 

10 Public Health Service Act (42 U.S.C. 300jj–12) 

11 shall recommend to the head of the Office of the Na12 tional Coordinator for Health Information Tech13 nology standards, implementation specifications, and 

14 certification criteria for the electronic exchange and 

15 use in certified electronic health records of a unique 

16 device identifier for each covered device (as defined 

17 under section 519(g)(1)(B) of the Federal Food, 

18 Drug, and Cosmetic Act, as added by subsection 

19 (a)). 

20 (2) STANDARDS, IMPLEMENTATION CRITERIA, 

21 AND CERTIFICATION CRITERIA.—The Secretary of 

22 Health and Human Services, acting through the 

23 head of the Office of the National Coordinator for 

24 Health Information Technology, shall adopt stand25 ards, implementation specifications, and certification 


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1 criteria for the electronic exchange and use in cer2 tified electronic health records of a unique device 

3 identifier for each covered device referred to in para4 graph (1), if such an identifier is required by section 

5 519(f) of the Federal Food, Drug, and Cosmetic Act 

6 (21 U.S.C. 360i(f)) for the device. 

7 (c) UNIQUE DEVICE IDENTIFICATION SYSTEM.—The 

8 Secretary of Health and Human Services, acting through 

9 the Commissioner of Food and Drugs, shall issue proposed 

10 regulations to implement section 519(f) of the Federal 

11 Food, Drug, and Cosmetic Act (21 U.S.C. 360i(f)) not 

12 later than 6 months after the date of the enactment of 

13 this Act. 

14 SEC. 2572. NUTRITION LABELING OF STANDARD MENU 

15 ITEMS AT CHAIN RESTAURANTS AND OF AR16 TICLES OF FOOD SOLD FROM VENDING MA17 CHINES. 

18 (a) TECHNICAL AMENDMENTS.—Section 

19 403(q)(5)(A) of the Federal Food, Drug, and Cosmetic 

20 Act (21 U.S.C. 343(q)(5)(A)) is amended— 

21 (1) in subclause (i), by inserting ‘‘except as pro22 vided in clause (H)(ii)(III),’’ after ‘‘(i)’’ ; and 

23 (2) in subclause (ii), by inserting ‘‘except as 

24 provided in clause (H)(ii)(III),’’ after ‘‘(ii)’’. 


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1 (b) LABELING REQUIREMENTS.—Section 403(q)(5) 

2 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 

3 343(q)(5)) is amended by adding at the end the following: 

4 ‘‘(H) RESTAURANTS, RETAIL FOOD ESTABLISH5 MENTS, AND VENDING MACHINES.— 

6 ‘‘(i) GENERAL REQUIREMENTS FOR RES7 TAURANTS AND SIMILAR RETAIL FOOD ESTABLISH8 MENTS.—Except for food described in subclause 

9 (vii), in the case of food that is a standard menu 

10 item that is offered for sale in a restaurant or simi11 lar retail food establishment that is part of a chain 

12 with 20 or more locations doing business under the 

13 same name (regardless of the type of ownership of 

14 the locations) and offering for sale substantially the 

15 same menu items, the restaurant or similar retail 

16 food establishment shall disclose the information de17 scribed in subclauses (ii) and (iii). 

18 ‘‘(ii) INFORMATION REQUIRED TO BE DIS19 CLOSED BY RESTAURANTS AND RETAIL FOOD ES20 TABLISHMENTS.—Except as provided in subclause 

21 (vii), the restaurant or similar retail food establish22 ment shall disclose in a clear and conspicuous man23 ner— 

24 ‘‘(I)(aa) in a nutrient content disclosure 

25 statement adjacent to the name of the standard 


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1 menu item, so as to be clearly associated with 

2 the standard menu item, on the menu listing 

3 the item for sale, the number of calories con4 tained in the standard menu item, as usually 

5 prepared and offered for sale; and 

6 ‘‘(bb) a succinct statement concerning sug7 gested daily caloric intake, as specified by the 

8 Secretary by regulation and posted prominently 

9 on the menu and designed to enable the public 

10 to understand, in the context of a total daily 

11 diet, the significance of the caloric information 

12 that is provided on the menu; 

13 ‘‘(II)(aa) in a nutrient content disclosure 

14 statement adjacent to the name of the standard 

15 menu item, so as to be clearly associated with 

16 the standard menu item, on the menu board, 

17 including a drive-through menu board, the 

18 number of calories contained in the standard 

19 menu item, as usually prepared and offered for 

20 sale; and 

21 ‘‘(bb) a succinct statement concerning sug22 gested daily caloric intake, as specified by the 

23 Secretary by regulation and posted prominently 

24 on the menu board, designed to enable the pub25 lic to understand, in the context of a total daily 


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1 diet, the significance of the nutrition informa2 tion that is provided on the menu board; 

3 ‘‘(III) in a written form, available on the 

4 premises of the restaurant or similar retail es5 tablishment and to the consumer upon request, 

6 the nutrition information required under 

7 clauses (C) and (D) of subparagraph (1); and 

8 ‘‘(IV) on the menu or menu board, a 

9 prominent, clear, and conspicuous statement re10 garding the availability of the information de11 scribed in item (III). 

12 ‘‘(iii) SELF-SERVICE FOOD AND FOOD ON DIS13 PLAY.—Except as provided in subclause (vii), in the 

14 case of food sold at a salad bar, buffet line, cafeteria 

15 line, or similar self-service facility, and for self-serv16 ice beverages or food that is on display and that is 

17 visible to customers, a restaurant or similar retail 

18 food establishment shall place adjacent to each food 

19 offered a sign that lists calories per displayed food 

20 item or per serving. 

21 ‘‘(iv) REASONABLE BASIS.—For the purposes of 

22 this clause, a restaurant or similar retail food estab23 lishment shall have a reasonable basis for its nutri24 ent content disclosures, including nutrient databases, 

25 cookbooks, laboratory analyses, and other reasonable 


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1 means, as described in section 101.10 of title 21, 

2 Code of Federal Regulations (or any successor regu3 lation) or in a related guidance of the Food and 

4 Drug Administration. 

5 ‘‘(v) MENU VARIABILITY AND COMBINATION

6 MEALS.—The Secretary shall establish by regulation 

7 standards for determining and disclosing the nutri8 ent content for standard menu items that come in 

9 different flavors, varieties, or combinations, but 

10 which are listed as a single menu item, such as soft 

11 drinks, ice cream, pizza, doughnuts, or children’s 

12 combination meals, through means determined by 

13 the Secretary, including ranges, averages, or other 

14 methods. 

15 ‘‘(vi) ADDITIONAL INFORMATION.—If the Sec16 retary determines that a nutrient, other than a nu17 trient required under subclause (ii)(III), should be 

18 disclosed for the purpose of providing information to 

19 assist consumers in maintaining healthy dietary 

20 practices, the Secretary may require, by regulation, 

21 disclosure of such nutrient in the written form re22 quired under subclause (ii)(III). 

23 ‘‘(vii) NONAPPLICABILITY TO CERTAIN FOOD.— 

24 ‘‘(I) IN GENERAL.—Subclauses (i) through 

25 (vi) do not apply to— 


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1 ‘‘(aa) items that are not listed on a 

2 menu or menu board (such as condiments 

3 and other items placed on the table or 

4 counter for general use); 

5 ‘‘(bb) daily specials, temporary menu 

6 items appearing on the menu for less than 

7 60 days per calendar year, or custom or8 ders; or 

9 ‘‘(cc) such other food that is part of 

10 a customary market test appearing on the 

11 menu for less than 90 days, under terms 

12 and conditions established by the Sec13 retary. 

14 ‘‘(II) WRITTEN FORMS.—Clause (C) shall 

15 apply to any regulations promulgated under 

16 subclauses (ii)(III) and (vi). 

17 ‘‘(viii) VENDING MACHINES.—In the case of an 

18 article of food sold from a vending machine that— 

19 ‘‘(I) does not permit a prospective pur20 chaser to examine the Nutrition Facts Panel 

21 before purchasing the article or does not other22 wise provide visible nutrition information at the 

23 point of purchase; and 


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1 ‘‘(II) is operated by a person who is en2 gaged in the business of owning or operating 20 

3 or more vending machines, 

4 the vending machine operator shall provide a sign in 

5 close proximity to each article of food or the selec6 tion button that includes a clear and conspicuous 

7 statement disclosing the number of calories con8 tained in the article. 

9 ‘‘(ix) VOLUNTARY PROVISION OF NUTRITION IN10 FORMATION.— 

11 ‘‘(I) IN GENERAL.—An authorized official 

12 of any restaurant or similar retail food estab13 lishment or vending machine operator not sub14 ject to the requirements of this clause may elect 

15 to be subject to the requirements of such 

16 clause, by registering biannually the name and 

17 address of such restaurant or similar retail food 

18 establishment or vending machine operator with 

19 the Secretary, as specified by the Secretary by 

20 regulation. 

21 ‘‘(II) REGISTRATION.—Within 120 days of 

22 the enactment of this clause, the Secretary shall 

23 publish a notice in the Federal Register speci24 fying the terms and conditions for implementaVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01516 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 tion of item (I), pending promulgation of regu2 lations. 

3 ‘‘(III) RULE OF CONSTRUCTION.—Nothing 

4 in this subclause shall be construed to authorize 

5 the Secretary to require an application, review, 

6 or licensing process for any entity to register 

7 with the Secretary, as described in such item. 

8 ‘‘(x) REGULATIONS.— 

9 ‘‘(I) PROPOSED REGULATION.—Not later 

10 than 1 year after the date of the enactment of 

11 this clause, the Secretary shall promulgate pro12 posed regulations to carry out this clause. 

13 ‘‘(II) CONTENTS.—In promulgating regula14 tions, the Secretary shall— 

15 ‘‘(aa) consider standardization of rec16 ipes and methods of preparation, reason17 able variation in serving size and formula18 tion of menu items, space on menus and 

19 menu boards, inadvertent human error, 

20 training of food service workers, variations 

21 in ingredients, and other factors, as the 

22 Secretary determines; and 

23 ‘‘(bb) specify the format and manner 

24 of the nutrient content disclosure require25 ments under this subclause. 


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1 ‘‘(III) REPORTING.—The Secretary shall 

2 submit to the Committee on Health, Education, 

3 Labor, and Pensions of the Senate and the 

4 Committee on Energy and Commerce of the 

5 House of Representatives a quarterly report 

6 that describes the Secretary’s progress toward 

7 promulgating final regulations under this sub8 paragraph. 

9 ‘‘(xi) DEFINITION.—In this clause, the term 

10 ‘menu’ or ‘menu board’ means the primary writing 

11 of the restaurant or other similar retail food estab12 lishment from which a consumer makes an order se13 lection.’’. 

14 (c) NATIONAL UNIFORMITY.—Section 403A(a)(4) of 

15 the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 

16 343–1(a)(4)) is amended by striking ‘‘except a require17 ment for nutrition labeling of food which is exempt under 

18 subclause (i) or (ii) of section 403(q)(5)(A)’’ and inserting 

19 ‘‘except that this paragraph does not apply to food that 

20 is offered for sale in a restaurant or similar retail food 

21 establishment that is not part of a chain with 20 or more 

22 locations doing business under the same name (regardless 

23 of the type of ownership of the locations) and offering for 

24 sale substantially the same menu items unless such res25 taurant or similar retail food establishment complies with 


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1 the voluntary provision of nutrition information require2 ments under section 403(q)(5)(H)(ix)’’. 

3 (d) RULE OF CONSTRUCTION.—Nothing in the 

4 amendments made by this section shall be construed— 

5 (1) to preempt any provision of State or local 

6 law, unless such provision establishes or continues 

7 into effect nutrient content disclosures of the type 

8 required under section 403(q)(5)(H) of the Federal 

9 Food, Drug, and Cosmetic Act (as added by sub10 section (b)) and is expressly preempted under sec11 tion 403A(a)(4) of such Act; 

12 (2) to apply to any State or local requirement 

13 respecting a statement in the labeling of food that 

14 provides for a warning concerning the safety of the 

15 food or component of the food; or 

16 (3) except as provided in section 

17 403(q)(5)(H)(ix) of the Federal Food, Drug, and 

18 Cosmetic Act (as added by subsection (b)), to apply 

19 to any restaurant or similar retail food establish20 ment other than a restaurant or similar retail food 

21 establishment described in section 403(q)(5)(H)(i) of 

22 such Act. 

23 SEC. 2573. PROTECTING CONSUMER ACCESS TO GENERIC 

24 DRUGS. 

25 (a) FINDINGS; PURPOSE.— 


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1 (1) FINDINGS.—The Congress finds the fol2 lowing: 

3 (A) In 1984, the Drug Price Competition 

4 and Patent Term Restoration Act (Pub. L. 98– 

5 417; in this subsection referred to as the ‘‘1984 

6 Act’’) was enacted with the intent of facilitating 

7 the early entry of generic drugs while pre8 serving incentives for innovation. 

9 (B) Prescription drugs make up 10 percent 

10 of national health care spending, but for the 

11 past decade have been one of the fastest grow12 ing segments of health care expenditures. 

13 (C) Until recently, the 1984 Act was suc14 cessful in facilitating generic competition to the 

15 benefit of consumers and health care payers— 

16 although 67 percent of all prescriptions dis17 pensed in the United States are generic drugs, 

18 they account for only 20 percent of all expendi19 tures. 

20 (D) In recent years, the intent of the 1984 

21 Act has been subverted by certain settlement 

22 agreements between brand companies and their 

23 potential generic competitors that make reverse 

24 payments, i.e., payments by the brand company 

25 to the generic company. 


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1 (E) These settlement agreements have un2 duly delayed the marketing of low-cost generic 

3 drugs contrary to free competition and the in4 terests of consumers. 

5 (F) The state of antitrust law relating to 

6 such settlement agreements is unsettled. 

7 (2) PURPOSE.—The purpose of this section is 

8 to provide an additional means to effectuate the in9 tent of the 1984 Act by enhancing competition in 

10 the pharmaceutical market by stopping agreements 

11 between brand name and generic drug manufactur12 ers that limit, delay, or otherwise prevent competi13 tion from generic drugs. 

14 (b) IN GENERAL.—Section 505 of the Federal Food, 

15 Drug, and Cosmetic Act (21 U.S.C. 355) is amended by 

16 adding at the end the following: 

17 ‘‘(w) PROTECTING CONSUMER ACCESS TO GENERIC

18 DRUGS.— 

19 ‘‘(1) UNFAIR AND DECEPTIVE ACTS AND PRAC20 TICES RELATED TO NEW DRUG APPLICATIONS.— 

21 ‘‘(A) CONDUCT PROHIBITED.—It shall be 

22 unlawful for any person to directly or indirectly 

23 be a party to any agreement resolving or set24 tling a patent infringement claim in which— 


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1 ‘‘(i) an ANDA filer receives anything 

2 of value; and 

3 ‘‘(ii) the ANDA filer agrees to limit or 

4 forego research, development, manufac5 turing, marketing, or sales, for any period 

6 of time, of the drug that is to be manufac7 tured under the ANDA involved and is the 

8 subject of the patent infringement claim. 

9 ‘‘(B) EXCEPTIONS.—Notwithstanding sub10 paragraph (A)(i), subparagraph (A) does not 

11 prohibit a resolution or settlement of a patent 

12 infringement claim in which the value received 

13 by the ANDA filer includes no more than— 

14 ‘‘(i) the right to market the drug that 

15 is to be manufactured under the ANDA in16 volved and is the subject of the patent in17 fringement claim, before the expiration 

18 of— 

19 ‘‘(I) the patent that is the basis 

20 for the patent infringement claim; or 

21 ‘‘(II) any other statutory exclu22 sivity that would prevent the mar23 keting of such drug; and 


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1 ‘‘(ii) the waiver of a patent infringe2 ment claim for damages based on prior 

3 marketing of such drug. 

4 ‘‘(C) ENFORCEMENT.— 

5 ‘‘(i) IN GENERAL.—A violation of sub6 paragraph (A) shall be treated as an un7 fair and deceptive act or practice and an 

8 unfair method of competition in or affect9 ing interstate commerce prohibited under 

10 section 5 of the Federal Trade Commission 

11 Act and shall be enforced by the Federal 

12 Trade Commission in the same manner, by 

13 the same means, and with the same juris14 diction as though all applicable terms and 

15 provisions of the Federal Trade Commis16 sion Act were incorporated into and made 

17 a part of this subsection. 

18 ‘‘(ii) INAPPLICABILITY.—Subchapter 

19 A of chapter VII shall not apply with re20 spect to this subsection. 

21 ‘‘(D) DEFINITIONS.—In this subsection: 

22 ‘‘(i) AGREEMENT.—The term ‘agree23 ment’ means anything that would con24 stitute an agreement under section 5 of the 

25 Federal Trade Commission Act. 


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1 ‘‘(ii) AGREEMENT RESOLVING OR SET2 TLING.—The term ‘agreement resolving or 

3 settling’, in reference to a patent infringe4 ment claim, includes any agreement that is 

5 contingent upon, provides a contingent 

6 condition for, or is otherwise related to the 

7 resolution or settlement of the claim. 

8 ‘‘(iii) ANDA.—The term ‘ANDA’ 

9 means an abbreviated new drug application 

10 for the approval of a new drug under sec11 tion (j). 

12 ‘‘(iv) ANDA FILER.—The term 

13 ‘ANDA filer’ means a party that has filed 

14 an ANDA with the Food and Drug Admin15 istration. 

16 ‘‘(v) PATENT INFRINGEMENT.—The 

17 term ‘patent infringement’ means infringe18 ment of any patent or of any filed patent 

19 application, extension, reissuance, renewal, 

20 division, continuation, continuation in part, 

21 reexamination, patent term restoration, 

22 patent of addition, or extension thereof. 

23 ‘‘(vi) PATENT INFRINGEMENT

24 CLAIM.—The term ‘patent infringement 

25 claim’ means any allegation made to an 


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1 ANDA filer, whether or not included in a 

2 complaint filed with a court of law, that its 

3 ANDA or drug to be manufactured under 

4 such ANDA may infringe any patent. 

5 ‘‘(2) FTC RULEMAKING.—The Federal Trade 

6 Commission may, by rule promulgated under section 

7 553 of title 5, United States Code, exempt certain 

8 agreements described in paragraph (1) from the re9 quirements of this subsection if the Commission 

10 finds such agreements to be in furtherance of mar11 ket competition and for the benefit of consumers. 

12 Consistent with the authority of the Commission, 

13 such rules may include interpretive rules and general 

14 statements of policy with respect to the practices 

15 prohibited under paragraph (1).’’. 

16 (c) NOTICE AND CERTIFICATION OF AGREEMENTS.— 

17 (1) NOTICE OF ALL AGREEMENTS.—Section 

18 1112(c)(2) of the Medicare Prescription Drug, Im19 provement, and Modernization Act of 2003 (21 

20 U.S.C. 3155 note) is amended by— 

21 (A) striking ‘‘the Commission the’’ and in22 serting the following: ‘‘the Commission— 

23 ‘‘(A) the’’; 

24 (B) striking the period at the end and in25 serting ‘‘; and’’; and 


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1 (C) adding at the end the following: 

2 ‘‘(B) any other agreement the parties enter 

3 into within 30 days of entering into an agree4 ment covered by subsection (a) or (b).’’. 

5 (2) CERTIFICATION OF AGREEMENTS.—Section 

6 1112 of such Act is amended by adding at the end 

7 the following: 

8 ‘‘(d) CERTIFICATION.—The chief executive officer or 

9 the company official responsible for negotiating any agree10 ment required to be filed under subsection (a), (b), or (c) 

11 shall execute and file with the Assistant Attorney General 

12 and the Commission a certification as follows: ‘I declare 

13 under penalty of perjury that the following is true and 

14 correct: The materials filed with the Federal Trade Com15 mission and the Department of Justice under section 1112 

16 of subtitle B of title XI of the Medicare Prescription Drug, 

17 Improvement, and Modernization Act of 2003, with re18 spect to the agreement referenced in this certification: (1) 

19 represent the complete, final, and exclusive agreement be20 tween the parties; (2) include any ancillary agreements 

21 that are contingent upon, provide a contingent condition 

22 for, or are otherwise related to, the referenced agreement; 

23 and (3) include written descriptions of any oral agree24 ments, representations, commitments, or promises be25 tween the parties that are responsive to subsection (a) or 


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1 (b) of such section 1112 and have not been reduced to 

2 writing.’.’’. 

3 (d) GAO STUDY.— 

4 (1) STUDY.—Beginning 2 years after the date 

5 of enactment of this Act, and each year for a period 

6 of 4 years thereafter, the Comptroller General shall 

7 conduct a study on the litigation in United States 

8 courts during the period beginning 5 years prior to 

9 the date of enactment of this Act relating to patent 

10 infringement claims involving generic drugs, the 

11 number of patent challenges initiated by manufac12 turers of generic drugs, and the number of settle13 ments of such litigation. The Comptroller General 

14 shall transmit to Congress a report of the findings 

15 of such a study and an analysis of the effect of the 

16 amendments made by subsections (b) and (c) on 

17 such litigation, whether such amendments have had 

18 an effect on the number and frequency of claims set19 tled, and whether such amendments resulted in ear20 lier or delayed entry of generic drugs to market, in21 cluding whether any harm or benefit to consumers 

22 has resulted. 

23 (2) DISCLOSURE OF AGREEMENTS.—Notwith24 standing any other law, agreements filed under sec25 tion 1112 of the Medicare Prescription Drug, ImVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01527 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 provement, and Modernization Act of 2003 (21 

2 U.S.C. 355 note), or unaggregated information from 

3 such agreements, shall be disclosed to the Comp4 troller General for purposes of the study under para5 graph (1) within 30 days of a request by the Comp6 troller General. 

7 PART 2—BIOSIMILARS 

8 SEC. 2575. LICENSURE PATHWAY FOR BIOSIMILAR BIO9 LOGICAL PRODUCTS. 

10 (a) LICENSURE OF BIOLOGICAL PRODUCTS AS BIO11 SIMILAR OR INTERCHANGEABLE.—Section 351 of the 

12 Public Health Service Act (42 U.S.C. 262) is amended— 

13 (1) in subsection (a)(1)(A), by inserting ‘‘under 

14 this subsection or subsection (k)’’ after ‘‘biologics li15 cense’’; and 

16 (2) by adding at the end the following: 

17 ‘‘(k) LICENSURE OF BIOLOGICAL PRODUCTS AS BIO18 SIMILAR OR INTERCHANGEABLE.— 

19 ‘‘(1) IN GENERAL.—Any person may submit an 

20 application for licensure of a biological product 

21 under this subsection. 

22 ‘‘(2) CONTENT.— 

23 ‘‘(A) IN GENERAL.— 

24 ‘‘(i) REQUIRED INFORMATION.—An 

25 application submitted under this subsection 


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1 shall include information demonstrating 

2 that— 

3 ‘‘(I) the biological product is bio4 similar to a reference product based 

5 upon data derived from— 

6 ‘‘(aa) analytical studies that 

7 demonstrate that the biological 

8 product is highly similar to the 

9 reference product notwith10 standing minor differences in 

11 clinically inactive components; 

12 ‘‘(bb) animal studies (includ13 ing the assessment of toxicity); 

14 and 

15 ‘‘(cc) a clinical study or 

16 studies (including the assessment 

17 of immunogenicity and phar18 macokinetics or 

19 pharmacodynamics) that are suf20 ficient to demonstrate safety, pu21 rity, and potency in 1 or more 

22 appropriate conditions of use for 

23 which the reference product is li24 censed and intended to be used 


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1 and for which licensure is sought 

2 for the biological product; 

3 ‘‘(II) the biological product and 

4 reference product utilize the same 

5 mechanism or mechanisms of action 

6 for the condition or conditions of use 

7 prescribed, recommended, or sug8 gested in the proposed labeling, but 

9 only to the extent the mechanism or 

10 mechanisms of action are known for 

11 the reference product; 

12 ‘‘(III) the condition or conditions 

13 of use prescribed, recommended, or 

14 suggested in the labeling proposed for 

15 the biological product have been pre16 viously approved for the reference 

17 product; 

18 ‘‘(IV) the route of administra19 tion, the dosage form, and the 

20 strength of the biological product are 

21 the same as those of the reference 

22 product; and 

23 ‘‘(V) the facility in which the bio24 logical product is manufactured, proc25 essed, packed, or held meets standVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01530 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 ards designed to assure that the bio2 logical product continues to be safe, 

3 pure, and potent. 

4 ‘‘(ii) DETERMINATION BY SEC5 RETARY.—The Secretary may determine, 

6 in the Secretary’s discretion, that an ele7 ment described in clause (i)(I) is unneces8 sary in an application submitted under this 

9 subsection. 

10 ‘‘(iii) ADDITIONAL INFORMATION.— 

11 An application submitted under this sub12 section— 

13 ‘‘(I) shall include publicly avail14 able information regarding the Sec15 retary’s previous determination that 

16 the reference product is safe, pure, 

17 and potent; and 

18 ‘‘(II) may include any additional 

19 information in support of the applica20 tion, including publicly available infor21 mation with respect to the reference 

22 product or another biological product. 

23 ‘‘(B) INTERCHANGEABILITY.—An applica24 tion (or a supplement to an application) sub25 mitted under this subsection may include inforVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01531 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 mation demonstrating that the biological prod2 uct meets the standards described in paragraph 

3 (4). 

4 ‘‘(3) EVALUATION BY SECRETARY.—Upon re5 view of an application (or a supplement to an appli6 cation) submitted under this subsection, the Sec7 retary shall license the biological product under this 

8 subsection if— 

9 ‘‘(A) the Secretary determines that the in10 formation submitted in the application (or the 

11 supplement) is sufficient to show that the bio12 logical product— 

13 ‘‘(i) is biosimilar to the reference 

14 product; or 

15 ‘‘(ii) meets the standards described in 

16 paragraph (4), and therefore is inter17 changeable with the reference product; and 

18 ‘‘(B) the applicant (or other appropriate 

19 person) consents to the inspection of the facility 

20 that is the subject of the application, in accord21 ance with subsection (c). 

22 ‘‘(4) SAFETY STANDARDS FOR DETERMINING

23 INTERCHANGEABILITY.—Upon review of an applica24 tion submitted under this subsection or any supple25 ment to such application, the Secretary shall deterVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01532 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 mine the biological product to be interchangeable 

2 with the reference product if the Secretary deter3 mines that the information submitted in the applica4 tion (or a supplement to such application) is suffi5 cient to show that— 

6 ‘‘(A) the biological product— 

7 ‘‘(i) is biosimilar to the reference 

8 product; and 

9 ‘‘(ii) can be expected to produce the 

10 same clinical result as the reference prod11 uct in any given patient; and 

12 ‘‘(B) for a biological product that is ad13 ministered more than once to an individual, the 

14 risk in terms of safety or diminished efficacy of 

15 alternating or switching between use of the bio16 logical product and the reference product is not 

17 greater than the risk of using the reference 

18 product without such alternation or switch. 

19 ‘‘(5) GENERAL RULES.— 

20 ‘‘(A) ONE REFERENCE PRODUCT PER AP21 PLICATION.—A biological product, in an appli22 cation submitted under this subsection, may not 

23 be evaluated against more than 1 reference 

24 product. 


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1 ‘‘(B) REVIEW.—An application submitted 

2 under this subsection shall be reviewed by the 

3 division within the Food and Drug Administra4 tion that is responsible for the review and ap5 proval of the application under which the ref6 erence product is licensed. 

7 ‘‘(C) RISK EVALUATION AND MITIGATION

8 STRATEGIES.—The authority of the Secretary 

9 with respect to risk evaluation and mitigation 

10 strategies under the Federal Food, Drug, and 

11 Cosmetic Act shall apply to biological products 

12 licensed under this subsection in the same man13 ner as such authority applies to biological prod14 ucts licensed under subsection (a). 

15 ‘‘(D) RESTRICTIONS ON BIOLOGICAL PROD16 UCTS CONTAINING DANGEROUS INGREDI17 ENTS.—If information in an application sub18 mitted under this subsection, in a supplement 

19 to such an application, or otherwise available to 

20 the Secretary shows that a biological product— 

21 ‘‘(i) is, bears, or contains a select 

22 agent or toxin listed in section 73.3 or 

23 73.4 of title 42, section 121.3 or 121.4 of 

24 title 9, or section 331.3 of title 7, Code of 


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1 Federal Regulations (or any successor reg2 ulations); or 

3 ‘‘(ii) is, bears, or contains a controlled 

4 substance in schedule I or II of section 

5 202 of the Controlled Substances Act, as 

6 listed in part 1308 of title 21, Code of 

7 Federal Regulations (or any successor reg8 ulations); 

9 the Secretary shall not license the biological 

10 product under this subsection unless the Sec11 retary determines, after consultation with ap12 propriate national security and drug enforce13 ment agencies, that there would be no increased 

14 risk to the security or health of the public from 

15 licensing such biological product under this sub16 section. 

17 ‘‘(6) EXCLUSIVITY FOR FIRST INTERCHANGE18 ABLE BIOLOGICAL PRODUCT.—Upon review of an 

19 application submitted under this subsection relying 

20 on the same reference product for which a prior bio21 logical product has received a determination of inter22 changeability for any condition of use, the Secretary 

23 shall not make a determination under paragraph (4) 

24 that the second or subsequent biological product is 


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1 interchangeable for any condition of use until the 

2 earlier of— 

3 ‘‘(A) 1 year after the first commercial 

4 marketing of the first interchangeable bio5 similar biological product to be approved as 

6 interchangeable for that reference product; 

7 ‘‘(B) 18 months after— 

8 ‘‘(i) a final court decision on all pat9 ents in suit in an action instituted under 

10 subsection (l)(5) against the applicant that 

11 submitted the application for the first ap12 proved interchangeable biosimilar biological 

13 product; or 

14 ‘‘(ii) the dismissal with or without 

15 prejudice of an action instituted under sub16 section (l)(5) against the applicant that 

17 submitted the application for the first ap18 proved interchangeable biosimilar biological 

19 product; or 

20 ‘‘(C)(i) 42 months after approval of the 

21 first interchangeable biosimilar biological prod22 uct if the applicant that submitted such appli23 cation has been sued under subsection (l)(5) 

24 and such litigation is still ongoing within such 

25 42-month period; or 


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1 ‘‘(ii) 18 months after approval of the first 

2 interchangeable biosimilar biological product if 

3 the applicant that submitted such application 

4 has not been sued under subsection (l)(5). 

5 For purposes of this paragraph, the term ‘final court 

6 decision’ means a final decision of a court from 

7 which no appeal (other than a petition to the United 

8 States Supreme Court for a writ of certiorari) has 

9 been or can be taken. 

10 ‘‘(7) EXCLUSIVITY FOR REFERENCE PROD11 UCT.— 

12 ‘‘(A) EFFECTIVE DATE OF BIOSIMILAR AP13 PLICATION APPROVAL.—Approval of an applica14 tion under this subsection may not be made ef15 fective by the Secretary until the date that is 

16 12 years after the date on which the reference 

17 product was first licensed under subsection (a). 

18 ‘‘(B) FILING PERIOD.—An application 

19 under this subsection may not be submitted to 

20 the Secretary until the date that is 4 years 

21 after the date on which the reference product 

22 was first licensed under subsection (a). 

23 ‘‘(C) FIRST LICENSURE.—Subparagraphs 

24 (A) and (B) shall not apply to a license for or 

25 approval of— 


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1 ‘‘(i) a supplement for the biological 

2 product that is the reference product; or 

3 ‘‘(ii) a subsequent application filed by 

4 the same sponsor or manufacturer of the 

5 biological product that is the reference 

6 product (or a licensor, predecessor in inter7 est, or other related entity) for— 

8 ‘‘(I) a change (not including a 

9 modification to the structure of the bi10 ological product) that results in a new 

11 indication, route of administration, 

12 dosing schedule, dosage form, delivery 

13 system, delivery device, or strength; or 

14 ‘‘(II) a modification to the struc15 ture of the biological product that 

16 does not result in a change in safety, 

17 purity, or potency. 

18 ‘‘(8) PEDIATRIC STUDIES.— 

19 ‘‘(A) EXCLUSIVITY.—If, before or after li20 censure of the reference product under sub21 section (a) of this section, the Secretary deter22 mines that information relating to the use of 

23 such product in the pediatric population may 

24 produce health benefits in that population, the 

25 Secretary makes a written request for pediatric 


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1 studies (which shall include a timeframe for 

2 completing such studies), the applicant or hold3 er of the approved application agrees to the re4 quest, such studies are completed using appro5 priate formulations for each age group for 

6 which the study is requested within any such 

7 timeframe, and the reports thereof are sub8 mitted and accepted in accordance with section 

9 505A(d)(3) of the Federal Food, Drug, and 

10 Cosmetic Act the period referred to in para11 graph (7)(A) of this subsection is deemed to be 

12 12 years and 6 months rather than 12 years. 

13 ‘‘(B) EXCEPTION.—The Secretary shall 

14 not extend the period referred to in subpara15 graph (A) of this paragraph if the determina16 tion under section 505A(d)(3) of the Federal 

17 Food, Drug, and Cosmetic Act is made later 

18 than 9 months prior to the expiration of such 

19 period. 

20 ‘‘(C) APPLICATION OF CERTAIN PROVI21 SIONS.—The provisions of subsections (a), (d), 

22 (e), (f), (h), (j), (k), and (l) of section 505A of 

23 the Federal Food, Drug, and Cosmetic Act 

24 shall apply with respect to the extension of a 

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1 graph to the same extent and in the same man2 ner as such provisions apply with respect to the 

3 extension of a period under subsection (b) or 

4 (c) of section 505A of the Federal Food, Drug, 

5 and Cosmetic Act. 

6 ‘‘(9) GUIDANCE DOCUMENTS.— 

7 ‘‘(A) IN GENERAL.—The Secretary may, 

8 after opportunity for public comment, issue 

9 guidance in accordance, except as provided in 

10 subparagraph (B)(i), with section 701(h) of the 

11 Federal Food, Drug, and Cosmetic Act with re12 spect to the licensure of a biological product 

13 under this subsection. Any such guidance may 

14 be general or specific. 

15 ‘‘(B) PUBLIC COMMENT.— 

16 ‘‘(i) IN GENERAL.—The Secretary 

17 shall provide the public an opportunity to 

18 comment on any proposed guidance issued 

19 under subparagraph (A) before issuing 

20 final guidance. 

21 ‘‘(ii) INPUT REGARDING MOST VALU22 ABLE GUIDANCE.—The Secretary shall es23 tablish a process through which the public 

24 may provide the Secretary with input re25 garding priorities for issuing guidance. 


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1 ‘‘(C) NO REQUIREMENT FOR APPLICATION

2 CONSIDERATION.—The issuance (or non3 issuance) of guidance under subparagraph (A) 

4 shall not preclude the review of, or action on, 

5 an application submitted under this subsection. 

6 ‘‘(D) REQUIREMENT FOR PRODUCT CLASS7 SPECIFIC GUIDANCE.—If the Secretary issues 

8 product class-specific guidance under subpara9 graph (A), such guidance shall include a de10 scription of— 

11 ‘‘(i) the criteria that the Secretary will 

12 use to determine whether a biological prod13 uct is highly similar to a reference product 

14 in such product class; and 

15 ‘‘(ii) the criteria, if available, that the 

16 Secretary will use to determine whether a 

17 biological product meets the standards de18 scribed in paragraph (4). 

19 ‘‘(E) CERTAIN PRODUCT CLASSES.— 

20 ‘‘(i) GUIDANCE.—The Secretary may 

21 indicate in a guidance document that the 

22 science and experience, as of the date of 

23 such guidance, with respect to a product or 

24 product class (not including any recom25 binant protein) does not allow approval of 


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1 an application for a license as provided 

2 under this subsection for such product or 

3 product class. 

4 ‘‘(ii) MODIFICATION OR REVERSAL.— 

5 The Secretary may issue a subsequent 

6 guidance document under subparagraph 

7 (A) to modify or reverse a guidance docu8 ment under clause (i). 

9 ‘‘(iii) NO EFFECT ON ABILITY TO

10 DENY LICENSE.—Clause (i) shall not be 

11 construed to require the Secretary to ap12 prove a product with respect to which the 

13 Secretary has not indicated in a guidance 

14 document that the science and experience, 

15 as described in clause (i), does not allow 

16 approval of such an application. 

17 ‘‘(10) NAMING.—The Secretary shall ensure 

18 that the labeling and packaging of each biological 

19 product licensed under this subsection bears a name 

20 that uniquely identifies the biological product and 

21 distinguishes it from the reference product and any 

22 other biological products licensed under this sub23 section following evaluation against such reference 

24 product. 


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1 ‘‘(l) PATENT NOTICES; RELATIONSHIP TO FINAL AP2 PROVAL.— 

3 ‘‘(1) DEFINITIONS.—For the purposes of this 

4 subsection, the term— 

5 ‘‘(A) ‘biosimilar product’ means the bio6 logical product that is the subject of the appli7 cation under subsection (k); 

8 ‘‘(B) ‘relevant patent’ means a patent 

9 that— 

10 ‘‘(i) expires after the date specified in 

11 subsection (k)(7)(A) that applies to the 

12 reference product; and 

13 ‘‘(ii) could reasonably be asserted 

14 against the applicant due to the unauthor15 ized making, use, sale, or offer for sale 

16 within the United States, or the importa17 tion into the United States of the bio18 similar product, or materials used in the 

19 manufacture of the biosimilar product, or 

20 due to a use of the biosimilar product in 

21 a method of treatment that is indicated in 

22 the application; 

23 ‘‘(C) ‘reference product sponsor’ means the 

24 holder of an approved application or license for 

25 the reference product; and 


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1 ‘‘(D) ‘interested third party’ means a per2 son other than the reference product sponsor 

3 that owns a relevant patent, or has the right to 

4 commence or participate in an action for in5 fringement of a relevant patent. 

6 ‘‘(2) HANDLING OF CONFIDENTIAL INFORMA7 TION.—Any entity receiving confidential information 

8 pursuant to this subsection shall designate one or 

9 more individuals to receive such information. Each 

10 individual so designated shall execute an agreement 

11 in accordance with regulations promulgated by the 

12 Secretary. The regulations shall require each such 

13 individual to take reasonable steps to maintain the 

14 confidentiality of information received pursuant to 

15 this subsection and use the information solely for 

16 purposes authorized by this subsection. The obliga17 tions imposed on an individual who has received con18 fidential information pursuant to this subsection 

19 shall continue until the individual returns or de20 stroys the confidential information, a court imposes 

21 a protective order that governs the use or handling 

22 of the confidential information, or the party pro23 viding the confidential information agrees to other 

24 terms or conditions regarding the handling or use of 

25 the confidential information. 


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1 ‘‘(3) PUBLIC NOTICE BY SECRETARY.—Within 

2 30 days of acceptance by the Secretary of an appli3 cation filed under subsection (k), the Secretary shall 

4 publish a notice identifying— 

5 ‘‘(A) the reference product identified in the 

6 application; and 

7 ‘‘(B) the name and address of an agent 

8 designated by the applicant to receive notices 

9 pursuant to paragraph (4)(B). 

10 ‘‘(4) EXCHANGES CONCERNING PATENTS.— 

11 ‘‘(A) EXCHANGES WITH REFERENCE

12 PRODUCT SPONSOR.— 

13 ‘‘(i) Within 30 days of the date of ac14 ceptance of the application by the Sec15 retary, the applicant shall provide the ref16 erence product sponsor with a copy of the 

17 application and information concerning the 

18 biosimilar product and its production. This 

19 information shall include a detailed de20 scription of the biosimilar product, its 

21 method of manufacture, and the materials 

22 used in the manufacture of the product. 

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1 uct sponsor shall provide to the applicant 

2 a list of relevant patents owned by the ref3 erence product sponsor, or in respect of 

4 which the reference product sponsor has 

5 the right to commence an action of in6 fringement or otherwise has an interest in 

7 the patent as such patent concerns the bio8 similar product. 

9 ‘‘(iii) If the reference product sponsor 

10 is issued or acquires an interest in a rel11 evant patent after the date on which the 

12 reference product sponsor provides the list 

13 required by clause (ii) to the applicant, the 

14 reference product sponsor shall identify 

15 that patent to the applicant within 30 days 

16 of the date of issue of the patent, or the 

17 date of acquisition of the interest in the 

18 patent, as applicable. 

19 ‘‘(B) EXCHANGES WITH INTERESTED

20 THIRD PARTIES.— 

21 ‘‘(i) At any time after the date on 

22 which the Secretary publishes a notice for 

23 an application under paragraph (3), any 

24 interested third party may provide notice 

25 to the designated agent of the applicant 


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1 that the interested third party owns or has 

2 rights under 1 or more patents that may 

3 be relevant patents. The notice shall iden4 tify at least 1 patent and shall designate 

5 an individual who has executed an agree6 ment in accordance with paragraph (2) to 

7 receive confidential information from the 

8 applicant. 

9 ‘‘(ii) Within 30 days of the date of re10 ceiving notice pursuant to clause (i), the 

11 applicant shall send to the individual des12 ignated by the interested third party the 

13 information specified in subparagraph 

14 (A)(i), unless the applicant and interested 

15 third party otherwise agree. 

16 ‘‘(iii) Within 90 days of the date of 

17 receiving information pursuant to clause 

18 (ii), the interested third party shall provide 

19 to the applicant a list of relevant patents 

20 which the interested third party owns, or 

21 in respect of which the interested third 

22 party has the right to commence or partici23 pate in an action for infringement. 

24 ‘‘(iv) If the interested third party is 

25 issued or acquires an interest in a relevant 


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1 patent after the date on which the inter2 ested third party provides the list required 

3 by clause (iii), the interested third party 

4 shall identify that patent within 30 days of 

5 the date of issue of the patent, or the date 

6 of acquisition of the interest in the patent, 

7 as applicable. 

8 ‘‘(C) IDENTIFICATION OF BASIS FOR IN9 FRINGEMENT.—For any patent identified under 

10 clause (ii) or (iii) of subparagraph (A) or under 

11 clause (iii) or (iv) of subparagraph (B), the ref12 erence product sponsor or the interested third 

13 party, as applicable— 

14 ‘‘(i) shall explain in writing why the 

15 sponsor or the interested third party be16 lieves the relevant patent would be in17 fringed by the making, use, sale, or offer 

18 for sale within the United States, or im19 portation into the United States, of the 

20 biosimilar product or by a use of the bio21 similar product in treatment that is indi22 cated in the application; 

23 ‘‘(ii) may specify whether the relevant 

24 patent is available for licensing; and 


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1 ‘‘(iii) shall specify the number and 

2 date of expiration of the relevant patent. 

3 ‘‘(D) CERTIFICATION BY APPLICANT CON4 CERNING IDENTIFIED RELEVANT PATENTS.— 

5 Not later than 45 days after the date on which 

6 a patent is identified under clause (ii) or (iii) of 

7 subparagraph (A) or under clause (iii) or (iv) of 

8 subparagraph (B), the applicant shall send a 

9 written statement regarding each identified pat10 ent to the party that identified the patent. Such 

11 statement shall either— 

12 ‘‘(i) state that the applicant will not 

13 commence marketing of the biosimilar 

14 product and has requested the Secretary to 

15 not grant final approval of the application 

16 before the date of expiration of the noticed 

17 patent; or 

18 ‘‘(ii) provide a detailed written expla19 nation setting forth the reasons why the 

20 applicant believes— 

21 ‘‘(I) the making, use, sale, or 

22 offer for sale within the United 

23 States, or the importation into the 

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1 uct in a treatment indicated in the ap2 plication, would not infringe the pat3 ent; or 

4 ‘‘(II) the patent is invalid or un5 enforceable. 

6 ‘‘(5) ACTION FOR INFRINGEMENT INVOLVING

7 REFERENCE PRODUCT SPONSOR.—If an action for 

8 infringement concerning a relevant patent identified 

9 by the reference product sponsor under clause (ii) or 

10 (iii) of paragraph (4)(A), or by an interested third 

11 party under clause (iii) or (iv) of paragraph (4)(B), 

12 is brought within 60 days of the date of receipt of 

13 a statement under paragraph (4)(D)(ii), and the 

14 court in which such action has been commenced de15 termines the patent is infringed prior to the date ap16 plicable under subsection (k)(7)(A) or (k)(8), the 

17 Secretary shall make approval of the application ef18 fective on the day after the date of expiration of the 

19 patent that has been found to be infringed. If more 

20 than one such patent is found to be infringed by the 

21 court, the approval of the application shall be made 

22 effective on the day after the date that the last such 

23 patent expires. 

24 ‘‘(6) NOTIFICATION OF AGREEMENTS.— 

25 ‘‘(A) REQUIREMENTS.— 


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1 ‘‘(i) AGREEMENT BETWEEN BIO2 SIMILAR PRODUCT APPLICANT AND REF3 ERENCE PRODUCT SPONSOR.—If a bio4 similar product applicant under subsection 

5 (k) and the reference product sponsor 

6 enter into an agreement described in sub7 paragraph (B), the applicant and sponsor 

8 shall each file the agreement in accordance 

9 with subparagraph (C). 

10 ‘‘(ii) AGREEMENT BETWEEN BIO11 SIMILAR PRODUCT APPLICANTS.—If 2 or 

12 more biosimilar product applicants submit 

13 an application under subsection (k) for bio14 similar products with the same reference 

15 product and enter into an agreement de16 scribed in subparagraph (B), the appli17 cants shall each file the agreement in ac18 cordance with subparagraph (C). 

19 ‘‘(B) SUBJECT MATTER OF AGREEMENT.— 

20 An agreement described in this subparagraph— 

21 ‘‘(i) is an agreement between the bio22 similar product applicant under subsection 

23 (k) and the reference product sponsor or 

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1 plicants under subsection (k) regarding the 

2 manufacture, marketing, or sale of— 

3 ‘‘(I) the biosimilar product (or 

4 biosimilar products) for which an ap5 plication was submitted; or 

6 ‘‘(II) the reference product; 

7 ‘‘(ii) includes any agreement between 

8 the biosimilar product applicant under sub9 section (k) and the reference product spon10 sor or between 2 or more biosimilar prod11 uct applicants under subsection (k) that is 

12 contingent upon, provides a contingent 

13 condition for, or otherwise relates to an 

14 agreement described in clause (i); and 

15 ‘‘(iii) excludes any agreement that 

16 solely concerns— 

17 ‘‘(I) purchase orders for raw ma18 terial supplies; 

19 ‘‘(II) equipment and facility con20 tracts; 

21 ‘‘(III) employment or consulting 

22 contracts; or 

23 ‘‘(IV) packaging and labeling 

24 contracts. 

25 ‘‘(C) FILING.— 


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1 ‘‘(i) IN GENERAL.—The text of an 

2 agreement required to be filed by subpara3 graph (A) shall be filed with the Assistant 

4 Attorney General and the Federal Trade 

5 Commission not later than— 

6 ‘‘(I) 10 business days after the 

7 date on which the agreement is exe8 cuted; and 

9 ‘‘(II) prior to the date of the first 

10 commercial marketing of, for agree11 ments described in subparagraph 

12 (A)(i), the biosimilar product that is 

13 the subject of the application or, for 

14 agreements described in subparagraph 

15 (A)(ii), any biosimilar product that is 

16 the subject of an application described 

17 in such subparagraph. 

18 ‘‘(ii) IF AGREEMENT NOT REDUCED

19 TO TEXT.—If an agreement required to be 

20 filed by subparagraph (A) has not been re21 duced to text, the persons required to file 

22 the agreement shall each file written de23 scriptions of the agreement that are suffi24 cient to disclose all the terms and condi25 tions of the agreement. 


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1 ‘‘(iii) CERTIFICATION.—The chief ex2 ecutive officer or the company official re3 sponsible for negotiating any agreement re4 quired to be filed by subparagraph (A) 

5 shall include in any filing under this para6 graph a certification as follows: ‘I declare 

7 under penalty of perjury that the following 

8 is true and correct: The materials filed 

9 with the Federal Trade Commission and 

10 the Department of Justice under section 

11 351(l)(6) of the Public Health Service Act, 

12 with respect to the agreement referenced in 

13 this certification: (1) represent the com14 plete, final, and exclusive agreement be15 tween the parties; (2) include any ancillary 

16 agreements that are contingent upon, pro17 vide a contingent condition for, or are oth18 erwise related to, the referenced agree19 ment; and (3) include written descriptions 

20 of any oral agreements, representations, 

21 commitments, or promises between the 

22 parties that are responsive to such section 

23 and have not been reduced to writing.’. 

24 ‘‘(D) DISCLOSURE EXEMPTION.—Any in25 formation or documentary material filed with 


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1 the Assistant Attorney General or the Federal 

2 Trade Commission pursuant to this paragraph 

3 shall be exempt from disclosure under section 

4 552 of title 5, United States Code, and no such 

5 information or documentary material may be 

6 made public, except as may be relevant to any 

7 administrative or judicial action or proceeding. 

8 Nothing in this subparagraph prevents disclo9 sure of information or documentary material to 

10 either body of the Congress or to any duly au11 thorized committee or subcommittee of the Con12 gress. 

13 ‘‘(E) ENFORCEMENT.— 

14 ‘‘(i) CIVIL PENALTY.—Any person 

15 that violates a provision of this paragraph 

16 shall be liable for a civil penalty of not 

17 more than $11,000 for each day on which 

18 the violation occurs. Such penalty may be 

19 recovered in a civil action— 

20 ‘‘(I) brought by the United 

21 States; or 

22 ‘‘(II) brought by the Federal 

23 Trade Commission in accordance with 

24 the procedures established in section 


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1 16(a)(1) of the Federal Trade Com2 mission Act. 

3 ‘‘(ii) COMPLIANCE AND EQUITABLE

4 RELIEF.—If any person violates any provi5 sion of this paragraph, the United States 

6 district court may order compliance, and 

7 may grant such other equitable relief as 

8 the court in its discretion determines nec9 essary or appropriate, upon application of 

10 the Assistant Attorney General or the Fed11 eral Trade Commission. 

12 ‘‘(F) RULEMAKING.—The Federal Trade 

13 Commission, with the concurrence of the Assist14 ant Attorney General and by rule in accordance 

15 with section 553 of title 5, United States Code, 

16 consistent with the purposes of this para17 graph— 

18 ‘‘(i) may define the terms used in this 

19 paragraph; 

20 ‘‘(ii) may exempt classes of persons or 

21 agreements from the requirements of this 

22 paragraph; and 

23 ‘‘(iii) may prescribe such other rules 

24 as may be necessary and appropriate to 

25 carry out the purposes of this paragraph. 


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1 ‘‘(G) SAVINGS CLAUSE.—Any action taken 

2 by the Assistant Attorney General or the Fed3 eral Trade Commission, or any failure of the 

4 Assistant Attorney General or the Commission 

5 to take action, under this paragraph shall not 

6 at any time bar any proceeding or any action 

7 with respect to any agreement between a bio8 similar product applicant under subsection (k) 

9 and the reference product sponsor, or any 

10 agreement between biosimilar product appli11 cants under subsection (k), under any other 

12 provision of law, nor shall any filing under this 

13 paragraph constitute or create a presumption of 

14 any violation of any competition laws.’’. 

15 (b) DEFINITIONS.—Section 351(i) of the Public 

16 Health Service Act (42 U.S.C. 262(i)) is amended— 

17 (1) by striking ‘‘In this section, the term ‘bio18 logical product’ means’’ and inserting the following: 

19 ‘‘In this section: 

20 ‘‘(1) The term ‘biological product’ means’’; 

21 (2) in paragraph (1), as so designated, by in22 serting ‘‘protein (except any chemically synthesized 

23 polypeptide),’’ after ‘‘allergenic product,’’; and 

24 (3) by adding at the end the following: 


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1 ‘‘(2) The term ‘biosimilar’ or ‘biosimilarity’, in 

2 reference to a biological product that is the subject 

3 of an application under subsection (k), means— 

4 ‘‘(A) that the biological product is highly 

5 similar to the reference product notwith6 standing minor differences in clinically inactive 

7 components; and 

8 ‘‘(B) there are no clinically meaningful dif9 ferences between the biological product and the 

10 reference product in terms of the safety, purity, 

11 and potency of the product. 

12 ‘‘(3) The term ‘interchangeable’ or ‘inter13 changeability’, in reference to a biological product 

14 that is shown to meet the standards described in 

15 subsection (k)(4), means that the biological product 

16 may be substituted for the reference product without 

17 the intervention of the health care provider who pre18 scribed the reference product. 

19 ‘‘(4) The term ‘reference product’ means the 

20 single biological product licensed under subsection 

21 (a) against which a biological product is evaluated in 

22 an application submitted under subsection (k).’’. 

23 (c) PRODUCTS PREVIOUSLY APPROVED UNDER SEC24 TION 505.— 


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1 (1) REQUIREMENT TO FOLLOW SECTION 351.— 

2 Except as provided in paragraph (2), an application 

3 for a biological product shall be submitted under 

4 section 351 of the Public Health Service Act (42 

5 U.S.C. 262) (as amended by this Act). 

6 (2) EXCEPTION.—An application for a biologi7 cal product may be submitted under section 505 of 

8 the Federal Food, Drug, and Cosmetic Act (21 

9 U.S.C. 355) if— 

10 (A) such biological product is in a product 

11 class for which a biological product in such 

12 product class is the subject of an application 

13 approved under such section 505 not later than 

14 the date of enactment of this Act; and 

15 (B) such application— 

16 (i) has been submitted to the Sec17 retary of Health and Human Services (re18 ferred to in this Act as the ‘‘Secretary’’) 

19 before the date of enactment of this Act; 

20 or 

21 (ii) is submitted to the Secretary not 

22 later than the date that is 10 years after 

23 the date of enactment of this Act. 

24 (3) LIMITATION.—Notwithstanding paragraph 

25 (2), an application for a biological product may not 


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1 be submitted under section 505 of the Federal Food, 

2 Drug, and Cosmetic Act (21 U.S.C. 355) if there is 

3 another biological product approved under sub4 section (a) of section 351 of the Public Health Serv5 ice Act that could be a reference product with re6 spect to such application (within the meaning of 

7 such section 351) if such application were submitted 

8 under subsection (k) of such section 351. 

9 (4) DEEMED APPROVED UNDER SECTION 351.— 

10 An approved application for a biological product 

11 under section 505 of the Federal Food, Drug, and 

12 Cosmetic Act (21 U.S.C. 355) shall be deemed to be 

13 a license for the biological product under such sec14 tion 351 on the date that is 10 years after the date 

15 of enactment of this Act. 

16 (5) DEFINITIONS.—For purposes of this sub17 section, the term ‘‘biological product’’ has the mean18 ing given such term under section 351 of the Public 

19 Health Service Act (42 U.S.C. 262) (as amended by 

20 this Act). 

21 SEC. 2576. FEES RELATING TO BIOSIMILAR BIOLOGICAL 

22 PRODUCTS. 

23 Subparagraph (B) of section 735(1) of the Federal 

24 Food, Drug, and Cosmetic Act (21 U.S.C. 379g(1)) is 

25 amended by inserting ‘‘, including licensure of a biological 


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1 product under section 351(k) of such Act’’ before the pe2 riod at the end. 

3 SEC. 2577. AMENDMENTS TO CERTAIN PATENT PROVI4 SIONS. 

5 (a) Section 271(e)(2) of title 35, United States Code 

6 is amended— 

7 (1) in subparagraph (A), by striking ‘‘or’’ after 

8 ‘‘patent,’’; 

9 (2) in subparagraph (B), by adding ‘‘or’’ after 

10 the comma at the end; 

11 (3) by inserting the following after subpara12 graph (B): 

13 ‘‘(C) a statement under section 

14 351(l)(4)(D)(ii) of the Public Health Service 

15 Act,’’; and 

16 (4) in the matter following subparagraph (C) 

17 (as added by paragraph (3)), by inserting before the 

18 period the following: ‘‘, or if the statement described 

19 in subparagraph (C) is provided in connection with 

20 an application to obtain a license to engage in the 

21 commercial manufacture, use, or sale of a biological 

22 product claimed in a patent or the use of which is 

23 claimed in a patent before the expiration of such 

24 patent’’. 


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1 (b) Section 271(e)(4) of title 35, United States Code, 

2 is amended by striking ‘‘in paragraph (2)’’ in both places 

3 it appears and inserting ‘‘in paragraph (2)(A) or (2)(B)’’. 

4 Subtitle D—Community Living 

5 Assistance Services and Supports 

6 SEC. 2581. ESTABLISHMENT OF NATIONAL VOLUNTARY IN7 SURANCE PROGRAM FOR PURCHASING COM8 MUNITY LIVING ASSISTANCE SERVICES AND 

9 SUPPORT (CLASS PROGRAM). 

10 (a) ESTABLISHMENT OF CLASS PROGRAM.—The 

11 Public Health Service Act (42 U.S.C. 201 et seq.), as 

12 amended by section 2301, is amended by adding at the 

13 end the following: 

14 ‘‘TITLE XXXII—COMMUNITY LIV15 ING ASSISTANCE SERVICES 

16 AND SUPPORTS 

17 ‘‘SEC. 3201. PURPOSE. 

18 ‘‘The purpose of this title is to establish a national 

19 voluntary insurance program for purchasing community 

20 living assistance services and supports in order to— 

21 ‘‘(1) provide individuals with functional limita22 tions with tools that will allow them to maintain 

23 their personal and financial independence and live in 

24 the community through a new financing strategy for 

25 community living assistance services and supports; 


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1 ‘‘(2) establish an infrastructure that will help 

2 address the Nation’s community living assistance 

3 services and supports needs; 

4 ‘‘(3) alleviate burdens on family caregivers; and 

5 ‘‘(4) address institutional bias by providing a fi6 nancing mechanism that supports personal choice 

7 and independence to live in the community. 

8 ‘‘SEC. 3202. DEFINITIONS. 

9 ‘‘In this title: 

10 ‘‘(1) ACTIVE ENROLLEE.—The term ‘active en11 rollee’ means an individual who is enrolled in the 

12 CLASS program in accordance with section 3204 

13 and who has paid any premiums due to maintain 

14 such enrollment. 

15 ‘‘(2) ACTIVELY EMPLOYED.—The term ‘actively 

16 employed’ means an individual who— 

17 ‘‘(A) is reporting for work at the individ18 ual’s usual place of employment or at another 

19 location to which the individual is required to 

20 travel because of the individual’s employment 

21 (or in the case of an individual who is a mem22 ber of the uniformed services, is on active duty 

23 and is physically able to perform the duties of 

24 the individual’s position); and 


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1 ‘‘(B) is able to perform all the usual and 

2 customary duties of the individual’s employment 

3 on the individual’s regular work schedule. 

4 ‘‘(3) ACTIVITIES OF DAILY LIVING.—The term 

5 ‘activities of daily living’ has the meaning given the 

6 term in section 7702B(c)(2)(B) of the Internal Rev7 enue Code of 1986. 

8 ‘‘(4) CLASS PROGRAM.—The term ‘CLASS 

9 program’ means the program established under this 

10 title. 

11 ‘‘(5) ELIGIBILITY ASSESSMENT SYSTEM.—The 

12 term ‘Eligibility Assessment System’ means the enti13 ty designated by the Secretary under section 

14 3205(a)(2)(A)(i). 

15 ‘‘(6) ELIGIBLE BENEFICIARY.— 

16 ‘‘(A) IN GENERAL.—The term ‘eligible 

17 beneficiary’ means any individual who is an ac18 tive enrollee in the CLASS program and, as of 

19 the date described in subparagraph (B)— 

20 ‘‘(i) has paid premiums for enrollment 

21 in such program for at least 60 months; 

22 ‘‘(ii) has earned, for each calendar 

23 year that occurs during the first 60 

24 months for which the individual has paid 

25 premiums for enrollment in the program, 


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1 at least an amount equal to the amount of 

2 wages and self-employment income which 

3 an individual must have in order to be 

4 credited with a quarter of coverage under 

5 section 213(d) of the Social Security Act 

6 for that year; and 

7 ‘‘(iii) has paid premiums for enroll8 ment in such program for at least 24 con9 secutive months, if a lapse in premium 

10 payments of more than 3 months has oc11 curred during the period that begins on the 

12 date of the individual’s enrollment and 

13 ends on the date of such determination. 

14 ‘‘(B) DATE DESCRIBED.—For purposes of 

15 subparagraph (A), the date described in this 

16 subparagraph is the date on which the indi17 vidual is determined to have a functional limita18 tion described in section 3203(a)(1)(C) that is 

19 expected to last for a continuous period of more 

20 than 90 days. 

21 ‘‘(C) REGULATIONS.—The Secretary shall 

22 promulgate regulations specifying exceptions to 

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1 ered an eligible beneficiary for certain popu2 lations. 

3 ‘‘(7) HOSPITAL; NURSING FACILITY; INTER4 MEDIATE CARE FACILITY FOR THE MENTALLY RE5 TARDED; INSTITUTION FOR MENTAL DISEASES.— 

6 The terms ‘hospital’, ‘nursing facility’, ‘intermediate 

7 care facility for the mentally retarded’, and ‘institu8 tion for mental diseases’ have the meanings given 

9 such terms for purposes of Medicaid. 

10 ‘‘(8) CLASS INDEPENDENCE ADVISORY COUN11 CIL.—The term ‘CLASS Independence Advisory 

12 Council’ or ‘Council’ means the Advisory Council es13 tablished under section 3207 to advise the Secretary. 

14 ‘‘(9) CLASS INDEPENDENCE BENEFIT PLAN.— 

15 The term ‘CLASS Independence Benefit Plan’ 

16 means the benefit plan developed and designated by 

17 the Secretary in accordance with section 3203. 

18 ‘‘(10) CLASS INDEPENDENCE FUND.—The 

19 term ‘CLASS Independence Fund’ or ‘Fund’ means 

20 the fund established under section 3206. 

21 ‘‘(11) MEDICAID.—The term ‘Medicaid’ means 

22 the program established under title XIX of the So23 cial Security Act. 

24 ‘‘(12) PROTECTION AND ADVOCACY SYSTEM.— 

25 The term ‘Protection and Advocacy System’ means 


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1 the system for each State established under section 

2 143 of the Developmental Disabilities Assistance 

3 and Bill of Rights Act of 2000. 

4 ‘‘SEC. 3203. CLASS INDEPENDENCE BENEFIT PLAN. 

5 ‘‘(a) PROCESS FOR DEVELOPMENT.— 

6 ‘‘(1) IN GENERAL.—The Secretary, in consulta7 tion with appropriate actuaries and other experts, 

8 shall develop at least 3 actuarially sound benefit 

9 plans as alternatives for consideration for designa10 tion by the Secretary as the CLASS Independence 

11 Benefit Plan under which eligible beneficiaries shall 

12 receive benefits under this title. Each of the plan al13 ternatives developed shall be designed to provide eli14 gible beneficiaries with the benefits described in sec15 tion 3205 consistent with the following require16 ments: 

17 ‘‘(A) PREMIUMS.—Beginning with the first 

18 year of the CLASS program, and for each year 

19 thereafter, the Secretary shall establish all pre20 miums to be paid by enrollees for the year 

21 based on an actuarial analysis of the 75-year 

22 costs of the program that ensures solvency 

23 throughout such 75-year period. 

24 ‘‘(B) VESTING PERIOD.—A 5-year vesting 

25 period for eligibility for benefits. 


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1 ‘‘(C) BENEFIT TRIGGERS.—A benefit trig2 ger for provision of benefits that requires a de3 termination that an individual has a functional 

4 limitation, as certified by a licensed health care 

5 practitioner, described in any of the following 

6 clauses that is expected to last for a continuous 

7 period of more than 90 days: 

8 ‘‘(i) The individual is determined to 

9 be unable to perform at least the minimum 

10 number (which may be 2 or 3) of activities 

11 of daily living as are required under the 

12 plan for the provision of benefits without 

13 substantial assistance (as defined by the 

14 Secretary) from another individual. 

15 ‘‘(ii) The individual requires substan16 tial supervision to protect the individual 

17 from threats to health and safety due to 

18 substantial cognitive impairment. 

19 ‘‘(iii) The individual has a level of 

20 functional limitation similar (as determined 

21 under regulations prescribed by the Sec22 retary) to the level of functional limitation 

23 described in clause (i) or (ii). 

24 ‘‘(D) CASH BENEFIT.—Payment of a cash 

25 benefit that satisfies the following requirements: 


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1 ‘‘(i) MINIMUM REQUIRED AMOUNT.— 

2 The benefit amount provides an eligible 

3 beneficiary with not less than an average 

4 of $50 per day (as determined based on 

5 the reasonably expected distribution of 

6 beneficiaries receiving benefits at various 

7 benefit levels). 

8 ‘‘(ii) AMOUNT SCALED TO FUNC9 TIONAL ABILITY.—The benefit amount is 

10 varied based on a scale of functional abil11 ity, with not less than 2, and not more 

12 than 6, benefit level amounts. 

13 ‘‘(iii) DAILY OR WEEKLY.—The ben14 efit is paid on a daily or weekly basis. 

15 ‘‘(iv) NO LIFETIME OR AGGREGATE

16 LIMIT.—The benefit is not subject to any 

17 lifetime or aggregate limit. 

18 ‘‘(2) REVIEW AND RECOMMENDATION BY THE

19 CLASS INDEPENDENCE ADVISORY COUNCIL.—The 

20 CLASS Independence Advisory Council shall— 

21 ‘‘(A) evaluate the alternative benefit plans 

22 developed under paragraph (1); and 

23 ‘‘(B) recommend for designation as the 

24 CLASS Independence Benefit Plan for offering 

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1 mines best balances price and benefits to meet 

2 enrollees’ needs in an actuarially sound manner, 

3 while optimizing the probability of the long4 term sustainability of the CLASS program. 

5 ‘‘(3) DESIGNATION BY THE SECRETARY.—Not 

6 later than October 1, 2012, the Secretary, taking 

7 into consideration the recommendation of the 

8 CLASS Independence Advisory Council under para9 graph (2)(B), shall designate a benefit plan as the 

10 CLASS Independence Benefit Plan. The Secretary 

11 shall publish such designation, along with details of 

12 the plan and the reasons for the selection by the 

13 Secretary, in a final rule that allows for a period of 

14 public comment. 

15 ‘‘(b) ADDITIONAL PREMIUM REQUIREMENTS.— 

16 ‘‘(1) ADJUSTMENT OF PREMIUMS.— 

17 ‘‘(A) IN GENERAL.—Except as provided in 

18 subparagraphs (B), (C), (D), and (E), the 

19 amount of the monthly premium determined for 

20 an individual upon such individual’s enrollment 

21 in the CLASS program shall remain the same 

22 for as long as the individual is an active en23 rollee in the program. 

24 ‘‘(B) RECALCULATED PREMIUM IF RE25 QUIRED FOR PROGRAM SOLVENCY.— 


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1 ‘‘(i) IN GENERAL.—Subject to clause 

2 (ii), if the Secretary determines, based on 

3 the most recent report of the Board of 

4 Trustees of the CLASS Independence 

5 Fund, the advice of the CLASS Independ6 ence Advisory Council, and the annual re7 port of the Inspector General of the De8 partment of Health and Human Services, 

9 and waste, fraud, and abuse, or such other 

10 information as the Secretary determines 

11 appropriate, that the monthly premiums 

12 and income to the CLASS Independence 

13 Fund for a year are projected to be insuffi14 cient with respect to the 20-year period 

15 that begins with that year, the Secretary 

16 shall adjust the monthly premiums for in17 dividuals enrolled in the CLASS program 

18 as necessary. 

19 ‘‘(ii) EXEMPTION FROM INCREASE.— 

20 Any increase in a monthly premium im21 posed as result of a determination de22 scribed in clause (i) shall not apply with 

23 respect to the monthly premium of any ac24 tive enrollee who— 

25 ‘‘(I) has attained age 65; 


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1 ‘‘(II) has paid premiums for en2 rollment in the program for at least 

3 20 years; and 

4 ‘‘(III) is not actively employed. 

5 ‘‘(C) RECALCULATED PREMIUM IF RE6 ENROLLMENT AFTER MORE THAN A 3-MONTH

7 LAPSE.— 

8 ‘‘(i) IN GENERAL.—The reenrollment 

9 of an individual after a 90-day period dur10 ing which the individual failed to pay the 

11 monthly premium required to maintain the 

12 individual’s enrollment in the CLASS pro13 gram shall be treated as an initial enroll14 ment for purposes of age-adjusting the 

15 premium for enrollment in the program. 

16 ‘‘(ii) CREDIT FOR PRIOR MONTHS IF

17 REENROLLED WITHIN 5 YEARS.—An indi18 vidual who reenrolls in the CLASS pro19 gram after such a 90-day period and be20 fore the end of the 5-year period that be21 gins with the first month for which the in22 dividual failed to pay the monthly premium 

23 required to maintain the individual’s en24 rollment in the program shall be— 


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1 ‘‘(I) credited with any months of 

2 paid premiums that accrued prior to 

3 the individual’s lapse in enrollment; 

4 and 

5 ‘‘(II) notwithstanding the total 

6 amount of any such credited months, 

7 required to satisfy section 

8 3202(6)(A)(ii) before being eligible to 

9 receive benefits. 

10 ‘‘(D) PENALTY FOR REENROLLMENT

11 AFTER 5-YEAR LAPSE.—In the case of an indi12 vidual who reenrolls in the CLASS program 

13 after the end of the 5-year period described in 

14 subparagraph (C)(ii), the monthly premium re15 quired for the individual shall be the age-ad16 justed premium that would be applicable to an 

17 initially enrolling individual who is the same age 

18 as the reenrolling individual, increased by the 

19 greater of— 

20 ‘‘(i) an amount that the Secretary de21 termines is actuarially sound for each 

22 month that occurs during the period that 

23 begins with the first month for which the 

24 individual failed to pay the monthly pre25 mium required to maintain the individual’s 


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1 enrollment in the CLASS program and 

2 ends with the month preceding the month 

3 in which the reenrollment is effective; or 

4 ‘‘(ii) 1 percent of the applicable age5 adjusted premium for each such month oc6 curring in such period. 

7 ‘‘(2) ADMINISTRATIVE EXPENSES.—In deter8 mining the monthly premiums for the CLASS pro9 gram, the Secretary may factor in costs for admin10 istering the program, not to exceed— 

11 ‘‘(A) in the case of the first 5 years in 

12 which the program is in effect under this title, 

13 an amount equal to 3 percent of all premiums 

14 paid during each such year; and 

15 ‘‘(B) in the case of subsequent years, an 

16 amount equal to 5 percent of the total amount 

17 of all expenditures (including benefits paid) 

18 under this title with respect to that year. 

19 ‘‘(3) NO UNDERWRITING REQUIREMENTS.—No 

20 underwriting (other than on the basis of age in ac21 cordance with paragraph (2)) shall be used to— 

22 ‘‘(A) determine the monthly premium for 

23 enrollment in the CLASS program; or 

24 ‘‘(B) prevent an individual from enrolling 

25 in the program. 


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1 ‘‘SEC. 3204. ENROLLMENT AND DISENROLLMENT REQUIRE2 MENTS. 

3 ‘‘(a) AUTOMATIC ENROLLMENT.— 

4 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

5 the Secretary shall establish procedures under which 

6 each individual described in subsection (c) shall be 

7 automatically enrolled in the CLASS program by an 

8 employer of such individual under rules similar to 

9 the rules of sections 401(k)(13) and 414(w) of the 

10 Internal Revenue Code of 1986. 

11 ‘‘(2) ALTERNATIVE ENROLLMENT PROCE12 DURES.—The procedures established under para13 graph (1) shall provide for an alternative enrollment 

14 process for an individual described in subsection (c) 

15 in the case of such an individual— 

16 ‘‘(A) who is self-employed; 

17 ‘‘(B) who has more than 1 employer; 

18 ‘‘(C) whose employer does not elect to par19 ticipate in the automatic enrollment process es20 tablished by the Secretary; or 

21 ‘‘(D) who is a spouse described in sub22 section (c)(2) of who is not subject to automatic 

23 enrollment. 

24 ‘‘(3) ADMINISTRATION.— 

25 ‘‘(A) IN GENERAL.—The Secretary shall, 

26 by regulation, establish procedures to— 


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1 ‘‘(i) ensure that an individual is not 

2 automatically enrolled in the CLASS pro3 gram by more than 1 employer; and 

4 ‘‘(ii) allow for an individual’s em5 ployer to deduct a premium for a spouse 

6 described in subsection (c)(1)(B) who is 

7 not subject to automatic enrollment. 

8 ‘‘(B) FORM.—Enrollment in the CLASS 

9 program shall be made in such manner as the 

10 Secretary may prescribe in order to ensure ease 

11 of administration. 

12 ‘‘(b) ELECTION TO OPT-OUT.—An individual de13 scribed in subsection (c) may elect to waive enrollment in 

14 the CLASS program at any time in such form and manner 

15 as the Secretary shall prescribe. 

16 ‘‘(c) INDIVIDUAL DESCRIBED.—For purposes of en17 rolling in the CLASS program, an individual described in 

18 this paragraph is— 

19 ‘‘(1) an individual— 

20 ‘‘(A) who has attained age 18; 

21 ‘‘(B) who receives wages on which there is 

22 imposed a tax under section 3101(a) or 3201(a) 

23 of the Internal Revenue Code of 1986; 

24 ‘‘(C) who is actively employed; and 

25 ‘‘(D) who is not— 


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1 ‘‘(i) a patient in a hospital or nursing 

2 facility, an intermediate care facility for 

3 the mentally retarded, or an institution for 

4 mental diseases and receiving medical as5 sistance under Medicaid; or 

6 ‘‘(ii) confined in a jail, prison, other 

7 penal institution or correctional facility, or 

8 by court order pursuant to conviction of a 

9 criminal offense or in connection with a 

10 verdict or finding described in section 

11 202(x)(1)(A)(ii) of the Social Security Act; 

12 or 

13 ‘‘(2) the spouse of an individual described in 

14 paragraph (1) and who would be an individual so de15 scribed but for subparagraph (B) or (C) of that 

16 paragraph. 

17 ‘‘(d) RULE OF CONSTRUCTION.—Nothing in this title 

18 shall be construed as requiring an active enrollee to con19 tinue to satisfy subparagraph (B) or (C) of subsection 

20 (c)(1) in order to maintain enrollment in the CLASS pro21 gram. 

22 ‘‘(e) PAYMENT.— 

23 ‘‘(1) PAYROLL DEDUCTION.—An amount equal 

24 to the monthly premium for the enrollment in the 

25 CLASS program of an individual shall be deducted 


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1 from the wages of such individual in accordance with 

2 such procedures as the Secretary shall establish for 

3 employers who elect to deduct and withhold such 

4 premiums on behalf of enrolled employees. 

5 ‘‘(2) ALTERNATIVE PAYMENT MECHANISM.— 

6 The Secretary shall establish alternative procedures 

7 for the payment of monthly premiums by an indi8 vidual enrolled in the CLASS program who does not 

9 have an employer who elects to deduct and withhold 

10 premiums in accordance with subparagraph (A). 

11 ‘‘(f) TRANSFER OF PREMIUMS COLLECTED.— 

12 ‘‘(1) IN GENERAL.—During each calendar year 

13 the Secretary of the Treasury shall deposit into the 

14 CLASS Independence Fund a total amount equal, in 

15 the aggregate, to 100 percent of the premiums col16 lected during that year. 

17 ‘‘(2) TRANSFERS BASED ON ESTIMATES.—The 

18 amount deposited pursuant to paragraph (1) shall be 

19 transferred in at least monthly payments to the 

20 CLASS Independence Fund on the basis of esti21 mates by the Secretary and certified to the Sec22 retary of the Treasury of the amounts collected in 

23 accordance with this section. Proper adjustments 

24 shall be made in amounts subsequently transferred 


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1 to the Fund to the extent prior estimates were in ex2 cess of, or were less than, actual amounts collected. 

3 ‘‘(g) OTHER ENROLLMENT AND DISENROLLMENT

4 OPPORTUNITIES.—The Secretary shall establish proce5 dures under which— 

6 ‘‘(1) an individual who, in the year of the indi7 vidual’s initial eligibility to enroll in the CLASS pro8 gram, has elected to waive enrollment in the pro9 gram, is eligible to elect to enroll in the program, in 

10 such form and manner as the Secretary shall estab11 lish, only during an open enrollment period estab12 lished by the Secretary that is specific to the indi13 vidual and that may not occur more frequently than 

14 biennially after the date on which the individual first 

15 elected to waive enrollment in the program; and 

16 ‘‘(2) an individual shall only be permitted to 

17 disenroll from the program during an annual 

18 disenrollment period established by the Secretary 

19 and in such form and manner as the Secretary shall 

20 establish. 

21 ‘‘SEC. 3205. BENEFITS. 

22 ‘‘(a) DETERMINATION OF ELIGIBILITY.— 

23 ‘‘(1) APPLICATION FOR RECEIPT OF BENE24 FITS.—The Secretary shall establish procedures 

25 under which an active enrollee shall apply for receipt 


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1 of benefits under the CLASS Independence Benefit 

2 Plan. 

3 ‘‘(2) ELIGIBILITY ASSESSMENTS.— 

4 ‘‘(A) IN GENERAL.—Not later than Janu5 ary 1, 2012, the Secretary shall— 

6 ‘‘(i) designate an entity (other than a 

7 service with which the Commissioner of So8 cial Security has entered into an agree9 ment, with respect to any State, to make 

10 disability determinations for purposes of 

11 title II or XVI of the Social Security Act) 

12 to serve as an Eligibility Assessment Sys13 tem by providing for eligibility assessments 

14 of active enrollees who apply for receipt of 

15 benefits; 

16 ‘‘(ii) enter into an agreement with the 

17 Protection and Advocacy System for each 

18 State to provide advocacy services in ac19 cordance with subsection (d); and 

20 ‘‘(iii) enter into an agreement with 

21 public and private entities to provide ad22 vice and assistance counseling in accord23 ance with subsection (e). 

24 ‘‘(B) REGULATIONS.—The Secretary shall 

25 promulgate regulations to develop an expedited 


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1 nationally equitable eligibility determination 

2 process, as certified by a licensed health care 

3 practitioner, an appeals process, and a redeter4 mination process, as certified by a licensed 

5 health care practitioner, including whether an 

6 applicant is eligible for a cash benefit under the 

7 program and if so, the amount of the cash ben8 efit (in accordance the sliding scale established 

9 under the plan). 

10 ‘‘(C) PRESUMPTIVE ELIGIBILITY FOR CER11 TAIN INSTITUTIONALIZED ENROLLEES PLAN12 NING TO DISCHARGE.—An active enrollee shall 

13 be deemed presumptively eligible if the en14 rollee— 

15 ‘‘(i) has applied for, and attests is eli16 gible for, the maximum cash benefit avail17 able under the sliding scale established 

18 under the CLASS Independence Benefit 

19 Plan; 

20 ‘‘(ii) is a patient in a hospital (but 

21 only if the hospitalization is for long-term 

22 care), nursing facility, intermediate care 

23 facility for the mentally retarded, or an in24 stitution for mental diseases; and 


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1 ‘‘(iii) is in the process of, or about to 

2 being the process of, planning to discharge 

3 from the hospital, facility, or institution, or 

4 within 60 days from the date of discharge 

5 from the hospital, facility, or institution. 

6 ‘‘(D) APPEALS.—The Secretary shall es7 tablish procedures under which an applicant for 

8 benefits under the CLASS Independence Ben9 efit Plan shall be guaranteed the right to ap10 peal an adverse determination. 

11 ‘‘(b) BENEFITS.—An eligible beneficiary shall receive 

12 the following benefits under the CLASS Independence 

13 Benefit Plan: 

14 ‘‘(1) CASH BENEFIT.—A cash benefit estab15 lished by the Secretary in accordance with the re16 quirements of section 3203(a)(1)(D) that— 

17 ‘‘(A) the first year in which beneficiaries 

18 receive the benefits under the plan, is not less 

19 than the average dollar amount specified in 

20 clause (i) of such section; and 

21 ‘‘(B) for any subsequent year, is not less 

22 than the average per day dollar limit applicable 

23 under this subparagraph for the preceding year, 

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1 sumer price index for all urban consumers 

2 (U.S. city average) over the previous year. 

3 ‘‘(2) ADVOCACY SERVICES.—Advocacy services 

4 in accordance with subsection (d). 

5 ‘‘(3) ADVICE AND ASSISTANCE COUNSELING.— 

6 Advice and assistance counseling in accordance with 

7 subsection (e). 

8 ‘‘(4) ADMINISTRATIVE EXPENSES.—Advocacy 

9 services and advise and assistance counseling serv10 ices under paragraphs (2) and (3) of this subsection 

11 shall be included as administrative expenses under 

12 section 3203(b)(2). 

13 ‘‘(c) PAYMENT OF BENEFITS.— 

14 ‘‘(1) LIFE INDEPENDENCE ACCOUNT.— 

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

16 establish procedures for administering the pro17 vision of benefits to eligible beneficiaries under 

18 the CLASS Independence Benefit Plan, includ19 ing the payment of the cash benefit for the ben20 eficiary into a Life Independence Account es21 tablished by the Secretary on behalf of each eli22 gible beneficiary. 

23 ‘‘(B) USE OF CASH BENEFITS.—Cash ben24 efits paid into a Life Independence Account of 

25 an eligible beneficiary shall be used to purchase 


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1 nonmedical services and supports that the bene2 ficiary needs to maintain his or her independ3 ence at home or in another residential setting 

4 of their choice in the community, including (but 

5 not limited to) home modifications, assistive 

6 technology, accessible transportation, home7 maker services, respite care, personal assistance 

8 services, home care aides, and nursing support. 

9 Nothing in the preceding sentence shall prevent 

10 an eligible beneficiary from using cash benefits 

11 paid into a Life Independence Account for ob12 taining assistance with decisionmaking con13 cerning medical care, including the right to ac14 cept or refuse medical or surgical treatment 

15 and the right to formulate advance directives or 

16 other written instructions recognized under 

17 State law, such as a living will or durable power 

18 of attorney for health care, in the case that an 

19 injury or illness causes the individual to be un20 able to make health care decisions. 

21 ‘‘(C) ELECTRONIC MANAGEMENT OF

22 FUNDS.—The Secretary shall establish proce23 dures for— 


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1 ‘‘(i) crediting an account established 

2 on behalf of a beneficiary with the bene3 ficiary’s cash daily benefit; 

4 ‘‘(ii) allowing the beneficiary to access 

5 such account through debit cards; and 

6 ‘‘(iii) accounting for withdrawals by 

7 the beneficiary from such account. 

8 ‘‘(D) PRIMARY PAYOR RULES FOR BENE9 FICIARIES WHO ARE ENROLLED IN MEDICAID.— 

10 In the case of an eligible beneficiary who is en11 rolled in Medicaid, the following payment rules 

12 shall apply: 

13 ‘‘(i) INSTITUTIONALIZED BENE14 FICIARY.—If the beneficiary is a patient in 

15 a hospital, nursing facility, intermediate 

16 care facility for the mentally retarded, or 

17 an institution for mental diseases, the ben18 eficiary shall retain an amount equal to 5 

19 percent of the beneficiary’s daily or weekly 

20 cash benefit (as applicable) (which shall be 

21 in addition to the amount of the bene22 ficiary’s personal needs allowance provided 

23 under Medicaid), and the remainder of 

24 such benefit shall be applied toward the fa25 cility’s cost of providing the beneficiary’s 


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1 care, and Medicaid shall provide secondary 

2 coverage for such care. 

3 ‘‘(ii) BENEFICIARIES RECEIVING

4 HOME AND COMMUNITY-BASED SERV5 ICES.— 

6 ‘‘(I) 50 PERCENT OF BENEFIT

7 RETAINED BY BENEFICIARY.—Subject 

8 to subclause (II), if a beneficiary is 

9 receiving medical assistance under 

10 Medicaid for home and community11 based services, the beneficiary shall 

12 retain an amount equal to 50 percent 

13 of the beneficiary’s daily or weekly 

14 cash benefit (as applicable), and the 

15 remainder of the daily or weekly cash 

16 benefit shall be applied toward the 

17 cost to the State of providing such as18 sistance (and shall not be used to 

19 claim Federal matching funds under 

20 Medicaid), and Medicaid shall provide 

21 secondary coverage for the remainder 

22 of any costs incurred in providing 

23 such assistance. 

24 ‘‘(II) REQUIREMENT FOR STATE

25 OFFSET.—A State shall be paid the 


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1 remainder of a beneficiary’s daily or 

2 weekly cash benefit under subclause 

3 (I) only if the State home and com4 munity-based waiver under section 

5 1115 of the Social Security Act or 

6 subsection (c) or (d) of section 1915 

7 of such Act, or the State plan amend8 ment under subsection (i) of such sec9 tion does not include a waiver of the 

10 requirements of section 1902(a)(1) of 

11 the Social Security Act (relating to 

12 statewideness) or of section 

13 1902(a)(10)(B) of such Act (relating 

14 to comparability) and the State offers 

15 at a minimum case management serv16 ices, personal care services, habili17 tation services, and respite care under 

18 such a waiver or State plan amend19 ment. 

20 ‘‘(III) DEFINITION OF HOME AND

21 COMMUNITY-BASED SERVICES.—In 

22 this clause, the term ‘home and com23 munity-based services’ means any 

24 services which may be offered under a 

25 home and community-based waiver 


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1 authorized for a State under section 

2 1115 of the Social Security Act or 

3 subsection (c) or (d) of section 1915 

4 of such Act or under a State plan 

5 amendment under subsection (i) of 

6 such section. 

7 ‘‘(iii) BENEFICIARIES ENROLLED IN

8 PROGRAMS OF ALL-INCLUSIVE CARE FOR

9 THE ELDERLY (PACE).— 

10 ‘‘(I) IN GENERAL.—Subject to 

11 subclause (II), if a beneficiary is re12 ceiving medical assistance under Med13 icaid for PACE program services 

14 under section 1934 of the Social Secu15 rity Act, the beneficiary shall retain 

16 an amount equal to 50 percent of the 

17 beneficiary’s daily or weekly cash ben18 efit (as applicable), and the remainder 

19 of the daily or weekly cash benefit 

20 shall be applied toward the cost to the 

21 State of providing such assistance 

22 (and shall not be used to claim Fed23 eral matching funds under Medicaid), 

24 and Medicaid shall provide secondary 

25 coverage for the remainder of any 


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1 costs incurred in providing such as2 sistance. 

3 ‘‘(II) INSTITUTIONALIZED RE4 CIPIENTS OF PACE PROGRAM SERV5 ICES.—If a beneficiary receiving as6 sistance under Medicaid for PACE 

7 program services is a patient in a hos8 pital, nursing facility, intermediate 

9 care facility for the mentally retarded, 

10 or an institution for mental diseases, 

11 the beneficiary shall be treated as in 

12 institutionalized beneficiary under 

13 clause (i). 

14 ‘‘(2) AUTHORIZED REPRESENTATIVES.— 

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

16 establish procedures to allow access to a bene17 ficiary’s cash benefits by an authorized rep18 resentative of the eligible beneficiary on whose 

19 behalf such benefits are paid. 

20 ‘‘(B) QUALITY ASSURANCE AND PROTEC21 TION AGAINST FRAUD AND ABUSE.—The proce22 dures established under subparagraph (A) shall 

23 ensure that authorized representatives of eligi24 ble beneficiaries comply with standards of con25 duct established by the Secretary, including 


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1 standards requiring that such representatives 

2 provide quality services on behalf of such bene3 ficiaries, do not have conflicts of interest, and 

4 do not misuse benefits paid on behalf of such 

5 beneficiaries or otherwise engage in fraud or 

6 abuse. 

7 ‘‘(3) COMMENCEMENT OF BENEFITS.—Benefits 

8 shall be paid to, or on behalf of, an eligible bene9 ficiary beginning with the first month in which an 

10 application for such benefits is approved. 

11 ‘‘(4) ROLLOVER OPTION FOR LUMP-SUM PAY12 MENT.—An eligible beneficiary may elect to— 

13 ‘‘(A) defer payment of their daily or weekly 

14 benefit and to rollover any such deferred bene15 fits from month-to-month, but not from year-to16 year; and 

17 ‘‘(B) receive a lump-sum payment of such 

18 deferred benefits in an amount that may not 

19 exceed the lesser of— 

20 ‘‘(i) the total amount of the accrued 

21 deferred benefits; or 

22 ‘‘(ii) the applicable annual benefit. 

23 ‘‘(5) PERIOD FOR DETERMINATION OF ANNUAL

24 BENEFITS.— 


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1 ‘‘(A) IN GENERAL.—The applicable period 

2 for determining with respect to an eligible bene3 ficiary the applicable annual benefit and the 

4 amount of any accrued deferred benefits is the 

5 12-month period that commences with the first 

6 month in which the beneficiary began to receive 

7 such benefits, and each 12-month period there8 after. 

9 ‘‘(B) INCLUSION OF INCREASED BENE10 FITS.—The Secretary shall establish procedures 

11 under which cash benefits paid to an eligible 

12 beneficiary that increase or decrease as a result 

13 of a change in the functional status of the bene14 ficiary before the end of a 12-month benefit pe15 riod shall be included in the determination of 

16 the applicable annual benefit paid to the eligible 

17 beneficiary. 

18 ‘‘(C) RECOUPMENT OF UNPAID, ACCRUED

19 BENEFITS.— 

20 ‘‘(i) IN GENERAL.—The Secretary, in 

21 coordination with the Secretary of the 

22 Treasury, shall recoup any accrued bene23 fits in the event of— 

24 ‘‘(I) the death of a beneficiary; or 


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1 ‘‘(II) the failure of a beneficiary 

2 to elect under paragraph (4)(B) to re3 ceive such benefits as a lump-sum 

4 payment before the end of the 12- 

5 month period in which such benefits 

6 accrued. 

7 ‘‘(ii) PAYMENT INTO CLASS INDE8 PENDENCE FUND.—Any benefits recouped 

9 in accordance with clause (i) shall be paid 

10 into the CLASS Independence Fund and 

11 used in accordance with section 3206. 

12 ‘‘(6) REQUIREMENT TO RECERTIFY ELIGIBILITY

13 FOR RECEIPT OF BENEFITS.—An eligible beneficiary 

14 shall periodically, as determined by the Secretary— 

15 ‘‘(A) recertify by submission of medical 

16 evidence the beneficiary’s continued eligibility 

17 for receipt of benefits; and 

18 ‘‘(B) submit records of expenditures attrib19 utable to the aggregate cash benefit received by 

20 the beneficiary during the preceding year. 

21 ‘‘(7) SUPPLEMENT, NOT SUPPLANT OTHER

22 HEALTH CARE BENEFITS.—Subject to the Medicaid 

23 payment rules under paragraph (1)(D), benefits re24 ceived by an eligible beneficiary shall supplement, 

25 but not supplant, other health care benefits for 


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1 which the beneficiary is eligible under Medicaid or 

2 any other Federally funded program that provides 

3 health care benefits or assistance. 

4 ‘‘(d) ADVOCACY SERVICES.—An agreement entered 

5 into under subsection (a)(2)(A)(ii) shall require the Pro6 tection and Advocacy System for the State to— 

7 ‘‘(1) assign, as needed, an advocacy counselor 

8 to each eligible beneficiary that is covered by such 

9 agreement and who shall provide an eligible bene10 ficiary with— 

11 ‘‘(A) information regarding how to access 

12 the appeals process established for the program; 

13 ‘‘(B) assistance with respect to the annual 

14 recertification and notification required under 

15 subsection (c)(6); and 

16 ‘‘(C) such other assistance with obtaining 

17 services as the Secretary, by regulation, shall 

18 require; and 

19 ‘‘(2) ensure that the System and such coun20 selors comply with the requirements of subsection 

21 (h). 

22 ‘‘(e) ADVICE AND ASSISTANCE COUNSELING.—An 

23 agreement entered into under subsection (a)(2)(A)(iii) 

24 shall require the entity to assign, as requested by an eligi25 ble beneficiary that is covered by such agreement, an adVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01593 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 vice and assistance counselor who shall provide an eligible 

2 beneficiary with information regarding— 

3 ‘‘(1) accessing and coordinating long-term serv4 ices and supports in the most integrated setting; 

5 ‘‘(2) possible eligibility for other benefits and 

6 services; 

7 ‘‘(3) development of a service and support plan; 

8 ‘‘(4) information about programs established 

9 under the Assistive Technology Act of 1998 and the 

10 services offered under such programs; 

11 ‘‘(5) available assistance with decisionmaking 

12 concerning medical care, including the right to ac13 cept or refuse medical or surgical treatment and the 

14 right to formulate advance directives or other writ15 ten instructions recognized under State law, such as 

16 a living will or durable power of attorney for health 

17 care, in the case that an injury or illness causes the 

18 individual to be unable to make health care deci19 sions; and 

20 ‘‘(6) such other services as the Secretary, by 

21 regulation, may require. 

22 ‘‘(f) NO EFFECT ON ELIGIBILITY FOR OTHER BENE23 FITS.—Benefits paid to an eligible beneficiary under the 

24 CLASS program shall be disregarded for purposes of de25 termining or continuing the beneficiary’s eligibility for reVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01594 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 ceipt of benefits under any other Federal, State, or locally 

2 funded assistance program, including benefits paid under 

3 titles II, XVI, XVIII, XIX, or XXI of the Social Security 

4 Act, under the laws administered by the Secretary of Vet5 erans Affairs, under low-income housing assistance pro6 grams, or under the supplemental nutrition assistance 

7 program established under the Food and Nutrition Act of 

8 2008. 

9 ‘‘(g) RULE OF CONSTRUCTION.—Nothing in this title 

10 shall be construed as prohibiting benefits paid under the 

11 CLASS Independence Benefit Plan from being used to 

12 compensate a family caregiver for providing community 

13 living assistance services and supports to an eligible bene14 ficiary. 

15 ‘‘(h) PROTECTION AGAINST CONFLICTS OF INTER16 EST.—The Secretary shall establish procedures to ensure 

17 that the Eligibility Assessment System, the Protection and 

18 Advocacy System for a State, advocacy counselors for eli19 gible beneficiaries, and any other entities that provide 

20 services to active enrollees and eligible beneficiaries under 

21 the CLASS program comply with the following: 

22 ‘‘(1) If the entity provides counseling or plan23 ning services, such services are provided in a manner 

24 that fosters the best interests of the active enrollee 

25 or beneficiary. 


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1 ‘‘(2) The entity has established operating proce2 dures that are designed to avoid or minimize con3 flicts of interest between the entity and an active en4 rollee or beneficiary. 

5 ‘‘(3) The entity provides information about all 

6 services and options available to the active enrollee 

7 or beneficiary, to the best of its knowledge, including 

8 services available through other entities or providers. 

9 ‘‘(4) The entity assists the active enrollee or 

10 beneficiary to access desired services, regardless of 

11 the provider. 

12 ‘‘(5) The entity reports the number of active 

13 enrollees and beneficiaries provided with assistance 

14 by age, disability, and whether such enrollees and 

15 beneficiaries received services from the entity or an16 other entity. 

17 ‘‘(6) If the entity provides counseling or plan18 ning services, the entity ensures that an active en19 rollee or beneficiary is informed of any financial in20 terest that the entity has in a service provider. 

21 ‘‘(7) The entity provides an active enrollee or 

22 beneficiary with a list of available service providers 

23 that can meet the needs of the active enrollee or 

24 beneficiary. 


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1 ‘‘SEC. 3206. CLASS INDEPENDENCE FUND. 

2 ‘‘(a) ESTABLISHMENT OF CLASS INDEPENDENCE

3 FUND.—There is established in the Treasury of the 

4 United States a trust fund to be known as the ‘CLASS 

5 Independence Fund’. The Secretary of the Treasury shall 

6 serve as Managing Trustee of such Fund. The Fund shall 

7 consist of all amounts derived from payments into the 

8 Fund under sections 3204(f) and 3205(c)(5)(C)(ii), and 

9 remaining after investment of such amounts under sub10 section (b), including additional amounts derived as in11 come from such investments. The amounts held in the 

12 Fund are appropriated and shall remain available without 

13 fiscal year limitation— 

14 ‘‘(1) to be held for investment on behalf of indi15 viduals enrolled in the CLASS program; 

16 ‘‘(2) to pay the administrative expenses related 

17 to the Fund and to investment under subsection (b); 

18 and 

19 ‘‘(3) to pay cash benefits to eligible bene20 ficiaries under the CLASS Independence Benefit 

21 Plan. 

22 ‘‘(b) INVESTMENT OF FUND BALANCE.—The Sec23 retary of the Treasury shall invest and manage the 

24 CLASS Independence Fund in the same manner, and to 

25 the same extent, as the Federal Supplementary Medical 

26 Insurance Trust Fund may be invested and managed 


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1 under subsections (c), (d), and (e) of section 1841(d) of 

2 the Social Security Act. 

3 ‘‘(c) BOARD OF TRUSTEES.— 

4 ‘‘(1) IN GENERAL.—With respect to the CLASS 

5 Independence Fund, there is hereby created a body 

6 to be known as the Board of Trustees of the CLASS 

7 Independence Fund (hereinafter in this section re8 ferred to as the ‘Board of Trustees’) composed of 

9 the Secretary of the Treasury, the Secretary of 

10 Labor, and the Secretary of Health and Human 

11 Services, all ex officio, and of two members of the 

12 public (both of whom may not be from the same po13 litical party), who shall be nominated by the Presi14 dent for a term of 4 years and subject to confirma15 tion by the Senate. A member of the Board of 

16 Trustees serving as a member of the public and 

17 nominated and confirmed to fill a vacancy occurring 

18 during a term shall be nominated and confirmed 

19 only for the remainder of such term. An individual 

20 nominated and confirmed as a member of the public 

21 may serve in such position after the expiration of 

22 such member’s term until the earlier of the time at 

23 which the member’s successor takes office or the 

24 time at which a report of the Board is first issued 

25 under paragraph (2) after the expiration of the 


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1 member’s term. The Secretary of the Treasury shall 

2 be the Managing Trustee of the Board of Trustees. 

3 The Board of Trustees shall meet not less frequently 

4 than once each calendar year. A person serving on 

5 the Board of Trustees shall not be considered to be 

6 a fiduciary and shall not be personally liable for ac7 tions taken in such capacity with respect to the 

8 Trust Fund. 

9 ‘‘(2) DUTIES.— 

10 ‘‘(A) IN GENERAL.—It shall be the duty of 

11 the Board of Trustees to do the following: 

12 ‘‘(i) Hold the CLASS Independence 

13 Fund. 

14 ‘‘(ii) Report to the Congress not later 

15 than the first day of April of each year on 

16 the operation and status of the CLASS 

17 Independence Fund during the preceding 

18 fiscal year and on its expected operation 

19 and status during the current fiscal year 

20 and the next 2 fiscal years. 

21 ‘‘(iii) Report immediately to the Con22 gress whenever the Board is of the opinion 

23 that the amount of the CLASS Independ24 ence Fund is not actuarially sound in reVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01599 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 gards to the projections under section 

2 3203(b)(1)(B)(i). 

3 ‘‘(iv) Review the general policies fol4 lowed in managing the CLASS Independ5 ence Fund, and recommend changes in 

6 such policies, including necessary changes 

7 in the provisions of law which govern the 

8 way in which the CLASS Independence 

9 Fund is to be managed. 

10 ‘‘(B) REPORT.—The report provided for in 

11 subparagraph (A)(ii) shall— 

12 ‘‘(i) include— 

13 ‘‘(I) a statement of the assets of, 

14 and the disbursements made from, the 

15 CLASS Independence Fund during 

16 the preceding fiscal year; 

17 ‘‘(II) an estimate of the expected 

18 income to, and disbursements to be 

19 made from, the CLASS Independence 

20 Fund during the current fiscal year 

21 and each of the next 2 fiscal years; 

22 ‘‘(III) a statement of the actu23 arial status of the CLASS Independ24 ence Fund for the current fiscal year, 

25 each of the next 2 fiscal years, and as 


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1 projected over the 75-year period be2 ginning with the current fiscal year; 

3 and 

4 ‘‘(IV) an actuarial opinion certi5 fying that the techniques and meth6 odologies used are generally accepted 

7 within the actuarial profession and 

8 that the assumptions and cost esti9 mates used are reasonable; and 

10 ‘‘(ii) be printed as a House document 

11 of the session of the Congress to which the 

12 report is made. 

13 ‘‘(C) RECOMMENDATIONS.—If the Board 

14 of Trustees determines that enrollment trends 

15 and expected future benefit claims on the 

16 CLASS Independence Fund are not actuarially 

17 sound in regards to the projections under sec18 tion 3203(b)(1)(B)(i) and are unlikely to be re19 solved with reasonable premium increases or 

20 through other means, the Board of Trustees 

21 shall include in the report provided for in sub22 paragraph (A)(ii) recommendations for such 

23 legislative action as the Board of Trustees de24 termine to be appropriate, including whether to 


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1 adjust monthly premiums or impose a tem2 porary moratorium on new enrollments. 

3 ‘‘SEC. 3207. CLASS INDEPENDENCE ADVISORY COUNCIL. 

4 ‘‘(a) ESTABLISHMENT.—There is hereby created an 

5 Advisory Committee to be known as the ‘CLASS Inde6 pendence Advisory Council’. 

7 ‘‘(b) MEMBERSHIP.— 

8 ‘‘(1) IN GENERAL.—The CLASS Independence 

9 Advisory Council shall be composed of not more 

10 than 15 individuals, not otherwise in the employ of 

11 the United States— 

12 ‘‘(A) who shall be appointed by the Presi13 dent without regard to the civil service laws and 

14 regulations; and 

15 ‘‘(B) a majority of whom shall be rep16 resentatives of individuals who participate or 

17 are likely to participate in the CLASS program, 

18 and shall include representatives of older and 

19 younger workers, individuals with disabilities, 

20 family caregivers of individuals who require 

21 services and supports to maintain their inde22 pendence at home or in another residential set23 ting of their choice in the community, individ24 uals with expertise in long-term care or dis25 ability insurance, actuarial science, economics, 


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1 and other relevant disciplines, as determined by 

2 the Secretary. 

3 ‘‘(2) TERMS.— 

4 ‘‘(A) IN GENERAL.—The members of the 

5 CLASS Independence Advisory Council shall 

6 serve overlapping terms of 3 years (unless ap7 pointed to fill a vacancy occurring prior to the 

8 expiration of a term, in which case the indi9 vidual shall serve for the remainder of the 

10 term). 

11 ‘‘(B) LIMITATION.—A member shall not be 

12 eligible to serve for more than 2 consecutive 

13 terms. 

14 ‘‘(3) CHAIR.—The President shall, from time to 

15 time, appoint one of the members of the CLASS 

16 Independence Advisory Council to serve as the 

17 Chair. 

18 ‘‘(c) DUTIES.—The CLASS Independence Advisory 

19 Council shall advise the Secretary on matters of general 

20 policy in the administration of the CLASS program estab21 lished under this title and in the formulation of regula22 tions under this title including with respect to— 

23 ‘‘(1) the development of the CLASS Independ24 ence Benefit Plan under section 3203; and 


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1 ‘‘(2) the determination of monthly premiums 

2 under such plan. 

3 ‘‘(d) APPLICATION OF FACA.—The Federal Advisory 

4 Committee Act, other than section 14 of that Act, shall 

5 apply to the CLASS Independence Advisory Council. 

6 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.— 

7 ‘‘(1) IN GENERAL.—There are authorized to be 

8 appropriated to the CLASS Independence Advisory 

9 Council to carry out its duties under this section, 

10 such sums as may be necessary for fiscal year 2011 

11 and for each fiscal year thereafter. 

12 ‘‘(2) AVAILABILITY.—Any sums appropriated 

13 under the authorization contained in this section 

14 shall remain available, without fiscal year limitation, 

15 until expended. 

16 ‘‘SEC. 3208. REGULATIONS; ANNUAL REPORT. 

17 ‘‘(a) REGULATIONS.—The Secretary shall promulgate 

18 such regulations as are necessary to carry out the CLASS 

19 program in accordance with this title. Such regulations 

20 shall include provisions to prevent fraud and abuse under 

21 the program. 

22 ‘‘(b) ANNUAL REPORT.—Beginning January 1, 2014, 

23 the Secretary shall submit an annual report to Congress 

24 on the CLASS program. Each report shall include the fol25 lowing: 


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1 ‘‘(1) The total number of enrollees in the pro2 gram. 

3 ‘‘(2) The total number of eligible beneficiaries 

4 during the fiscal year. 

5 ‘‘(3) The total amount of cash benefits provided 

6 during the fiscal year. 

7 ‘‘(4) A description of instances of fraud or 

8 abuse identified during the fiscal year. 

9 ‘‘(5) Recommendations for such administrative 

10 or legislative action as the Secretary determines is 

11 necessary to improve the program or to prevent the 

12 occurrence of fraud or abuse. 

13 ‘‘SEC. 3209. INSPECTOR GENERAL’S REPORT. 

14 ‘‘The Inspector General of the Department of Health 

15 and Human Services shall submit an annual report to the 

16 Secretary and Congress relating to the overall progress of 

17 the CLASS program and of the existence of waste, fraud, 

18 and abuse in the CLASS program. Each such report shall 

19 include findings in the following areas: 

20 ‘‘(1) The eligibility determination process. 

21 ‘‘(2) The provision of cash benefits. 

22 ‘‘(3) Quality assurance and protection against 

23 waste, fraud, and abuse. 

24 ‘‘(4) Recouping of unpaid and accrued bene25 fits.’’. 


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1 (b) CONFORMING AMENDMENTS TO MEDICAID.—For 

2 conforming provisions amending the Medicaid program, 

3 see section 1739. 

4 Subtitle E—Miscellaneous 

5 SEC. 2585. STATES FAILING TO ADHERE TO CERTAIN EM6 PLOYMENT OBLIGATIONS. 

7 A State is eligible for Federal funds under the provi8 sions of the Public Health Service Act (42 U.S.C. 201 et 

9 seq.) only if the State— 

10 (1) agrees to be subject in its capacity as an 

11 employer to each obligation under division A of this 

12 Act and the amendments made by such division ap13 plicable to persons in their capacity as an employer; 

14 and 

15 (2) assures that all political subdivisions in the 

16 State will do the same. 

17 SEC. 2586. HEALTH CENTERS UNDER PUBLIC HEALTH 

18 SERVICE ACT; LIABILITY PROTECTIONS FOR 

19 VOLUNTEER PRACTITIONERS. 

20 (a) IN GENERAL.—Section 224 (42 U.S.C. 233) is 

21 amended— 

22 (1) in subsection (g)(1)(A)— 

23 (A) in the first sentence, by striking ‘‘or 

24 employee’’ and inserting ‘‘employee, or (subject 


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1 to subsection (k)(4)) volunteer practitioner’’; 

2 and 

3 (B) in the second sentence, by inserting 

4 ‘‘and subsection (k)(4)’’ after ‘‘subject to para5 graph (5)’’; and 

6 (2) in each of subsections (g), (i), (j), (l), and 

7 (m), by striking the term ‘‘employee, or contractor’’ 

8 each place such term appears and inserting ‘‘em9 ployee, volunteer practitioner, or contractor’’; 

10 (3) in subsection (g)(1)(H), by striking the 

11 term ‘‘employee, and contractor’’ each place such 

12 term appears and inserting ‘‘employee, volunteer 

13 practitioner, and contractor’’; 

14 (4) in subsection (l), by striking the term ‘‘em15 ployee, or any contractor’’ and inserting ‘‘employee, 

16 volunteer practitioner, or contractor’’; and 

17 (5) in subsections (h)(3) and (k), by striking 

18 the term ‘‘employees, or contractors’’ each place 

19 such term appears and inserting ‘‘employees, volun20 teer practitioners, or contractors’’. 

21 (b) APPLICABILITY; DEFINITION.—Section 224(k) 

22 (42 U.S.C. 233(k)) is amended by adding at the end the 

23 following paragraph: 

24 ‘‘(4)(A) Subsections (g) through (m) apply with re25 spect to volunteer practitioners beginning with the first 


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1 fiscal year for which an appropriations Act provides that 

2 amounts in the fund under paragraph (2) are available 

3 with respect to such practitioners. 

4 ‘‘(B) For purposes of subsections (g) through (m), 

5 the term ‘volunteer practitioner’ means a practitioner who, 

6 with respect to an entity described in subsection (g)(4), 

7 meets the following conditions: 

8 ‘‘(i) The practitioner is a licensed physician, a 

9 licensed clinical psychologist, or other licensed or 

10 certified health care practitioner. 

11 ‘‘(ii) At the request of such entity, the practi12 tioner provides services to patients of the entity, at 

13 a site at which the entity operates or at a site des14 ignated by the entity. The weekly number of hours 

15 of services provided to the patients by the practi16 tioner is not a factor with respect to meeting condi17 tions under this subparagraph. 

18 ‘‘(iii) The practitioner does not for the provision 

19 of such services receive any compensation from such 

20 patients, from the entity, or from third-party payors 

21 (including reimbursement under any insurance pol22 icy or health plan, or under any Federal or State 

23 health benefits program).’’. 


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1 SEC. 2587. REPORT TO CONGRESS ON THE CURRENT STATE 

2 OF PARASITIC DISEASES THAT HAVE BEEN 

3 OVERLOOKED AMONG THE POOREST AMERI4 CANS. 

5 Not later than 12 months after the date of the enact6 ment of this Act, the Secretary of Health and Human 

7 Services shall report to Congress on the epidemiology of, 

8 impact of, and appropriate funding required to address ne9 glected diseases of poverty, including neglected parasitic 

10 diseases identified as Chagas disease, cysticercosis, 

11 toxocariasis, toxoplasmosis, trichomoniasis, the soil-trans12 mitted helminths, and others. The report should provide 

13 the information necessary to enhance health policy to ac14 curately evaluate and address the threat of these diseases. 

15 SEC. 2588. OFFICE OF WOMEN’S HEALTH. 

16 (a) HEALTH AND HUMAN SERVICES OFFICE ON

17 WOMEN’S HEALTH.— 

18 (1) ESTABLISHMENT.—Part A of title II (42 

19 U.S.C. 202 et seq.) is amended by adding at the end 

20 the following: 

21 ‘‘SEC. 229. HEALTH AND HUMAN SERVICES OFFICE ON 

22 WOMEN’S HEALTH. 

23 ‘‘(a) ESTABLISHMENT OF OFFICE.—There is estab24 lished within the Office of the Secretary, an Office on 

25 Women’s Health (referred to in this section as the ‘Of26 fice’). The Office shall be headed by a Deputy Assistant 


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1 Secretary for Women’s Health who may report to the Sec2 retary. 

3 ‘‘(b) DUTIES.—The Secretary, acting through the Of4 fice, with respect to the health concerns of women, shall— 

5 ‘‘(1) establish short-range and long-range goals 

6 and objectives within the Department of Health and 

7 Human Services and, as relevant and appropriate, 

8 coordinate with other appropriate offices on activi9 ties within the Department that relate to disease 

10 prevention, health promotion, service delivery, re11 search, and public and health care professional edu12 cation, for issues of particular concern to women 

13 throughout their lifespan; 

14 ‘‘(2) provide expert advice and consultation to 

15 the Secretary concerning scientific, legal, ethical, 

16 and policy issues relating to women’s health; 

17 ‘‘(3) monitor the Department of Health and 

18 Human Services’ offices, agencies, and regional ac19 tivities regarding women’s health and identify needs 

20 regarding the coordination of activities, including in21 tramural and extramural multidisciplinary activities; 

22 ‘‘(4) establish a Department of Health and 

23 Human Services Coordinating Committee on Wom24 en’s Health, which shall be chaired by the Deputy 

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1 posed of senior level representatives from each of the 

2 agencies and offices of the Department of Health 

3 and Human Services; 

4 ‘‘(5) establish a National Women’s Health In5 formation Center to— 

6 ‘‘(A) facilitate the exchange of information 

7 regarding matters relating to health informa8 tion, health promotion, preventive health serv9 ices, research advances, and education in the 

10 appropriate use of health care; 

11 ‘‘(B) facilitate access to such information; 

12 ‘‘(C) assist in the analysis of issues and 

13 problems relating to the matters described in 

14 this paragraph; and 

15 ‘‘(D) provide technical assistance with re16 spect to the exchange of information (including 

17 facilitating the development of materials for 

18 such technical assistance); 

19 ‘‘(6) coordinate efforts to promote women’s 

20 health programs and policies with the private sector; 

21 and 

22 ‘‘(7) through publications and any other means 

23 appropriate, provide for the exchange of information 

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1 tween the Office and health professionals and the 

2 general public. 

3 ‘‘(c) GRANTS AND CONTRACTS REGARDING DU4 TIES.— 

5 ‘‘(1) AUTHORITY.—In carrying out subsection 

6 (b), the Secretary may make grants to, and enter 

7 into cooperative agreements, contracts, and inter8 agency agreements with, public and private entities, 

9 agencies, and organizations. 

10 ‘‘(2) EVALUATION AND DISSEMINATION.—The 

11 Secretary shall directly or through contracts with 

12 public and private entities, agencies, and organiza13 tions, provide for evaluations of projects carried out 

14 with financial assistance provided under paragraph 

15 (1) and for the dissemination of information devel16 oped as a result of such projects. 

17 ‘‘(d) REPORTS.—Not later than 1 year after the date 

18 of enactment of this section, and every second year there19 after, the Secretary shall prepare and submit to the appro20 priate committees of Congress a report describing the ac21 tivities carried out under this section during the period 

22 for which the report is being prepared.’’. 

23 (2) TRANSFER OF FUNCTIONS.—There are 

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1 ice Act, as added by this section), all functions exer2 cised by the Office on Women’s Health of the Public 

3 Health Service prior to the date of enactment of this 

4 section, including all personnel and compensation 

5 authority, all delegation and assignment authority, 

6 and all remaining appropriations. All orders, deter7 minations, rules, regulations, permits, agreements, 

8 grants, contracts, certificates, licenses, registrations, 

9 privileges, and other administrative actions that— 

10 (A) have been issued, made, granted, or al11 lowed to become effective by the President, any 

12 Federal agency or official thereof, or by a court 

13 of competent jurisdiction, in the performance of 

14 functions transferred under this paragraph; and 

15 (B) are in effect at the time this section 

16 takes effect, or were final before the date of en17 actment of this section and are to become effec18 tive on or after such date; 

19 shall continue in effect according to their terms until 

20 modified, terminated, superseded, set aside, or re21 voked in accordance with law by the President, the 

22 Secretary, or other authorized official, a court of 

23 competent jurisdiction, or by operation of law. 

24 (b) CENTERS FOR DISEASE CONTROL AND PREVEN25 TION OFFICE OF WOMEN’S HEALTH.—Part A of title III 


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1 (42 U.S.C. 241 et seq.) is amended by adding at the end 

2 the following: 

3 ‘‘SEC. 310A. CENTERS FOR DISEASE CONTROL AND PREVEN4 TION OFFICE OF WOMEN’S HEALTH. 

5 ‘‘(a) ESTABLISHMENT.—There is established within 

6 the Office of the Director of the Centers for Disease Con7 trol and Prevention, an office to be known as the Office 

8 of Women’s Health (referred to in this section as the ‘Of9 fice’). The Office shall be headed by a director who shall 

10 be appointed by the Director of such Centers. 

11 ‘‘(b) PURPOSE.—The Director of the Office shall— 

12 ‘‘(1) report to the Director of the Centers for 

13 Disease Control and Prevention on the current level 

14 of the Centers’ activity regarding women’s health 

15 conditions across, where appropriate, age, biological, 

16 and sociocultural contexts, in all aspects of the Cen17 ters’ work, including prevention programs, public 

18 and professional education, services, and treatment; 

19 ‘‘(2) establish short-range and long-range goals 

20 and objectives within the Centers for women’s health 

21 and, as relevant and appropriate, coordinate with 

22 other appropriate offices on activities within the 

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1 velopment, for issues of particular concern to 

2 women; 

3 ‘‘(3) identify projects in women’s health that 

4 should be conducted or supported by the Centers; 

5 ‘‘(4) consult with health professionals, non6 governmental organizations, consumer organizations, 

7 women’s health professionals, and other individuals 

8 and groups, as appropriate, on the policy of the Cen9 ters with regard to women; and 

10 ‘‘(5) serve as a member of the Department of 

11 Health and Human Services Coordinating Com12 mittee on Women’s Health (established under sec13 tion 229(b)(4)). 

14 ‘‘(c) DEFINITION.—As used in this section, the term 

15 ‘women’s health conditions’, with respect to women of all 

16 age, ethnic, and racial groups, means diseases, disorders, 

17 and conditions— 

18 ‘‘(1) unique to, significantly more serious for, 

19 or significantly more prevalent in women; and 

20 ‘‘(2) for which the factors of medical risk or 

21 type of medical intervention are different for women, 

22 or for which there is reasonable evidence that indi23 cates that such factors or types may be different for 

24 women.’’. 


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1 (c) OFFICE OF WOMEN’S HEALTH RESEARCH.—Sec2 tion 486(a) (42 U.S.C. 287d(a)) is amended by inserting 

3 ‘‘and who shall report directly to the Director’’ before the 

4 period at the end thereof. 

5 (d) SUBSTANCE ABUSE AND MENTAL HEALTH

6 SERVICES ADMINISTRATION.—Section 501(f) (42 U.S.C. 

7 290aa(f)) is amended— 

8 (1) in paragraph (1), by inserting ‘‘who shall 

9 report directly to the Administrator’’ before the pe10 riod; 

11 (2) by redesignating paragraph (4) as para12 graph (5); and 

13 (3) by inserting after paragraph (3), the fol14 lowing: 

15 ‘‘(4) OFFICE.—Nothing in this subsection shall 

16 be construed to preclude the Secretary from estab17 lishing within the Substance Abuse and Mental 

18 Health Administration an Office of Women’s 

19 Health.’’. 

20 (e) AGENCY FOR HEALTHCARE RESEARCH AND

21 QUALITY ACTIVITIES REGARDING WOMEN’S HEALTH.— 

22 Part C of title IX (42 U.S.C. 299c et seq.) is amended— 

23 (1) by redesignating sections 927 and 928 as 

24 sections 928 and 929, respectively; 

25 (2) by inserting after section 926 the following: 


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1 ‘‘SEC. 927. ACTIVITIES REGARDING WOMEN’S HEALTH. 

2 ‘‘(a) ESTABLISHMENT.—There is established within 

3 the Office of the Director, an Office of Women’s Health 

4 and Gender-Based Research (referred to in this section 

5 as the ‘Office’). The Office shall be headed by a director 

6 who shall be appointed by the Director of Healthcare and 

7 Research Quality. 

8 ‘‘(b) PURPOSE.—The official designated under sub9 section (a) shall— 

10 ‘‘(1) report to the Director on the current 

11 Agency level of activity regarding women’s health, 

12 across, where appropriate, age, biological, and 

13 sociocultural contexts, in all aspects of Agency work, 

14 including the development of evidence reports and 

15 clinical practice protocols and the conduct of re16 search into patient outcomes, delivery of health care 

17 services, quality of care, and access to health care; 

18 ‘‘(2) establish short-range and long-range goals 

19 and objectives within the Agency for research impor20 tant to women’s health and, as relevant and appro21 priate, coordinate with other appropriate offices on 

22 activities within the Agency that relate to health 

23 services and medical effectiveness research, for 

24 issues of particular concern to women; 

25 ‘‘(3) identify projects in women’s health that 

26 should be conducted or supported by the Agency; 


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1 ‘‘(4) consult with health professionals, non2 governmental organizations, consumer organizations, 

3 women’s health professionals, and other individuals 

4 and groups, as appropriate, on Agency policy with 

5 regard to women; and 

6 ‘‘(5) serve as a member of the Department of 

7 Health and Human Services Coordinating Com8 mittee on Women’s Health (established under sec9 tion 229(b)(4)).’’; and 

10 (3) by adding at the end of section 928 (as re11 designated by paragraph (1)) the following: 

12 ‘‘(e) WOMEN’S HEALTH.—For the purpose of car13 rying out section 927 regarding women’s health, there are 

14 authorized to be appropriated such sums as may be nec15 essary for each of fiscal years 2011 through 2015.’’. 

16 (f) HEALTH RESOURCES AND SERVICES ADMINIS17 TRATION OFFICE OF WOMEN’S HEALTH.—Title VII of 

18 the Social Security Act (42 U.S.C. 901 et seq.) is amended 

19 by adding at the end the following: 

20 ‘‘SEC. 713. OFFICE OF WOMEN’S HEALTH. 

21 ‘‘(a) ESTABLISHMENT.—The Secretary shall estab22 lish within the Office of the Administrator of the Health 

23 Resources and Services Administration, an office to be 

24 known as the Office of Women’s Health. The Office shall 


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1 be headed by a director who shall be appointed by the Ad2 ministrator. 

3 ‘‘(b) PURPOSE.—The Director of the Office shall— 

4 ‘‘(1) report to the Administrator on the current 

5 Administration level of activity regarding women’s 

6 health across, where appropriate, age, biological, and 

7 sociocultural contexts; 

8 ‘‘(2) establish short-range and long-range goals 

9 and objectives within the Health Resources and 

10 Services Administration for women’s health and, as 

11 relevant and appropriate, coordinate with other ap12 propriate offices on activities within the Administra13 tion that relate to health care provider training, 

14 health service delivery, research, and demonstration 

15 projects, for issues of particular concern to women; 

16 ‘‘(3) identify projects in women’s health that 

17 should be conducted or supported by the bureaus of 

18 the Administration; 

19 ‘‘(4) consult with health professionals, non20 governmental organizations, consumer organizations, 

21 women’s health professionals, and other individuals 

22 and groups, as appropriate, on Administration policy 

23 with regard to women; and 

24 ‘‘(5) serve as a member of the Department of 

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1 mittee on Women’s Health (established under sec2 tion 229(b)(4) of the Public Health Service Act). 

3 ‘‘(c) CONTINUED ADMINISTRATION OF EXISTING

4 PROGRAMS.—The Director of the Office shall assume the 

5 authority for the development, implementation, adminis6 tration, and evaluation of any projects carried out through 

7 the Health Resources and Services Administration relat8 ing to women’s health on the date of enactment of this 

9 section. 

10 ‘‘(d) DEFINITIONS.—For purposes of this section: 

11 ‘‘(1) ADMINISTRATION.—The term ‘Administra12 tion’ means the Health Resources and Services Ad13 ministration. 

14 ‘‘(2) ADMINISTRATOR.—The term ‘Adminis15 trator’ means the Administrator of the Health Re16 sources and Services Administration. 

17 ‘‘(3) OFFICE.—The term ‘Office’ means the Of18 fice of Women’s Health established under this sec19 tion in the Administration.’’. 

20 (g) FOOD AND DRUG ADMINISTRATION OFFICE OF

21 WOMEN’S HEALTH.—Chapter IX of the Federal Food, 

22 Drug, and Cosmetic Act (21 U.S.C. 391 et seq.) is amend23 ed by adding at the end the following: 


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1 ‘‘SEC. 911. OFFICE OF WOMEN’S HEALTH. 

2 ‘‘(a) ESTABLISHMENT.—There is established within 

3 the Office of the Commissioner, an office to be known as 

4 the Office of Women’s Health (referred to in this section 

5 as the ‘Office’). The Office shall be headed by a director 

6 who shall be appointed by the Commissioner of Food and 

7 Drugs. 

8 ‘‘(b) PURPOSE.—The Director of the Office shall— 

9 ‘‘(1) report to the Commissioner of Food and 

10 Drugs on current Food and Drug Administration 

11 (referred to in this section as the ‘Administration’) 

12 levels of activity regarding women’s participation in 

13 clinical trials and the analysis of data by sex in the 

14 testing of drugs, medical devices, and biological 

15 products across, where appropriate, age, biological, 

16 and sociocultural contexts; 

17 ‘‘(2) establish short-range and long-range goals 

18 and objectives within the Administration for issues 

19 of particular concern to women’s health within the 

20 jurisdiction of the Administration, including, where 

21 relevant and appropriate, adequate inclusion of 

22 women and analysis of data by sex in Administration 

23 protocols and policies; 

24 ‘‘(3) provide information to women and health 

25 care providers on those areas in which differences 

26 between men and women exist; 


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1 ‘‘(4) consult with pharmaceutical, biologics, and 

2 device manufacturers, health professionals with ex3 pertise in women’s issues, consumer organizations, 

4 and women’s health professionals on Administration 

5 policy with regard to women; 

6 ‘‘(5) make annual estimates of funds needed to 

7 monitor clinical trials and analysis of data by sex in 

8 accordance with needs that are identified; and 

9 ‘‘(6) serve as a member of the Department of 

10 Health and Human Services Coordinating Com11 mittee on Women’s Health (established under sec12 tion 229(b)(4) of the Public Health Service Act).’’. 

13 (h) NO NEW REGULATORY AUTHORITY.—Nothing in 

14 this section and the amendments made by this section may 

15 be construed as establishing regulatory authority or modi16 fying any existing regulatory authority. 

17 (i) LIMITATION ON TERMINATION.—Notwithstanding 

18 any other provision of law, a Federal office of women’s 

19 health (including the Office of Research on Women’s 

20 Health of the National Institutes of Health) or Federal 

21 appointive position with primary responsibility over wom22 en’s health issues (including the Associate Administrator 

23 for Women’s Services under the Substance Abuse and 

24 Mental Health Services Administration) that is in exist25 ence on the date of enactment of this section shall not 


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1 be terminated, reorganized, or have any of its powers or 

2 duties transferred unless such termination, reorganization, 

3 or transfer is approved by an Act of Congress. 

4 (j) RULE OF CONSTRUCTION.—Nothing in this sec5 tion (or the amendments made by this section) shall be 

6 construed to limit the authority of the Secretary of Health 

7 and Human Services with respect to women’s health, or 

8 with respect to activities carried out through the Depart9 ment of Health and Human Services on the date of enact10 ment of this section. 

11 SEC. 2589. LONG-TERM CARE AND FAMILY CAREGIVER SUP12 PORT. 

13 (a) AMENDMENTS TO THE OLDER AMERICANS ACT

14 OF 1965.— 

15 (1) PROMOTION OF DIRECT CARE WORK16 FORCE.—Section 202(b)(1) of the Older Americans 

17 Act of 1965 (42 U.S.C. 3012(b)(1)) is amended by 

18 inserting before the semicolon the following: ‘‘, and, 

19 in carrying out the purposes of this paragraph, shall 

20 make recommendations to other Federal entities re21 garding appropriate and effective means of identi22 fying, promoting, and implementing investments in 

23 the direct care workforce necessary to meet the 

24 growing demand for long-term health services and 

25 supports and of assisting States in developing a 


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1 comprehensive State workforce development plan 

2 with respect to such workforce, including assisting 

3 efforts to systematically assess, track, and report on 

4 workforce adequacy and capacity’’. 

5 (2) PERSONAL CARE ATTENDANT WORKFORCE

6 ADVISORY PANEL.—Section 202 of such Act (42 

7 U.S.C. 3012) is amended by adding at the end the 

8 following: 

9 ‘‘(g)(1) Not later than 90 days after the date of the 

10 enactment of this subsection, the Assistant Secretary shall 

11 establish a Personal Care Attendant Workforce Advisory 

12 Panel to examine and formulate recommendations on— 

13 ‘‘(A) working conditions and training for work14 ers providing long-term services and supports, in15 cluding home health aides, certified nurse aides, and 

16 personal care attendants; and 

17 ‘‘(B) other workforce issues related to such 

18 workers, including with respect to the adequacy of 

19 the number of such workers; the salaries, wages, and 

20 benefits of such workers; and access to the services 

21 provided by such workers. 

22 ‘‘(2) The Panel shall include representatives of— 

23 ‘‘(A) relevant home- and community-based serv24 ice providers, health care agencies, and facilities (in25 cluding personal or home care agencies, home health 


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1 care agencies, nursing homes, assisted living facili2 ties, and residential care facilities); 

3 ‘‘(B) the disability community, including indi4 viduals with disabilities and family caregivers; 

5 ‘‘(C) the nursing community; 

6 ‘‘(D) direct care workers (which may include 

7 unions and national organizations); 

8 ‘‘(E) older individuals, including senior individ9 uals and family caregivers; 

10 ‘‘(F) State and Federal health care entities; 

11 and 

12 ‘‘(G) experts in workforce development and 

13 adult learning. 

14 ‘‘(3) Within one year after the establishment of the 

15 Panel, the Panel shall submit a report to the Assistant 

16 Secretary and the Congress on workforce issues related 

17 to providing long-term services and supports, including in18 formation on core competencies for eligible personal or 

19 home care aides necessary to successfully provide long20 term services and supports to eligible consumers, as well 

21 as recommended training curricula and resources. 

22 ‘‘(4) Within 180 days after receipt by the Assistant 

23 Secretary of the report under paragraph (3), the Assistant 

24 Secretary shall establish a 3-year demonstration program 

25 in 4 States to pilot and evaluate the effectiveness of the 


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1 competencies articulated by the Panel and the training 

2 curricula and training methods recommended by the 

3 Panel. 

4 ‘‘(5) Not later than 1 year after the completion of 

5 the demonstration program under paragraph (4), the As6 sistant Secretary shall submit to the Congress a report 

7 containing the results of the evaluations by the Assistant 

8 Secretary pursuant to paragraph (4), together with such 

9 recommendations for legislation or administrative action 

10 as the Assistant Secretary determines appropriate.’’. 

11 (b) AUTHORIZATION OF ADDITIONAL APPROPRIA12 TIONS FOR THE FAMILY CAREGIVER SUPPORT PROGRAM

13 UNDER THE OLDER AMERICANS ACT OF 1965.—Section 

14 303(e)(2) of the Older Americans Act of 1965 (42 U.S.C. 

15 3023(e)(2)) is amended by striking ‘‘, $173,000,000’’ and 

16 all that follows through ‘‘2011’’, and inserting ‘‘and 

17 $250,000,000 for each of fiscal years 2011, 2012, and 

18 2013’’. 

19 SEC. 2590. WEB SITE ON HEALTH CARE LABOR MARKET 

20 AND RELATED EDUCATIONAL AND TRAINING 

21 OPPORTUNITIES. 

22 (a) IN GENERAL.—The Secretary of Labor, in con23 sultation with the National Center for Health Workforce 

24 Analysis, shall establish and maintain a Web site to serve 

25 as a comprehensive source of information, searchable by 


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1 workforce region, on the health care labor market and re2 lated educational and training opportunities. 

3 (b) CONTENTS.—The Web site maintained under this 

4 section shall include the following: 

5 (1) Information on the types of jobs that are 

6 currently or are projected to be in high demand in 

7 the health care field, including— 

8 (A) salary information; and 

9 (B) training requirements, such as require10 ments for educational credentials, licensure, or 

11 certification. 

12 (2) Information on training and educational op13 portunities within each region for the type of jobs 

14 described in paragraph (1), including by— 

15 (A) type of provider or program (such as 

16 public, private nonprofit, or private for-profit); 

17 (B) duration; 

18 (C) cost (such as tuition, fees, books, lab19 oratory expenses, and other mandatory costs); 

20 (D) performance outcomes (such as grad21 uation rates, job placement, average salary, job 

22 retention, and wage progression); 

23 (E) Federal financial aid participation; 

24 (F) average graduate loan debt; 

25 (G) student loan default rates; 


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1 (H) average institutional grant aid pro2 vided; 

3 (I) Federal and State accreditation infor4 mation; and 

5 (J) other information determined by the 

6 Secretary. 

7 (3) A mechanism for searching and comparing 

8 training and educational options for specific health 

9 care occupations to facilitate informed career and 

10 education choices. 

11 (4) Financial aid information, including with 

12 respect to loan forgiveness, loan cancellation, loan 

13 repayment, stipends, scholarships, and grants or 

14 other assistance authorized by this Act or other Fed15 eral or State programs. 

16 (c) PUBLIC ACCESSIBILITY.—The Web site main17 tained under this section shall— 

18 (1) be publicly accessible; 

19 (2) be user friendly and convey information in 

20 a manner that is easily understandable; and 

21 (3) be in English and the second most prevalent 

22 language spoken based on the latest Census informa23 tion. 


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1 SEC. 2591. ONLINE HEALTH WORKFORCE TRAINING PRO2 GRAMS. 

3 Section 171 of the Workforce Investment Act of 1998 

4 (29 U.S.C. 2916) is amended by adding at the end the 

5 following: 

6 ‘‘(f) ONLINE HEALTH WORKFORCE TRAINING PRO7 GRAM.— 

8 ‘‘(1) GRANT PROGRAM.— 

9 ‘‘(A) IN GENERAL.—The Secretary in con10 sultation with the Secretary of Health and 

11 Human Services, shall award National Health 

12 Workforce Online Training Grants on a com13 petitive basis to eligible entities to enable such 

14 entities to carry out training for individuals to 

15 attain or advance in health care occupations. 

16 An entity may leverage such grant with other 

17 Federal, State, local, and private resources, in 

18 order to expand the participation of businesses, 

19 employees, and individuals in such training pro20 grams. 

21 ‘‘(B) ELIGIBILITY.—In order to receive a 

22 grant under the program established under this 

23 paragraph— 

24 ‘‘(i) an entity shall be an educational 

25 institution, community-based organization, 

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1 ment board, or local or county government; 

2 and 

3 ‘‘(ii) an entity shall provide online 

4 workforce training for individuals seeking 

5 to attain or advance in health care occupa6 tions, including nursing, nursing assist7 ants, dentistry, pharmacy, health care 

8 management and administration, public 

9 health, health information systems anal10 ysis, medical assistants, and other health 

11 care practitioner and support occupations. 

12 ‘‘(C) PRIORITY.—Priority in awarding 

13 grants under this paragraph shall be given to 

14 entities that— 

15 ‘‘(i) have demonstrated experience in 

16 implementing and operating online worker 

17 skills training and education programs; 

18 ‘‘(ii) have demonstrated experience co19 ordinating activities, where appropriate, 

20 with the workforce investment system; and 

21 ‘‘(iii) conduct training for occupations 

22 with national or local shortages. 

23 ‘‘(D) DATA COLLECTION.—Grantees under 

24 this paragraph shall collect and report informa25 tion on— 


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1 ‘‘(i) the number of participants; 

2 ‘‘(ii) the services received by the par3 ticipants; 

4 ‘‘(iii) program completion rates; 

5 ‘‘(iv) factors determined as signifi6 cantly interfering with program participa7 tion or completion; 

8 ‘‘(v) the rate of job placement; and 

9 ‘‘(vi) other information as determined 

10 as needed by the Secretary. 

11 ‘‘(E) OUTREACH.—Grantees under this 

12 paragraph shall conduct outreach activities to 

13 disseminate information about their program 

14 and results to workforce investment boards, 

15 local governments, educational institutions, and 

16 other workforce training organizations. 

17 ‘‘(F) PERFORMANCE LEVELS.—The Sec18 retary shall establish indicators of performance 

19 that will be used to evaluate the performance of 

20 grantees under this paragraph in carrying out 

21 the activities described in this paragraph. The 

22 Secretary shall negotiate and reach agreement 

23 with each grantee regarding the levels of per24 formance expected to be achieved by the grant25 ee on the indicators of performance. 


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1 ‘‘(G) AUTHORIZATION OF APPROPRIA2 TIONS.—There are authorized to be appro3 priated to the Secretary to carry out this sub4 section $50,000,000 for fiscal years 2011 

5 through 2020. 

6 ‘‘(2) ONLINE HEALTH PROFESSIONS TRAINING

7 PROGRAM CLEARINGHOUSE.— 

8 ‘‘(A) DESCRIPTION OF GRANT.—The Sec9 retary may award one or more grants to eligible 

10 postsecondary educational institutions to pro11 vide the services described in this paragraph. 

12 ‘‘(B) ELIGIBILITY.—To be eligible to re13 ceive a grant under this paragraph, a postsec14 ondary educational institution shall— 

15 ‘‘(i) have demonstrated the ability to 

16 disseminate research on best practices for 

17 implementing workforce investment pro18 grams; and 

19 ‘‘(ii) be a national leader in producing 

20 cutting-edge research on technology related 

21 to workforce investment systems under 

22 subtitle B. 

23 ‘‘(C) SERVICES.—The postsecondary edu24 cational institution that receives a grant under 

25 this paragraph shall use such grant— 


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1 ‘‘(i) to provide technical assistance to 

2 entities that receive grants under para3 graph (1); 

4 ‘‘(ii) to collect and nationally dissemi5 nate the data gathered by entities that re6 ceive grants under paragraph (1); and 

7 ‘‘(iii) to disseminate the best practices 

8 identified by the National Health Work9 force Online Training Grant Program to 

10 other workforce training organizations. 

11 ‘‘(D) AUTHORIZATION OF APPROPRIA12 TIONS.—There are authorized to be appro13 priated to the Secretary to carry out this sub14 section $1,000,000 for fiscal years 2011 

15 through 2020.’’. 

16 SEC. 2592. ACCESS FOR INDIVIDUALS WITH DISABILITIES. 

17 Title V of the Rehabilitation Act of 1973 (29 U.S.C. 

18 791 et seq.) is amended by adding at the end of the fol19 lowing: 

20 ‘‘SEC. 510. STANDARDS FOR ACCESSIBILITY OF MEDICAL 

21 DIAGNOSTIC EQUIPMENT. 

22 ‘‘(a) STANDARDS.—Not later than 9 months after the 

23 date of enactment of the Affordable Health Care for 

24 America Act, the Architectural and Transportation Bar25 riers Compliance Board (Access Board) shall issue guideVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01633 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 lines setting forth the minimum technical criteria for new 

2 medical diagnostic equipment to be purchased for use in 

3 (or in conjunction with) physician’s offices, clinics, emer4 gency rooms, hospitals, and other medical settings. The 

5 guidelines shall ensure that such equipment is accessible 

6 to, and usable by, individuals with disabilities, including 

7 provisions to ensure independent entry to, use of, and exit 

8 from the equipment by such individuals to the maximum 

9 extent possible. 

10 ‘‘(b) MEDICAL DIAGNOSTIC EQUIPMENT COV11 ERED.—The guidelines issued under subsection (a) for 

12 medical diagnostic equipment shall apply to new purchases 

13 of equipment that includes examination tables, examina14 tion chairs (including chairs used for eye examinations or 

15 procedures, and dental examinations or procedures), 

16 weight scales, mammography equipment, x-ray machines, 

17 and other equipment commonly used for diagnostic or ex18 amination purposes by health professionals. 

19 ‘‘(c) REGULATIONS.—Not later than 6 months after 

20 the date of the issuance of the guidelines under subsection 

21 (a), each appropriate Federal agency authorized to pro22 mulgate regulations under this Act or under the Ameri23 cans with Disabilities Act shall— 

24 ‘‘(1) prescribe regulations in an accessible for25 mat as necessary to carry out the provisions of such 


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1 Act and section 504 of this Act that include accessi2 bility standards that are consistent with the guide3 lines issued under subsection (a); and 

4 ‘‘(2) ensure that health care providers and 

5 health care plans covered by the Affordable Health 

6 Care for America Act meet the requirements of the 

7 Americans with Disabilities Act and section 504, in8 cluding provisions ensuring that individuals with dis9 abilities receive equal access to all aspects of the 

10 health care delivery system. 

11 ‘‘(d) REVIEW AND AMEND.—The Architectural and 

12 Transportation Barriers Compliance Board (Access 

13 Board) shall periodically review and, as appropriate, 

14 amend the guidelines as prescribed under subsection (a). 

15 Not later than 6 months after the date of the issuance 

16 of such revised guidelines, revised regulations consistent 

17 with such guidelines shall be promulgated in an accessible 

18 format by the appropriate Federal agencies described in 

19 subsection (c).’’. 

20 DIVISION D—INDIAN HEALTH 

21 CARE IMPROVEMENT 

22 SEC. 3001. SHORT TITLE; TABLE OF CONTENTS. 

23 (a) SHORT TITLE.—This division may be cited as the 

24 ‘‘Indian Health Care Improvement Act Amendments of 

25 2009’’. 


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1 (b) TABLE OF CONTENTS.—The table of contents of 

2 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. 

3 TITLE I—AMENDMENTS TO 

4 INDIAN LAWS 

5 SEC. 3101. INDIAN HEALTH CARE IMPROVEMENT AMEND6 ED. 

7 (a) IN GENERAL.—The Indian Health Care Improve8 ment Act (25 U.S.C. 1601 et seq.) is amended to read 

9 as follows: 

10 ‘‘SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

12 ‘Indian Health Care Improvement Act’. 


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1 ‘‘(b) TABLE OF CONTENTS.—The table of contents 

2 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. 


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‘‘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). 


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‘‘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. 


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‘‘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. 

1 ‘‘SEC. 2. FINDINGS. 

2 ‘‘Congress makes the following findings: 

3 ‘‘(1) Federal health services to maintain and 

4 improve the health of the Indians are consonant 

5 with and required by the Federal Government’s his6 torical and unique legal relationship with, and re7 sulting responsibility to, the American Indian people. 

8 ‘‘(2) A major national goal of the United States 

9 is to provide the resources, processes, and structure 

10 that will enable Indian tribes and tribal members to 

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1 ices and opportunities that will eradicate the health 

2 disparities between Indians the general population. 

3 ‘‘(3) A major national goal of the United States 

4 is to provide the quantity and quality of health serv5 ices which will permit the health status of Indians 

6 to be raised to the highest possible level and to en7 courage the maximum participation of Indians in the 

8 planning and management of those services. 

9 ‘‘(4) Federal health services to Indians have re10 sulted in a reduction in the prevalence and incidence 

11 of preventable illnesses among, and unnecessary and 

12 premature deaths of, Indians. 

13 ‘‘(5) Despite such services, the unmet health 

14 needs of the American Indian people are severe and 

15 the health status of the Indians is far below that of 

16 the general population of the United States. 

17 ‘‘SEC. 3. DECLARATION OF NATIONAL INDIAN HEALTH POL18 ICY. 

19 ‘‘Congress declares that it is the policy of this Nation, 

20 in fulfillment of its special trust responsibilities and legal 

21 obligations to Indians— 

22 ‘‘(1) to assure the highest possible health status 

23 for Indians and Urban Indians and to provide all re24 sources necessary to effect that policy; 


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1 ‘‘(2) to raise the health status of Indians and 

2 Urban Indians to at least the levels set forth in the 

3 goals contained within the Health People 2010 or 

4 successor objectives; 

5 ‘‘(3) to the greatest extent possible, to allow In6 dians to set their own health care priorities and es7 tablish goals that reflect their unmet needs; 

8 ‘‘(4) to increase the proportion of all degrees in 

9 the health professions and allied and associated 

10 health professions awarded to Indians so that the 

11 proportion of Indian health professionals in each 

12 Service Area is raised to at least the level of that of 

13 the general population; 

14 ‘‘(5) to require meaningful consultation with In15 dian Tribes, Tribal Organizations, and urban Indian 

16 organizations to implement this Act and the national 

17 policy of Indian self-determination; and 

18 ‘‘(6) to provide funding for programs and facili19 ties operated by Indian Tribes, Tribal Organizations, 

20 and Urban Indian Organizations in amounts that 

21 are not less than the amounts provided to programs 

22 and facilities operated directly by the Service. 

23 ‘‘SEC. 4. DEFINITIONS. 

24 ‘‘For purposes of this Act: 


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1 ‘‘(1) The term ‘accredited and accessible’ means 

2 on or near a reservation and accredited by a na3 tional or regional organization with accrediting au4 thority. 

5 ‘‘(2) The term ‘Area Office’ means an adminis6 trative entity, including a program office, within the 

7 Service through which services and funds are pro8 vided to the Service Units within a defined geo9 graphic area. 

10 ‘‘(3) The term ‘Assistant Secretary’ means the 

11 Assistant Secretary of Indian Health. 

12 ‘‘(4)(A) The term ‘behavioral health’ means the 

13 blending of substance (including alcohol, drugs, 

14 inhalants, and tobacco) abuse and mental health 

15 prevention and treatment, for the purpose of pro16 viding comprehensive services. 

17 ‘‘(B) The term ‘behavioral health’ includes the 

18 joint development of substance abuse and mental 

19 health treatment planning and coordinated case 

20 management using a multidisciplinary approach. 

21 ‘‘(5) The term ‘California Indians’ means those 

22 Indians who are eligible for health services of the 

23 Service pursuant to section 805. 

24 ‘‘(6) The term ‘community college’ means— 

25 ‘‘(A) a tribal college or university, or 


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1 ‘‘(B) a junior or community college. 

2 ‘‘(7) The term ‘contract health service’ means 

3 health services provided at the expense of the Serv4 ice or a Tribal Health Program by public or private 

5 medical providers or hospitals, other than the Serv6 ice Unit or the Tribal Health Program at whose ex7 pense the services are provided. 

8 ‘‘(8) The term ‘Department’ means, unless oth9 erwise designated, the Department of Health and 

10 Human Services. 

11 ‘‘(9) The term ‘disease prevention’ means the 

12 reduction, limitation, and prevention of disease and 

13 its complications and reduction in the consequences 

14 of disease, including— 

15 ‘‘(A) controlling— 

16 ‘‘(i) the development of diabetes; 

17 ‘‘(ii) high blood pressure; 

18 ‘‘(iii) infectious agents; 

19 ‘‘(iv) injuries; 

20 ‘‘(v) occupational hazards and disabil21 ities; 

22 ‘‘(vi) sexually transmittable diseases; 

23 and 

24 ‘‘(vii) toxic agents; and 

25 ‘‘(B) providing— 


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1 ‘‘(i) fluoridation of water; and 

2 ‘‘(ii) immunizations. 

3 ‘‘(10) The term ‘health profession’ means 

4 allopathic medicine, family medicine, internal medi5 cine, pediatrics, geriatric medicine, obstetrics and 

6 gynecology, podiatric medicine, nursing, public 

7 health nursing, dentistry, psychiatry, osteopathy, op8 tometry, pharmacy, psychology, public health, social 

9 work, marriage and family therapy, chiropractic 

10 medicine, environmental health and engineering, al11 lied health professions, naturopathic medicine, and 

12 any other health profession. 

13 ‘‘(11) The term ‘health promotion’ means— 

14 ‘‘(A) fostering social, economic, environ15 mental, and personal factors conducive to 

16 health, including raising public awareness about 

17 health matters and enabling the people to cope 

18 with health problems by increasing their knowl19 edge and providing them with valid information; 

20 ‘‘(B) encouraging adequate and appro21 priate diet, exercise, and sleep; 

22 ‘‘(C) promoting education and work in con23 formity with physical and mental capacity; 

24 ‘‘(D) making available safe water and sani25 tary facilities; 


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1 ‘‘(E) improving the physical, economic, cul2 tural, psychological, and social environment; 

3 ‘‘(F) promoting culturally competent care; 

4 and 

5 ‘‘(G) providing adequate and appropriate 

6 programs, which may include— 

7 ‘‘(i) abuse prevention (mental and 

8 physical); 

9 ‘‘(ii) community health; 

10 ‘‘(iii) community safety; 

11 ‘‘(iv) consumer health education; 

12 ‘‘(v) diet and nutrition; 

13 ‘‘(vi) immunization and other preven14 tion of communicable diseases, including 

15 HIV/AIDS; 

16 ‘‘(vii) environmental health; 

17 ‘‘(viii) exercise and physical fitness; 

18 ‘‘(ix) avoidance of fetal alcohol dis19 orders; 

20 ‘‘(x) first aid and CPR education; 

21 ‘‘(xi) human growth and development; 

22 ‘‘(xii) injury prevention and personal 

23 safety; 

24 ‘‘(xiii) behavioral health; 


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1 ‘‘(xiv) monitoring of disease indicators 

2 between health care provider visits, 

3 through appropriate means, including 

4 Internet-based health care management 

5 systems; 

6 ‘‘(xv) personal health and wellness 

7 practices; 

8 ‘‘(xvi) personal capacity building; 

9 ‘‘(xvii) prenatal, pregnancy, and in10 fant care; 

11 ‘‘(xviii) psychological well-being; 

12 ‘‘(xix) reproductive health and family 

13 planning; 

14 ‘‘(xx) safe and adequate water; 

15 ‘‘(xxi) healthy work environments; 

16 ‘‘(xxii) elimination, reduction, and 

17 prevention of contaminants that create 

18 unhealthy household conditions (including 

19 mold and other allergens); 

20 ‘‘(xxiii) stress control; 

21 ‘‘(xxiv) substance abuse; 

22 ‘‘(xxv) sanitary facilities; 

23 ‘‘(xxvi) sudden infant death syndrome 

24 prevention; 


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1 ‘‘(xxvii) tobacco use cessation and re2 duction; 

3 ‘‘(xxviii) violence prevention; and 

4 ‘‘(xxix) activities to promote achieve5 ment of any of the objectives described in 

6 section 3(2). 

7 ‘‘(12) The term ‘Indian’, unless otherwise des8 ignated, means any person who is a member of an 

9 Indian Tribe or is eligible for health services under 

10 section 805, except that, for the purpose of sections 

11 102 and 103, the term also means any individual 

12 who— 

13 ‘‘(A)(i) irrespective of whether the indi14 vidual lives on or near a reservation, is a mem15 ber of a tribe, band, or other organized group 

16 of Indians, including those tribes, bands, or 

17 groups terminated since 1940 and those recog18 nized now or in the future by the State in 

19 which they reside; or 

20 ‘‘(ii) is a descendant, in the first or second 

21 degree, of any such member; 

22 ‘‘(B) is an Eskimo or Aleut or other Alas23 ka Native; 

24 ‘‘(C) is considered by the Secretary of the 

25 Interior to be an Indian for any purpose; or 


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1 ‘‘(D) is determined to be an Indian under 

2 regulations promulgated by the Secretary. 

3 ‘‘(13) The term ‘Indian Health Program’ 

4 means— 

5 ‘‘(A) any health program administered di6 rectly by the Service; 

7 ‘‘(B) any Tribal Health Program; or 

8 ‘‘(C) any Indian Tribe or Tribal Organiza9 tion to which the Secretary provides funding 

10 pursuant to section 23 of the Act of June 25, 

11 1910 (25 U.S.C. 47) (commonly known as the 

12 ‘Buy Indian Act’). 

13 ‘‘(14) The term ‘Indian Tribe’ has the meaning 

14 given the term in the Indian Self-Determination and 

15 Education Assistance Act (25 U.S.C. 450 et seq.). 

16 ‘‘(15) The term ‘junior or community college’ 

17 has the meaning given the term by section 312(f) of 

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

19 1058(f)). 

20 ‘‘(16) The term ‘reservation’ means any feder21 ally recognized Indian Tribe’s reservation, Pueblo, or 

22 colony, including former reservations in Oklahoma, 

23 Indian allotments, and Alaska Native Regions estab24 lished pursuant to the Alaska Native Claims Settle25 ment Act (43 U.S.C. 1601 et seq.). 


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1 ‘‘(17) The term ‘Secretary’, unless otherwise 

2 designated, means the Secretary of Health and 

3 Human Services. 

4 ‘‘(18) The term ‘Service’ means the Indian 

5 Health Service. 

6 ‘‘(19) The term ‘Service Area’ means the geo7 graphical area served by each Area Office. 

8 ‘‘(20) The term ‘Service Unit’ means an admin9 istrative entity of the Service, or a Tribal Health 

10 Program through which services are provided, di11 rectly or by contract, to eligible Indians within a de12 fined geographic area. 

13 ‘‘(21) The term ‘telehealth’ has the meaning 

14 given the term in section 330K(a) of the Public 

15 Health Service Act (42 U.S.C. 254c–16(a)). 

16 ‘‘(22) The term ‘telemedicine’ means a tele17 communications link to an end user through the use 

18 of eligible equipment that electronically links health 

19 professionals or patients and health professionals at 

20 separate sites in order to exchange health care infor21 mation in audio, video, graphic, or other format for 

22 the purpose of providing improved health care serv23 ices. 


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1 ‘‘(23) The term ‘tribal college or university’ has 

2 the meaning given the term in section 316(b)(3) of 

3 the Higher Education Act (20 U.S.C. 1059c(b)(3)). 

4 ‘‘(24) The term ‘Tribal Health Program’ means 

5 an Indian Tribe or Tribal Organization that oper6 ates any health program, service, function, activity, 

7 or facility funded, in whole or part, by the Service 

8 through, or provided for in, a contract or compact 

9 with the Service under the Indian Self-Determina10 tion and Education Assistance Act (25 U.S.C. 450 

11 et seq.). 

12 ‘‘(25) The term ‘Tribal Organization’ has the 

13 meaning given the term in the Indian Self-Deter14 mination and Education Assistance Act (25 U.S.C. 

15 450 et seq.). 

16 ‘‘(26) The term ‘Urban Center’ means any com17 munity which has a sufficient Urban Indian popu18 lation with unmet health needs to warrant assistance 

19 under title V of this Act, as determined by the Sec20 retary. 

21 ‘‘(27) The term ‘Urban Indian’ means any indi22 vidual who resides in an Urban Center and who 

23 meets 1 or more of the following criteria: 

24 ‘‘(A) Irrespective of whether the individual 

25 lives on or near a reservation, the individual is 


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1 a member of a tribe, band, or other organized 

2 group of Indians, including those tribes, bands, 

3 or groups terminated since 1940 and those 

4 tribes, bands, or groups that are recognized by 

5 the States in which they reside, or who is a de6 scendant in the first or second degree of any 

7 such member. 

8 ‘‘(B) The individual is an Eskimo, Aleut, 

9 or other Alaska Native. 

10 ‘‘(C) The individual is considered by the 

11 Secretary of the Interior to be an Indian for 

12 any purpose. 

13 ‘‘(D) The individual is determined to be an 

14 Indian under regulations promulgated by the 

15 Secretary. 

16 ‘‘(28) The term ‘urban Indian organization’ 

17 means a nonprofit corporate body that (A) is situ18 ated in an Urban Center; (B) is governed by an 

19 Urban Indian-controlled board of directors; (C) pro20 vides for the participation of all interested Indian 

21 groups and individuals; and (D) is capable of legally 

22 cooperating with other public and private entities for 

23 the purpose of performing the activities described in 

24 section 503(a). 


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1 ‘‘TITLE I—INDIAN HEALTH, 

2 HUMAN RESOURCES, AND DE3 VELOPMENT 

4 ‘‘SEC. 101. PURPOSE. 

5 ‘‘The purpose of this title is to increase, to the max6 imum extent feasible, the number of Indians entering the 

7 health professions and providing health services, and to 

8 assure an optimum supply of health professionals to the 

9 Indian Health Programs and urban Indian organizations 

10 involved in the provision of health services to Indians. 

11 ‘‘SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM 

12 FOR INDIANS. 

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

14 the Service, shall make grants to public or nonprofit pri15 vate health or educational entities, Tribal Health Pro16 grams, or urban Indian organizations to assist such enti17 ties in meeting the costs of— 

18 ‘‘(1) identifying Indians with a potential for 

19 education or training in the health professions and 

20 encouraging and assisting them— 

21 ‘‘(A) to enroll in courses of study in such 

22 health professions; or 

23 ‘‘(B) if they are not qualified to enroll in 

24 any such courses of study, to undertake such 


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1 postsecondary education or training as may be 

2 required to qualify them for enrollment; 

3 ‘‘(2) publicizing existing sources of financial aid 

4 available to Indians enrolled in any course of study 

5 referred to in paragraph (1) or who are undertaking 

6 training necessary to qualify them to enroll in any 

7 such course of study; or 

8 ‘‘(3) establishing other programs which the Sec9 retary determines will enhance and facilitate the en10 rollment of Indians in, and the subsequent pursuit 

11 and completion by them of, courses of study referred 

12 to in paragraph (1). 

13 ‘‘(b) GRANTS.— 

14 ‘‘(1) APPLICATION.—No grant may be made 

15 under this section unless an application has been 

16 submitted to, and approved by, the Secretary. Such 

17 application shall be in such form, submitted in such 

18 manner, and contain such information, as the Sec19 retary shall by regulation prescribe pursuant to this 

20 Act. The Secretary shall give a preference to appli21 cations submitted by Tribal Health Programs or 

22 urban Indian organizations. 

23 ‘‘(2) AMOUNT OF GRANTS; PAYMENT.—The 

24 amount of a grant under this section shall be deter25 mined by the Secretary. Payments pursuant to this 


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1 section may be made in advance or by way of reim2 bursement, and at such intervals and on such condi3 tions as provided for in regulations issued pursuant 

4 to this Act. To the extent not otherwise prohibited 

5 by law, grants shall be for 3 years, as provided in 

6 regulations issued pursuant to this Act. 

7 ‘‘SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOL8 ARSHIP PROGRAM FOR INDIANS. 

9 ‘‘(a) SCHOLARSHIPS AUTHORIZED.—The Secretary, 

10 acting through the Service, shall provide scholarship 

11 grants to Indians who— 

12 ‘‘(1) have successfully completed their high 

13 school education or high school equivalency; and 

14 ‘‘(2) have demonstrated the potential to suc15 cessfully complete courses of study in the health pro16 fessions. 

17 ‘‘(b) PURPOSES.—Scholarship grants provided pursu18 ant to this section shall be for the following purposes: 

19 ‘‘(1) Compensatory preprofessional education of 

20 any recipient, such scholarship not to exceed 2 years 

21 on a full-time basis (or the part-time equivalent 

22 thereof, as determined by the Secretary pursuant to 

23 regulations issued under this Act). 

24 ‘‘(2) Pregraduate education of any recipient 

25 leading to a baccalaureate degree in an approved 


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1 course of study preparatory to a field of study in a 

2 health profession, such scholarship not to exceed 4 

3 years. An extension of up to 2 years (or the part4 time equivalent thereof, as determined by the Sec5 retary pursuant to regulations issued pursuant to 

6 this Act) may be approved. 

7 ‘‘(c) OTHER CONDITIONS.—Scholarships under this 

8 section— 

9 ‘‘(1) may cover costs of tuition, books, trans10 portation, board, and other necessary related ex11 penses of a recipient while attending school; 

12 ‘‘(2) shall not be denied solely on the basis of 

13 the applicant’s scholastic achievement if such appli14 cant has been admitted to, or maintained good 

15 standing at, an accredited institution; and 

16 ‘‘(3) shall not be denied solely by reason of such 

17 applicant’s eligibility for assistance or benefits under 

18 any other Federal program. 

19 ‘‘SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS. 

20 ‘‘(a) IN GENERAL.— 

21 ‘‘(1) AUTHORITY.—The Secretary, acting 

22 through the Service, shall make scholarship grants 

23 to Indians who are enrolled full or part time in ac24 credited schools pursuing courses of study in the 

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1 ignated Indian Health Scholarships and shall be 

2 made in accordance with section 338A of the Public 

3 Health Services Act (42 U.S.C. 254l), except as pro4 vided in subsection (b) of this section. 

5 ‘‘(2) DETERMINATIONS BY SECRETARY.—The 

6 Secretary, acting through the Service, shall deter7 mine— 

8 ‘‘(A) who shall receive scholarship grants 

9 under subsection (a); and 

10 ‘‘(B) the distribution of the scholarships 

11 among health professions on the basis of the 

12 relative needs of Indians for additional service 

13 in the health professions. 

14 ‘‘(3) CERTAIN DELEGATION NOT ALLOWED.— 

15 The administration of this section shall be a respon16 sibility of the Assistant Secretary and shall not be 

17 delegated in a contract or compact under the Indian 

18 Self-Determination and Education Assistance Act 

19 (25 U.S.C. 450 et seq.). 

20 ‘‘(b) ACTIVE DUTY SERVICE OBLIGATION.— 

21 ‘‘(1) OBLIGATION MET.—The active duty serv22 ice obligation under a written contract with the Sec23 retary under this section that an Indian has entered 

24 into shall, if that individual is a recipient of an In25 dian Health Scholarship, be met in full-time practice 


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1 equal to 1 year for each school year for which the 

2 participant receives a scholarship award under this 

3 part, or 2 years, whichever is greater, by service in 

4 1 or more of the following: 

5 ‘‘(A) In an Indian Health Program. 

6 ‘‘(B) In a program assisted under title V 

7 of this Act. 

8 ‘‘(C) In the private practice of the applica9 ble profession if, as determined by the Sec10 retary, in accordance with guidelines promul11 gated by the Secretary, such practice is situated 

12 in a physician or other health professional 

13 shortage area and addresses the health care 

14 needs of a substantial number of Indians. 

15 ‘‘(D) In a teaching capacity in a tribal col16 lege or university nursing program (or a related 

17 health profession program) if, as determined by 

18 the Secretary, the health service provided to In19 dians would not decrease. 

20 ‘‘(2) OBLIGATION DEFERRED.—At the request 

21 of any individual who has entered into a contract re22 ferred to in paragraph (1) and who receives a health 

23 professions degree requiring postgraduate training 

24 for licensure or to improve clinical skills, the Sec25 retary shall defer the active duty service obligation 


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1 of that individual under that contract, in order that 

2 such individual may complete any internship, resi3 dency, or other advanced clinical training that is re4 quired for the practice of that health profession, for 

5 an appropriate period (in years, as determined by 

6 the Secretary), subject to the following conditions: 

7 ‘‘(A) No period of internship, residency, or 

8 other advanced clinical training shall be counted 

9 as satisfying any period of obligated service 

10 under this subsection. 

11 ‘‘(B) The active duty service obligation of 

12 that individual shall commence not later than 

13 90 days after the completion of that advanced 

14 clinical training (or by a date specified by the 

15 Secretary). 

16 ‘‘(C) The active duty service obligation will 

17 be served in the health profession of that indi18 vidual in a manner consistent with paragraph 

19 (1). 

20 ‘‘(D) A recipient of a scholarship under 

21 this section may, at the election of the recipient, 

22 meet the active duty service obligation described 

23 in paragraph (1) by service in a program speci24 fied under that paragraph that— 


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1 ‘‘(i) is located on the reservation of 

2 the Indian Tribe in which the recipient is 

3 enrolled; or 

4 ‘‘(ii) serves the Indian Tribe in which 

5 the recipient is enrolled. 

6 ‘‘(3) PRIORITY WHEN MAKING ASSIGNMENTS.— 

7 Subject to paragraph (2), the Secretary, in making 

8 assignments of Indian Health Scholarship recipients 

9 required to meet the active duty service obligation 

10 described in paragraph (1), shall give priority to as11 signing individuals to service in those programs 

12 specified in paragraph (1) that have a need for 

13 health professionals to provide health care services 

14 as a result of individuals having breached contracts 

15 entered into under this section. 

16 ‘‘(c) PART-TIME STUDENTS.—In the case of an indi17 vidual receiving a scholarship under this section who is 

18 enrolled part time in an approved course of study— 

19 ‘‘(1) such scholarship shall be for a period of 

20 years not to exceed the part-time equivalent of 4 

21 years, as determined by the Secretary; 

22 ‘‘(2) the period of obligated service described in 

23 subsection (b)(1) shall be equal to the greater of— 

24 ‘‘(A) the part-time equivalent of 1 year for 

25 each year for which the individual was provided 


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1 a scholarship (as determined by the Secretary); 

2 or 

3 ‘‘(B) 2 years; and 

4 ‘‘(3) the amount of the monthly stipend speci5 fied in section 338A(g)(1)(B) of the Public Health 

6 Service Act (42 U.S.C. 254l(g)(1)(B)) shall be re7 duced pro rata (as determined by the Secretary) 

8 based on the number of hours such student is en9 rolled. 

10 ‘‘(d) BREACH OF CONTRACT.— 

11 ‘‘(1) SPECIFIED BREACHES.—An individual 

12 shall be liable to the United States for the amount 

13 which has been paid to the individual, or on behalf 

14 of the individual, under a contract entered into with 

15 the Secretary under this section on or after the date 

16 of enactment of the Indian Health Care Improve17 ment Act Amendments of 2009 if that individual— 

18 ‘‘(A) fails to maintain an acceptable level 

19 of academic standing in the educational institu20 tion in which he or she is enrolled (such level 

21 determined by the educational institution under 

22 regulations of the Secretary); 

23 ‘‘(B) is dismissed from such educational 

24 institution for disciplinary reasons; 


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1 ‘‘(C) voluntarily terminates the training in 

2 such an educational institution for which he or 

3 she is provided a scholarship under such con4 tract before the completion of such training; or 

5 ‘‘(D) fails to accept payment, or instructs 

6 the educational institution in which he or she is 

7 enrolled not to accept payment, in whole or in 

8 part, of a scholarship under such contract, in 

9 lieu of any service obligation arising under such 

10 contract. 

11 ‘‘(2) OTHER BREACHES.—If for any reason not 

12 specified in paragraph (1) an individual breaches a 

13 written contract by failing either to begin such indi14 vidual’s service obligation required under such con15 tract or to complete such service obligation, the 

16 United States shall be entitled to recover from the 

17 individual an amount determined in accordance with 

18 the formula specified in subsection (l) of section 110 

19 in the manner provided for in such subsection. 

20 ‘‘(3) CANCELLATION UPON DEATH OF RECIPI21 ENT.—Upon the death of an individual who receives 

22 an Indian Health Scholarship, any outstanding obli23 gation of that individual for service or payment that 

24 relates to that scholarship shall be canceled. 


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1 ‘‘(4) WAIVERS AND SUSPENSIONS.—The Sec2 retary shall provide for the partial or total waiver or 

3 suspension of any obligation of service or payment of 

4 a recipient of an Indian Health Scholarship if the 

5 Secretary determines that— 

6 ‘‘(A) it is not possible for the recipient to 

7 meet that obligation or make that payment; 

8 ‘‘(B) requiring that recipient to meet that 

9 obligation or make that payment would result 

10 in extreme hardship to the recipient; or 

11 ‘‘(C) the enforcement of the requirement to 

12 meet the obligation or make the payment would 

13 be unconscionable. 

14 ‘‘(5) EXTREME HARDSHIP.—Notwithstanding 

15 any other provision of law, in any case of extreme 

16 hardship or for other good cause shown, the Sec17 retary may waive, in whole or in part, the right of 

18 the United States to recover funds made available 

19 under this section. 

20 ‘‘(6) BANKRUPTCY.—Notwithstanding any 

21 other provision of law, with respect to a recipient of 

22 an Indian Health Scholarship, no obligation for pay23 ment may be released by a discharge in bankruptcy 

24 under title 11, United States Code, unless that dis25 charge is granted after the expiration of the 5-year 


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1 period beginning on the initial date on which that 

2 payment is due, and only if the bankruptcy court 

3 finds that the nondischarge of the obligation would 

4 be unconscionable. 

5 ‘‘SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PRO6 GRAM. 

7 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

8 through the Service, shall make grants of not more than 

9 $300,000 to each of 9 colleges and universities for the pur10 pose of developing and maintaining Indian psychology ca11 reer recruitment programs as a means of encouraging In12 dians to enter the behavioral health field. These programs 

13 shall be located at various locations throughout the coun14 try to maximize their availability to Indian students and 

15 new programs shall be established in different locations 

16 from time to time. 

17 ‘‘(b) QUENTIN N. BURDICK PROGRAM GRANT.—The 

18 Secretary shall provide a grant authorized under sub19 section (a) to develop and maintain a program at the Uni20 versity of North Dakota to be known as the ‘Quentin N. 

21 Burdick American Indians Into Psychology Program’. 

22 Such program shall, to the maximum extent feasible, co23 ordinate with the Quentin N. Burdick Indian Health Pro24 grams authorized under section 117(b), the Quentin N. 

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1 ized under section 115(e), and existing university research 

2 and communications networks. 

3 ‘‘(c) REGULATIONS.—The Secretary shall issue regu4 lations pursuant to this Act for the competitive awarding 

5 of grants provided under this section. 

6 ‘‘(d) CONDITIONS OF GRANT.—Applicants under this 

7 section shall agree to provide a program which, at a min8 imum— 

9 ‘‘(1) provides outreach and recruitment for 

10 health professions to Indian communities including 

11 elementary, secondary, and accredited and accessible 

12 community colleges that will be served by the pro13 gram; 

14 ‘‘(2) incorporates a program advisory board 

15 comprised of representatives from the tribes and 

16 communities that will be served by the program; 

17 ‘‘(3) provides summer enrichment programs to 

18 expose Indian students to the various fields of psy19 chology through research, clinical, and experimental 

20 activities; 

21 ‘‘(4) provides stipends to undergraduate and 

22 graduate students to pursue a career in psychology; 

23 ‘‘(5) develops affiliation agreements with tribal 

24 colleges and universities, the Service, university af25 filiated programs, and other appropriate accredited 


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1 and accessible entities to enhance the education of 

2 Indian students; 

3 ‘‘(6) to the maximum extent feasible, uses exist4 ing university tutoring, counseling, and student sup5 port services; and 

6 ‘‘(7) to the maximum extent feasible, employs 

7 qualified Indians in the program. 

8 ‘‘(e) ACTIVE DUTY SERVICE REQUIREMENT.—The 

9 active duty service obligation prescribed under section 

10 338C of the Public Health Service Act (42 U.S.C. 254m) 

11 shall be met by each graduate who receives a stipend de12 scribed in subsection (d)(4) that is funded under this sec13 tion. Such obligation shall be met by service— 

14 ‘‘(1) in an Indian Health Program; 

15 ‘‘(2) in a program assisted under title V of this 

16 Act; or 

17 ‘‘(3) in the private practice of psychology if, as 

18 determined by the Secretary, in accordance with 

19 guidelines promulgated by the Secretary, such prac20 tice is situated in a physician or other health profes21 sional shortage area and addresses the health care 

22 needs of a substantial number of Indians. 

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

24 is authorized to be appropriated such sums as may be nec25 essary to carry out this section. 


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1 ‘‘SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES. 

2 ‘‘(a) IN GENERAL.— 

3 ‘‘(1) GRANTS AUTHORIZED.—The Secretary, 

4 acting through the Service, shall make grants to 

5 Tribal Health Programs for the purpose of providing 

6 scholarships for Indians to serve as health profes7 sionals in Indian communities. 

8 ‘‘(2) AMOUNT.—Amounts available under para9 graph (1) for any fiscal year shall not exceed 5 per10 cent of the amounts available for each fiscal year for 

11 Indian Health Scholarships under section 104. 

12 ‘‘(3) APPLICATION.—An application for a grant 

13 under paragraph (1) shall be in such form and con14 tain such agreements, assurances, and information 

15 as consistent with this section. 

16 ‘‘(b) REQUIREMENTS.— 

17 ‘‘(1) IN GENERAL.—A Tribal Health Program 

18 receiving a grant under subsection (a) shall provide 

19 scholarships to Indians in accordance with the re20 quirements of this section. 

21 ‘‘(2) COSTS.—With respect to costs of providing 

22 any scholarship pursuant to subsection (a)— 

23 ‘‘(A) 80 percent of the costs of the scholar24 ship shall be paid from the funds made avail25 able pursuant to subsection (a)(1) provided to 

26 the Tribal Health Program; and 


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1 ‘‘(B) 20 percent of such costs may be paid 

2 from any other source of funds. 

3 ‘‘(c) COURSE OF STUDY.—A Tribal Health Program 

4 shall provide scholarships under this section only to Indi5 ans enrolled or accepted for enrollment in a course of 

6 study (approved by the Secretary) in 1 of the health pro7 fessions contemplated by this Act. 

8 ‘‘(d) CONTRACT.— 

9 ‘‘(1) IN GENERAL.—In providing scholarships 

10 under subsection (b), the Secretary and the Tribal 

11 Health Program shall enter into a written contract 

12 with each recipient of such scholarship. 

13 ‘‘(2) REQUIREMENTS.—Such contract shall— 

14 ‘‘(A) obligate such recipient to provide 

15 service in an Indian Health Program or urban 

16 Indian organization, in the same Service Area 

17 where the Tribal Health Program providing the 

18 scholarship is located, for— 

19 ‘‘(i) a number of years for which the 

20 scholarship is provided (or the part-time 

21 equivalent thereof, as determined by the 

22 Secretary), or for a period of 2 years, 

23 whichever period is greater; or 


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1 ‘‘(ii) such greater period of time as 

2 the recipient and the Tribal Health Pro3 gram may agree; 

4 ‘‘(B) provide that the amount of the schol5 arship— 

6 ‘‘(i) may only be expended for— 

7 ‘‘(I) tuition expenses, other rea8 sonable educational expenses, and rea9 sonable living expenses incurred in at10 tendance at the educational institu11 tion; and 

12 ‘‘(II) payment to the recipient of 

13 a monthly stipend of not more than 

14 the amount authorized by section 

15 338(g)(1)(B) of the Public Health 

16 Service Act (42 U.S.C. 

17 254m(g)(1)(B)), with such amount to 

18 be reduced pro rata (as determined by 

19 the Secretary) based on the number of 

20 hours such student is enrolled, and 

21 not to exceed, for any year of attend22 ance for which the scholarship is pro23 vided, the total amount required for 

24 the year for the purposes authorized 

25 in this clause; and 


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1 ‘‘(ii) may not exceed, for any year of 

2 attendance for which the scholarship is 

3 provided, the total amount required for the 

4 year for the purposes authorized in clause 

5 (i); 

6 ‘‘(C) require the recipient of such scholar7 ship to maintain an acceptable level of academic 

8 standing as determined by the educational insti9 tution in accordance with regulations issued 

10 pursuant to this Act; and 

11 ‘‘(D) require the recipient of such scholar12 ship to meet the educational and licensure re13 quirements appropriate to each health profes14 sion. 

15 ‘‘(3) SERVICE IN OTHER SERVICE AREAS.—The 

16 contract may allow the recipient to serve in another 

17 Service Area, provided the Tribal Health Program 

18 and Secretary approve and services are not dimin19 ished to Indians in the Service Area where the Trib20 al Health Program providing the scholarship is lo21 cated. 

22 ‘‘(e) BREACH OF CONTRACT.— 

23 ‘‘(1) SPECIFIC BREACHES.—An individual who 

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1 section (d) shall be liable to the United States for 

2 the Federal share of the amount which has been 

3 paid to him or her, or on his or her behalf, under 

4 the contract if that individual— 

5 ‘‘(A) fails to maintain an acceptable level 

6 of academic standing in the educational institu7 tion in which he or she is enrolled (such level 

8 as determined by the educational institution 

9 under regulations of the Secretary); 

10 ‘‘(B) is dismissed from such educational 

11 institution for disciplinary reasons; 

12 ‘‘(C) voluntarily terminates the training in 

13 such an educational institution for which he or 

14 she is provided a scholarship under such con15 tract before the completion of such training; or 

16 ‘‘(D) fails to accept payment, or instructs 

17 the educational institution in which he or she is 

18 enrolled not to accept payment, in whole or in 

19 part, of a scholarship under such contract, in 

20 lieu of any service obligation arising under such 

21 contract. 

22 ‘‘(2) OTHER BREACHES.—If for any reason not 

23 specified in paragraph (1), an individual breaches a 

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1 tract or to complete such service obligation, the 

2 United States shall be entitled to recover from the 

3 individual an amount determined in accordance with 

4 the formula specified in subsection (l) of section 110 

5 in the manner provided for in such subsection. 

6 ‘‘(3) CANCELLATION UPON DEATH OF RECIPI7 ENT.—Upon the death of an individual who receives 

8 an Indian Health Scholarship, any outstanding obli9 gation of that individual for service or payment that 

10 relates to that scholarship shall be canceled. 

11 ‘‘(4) INFORMATION.—The Secretary may carry 

12 out this subsection on the basis of information re13 ceived from Tribal Health Programs involved or on 

14 the basis of information collected through such other 

15 means as the Secretary deems appropriate. 

16 ‘‘(f) RELATION TO SOCIAL SECURITY ACT.—The re17 cipient of a scholarship under this section shall agree, in 

18 providing health care pursuant to the requirements here19 in— 

20 ‘‘(1) not to discriminate against an individual 

21 seeking care on the basis of the ability of the indi22 vidual to pay for such care or on the basis that pay23 ment for such care will be made pursuant to a pro24 gram established in title XVIII of the Social SecuVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01672 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 rity Act or pursuant to the programs established in 

2 title XIX or title XXI of such Act; and 

3 ‘‘(2) to accept assignment under section 

4 1842(b)(3)(B)(ii) of the Social Security Act for all 

5 services for which payment may be made under part 

6 B of title XVIII of such Act, and to enter into an 

7 appropriate agreement with the State agency that 

8 administers the State plan for medical assistance 

9 under title XIX, or the State child health plan under 

10 title XXI, of such Act to provide service to individ11 uals entitled to medical assistance or child health as12 sistance, respectively, under the plan. 

13 ‘‘(g) CONTINUANCE OF FUNDING.—The Secretary 

14 shall make payments under this section to a Tribal Health 

15 Program for any fiscal year subsequent to the first fiscal 

16 year of such payments unless the Secretary determines 

17 that, for the immediately preceding fiscal year, the Tribal 

18 Health Program has not complied with the requirements 

19 of this section. 

20 ‘‘SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS. 

21 ‘‘(a) EMPLOYMENT PREFERENCE.—Any individual 

22 who receives a scholarship pursuant to section 104 or 106 

23 shall be given preference for employment in the Service, 

24 or may be employed by a Tribal Health Program or an 

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1 partment as available, during any nonacademic period of 

2 the year. 

3 ‘‘(b) NOT COUNTED TOWARD ACTIVE DUTY SERVICE

4 OBLIGATION.—Periods of employment pursuant to this 

5 subsection shall not be counted in determining fulfillment 

6 of the service obligation incurred as a condition of the 

7 scholarship. 

8 ‘‘(c) TIMING; LENGTH OF EMPLOYMENT.—Any indi9 vidual enrolled in a program, including a high school pro10 gram, authorized under section 102(a) may be employed 

11 by the Service or by a Tribal Health Program or an urban 

12 Indian organization during any nonacademic period of the 

13 year. Any such employment shall not exceed 120 days dur14 ing any calendar year. 

15 ‘‘(d) NONAPPLICABILITY OF COMPETITIVE PER16 SONNEL SYSTEM.—Any employment pursuant to this sec17 tion shall be made without regard to any competitive per18 sonnel system or agency personnel limitation and to a po19 sition which will enable the individual so employed to re20 ceive practical experience in the health profession in which 

21 he or she is engaged in study. Any individual so employed 

22 shall receive payment for his or her services comparable 

23 to the salary he or she would receive if he or she were 

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1 ployed shall not be counted against any employment ceil2 ing affecting the Service or the Department. 

3 ‘‘SEC. 108. CONTINUING EDUCATION ALLOWANCES. 

4 ‘‘In order to encourage scholarship and stipend re5 cipients under sections 104, 105, 106, and 115 and health 

6 professionals, including community health representatives 

7 and emergency medical technicians, to join or continue in 

8 an Indian Health Program and to provide their services 

9 in the rural and remote areas where a significant portion 

10 of Indians reside, the Secretary, acting through the Serv11 ice, may— 

12 ‘‘(1) provide programs or allowances to transi13 tion into an Indian Health Program, including li14 censing, board or certification examination assist15 ance, and technical assistance in fulfilling service ob16 ligations under sections 104, 105, 106, and 115; and 

17 ‘‘(2) provide programs or allowances to health 

18 professionals employed in an Indian Health Program 

19 to enable them for a period of time each year pre20 scribed by regulation of the Secretary to take leave 

21 of their duty stations for professional consultation, 

22 management, leadership, and refresher training 

23 courses. 


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1 ‘‘SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PRO2 GRAM. 

3 ‘‘(a) IN GENERAL.—Under the authority of the Act 

4 of November 2, 1921 (25 U.S.C. 13) (commonly known 

5 as the ‘Snyder Act’), the Secretary, acting through the 

6 Service, shall maintain a Community Health Representa7 tive Program under which Indian Health Programs— 

8 ‘‘(1) provide for the training of Indians as com9 munity health representatives; and 

10 ‘‘(2) use such community health representatives 

11 in the provision of health care, health promotion, 

12 and disease prevention services to Indian commu13 nities. 

14 ‘‘(b) DUTIES.—The Community Health Representa15 tive Program of the Service, shall— 

16 ‘‘(1) provide a high standard of training for 

17 community health representatives to ensure that the 

18 community health representatives provide quality 

19 health care, health promotion, and disease preven20 tion services to the Indian communities served by 

21 the Program; 

22 ‘‘(2) in order to provide such training, develop 

23 and maintain a curriculum that— 

24 ‘‘(A) combines education in the theory of 

25 health care with supervised practical experience 

26 in the provision of health care; and 


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1 ‘‘(B) provides instruction and practical ex2 perience in health promotion and disease pre3 vention activities, with appropriate consider4 ation given to lifestyle factors that have an im5 pact on Indian health status, such as alco6 holism, family dysfunction, and poverty; 

7 ‘‘(3) maintain a system which identifies the 

8 needs of community health representatives for con9 tinuing education in health care, health promotion, 

10 and disease prevention and develop programs that 

11 meet the needs for continuing education; 

12 ‘‘(4) maintain a system that provides close su13 pervision of Community Health Representatives; 

14 ‘‘(5) maintain a system under which the work 

15 of Community Health Representatives is reviewed 

16 and evaluated; and 

17 ‘‘(6) promote traditional health care practices 

18 of the Indian Tribes served consistent with the Serv19 ice standards for the provision of health care, health 

20 promotion, and disease prevention. 

21 ‘‘SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT 

22 PROGRAM. 

23 ‘‘(a) ESTABLISHMENT.—The Secretary, acting 

24 through the Service, shall establish and administer a pro25 gram to be known as the Service Loan Repayment ProVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01677 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 gram (hereinafter referred to as the ‘Loan Repayment 

2 Program’) in order to ensure an adequate supply of 

3 trained health professionals necessary to maintain accredi4 tation of, and provide health care services to Indians 

5 through, Indian Health Programs and urban Indian orga6 nizations. 

7 ‘‘(b) ELIGIBLE INDIVIDUALS.—To be eligible to par8 ticipate in the Loan Repayment Program, an individual 

9 must— 

10 ‘‘(1)(A) be enrolled— 

11 ‘‘(i) in a course of study or program in an 

12 accredited educational institution (as deter13 mined by the Secretary under section 

14 338B(b)(1)(c)(i) of the Public Health Service 

15 Act (42 U.S.C. 254l–1(b)(1)(c)(i))) and be 

16 scheduled to complete such course of study in 

17 the same year such individual applies to partici18 pate in such program; or 

19 ‘‘(ii) in an approved graduate training pro20 gram in a health profession; or 

21 ‘‘(B) have— 

22 ‘‘(i) a degree in a health profession; and 

23 ‘‘(ii) a license to practice a health profes24 sion; 


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1 ‘‘(2)(A) be eligible for, or hold, an appointment 

2 as a commissioned officer in the Regular or Reserve 

3 Corps of the Public Health Service; 

4 ‘‘(B) meet the professional standards for civil 

5 service employment in the Service; or 

6 ‘‘(C) be employed in an Indian Health Program 

7 or urban Indian organization without a service obli8 gation; and 

9 ‘‘(3) submit to the Secretary an application for 

10 a contract described in subsection (e). 

11 ‘‘(c) APPLICATION.— 

12 ‘‘(1) INFORMATION TO BE INCLUDED WITH

13 FORMS.—In disseminating application forms and 

14 contract forms to individuals desiring to participate 

15 in the Loan Repayment Program, the Secretary 

16 shall include with such forms a fair summary of the 

17 rights and liabilities of an individual whose applica18 tion is approved (and whose contract is accepted) by 

19 the Secretary, including in the summary a clear ex20 planation of the damages to which the United States 

21 is entitled under subsection (l) in the case of the in22 dividual’s breach of contract. The Secretary shall 

23 provide such individuals with sufficient information 

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1 serve Corps of the Public Health Service or a civil2 ian employee of the Service to enable the individual 

3 to make a decision on an informed basis. 

4 ‘‘(2) CLEAR LANGUAGE.—The application form, 

5 contract form, and all other information furnished 

6 by the Secretary under this section shall be written 

7 in a manner calculated to be understood by the aver8 age individual applying to participate in the Loan 

9 Repayment Program. 

10 ‘‘(3) TIMELY AVAILABILITY OF FORMS.—The 

11 Secretary shall make such application forms, con12 tract forms, and other information available to indi13 viduals desiring to participate in the Loan Repay14 ment Program on a date sufficiently early to ensure 

15 that such individuals have adequate time to carefully 

16 review and evaluate such forms and information. 

17 ‘‘(d) PRIORITIES.— 

18 ‘‘(1) LIST.—Consistent with subsection (j), the 

19 Secretary shall annually— 

20 ‘‘(A) identify the positions in each Indian 

21 Health Program or urban Indian organization 

22 for which there is a need or a vacancy; and 

23 ‘‘(B) rank those positions in order of pri24 ority. 


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1 ‘‘(2) APPROVALS.—Consistent with the priority 

2 determined under paragraph (1), the Secretary, in 

3 determining which applications under the Loan Re4 payment Program to approve (and which contracts 

5 to accept), shall— 

6 ‘‘(A) give first priority to applications 

7 made by individual Indians; and 

8 ‘‘(B) after making determinations on all 

9 applications submitted by individual Indians as 

10 required under subparagraph (A), give priority 

11 to— 

12 ‘‘(i) individuals recruited through the 

13 efforts of an Indian Health Program or 

14 urban Indian organization; and 

15 ‘‘(ii) other individuals based on the 

16 priority rankings under paragraph (1). 

17 ‘‘(e) RECIPIENT CONTRACTS.— 

18 ‘‘(1) CONTRACT REQUIRED.—An individual be19 comes a participant in the Loan Repayment Pro20 gram only upon the Secretary and the individual en21 tering into a written contract described in paragraph 

22 (2). 

23 ‘‘(2) CONTENTS OF CONTRACT.—The written 

24 contract referred to in this section between the Sec25 retary and an individual shall contain— 


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1 ‘‘(A) an agreement under which— 

2 ‘‘(i) subject to subparagraph (C), the 

3 Secretary agrees— 

4 ‘‘(I) to pay loans on behalf of the 

5 individual in accordance with the pro6 visions of this section; and 

7 ‘‘(II) to accept (subject to the 

8 availability of appropriated funds for 

9 carrying out this section) the indi10 vidual into the Service or place the in11 dividual with a Tribal Health Pro12 gram or urban Indian organization as 

13 provided in clause (ii)(III); and 

14 ‘‘(ii) subject to subparagraph (C), the 

15 individual agrees— 

16 ‘‘(I) to accept loan payments on 

17 behalf of the individual; 

18 ‘‘(II) in the case of an individual 

19 described in subsection (b)(1)— 

20 ‘‘(aa) to maintain enrollment 

21 in a course of study or training 

22 described in subsection (b)(1)(A) 

23 until the individual completes the 

24 course of study or training; and 


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1 ‘‘(bb) while enrolled in such 

2 course of study or training, to 

3 maintain an acceptable level of 

4 academic standing (as deter5 mined under regulations of the 

6 Secretary by the educational in7 stitution offering such course of 

8 study or training); and 

9 ‘‘(III) to serve for a time period 

10 (in this section referred to as the ‘pe11 riod of obligated service’) equal to 2 

12 years or such longer period as the in13 dividual may agree to serve in the 

14 full-time clinical practice of such indi15 vidual’s profession in an Indian 

16 Health Program or urban Indian or17 ganization to which the individual 

18 may be assigned by the Secretary; 

19 ‘‘(B) a provision permitting the Secretary 

20 to extend for such longer additional periods, as 

21 the individual may agree to, the period of obli22 gated service agreed to by the individual under 

23 subparagraph (A)(ii)(III); 

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1 tract entered into under this section and any 

2 obligation of the individual which is conditioned 

3 thereon is contingent upon funds being appro4 priated for loan repayments under this section; 

5 ‘‘(D) a statement of the damages to which 

6 the United States is entitled under subsection 

7 (k) for the individual’s breach of the contract; 

8 and 

9 ‘‘(E) such other statements of the rights 

10 and liabilities of the Secretary and of the indi11 vidual, not inconsistent with this section. 

12 ‘‘(f) DEADLINE FOR DECISION ON APPLICATION.— 

13 The Secretary shall provide written notice to an individual 

14 within 21 days on— 

15 ‘‘(1) the Secretary’s approving, under sub16 section (e)(1), of the individual’s participation in the 

17 Loan Repayment Program, including extensions re18 sulting in an aggregate period of obligated service in 

19 excess of 4 years; or 

20 ‘‘(2) the Secretary’s disapproving an individ21 ual’s participation in such Program. 

22 ‘‘(g) PAYMENTS.— 

23 ‘‘(1) IN GENERAL.—A loan repayment provided 

24 for an individual under a written contract under the 

25 Loan Repayment Program shall consist of payment, 


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1 in accordance with paragraph (2), on behalf of the 

2 individual of the principal, interest, and related ex3 penses on government and commercial loans received 

4 by the individual regarding the undergraduate or 

5 graduate education of the individual (or both), which 

6 loans were made for— 

7 ‘‘(A) tuition expenses; 

8 ‘‘(B) all other reasonable educational ex9 penses, including fees, books, and laboratory ex10 penses, incurred by the individual; and 

11 ‘‘(C) reasonable living expenses as deter12 mined by the Secretary. 

13 ‘‘(2) AMOUNT.—For each year of obligated 

14 service that an individual contracts to serve under 

15 subsection (e), the Secretary may pay up to $35,000 

16 or an amount equal to the amount specified in sec17 tion 338B(g)(2)(A) of the Public Health Service 

18 Act, whichever is more, on behalf of the individual 

19 for loans described in paragraph (1). In making a 

20 determination of the amount to pay for a year of 

21 such service by an individual, the Secretary shall 

22 consider the extent to which each such determina23 tion— 

24 ‘‘(A) affects the ability of the Secretary to 

25 maximize the number of contracts that can be 


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1 provided under the Loan Repayment Program 

2 from the amounts appropriated for such con3 tracts; 

4 ‘‘(B) provides an incentive to serve in In5 dian Health Programs and urban Indian orga6 nizations with the greatest shortages of health 

7 professionals; and 

8 ‘‘(C) provides an incentive with respect to 

9 the health professional involved remaining in an 

10 Indian Health Program or urban Indian organi11 zation with such a health professional shortage, 

12 and continuing to provide primary health serv13 ices, after the completion of the period of obli14 gated service under the Loan Repayment Pro15 gram. 

16 ‘‘(3) TIMING.—Any arrangement made by the 

17 Secretary for the making of loan repayments in ac18 cordance with this subsection shall provide that any 

19 repayments for a year of obligated service shall be 

20 made no later than the end of the fiscal year in 

21 which the individual completes such year of service. 

22 ‘‘(4) REIMBURSEMENTS FOR TAX LIABILITY.— 

23 For the purpose of providing reimbursements for tax 

24 liability resulting from a payment under paragraph 

25 (2) on behalf of an individual, the Secretary— 


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1 ‘‘(A) in addition to such payments, may 

2 make payments to the individual in an amount 

3 equal to not less than 20 percent and not more 

4 than 39 percent of the total amount of loan re5 payments made for the taxable year involved; 

6 and 

7 ‘‘(B) may make such additional payments 

8 as the Secretary determines to be appropriate 

9 with respect to such purpose. 

10 ‘‘(5) PAYMENT SCHEDULE.—The Secretary 

11 may enter into an agreement with the holder of any 

12 loan for which payments are made under the Loan 

13 Repayment Program to establish a schedule for the 

14 making of such payments. 

15 ‘‘(h) EMPLOYMENT CEILING.—Notwithstanding any 

16 other provision of law, individuals who have entered into 

17 written contracts with the Secretary under this section 

18 shall not be counted against any employment ceiling af19 fecting the Department while those individuals are under20 going academic training. 

21 ‘‘(i) RECRUITMENT.—The Secretary shall conduct re22 cruiting programs for the Loan Repayment Program and 

23 other manpower programs of the Service at educational 

24 institutions training health professionals or specialists 

25 identified in subsection (a). 


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1 ‘‘(j) APPLICABILITY OF LAW.—Section 214 of the 

2 Public Health Service Act (42 U.S.C. 215) shall not apply 

3 to individuals during their period of obligated service 

4 under the Loan Repayment Program. 

5 ‘‘(k) ASSIGNMENT OF INDIVIDUALS.—The Secretary, 

6 in assigning individuals to serve in Indian Health Pro7 grams or urban Indian organizations pursuant to con8 tracts entered into under this section, shall— 

9 ‘‘(1) ensure that the staffing needs of Tribal 

10 Health Programs and urban Indian organizations 

11 receive consideration on an equal basis with pro12 grams that are administered directly by the Service; 

13 and 

14 ‘‘(2) give priority to assigning individuals to In15 dian Health Programs and urban Indian organiza16 tions that have a need for health professionals to 

17 provide health care services as a result of individuals 

18 having breached contracts entered into under this 

19 section. 

20 ‘‘(l) BREACH OF CONTRACT.— 

21 ‘‘(1) SPECIFIC BREACHES.—An individual who 

22 has entered into a written contract with the Sec23 retary under this section and has not received a 

24 waiver under subsection (m) shall be liable, in lieu 

25 of any service obligation arising under such contract, 


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1 to the United States for the amount which has been 

2 paid on such individual’s behalf under the contract 

3 if that individual— 

4 ‘‘(A) is enrolled in the final year of a 

5 course of study and— 

6 ‘‘(i) fails to maintain an acceptable 

7 level of academic standing in the edu8 cational institution in which he or she is 

9 enrolled (such level determined by the edu10 cational institution under regulations of 

11 the Secretary); 

12 ‘‘(ii) voluntarily terminates such en13 rollment; or 

14 ‘‘(iii) is dismissed from such edu15 cational institution before completion of 

16 such course of study; or 

17 ‘‘(B) is enrolled in a graduate training pro18 gram and fails to complete such training pro19 gram. 

20 ‘‘(2) OTHER BREACHES; FORMULA FOR

21 AMOUNT OWED.—If, for any reason not specified in 

22 paragraph (1), an individual breaches his or her 

23 written contract under this section by failing either 

24 to begin, or complete, such individual’s period of ob25 ligated service in accordance with subsection (e)(2), 


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1 the United States shall be entitled to recover from 

2 such individual an amount to be determined in ac3 cordance with the following formula: A=3Z(t¥s/t) 

4 in which— 

5 ‘‘(A) ‘A’ is the amount the United States 

6 is entitled to recover; 

7 ‘‘(B) ‘Z’ is the sum of the amounts paid 

8 under this section to, or on behalf of, the indi9 vidual and the interest on such amounts which 

10 would be payable if, at the time the amounts 

11 were paid, they were loans bearing interest at 

12 the maximum legal prevailing rate, as deter13 mined by the Secretary of the Treasury; 

14 ‘‘(C) ‘t’ is the total number of months in 

15 the individual’s period of obligated service; and 

16 ‘‘(D) ‘s’ is the number of months of such 

17 period served by such individual in accordance 

18 with this section. 

19 ‘‘(3) TIME PERIOD FOR REPAYMENT.—Any 

20 amount of damages which the United States is enti21 tled to recover under this subsection shall be paid to 

22 the United States within the 1-year period beginning 

23 on the date of the breach or such longer period be24 ginning on such date as shall be specified by the 

25 Secretary. 


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1 ‘‘(4) DEDUCTIONS IN MEDICARE PAYMENTS.— 

2 Amounts not paid within such period shall be sub3 ject to collection through deductions in Medicare 

4 payments pursuant to section 1892 of the Social Se5 curity Act. 

6 ‘‘(5) RECOVERY OF DELINQUENCY.— 

7 ‘‘(A) IN GENERAL.—If damages described 

8 in paragraph (4) are delinquent for 3 months, 

9 the Secretary shall, for the purpose of recov10 ering such damages— 

11 ‘‘(i) use collection agencies contracted 

12 with by the Administrator of General Serv13 ices; or 

14 ‘‘(ii) enter into contracts for the re15 covery of such damages with collection 

16 agencies selected by the Secretary. 

17 ‘‘(B) REPORT.—Each contract for recov18 ering damages pursuant to this subsection shall 

19 provide that the contractor will, not less than 

20 once each 6 months, submit to the Secretary a 

21 status report on the success of the contractor in 

22 collecting such damages. Section 3718 of title 

23 31, United States Code, shall apply to any such 

24 contract to the extent not inconsistent with this 

25 subsection. 


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1 ‘‘(m) WAIVER OR SUSPENSION OF OBLIGATION.— 

2 ‘‘(1) IN GENERAL.—The Secretary shall by reg3 ulation provide for the partial or total waiver or sus4 pension of any obligation of service or payment by 

5 an individual under the Loan Repayment Program 

6 whenever compliance by the individual is impossible 

7 or would involve extreme hardship to the individual 

8 and if enforcement of such obligation with respect to 

9 any individual would be unconscionable. 

10 ‘‘(2) CANCELED UPON DEATH.—Any obligation 

11 of an individual under the Loan Repayment Pro12 gram for service or payment of damages shall be 

13 canceled upon the death of the individual. 

14 ‘‘(3) HARDSHIP WAIVER.—The Secretary may 

15 waive, in whole or in part, the rights of the United 

16 States to recover amounts under this section in any 

17 case of extreme hardship or other good cause shown, 

18 as determined by the Secretary. 

19 ‘‘(4) BANKRUPTCY.—Any obligation of an indi20 vidual under the Loan Repayment Program for pay21 ment of damages may be released by a discharge in 

22 bankruptcy under title 11 of the United States Code 

23 only if such discharge is granted after the expiration 

24 of the 5-year period beginning on the first date that 

25 payment of such damages is required, and only if 


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1 the bankruptcy court finds that nondischarge of the 

2 obligation would be unconscionable. 

3 ‘‘(n) REPORT.—The Secretary shall submit to the 

4 President, for inclusion in the report required to be sub5 mitted to Congress under section 801, a report concerning 

6 the previous fiscal year which sets forth by Service Area 

7 the following: 

8 ‘‘(1) A list of the health professional positions 

9 maintained by Indian Health Programs and urban 

10 Indian organizations for which recruitment or reten11 tion is difficult. 

12 ‘‘(2) The number of Loan Repayment Program 

13 applications filed with respect to each type of health 

14 profession. 

15 ‘‘(3) The number of contracts described in sub16 section (e) that are entered into with respect to each 

17 health profession. 

18 ‘‘(4) The amount of loan payments made under 

19 this section, in total and by health profession. 

20 ‘‘(5) The number of scholarships that are pro21 vided under sections 104 and 106 with respect to 

22 each health profession. 

23 ‘‘(6) The amount of scholarship grants provided 

24 under sections 104 and 106, in total and by health 

25 profession. 


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1 ‘‘(7) The number of providers of health care 

2 that will be needed by Indian Health Programs and 

3 urban Indian organizations, by location and profes4 sion, during the 3 fiscal years beginning after the 

5 date the report is filed. 

6 ‘‘(8) The measures the Secretary plans to take 

7 to fill the health professional positions maintained 

8 by Indian Health Programs or urban Indian organi9 zations for which recruitment or retention is dif10 ficult. 

11 ‘‘SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOV12 ERY FUND. 

13 ‘‘(a) ESTABLISHMENT.—There is established in the 

14 Treasury of the United States a fund to be known as the 

15 Indian Health Scholarship and Loan Repayment Recovery 

16 Fund (hereafter in this section referred to as the ‘LRRF’). 

17 The LRRF shall consist of such amounts as may be col18 lected from individuals under section 104(d), section 

19 106(e), and section 110(l) for breach of contract, such 

20 funds as may be appropriated to the LRRF, and interest 

21 earned on amounts in the LRRF. All amounts collected, 

22 appropriated, or earned relative to the LRRF shall remain 

23 available until expended. 

24 ‘‘(b) USE OF FUNDS.— 


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1 ‘‘(1) BY SECRETARY.—Amounts in the LRRF 

2 may be expended by the Secretary, acting through 

3 the Service, to make payments to an Indian Health 

4 Program— 

5 ‘‘(A) to which a scholarship recipient under 

6 section 104 and 106 or a loan repayment pro7 gram participant under section 110 has been 

8 assigned to meet the obligated service require9 ments pursuant to such sections; and 

10 ‘‘(B) that has a need for a health profes11 sional to provide health care services as a result 

12 of such recipient or participant having breached 

13 the contract entered into under section 104, 

14 106, or 110. 

15 ‘‘(2) BY TRIBAL HEALTH PROGRAMS.—A Tribal 

16 Health Program receiving payments pursuant to 

17 paragraph (1) may expend the payments to provide 

18 scholarships or recruit and employ, directly or by 

19 contract, health professionals to provide health care 

20 services. 

21 ‘‘(c) INVESTMENT OF FUNDS.—The Secretary of the 

22 Treasury shall invest such amounts of the LRRF as the 

23 Secretary of Health and Human Services determines are 

24 not required to meet current withdrawals from the LRRF. 

25 Such investments may be made only in interest bearing 


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1 obligations of the United States. For such purpose, such 

2 obligations may be acquired on original issue at the issue 

3 price, or by purchase of outstanding obligations at the 

4 market price. 

5 ‘‘(d) SALE OF OBLIGATIONS.—Any obligation ac6 quired by the LRRF may be sold by the Secretary of the 

7 Treasury at the market price. 

8 ‘‘SEC. 112. RECRUITMENT ACTIVITIES. 

9 ‘‘(a) REIMBURSEMENT FOR TRAVEL.—The Sec10 retary, acting through the Service, may reimburse health 

11 professionals seeking positions with Indian Health Pro12 grams or urban Indian organizations, including individ13 uals considering entering into a contract under section 

14 110 and their spouses, for actual and reasonable expenses 

15 incurred in traveling to and from their places of residence 

16 to an area in which they may be assigned for the purpose 

17 of evaluating such area with respect to such assignment. 

18 ‘‘(b) RECRUITMENT PERSONNEL.—The Secretary, 

19 acting through the Service, shall assign 1 individual in 

20 each Area Office to be responsible on a full-time basis for 

21 recruitment activities. 

22 ‘‘SEC. 113. INDIAN RECRUITMENT AND RETENTION PRO23 GRAM. 

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

25 the Service, shall fund, on a competitive basis, innovative 


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1 demonstration projects for a period not to exceed 3 years 

2 to enable Indian Health Programs and urban Indian orga3 nizations to recruit, place, and retain health professionals 

4 to meet their staffing needs. 

5 ‘‘(b) ELIGIBLE ENTITIES; APPLICATION.—Any In6 dian Health Program or Urban Indian organization may 

7 submit an application for funding of a project pursuant 

8 to this section. 

9 ‘‘SEC. 114. ADVANCED TRAINING AND RESEARCH. 

10 ‘‘(a) DEMONSTRATION PROGRAM.—The Secretary, 

11 acting through the Service, shall establish a demonstration 

12 project to enable health professionals who have worked in 

13 an Indian Health Program or urban Indian organization 

14 for a substantial period of time to pursue advanced train15 ing or research areas of study for which the Secretary de16 termines a need exists. 

17 ‘‘(b) SERVICE OBLIGATION.—An individual who par18 ticipates in a program under subsection (a), where the 

19 educational costs are borne by the Service, shall incur an 

20 obligation to serve in an Indian Health Program or urban 

21 Indian organization for a period of obligated service equal 

22 to at least the period of time during which the individual 

23 participates in such program. In the event that the indi24 vidual fails to complete such obligated service, the indi25 vidual shall be liable to the United States for the period 


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1 of service remaining. In such event, with respect to indi2 viduals entering the program after the date of enactment 

3 of the Indian Health Care Improvement Act Amendments 

4 of 2009, the United States shall be entitled to recover 

5 from such individual an amount to be determined in ac6 cordance with the formula specified in subsection (l) of 

7 section 110 in the manner provided for in such subsection. 

8 ‘‘(c) EQUAL OPPORTUNITY FOR PARTICIPATION.— 

9 Health professionals from Tribal Health Programs and 

10 urban Indian organizations shall be given an equal oppor11 tunity to participate in the program under subsection (a). 

12 ‘‘SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO 

13 NURSING PROGRAM. 

14 ‘‘(a) GRANTS AUTHORIZED.—For the purpose of in15 creasing the number of nurses, nurse midwives, and nurse 

16 practitioners who deliver health care services to Indians, 

17 the Secretary, acting through the Service, shall provide 

18 grants to the following: 

19 ‘‘(1) Public or private schools of nursing. 

20 ‘‘(2) Tribal colleges or universities. 

21 ‘‘(3) Nurse midwife programs and advanced 

22 practice nurse programs that are provided by any 

23 tribal college or university accredited nursing pro24 gram, or in the absence of such, any other public or 

25 private institutions. 


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1 ‘‘(b) USE OF GRANTS.—Grants provided under sub2 section (a) may be used for 1 or more of the following: 

3 ‘‘(1) To recruit individuals for programs which 

4 train individuals to be nurses, nurse midwives, or 

5 advanced practice nurses. 

6 ‘‘(2) To provide scholarships to Indians enrolled 

7 in such programs that may pay the tuition charged 

8 for such program and other expenses incurred in 

9 connection with such program, including books, fees, 

10 room and board, and stipends for living expenses. 

11 ‘‘(3) To provide a program that encourages 

12 nurses, nurse midwives, and advanced practice 

13 nurses to provide, or continue to provide, health care 

14 services to Indians. 

15 ‘‘(4) To provide a program that increases the 

16 skills of, and provides continuing education to, 

17 nurses, nurse midwives, and advanced practice 

18 nurses. 

19 ‘‘(5) To provide any program that is designed 

20 to achieve the purpose described in subsection (a). 

21 ‘‘(c) APPLICATIONS.—Each application for a grant 

22 under subsection (a) shall include such information as the 

23 Secretary may require to establish the connection between 

24 the program of the applicant and a health care facility 

25 that primarily serves Indians. 


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1 ‘‘(d) PREFERENCES FOR GRANT RECIPIENTS.—In 

2 providing grants under subsection (a), the Secretary shall 

3 extend a preference to the following: 

4 ‘‘(1) Programs that provide a preference to In5 dians. 

6 ‘‘(2) Programs that train nurse midwives or ad7 vanced practice nurses. 

8 ‘‘(3) Programs that are interdisciplinary. 

9 ‘‘(4) Programs that are conducted in coopera10 tion with a program for gifted and talented Indian 

11 students. 

12 ‘‘(5) Programs conducted by tribal colleges and 

13 universities. 

14 ‘‘(e) QUENTIN N. BURDICK PROGRAM GRANT.—The 

15 Secretary shall provide 1 of the grants authorized under 

16 subsection (a) to establish and maintain a program at the 

17 University of North Dakota to be known as the ‘Quentin 

18 N. Burdick American Indians Into Nursing Program’. 

19 Such program shall, to the maximum extent feasible, co20 ordinate with the Quentin N. Burdick Indian Health Pro21 grams established under section 117(b) and the Quentin 

22 N. Burdick American Indians Into Psychology Program 

23 established under section 105(b). 

24 ‘‘(f) ACTIVE DUTY SERVICE OBLIGATION.—The ac25 tive duty service obligation prescribed under section 338C 


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1 of the Public Health Service Act (42 U.S.C. 254m) shall 

2 be met by each individual who receives training or assist3 ance described in paragraph (1) or (2) of subsection (b) 

4 that is funded by a grant provided under subsection (a). 

5 Such obligation shall be met by service— 

6 ‘‘(1) in the Service; 

7 ‘‘(2) in a program of an Indian Tribe or Tribal 

8 Organization conducted under the Indian Self-Deter9 mination and Education Assistance Act (25 U.S.C. 

10 450 et seq.) (including programs under agreements 

11 with the Bureau of Indian Affairs); 

12 ‘‘(3) in a program assisted under title V of this 

13 Act; 

14 ‘‘(4) in the private practice of nursing if, as de15 termined by the Secretary, in accordance with guide16 lines promulgated by the Secretary, such practice is 

17 situated in a physician or other health shortage area 

18 and addresses the health care needs of a substantial 

19 number of Indians; or 

20 ‘‘(5) in a teaching capacity in a tribal college or 

21 university nursing program (or a related health pro22 fession program) if, as determined by the Secretary, 

23 health services provided to Indians would not de24 crease. 


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1 ‘‘SEC. 116. TRIBAL CULTURAL ORIENTATION. 

2 ‘‘(a) CULTURAL EDUCATION OF EMPLOYEES.—The 

3 Secretary, acting through the Service, shall require that 

4 appropriate employees of the Service who serve Indian 

5 Tribes in each Service Area receive educational instruction 

6 in the history and culture of such Indian Tribes and their 

7 relationship to the Service. 

8 ‘‘(b) PROGRAM.—In carrying out subsection (a), the 

9 Secretary shall establish a program which shall, to the ex10 tent feasible— 

11 ‘‘(1) be developed in consultation with the af12 fected Indian Tribes, Tribal Organizations, and 

13 urban Indian organizations; 

14 ‘‘(2) be carried out through tribal colleges or 

15 universities; 

16 ‘‘(3) include instruction in American Indian 

17 studies; and 

18 ‘‘(4) describe the use and place of traditional 

19 health care practices of the Indian Tribes in the 

20 Service Area. 

21 ‘‘SEC. 117. INMED PROGRAM. 

22 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

23 through the Service, is authorized to provide grants to col24 leges and universities for the purpose of maintaining and 

25 expanding the Indian health careers recruitment program 

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1 after in this section referred to as ‘INMED’) as a means 

2 of encouraging Indians to enter the health professions. 

3 ‘‘(b) QUENTIN N. BURDICK GRANT.—The Secretary 

4 shall provide 1 of the grants authorized under subsection 

5 (a) to maintain the INMED program at the University 

6 of North Dakota, to be known as the ‘Quentin N. Burdick 

7 Indian Health Programs’, unless the Secretary makes a 

8 determination, based upon program reviews, that the pro9 gram is not meeting the purposes of this section. Such 

10 program shall, to the maximum extent feasible, coordinate 

11 with the Quentin N. Burdick American Indians Into Psy12 chology Program established under section 105(b) and the 

13 Quentin N. Burdick American Indians Into Nursing Pro14 gram established under section 115. 

15 ‘‘(c) REGULATIONS.—The Secretary, pursuant to this 

16 Act, shall develop regulations to govern grants pursuant 

17 to this section. 

18 ‘‘(d) REQUIREMENTS.—Applicants for grants pro19 vided under this section shall agree to provide a program 

20 which— 

21 ‘‘(1) provides outreach and recruitment for 

22 health professions to Indian communities including 

23 elementary and secondary schools and community 

24 colleges located on reservations which will be served 

25 by the program; 


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1 ‘‘(2) incorporates a program advisory board 

2 comprised of representatives from the Indian Tribes 

3 and Indian communities which will be served by the 

4 program; 

5 ‘‘(3) provides summer preparatory programs for 

6 Indian students who need enrichment in the subjects 

7 of math and science in order to pursue training in 

8 the health professions; 

9 ‘‘(4) provides tutoring, counseling, and support 

10 to students who are enrolled in a health career pro11 gram of study at the respective college or university; 

12 and 

13 ‘‘(5) to the maximum extent feasible, employs 

14 qualified Indians in the program. 

15 ‘‘SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY 

16 COLLEGES. 

17 ‘‘(a) GRANTS TO ESTABLISH PROGRAMS.— 

18 ‘‘(1) IN GENERAL.—The Secretary, acting 

19 through the Service, shall award grants to accredited 

20 and accessible community colleges for the purpose of 

21 assisting such community colleges in the establish22 ment of programs which provide education in a 

23 health profession leading to a degree or diploma in 

24 a health profession for individuals who desire to 


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1 practice such profession on or near a reservation or 

2 in an Indian Health Program. 

3 ‘‘(2) AMOUNT OF GRANTS.—The amount of any 

4 grant awarded to a community college under para5 graph (1) for the first year in which such a grant 

6 is provided to the community college shall not exceed 

7 $250,000. 

8 ‘‘(b) GRANTS FOR MAINTENANCE AND RECRUIT9 ING.— 

10 ‘‘(1) IN GENERAL.—The Secretary, acting 

11 through the Service, shall award grants to accredited 

12 and accessible community colleges that have estab13 lished a program described in subsection (a)(1) for 

14 the purpose of maintaining the program and recruit15 ing students for the program. 

16 ‘‘(2) REQUIREMENTS.—Grants may only be 

17 made under this section to a community college 

18 which— 

19 ‘‘(A) is accredited; 

20 ‘‘(B) has a relationship with a hospital fa21 cility, Service facility, or hospital that could 

22 provide training of nurses or health profes23 sionals; 


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1 ‘‘(C) has entered into an agreement with 

2 an accredited college or university medical 

3 school, the terms of which— 

4 ‘‘(i) provide a program that enhances 

5 the transition and recruitment of students 

6 into advanced baccalaureate or graduate 

7 programs that train health professionals; 

8 and 

9 ‘‘(ii) stipulate certifications necessary 

10 to approve internship and field placement 

11 opportunities at Indian Health Programs; 

12 ‘‘(D) has a qualified staff which has the 

13 appropriate certifications; 

14 ‘‘(E) is capable of obtaining State or re15 gional accreditation of the program described in 

16 subsection (a)(1); and 

17 ‘‘(F) agrees to provide for Indian pref18 erence for applicants for programs under this 

19 section. 

20 ‘‘(c) TECHNICAL ASSISTANCE.—The Secretary shall 

21 encourage community colleges described in subsection 

22 (b)(2) to establish and maintain programs described in 

23 subsection (a)(1) by— 

24 ‘‘(1) entering into agreements with such col25 leges for the provision of qualified personnel of the 


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1 Service to teach courses of study in such programs; 

2 and 

3 ‘‘(2) providing technical assistance and support 

4 to such colleges. 

5 ‘‘(d) ADVANCED TRAINING.— 

6 ‘‘(1) REQUIRED.—Any program receiving as7 sistance under this section that is conducted with re8 spect to a health profession shall also offer courses 

9 of study which provide advanced training for any 

10 health professional who— 

11 ‘‘(A) has already received a degree or di12 ploma in such health profession; and 

13 ‘‘(B) provides clinical services on or near a 

14 reservation or for an Indian Health Program. 

15 ‘‘(2) MAY BE OFFERED AT ALTERNATE SITE.— 

16 Such courses of study may be offered in conjunction 

17 with the college or university with which the commu18 nity college has entered into the agreement required 

19 under subsection (b)(2)(C). 

20 ‘‘(e) PRIORITY.—Where the requirements of sub21 section (b) are met, grant award priority shall be provided 

22 to tribal colleges and universities in Service Areas where 

23 they exist. 


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1 ‘‘SEC. 119. RETENTION BONUS. 

2 ‘‘(a) BONUS AUTHORIZED.—The Secretary may pay 

3 a retention bonus to any health professional employed by, 

4 or assigned to, and serving in, an Indian Health Program 

5 or urban Indian organization either as a civilian employee 

6 or as a commissioned officer in the Regular or Reserve 

7 Corps of the Public Health Service who— 

8 ‘‘(1) is assigned to, and serving in, a position 

9 for which recruitment or retention of personnel is 

10 difficult; 

11 ‘‘(2) the Secretary determines is needed by In12 dian Health Programs and urban Indian organiza13 tions; 

14 ‘‘(3) has— 

15 ‘‘(A) completed 2 years of employment 

16 with an Indian Health Program or urban In17 dian organization; or 

18 ‘‘(B) completed any service obligations in19 curred as a requirement of— 

20 ‘‘(i) any Federal scholarship program; 

21 or 

22 ‘‘(ii) any Federal education loan re23 payment program; and 

24 ‘‘(4) enters into an agreement with an Indian 

25 Health Program or urban Indian organization for 


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1 continued employment for a period of not less than 

2 1 year. 

3 ‘‘(b) RATES.—The Secretary may establish rates for 

4 the retention bonus which shall provide for a higher an5 nual rate for multiyear agreements than for single year 

6 agreements referred to in subsection (a)(4), but in no 

7 event shall the annual rate be more than $25,000 per 

8 annum. 

9 ‘‘(c) DEFAULT OF RETENTION AGREEMENT.—Any 

10 health professional failing to complete the agreed upon 

11 term of service, except where such failure is through no 

12 fault of the individual, shall be obligated to refund to the 

13 Government the full amount of the retention bonus for the 

14 period covered by the agreement, plus interest as deter15 mined by the Secretary in accordance with section 

16 110(l)(2)(B). 

17 ‘‘(d) OTHER RETENTION BONUS.—The Secretary 

18 may pay a retention bonus to any health professional em19 ployed by a Tribal Health Program if such health profes20 sional is serving in a position which the Secretary deter21 mines is— 

22 ‘‘(1) a position for which recruitment or reten23 tion is difficult; and 

24 ‘‘(2) necessary for providing health care services 

25 to Indians. 


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1 ‘‘SEC. 120. NURSING RESIDENCY PROGRAM. 

2 ‘‘(a) ESTABLISHMENT OF PROGRAM.—The Sec3 retary, acting through the Service, shall establish a pro4 gram to enable Indians who are licensed practical nurses, 

5 licensed vocational nurses, and registered nurses who are 

6 working in an Indian Health Program or urban Indian 

7 organization, and have done so for a period of not less 

8 than 1 year, to pursue advanced training. Such program 

9 shall include a combination of education and work study 

10 in an Indian Health Program or urban Indian organiza11 tion leading to an associate or bachelor’s degree (in the 

12 case of a licensed practical nurse or licensed vocational 

13 nurse), a bachelor’s degree (in the case of a registered 

14 nurse), or advanced degrees or certifications in nursing 

15 and public health. 

16 ‘‘(b) SERVICE OBLIGATION.—An individual who par17 ticipates in a program under subsection (a), where the 

18 educational costs are paid by the Service, shall incur an 

19 obligation to serve in an Indian Health Program or urban 

20 Indian organization for a period of obligated service equal 

21 to 1 year for every year that nonprofessional employee (li22 censed practical nurses, licensed vocational nurses, nurs23 ing assistants, and various health care technicians), or 2 

24 years for every year that professional nurse (associate de25 gree and bachelor-prepared registered nurses), partici26 pates in such program. In the event that the individual 


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1 fails to complete such obligated service, the United States 

2 shall be entitled to recover from such individual an amount 

3 determined in accordance with the formula specified sub4 section (d)(1) of Section 104 for individuals failing to 

5 graduate from their degree program and subsection (l) of 

6 Section 110 for individuals failing to start or complete the 

7 obligated service. 

8 ‘‘SEC. 121. COMMUNITY HEALTH AIDE PROGRAM. 

9 ‘‘(a) GENERAL PURPOSES OF PROGRAM.—Under the 

10 authority of the Act of November 2, 1921 (25 U.S.C. 13) 

11 (commonly known as the ‘Snyder Act’), the Secretary, act12 ing through the Service, shall develop and operate a Com13 munity Health Aide Program in Alaska under which the 

14 Service— 

15 ‘‘(1) provides for the training of Alaska Natives 

16 as health aides or community health practitioners; 

17 ‘‘(2) uses such aides or practitioners in the pro18 vision of health care, health promotion, and disease 

19 prevention services to Alaska Natives living in vil20 lages in rural Alaska; and 

21 ‘‘(3) provides for the establishment of tele22 conferencing capacity in health clinics located in or 

23 near such villages for use by community health aides 

24 or community health practitioners. 


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1 ‘‘(b) SPECIFIC PROGRAM REQUIREMENTS.—The Sec2 retary, acting through the Community Health Aide Pro3 gram of the Service, shall— 

4 ‘‘(1) using trainers accredited by the Program, 

5 provide a high standard of training to community 

6 health aides and community health practitioners to 

7 ensure that such aides and practitioners provide 

8 quality health care, health promotion, and disease 

9 prevention services to the villages served by the Pro10 gram; 

11 ‘‘(2) in order to provide such training, develop 

12 a curriculum that— 

13 ‘‘(A) combines education in the theory of 

14 health care with supervised practical experience 

15 in the provision of health care; 

16 ‘‘(B) provides instruction and practical ex17 perience in the provision of acute care, emer18 gency care, health promotion, disease preven19 tion, and the efficient and effective manage20 ment of clinic pharmacies, supplies, equipment, 

21 and facilities; and 

22 ‘‘(C) promotes the achievement of the 

23 health status objectives specified in section 

24 3(2); 


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1 ‘‘(3) establish and maintain a Community 

2 Health Aide Certification Board to certify as com3 munity health aides or community health practi4 tioners individuals who have successfully completed 

5 the training described in paragraph (1) or can dem6 onstrate equivalent experience; 

7 ‘‘(4) develop and maintain a system which iden8 tifies the needs of community health aides and com9 munity health practitioners for continuing education 

10 in the provision of health care, including the areas 

11 described in paragraph (2)(B), and develop pro12 grams that meet the needs for such continuing edu13 cation; 

14 ‘‘(5) develop and maintain a system that pro15 vides close supervision of community health aides 

16 and community health practitioners; 

17 ‘‘(6) develop a system under which the work of 

18 community health aides and community health prac19 titioners is reviewed and evaluated to assure the pro20 vision of quality health care, health promotion, and 

21 disease prevention services; and 

22 ‘‘(7) ensure that pulpal therapy (not including 

23 pulpotomies on deciduous teeth) or extraction of 

24 adult teeth can be performed by a dental health aide 

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1 tist who determines that the procedure is a medical 

2 emergency that cannot be resolved with palliative 

3 treatment, and further that dental health aide thera4 pists are strictly prohibited from performing all 

5 other oral or jaw surgeries, provided that uncompli6 cated extractions shall not be considered oral sur7 gery under this section. 

8 ‘‘(c) PROGRAM REVIEW.— 

9 ‘‘(1) NEUTRAL PANEL.— 

10 ‘‘(A) ESTABLISHMENT.—The Secretary, 

11 acting through the Service, shall establish a 

12 neutral panel to carry out the study under 

13 paragraph (2). 

14 ‘‘(B) MEMBERSHIP.—Members of the neu15 tral panel shall be appointed by the Secretary 

16 from among clinicians, economists, community 

17 practitioners, oral epidemiologists, and Alaska 

18 Natives. 

19 ‘‘(2) STUDY.— 

20 ‘‘(A) IN GENERAL.—The neutral panel es21 tablished under paragraph (1) shall conduct a 

22 study of the dental health aide therapist serv23 ices provided by the Community Health Aide 

24 Program under this section to ensure that the 


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1 quality of care provided through those services 

2 is adequate and appropriate. 

3 ‘‘(B) PARAMETERS OF STUDY.—The Sec4 retary, in consultation with interested parties, 

5 including professional dental organizations, 

6 shall develop the parameters of the study. 

7 ‘‘(C) INCLUSIONS.—The study shall in8 clude a determination by the neutral panel with 

9 respect to— 

10 ‘‘(i) the ability of the dental health 

11 aide therapist services under this section to 

12 address the dental care needs of Alaska 

13 Natives; 

14 ‘‘(ii) the quality of care provided 

15 through those services, including any train16 ing, improvement, or additional oversight 

17 required to improve the quality of care; 

18 and 

19 ‘‘(iii) whether safer and less costly al20 ternatives to the dental health aide thera21 pist services exist. 

22 ‘‘(D) CONSULTATION.—In carrying out the 

23 study under this paragraph, the neutral panel 

24 shall consult with Alaska Tribal Organizations 


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1 with respect to the adequacy and accuracy of 

2 the study. 

3 ‘‘(3) REPORT.—The neutral panel shall submit 

4 to the Secretary, the Committee on Indian Affairs of 

5 the Senate, and the Committee on Natural Re6 sources of the House of Representatives a report de7 scribing the results of the study under paragraph 

8 (2), including a description of— 

9 ‘‘(A) any determination of the neutral 

10 panel under paragraph (2)(C); and 

11 ‘‘(B) any comments received from an Alas12 ka Tribal Organization under paragraph 

13 (2)(D). 

14 ‘‘(d) NATIONALIZATION OF PROGRAM.— 

15 ‘‘(1) IN GENERAL.—Except as provided in para16 graph (2), the Secretary, acting through the Service, 

17 may establish a national Community Health Aide 

18 Program in accordance with the program under this 

19 section, as the Secretary determines to be appro20 priate. 

21 ‘‘(2) EXCEPTION.—The national Community 

22 Health Aide Program under paragraph (1) shall not 

23 include dental health aide therapist services. 

24 ‘‘(3) REQUIREMENT.—In establishing a na25 tional program under paragraph (1), the Secretary 


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1 shall not reduce the amount of funds provided for 

2 the Community Health Aide Program described in 

3 subsections (a) and (b). 

4 ‘‘SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION. 

5 ‘‘The Secretary shall, by contract or otherwise, pro6 vide training for individuals in the administration and 

7 planning of Tribal Health Programs, with priority to Indi8 ans. 

9 ‘‘SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE 

10 DEMONSTRATION PROGRAMS. 

11 ‘‘(a) DEMONSTRATION PROGRAMS AUTHORIZED.— 

12 The Secretary, acting through the Service, may fund dem13 onstration programs for Tribal Health Programs to ad14 dress the chronic shortages of health professionals. 

15 ‘‘(b) PURPOSES OF PROGRAMS.—The purposes of 

16 demonstration programs funded under subsection (a) shall 

17 be— 

18 ‘‘(1) to provide direct clinical and practical ex19 perience at a Service Unit to health profession stu20 dents and residents from medical schools; 

21 ‘‘(2) to improve the quality of health care for 

22 Indians by assuring access to qualified health care 

23 professionals; and 

24 ‘‘(3) to provide academic and scholarly opportu25 nities for health professionals serving Indians by 


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1 identifying all academic and scholarly resources of 

2 the region. 

3 ‘‘(c) ADVISORY BOARD.—The demonstration pro4 grams established pursuant to subsection (a) shall incor5 porate a program advisory board composed of representa6 tives from the Indian Tribes and Indian communities in 

7 the area which will be served by the program. 

8 ‘‘SEC. 124. NATIONAL HEALTH SERVICE CORPS. 

9 ‘‘(a) NO REDUCTION IN SERVICES.—The Secretary 

10 shall not— 

11 ‘‘(1) remove a member of the National Health 

12 Service Corps from an Indian Health Program or 

13 urban Indian organization; or 

14 ‘‘(2) withdraw funding used to support such 

15 member, unless the Secretary, acting through the 

16 Service, has ensured that the Indians receiving serv17 ices from such member will experience no reduction 

18 in services. 

19 ‘‘(b) TREATMENT OF INDIAN HEALTH PROGRAMS.— 

20 At the request of an Indian Health Program, the services 

21 of a member of the National Health Service Corps as22 signed to an Indian Health Program may be limited to 

23 the persons who are eligible for services from such Pro24 gram. 


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1 ‘‘SEC. 125. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL 

2 CURRICULA DEMONSTRATION PROGRAMS. 

3 ‘‘(a) CONTRACTS AND GRANTS.—The Secretary, act4 ing through the Service, may enter into contracts with, 

5 or make grants to, accredited tribal colleges and univer6 sities and eligible accredited and accessible community col7 leges to establish demonstration programs to develop edu8 cational curricula for substance abuse counseling. 

9 ‘‘(b) USE OF FUNDS.—Funds provided under this 

10 section shall be used only for developing and providing 

11 educational curriculum for substance abuse counseling (in12 cluding paying salaries for instructors). Such curricula 

13 may be provided through satellite campus programs. 

14 ‘‘(c) TIME PERIOD OF ASSISTANCE; RENEWAL.—A 

15 contract entered into or a grant provided under this sec16 tion shall be for a period of 3 years. Such contract or 

17 grant may be renewed for an additional 2-year period 

18 upon the approval of the Secretary. 

19 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP20 PLICATIONS.—Not later than 180 days after the date of 

21 enactment of the Indian Health Care Improvement Act 

22 Amendments of 2009, the Secretary, after consultation 

23 with Indian Tribes and administrators of tribal colleges 

24 and universities and eligible accredited and accessible com25 munity colleges, shall develop and issue criteria for the 

26 review and approval of applications for funding (including 


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1 applications for renewals of funding) under this section. 

2 Such criteria shall ensure that demonstration programs 

3 established under this section promote the development of 

4 the capacity of such entities to educate substance abuse 

5 counselors. 

6 ‘‘(e) ASSISTANCE.—The Secretary shall provide such 

7 technical and other assistance as may be necessary to en8 able grant recipients to comply with the provisions of this 

9 section. 

10 ‘‘(f) REPORT.—Each fiscal year, the Secretary shall 

11 submit to the President, for inclusion in the report which 

12 is required to be submitted under section 801 for that fis13 cal year, a report on the findings and conclusions derived 

14 from the demonstration programs conducted under this 

15 section during that fiscal year. 

16 ‘‘(g) DEFINITION.—For the purposes of this section, 

17 the term ‘educational curriculum’ means 1 or more of the 

18 following: 

19 ‘‘(1) Classroom education. 

20 ‘‘(2) Clinical work experience. 

21 ‘‘(3) Continuing education workshops. 

22 ‘‘SEC. 126. BEHAVIORAL HEALTH TRAINING AND COMMU23 NITY EDUCATION PROGRAMS. 

24 ‘‘(a) STUDY; LIST.—The Secretary, acting through 

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1 tion with Indian Tribes and Tribal Organizations, shall 

2 conduct a study and compile a list of the types of staff 

3 positions specified in subsection (b) whose qualifications 

4 include, or should include, training in the identification, 

5 prevention, education, referral, or treatment of mental ill6 ness, or dysfunctional and self-destructive behavior. 

7 ‘‘(b) POSITIONS.—The positions referred to in sub8 section (a) are— 

9 ‘‘(1) staff positions within the Bureau of Indian 

10 Affairs, including existing positions, in the fields 

11 of— 

12 ‘‘(A) elementary and secondary education; 

13 ‘‘(B) social services and family and child 

14 welfare; 

15 ‘‘(C) law enforcement and judicial services; 

16 and 

17 ‘‘(D) alcohol and substance abuse; 

18 ‘‘(2) staff positions within the Service; and 

19 ‘‘(3) staff positions similar to those identified in 

20 paragraphs (1) and (2) established and maintained 

21 by Indian Tribes, Tribal Organizations (without re22 gard to the funding source), and urban Indian orga23 nizations. 

24 ‘‘(c) TRAINING CRITERIA.— 


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1 ‘‘(1) IN GENERAL.—The appropriate Secretary 

2 shall provide training criteria appropriate to each 

3 type of position identified in subsection (b)(1) and 

4 (b)(2) and ensure that appropriate training has 

5 been, or shall be provided to any individual in any 

6 such position. With respect to any such individual in 

7 a position identified pursuant to subsection (b)(3), 

8 the respective Secretaries shall provide appropriate 

9 training to, or provide funds to, an Indian Tribe, 

10 Tribal Organization, or urban Indian organization 

11 for training of appropriate individuals. In the case of 

12 positions funded under a contract or compact under 

13 the Indian Self-Determination and Education Assist14 ance Act (25 U.S.C. 450 et seq.), the appropriate 

15 Secretary shall ensure that such training costs are 

16 included in the contract or compact, as the Sec17 retary determines necessary. 

18 ‘‘(2) POSITION SPECIFIC TRAINING CRITERIA.— 

19 Position specific training criteria shall be culturally 

20 relevant to Indians and Indian Tribes and shall en21 sure that appropriate information regarding tradi22 tional health care practices is provided. 

23 ‘‘(d) COMMUNITY EDUCATION ON MENTAL ILL24 NESS.—The Service shall develop and implement, on re25 quest of an Indian Tribe, Tribal Organization, or urban 


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1 Indian organization, or assist the Indian Tribe, Tribal Or2 ganization, or urban Indian organization to develop and 

3 implement, a program of community education on mental 

4 illness. In carrying out this subsection, the Service shall, 

5 upon request of an Indian Tribe, Tribal Organization, or 

6 urban Indian organization, provide technical assistance to 

7 the Indian Tribe, Tribal Organization, or urban Indian or8 ganization to obtain and develop community educational 

9 materials on the identification, prevention, referral, and 

10 treatment of mental illness and dysfunctional and self-de11 structive behavior. 

12 ‘‘(e) PLAN.—Not later than 90 days after the date 

13 of enactment of the Indian Health Care Improvement Act 

14 Amendments of 2009, the Secretary shall develop a plan 

15 under which the Service will increase the health care staff 

16 providing behavioral health services by at least 500 posi17 tions within 5 years after the date of enactment of this 

18 section, with at least 200 of such positions devoted to 

19 child, adolescent, and family services. The plan developed 

20 under this subsection shall be implemented under the Act 

21 of November 2, 1921 (25 U.S.C. 13) (commonly known 

22 as the ‘Snyder Act’). 

23 ‘‘SEC. 127. EXEMPTION FROM PAYMENT OF CERTAIN FEES. 

24 ‘‘Employees of a Tribal Health Program or an Urban 

25 Indian Organization shall be exempt from payment of liVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01723 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 censing, registration, and other fees imposed by a Federal 

2 agency to the same extent that Commissioned Corps Offi3 cers or other employees of the Indian Health Service are 

4 exempt from such fees. 

5 ‘‘SEC. 128. AUTHORIZATION OF APPROPRIATIONS. 

6 ‘‘There are authorized to be appropriated such sums 

7 as may be necessary to carry out this title. 

8 ‘‘TITLE II—HEALTH SERVICES 

9 ‘‘SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND. 

10 ‘‘(a) USE OF FUNDS.—The Secretary, acting through 

11 the Service, is authorized to expend funds, directly or 

12 under the authority of the Indian Self-Determination and 

13 Education Assistance Act (25 U.S.C. 450 et seq.), which 

14 are appropriated under the authority of this section, for 

15 the purposes of— 

16 ‘‘(1) eliminating the deficiencies in health sta17 tus and health resources of all Indian Tribes; 

18 ‘‘(2) eliminating backlogs in the provision of 

19 health care services to Indians; 

20 ‘‘(3) meeting the health needs of Indians in an 

21 efficient and equitable manner, including the use of 

22 telehealth and telemedicine when appropriate; 

23 ‘‘(4) eliminating inequities in funding for both 

24 direct care and contract health service programs; 

25 and 


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1 ‘‘(5) augmenting the ability of the Service to 

2 meet the following health service responsibilities with 

3 respect to those Indian Tribes with the highest levels 

4 of health status deficiencies and resource defi5 ciencies: 

6 ‘‘(A) Clinical care, including inpatient care, 

7 outpatient care (including audiology, clinical 

8 eye, and vision care), primary care, secondary 

9 and tertiary care, and long-term care. 

10 ‘‘(B) Preventive health, including mam11 mography and other cancer screening in accord12 ance with section 207. 

13 ‘‘(C) Dental care. 

14 ‘‘(D) Mental health, including community 

15 mental health services, inpatient mental health 

16 services, dormitory mental health services, 

17 therapeutic and residential treatment centers, 

18 and training of traditional health care practi19 tioners. 

20 ‘‘(E) Emergency medical services. 

21 ‘‘(F) Treatment and control of, and reha22 bilitative care related to, alcoholism and drug 

23 abuse (including fetal alcohol syndrome) among 

24 Indians. 


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1 ‘‘(G) Injury prevention programs, includ2 ing data collection and evaluation, demonstra3 tion projects, training, and capacity building. 

4 ‘‘(H) Home health care. 

5 ‘‘(I) Community health representatives. 

6 ‘‘(J) Maintenance and improvement. 

7 ‘‘(b) NO OFFSET OR LIMITATION.—Any funds appro8 priated under the authority of this section shall not be 

9 used to offset or limit any other appropriations made to 

10 the Service under this Act or the Act of November 2, 1921 

11 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), 

12 or any other provision of law. 

13 ‘‘(c) ALLOCATION; USE.— 

14 ‘‘(1) IN GENERAL.—Funds appropriated under 

15 the authority of this section shall be allocated to 

16 Service Units, Indian Tribes, or Tribal Organiza17 tions. The funds allocated to each Indian Tribe, 

18 Tribal Organization, or Service Unit under this 

19 paragraph shall be used by the Indian Tribe, Tribal 

20 Organization, or Service Unit under this paragraph 

21 to improve the health status and reduce the resource 

22 deficiency of each Indian Tribe served by such Serv23 ice Unit, Indian Tribe, or Tribal Organization. 

24 ‘‘(2) APPORTIONMENT OF ALLOCATED

25 FUNDS.—The apportionment of funds allocated to a 


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1 Service Unit, Indian Tribe, or Tribal Organization 

2 under paragraph (1) among the health service re3 sponsibilities described in subsection (a)(5) shall be 

4 determined by the Service in consultation with, and 

5 with the active participation of, the affected Indian 

6 Tribes and Tribal Organizations. 

7 ‘‘(d) PROVISIONS RELATING TO HEALTH STATUS

8 AND RESOURCE DEFICIENCIES.—For the purposes of this 

9 section, the following definitions apply: 

10 ‘‘(1) DEFINITION.—The term ‘health status 

11 and resource deficiency’ means the extent to 

12 which— 

13 ‘‘(A) the health status objectives set forth 

14 in section 3(2) are not being achieved; and 

15 ‘‘(B) the Indian Tribe or Tribal Organiza16 tion does not have available to it the health re17 sources it needs, taking into account the actual 

18 cost of providing health care services given local 

19 geographic, climatic, rural, or other cir20 cumstances. 

21 ‘‘(2) AVAILABLE RESOURCES.—The health re22 sources available to an Indian Tribe or Tribal Orga23 nization include health resources provided by the 

24 Service as well as health resources used by the In25 dian Tribe or Tribal Organization, including services 


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1 and financing systems provided by any Federal pro2 grams, private insurance, and programs of State or 

3 local governments. 

4 ‘‘(3) PROCESS FOR REVIEW OF DETERMINA5 TIONS.—The Secretary shall establish procedures 

6 which allow any Indian Tribe or Tribal Organization 

7 to petition the Secretary for a review of any deter8 mination of the extent of the health status and re9 source deficiency of such Indian Tribe or Tribal Or10 ganization. 

11 ‘‘(e) ELIGIBILITY FOR FUNDS.—Tribal Health Pro12 grams shall be eligible for funds appropriated under the 

13 authority of this section on an equal basis with programs 

14 that are administered directly by the Service. 

15 ‘‘(f) REPORT.—By no later than the date that is 3 

16 years after the date of enactment of the Indian Health 

17 Care Improvement Act Amendments of 2009, the Sec18 retary shall submit to Congress the current health status 

19 and resource deficiency report of the Service for each 

20 Service Unit, including newly recognized or acknowledged 

21 Indian Tribes. Such report shall set out— 

22 ‘‘(1) the methodology then in use by the Service 

23 for determining Tribal health status and resource 

24 deficiencies, as well as the most recent application of 

25 that methodology; 


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1 ‘‘(2) the extent of the health status and re2 source deficiency of each Indian Tribe served by the 

3 Service or a Tribal Health Program; 

4 ‘‘(3) the amount of funds necessary to eliminate 

5 the health status and resource deficiencies of all In6 dian Tribes served by the Service or a Tribal Health 

7 Program; and 

8 ‘‘(4) an estimate of— 

9 ‘‘(A) the amount of health service funds 

10 appropriated under the authority of this Act, or 

11 any other Act, including the amount of any 

12 funds transferred to the Service for the pre13 ceding fiscal year which is allocated to each 

14 Service Unit, Indian Tribe, or Tribal Organiza15 tion; 

16 ‘‘(B) the number of Indians eligible for 

17 health services in each Service Unit or Indian 

18 Tribe or Tribal Organization; and 

19 ‘‘(C) the number of Indians using the 

20 Service resources made available to each Service 

21 Unit, Indian Tribe or Tribal Organization, and, 

22 to the extent available, information on the wait23 ing lists and number of Indians turned away for 

24 services due to lack of resources. 


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1 ‘‘(g) INCLUSION IN BASE BUDGET.—Funds appro2 priated under this section for any fiscal year shall be in3 cluded in the base budget of the Service for the purpose 

4 of determining appropriations under this section in subse5 quent fiscal years. 

6 ‘‘(h) CLARIFICATION.—Nothing in this section is in7 tended to diminish the primary responsibility of the Serv8 ice to eliminate existing backlogs in unmet health care 

9 needs, nor are the provisions of this section intended to 

10 discourage the Service from undertaking additional efforts 

11 to achieve equity among Indian Tribes and Tribal Organi12 zations. 

13 ‘‘(i) FUNDING DESIGNATION.—Any funds appro14 priated under the authority of this section shall be des15 ignated as the ‘Indian Health Care Improvement Fund’. 

16 ‘‘SEC. 202. HEALTH PROMOTION AND DISEASE PREVENTION 

17 SERVICES. 

18 ‘‘(a) FINDINGS.—Congress finds that health pro19 motion and disease prevention activities— 

20 ‘‘(1) improve the health and well-being of Indi21 ans; and 

22 ‘‘(2) reduce the expenses for health care of In23 dians. 

24 ‘‘(b) PROVISION OF SERVICES.—The Secretary, act25 ing through the Service, shall provide health promotion 


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1 and disease prevention services to Indians to achieve the 

2 health status objectives set forth in section 3(2). 

3 ‘‘(c) EVALUATION.—The Secretary, after obtaining 

4 input from the affected Tribal Health Programs, shall 

5 submit to the President for inclusion in the report which 

6 is required to be submitted to Congress under section 801 

7 an evaluation of— 

8 ‘‘(1) the health promotion and disease preven9 tion needs of Indians; 

10 ‘‘(2) the health promotion and disease preven11 tion activities which would best meet such needs; 

12 ‘‘(3) the internal capacity of the Service and 

13 Tribal Health Programs to meet such needs; and 

14 ‘‘(4) the resources which would be required to 

15 enable the Service and Tribal Health Programs to 

16 undertake the health promotion and disease preven17 tion activities necessary to meet such needs. 

18 ‘‘SEC. 203. DIABETES PREVENTION, TREATMENT, AND CON19 TROL. 

20 ‘‘(a) DETERMINATIONS REGARDING DIABETES.— 

21 The Secretary, acting through the Service, and in con22 sultation with Indian Tribes and Tribal Organizations, 

23 shall determine— 


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1 ‘‘(1) by Indian Tribe and by Service Unit, the 

2 incidence of, and the types of complications resulting 

3 from, diabetes among Indians; and 

4 ‘‘(2) based on the determinations made pursu5 ant to paragraph (1), the measures (including pa6 tient education and effective ongoing monitoring of 

7 disease indicators) each Service Unit should take to 

8 reduce the incidence of, and prevent, treat, and con9 trol the complications resulting from, diabetes 

10 among Indian Tribes within that Service Unit. 

11 ‘‘(b) DIABETES SCREENING.—To the extent medi12 cally indicated and with informed consent, the Secretary 

13 shall screen each Indian who receives services from the 

14 Service for diabetes and for conditions which indicate a 

15 high risk that the individual will become diabetic and es16 tablish a cost-effective approach to ensure ongoing moni17 toring of disease indicators. Such screening and moni18 toring may be conducted by a Tribal Health Program and 

19 may be conducted through appropriate Internet-based 

20 health care management programs. 

21 ‘‘(c) DIABETES PROJECTS.—The Secretary shall con22 tinue to maintain each model diabetes project in existence 

23 on the date of enactment of the Indian Health Care Im24 provement Act Amendments of 2009. 


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1 ‘‘(d) DIALYSIS PROGRAMS.—The Secretary is author2 ized to provide, through the Service, Indian Tribes, and 

3 Tribal Organizations, dialysis programs, including the 

4 purchase of dialysis equipment and the provision of nec5 essary staffing. 

6 ‘‘(e) OTHER DUTIES OF THE SECRETARY.— 

7 ‘‘(1) IN GENERAL.—The Secretary shall, to the 

8 extent funding is available— 

9 ‘‘(A) in each Area Office, consult with In10 dian Tribes and Tribal Organizations regarding 

11 programs for the prevention, treatment, and 

12 control of diabetes; 

13 ‘‘(B) establish in each Area Office a reg14 istry of patients with diabetes to track the inci15 dence of diabetes and the complications from 

16 diabetes in that area; and 

17 ‘‘(C) ensure that data collected in each 

18 Area Office regarding diabetes and related com19 plications among Indians are disseminated to 

20 all other Area Offices, subject to applicable pa21 tient privacy laws. 

22 ‘‘(2) DIABETES CONTROL OFFICERS.— 

23 ‘‘(A) IN GENERAL.—The Secretary may es24 tablish and maintain in each Area Office a posi25 tion of diabetes control officer to coordinate and 


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1 manage any activity of that Area Office relating 

2 to the prevention, treatment, or control of dia3 betes to assist the Secretary in carrying out a 

4 program under this section or section 330C of 

5 the Public Health Service Act (42 U.S.C. 254c– 

6 3). 

7 ‘‘(B) CERTAIN ACTIVITIES.—Any activity 

8 carried out by a diabetes control officer under 

9 subparagraph (A) that is the subject of a con10 tract or compact under the Indian Self-Deter11 mination and Education Assistance Act (25 

12 U.S.C. 450 et seq.), and any funds made avail13 able to carry out such an activity, shall not be 

14 divisible for purposes of that Act. 

15 ‘‘SEC. 204. SHARED SERVICES FOR LONG-TERM CARE. 

16 ‘‘(a) LONG-TERM CARE.—Notwithstanding any other 

17 provision of law, the Secretary, acting through the Service, 

18 is authorized to provide directly, or enter into contracts 

19 or compacts under the Indian Self-Determination and 

20 Education Assistance Act (25 U.S.C. 450 et seq.) with 

21 Indian Tribes or Tribal Organizations for, the delivery of 

22 long-term care (including health care services associated 

23 with long-term care) provided in a facility to Indians. Such 

24 agreements shall provide for the sharing of staff or other 

25 services between the Service or a Tribal Health Program 


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1 and a long-term care or related facility owned and oper2 ated (directly or through a contract or compact under the 

3 Indian Self-Determination and Education Assistance Act 

4 (25 U.S.C. 450 et seq.)) by such Indian Tribe or Tribal 

5 Organization. 

6 ‘‘(b) CONTENTS OF AGREEMENTS.—An agreement 

7 entered into pursuant to subsection (a)— 

8 ‘‘(1) may, at the request of the Indian Tribe or 

9 Tribal Organization, delegate to such Indian Tribe 

10 or Tribal Organization such powers of supervision 

11 and control over Service employees as the Secretary 

12 deems necessary to carry out the purposes of this 

13 section; 

14 ‘‘(2) shall provide that expenses (including sala15 ries) relating to services that are shared between the 

16 Service and the Tribal Health Program be allocated 

17 proportionately between the Service and the Indian 

18 Tribe or Tribal Organization; and 

19 ‘‘(3) may authorize such Indian Tribe or Tribal 

20 Organization to construct, renovate, or expand a 

21 long-term care or other similar facility (including the 

22 construction of a facility attached to a Service facil23 ity). 

24 ‘‘(c) MINIMUM REQUIREMENT.—Any nursing facility 

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1 ments for nursing facilities under section 1919 of the So2 cial Security Act. 

3 ‘‘(d) OTHER ASSISTANCE.—The Secretary shall pro4 vide such technical and other assistance as may be nec5 essary to enable applicants to comply with the provisions 

6 of this section. 

7 ‘‘(e) USE OF EXISTING OR UNDERUSED FACILI8 TIES.—The Secretary shall encourage the use of existing 

9 facilities that are underused or allow the use of swing beds 

10 for long-term or similar care. 

11 ‘‘SEC. 205. HEALTH SERVICES RESEARCH. 

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

13 the Service, shall make funding available for research to 

14 further the performance of the health service responsibil15 ities of Indian Health Programs. 

16 ‘‘(b) COORDINATION OF RESOURCES AND ACTIVI17 TIES.—The Secretary shall also, to the maximum extent 

18 practicable, coordinate departmental research resources 

19 and activities to address relevant Indian Health Program 

20 research needs. 

21 ‘‘(c) AVAILABILITY.—Tribal Health Programs shall 

22 be given an equal opportunity to compete for, and receive, 

23 research funds under this section. 

24 ‘‘(d) USE OF FUNDS.—This funding may be used for 

25 both clinical and nonclinical research. 


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1 ‘‘(e) EVALUATION AND DISSEMINATION.—The Sec2 retary shall periodically— 

3 ‘‘(1) evaluate the impact of research conducted 

4 under this section; and 

5 ‘‘(2) disseminate to Tribal Health Programs in6 formation regarding that research as the Secretary 

7 determines to be appropriate. 

8 ‘‘SEC. 206. MAMMOGRAPHY AND OTHER CANCER SCREEN9 ING. 

10 ‘‘The Secretary, acting through the Service, shall pro11 vide for screening as follows: 

12 ‘‘(1) Screening mammography (as defined in 

13 section 1861(jj) of the Social Security Act) for In14 dian women at a frequency appropriate to such 

15 women under accepted and appropriate national 

16 standards, and under such terms and conditions as 

17 are consistent with standards established by the Sec18 retary to ensure the safety and accuracy of screen19 ing mammography under part B of title XVIII of 

20 such Act. 

21 ‘‘(2) Other cancer screening that receives an A 

22 or B rating as recommended by the United States 

23 Preventive Services Task Force established under 

24 section 915(a)(1) of the Public Health Service Act 

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1 sure that screening provided for under this para2 graph complies with the recommendations of the 

3 Task Force with respect to— 

4 ‘‘(A) frequency; 

5 ‘‘(B) the population to be served; 

6 ‘‘(C) the procedure or technology to be 

7 used; 

8 ‘‘(D) evidence of effectiveness; and 

9 ‘‘(E) other matters that the Secretary de10 termines appropriate. 

11 ‘‘SEC. 207. PATIENT TRAVEL COSTS. 

12 ‘‘(a) DEFINITION OF QUALIFIED ESCORT.—In this 

13 section, the term ‘qualified escort’ means— 

14 ‘‘(1) an adult escort (including a parent, guard15 ian, or other family member) who is required be16 cause of the physical or mental condition, or age, of 

17 the applicable patient; 

18 ‘‘(2) a health professional for the purpose of 

19 providing necessary medical care during travel by 

20 the applicable patient; or 

21 ‘‘(3) other escorts, as the Secretary or applica22 ble Indian Health Program determines to be appro23 priate. 

24 ‘‘(b) PROVISION OF FUNDS.—The Secretary, acting 

25 through the Service, is authorized to provide funds for the 


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1 following patient travel costs, including qualified escorts, 

2 associated with receiving health care services provided (ei3 ther through direct or contract care or through a contract 

4 or compact under the Indian Self-Determination and Edu5 cation Assistance Act (25 U.S.C. 450 et seq.)) under this 

6 Act— 

7 ‘‘(1) emergency air transportation and non8 emergency air transportation where ground trans9 portation is infeasible; 

10 ‘‘(2) transportation by private vehicle (where no 

11 other means of transportation is available), specially 

12 equipped vehicle, and ambulance; and 

13 ‘‘(3) transportation by such other means as 

14 may be available and required when air or motor ve15 hicle transportation is not available. 

16 ‘‘SEC. 208. EPIDEMIOLOGY CENTERS. 

17 ‘‘(a) ESTABLISHMENT OF CENTERS.—The Secretary 

18 shall establish an epidemiology center in each Service Area 

19 to carry out the functions described in subsection (b). Any 

20 new center established after the date of enactment of the 

21 Indian Health Care Improvement Act Amendments of 

22 2008 may be operated under a grant authorized by sub23 section (d), but funding under such a grant shall not be 

24 divisible. 


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1 ‘‘(b) FUNCTIONS OF CENTERS.—In consultation with 

2 and upon the request of Indian Tribes, Tribal Organiza3 tions, and Urban Indian communities, each Service Area 

4 epidemiology center established under this section shall, 

5 with respect to such Service Area— 

6 ‘‘(1) collect data relating to, and monitor 

7 progress made toward meeting, each of the health 

8 status objectives of the Service, the Indian Tribes, 

9 Tribal Organizations, and Urban Indian commu10 nities in the Service Area; 

11 ‘‘(2) evaluate existing delivery systems, data 

12 systems, and other systems that impact the improve13 ment of Indian health; 

14 ‘‘(3) assist Indian Tribes, Tribal Organizations, 

15 and Urban Indian Organizations in identifying their 

16 highest priority health status objectives and the 

17 services needed to achieve such objectives, based on 

18 epidemiological data; 

19 ‘‘(4) make recommendations for the targeting 

20 of services needed by the populations served; 

21 ‘‘(5) make recommendations to improve health 

22 care delivery systems for Indians and Urban Indi23 ans; 

24 ‘‘(6) provide requested technical assistance to 

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1 dian Organizations in the development of local 

2 health service priorities and incidence and prevalence 

3 rates of disease and other illness in the community; 

4 and 

5 ‘‘(7) provide disease surveillance and assist In6 dian Tribes, Tribal Organizations, and Urban Indian 

7 communities to promote public health. 

8 ‘‘(c) TECHNICAL ASSISTANCE.—The Director of the 

9 Centers for Disease Control and Prevention shall provide 

10 technical assistance to the centers in carrying out the re11 quirements of this section. 

12 ‘‘(d) GRANTS FOR STUDIES.— 

13 ‘‘(1) IN GENERAL.—The Secretary may make 

14 grants to Indian Tribes, Tribal Organizations, In15 dian organizations, and eligible intertribal consortia 

16 to conduct epidemiological studies of Indian commu17 nities. 

18 ‘‘(2) ELIGIBLE INTERTRIBAL CONSORTIA.—An 

19 intertribal consortium or Indian organization is eligi20 ble to receive a grant under this subsection if— 

21 ‘‘(A) the intertribal consortium is incor22 porated for the primary purpose of improving 

23 Indian health; and 

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1 dian communities in which the intertribal con2 sortium is located. 

3 ‘‘(3) APPLICATIONS.—An application for a 

4 grant under this subsection shall be submitted in 

5 such manner and at such time as the Secretary shall 

6 prescribe. 

7 ‘‘(4) REQUIREMENTS.—An applicant for a 

8 grant under this subsection shall— 

9 ‘‘(A) demonstrate the technical, adminis10 trative, and financial expertise necessary to 

11 carry out the functions described in paragraph 

12 (5); 

13 ‘‘(B) consult and cooperate with providers 

14 of related health and social services in order to 

15 avoid duplication of existing services; and 

16 ‘‘(C) demonstrate cooperation from Indian 

17 Tribes or Urban Indian Organizations in the 

18 area to be served. 

19 ‘‘(5) USE OF FUNDS.—A grant awarded under 

20 paragraph (1) may be used— 

21 ‘‘(A) to carry out the functions described 

22 in subsection (b); 

23 ‘‘(B) to provide information to and consult 

24 with tribal leaders, urban Indian community 


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1 leaders, and related health staff on health care 

2 and health service management issues; and 

3 ‘‘(C) in collaboration with Indian Tribes, 

4 Tribal Organizations, and urban Indian com5 munities, to provide the Service with informa6 tion regarding ways to improve the health sta7 tus of Indians. 

8 ‘‘(e) ACCESS TO INFORMATION.— 

9 ‘‘(1) An epidemiology center operated by a 

10 grantee pursuant to a grant awarded under sub11 section (d) shall be treated as a public health au12 thority for purposes of the Health Insurance Port13 ability and Accountability Act of 1996, as such enti14 ties are defined in part 164.501 of title 45, Code of 

15 Federal Regulations. 

16 ‘‘(2) The Secretary shall grant to such epidemi17 ology center access to use of the data, data sets, 

18 monitoring systems, delivery systems, and other pro19 tected health information in the possession of the 

20 Secretary. 

21 ‘‘(3) The activities of such an epidemiology cen22 ter shall be for the purposes of research and for pre23 venting and controlling disease, injury, or disability 

24 for purposes of the Health Insurance Portability and 

25 Accountability Act of 1996 (Public Law 104–191; 


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1 110 Stat. 2033), as such activities are described in 

2 part 164.512 of title 45, Code of Federal Regula3 tions (or a successor regulation). 

4 ‘‘(f) FUNDS NOT DIVISIBLE.—An epidemiology cen5 ter established under this section shall be subject to the 

6 provisions of the Indian Self-Determination and Edu7 cation Assistance Act (25 U.S.C. 450 et seq.), but the 

8 funds for such center shall not be divisible. 

9 ‘‘SEC. 209. COMPREHENSIVE SCHOOL HEALTH EDUCATION 

10 PROGRAMS. 

11 ‘‘(a) FUNDING FOR DEVELOPMENT OF PROGRAMS.— 

12 In addition to carrying out any other program for health 

13 promotion or disease prevention, the Secretary, acting 

14 through the Service, is authorized to award grants to In15 dian Tribes and Tribal Organizations to develop com16 prehensive school health education programs for children 

17 from pre-school through grade 12 in schools for the benefit 

18 of Indian children. 

19 ‘‘(b) USE OF GRANT FUNDS.—A grant awarded 

20 under this section may be used for purposes which may 

21 include, but are not limited to, the following: 

22 ‘‘(1) Developing health education materials both 

23 for regular school programs and afterschool pro24 grams. 


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1 ‘‘(2) Training teachers in comprehensive school 

2 health education materials. 

3 ‘‘(3) Integrating school-based, community4 based, and other public and private health promotion 

5 efforts. 

6 ‘‘(4) Encouraging healthy, tobacco-free school 

7 environments. 

8 ‘‘(5) Coordinating school-based health programs 

9 with existing services and programs available in the 

10 community. 

11 ‘‘(6) Developing school programs on nutrition 

12 education, personal health, oral health, and fitness. 

13 ‘‘(7) Developing behavioral health wellness pro14 grams. 

15 ‘‘(8) Developing chronic disease prevention pro16 grams. 

17 ‘‘(9) Developing substance abuse prevention 

18 programs. 

19 ‘‘(10) Developing injury prevention and safety 

20 education programs. 

21 ‘‘(11) Developing activities for the prevention 

22 and control of communicable diseases. 

23 ‘‘(12) Developing community and environmental 

24 health education programs that include traditional 

25 health care practitioners. 


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1 ‘‘(13) Violence prevention. 

2 ‘‘(14) Such other health issues as are appro3 priate. 

4 ‘‘(c) TECHNICAL ASSISTANCE.—Upon request, the 

5 Secretary, acting through the Service, shall provide tech6 nical assistance to Indian Tribes and Tribal Organizations 

7 in the development of comprehensive health education 

8 plans and the dissemination of comprehensive health edu9 cation materials and information on existing health pro10 grams and resources. 

11 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP12 PLICATIONS.—The Secretary, acting through the Service, 

13 and in consultation with Indian Tribes and Tribal Organi14 zations, shall establish criteria for the review and approval 

15 of applications for grants awarded under this section. 

16 ‘‘(e) DEVELOPMENT OF PROGRAM FOR BIA-FUNDED

17 SCHOOLS.— 

18 ‘‘(1) IN GENERAL.—The Secretary of the Inte19 rior, acting through the Bureau of Indian Affairs 

20 and in cooperation with the Secretary, acting 

21 through the Service, shall develop a comprehensive 

22 school health education program for children from 

23 preschool through grade 12 in schools for which sup24 port is provided by the Bureau of Indian Affairs. 


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1 ‘‘(2) REQUIREMENTS FOR PROGRAMS.—Such 

2 programs shall include— 

3 ‘‘(A) school programs on nutrition edu4 cation, personal health, oral health, and fitness; 

5 ‘‘(B) behavioral health wellness programs; 

6 ‘‘(C) chronic disease prevention programs; 

7 ‘‘(D) substance abuse prevention pro8 grams; 

9 ‘‘(E) injury prevention and safety edu10 cation programs; and 

11 ‘‘(F) activities for the prevention and con12 trol of communicable diseases. 

13 ‘‘(3) DUTIES OF THE SECRETARY.—The Sec14 retary of the Interior shall— 

15 ‘‘(A) provide training to teachers in com16 prehensive school health education materials; 

17 ‘‘(B) ensure the integration and coordina18 tion of school-based programs with existing 

19 services and health programs available in the 

20 community; and 

21 ‘‘(C) encourage healthy, tobacco-free school 

22 environments. 

23 ‘‘SEC. 210. INDIAN YOUTH PROGRAM. 

24 ‘‘(a) PROGRAM AUTHORIZED.—The Secretary, acting 

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1 ister a program to provide grants to Indian Tribes, Tribal 

2 Organizations, and urban Indian organizations for innova3 tive mental and physical disease prevention and health 

4 promotion and treatment programs for Indian and urban 

5 Indian preadolescent and adolescent youths. 

6 ‘‘(b) USE OF FUNDS.— 

7 ‘‘(1) ALLOWABLE USES.—Funds made available 

8 under this section may be used to— 

9 ‘‘(A) develop prevention and treatment 

10 programs for Indian youth which promote men11 tal and physical health and incorporate cultural 

12 values, community and family involvement, and 

13 traditional health care practitioners; and 

14 ‘‘(B) develop and provide community train15 ing and education. 

16 ‘‘(2) PROHIBITED USE.—Funds made available 

17 under this section may not be used to provide serv18 ices described in section 707(c). 

19 ‘‘(c) DUTIES OF THE SECRETARY.—The Secretary 

20 shall— 

21 ‘‘(1) disseminate to Indian Tribes, Tribal Orga22 nizations, and urban Indian organizations informa23 tion regarding models for the delivery of comprehen24 sive health care services to Indian and urban Indian 

25 adolescents; 


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1 ‘‘(2) encourage the implementation of such 

2 models; and 

3 ‘‘(3) at the request of an Indian Tribe, Tribal 

4 Organization, or urban Indian organization, provide 

5 technical assistance in the implementation of such 

6 models. 

7 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP8 PLICATIONS.—The Secretary, in consultation with Indian 

9 Tribes, Tribal Organizations, and urban Indian organiza10 tions, shall establish criteria for the review and approval 

11 of applications or proposals under this section. 

12 ‘‘SEC. 211. PREVENTION, CONTROL, AND ELIMINATION OF 

13 COMMUNICABLE AND INFECTIOUS DISEASES. 

14 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

15 through the Service, and after consultation with the Cen16 ters for Disease Control and Prevention, may make grants 

17 available to Indian Tribes, Tribal Organizations, and 

18 urban Indian organizations for the following: 

19 ‘‘(1) Projects for the prevention, control, and 

20 elimination of communicable and infectious diseases, 

21 including tuberculosis, hepatitis, HIV, respiratory 

22 syncytial virus, hanta virus, sexually transmitted dis23 eases, and H. Pylori. 


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1 ‘‘(2) Public information and education pro2 grams for the prevention, control, and elimination of 

3 communicable and infectious diseases. 

4 ‘‘(3) Education, training, and clinical skills im5 provement activities in the prevention, control, and 

6 elimination of communicable and infectious diseases 

7 for health professionals, including allied health pro8 fessionals. 

9 ‘‘(4) Demonstration projects for the screening, 

10 treatment, and prevention of hepatitis C virus 

11 (HCV). 

12 ‘‘(b) APPLICATION REQUIRED.—The Secretary may 

13 provide funding under subsection (a) only if an application 

14 or proposal for funding is submitted to the Secretary. 

15 ‘‘(c) COORDINATION WITH HEALTH AGENCIES.—In16 dian Tribes, Tribal Organizations, and urban Indian orga17 nizations receiving funding under this section are encour18 aged to coordinate their activities with the Centers for 

19 Disease Control and Prevention and State and local health 

20 agencies. 

21 ‘‘(d) TECHNICAL ASSISTANCE; REPORT.—In carrying 

22 out this section, the Secretary— 

23 ‘‘(1) may, at the request of an Indian Tribe, 

24 Tribal Organization, or urban Indian organization, 

25 provide technical assistance; and 


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1 ‘‘(2) shall prepare and submit a report to Con2 gress biennially on the use of funds under this sec3 tion and on the progress made toward the preven4 tion, control, and elimination of communicable and 

5 infectious diseases among Indians and Urban Indi6 ans. 

7 ‘‘SEC. 212. OTHER AUTHORITY FOR PROVISION OF SERV8 ICES. 

9 ‘‘(a) FUNDING AUTHORIZED.—The Secretary may 

10 provide funding under this Act to meet the objectives set 

11 forth in section 3 of this Act through health care-related 

12 services and programs of the Service, Indian Tribes, and 

13 Tribal Organizations not otherwise described in this Act 

14 for the following services: 

15 ‘‘(1) Hospice care. 

16 ‘‘(2) Assisted living services. 

17 ‘‘(3) Long-term care services. 

18 ‘‘(4) Home- and community-based services. 

19 ‘‘(b) ELIGIBILITY.—The following individuals shall be 

20 eligible to receive long-term care under this section: 

21 ‘‘(1) Individuals who are unable to perform a 

22 certain number of activities of daily living without 

23 assistance. 

24 ‘‘(2) Individuals with a mental impairment, 

25 such as dementia, Alzheimer’s disease, or another 


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1 disabling mental illness, who may be able to perform 

2 activities of daily living under supervision. 

3 ‘‘(3) Such other individuals as an applicable In4 dian Health Program determines to be appropriate. 

5 ‘‘(c) DEFINITIONS.—For the purposes of this section, 

6 the following definitions shall apply: 

7 ‘‘(1) The term ‘assisted living services’ means 

8 any service provided by an assisted living facility (as 

9 defined in section 232(b) of the National Housing 

10 Act (12 U.S.C. 1715w(b))), except that such an as11 sisted living facility— 

12 ‘‘(A) shall not be required to obtain a li13 cense; but 

14 ‘‘(B) shall meet all applicable standards 

15 for licensure. 

16 ‘‘(2) The term ‘home- and community-based 

17 services’ means 1 or more of the services specified 

18 in paragraphs (1) through (9) of section 1929(a) of 

19 the Social Security Act (42 U.S.C. 1396t(a)) 

20 (whether provided by the Service or by an Indian 

21 Tribe or Tribal Organization pursuant to the Indian 

22 Self-Determination and Education Assistance Act 

23 (25 U.S.C. 450 et seq.)) that are or will be provided 

24 in accordance with applicable standards. 


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1 ‘‘(3) The term ‘hospice care’ means the items 

2 and services specified in subparagraphs (A) through 

3 (H) of section 1861(dd)(1) of the Social Security 

4 Act (42 U.S.C. 1395x(dd)(1)), and such other serv5 ices which an Indian Tribe or Tribal Organization 

6 determines are necessary and appropriate to provide 

7 in furtherance of this care. 

8 ‘‘(4) The term ‘long-term care services’ has the 

9 meaning given the term ‘qualified long-term care 

10 services’ in section 7702B(c) of the Internal Rev11 enue Code of 1986. 

12 ‘‘(d) AUTHORIZATION OF CONVENIENT CARE SERV13 ICES.—The Secretary, acting through the Service, Indian 

14 Tribes, and Tribal Organizations, may also provide fund15 ing under this Act to meet the objectives set forth in sec16 tion 3 of this Act for convenient care services programs 

17 pursuant to section 306(c)(2)(A). 

18 ‘‘SEC. 213. INDIAN WOMEN’S HEALTH CARE. 

19 ‘‘The Secretary, acting through the Service and In20 dian Tribes, Tribal Organizations, and Urban Indian Or21 ganizations, shall monitor and improve the quality of 

22 health care for Indian women of all ages through the plan23 ning and delivery of programs administered by the Service, 

24 in order to improve and enhance the treatment models of 

25 care for Indian women. 


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1 ‘‘SEC. 214. ENVIRONMENTAL AND NUCLEAR HEALTH HAZ2 ARDS. 

3 ‘‘(a) STUDIES AND MONITORING.—The Secretary 

4 and the Service shall conduct, in conjunction with other 

5 appropriate Federal agencies and in consultation with con6 cerned Indian Tribes and Tribal Organizations, studies 

7 and ongoing monitoring programs to determine trends in 

8 the health hazards to Indian miners and to Indians on 

9 or near reservations and Indian communities as a result 

10 of environmental hazards which may result in chronic or 

11 life threatening health problems, such as nuclear resource 

12 development, petroleum contamination, and contamination 

13 of water source and of the food chain. Such studies shall 

14 include— 

15 ‘‘(1) an evaluation of the nature and extent of 

16 health problems caused by environmental hazards 

17 currently exhibited among Indians and the causes of 

18 such health problems; 

19 ‘‘(2) an analysis of the potential effect of ongo20 ing and future environmental resource development 

21 on or near reservations and Indian communities, in22 cluding the cumulative effect over time on health; 

23 ‘‘(3) an evaluation of the types and nature of 

24 activities, practices, and conditions causing or affect25 ing such health problems, including uranium mining 

26 and milling, uranium mine tailing deposits, nuclear 


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1 power plant operation and construction, and nuclear 

2 waste disposal; oil and gas production or transpor3 tation on or near reservations or Indian commu4 nities; and other development that could affect the 

5 health of Indians and their water supply and food 

6 chain; 

7 ‘‘(4) a summary of any findings and rec8 ommendations provided in Federal and State stud9 ies, reports, investigations, and inspections during 

10 the 5 years prior to the date of enactment of the In11 dian Health Care Improvement Act Amendments of 

12 2009 that directly or indirectly relate to the activi13 ties, practices, and conditions affecting the health or 

14 safety of such Indians; and 

15 ‘‘(5) the efforts that have been made by Federal 

16 and State agencies and resource and economic devel17 opment companies to effectively carry out an edu18 cation program for such Indians regarding the 

19 health and safety hazards of such development. 

20 ‘‘(b) HEALTH CARE PLANS.—Upon completion of 

21 such studies, the Secretary and the Service shall take into 

22 account the results of such studies and develop health care 

23 plans to address the health problems studied under sub24 section (a). The plans shall include— 


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1 ‘‘(1) methods for diagnosing and treating Indi2 ans currently exhibiting such health problems; 

3 ‘‘(2) preventive care and testing for Indians 

4 who may be exposed to such health hazards, includ5 ing the monitoring of the health of individuals who 

6 have or may have been exposed to excessive amounts 

7 of radiation or affected by other activities that have 

8 had or could have a serious impact upon the health 

9 of such individuals; and 

10 ‘‘(3) a program of education for Indians who, 

11 by reason of their work or geographic proximity to 

12 such nuclear or other development activities, may ex13 perience health problems. 

14 ‘‘(c) SUBMISSION OF REPORT AND PLAN TO CON15 GRESS.—The Secretary and the Service shall submit to 

16 Congress the study prepared under subsection (a) no later 

17 than 18 months after the date of enactment of the Indian 

18 Health Care Improvement Act Amendments of 2009. The 

19 health care plan prepared under subsection (b) shall be 

20 submitted in a report no later than 1 year after the study 

21 prepared under subsection (a) is submitted to Congress. 

22 Such report shall include recommended activities for the 

23 implementation of the plan, as well as an evaluation of 

24 any activities previously undertaken by the Service to ad25 dress such health problems. 


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1 ‘‘(d) INTERGOVERNMENTAL TASK FORCE.— 

2 ‘‘(1) ESTABLISHMENT; MEMBERS.—There is es3 tablished an Intergovernmental Task Force to be 

4 composed of the following individuals (or their des5 ignees): 

6 ‘‘(A) The Secretary of Energy. 

7 ‘‘(B) The Secretary of the Environmental 

8 Protection Agency. 

9 ‘‘(C) The Director of the Bureau of Mines. 

10 ‘‘(D) The Assistant Secretary for Occupa11 tional Safety and Health. 

12 ‘‘(E) The Secretary of the Interior. 

13 ‘‘(F) The Secretary of Health and Human 

14 Services. 

15 ‘‘(G) The Director of the Indian Health 

16 Service. 

17 ‘‘(2) DUTIES.—The Task Force shall— 

18 ‘‘(A) identify existing and potential oper19 ations related to nuclear resource development 

20 or other environmental hazards that affect or 

21 may affect the health of Indians on or near a 

22 reservation or in an Indian community; and 

23 ‘‘(B) enter into activities to correct exist24 ing health hazards and ensure that current and 

25 future health problems resulting from nuclear 


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1 resource or other development activities are 

2 minimized or reduced. 

3 ‘‘(3) CHAIRMAN; MEETINGS.—The Secretary of 

4 Health and Human Services shall be the Chairman 

5 of the Task Force. The Task Force shall meet at 

6 least twice each year. 

7 ‘‘(e) HEALTH SERVICES TO CERTAIN EMPLOYEES.— 

8 In the case of any Indian who— 

9 ‘‘(1) as a result of employment in or near a 

10 uranium mine or mill or near any other environ11 mental hazard, suffers from a work-related illness or 

12 condition; 

13 ‘‘(2) is eligible to receive diagnosis and treat14 ment services from an Indian Health Program; and 

15 ‘‘(3) by reason of such Indian’s employment, is 

16 entitled to medical care at the expense of such mine 

17 or mill operator or entity responsible for the environ18 mental hazard, the Indian Health Program shall, at 

19 the request of such Indian, render appropriate med20 ical care to such Indian for such illness or condition 

21 and may be reimbursed for any medical care so ren22 dered to which such Indian is entitled at the expense 

23 of such operator or entity from such operator or en24 tity. Nothing in this subsection shall affect the 

25 rights of such Indian to recover damages other than 


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1 such amounts paid to the Indian Health Program 

2 from the employer for providing medical care for 

3 such illness or condition. 

4 ‘‘SEC. 215. ARIZONA AS A CONTRACT HEALTH SERVICE DE5 LIVERY AREA. 

6 ‘‘(a) IN GENERAL.—For fiscal years beginning with 

7 the fiscal year ending September 30, 1983, and ending 

8 with the fiscal year ending September 30, 2025, the State 

9 of Arizona shall be designated as a contract health service 

10 delivery area by the Service for the purpose of providing 

11 contract health care services to members of federally rec12 ognized Indian Tribes of Arizona. 

13 ‘‘(b) MAINTENANCE OF SERVICES.—The Service 

14 shall not curtail any health care services provided to Indi15 ans residing on reservations in the State of Arizona if such 

16 curtailment is due to the provision of contract services in 

17 such State pursuant to the designation of such State as 

18 a contract health service delivery area pursuant to sub19 section (a). 

20 ‘‘SEC. 216. NORTH DAKOTA AND SOUTH DAKOTA AS CON21 TRACT HEALTH SERVICE DELIVERY AREA. 

22 ‘‘(a) IN GENERAL.—Beginning in fiscal year 2003, 

23 the States of North Dakota and South Dakota shall be 

24 designated as a contract health service delivery area by 

25 the Service for the purpose of providing contract health 


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1 care services to members of federally recognized Indian 

2 Tribes of North Dakota and South Dakota. 

3 ‘‘(b) LIMITATION.—The Service shall not curtail any 

4 health care services provided to Indians residing on any 

5 reservation, or in any county that has a common boundary 

6 with any reservation, in the State of North Dakota or 

7 South Dakota if such curtailment is due to the provision 

8 of contract services in such States pursuant to the des9 ignation of such States as a contract health service deliv10 ery area pursuant to subsection (a). 

11 ‘‘SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PRO12 GRAM. 

13 ‘‘(a) FUNDING AUTHORIZED.—The Secretary is au14 thorized to fund a program using the California Rural In15 dian Health Board (hereafter in this section referred to 

16 as the ‘CRIHB’) as a contract care intermediary to im17 prove the accessibility of health services to California Indi18 ans. 

19 ‘‘(b) REIMBURSEMENT CONTRACT.—The Secretary 

20 shall enter into an agreement with the CRIHB to reim21 burse the CRIHB for costs (including reasonable adminis22 trative costs) incurred pursuant to this section, in pro23 viding medical treatment under contract to California In24 dians described in section 805(a) throughout the CaliVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01760 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 fornia contract health services delivery area described in 

2 section 219 with respect to high cost contract care cases. 

3 ‘‘(c) ADMINISTRATIVE EXPENSES.—Not more than 5 

4 percent of the amounts provided to the CRIHB under this 

5 section for any fiscal year may be for reimbursement for 

6 administrative expenses incurred by the CRIHB during 

7 such fiscal year. 

8 ‘‘(d) LIMITATION ON PAYMENT.—No payment may 

9 be made for treatment provided hereunder to the extent 

10 payment may be made for such treatment under the In11 dian Catastrophic Health Emergency Fund described in 

12 section 202 or from amounts appropriated or otherwise 

13 made available to the California contract health service de14 livery area for a fiscal year. 

15 ‘‘(e) ADVISORY BOARD.—There is established an ad16 visory board which shall advise the CRIHB in carrying 

17 out this section. The advisory board shall be composed of 

18 representatives, selected by the CRIHB, from not less 

19 than 8 Tribal Health Programs serving California Indians 

covered under this section at least 1 20 ⁄2 of whom of whom 

21 are not affiliated with the CRIHB. 

22 ‘‘SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE 

23 DELIVERY AREA. 

24 ‘‘The State of California, excluding the counties of 

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1 ramento, San Francisco, San Mateo, Santa Clara, Kern, 

2 Merced, Monterey, Napa, San Benito, San Joaquin, San 

3 Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ven4 tura, shall be designated as a contract health service deliv5 ery area by the Service for the purpose of providing con6 tract health services to California Indians. However, any 

7 of the counties listed herein may only be included in the 

8 contract health services delivery area if funding is specifi9 cally provided by the Service for such services in those 

10 counties. 

11 ‘‘SEC. 219. CONTRACT HEALTH SERVICES FOR THE TREN12 TON SERVICE AREA. 

13 ‘‘(a) AUTHORIZATION FOR SERVICES.—The Sec14 retary, acting through the Service, is directed to provide 

15 contract health services to members of the Turtle Moun16 tain Band of Chippewa Indians that reside in the Trenton 

17 Service Area of Divide, McKenzie, and Williams counties 

18 in the State of North Dakota and the adjoining counties 

19 of Richland, Roosevelt, and Sheridan in the State of Mon20 tana. 

21 ‘‘(b) NO EXPANSION OF ELIGIBILITY.—Nothing in 

22 this section may be construed as expanding the eligibility 

23 of members of the Turtle Mountain Band of Chippewa In24 dians for health services provided by the Service beyond 


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1 the scope of eligibility for such health services that applied 

2 on May 1, 1986. 

3 ‘‘SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND 

4 TRIBAL ORGANIZATIONS. 

5 ‘‘The Service shall provide funds for health care pro6 grams, functions, services, activities, information tech7 nology, and facilities operated by Tribal Health Programs 

8 on the same basis as such funds are provided to programs, 

9 functions, services, activities, information technology, and 

10 facilities operated directly by the Service. 

11 ‘‘SEC. 221. LICENSING. 

12 ‘‘Licensed health care professionals employed by a 

13 Tribal Health Program shall, if licensed in any State, be 

14 exempt from the licensing requirements of the State in 

15 which the Tribal Health Program performs the services 

16 described in its contract or compact under the Indian Self17 Determination and Education Assistance Act (25 U.S.C. 

18 450 et seq.) while performing such services. 

19 ‘‘SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY 

20 CONTRACT HEALTH SERVICES. 

21 ‘‘With respect to an elderly Indian or an Indian with 

22 a disability receiving emergency medical care or services 

23 from a non-Service provider or in a non-Service facility 

24 under the authority of this Act, the time limitation (as 


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1 a condition of payment) for notifying the Service of such 

2 treatment or admission shall be 30 days. 

3 ‘‘SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS. 

4 ‘‘(a) DEADLINE FOR RESPONSE.—The Service shall 

5 respond to a notification of a claim by a provider of a 

6 contract care service with either an individual purchase 

7 order or a denial of the claim within 5 working days after 

8 the receipt of such notification. 

9 ‘‘(b) EFFECT OF UNTIMELY RESPONSE.—If the 

10 Service fails to respond to a notification of a claim in ac11 cordance with subsection (a), the Service shall accept as 

12 valid the claim submitted by the provider of a contract 

13 care service. 

14 ‘‘(c) DEADLINE FOR PAYMENT OF VALID CLAIM.— 

15 The Service shall pay a valid contract care service claim 

16 within 30 days after the completion of the claim. 

17 ‘‘SEC. 224. LIABILITY FOR PAYMENT. 

18 ‘‘(a) NO PATIENT LIABILITY.—A patient who re19 ceives contract health care services that are authorized by 

20 the Service shall not be liable for the payment of any 

21 charges or costs associated with the provision of such serv22 ices. 

23 ‘‘(b) NOTIFICATION.—The Secretary shall notify a 

24 contract care provider and any patient who receives con25 tract health care services authorized by the Service that 


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1 such patient is not liable for the payment of any charges 

2 or costs associated with the provision of such services not 

3 later than 5 business days after receipt of a notification 

4 of a claim by a provider of contract care services. 

5 ‘‘(c) NO RECOURSE.—Following receipt of the notice 

6 provided under subsection (b), or, if a claim has been 

7 deemed accepted under section 224(b), the provider shall 

8 have no further recourse against the patient who received 

9 the services. 

10 ‘‘SEC. 225. OFFICE OF INDIAN MEN’S HEALTH. 

11 ‘‘(a) ESTABLISHMENT.—The Secretary may establish 

12 within the Service an office to be known as the ‘Office 

13 of Indian Men’s Health’ (referred to in this section as the 

14 ‘Office’). 

15 ‘‘(b) DIRECTOR.— 

16 ‘‘(1) IN GENERAL.—The Office shall be headed 

17 by a director, to be appointed by the Secretary. 

18 ‘‘(2) DUTIES.—The director shall coordinate 

19 and promote the status of the health of Indian men 

20 in the United States. 

21 ‘‘(c) REPORT.—Not later than 2 years after the date 

22 of enactment of the Indian Health Care Improvement Act 

23 Amendments of 2009, the Secretary, acting through the 

24 director of the Office, shall submit to Congress a report 

25 describing— 


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1 ‘‘(1) any activity carried out by the director as 

2 of the date on which the report is prepared; and 

3 ‘‘(2) any finding of the director with respect to 

4 the health of Indian men. 

5 ‘‘SEC. 226. CATASTROPHIC HEALTH EMERGENCY FUND. 

6 ‘‘(a) ESTABLISHMENT.—There is established an In7 dian Catastrophic Health Emergency Fund (hereafter in 

8 this section referred to as the ‘CHEF’) consisting of— 

9 ‘‘(1) the amounts deposited under subsection 

10 (f); and 

11 ‘‘(2) the amounts appropriated to CHEF under 

12 this section. 

13 ‘‘(b) ADMINISTRATION.—CHEF shall be adminis14 tered by the Secretary, acting through the headquarters 

15 of the Service, solely for the purpose of meeting the ex16 traordinary medical costs associated with the treatment of 

17 victims of disasters or catastrophic illnesses who are with18 in the responsibility of the Service. 

19 ‘‘(c) CONDITIONS ON USE OF FUND.—No part of 

20 CHEF or its administration shall be subject to contract 

21 or grant under any law, including the Indian Self-Deter22 mination and Education Assistance Act (25 U.S.C. 450 

23 et seq.), nor shall CHEF funds be allocated, apportioned, 

24 or delegated on an Area Office, Service Unit, or other 

25 similar basis. 


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1 ‘‘(d) REGULATIONS.—The Secretary shall promul2 gate regulations consistent with the provisions of this sec3 tion to— 

4 ‘‘(1) establish a definition of disasters and cata5 strophic illnesses for which the cost of the treatment 

6 provided under contract would qualify for payment 

7 from CHEF; 

8 ‘‘(2) provide that a Service Unit shall not be el9 igible for reimbursement for the cost of treatment 

10 from CHEF until its cost of treating any victim of 

11 such catastrophic illness or disaster has reached a 

12 certain threshold cost which the Secretary shall es13 tablish at— 

14 ‘‘(A) the 2000 level of $19,000; and 

15 ‘‘(B) for any subsequent year, not less 

16 than the threshold cost of the previous year in17 creased by the percentage increase in the med18 ical care expenditure category of the consumer 

19 price index for all urban consumers (United 

20 States city average) for the 12-month period 

21 ending with December of the previous year; 

22 ‘‘(3) establish a procedure for the reimburse23 ment of the portion of the costs that exceeds such 

24 threshold cost incurred by— 

25 ‘‘(A) Service Units; or 


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1 ‘‘(B) whenever otherwise authorized by the 

2 Service, non-Service facilities or providers; 

3 ‘‘(4) establish a procedure for payment from 

4 CHEF in cases in which the exigencies of the med5 ical circumstances warrant treatment prior to the 

6 authorization of such treatment by the Service; and 

7 ‘‘(5) establish a procedure that will ensure that 

8 no payment shall be made from CHEF to any pro9 vider of treatment to the extent that such provider 

10 is eligible to receive payment for the treatment from 

11 any other Federal, State, local, or private source of 

12 reimbursement for which the patient is eligible. 

13 ‘‘(e) NO OFFSET OR LIMITATION.—Amounts appro14 priated to CHEF under this section shall not be used to 

15 offset or limit appropriations made to the Service under 

16 the authority of the Act of November 2, 1921 (25 U.S.C. 

17 13) (commonly known as the ‘Snyder Act’), or any other 

18 law. 

19 ‘‘(f) DEPOSIT OF REIMBURSEMENT FUNDS.—There 

20 shall be deposited into CHEF all reimbursements to which 

21 the Service is entitled from any Federal, State, local, or 

22 private source (including third party insurance) by reason 

23 of treatment rendered to any victim of a disaster or cata24 strophic illness the cost of which was paid from CHEF. 


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1 ‘‘SEC. 227. AUTHORIZATION OF APPROPRIATIONS. 

2 ‘‘There are authorized to be appropriated such sums 

3 as may be necessary to carry out this title. 

4 ‘‘TITLE III—FACILITIES 

5 ‘‘SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVA6 TION OF FACILITIES; REPORTS. 

7 ‘‘(a) PREREQUISITES FOR EXPENDITURE OF

8 FUNDS.—Prior to the expenditure of, or the making of 

9 any binding commitment to expend, any funds appro10 priated for the planning, design, construction, or renova11 tion of facilities pursuant to the Act of November 2, 1921 

12 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), 

13 the Secretary, acting through the Service, shall— 

14 ‘‘(1) consult with any Indian Tribe that would 

15 be significantly affected by such expenditure for the 

16 purpose of determining and, whenever practicable, 

17 honoring tribal preferences concerning size, location, 

18 type, and other characteristics of any facility on 

19 which such expenditure is to be made; and 

20 ‘‘(2) ensure, whenever practicable and applica21 ble, that such facility meets the construction stand22 ards of any accrediting body recognized by the Sec23 retary for the purposes of the Medicare, Medicaid, 

24 and SCHIP programs under titles XVIII, XIX, and 

25 XXI of the Social Security Act by not later than 1 


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1 year after the date on which the construction or ren2 ovation of such facility is completed. 

3 ‘‘(b) CLOSURES.— 

4 ‘‘(1) EVALUATION REQUIRED.—Notwith5 standing any other provision of law, no facility oper6 ated by the Service may be closed if the Secretary 

7 has not submitted to Congress, not less than 1 year 

8 and not more than 2 years before the date of the 

9 proposed closure, an evaluation, completed not more 

10 than 2 years before such submission, of the impact 

11 of the proposed closure that specifies, in addition to 

12 other considerations— 

13 ‘‘(A) the accessibility of alternative health 

14 care resources for the population served by such 

15 facility; 

16 ‘‘(B) the cost-effectiveness of such closure; 

17 ‘‘(C) the quality of health care to be pro18 vided to the population served by such facility 

19 after such closure; 

20 ‘‘(D) the availability of contract health 

21 care funds to maintain existing levels of service; 

22 ‘‘(E) the views of the Indian Tribes served 

23 by such facility concerning such closure; 

24 ‘‘(F) the level of use of such facility by all 

25 eligible Indians; and 


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1 ‘‘(G) the distance between such facility and 

2 the nearest operating Service hospital. 

3 ‘‘(2) EXCEPTION FOR CERTAIN TEMPORARY

4 CLOSURES.—Paragraph (1) shall not apply to any 

5 temporary closure of a facility or any portion of a 

6 facility if such closure is necessary for medical, envi7 ronmental, or construction safety reasons. 

8 ‘‘(c) HEALTH CARE FACILITY PRIORITY SYSTEM.— 

9 ‘‘(1) IN GENERAL.— 

10 ‘‘(A) PRIORITY SYSTEM.—The Secretary, 

11 acting through the Service, shall maintain a 

12 health care facility priority system, which— 

13 ‘‘(i) shall be developed in consultation 

14 with Indian Tribes and Tribal Organiza15 tions; 

16 ‘‘(ii) shall give Indian Tribes’ needs 

17 the highest priority; 

18 ‘‘(iii)(I) may include the lists required 

19 in paragraph (2)(B)(ii); and 

20 ‘‘(II) shall include the methodology re21 quired in paragraph (2)(B)(v); and 

22 ‘‘(III) may include such other facili23 ties, and such renovation or expansion 

24 needs of any health care facility, as the 


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1 Service, Indian Tribes, and Tribal Organi2 zations may identify; and 

3 ‘‘(iv) shall provide an opportunity for 

4 the nomination of planning, design, and 

5 construction projects by the Service, In6 dian Tribes, and Tribal Organizations for 

7 consideration under the priority system at 

8 least once every 3 years, or more fre9 quently as the Secretary determines to be 

10 appropriate. 

11 ‘‘(B) NEEDS OF FACILITIES UNDER

12 ISDEAA AGREEMENTS.—The Secretary shall en13 sure that the planning, design, construction, 

14 renovation, and expansion needs of Service and 

15 non-Service facilities operated under contracts 

16 or compacts in accordance with the Indian Self17 Determination and Education Assistance Act 

18 (25 U.S.C. 450 et seq.) are fully and equitably 

19 integrated into the health care facility priority 

20 system. 

21 ‘‘(C) CRITERIA FOR EVALUATING

22 NEEDS.—For purposes of this subsection, the 

23 Secretary, in evaluating the needs of facilities 

24 operated under a contract or compact under the 

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1 sistance Act (25 U.S.C. 450 et seq.), shall use 

2 the criteria used by the Secretary in evaluating 

3 the needs of facilities operated directly by the 

4 Service. 

5 ‘‘(D) PRIORITY OF CERTAIN PROJECTS

6 PROTECTED.—The priority of any project estab7 lished under the construction priority system in 

8 effect on the date of enactment of the Indian 

9 Health Care Improvement Act Amendments of 

10 2009 shall not be affected by any change in the 

11 construction priority system taking place after 

12 that date if the project— 

13 ‘‘(i) was identified in the fiscal year 

14 2008 Service budget justification as— 

15 ‘‘(I) 1 of the 10 top-priority inpa16 tient projects; 

17 ‘‘(II) 1 of the 10 top-priority out18 patient projects; 

19 ‘‘(III) 1 of the 10 top-priority 

20 staff quarters developments; or 

21 ‘‘(IV) 1 of the 10 top-priority 

22 Youth Regional Treatment Centers; 

23 ‘‘(ii) had completed both Phase I and 

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1 tem in effect on the date of enactment of 

2 such Act; or 

3 ‘‘(iii) is not included in clause (i) or 

4 (ii) and is selected, as determined by the 

5 Secretary— 

6 ‘‘(I) on the initiative of the Sec7 retary; or 

8 ‘‘(II) pursuant to a request of an 

9 Indian Tribe or Tribal Organization. 

10 ‘‘(2) REPORT; CONTENTS.— 

11 ‘‘(A) INITIAL COMPREHENSIVE REPORT.— 

12 ‘‘(i) DEFINITIONS.—In this subpara13 graph: 

14 ‘‘(I) FACILITIES APPROPRIATION

15 ADVISORY BOARD.—The term ‘Facili16 ties Appropriation Advisory Board’ 

17 means the advisory board, comprised 

18 of 12 members representing Indian 

19 tribes and 2 members representing 

20 the Service, established at the discre21 tion of the Assistant Secretary— 

22 ‘‘(aa) to provide advice and 

23 recommendations for policies and 

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1 ed pursuant to facilities appro2 priations; and 

3 ‘‘(bb) to address other facili4 ties issues. 

5 ‘‘(II) FACILITIES NEEDS ASSESS6 MENT WORKGROUP.—The term ‘Fa7 cilities Needs Assessment Workgroup’ 

8 means the workgroup established at 

9 the discretion of the Assistant Sec10 retary— 

11 ‘‘(aa) to review the health 

12 care facilities construction pri13 ority system; and 

14 ‘‘(bb) to make recommenda15 tions to the Facilities Appropria16 tion Advisory Board for revising 

17 the priority system. 

18 ‘‘(ii) INITIAL REPORT.— 

19 ‘‘(I) IN GENERAL.—Not later 

20 than 1 year after the date of enact21 ment of the Indian Health Care Im22 provement Act Amendments of 2009, 

23 the Secretary shall submit to the 

24 Committee on Indian Affairs of the 

25 Senate and the Committee on Natural 


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1 Resources of the House of Represent2 atives a report that describes the com3 prehensive, national, ranked list of all 

4 health care facilities needs for the 

5 Service, Indian Tribes, and Tribal Or6 ganizations (including inpatient health 

7 care facilities, outpatient health care 

8 facilities, specialized health care facili9 ties (such as for long-term care and 

10 alcohol and drug abuse treatment), 

11 wellness centers, staff quarters and 

12 hostels associated with health care fa13 cilities, and the renovation and expan14 sion needs, if any, of such facilities) 

15 developed by the Service, Indian 

16 Tribes, and Tribal Organizations for 

17 the Facilities Needs Assessment 

18 Workgroup and the Facilities Appro19 priation Advisory Board. 

20 ‘‘(II) INCLUSIONS.—The initial 

21 report shall include— 

22 ‘‘(aa) the methodology and 

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1 lishing the ranking of the facili2 ties needs; and 

3 ‘‘(bb) such other information 

4 as the Secretary determines to be 

5 appropriate. 

6 ‘‘(iii) UPDATES OF REPORT.—Begin7 ning in calendar year 2011, the Secretary 

8 shall— 

9 ‘‘(I) update the report under 

10 clause (ii) not less frequently that 

11 once every 5 years; and 

12 ‘‘(II) include the updated report 

13 in the appropriate annual report 

14 under subparagraph (B) for submis15 sion to Congress under section 801. 

16 ‘‘(B) ANNUAL REPORTS.—The Secretary 

17 shall submit to the President, for inclusion in 

18 the report required to be transmitted to Con19 gress under section 801, a report which sets 

20 forth the following: 

21 ‘‘(i) A description of the health care 

22 facility priority system of the Service es23 tablished under paragraph (1). 

24 ‘‘(ii) Health care facilities lists, which 

25 may include— 


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1 ‘‘(I) the 10 top-priority inpatient 

2 health care facilities; 

3 ‘‘(II) the 10 top-priority out4 patient health care facilities; 

5 ‘‘(III) the 10 top-priority special6 ized health care facilities (such as 

7 long-term care and alcohol and drug 

8 abuse treatment); 

9 ‘‘(IV) the 10 top-priority staff 

10 quarters developments associated with 

11 health care facilities; and 

12 ‘‘(V) the 10 top-priority hostels 

13 associated with health care facilities. 

14 ‘‘(iii) The justification for such order 

15 of priority. 

16 ‘‘(iv) The projected cost of such 

17 projects. 

18 ‘‘(v) The methodology adopted by the 

19 Service in establishing priorities under its 

20 health care facility priority system. 

21 ‘‘(3) REQUIREMENTS FOR PREPARATION OF RE22 PORTS.—In preparing the report required under 

23 paragraph (2), the Secretary shall— 

24 ‘‘(A) consult with and obtain information 

25 on all health care facilities needs from Indian 


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1 Tribes, Tribal Organizations, and urban Indian 

2 organizations; and 

3 ‘‘(B) review the total unmet needs of all 

4 Indian Tribes, Tribal Organizations, and urban 

5 Indian organizations for health care facilities 

6 (including hostels and staff quarters), including 

7 needs for renovation and expansion of existing 

8 facilities. 

9 ‘‘(d) REVIEW OF METHODOLOGY USED FOR HEALTH

10 FACILITIES CONSTRUCTION PRIORITY SYSTEM.— 

11 ‘‘(1) IN GENERAL.—Not later than 1 year after 

12 the establishment of the priority system under sub13 section (c)(1)(A), the Comptroller General of the 

14 United States shall prepare and finalize a report re15 viewing the methodologies applied, and the processes 

16 followed, by the Service in making each assessment 

17 of needs for the list under subsection (c)(2)(A)(ii) 

18 and developing the priority system under subsection 

19 (c)(1), including a review of— 

20 ‘‘(A) the recommendations of the Facilities 

21 Appropriation Advisory Board and the Facili22 ties Needs Assessment Workgroup (as those 

23 terms are defined in subsection (c)(2)(A)(i)); 

24 and 


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1 ‘‘(B) the relevant criteria used in ranking 

2 or prioritizing facilities other than hospitals or 

3 clinics. 

4 ‘‘(2) SUBMISSION TO CONGRESS.—The Comp5 troller General of the United States shall submit the 

6 report under paragraph (1) to— 

7 ‘‘(A) the Committees on Indian Affairs and 

8 Appropriations of the Senate; 

9 ‘‘(B) the Committees on Natural Re10 sources and Appropriations of the House of 

11 Representatives; and 

12 ‘‘(C) the Secretary. 

13 ‘‘(e) FUNDING CONDITION.—All funds appropriated 

14 under the Act of November 2, 1921 (25 U.S.C. 13) (com15 monly known as the ‘Snyder Act’), for the planning, de16 sign, construction, or renovation of health facilities for the 

17 benefit of 1 or more Indian Tribes shall be subject to the 

18 provisions of the Indian Self-Determination and Edu19 cation Assistance Act (25 U.S.C. 450 et seq.). 

20 ‘‘(f) DEVELOPMENT OF INNOVATIVE APPROACHES.— 

21 The Secretary shall consult and cooperate with Indian 

22 Tribes, Tribal Organizations, and urban Indian organiza23 tions in developing innovative approaches to address all 

24 or part of the total unmet need for construction of health 


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1 facilities, including those provided for in other sections of 

2 this title and other approaches. 

3 ‘‘SEC. 302. SANITATION FACILITIES. 

4 ‘‘(a) FINDINGS.—Congress finds the following: 

5 ‘‘(1) The provision of sanitation facilities is pri6 marily a health consideration and function. 

7 ‘‘(2) Indian people suffer an inordinately high 

8 incidence of disease, injury, and illness directly at9 tributable to the absence or inadequacy of sanitation 

10 facilities. 

11 ‘‘(3) The long-term cost to the United States of 

12 treating and curing such disease, injury, and illness 

13 is substantially greater than the short-term cost of 

14 providing sanitation facilities and other preventive 

15 health measures. 

16 ‘‘(4) Many Indian homes and Indian commu17 nities still lack sanitation facilities. 

18 ‘‘(5) It is in the interest of the United States, 

19 and it is the policy of the United States, that all In20 dian communities and Indian homes, new and exist21 ing, be provided with sanitation facilities. 

22 ‘‘(b) FACILITIES AND SERVICES.—In furtherance of 

23 the findings made in subsection (a), Congress reaffirms 

24 the primary responsibility and authority of the Service to 

25 provide the necessary sanitation facilities and services as 


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1 provided in section 7 of the Act of August 5, 1954 (42 

2 U.S.C. 2004a). Under such authority, the Secretary, act3 ing through the Service, is authorized to provide the fol4 lowing: 

5 ‘‘(1) Financial and technical assistance to In6 dian Tribes, Tribal Organizations, and Indian com7 munities in the establishment, training, and equip8 ping of utility organizations to operate and maintain 

9 sanitation facilities, including the provision of exist10 ing plans, standard details, and specifications avail11 able in the Department, to be used at the option of 

12 the Indian Tribe, Tribal Organization, or Indian 

13 community. 

14 ‘‘(2) Ongoing technical assistance and training 

15 to Indian Tribes, Tribal Organizations, and Indian 

16 communities in the management of utility organiza17 tions which operate and maintain sanitation facili18 ties. 

19 ‘‘(3) Priority funding for operation and mainte20 nance assistance for, and emergency repairs to, sani21 tation facilities operated by an Indian Tribe, Tribal 

22 Organization or Indian community when necessary 

23 to avoid an imminent health threat or to protect the 

24 investment in sanitation facilities and the investment 


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1 in the health benefits gained through the provision 

2 of sanitation facilities. 

3 ‘‘(c) FUNDING.—Notwithstanding any other provi4 sion of law— 

5 ‘‘(1) the Secretary of Housing and Urban De6 velopment is authorized to transfer funds appro7 priated under the Native American Housing Assist8 ance and Self-Determination Act of 1996 (25 U.S.C. 

9 4101 et seq.) to the Secretary of Health and Human 

10 Services; 

11 ‘‘(2) the Secretary of Health and Human Serv12 ices is authorized to accept and use such funds for 

13 the purpose of providing sanitation facilities and 

14 services for Indians under section 7 of the Act of 

15 August 5, 1954 (42 U.S.C. 2004a); 

16 ‘‘(3) unless specifically authorized when funds 

17 are appropriated, the Secretary shall not use funds 

18 appropriated under section 7 of the Act of August 

19 5, 1954 (42 U.S.C. 2004a), to provide sanitation fa20 cilities to new homes constructed using funds pro21 vided by the Department of Housing and Urban De22 velopment; 

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1 pose of providing sanitation facilities and services 

2 and place these funds into contracts or compacts 

3 under the Indian Self-Determination and Education 

4 Assistance Act (25 U.S.C. 450 et seq.); 

5 ‘‘(5) except as otherwise prohibited by this sec6 tion, the Secretary may use funds appropriated 

7 under the authority of section 7 of the Act of Au8 gust 5, 1954 (42 U.S.C. 2004a), to fund up to 100 

9 percent of the amount of an Indian Tribe’s loan ob10 tained under any Federal program for new projects 

11 to construct eligible sanitation facilities to serve In12 dian homes; 

13 ‘‘(6) except as otherwise prohibited by this sec14 tion, the Secretary may use funds appropriated 

15 under the authority of section 7 of the Act of Au16 gust 5, 1954 (42 U.S.C. 2004a), to meet matching 

17 or cost participation requirements under other Fed18 eral and non-Federal programs for new projects to 

19 construct eligible sanitation facilities; 

20 ‘‘(7) all Federal agencies are authorized to 

21 transfer to the Secretary funds identified, granted, 

22 loaned, or appropriated whereby the Department’s 

23 applicable policies, rules, and regulations shall apply 

24 in the implementation of such projects; 


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1 ‘‘(8) the Secretary of Health and Human Serv2 ices shall enter into interagency agreements with 

3 Federal and State agencies for the purpose of pro4 viding financial assistance for sanitation facilities 

5 and services under this Act; 

6 ‘‘(9) the Secretary of Health and Human Serv7 ices shall, by regulation, establish standards applica8 ble to the planning, design, and construction of sani9 tation facilities funded under this Act; and 

10 ‘‘(10) the Secretary of Health and Human 

11 Services is authorized to accept payments for goods 

12 and services furnished by the Service from appro13 priate public authorities, nonprofit organizations or 

14 agencies, or Indian Tribes, as contributions by that 

15 authority, organization, agency, or tribe to agree16 ments made under section 7 of the Act of August 5, 

17 1954 (42 U.S.C. 2004a), and such payments shall 

18 be credited to the same or subsequent appropriation 

19 account as funds appropriated under the authority 

20 of section 7 of the Act of August 5, 1954 (42 U.S.C. 

21 2004a). 

22 ‘‘(d) CERTAIN CAPABILITIES NOT PREREQUISITE.— 

23 The financial and technical capability of an Indian Tribe, 

24 Tribal Organization, or Indian community to safely oper25 ate, manage, and maintain a sanitation facility shall not 


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1 be a prerequisite to the provision or construction of sanita2 tion facilities by the Secretary. 

3 ‘‘(e) FINANCIAL ASSISTANCE.—The Secretary is au4 thorized to provide financial assistance to Indian Tribes, 

5 Tribal Organizations, and Indian communities in an 

6 amount equal to the Federal share of the costs of oper7 ating, managing, and maintaining the facilities provided 

8 under the plan described in subsection (h)(1)(F). 

9 ‘‘(f) OPERATION, MANAGEMENT, AND MAINTENANCE

10 OF FACILITIES.—The Indian Tribe has the primary re11 sponsibility to establish, collect, and use reasonable user 

12 fees, or otherwise set aside funding, for the purpose of 

13 operating, managing, and maintaining sanitation facilities. 

14 If a sanitation facility serving a community that is oper15 ated by an Indian Tribe or Tribal Organization is threat16 ened with imminent failure and such operator lacks capac17 ity to maintain the integrity or the health benefits of the 

18 sanitation facility, then the Secretary is authorized to as19 sist the Indian Tribe, Tribal Organization, or Indian com20 munity in the resolution of the problem on a short-term 

21 basis through cooperation with the emergency coordinator 

22 or by providing operation, management, and maintenance 

23 service. 

24 ‘‘(g) ISDEAA PROGRAM FUNDED ON EQUAL

25 BASIS.—Tribal Health Programs shall be eligible (on an 


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1 equal basis with programs that are administered directly 

2 by the Service) for— 

3 ‘‘(1) any funds appropriated pursuant to this 

4 section; and 

5 ‘‘(2) any funds appropriated for the purpose of 

6 providing sanitation facilities. 

7 ‘‘(h) REPORT.— 

8 ‘‘(1) REQUIRED; CONTENTS.—The Secretary, in 

9 consultation with the Secretary of Housing and 

10 Urban Development, Indian Tribes, Tribal Organiza11 tions, and tribally designated housing entities (as de12 fined in section 4 of the Native American Housing 

13 Assistance and Self-Determination Act of 1996 (25 

14 U.S.C. 4103)) shall submit to the President, for in15 clusion in the report required to be transmitted to 

16 Congress under section 801, a report which sets 

17 forth— 

18 ‘‘(A) the current Indian sanitation facility 

19 priority system of the Service; 

20 ‘‘(B) the methodology for determining 

21 sanitation deficiencies and needs; 

22 ‘‘(C) the criteria on which the deficiencies 

23 and needs will be evaluated; 

24 ‘‘(D) the level of initial and final sanitation 

25 deficiency for each type of sanitation facility for 


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1 each project of each Indian Tribe or Indian 

2 community; 

3 ‘‘(E) the amount and most effective use of 

4 funds, derived from whatever source, necessary 

5 to accommodate the sanitation facilities needs 

6 of new homes assisted with funds under the 

7 Native American Housing Assistance and Self8 Determination Act (25 U.S.C. 4101 et seq.), 

9 and to reduce the identified sanitation defi10 ciency levels of all Indian Tribes and Indian 

11 communities to level I sanitation deficiency as 

12 defined in paragraph (3)(A); and 

13 ‘‘(F) a 10-year plan to provide sanitation 

14 facilities to serve existing Indian homes and In15 dian communities and new and renovated In16 dian homes. 

17 ‘‘(2) UNIFORM METHODOLOGY.—The method18 ology used by the Secretary in determining, pre19 paring cost estimates for, and reporting sanitation 

20 deficiencies for purposes of paragraph (1) shall be 

21 applied uniformly to all Indian Tribes and Indian 

22 communities. 

23 ‘‘(3) SANITATION DEFICIENCY LEVELS.—For 

24 purposes of this subsection, the sanitation deficiency 

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1 munity sanitation facility to serve Indian homes are 

2 determined as follows: 

3 ‘‘(A) A level I deficiency exists if a sanita4 tion facility serving an individual, Indian Tribe, 

5 or Indian community— 

6 ‘‘(i) complies with all applicable water 

7 supply, pollution control, and solid waste 

8 disposal laws; and 

9 ‘‘(ii) deficiencies relate to routine re10 placement, repair, or maintenance needs. 

11 ‘‘(B) A level II deficiency exists if a sanita12 tion facility serving an individual, Indian Tribe, 

13 or Indian community substantially or recently 

14 complied with all applicable water supply, pollu15 tion control, and solid waste laws and any defi16 ciencies relate to— 

17 ‘‘(i) small or minor capital improve18 ments needed to bring the facility back 

19 into compliance; 

20 ‘‘(ii) capital improvements that are 

21 necessary to enlarge or improve the facili22 ties in order to meet the current needs for 

23 domestic sanitation facilities; or 

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1 tion, or an Indian community to properly 

2 operate and maintain the sanitation facili3 ties. 

4 ‘‘(C) A level III deficiency exists if a sani5 tation facility serving an individual, Indian 

6 Tribe or Indian community meets 1 or more of 

7 the following conditions— 

8 ‘‘(i) water or sewer service in the 

9 home is provided by a haul system with 

10 holding tanks and interior plumbing; 

11 ‘‘(ii) major significant interruptions to 

12 water supply or sewage disposal occur fre13 quently, requiring major capital improve14 ments to correct the deficiencies; or 

15 ‘‘(iii) there is no access to or no ap16 proved or permitted solid waste facility 

17 available. 

18 ‘‘(D) A level IV deficiency exists— 

19 ‘‘(i) if a sanitation facility for an indi20 vidual home, an Indian Tribe, or an Indian 

21 community exists but— 

22 ‘‘(I) lacks— 

23 ‘‘(aa) a safe water supply 

24 system; or 


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1 ‘‘(bb) a waste disposal sys2 tem; 

3 ‘‘(II) contains no piped water or 

4 sewer facilities; or 

5 ‘‘(III) has become inoperable due 

6 to a major component failure; or 

7 ‘‘(ii) if only a washeteria or central fa8 cility exists in the community. 

9 ‘‘(E) A level V deficiency exists in the ab10 sence of a sanitation facility, where individual 

11 homes do not have access to safe drinking 

12 water or adequate wastewater (including sew13 age) disposal. 

14 ‘‘(i) DEFINITIONS.—For purposes of this section, the 

15 following terms apply: 

16 ‘‘(1) INDIAN COMMUNITY.—The term ‘Indian 

17 community’ means a geographic area, a significant 

18 proportion of whose inhabitants are Indians and 

19 which is served by or capable of being served by a 

20 facility described in this section. 

21 ‘‘(2) SANITATION FACILITIES.—The terms 

22 ‘sanitation facility’ and ‘sanitation facilities’ mean 

23 safe and adequate water supply systems, sanitary 

24 sewage disposal systems, and sanitary solid waste 


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1 systems (and all related equipment and support in2 frastructure). 

3 ‘‘SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS. 

4 ‘‘(a) BUY INDIAN ACT.—The Secretary, acting 

5 through the Service, may use the negotiating authority of 

6 section 23 of the Act of June 25, 1910 (25 U.S.C. 47, 

7 commonly known as the ‘Buy Indian Act’), to give pref8 erence to any Indian or any enterprise, partnership, cor9 poration, or other type of business organization owned and 

10 controlled by an Indian or Indians including former or 

11 currently federally recognized Indian Tribes in the State 

12 of New York (hereinafter referred to as an ‘Indian firm’) 

13 in the construction and renovation of Service facilities pur14 suant to section 301 and in the construction of sanitation 

15 facilities pursuant to section 302. Such preference may be 

16 accorded by the Secretary unless the Secretary finds, pur17 suant to regulations, that the project or function to be 

18 contracted for will not be satisfactory or such project or 

19 function cannot be properly completed or maintained 

20 under the proposed contract. The Secretary, in arriving 

21 at such a finding, shall consider whether the Indian or 

22 Indian firm will be deficient with respect to— 

23 ‘‘(1) ownership and control by Indians; 

24 ‘‘(2) equipment; 

25 ‘‘(3) bookkeeping and accounting procedures; 


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1 ‘‘(4) substantive knowledge of the project or 

2 function to be contracted for; 

3 ‘‘(5) adequately trained personnel; or 

4 ‘‘(6) other necessary components of contract 

5 performance. 

6 ‘‘(b) PAY RATES.—For the purposes of implementing 

7 the provisions of this title, the Secretary shall assure that 

8 the rates of pay for personnel engaged in the construction 

9 or renovation of facilities constructed or renovated in 

10 whole or in part by funds made available pursuant to this 

11 title are not less than the prevailing local wage rates for 

12 similar work as determined in accordance with the Act of 

13 March 3, 1931 (40 U.S.C. 276a–276a-5, known as the 

14 Davis-Bacon Act). 

15 ‘‘(c) LABOR STANDARDS.—For the purposes of im16 plementing the provisions of this title, contracts for the 

17 construction or renovation of health care facilities, staff 

18 quarters, and sanitation facilities, and related support in19 frastructure, funded in whole or in part with funds made 

20 available pursuant to this title, shall contain a provision 

21 requiring compliance with subchapter IV of chapter 31 of 

22 title 40, United States Code (commonly known as the 

23 ‘Davis-Bacon Act’). 


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1 ‘‘SEC. 304. EXPENDITURE OF NON-SERVICE FUNDS FOR 

2 RENOVATION. 

3 ‘‘(a) IN GENERAL.—Notwithstanding any other pro4 vision of law, if the requirements of subsection (c) are met, 

5 the Secretary, acting through the Service, is authorized 

6 to accept any major expansion, renovation, or moderniza7 tion by any Indian Tribe or Tribal Organization of any 

8 Service facility or of any other Indian health facility oper9 ated pursuant to a contract or compact under the Indian 

10 Self-Determination and Education Assistance Act (25 

11 U.S.C. 450 et seq.), including— 

12 ‘‘(1) any plans or designs for such expansion, 

13 renovation, or modernization; and 

14 ‘‘(2) any expansion, renovation, or moderniza15 tion for which funds appropriated under any Federal 

16 law were lawfully expended. 

17 ‘‘(b) PRIORITY LIST.— 

18 ‘‘(1) IN GENERAL.—The Secretary shall main19 tain a separate priority list to address the needs for 

20 increased operating expenses, personnel, or equip21 ment for such facilities. The methodology for estab22 lishing priorities shall be developed through regula23 tions. The list of priority facilities will be revised an24 nually in consultation with Indian Tribes and Tribal 

25 Organizations. 


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1 ‘‘(2) REPORT.—The Secretary shall submit to 

2 the President, for inclusion in the report required to 

3 be transmitted to Congress under section 801, the 

4 priority list maintained pursuant to paragraph (1). 

5 ‘‘(c) REQUIREMENTS.—The requirements of this sub6 section are met with respect to any expansion, renovation, 

7 or modernization if— 

8 ‘‘(1) the Indian Tribe or Tribal Organization— 

9 ‘‘(A) provides notice to the Secretary of its 

10 intent to expand, renovate, or modernize; and 

11 ‘‘(B) applies to the Secretary to be placed 

12 on a separate priority list to address the needs 

13 of such new facilities for increased operating ex14 penses, personnel, or equipment; and 

15 ‘‘(2) the expansion, renovation, or moderniza16 tion— 

17 ‘‘(A) is approved by the appropriate area 

18 director of the Service for Federal facilities; and 

19 ‘‘(B) is administered by the Indian Tribe 

20 or Tribal Organization in accordance with any 

21 applicable regulations prescribed by the Sec22 retary with respect to construction or renova23 tion of Service facilities. 

24 ‘‘(d) ADDITIONAL REQUIREMENT FOR EXPANSION.— 

25 In addition to the requirements under subsection (c), for 


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1 any expansion, the Indian Tribe or Tribal Organization 

2 shall provide to the Secretary additional information pur3 suant to regulations, including additional staffing, equip4 ment, and other costs associated with the expansion. 

5 ‘‘(e) CLOSURE OR CONVERSION OF FACILITIES.—If 

6 any Service facility which has been expanded, renovated, 

7 or modernized by an Indian Tribe or Tribal Organization 

8 under this section ceases to be used as a Service facility 

9 during the 20-year period beginning on the date such ex10 pansion, renovation, or modernization is completed, such 

11 Indian Tribe or Tribal Organization shall be entitled to 

12 recover from the United States an amount which bears 

13 the same ratio to the value of such facility at the time 

14 of such cessation as the value of such expansion, renova15 tion, or modernization (less the total amount of any funds 

16 provided specifically for such facility under any Federal 

17 program that were expended for such expansion, renova18 tion, or modernization) bore to the value of such facility 

19 at the time of the completion of such expansion, renova20 tion, or modernization. 

21 ‘‘SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, 

22 AND MODERNIZATION OF SMALL AMBULA23 TORY CARE FACILITIES. 

24 ‘‘(a) GRANTS.— 


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1 ‘‘(1) IN GENERAL.—The Secretary, acting 

2 through the Service, shall make grants to Indian 

3 Tribes and Tribal Organizations for the construc4 tion, expansion, or modernization of facilities for the 

5 provision of ambulatory care services to eligible Indi6 ans (and noneligible persons pursuant to subsections 

7 (b)(2) and (c)(1)(C)). A grant made under this sec8 tion may cover up to 100 percent of the costs of 

9 such construction, expansion, or modernization. For 

10 the purposes of this section, the term ‘construction’ 

11 includes the replacement of an existing facility. 

12 ‘‘(2) GRANT AGREEMENT REQUIRED.—A grant 

13 under paragraph (1) may only be made available to 

14 a Tribal Health Program operating an Indian health 

15 facility (other than a facility owned or constructed 

16 by the Service, including a facility originally owned 

17 or constructed by the Service and transferred to an 

18 Indian Tribe or Tribal Organization). 

19 ‘‘(b) USE OF GRANT FUNDS.— 

20 ‘‘(1) ALLOWABLE USES.—A grant awarded 

21 under this section may be used for the construction, 

22 expansion, or modernization (including the planning 

23 and design of such construction, expansion, or mod24 ernization) of an ambulatory care facility— 

25 ‘‘(A) located apart from a hospital; 


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1 ‘‘(B) not funded under section 301 or sec2 tion 306; and 

3 ‘‘(C) which, upon completion of such con4 struction or modernization will— 

5 ‘‘(i) have a total capacity appropriate 

6 to its projected service population; 

7 ‘‘(ii) provide annually no fewer than 

8 150 patient visits by eligible Indians and 

9 other users who are eligible for services in 

10 such facility in accordance with section 

11 806(c)(2); and 

12 ‘‘(iii) provide ambulatory care in a 

13 Service Area (specified in the contract or 

14 compact under the Indian Self-Determina15 tion and Education Assistance Act (25 

16 U.S.C. 450 et seq.)) with a population of 

17 no fewer than 1,500 eligible Indians and 

18 other users who are eligible for services in 

19 such facility in accordance with section 

20 806(c)(2). 

21 ‘‘(2) ADDITIONAL ALLOWABLE USE.—The Sec22 retary may also reserve a portion of the funding pro23 vided under this section and use those reserved 

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1 struction, expansion, or modernization of an ambula2 tory care facility that meets the requirements under 

3 paragraph (1). The provisions of this section shall 

4 apply, except that such applications for funding 

5 under this paragraph shall be considered separately 

6 from applications for funding under paragraph (1). 

7 ‘‘(3) USE ONLY FOR CERTAIN PORTION OF

8 COSTS.—A grant provided under this section may be 

9 used only for the cost of that portion of a construc10 tion, expansion, or modernization project that bene11 fits the Service population identified above in sub12 section (b)(1)(C) (ii) and (iii). The requirements of 

13 clauses (ii) and (iii) of paragraph (1)(C) shall not 

14 apply to an Indian Tribe or Tribal Organization ap15 plying for a grant under this section for a health 

16 care facility located or to be constructed on an is17 land or when such facility is not located on a road 

18 system providing direct access to an inpatient hos19 pital where care is available to the Service popu20 lation. 

21 ‘‘(c) GRANTS.— 

22 ‘‘(1) APPLICATION.—No grant may be made 

23 under this section unless an application or proposal 

24 for the grant has been approved by the Secretary in 

25 accordance with applicable regulations and has set 


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1 forth reasonable assurance by the applicant that, at 

2 all times after the construction, expansion, or mod3 ernization of a facility carried out using a grant re4 ceived under this section— 

5 ‘‘(A) adequate financial support will be 

6 available for the provision of services at such 

7 facility; 

8 ‘‘(B) such facility will be available to eligi9 ble Indians without regard to ability to pay or 

10 source of payment; and 

11 ‘‘(C) such facility will, as feasible without 

12 diminishing the quality or quantity of services 

13 provided to eligible Indians, serve noneligible 

14 persons on a cost basis. 

15 ‘‘(2) PRIORITY.—In awarding grants under this 

16 section, the Secretary shall give priority to Indian 

17 Tribes and Tribal Organizations that demonstrate— 

18 ‘‘(A) a need for increased ambulatory care 

19 services; and 

20 ‘‘(B) insufficient capacity to deliver such 

21 services. 

22 ‘‘(3) PEER REVIEW PANELS.—The Secretary 

23 may provide for the establishment of peer review 

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1 garding such applications using the criteria devel2 oped pursuant to subsection (a)(1). 

3 ‘‘(d) REVERSION OF FACILITIES.—If any facility (or 

4 portion thereof) with respect to which funds have been 

5 paid under this section, ceases, at any time after comple6 tion of the construction, expansion, or modernization car7 ried out with such funds, to be used for the purposes of 

8 providing health care services to eligible Indians, all of the 

9 right, title, and interest in and to such facility (or portion 

10 thereof) shall transfer to the United States unless other11 wise negotiated by the Service and the Indian Tribe or 

12 Tribal Organization. 

13 ‘‘(e) FUNDING NONRECURRING.—Funding provided 

14 under this section shall be nonrecurring and shall not be 

15 available for inclusion in any individual Indian Tribe’s 

16 tribal share for an award under the Indian Self-Deter17 mination and Education Assistance Act (25 U.S.C. 450 

18 et seq.) or for reallocation or redesign thereunder. 

19 ‘‘SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRA20 TION PROJECT. 

21 ‘‘(a) HEALTH CARE DEMONSTRATION PROJECTS.— 

22 The Secretary, acting through the Service, is authorized 

23 to make grants to, and enter into construction contracts 

24 or construction project agreements with, Indian Tribes or 

25 Tribal Organizations under the Indian Self-Determination 


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1 and Education Assistance Act (25 U.S.C. 450 et seq.) for 

2 the purpose of carrying out a health care delivery dem3 onstration project to test alternative means of delivering 

4 health care and services to Indians through facilities. 

5 ‘‘(b) USE OF FUNDS.—The Secretary, in approving 

6 projects pursuant to this section, may authorize such con7 tracts for the construction and renovation of hospitals, 

8 health centers, health stations, and other facilities to de9 liver health care services and is authorized to— 

10 ‘‘(1) waive any leasing prohibition; 

11 ‘‘(2) permit carryover of funds appropriated for 

12 the provision of health care services; 

13 ‘‘(3) permit the use of other available funds; 

14 ‘‘(4) permit the use of funds or property do15 nated from any source for project purposes; 

16 ‘‘(5) provide for the reversion of donated real or 

17 personal property to the donor; and 

18 ‘‘(6) permit the use of Service funds to match 

19 other funds, including Federal funds. 

20 ‘‘(c) REGULATIONS.—The Secretary shall develop 

21 and promulgate regulations, not later than 1 year after 

22 the date of enactment of the Indian Health Care Improve23 ment Act Amendments of 2009, for the review and ap24 proval of applications submitted under this section. 


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1 ‘‘(d) CRITERIA.—The Secretary may approve projects 

2 that meet the following criteria: 

3 ‘‘(1) There is a need for a new facility or pro4 gram or the reorientation of an existing facility or 

5 program. 

6 ‘‘(2) A significant number of Indians, including 

7 those with low health status, will be served by the 

8 project. 

9 ‘‘(3) The project has the potential to deliver 

10 services in an efficient and effective manner. 

11 ‘‘(4) The project is economically viable. 

12 ‘‘(5) The Indian Tribe or Tribal Organization 

13 has the administrative and financial capability to ad14 minister the project. 

15 ‘‘(6) The project is integrated with providers of 

16 related health and social services and is coordinated 

17 with, and avoids duplication of, existing services. 

18 ‘‘(e) PEER REVIEW PANELS.—The Secretary may 

19 provide for the establishment of peer review panels, as nec20 essary, to review and evaluate applications using the cri21 teria developed pursuant to subsection (d). 

22 ‘‘(f) PRIORITY.—The Secretary shall give priority to 

23 applications for demonstration projects in each of the fol24 lowing Service Units to the extent that such applications 


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1 are timely filed and meet the criteria specified in sub2 section (d): 

3 ‘‘(1) Cass Lake, Minnesota. 

4 ‘‘(2) Mescalero, New Mexico. 

5 ‘‘(3) Owyhee, Nevada. 

6 ‘‘(4) Schurz, Nevada. 

7 ‘‘(5) Ft. Yuma, California. 

8 ‘‘(g) TECHNICAL ASSISTANCE.—The Secretary shall 

9 provide such technical and other assistance as may be nec10 essary to enable applicants to comply with the provisions 

11 of this section. 

12 ‘‘(h) SERVICE TO INELIGIBLE PERSONS.—Subject to 

13 section 806, the authority to provide services to persons 

14 otherwise ineligible for the health care benefits of the 

15 Service and the authority to extend hospital privileges in 

16 Service facilities to non-Service health practitioners as 

17 provided in section 806 may be included, subject to the 

18 terms of such section, in any demonstration project ap19 proved pursuant to this section. 

20 ‘‘(i) EQUITABLE TREATMENT.—For purposes of sub21 section (d)(1), the Secretary shall, in evaluating facilities 

22 operated under any contract or compact under the Indian 

23 Self-Determination and Education Assistance Act (25 

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1 retary uses in evaluating facilities operated directly by the 

2 Service. 

3 ‘‘(j) EQUITABLE INTEGRATION OF FACILITIES.—The 

4 Secretary shall ensure that the planning, design, construc5 tion, renovation, and expansion needs of Service and non6 Service facilities which are the subject of a contract or 

7 compact under the Indian Self-Determination and Edu8 cation Assistance Act (25 U.S.C. 450 et seq.) for health 

9 services are fully and equitably integrated into the imple10 mentation of the health care delivery demonstration 

11 projects under this section. 

12 ‘‘SEC. 307. LAND TRANSFER. 

13 ‘‘Notwithstanding any other provision of law, the Bu14 reau of Indian Affairs and all other agencies and depart15 ments of the United States are authorized to transfer, at 

16 no cost, land and improvements to the Service for the pro17 vision of health care services. The Secretary is authorized 

18 to accept such land and improvements for such purposes. 

19 ‘‘SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS. 

20 ‘‘The Secretary, acting through the Service, may 

21 enter into leases, contracts, and other agreements with In22 dian Tribes and Tribal Organizations which hold (1) title 

23 to, (2) a leasehold interest in, or (3) a beneficial interest 

24 in (when title is held by the United States in trust for 

25 the benefit of an Indian Tribe) facilities used or to be used 


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1 for the administration and delivery of health services by 

2 an Indian Health Program. Such leases, contracts, or 

3 agreements may include provisions for construction or ren4 ovation and provide for compensation to the Indian Tribe 

5 or Tribal Organization of rental and other costs consistent 

6 with section 105(l) of the Indian Self-Determination and 

7 Education Assistance Act (25 U.S.C. 450j(l)) and regula8 tions thereunder. 

9 ‘‘SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND 

10 LOAN REPAYMENT. 

11 ‘‘(a) IN GENERAL.—The Secretary, in consultation 

12 with the Secretary of the Treasury, Indian Tribes, and 

13 Tribal Organizations, shall carry out a study to determine 

14 the feasibility of establishing a loan fund to provide to In15 dian Tribes and Tribal Organizations direct loans or guar16 antees for loans for the construction of health care facili17 ties, including— 

18 ‘‘(1) inpatient facilities; 

19 ‘‘(2) outpatient facilities; 

20 ‘‘(3) staff quarters; 

21 ‘‘(4) hostels; and 

22 ‘‘(5) specialized care facilities, such as behav23 ioral health and elder care facilities. 

24 ‘‘(b) DETERMINATIONS.—In carrying out the study 

25 under subsection (a), the Secretary shall determine— 


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1 ‘‘(1) the maximum principal amount of a loan 

2 or loan guarantee that should be offered to a recipi3 ent from the loan fund; 

4 ‘‘(2) the percentage of eligible costs, not to ex5 ceed 100 percent, that may be covered by a loan or 

6 loan guarantee from the loan fund (including costs 

7 relating to planning, design, financing, site land de8 velopment, construction, rehabilitation, renovation, 

9 conversion, improvements, medical equipment and 

10 furnishings, and other facility-related costs and cap11 ital purchase (but excluding staffing)); 

12 ‘‘(3) the cumulative total of the principal of di13 rect loans and loan guarantees, respectively, that 

14 may be outstanding at any 1 time; 

15 ‘‘(4) the maximum term of a loan or loan guar16 antee that may be made for a facility from the loan 

17 fund; 

18 ‘‘(5) the maximum percentage of funds from 

19 the loan fund that should be allocated for payment 

20 of costs associated with planning and applying for a 

21 loan or loan guarantee; 

22 ‘‘(6) whether acceptance by the Secretary of an 

23 assignment of the revenue of an Indian Tribe or 

24 Tribal Organization as security for any direct loan 


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1 or loan guarantee from the loan fund would be ap2 propriate; 

3 ‘‘(7) whether, in the planning and design of 

4 health facilities under this section, users eligible 

5 under section 806(c) may be included in any projec6 tion of patient population; 

7 ‘‘(8) whether funds of the Service provided 

8 through loans or loan guarantees from the loan fund 

9 should be eligible for use in matching other Federal 

10 funds under other programs; 

11 ‘‘(9) the appropriateness of, and best methods 

12 for, coordinating the loan fund with the health care 

13 priority system of the Service under section 301; and 

14 ‘‘(10) any legislative or regulatory changes re15 quired to implement recommendations of the Sec16 retary based on results of the study. 

17 ‘‘(c) REPORT.—Not later than September 30, 2010, 

18 the Secretary shall submit to the Committee on Indian Af19 fairs of the Senate and the Committee on Natural Re20 sources and the Committee on Energy and Commerce of 

21 the House of Representatives a report that describes— 

22 ‘‘(1) the manner of consultation made as re23 quired by subsection (a); and 


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1 ‘‘(2) the results of the study, including any rec2 ommendations of the Secretary based on results of 

3 the study. 

4 ‘‘SEC. 310. TRIBAL LEASING. 

5 ‘‘A Tribal Health Program may lease permanent 

6 structures for the purpose of providing health care services 

7 without obtaining advance approval in appropriation Acts. 

8 ‘‘SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES 

9 JOINT VENTURE PROGRAM. 

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

11 the Service, shall make arrangements with Indian Tribes 

12 and Tribal Organizations to establish joint venture dem13 onstration projects under which an Indian Tribe or Tribal 

14 Organization shall expend tribal, private, or other avail15 able funds, for the acquisition or construction of a health 

16 facility for a minimum of 10 years, under a no-cost lease, 

17 in exchange for agreement by the Service to provide the 

18 equipment, supplies, and staffing for the operation and 

19 maintenance of such a health facility. An Indian Tribe or 

20 Tribal Organization may use tribal funds, private sector, 

21 or other available resources, including loan guarantees, to 

22 fulfill its commitment under a joint venture entered into 

23 under this subsection. An Indian Tribe or Tribal Organi24 zation shall be eligible to establish a joint venture project 

25 if, when it submits a letter of intent, it— 


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1 ‘‘(1) has begun but not completed the process 

2 of acquisition or construction of a health facility to 

3 be used in the joint venture project; 

4 ‘‘(2) has not begun the process of acquisition or 

5 construction of a health facility for use in the joint 

6 venture project; or 

7 ‘‘(3) in its application for a joint venture agree8 ment, agrees— 

9 ‘‘(A) to construct a facility for the joint 

10 venture which complies with the size and space 

11 criteria established by the Service; or 

12 ‘‘(B) if the facility it proposes for the joint 

13 venture is already in existence or under con14 struction, that only the portion of such facility 

15 which complies with the size and space criteria 

16 of the Service will be eligible for the joint ven17 ture agreement. 

18 ‘‘(b) REQUIREMENTS.—The Secretary shall make 

19 such an arrangement with an Indian Tribe or Tribal Orga20 nization only if— 

21 ‘‘(1) the Secretary first determines that the In22 dian Tribe or Tribal Organization has the adminis23 trative and financial capabilities necessary to com24 plete the timely acquisition or construction of the 

25 relevant health facility; and 


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1 ‘‘(2) the Indian Tribe or Tribal Organization 

2 meets the need criteria determined using the criteria 

3 developed under the health care facility priority sys4 tem under section 301, unless the Secretary deter5 mines, pursuant to regulations, that other criteria 

6 will result in a more cost-effective and efficient 

7 method of facilitating and completing construction of 

8 health care facilities. 

9 ‘‘(c) CONTINUED OPERATION.—The Secretary shall 

10 negotiate an agreement with the Indian Tribe or Tribal 

11 Organization regarding the continued operation of the fa12 cility at the end of the initial 10 year no-cost lease period. 

13 ‘‘(d) BREACH OF AGREEMENT.—An Indian Tribe or 

14 Tribal Organization that has entered into a written agree15 ment with the Secretary under this section, and that 

16 breaches or terminates without cause such agreement, 

17 shall be liable to the United States for the amount that 

18 has been paid to the Indian Tribe or Tribal Organization, 

19 or paid to a third party on the Indian Tribe’s or Tribal 

20 Organization’s behalf, under the agreement. The Sec21 retary has the right to recover tangible property (including 

22 supplies) and equipment, less depreciation, and any funds 

23 expended for operations and maintenance under this sec24 tion. The preceding sentence does not apply to any funds 


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1 expended for the delivery of health care services, per2 sonnel, or staffing. 

3 ‘‘(e) RECOVERY FOR NONUSE.—An Indian Tribe or 

4 Tribal Organization that has entered into a written agree5 ment with the Secretary under this subsection shall be en6 titled to recover from the United States an amount that 

7 is proportional to the value of such facility if, at any time 

8 within the 10-year term of the agreement, the Service 

9 ceases to use the facility or otherwise breaches the agree10 ment. 

11 ‘‘(f) DEFINITION.—For the purposes of this section, 

12 the term ‘health facility’ or ‘health facilities’ includes 

13 quarters needed to provide housing for staff of the rel14 evant Tribal Health Program. 

15 ‘‘SEC. 312. LOCATION OF FACILITIES. 

16 ‘‘(a) IN GENERAL.—In all matters involving the reor17 ganization or development of Service facilities or in the 

18 establishment of related employment projects to address 

19 unemployment conditions in economically depressed areas, 

20 the Bureau of Indian Affairs and the Service shall give 

21 priority to locating such facilities and projects on Indian 

22 lands, or lands in Alaska owned by any Alaska Native vil23 lage, or village or regional corporation under the Alaska 

24 Native Claims Settlement Act (43 U.S.C. 1601 et seq.), 

25 or any land allotted to any Alaska Native, if requested 


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1 by the Indian owner and the Indian Tribe with jurisdiction 

2 over such lands or other lands owned or leased by the In3 dian Tribe or Tribal Organization. Top priority shall be 

4 given to Indian land owned by 1 or more Indian Tribes. 

5 ‘‘(b) DEFINITION.—For purposes of this section, the 

6 term ‘Indian lands’ means— 

7 ‘‘(1) all lands within the exterior boundaries of 

8 any reservation; and 

9 ‘‘(2) any lands title to which is held in trust by 

10 the United States for the benefit of any Indian 

11 Tribe or individual Indian or held by any Indian 

12 Tribe or individual Indian subject to restriction by 

13 the United States against alienation. 

14 ‘‘SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH 

15 CARE FACILITIES. 

16 ‘‘(a) REPORT.—The Secretary shall submit to the 

17 President, for inclusion in the report required to be trans18 mitted to Congress under section 801, a report which iden19 tifies the backlog of maintenance and repair work required 

20 at both Service and tribal health care facilities, including 

21 new health care facilities expected to be in operation in 

22 the next fiscal year. The report shall also identify the need 

23 for renovation and expansion of existing facilities to sup24 port the growth of health care programs. 


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1 ‘‘(b) MAINTENANCE OF NEWLY CONSTRUCTED

2 SPACE.—The Secretary, acting through the Service, is au3 thorized to expend maintenance and improvement funds 

4 to support maintenance of newly constructed space only 

5 if such space falls within the approved supportable space 

6 allocation for the Indian Tribe or Tribal Organization. 

7 Supportable space allocation shall be defined through the 

8 health care facility priority system under section 301(c). 

9 ‘‘(c) REPLACEMENT FACILITIES.—In addition to 

10 using maintenance and improvement funds for renovation, 

11 modernization, and expansion of facilities, an Indian Tribe 

12 or Tribal Organization may use maintenance and improve13 ment funds for construction of a replacement facility if 

14 the costs of renovation of such facility would exceed a 

15 maximum renovation cost threshold. The Secretary shall 

16 consult with Indian Tribes and Tribal Organizations in de17 termining the maximum renovation cost threshold. 

18 ‘‘SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED 

19 QUARTERS. 

20 ‘‘(a) RENTAL RATES.— 

21 ‘‘(1) ESTABLISHMENT.—Notwithstanding any 

22 other provision of law, a Tribal Health Program 

23 which operates a hospital or other health facility and 

24 the federally owned quarters associated therewith 

25 pursuant to a contract or compact under the Indian 


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1 Self-Determination and Education Assistance Act 

2 (25 U.S.C. 450 et seq.) shall have the authority to 

3 establish the rental rates charged to the occupants 

4 of such quarters by providing notice to the Secretary 

5 of its election to exercise such authority. 

6 ‘‘(2) OBJECTIVES.—In establishing rental rates 

7 pursuant to authority of this subsection, a Tribal 

8 Health Program shall endeavor to achieve the fol9 lowing objectives: 

10 ‘‘(A) To base such rental rates on the rea11 sonable value of the quarters to the occupants 

12 thereof. 

13 ‘‘(B) To generate sufficient funds to pru14 dently provide for the operation and mainte15 nance of the quarters, and subject to the discre16 tion of the Tribal Health Program, to supply 

17 reserve funds for capital repairs and replace18 ment of the quarters. 

19 ‘‘(3) EQUITABLE FUNDING.—Any quarters 

20 whose rental rates are established by a Tribal 

21 Health Program pursuant to this subsection shall 

22 remain eligible for quarters improvement and repair 

23 funds to the same extent as all federally owned 

24 quarters used to house personnel in Services-sup25 ported programs. 


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1 ‘‘(4) NOTICE OF RATE CHANGE.—A Tribal 

2 Health Program which exercises the authority pro3 vided under this subsection shall provide occupants 

4 with no less than 60 days notice of any change in 

5 rental rates. 

6 ‘‘(b) DIRECT COLLECTION OF RENT.— 

7 ‘‘(1) IN GENERAL.—Notwithstanding any other 

8 provision of law, and subject to paragraph (2), a 

9 Tribal Health Program shall have the authority to 

10 collect rents directly from Federal employees who oc11 cupy such quarters in accordance with the following: 

12 ‘‘(A) The Tribal Health Program shall no13 tify the Secretary and the subject Federal em14 ployees of its election to exercise its authority 

15 to collect rents directly from such Federal em16 ployees. 

17 ‘‘(B) Upon receipt of a notice described in 

18 subparagraph (A), the Federal employees shall 

19 pay rents for occupancy of such quarters di20 rectly to the Tribal Health Program and the 

21 Secretary shall have no further authority to col22 lect rents from such employees through payroll 

23 deduction or otherwise. 

24 ‘‘(C) Such rent payments shall be retained 

25 by the Tribal Health Program and shall not be 


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1 made payable to or otherwise be deposited with 

2 the United States. 

3 ‘‘(D) Such rent payments shall be depos4 ited into a separate account which shall be used 

5 by the Tribal Health Program for the mainte6 nance (including capital repairs and replace7 ment) and operation of the quarters and facili8 ties as the Tribal Health Program shall deter9 mine. 

10 ‘‘(2) RETROCESSION OF AUTHORITY.—If a 

11 Tribal Health Program which has made an election 

12 under paragraph (1) requests retrocession of its au13 thority to directly collect rents from Federal employ14 ees occupying federally owned quarters, such ret15 rocession shall become effective on the earlier of— 

16 ‘‘(A) the first day of the month that begins 

17 no less than 180 days after the Tribal Health 

18 Program notifies the Secretary of its desire to 

19 retrocede; or 

20 ‘‘(B) such other date as may be mutually 

21 agreed by the Secretary and the Tribal Health 

22 Program. 

23 ‘‘(c) RATES IN ALASKA.—To the extent that a Tribal 

24 Health Program, pursuant to authority granted in sub25 section (a), establishes rental rates for federally owned 


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1 quarters provided to a Federal employee in Alaska, such 

2 rents may be based on the cost of comparable private rent3 al housing in the nearest established community with a 

4 year-round population of 1,500 or more individuals. 

5 ‘‘SEC. 315. APPLICABILITY OF BUY AMERICAN ACT RE6 QUIREMENT. 

7 ‘‘(a) APPLICABILITY.—The Secretary shall ensure 

8 that the requirements of the Buy American Act apply to 

9 all procurements made with funds provided pursuant to 

10 section 317. Indian Tribes and Tribal Organizations shall 

11 be exempt from these requirements. 

12 ‘‘(b) EFFECT OF VIOLATION.—If it has been finally 

13 determined by a court or Federal agency that any person 

14 intentionally affixed a label bearing a ‘Made in America’ 

15 inscription or any inscription with the same meaning, to 

16 any product sold in or shipped to the United States that 

17 is not made in the United States, such person shall be 

18 ineligible to receive any contract or subcontract made with 

19 funds provided pursuant to section 317, pursuant to the 

20 debarment, suspension, and ineligibility procedures de21 scribed in sections 9.400 through 9.409 of title 48, Code 

22 of Federal Regulations. 

23 ‘‘(c) DEFINITIONS.—For purposes of this section, the 

24 term ‘Buy American Act’ means title III of the Act enti25 tled ‘An Act making appropriations for the Treasury and 


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1 Post Office Departments for the fiscal year ending June 

2 30, 1934, and for other purposes’, approved March 3, 

3 1933 (41 U.S.C. 10a et seq.). 

4 ‘‘SEC. 316. OTHER FUNDING FOR FACILITIES. 

5 ‘‘(a) AUTHORITY TO ACCEPT FUNDS.—The Sec6 retary is authorized to accept from any source, including 

7 Federal and State agencies, funds that are available for 

8 the construction of health care facilities and use such 

9 funds to plan, design, and construct health care facilities 

10 for Indians and to place such funds into a contract or com11 pact under the Indian Self-Determination and Education 

12 Assistance Act (25 U.S.C. 450 et seq.). Receipt of such 

13 funds shall have no effect on the priorities established pur14 suant to section 301. 

15 ‘‘(b) INTERAGENCY AGREEMENTS.—The Secretary is 

16 authorized to enter into interagency agreements with 

17 other Federal agencies or State agencies and other entities 

18 and to accept funds from such Federal or State agencies 

19 or other sources to provide for the planning, design, and 

20 construction of health care facilities to be administered by 

21 Indian Health Programs in order to carry out the pur22 poses of this Act and the purposes for which the funds 

23 were appropriated or for which the funds were otherwise 

24 provided. 


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1 ‘‘(c) TRANSFERRED FUNDS.—Any Federal agency to 

2 which funds for the construction of health care facilities 

3 are appropriated is authorized to transfer such funds to 

4 the Secretary for the construction of health care facilities 

5 to carry out the purposes of this Act as well as the pur6 poses for which such funds are appropriated to such other 

7 Federal agency. 

8 ‘‘(d) ESTABLISHMENT OF STANDARDS.—The Sec9 retary, through the Service, shall establish standards by 

10 regulation for the planning, design, and construction of 

11 health care facilities serving Indians under this Act. 

12 ‘‘SEC. 317. AUTHORIZATION OF APPROPRIATIONS. 

13 ‘‘There are authorized to be appropriated such sums 

14 as may be necessary to carry out this title. 

15 ‘‘TITLE IV—ACCESS TO HEALTH 

16 SERVICES 

17 ‘‘SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SE18 CURITY ACT HEALTH BENEFITS PROGRAMS. 

19 ‘‘(a) DISREGARD OF MEDICARE, MEDICAID, AND

20 SCHIP PAYMENTS IN DETERMINING APPROPRIATIONS.— 

21 Any payments received by an Indian Health Program or 

22 by an urban Indian organization under title XVIII, XIX, 

23 or XXI of the Social Security Act for services provided 

24 to Indians eligible for benefits under such respective titles 


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1 shall not be considered in determining appropriations for 

2 the provision of health care and services to Indians. 

3 ‘‘(b) NONPREFERENTIAL TREATMENT.—Nothing in 

4 this Act authorizes the Secretary to provide services to an 

5 Indian with coverage under title XVIII, XIX, or XXI of 

6 the Social Security Act in preference to an Indian without 

7 such coverage. 

8 ‘‘(c) USE OF FUNDS.— 

9 ‘‘(1) SPECIAL FUND.— 

10 ‘‘(A) 100 PERCENT PASS-THROUGH OF

11 PAYMENTS DUE TO FACILITIES.—Notwith12 standing any other provision of law, but subject 

13 to paragraph (2), payments to which a facility 

14 of the Service is entitled by reason of a provi15 sion of title XVIII or XIX of the Social Secu16 rity Act shall be placed in a special fund to be 

17 held by the Secretary. In making payments 

18 from such fund, the Secretary shall ensure that 

19 each Service Unit of the Service receives 100 

20 percent of the amount to which the facilities of 

21 the Service, for which such Service Unit makes 

22 collections, are entitled by reason of a provision 

23 of either such title. 

24 ‘‘(B) USE OF FUNDS.—Amounts received 

25 by a facility of the Service under subparagraph 


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1 (A) by reason of a provision of title XVIII or 

2 XIX of the Social Security Act shall first be 

3 used (to such extent or in such amounts as are 

4 provided in appropriation Acts) for the purpose 

5 of making any improvements in the programs 

6 of the Service operated by or through such fa7 cility which may be necessary to achieve or 

8 maintain compliance with the applicable condi9 tions and requirements of such respective title. 

10 Any amounts so received that are in excess of 

11 the amount necessary to achieve or maintain 

12 such conditions and requirements shall, subject 

13 to consultation with the Indian Tribes being 

14 served by the Service Unit, be used for increas15 ing the facility’s capacity to provide, or improv16 ing the quality or accessibility of, services. 

17 ‘‘(2) DIRECT PAYMENT OPTION.—Paragraph 

18 (1) shall not apply to a Tribal Health Program upon 

19 the election of such Program under subsection (d) to 

20 receive payments directly. No payment may be made 

21 out of the special fund described in such paragraph 

22 with respect to reimbursement made for services 

23 provided by such Program during the period of such 

24 election. 

25 ‘‘(d) DIRECT BILLING.— 


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1 ‘‘(1) IN GENERAL.—Subject to complying with 

2 the requirements of paragraph (2), a Tribal Health 

3 Program may elect to directly bill for, and receive 

4 payment for, health care items and services provided 

5 by such Program for which payment is made under 

6 title XVIII, XIX, or XXI of the Social Security Act. 

7 ‘‘(2) DIRECT REIMBURSEMENT.— 

8 ‘‘(A) USE OF FUNDS.—Each Tribal Health 

9 Program making the election described in para10 graph (1) with respect to a program under title 

11 XVIII, XIX, or XXI of the Social Security Act 

12 shall be reimbursed directly by that program 

13 for items and services furnished without regard 

14 to subsection (c)(1), but all amounts so reim15 bursed shall be used by the Tribal Health Pro16 gram for the same purposes with respect to 

17 such Program for which payment under sub18 paragraph (A) of subsection (c)(1) to a facility 

19 of the Service may be used pursuant to sub20 paragraph (B) of such subsection with respect 

21 to the Service. 

22 ‘‘(B) AUDITS.—The amounts paid to a 

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1 cial Security Act shall be subject to all auditing 

2 requirements applicable to the program under 

3 such title, as well as all auditing requirements 

4 applicable to programs administered by an In5 dian Health Program. Nothing in the preceding 

6 sentence shall be construed as limiting the ap7 plication of auditing requirements applicable to 

8 amounts paid under title XVIII, XIX, or XXI 

9 of the Social Security Act. 

10 ‘‘(C) IDENTIFICATION OF SOURCE OF PAY11 MENTS.—Any Tribal Health Program that re12 ceives reimbursements or payments under title 

13 XVIII, XIX, or XXI of the Social Security Act 

14 shall provide to the Service a list of each pro15 vider enrollment number (or other identifier) 

16 under which such Program receives such reim17 bursements or payments. 

18 ‘‘(3) EXAMINATION AND IMPLEMENTATION OF

19 CHANGES.— 

20 ‘‘(A) IN GENERAL.—The Secretary, acting 

21 through the Service and with the assistance of 

22 the Administrator of the Centers for Medicare 

23 & Medicaid Services, shall examine on an ongo24 ing basis and implement any administrative 

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1 rect billing and reimbursement under the pro2 gram established under this subsection, includ3 ing any agreements with States that may be 

4 necessary to provide for direct billing under a 

5 program under title XIX or XXI of the Social 

6 Security Act. 

7 ‘‘(B) COORDINATION OF INFORMATION.— 

8 The Service shall provide the Administrator of 

9 the Centers for Medicare & Medicaid Services 

10 with copies of the lists submitted to the Service 

11 under paragraph (2)(C), enrollment data re12 garding patients served by the Service (and by 

13 Tribal Health Programs, to the extent such 

14 data is available to the Service), and such other 

15 information as the Administrator may require 

16 for purposes of administering title XVIII, XIX, 

17 or XXI of the Social Security Act. 

18 ‘‘(4) WITHDRAWAL FROM PROGRAM.—A Tribal 

19 Health Program that bills directly under the pro20 gram established under this subsection may with21 draw from participation in the same manner and 

22 under the same conditions that an Indian Tribe or 

23 Tribal Organization may retrocede a contracted pro24 gram to the Secretary under the authority of the In25 dian Self-Determination and Education Assistance 


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1 Act (25 U.S.C. 450 et seq.). All cost accounting and 

2 billing authority under the program established 

3 under this subsection shall be returned to the Sec4 retary upon the Secretary’s acceptance of the with5 drawal of participation in this program. 

6 ‘‘(5) TERMINATION FOR FAILURE TO COMPLY

7 WITH REQUIREMENTS.—The Secretary may termi8 nate the participation of a Tribal Health Program or 

9 in the direct billing program established under this 

10 subsection if the Secretary determines that the Pro11 gram has failed to comply with the requirements of 

12 paragraph (2). The Secretary shall provide a Tribal 

13 Health Program with notice of a determination that 

14 the Program has failed to comply with any such re15 quirement and a reasonable opportunity to correct 

16 such noncompliance prior to terminating the Pro17 gram’s participation in the direct billing program es18 tablished under this subsection. 

19 ‘‘(e) RELATED PROVISIONS UNDER THE SOCIAL SE20 CURITY ACT.—For provisions related to subsections (c) 

21 and (d), see sections 1880, 1911, and 2107(e)(1)(D) of 

22 the Social Security Act. 


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1 ‘‘SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERV2 ICE, INDIAN TRIBES, TRIBAL ORGANIZA3 TIONS, AND URBAN INDIAN ORGANIZATIONS 

4 TO FACILITATE OUTREACH, ENROLLMENT, 

5 AND COVERAGE OF INDIANS UNDER SOCIAL 

6 SECURITY ACT HEALTH BENEFIT PROGRAMS. 

7 ‘‘(a) INDIAN TRIBES AND TRIBAL ORGANIZA8 TIONS.—The Secretary, acting through the Service, shall 

9 make grants to or enter into contracts with Indian Tribes 

10 and Tribal Organizations to assist such Tribes and Tribal 

11 Organizations in establishing and administering programs 

12 on or near reservations, trust lands, and Alaska Native 

13 Villages, including programs to provide outreach and en14 rollment through video, electronic delivery methods, or 

15 telecommunication devices that allow real-time or time-de16 layed communication between individual Indians and the 

17 benefit program, to assist individual Indians— 

18 ‘‘(1) to enroll for benefits under a program es19 tablished under title XVIII, XIX, or XXI of the So20 cial Security Act; and 

21 ‘‘(2) with respect to such programs for which 

22 the charging of premiums and cost sharing is not 

23 prohibited under such programs, to pay premiums or 

24 cost sharing for coverage for such benefits, which 

25 may be based on financial need (as determined by 

26 the Indian Tribe or Tribes or Tribal Organizations 


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1 being served based on a schedule of income levels de2 veloped or implemented by such Tribe, Tribes, or 

3 Tribal Organizations). 

4 ‘‘(b) CONDITIONS.—The Secretary, acting through 

5 the Service, shall place conditions as deemed necessary to 

6 effect the purpose of this section in any grant or contract 

7 which the Secretary makes with any Indian Tribe or Trib8 al Organization pursuant to this section. Such conditions 

9 shall include requirements that the Indian Tribe or Tribal 

10 Organization successfully undertake— 

11 ‘‘(1) to determine the population of Indians eli12 gible for the benefits described in subsection (a); 

13 ‘‘(2) to educate Indians with respect to the ben14 efits available under the respective programs; 

15 ‘‘(3) to provide transportation for such indi16 vidual Indians to the appropriate offices for enroll17 ment or applications for such benefits; and 

18 ‘‘(4) to develop and implement methods of im19 proving the participation of Indians in receiving ben20 efits under such programs. 

21 ‘‘(c) APPLICATION TO URBAN INDIAN ORGANIZA22 TIONS.— 

23 ‘‘(1) IN GENERAL.—The provisions of sub24 section (a) shall apply with respect to grants and 

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1 spect to populations served by such organizations in 

2 the same manner they apply to grants and contracts 

3 with Indian Tribes and Tribal Organizations with 

4 respect to programs on or near reservations. 

5 ‘‘(2) REQUIREMENTS.—The Secretary shall in6 clude in the grants or contracts made or provided 

7 under paragraph (1) requirements that are— 

8 ‘‘(A) consistent with the requirements im9 posed by the Secretary under subsection (b); 

10 ‘‘(B) appropriate to urban Indian organi11 zations and urban Indians; and 

12 ‘‘(C) necessary to effect the purposes of 

13 this section. 

14 ‘‘(d) FACILITATING COOPERATION IN ENROLLMENT

15 AND RETENTION.—The Secretary, acting through the 

16 Centers for Medicare & Medicaid Services, shall consult 

17 with States, the Service, Indian Tribes, Tribal Organiza18 tions, and urban Indian organizations to develop and dis19 seminate best practices with respect to facilitating agree20 ments between the States and Indian Tribes, Tribal Orga21 nizations, and urban Indian organizations relating to en22 rollment and retention of Indians in programs established 

23 under titles XVIII, XIX, and XXI of the Social Security 

24 Act. 


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1 ‘‘(e) AGREEMENTS TO IMPROVE ENROLLMENT OF

2 INDIANS UNDER SOCIAL SECURITY ACT HEALTH BENE3 FITS PROGRAMS.—For provisions relating to agreements 

4 between the Secretary and the Service, Indian Tribes, 

5 Tribal Organizations, and urban Indian organizations for 

6 the collection, preparation, and submission of applications 

7 by Indians for assistance under the Medicaid and chil8 dren’s health insurance programs established under titles 

9 XIX and XXI of the Social Security Act, and benefits 

10 under the Medicare program established under title XVIII 

11 of such Act, see subsections (a) and (b) of section 1139 

12 of the Social Security Act. 

13 ‘‘(f) DEFINITIONS.—In this section: 

14 ‘‘(1) PREMIUM.—The term ‘premium’ includes 

15 any enrollment fee or similar charge. 

16 ‘‘(2) COST SHARING.—The term ‘cost sharing’ 

17 includes any deduction, deductible, copayment, coin18 surance, or similar charge. 

19 ‘‘(3) BENEFITS.—The term ‘benefits’ means, 

20 with respect to— 

21 ‘‘(A) title XVIII of the Social Security Act, 

22 benefits under such title; 

23 ‘‘(B) title XIX of such Act, medical assist24 ance under such title; and 


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1 ‘‘(C) title XXI of such Act, assistance 

2 under such title. 

3 ‘‘SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PAR4 TIES OF COSTS OF HEALTH SERVICES. 

5 ‘‘(a) RIGHT OF RECOVERY.—Except as provided in 

6 subsection (f), the United States, an Indian Tribe, or 

7 Tribal Organization shall have the right to recover from 

8 an insurance company, health maintenance organization, 

9 employee benefit plan, third-party tortfeasor, or any other 

10 responsible or liable third party (including a political sub11 division or local governmental entity of a State) the rea12 sonable charges incurred by the Secretary, an Indian 

13 Tribe, or Tribal Organization, or, if higher, the highest 

14 amount the third party would pay for care and services 

15 furnished by providers other than governmental entities, 

16 in providing health services through the Service, an Indian 

17 Tribe, or Tribal Organization to any individual to the 

18 same extent that such individual, or any nongovernmental 

19 provider of such services, would be eligible to receive dam20 ages, reimbursement, or indemnification for such charges 

21 if— 

22 ‘‘(1) such services had been provided by a non23 governmental provider; and 


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1 ‘‘(2) such individual had been required to pay 

2 such charges or expenses and did pay such charges 

3 or expenses. 

4 ‘‘(b) LIMITATIONS ON RECOVERIES FROM STATES.— 

5 Subsection (a) shall provide a right of recovery against 

6 any State, only if the injury, illness, or disability for which 

7 health services were provided is covered under— 

8 ‘‘(1) workers’ compensation laws; or 

9 ‘‘(2) a no-fault automobile accident insurance 

10 plan or program. 

11 ‘‘(c) NONAPPLICATION OF OTHER LAWS.—No law of 

12 any State, or of any political subdivision of a State and 

13 no provision of any contract, insurance or health mainte14 nance organization policy, employee benefit plan, self-in15 surance plan, managed care plan, or other health care plan 

16 or program entered into or renewed after the date of the 

17 enactment of the Indian Health Care Amendments of 

18 1988, shall prevent or hinder the right of recovery of the 

19 United States, an Indian Tribe, or Tribal Organization 

20 under subsection (a). 

21 ‘‘(d) NO EFFECT ON PRIVATE RIGHTS OF ACTION.— 

22 No action taken by the United States, an Indian Tribe, 

23 or Tribal Organization to enforce the right of recovery 

24 provided under this section shall operate to deny to the 


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1 injured person the recovery for that portion of the person’s 

2 damage not covered hereunder. 

3 ‘‘(e) ENFORCEMENT.— 

4 ‘‘(1) IN GENERAL.—The United States, an In5 dian Tribe, or Tribal Organization may enforce the 

6 right of recovery provided under subsection (a) by— 

7 ‘‘(A) intervening or joining in any civil ac8 tion or proceeding brought— 

9 ‘‘(i) by the individual for whom health 

10 services were provided by the Secretary, an 

11 Indian Tribe, or Tribal Organization; or 

12 ‘‘(ii) by any representative or heirs of 

13 such individual, or 

14 ‘‘(B) instituting a civil action, including a 

15 civil action for injunctive relief and other relief 

16 and including, with respect to a political sub17 division or local governmental entity of a State, 

18 such an action against an official thereof. 

19 ‘‘(2) NOTICE.—All reasonable efforts shall be 

20 made to provide notice of action instituted under 

21 paragraph (1)(B) to the individual to whom health 

22 services were provided, either before or during the 

23 pendency of such action. 

24 ‘‘(3) RECOVERY FROM TORTFEASORS.— 


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1 ‘‘(A) IN GENERAL.—In any case in which 

2 an Indian Tribe or Tribal Organization that is 

3 authorized or required under a compact or con4 tract issued pursuant to the Indian Self-Deter5 mination and Education Assistance Act (25 

6 U.S.C. 450 et seq.) to furnish or pay for health 

7 services to a person who is injured or suffers a 

8 disease on or after the date of enactment of the 

9 Indian Health Care Improvement Act Amend10 ments of 2009 under circumstances that estab11 lish grounds for a claim of liability against the 

12 tortfeasor with respect to the injury or disease, 

13 the Indian Tribe or Tribal Organization shall 

14 have a right to recover from the tortfeasor (or 

15 an insurer of the tortfeasor) the reasonable 

16 value of the health services so furnished, paid 

17 for, or to be paid for, in accordance with the 

18 Federal Medical Care Recovery Act (42 U.S.C. 

19 2651 et seq.), to the same extent and under the 

20 same circumstances as the United States may 

21 recover under that Act. 

22 ‘‘(B) TREATMENT.—The right of an In23 dian Tribe or Tribal Organization to recover 

24 under subparagraph (A) shall be independent of 

25 the rights of the injured or diseased person 


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1 served by the Indian Tribe or Tribal Organiza2 tion. 

3 ‘‘(f) LIMITATION.—Absent specific written authoriza4 tion by the governing body of an Indian Tribe for the pe5 riod of such authorization (which may not be for a period 

6 of more than 1 year and which may be revoked at any 

7 time upon written notice by the governing body to the 

8 Service), the United States shall not have a right of recov9 ery under this section if the injury, illness, or disability 

10 for which health services were provided is covered under 

11 a self-insurance plan funded by an Indian Tribe, Tribal 

12 Organization, or urban Indian organization. Where such 

13 authorization is provided, the Service may receive and ex14 pend such amounts for the provision of additional health 

15 services consistent with such authorization. 

16 ‘‘(g) COSTS AND ATTORNEYS’ FEES.—In any action 

17 brought to enforce the provisions of this section, a pre18 vailing plaintiff shall be awarded its reasonable attorneys’ 

19 fees and costs of litigation. 

20 ‘‘(h) NONAPPLICATION OF CLAIMS FILING REQUIRE21 MENTS.—An insurance company, health maintenance or22 ganization, self-insurance plan, managed care plan, or 

23 other health care plan or program (under the Social Secu24 rity Act or otherwise) may not deny a claim for benefits 

25 submitted by the Service or by an Indian Tribe or Tribal 


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1 Organization based on the format in which the claim is 

2 submitted if such format complies with the format re3 quired for submission of claims under title XVIII of the 

4 Social Security Act or recognized under section 1175 of 

5 such Act. 

6 ‘‘(i) APPLICATION TO URBAN INDIAN ORGANIZA7 TIONS.—The previous provisions of this section shall apply 

8 to urban Indian organizations with respect to populations 

9 served by such Organizations in the same manner they 

10 apply to Indian Tribes and Tribal Organizations with re11 spect to populations served by such Indian Tribes and 

12 Tribal Organizations. 

13 ‘‘(j) STATUTE OF LIMITATIONS.—The provisions of 

14 section 2415 of title 28, United States Code, shall apply 

15 to all actions commenced under this section, and the ref16 erences therein to the United States are deemed to include 

17 Indian Tribes, Tribal Organizations, and urban Indian or18 ganizations. 

19 ‘‘(k) SAVINGS.—Nothing in this section shall be con20 strued to limit any right of recovery available to the 

21 United States, an Indian Tribe, or Tribal Organization 

22 under the provisions of any applicable, Federal, State, or 

23 Tribal law, including medical lien laws. 


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1 ‘‘SEC. 404. CREDITING OF REIMBURSEMENTS. 

2 ‘‘(a) RETENTION OF AMOUNTS FOR USE BY PRO3 GRAM.—Except as provided in section 202(f) (relating to 

4 the Catastrophic Health Emergency Fund) and section 

5 806 (relating to health services for ineligible persons), all 

6 reimbursements received or recovered, including under 

7 section 806, by reason of the provision of health services 

8 by the Service, by an Indian Tribe or Tribal Organization, 

9 or by an urban Indian organization, shall be credited to 

10 the Service, such Indian Tribe or Tribal Organization, or 

11 such urban Indian organization, respectively, and may be 

12 used as provided in section 401. In the case of such a 

13 service provided by or through a Service Unit, such 

14 amounts shall be credited to such unit and used for such 

15 purposes. 

16 ‘‘(b) NO OFFSET OF AMOUNTS.—The Service may 

17 not offset or limit any amount obligated to any Service 

18 Unit or entity receiving funding from the Service because 

19 of the receipt of reimbursements under subsection (a). 

20 ‘‘SEC. 405. PURCHASING HEALTH CARE COVERAGE. 

21 ‘‘(a) PURCHASING COVERAGE.— 

22 ‘‘(1) IN GENERAL.—Insofar as amounts are 

23 made available under law (including a provision of 

24 the Social Security Act, the Indian Self-Determina25 tion and Education Assistance Act (25 U.S.C. 450 

26 et seq.), or other law, other than under section 402) 


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1 to Indian Tribes, Tribal Organizations, and urban 

2 Indian organizations for health benefits for Service 

3 beneficiaries, Indian Tribes, Tribal Organizations, 

4 and urban Indian organizations may use such 

5 amounts to purchase health benefits coverage that 

6 qualifies as creditable coverage under section 

7 2701(c)(1) of the Public Health Service Act for such 

8 beneficiaries, including, subject to paragraph (2), 

9 through— 

10 ‘‘(A) a tribally owned and operated health 

11 care plan; 

12 ‘‘(B) a State or locally authorized or li13 censed health care plan; 

14 ‘‘(C) a health insurance provider or man15 aged care organization; or 

16 ‘‘(D) a self-insured plan. 

17 ‘‘(2) EXCEPTION.—The coverage provided 

18 under paragraph (1) may not include coverage con19 sisting of— 

20 ‘‘(A) benefits provided under a health flexi21 ble spending arrangement (as defined in section 

22 106(c)(2) of the Internal Revenue Code of 

23 1986); or 

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1 out regard to whether the plan is purchased in 

2 conjunction with a health savings account (as 

3 defined under section 223(d) of such Code). 

4 ‘‘(3) PERMITTING PURCHASE OF COVERAGE

5 BASED ON FINANCIAL NEED.—The purchase of cov6 erage by an Indian Tribe, Tribal Organization, or 

7 urban Indian organization under this subsection may 

8 be based on the financial needs of beneficiaries (as 

9 determined by the Indian Tribe or Tribes being 

10 served based on a schedule of income levels devel11 oped or implemented by such Indian Tribe or 

12 Tribes). 

13 ‘‘(b) EXPENSES FOR SELF-INSURED PLAN.—In the 

14 case of a self-insured plan under subsection (a)(4), the 

15 amounts may be used for expenses of operating the plan, 

16 including administration and insurance to limit the finan17 cial risks to the entity offering the plan. 

18 ‘‘(c) CONSTRUCTION.—Nothing in this section shall 

19 be construed as affecting the use of any amounts not re20 ferred to in subsection (a). 

21 ‘‘SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGEN22 CIES. 

23 ‘‘(a) AUTHORITY.— 

24 ‘‘(1) IN GENERAL.—The Secretary may enter 

25 into (or expand) arrangements for the sharing of 


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1 medical facilities and services between the Service, 

2 Indian Tribes, and Tribal Organizations and the De3 partment of Veterans Affairs and the Department of 

4 Defense. 

5 ‘‘(2) CONSULTATION BY SECRETARY RE6 QUIRED.—The Secretary may not finalize any ar7 rangement between the Service and a Department 

8 described in paragraph (1) without first consulting 

9 with the Indian Tribes which will be significantly af10 fected by the arrangement. 

11 ‘‘(b) LIMITATIONS.—The Secretary shall not take 

12 any action under this section or under subchapter IV of 

13 chapter 81 of title 38, United States Code, which would 

14 impair— 

15 ‘‘(1) the priority access of any Indian to health 

16 care services provided through the Service and the 

17 eligibility of any Indian to receive health services 

18 through the Service; 

19 ‘‘(2) the quality of health care services provided 

20 to any Indian through the Service; 

21 ‘‘(3) the priority access of any veteran to health 

22 care services provided by the Department of Vet23 erans Affairs; 


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1 ‘‘(4) the quality of health care services provided 

2 by the Department of Veterans Affairs or the De3 partment of Defense; or 

4 ‘‘(5) the eligibility of any Indian who is a vet5 eran to receive health services through the Depart6 ment of Veterans Affairs. 

7 ‘‘(c) REIMBURSEMENT.—The Service, Indian Tribe, 

8 or Tribal Organization shall be reimbursed by the Depart9 ment of Veterans Affairs or the Department of Defense 

10 (as the case may be) where services are provided through 

11 the Service, an Indian Tribe, or a Tribal Organization to 

12 beneficiaries eligible for services from either such Depart13 ment, notwithstanding any other provision of law. 

14 ‘‘(d) CONSTRUCTION.—Nothing in this section may 

15 be construed as creating any right of a non-Indian veteran 

16 to obtain health services from the Service. 

17 ‘‘SEC. 407. ELIGIBLE INDIAN VETERAN SERVICES. 

18 ‘‘(a) FINDINGS; PURPOSE.— 

19 ‘‘(1) FINDINGS.—Congress finds that— 

20 ‘‘(A) collaborations between the Secretary 

21 and the Secretary of Veterans Affairs regarding 

22 the treatment of Indian veterans at facilities of 

23 the Service should be encouraged to the max24 imum extent practicable; and 


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1 ‘‘(B) increased enrollment for services of 

2 the Department of Veterans Affairs by veterans 

3 who are members of Indian tribes should be en4 couraged to the maximum extent practicable. 

5 ‘‘(2) PURPOSE.—The purpose of this section is 

6 to reaffirm the goals stated in the document entitled 

7 ‘Memorandum of Understanding Between the VA/ 

8 Veterans Health Administration And HHS/Indian 

9 Health Service’ and dated February 25, 2003 (relat10 ing to cooperation and resource sharing between the 

11 Veterans Health Administration and Service). 

12 ‘‘(b) DEFINITIONS.—In this section: 

13 ‘‘(1) ELIGIBLE INDIAN VETERAN.—The term 

14 ‘eligible Indian veteran’ means an Indian or Alaska 

15 Native veteran who receives any medical service that 

16 is— 

17 ‘‘(A) authorized under the laws adminis18 tered by the Secretary of Veterans Affairs; and 

19 ‘‘(B) administered at a facility of the Serv20 ice (including a facility operated by an Indian 

21 tribe or tribal organization through a contract 

22 or compact with the Service under the Indian 

23 Self-Determination and Education Assistance 

24 Act (25 U.S.C. 450 et seq.)) pursuant to a local 

25 memorandum of understanding. 


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1 ‘‘(2) LOCAL MEMORANDUM OF UNDER2 STANDING.—The term ‘local memorandum of under3 standing’ means a memorandum of understanding 

4 between the Secretary (or a designee, including the 

5 director of any Area Office of the Service) and the 

6 Secretary of Veterans Affairs (or a designee) to im7 plement the document entitled ‘Memorandum of Un8 derstanding Between the VA/Veterans Health Ad9 ministration And HHS/Indian Health Service’ and 

10 dated February 25, 2003 (relating to cooperation 

11 and resource sharing between the Veterans Health 

12 Administration and Indian Health Service). 

13 ‘‘(c) ELIGIBLE INDIAN VETERANS’ EXPENSES.— 

14 ‘‘(1) IN GENERAL.—Notwithstanding any other 

15 provision of law, the Secretary shall provide for vet16 eran-related expenses incurred by eligible Indian vet17 erans as described in subsection (b)(1)(B). 

18 ‘‘(2) METHOD OF PAYMENT.—The Secretary 

19 shall establish such guidelines as the Secretary de20 termines to be appropriate regarding the method of 

21 payments to the Secretary of Veterans Affairs under 

22 paragraph (1). 

23 ‘‘(d) TRIBAL APPROVAL OF MEMORANDA.—In nego24 tiating a local memorandum of understanding with the 

25 Secretary of Veterans Affairs regarding the provision of 


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1 services to eligible Indian veterans, the Secretary shall 

2 consult with each Indian tribe that would be affected by 

3 the local memorandum of understanding. 

4 ‘‘(e) FUNDING.— 

5 ‘‘(1) TREATMENT.—Expenses incurred by the 

6 Secretary in carrying out subsection (c)(1) shall not 

7 be considered to be Contract Health Service ex8 penses. 

9 ‘‘(2) USE OF FUNDS.—Of funds made available 

10 to the Secretary in appropriations Acts for the Serv11 ice (excluding funds made available for facilities, 

12 Contract Health Services, or contract support costs), 

13 the Secretary shall use such sums as are necessary 

14 to carry out this section. 

15 ‘‘SEC. 408. PAYOR OF LAST RESORT. 

16 ‘‘Indian Health Programs and health care programs 

17 operated by Urban Indian Organizations shall be the 

18 payor of last resort for services provided to persons eligible 

19 for services from Indian Health Programs and Urban In20 dian Organizations, notwithstanding any Federal, State, 

21 or local law to the contrary. 

22 ‘‘SEC. 409. CONSULTATION. 

23 ‘‘For provisions related to consultation with rep24 resentatives of Indian Health Programs and urban Indian 

25 organizations with respect to the health care programs esVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01844 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 tablished under titles XVIII, XIX, and XXI of the Social 

2 Security Act, see section 1139(d) of the Social Security 

3 Act (42 U.S.C. 1320b–9(d)). 

4 ‘‘SEC. 410. STATE CHILDREN’S HEALTH INSURANCE PRO5 GRAM (SCHIP). 

6 ‘‘For provisions relating to— 

7 ‘‘(1) outreach to families of Indian children 

8 likely to be eligible for child health assistance under 

9 the State children’s health insurance program estab10 lished under title XXI of the Social Security Act, see 

11 sections 2105(c)(2)(C) and 1139(a) of such Act (42 

12 U.S.C. 1397ee(c)(2), 1320b–9); and 

13 ‘‘(2) ensuring that child health assistance is 

14 provided under such program to targeted low-income 

15 children who are Indians and that payments are 

16 made under such program to Indian Health Pro17 grams and urban Indian organizations operating in 

18 the State that provide such assistance, see sections 

19 2102(b)(3)(D) and 2105(c)(6)(B) of such Act (42 

20 U.S.C. 1397bb(b)(3)(D), 1397ee(c)(6)(B)). 


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1 ‘‘SEC. 411. PREMIUM AND COST SHARING PROTECTIONS 

2 AND ELIGIBILITY DETERMINATIONS UNDER 

3 MEDICAID AND SCHIP AND PROTECTION OF 

4 CERTAIN INDIAN PROPERTY FROM MEDICAID 

5 ESTATE RECOVERY. 

6 ‘‘For provisions relating to— 

7 ‘‘(1) premiums or cost sharing protections for 

8 Indians furnished items or services directly by In9 dian Health Programs or through referral under the 

10 contract health service under the Medicaid program 

11 established under title XIX of the Social Security 

12 Act, see sections 1916(j) and 1916A(a)(1) of the So13 cial Security Act (42 U.S.C. 1396o(j), 1396o– 

14 1(a)(1)); 

15 ‘‘(2) rules regarding the treatment of certain 

16 property for purposes of determining eligibility 

17 under such programs, see sections 1902(e)(13) and 

18 2107(e)(1)(B) of such Act (42 U.S.C. 1396a(e)(13), 

19 1397gg(e)(1)(B)); and 

20 ‘‘(3) the protection of certain property from es21 tate recovery provisions under the Medicaid pro22 gram, see section 1917(b)(3)(B) of such Act (42 

23 U.S.C. 1396p(b)(3)(B)). 


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1 ‘‘SEC. 412. TREATMENT UNDER MEDICAID AND SCHIP MAN2 AGED CARE. 

3 ‘‘For provisions relating to the treatment of Indians 

4 enrolled in a managed care entity under the Medicaid pro5 gram under title XIX of the Social Security Act and In6 dian Health Programs and urban Indian organizations 

7 that are providers of items or services to such Indian en8 rollees, see sections 1932(h) and 2107(e)(1)(H) of the So9 cial Security Act (42 U.S.C. 1396u–2(h), 

10 1397gg(e)(1)(H)). 

11 ‘‘SEC. 413. NAVAJO NATION MEDICAID AGENCY FEASI12 BILITY STUDY. 

13 ‘‘(a) STUDY.—The Secretary shall conduct a study 

14 to determine the feasibility of treating the Navajo Nation 

15 as a State for the purposes of title XIX of the Social Secu16 rity Act, to provide services to Indians living within the 

17 boundaries of the Navajo Nation through an entity estab18 lished having the same authority and performing the same 

19 functions as single-State Medicaid agencies responsible for 

20 the administration of the State plan under title XIX of 

21 the Social Security Act. 

22 ‘‘(b) CONSIDERATIONS.—In conducting the study, 

23 the Secretary shall consider the feasibility of— 

24 ‘‘(1) assigning and paying all expenditures for 

25 the provision of services and related administration 

26 funds, under title XIX of the Social Security Act, to 


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1 Indians living within the boundaries of the Navajo 

2 Nation that are currently paid to or would otherwise 

3 be paid to the State of Arizona, New Mexico, or 

4 Utah; 

5 ‘‘(2) providing assistance to the Navajo Nation 

6 in the development and implementation of such enti7 ty for the administration, eligibility, payment, and 

8 delivery of medical assistance under title XIX of the 

9 Social Security Act; 

10 ‘‘(3) providing an appropriate level of matching 

11 funds for Federal medical assistance with respect to 

12 amounts such entity expends for medical assistance 

13 for services and related administrative costs; and 

14 ‘‘(4) authorizing the Secretary, at the option of 

15 the Navajo Nation, to treat the Navajo Nation as a 

16 State for the purposes of title XIX of the Social Se17 curity Act (relating to the State children’s health in18 surance program) under terms equivalent to those 

19 described in paragraphs (2) through (4). 

20 ‘‘(c) REPORT.—Not later than 3 years after the date 

21 of enactment of the Indian Health Care Improvement Act 

22 Amendments of 2009, the Secretary shall submit to the 

23 Committee on Indian Affairs and Committee on Finance 

24 of the Senate and the Committee on Natural Resources 


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1 and Committee on Energy and Commerce of the House 

2 of Representatives a report that includes— 

3 ‘‘(1) the results of the study under this section; 

4 ‘‘(2) a summary of any consultation that oc5 curred between the Secretary and the Navajo Na6 tion, other Indian Tribes, the States of Arizona, 

7 New Mexico, and Utah, counties which include Nav8 ajo Lands, and other interested parties, in con9 ducting this study; 

10 ‘‘(3) projected costs or savings associated with 

11 establishment of such entity, and any estimated im12 pact on services provided as described in this section 

13 in relation to probable costs or savings; and 

14 ‘‘(4) legislative actions that would be required 

15 to authorize the establishment of such entity if such 

16 entity is determined by the Secretary to be feasible. 

17 ‘‘SEC. 414. EXCEPTION FOR EXCEPTED BENEFITS. 

18 ‘‘The previous provisions of this title shall not apply 

19 to the provision of excepted benefits described in para20 graph (1)(A) or (3) of section 2791(c) of the Public 

21 Health Service Act (42 U.S.C. 300gg–91(c)). 

22 ‘‘SEC. 415. AUTHORIZATION OF APPROPRIATIONS. 

23 ‘‘There are authorized to be appropriated such sums 

24 as may be necessary to carry out this title. 


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1 ‘‘TITLE V—HEALTH SERVICES 

2 FOR URBAN INDIANS 

3 ‘‘SEC. 501. PURPOSE. 

4 ‘‘The purpose of this title is to establish and maintain 

5 programs in Urban Centers to make health services more 

6 accessible and available to Urban Indians. 

7 ‘‘SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN IN8 DIAN ORGANIZATIONS. 

9 ‘‘Under authority of the Act of November 2, 1921 

10 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), 

11 the Secretary, acting through the Service, shall enter into 

12 contracts with, or make grants to, urban Indian organiza13 tions to assist such organizations in the establishment and 

14 administration, within Urban Centers, of programs which 

15 meet the requirements set forth in this title. Subject to 

16 section 506, the Secretary, acting through the Service, 

17 shall include such conditions as the Secretary considers 

18 necessary to effect the purpose of this title in any contract 

19 into which the Secretary enters with, or in any grant the 

20 Secretary makes to, any urban Indian organization pursu21 ant to this title. 

22 ‘‘SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION 

23 OF HEALTH CARE AND REFERRAL SERVICES. 

24 ‘‘(a) REQUIREMENTS FOR GRANTS AND CON25 TRACTS.—Under authority of the Act of November 2, 


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1 1921 (25 U.S.C. 13) (commonly known as the ‘Snyder 

2 Act’), the Secretary, acting through the Service, shall 

3 enter into contracts with, and make grants to, urban In4 dian organizations for the provision of health care and re5 ferral services for Urban Indians. Any such contract or 

6 grant shall include requirements that the urban Indian or7 ganization successfully undertake to— 

8 ‘‘(1) estimate the population of Urban Indians 

9 residing in the Urban Center or centers that the or10 ganization proposes to serve who are or could be re11 cipients of health care or referral services; 

12 ‘‘(2) estimate the current health status of 

13 Urban Indians residing in such Urban Center or 

14 centers; 

15 ‘‘(3) estimate the current health care needs of 

16 Urban Indians residing in such Urban Center or 

17 centers; 

18 ‘‘(4) provide basic health education, including 

19 health promotion and disease prevention education, 

20 to Urban Indians; 

21 ‘‘(5) make recommendations to the Secretary 

22 and Federal, State, local, and other resource agen23 cies on methods of improving health service pro24 grams to meet the needs of Urban Indians; and 


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1 ‘‘(6) where necessary, provide, or enter into 

2 contracts for the provision of, health care services 

3 for Urban Indians. 

4 ‘‘(b) CRITERIA.—The Secretary, acting through the 

5 Service, shall, by regulation, prescribe the criteria for se6 lecting urban Indian organizations to enter into contracts 

7 or receive grants under this section. Such criteria shall, 

8 among other factors, include— 

9 ‘‘(1) the extent of unmet health care needs of 

10 Urban Indians in the Urban Center or centers in11 volved; 

12 ‘‘(2) the size of the urban Indian population in 

13 the Urban Center or centers involved; 

14 ‘‘(3) the extent, if any, to which the activities 

15 set forth in subsection (a) would duplicate any 

16 project funded under this title, or under any current 

17 public health service project funded in a manner 

18 other than pursuant to this title; 

19 ‘‘(4) the capability of an urban Indian organiza20 tion to perform the activities set forth in subsection 

21 (a) and to enter into a contract with the Secretary 

22 or to meet the requirements for receiving a grant 

23 under this section; 


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1 ‘‘(5) the satisfactory performance and success2 ful completion by an urban Indian organization of 

3 other contracts with the Secretary under this title; 

4 ‘‘(6) the appropriateness and likely effectiveness 

5 of conducting the activities set forth in subsection 

6 (a) in an Urban Center or centers; and 

7 ‘‘(7) the extent of existing or likely future par8 ticipation in the activities set forth in subsection (a) 

9 by appropriate health and health-related Federal, 

10 State, local, and other agencies. 

11 ‘‘(c) ACCESS TO HEALTH PROMOTION AND DISEASE

12 PREVENTION PROGRAMS.—The Secretary, acting through 

13 the Service, shall facilitate access to or provide health pro14 motion and disease prevention services for Urban Indians 

15 through grants made to urban Indian organizations ad16 ministering contracts entered into or receiving grants 

17 under subsection (a). 

18 ‘‘(d) IMMUNIZATION SERVICES.— 

19 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The 

20 Secretary, acting through the Service, shall facilitate 

21 access to, or provide, immunization services for 

22 Urban Indians through grants made to urban Indian 

23 organizations administering contracts entered into or 

24 receiving grants under this section. 


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1 ‘‘(2) DEFINITION.—For purposes of this sub2 section, the term ‘immunization services’ means 

3 services to provide without charge immunizations 

4 against vaccine-preventable diseases. 

5 ‘‘(e) BEHAVIORAL HEALTH SERVICES.— 

6 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The 

7 Secretary, acting through the Service, shall facilitate 

8 access to, or provide, behavioral health services for 

9 Urban Indians through grants made to urban Indian 

10 organizations administering contracts entered into or 

11 receiving grants under subsection (a). 

12 ‘‘(2) ASSESSMENT REQUIRED.—Except as pro13 vided by paragraph (3)(A), a grant may not be made 

14 under this subsection to an urban Indian organiza15 tion until that organization has prepared, and the 

16 Service has approved, an assessment of the fol17 lowing: 

18 ‘‘(A) The behavioral health needs of the 

19 urban Indian population concerned. 

20 ‘‘(B) The behavioral health services and 

21 other related resources available to that popu22 lation. 

23 ‘‘(C) The barriers to obtaining those serv24 ices and resources. 


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1 ‘‘(D) The needs that are unmet by such 

2 services and resources. 

3 ‘‘(3) PURPOSES OF GRANTS.—Grants may be 

4 made under this subsection for the following: 

5 ‘‘(A) To prepare assessments required 

6 under paragraph (2). 

7 ‘‘(B) To provide outreach, educational, and 

8 referral services to Urban Indians regarding the 

9 availability of direct behavioral health services, 

10 to educate Urban Indians about behavioral 

11 health issues and services, and effect coordina12 tion with existing behavioral health providers in 

13 order to improve services to Urban Indians. 

14 ‘‘(C) To provide outpatient behavioral 

15 health services to Urban Indians, including the 

16 identification and assessment of illness, thera17 peutic treatments, case management, support 

18 groups, family treatment, and other treatment. 

19 ‘‘(D) To develop innovative behavioral 

20 health service delivery models which incorporate 

21 Indian cultural support systems and resources. 

22 ‘‘(f) PREVENTION OF CHILD ABUSE.— 

23 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The 

24 Secretary, acting through the Service, shall facilitate 

25 access to or provide services for Urban Indians 


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1 through grants to urban Indian organizations ad2 ministering contracts entered into or receiving 

3 grants under subsection (a) to prevent and treat 

4 child abuse (including sexual abuse) among Urban 

5 Indians. 

6 ‘‘(2) EVALUATION REQUIRED.—Except as pro7 vided by paragraph (3)(A), a grant may not be made 

8 under this subsection to an urban Indian organiza9 tion until that organization has prepared, and the 

10 Service has approved, an assessment that documents 

11 the prevalence of child abuse in the urban Indian 

12 population concerned and specifies the services and 

13 programs (which may not duplicate existing services 

14 and programs) for which the grant is requested. 

15 ‘‘(3) PURPOSES OF GRANTS.—Grants may be 

16 made under this subsection for the following: 

17 ‘‘(A) To prepare assessments required 

18 under paragraph (2). 

19 ‘‘(B) For the development of prevention, 

20 training, and education programs for Urban In21 dians, including child education, parent edu22 cation, provider training on identification and 

23 intervention, education on reporting require24 ments, prevention campaigns, and establishing 


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1 service networks of all those involved in Indian 

2 child protection. 

3 ‘‘(C) To provide direct outpatient treat4 ment services (including individual treatment, 

5 family treatment, group therapy, and support 

6 groups) to Urban Indians who are child victims 

7 of abuse (including sexual abuse) or adult sur8 vivors of child sexual abuse, to the families of 

9 such child victims, and to urban Indian per10 petrators of child abuse (including sexual 

11 abuse). 

12 ‘‘(4) CONSIDERATIONS WHEN MAKING

13 GRANTS.—In making grants to carry out this sub14 section, the Secretary shall take into consideration— 

15 ‘‘(A) the support for the urban Indian or16 ganization demonstrated by the child protection 

17 authorities in the area, including committees or 

18 other services funded under the Indian Child 

19 Welfare Act of 1978 (25 U.S.C. 1901 et seq.), 

20 if any; 

21 ‘‘(B) the capability and expertise dem22 onstrated by the urban Indian organization to 

23 address the complex problem of child sexual 

24 abuse in the community; and 


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1 ‘‘(C) the assessment required under para2 graph (2). 

3 ‘‘(g) OTHER GRANTS.—The Secretary, acting 

4 through the Service, may enter into a contract with or 

5 make grants to an urban Indian organization that pro6 vides or arranges for the provision of health care services 

7 (through satellite facilities, provider networks, or other8 wise) to Urban Indians in more than 1 Urban Center. 

9 ‘‘SEC. 504. USE OF FEDERAL GOVERNMENT FACILITIES AND 

10 SOURCES OF SUPPLY. 

11 ‘‘(a) IN GENERAL.—The Secretary may permit an 

12 urban Indian organization that has entered into a contract 

13 or received a grant pursuant to this title, in carrying out 

14 such contract or grant, to use existing facilities and all 

15 equipment therein or pertaining thereto and other per16 sonal property owned by the Federal Government within 

17 the Secretary’s jurisdiction under such terms and condi18 tions as may be agreed upon for their use and mainte19 nance. 

20 ‘‘(b) DONATIONS.—Subject to subsection (d), the 

21 Secretary may donate to an urban Indian organization 

22 that has entered into a contract or received a grant pursu23 ant to this title any personal or real property determined 

24 to be excess to the needs of the Indian Health Service or 


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1 the General Services Administration for the purposes of 

2 carrying out the contract or grant. 

3 ‘‘(c) ACQUISITION OF PROPERTY.—The Secretary 

4 may acquire excess or surplus government personal or real 

5 property for donation, subject to subsection (d) to an 

6 urban Indian organization that has entered into a contract 

7 or received a grant pursuant to this title if the Secretary 

8 determines that the property is appropriate for use by the 

9 urban Indian organization for a purpose for which a con10 tract or grant is authorized under this title. 

11 ‘‘(d) PRIORITY.—In the event that the Secretary re12 ceives a request for a specific item of personal or real 

13 property described in subsections (b) or (c) from an urban 

14 Indian organization and from an Indian Tribe or Tribal 

15 Organization, the Secretary shall give priority to the re16 quest for donation to the Indian Tribe or Tribal Organiza17 tion if the Secretary receives the request from the Indian 

18 Tribe or Tribal Organization before the date the Secretary 

19 transfers title to the property or, if earlier, the date the 

20 Secretary transfers the property physically, to the urban 

21 Indian organization. 

22 ‘‘(e) EXECUTIVE AGENCY STATUS.—For purposes of 

23 section 201(a) of the Federal Property and Administrative 

24 Services Act of 1949 (40 U.S.C. 481(a)) (relating to Fed25 eral sources of supply), an urban Indian organization that 


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1 has entered into a contract or received a grant pursuant 

2 to this title may be deemed to be an executive agency when 

3 carrying out such contract or grant. 

4 ‘‘SEC. 505. CONTRACTS AND GRANTS FOR THE DETERMINA5 TION OF UNMET HEALTH CARE NEEDS. 

6 ‘‘(a) GRANTS AND CONTRACTS AUTHORIZED.— 

7 Under authority of the Act of November 2, 1921 (25 

8 U.S.C. 13) (commonly known as the ‘Snyder Act’), the 

9 Secretary, acting through the Service, may enter into con10 tracts with or make grants to urban Indian organizations 

11 situated in Urban Centers for which contracts have not 

12 been entered into or grants have not been made under sec13 tion 503. 

14 ‘‘(b) PURPOSE.—The purpose of a contract or grant 

15 made under this section shall be the determination of the 

16 matters described in subsection (c)(1) in order to assist 

17 the Secretary in assessing the health status and health 

18 care needs of Urban Indians in the Urban Center involved 

19 and determining whether the Secretary should enter into 

20 a contract or make a grant under section 503 with respect 

21 to the urban Indian organization which the Secretary has 

22 entered into a contract with, or made a grant to, under 

23 this section. 


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1 ‘‘(c) GRANT AND CONTRACT REQUIREMENTS.—Any 

2 contract entered into, or grant made, by the Secretary 

3 under this section shall include requirements that— 

4 ‘‘(1) the urban Indian organization successfully 

5 undertakes to— 

6 ‘‘(A) document the health care status and 

7 unmet health care needs of urban Indians in 

8 the Urban Center involved; and 

9 ‘‘(B) with respect to urban Indians in the 

10 Urban Center involved, determine the matters 

11 described in paragraphs (2), (3), (4), and (7) of 

12 section 503(b); and 

13 ‘‘(2) the urban Indian organization complete 

14 performance of the contract, or carry out the re15 quirements of the grant, within 1 year after the date 

16 on which the Secretary and such organization enter 

17 into such contract, or within 1 year after such orga18 nization receives such grant, whichever is applicable. 

19 ‘‘(d) NO RENEWALS.—The Secretary may not renew 

20 any contract entered into or grant made under this sec21 tion. 

22 ‘‘SEC. 506. EVALUATIONS; RENEWALS. 

23 ‘‘(a) PROCEDURES FOR EVALUATIONS.—The Sec24 retary, acting through the Service, shall develop proce25 dures to evaluate compliance with grant requirements and 


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1 compliance with and performance of contracts entered into 

2 by urban Indian organizations under this title. Such pro3 cedures shall include provisions for carrying out the re4 quirements of this section. 

5 ‘‘(b) EVALUATIONS.—The Secretary, acting through 

6 the Service, shall evaluate the compliance of each Urban 

7 Indian Organization which has entered into a contract or 

8 received a grant under section 503 with the terms of such 

9 contract or grant. For purposes of this evaluation, the 

10 Secretary shall— 

11 ‘‘(1) acting through the Service, conduct an an12 nual onsite evaluation of the organization; or 

13 ‘‘(2) accept in lieu of such onsite evaluation evi14 dence of the organization’s provisional or full accred15 itation by a private independent entity recognized by 

16 the Secretary for purposes of conducting quality re17 views of providers participating in the Medicare pro18 gram under title XVIII of the Social Security Act. 

19 ‘‘(c) NONCOMPLIANCE; UNSATISFACTORY PERFORM20 ANCE.—If, as a result of the evaluations conducted under 

21 this section, the Secretary determines that an urban In22 dian organization has not complied with the requirements 

23 of a grant or complied with or satisfactorily performed a 

24 contract under section 503, the Secretary shall, prior to 

25 renewing such contract or grant, attempt to resolve with 


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1 the organization the areas of noncompliance or unsatisfac2 tory performance and modify the contract or grant to pre3 vent future occurrences of noncompliance or unsatisfac4 tory performance. If the Secretary determines that the 

5 noncompliance or unsatisfactory performance cannot be 

6 resolved and prevented in the future, the Secretary shall 

7 not renew the contract or grant with the organization and 

8 is authorized to enter into a contract or make a grant 

9 under section 503 with another urban Indian organization 

10 which is situated in the same Urban Center as the urban 

11 Indian organization whose contract or grant is not re12 newed under this section. 

13 ‘‘(d) CONSIDERATIONS FOR RENEWALS.—In deter14 mining whether to renew a contract or grant with an 

15 urban Indian organization under section 503 which has 

16 completed performance of a contract or grant under sec17 tion 504, the Secretary shall review the records of the 

18 urban Indian organization, the reports submitted under 

19 section 507, and shall consider the results of the onsite 

20 evaluations or accreditations under subsection (b). 

21 ‘‘SEC. 507. OTHER CONTRACT AND GRANT REQUIREMENTS. 

22 ‘‘(a) PROCUREMENT.—Contracts with urban Indian 

23 organizations entered into pursuant to this title shall be 

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1 tion of the Secretary, such contracts may be negotiated 

2 without advertising and need not conform to the provisions 

3 of sections 1304 and 3131 through 3133 of title 40, 

4 United States Code. 

5 ‘‘(b) PAYMENTS UNDER CONTRACTS OR GRANTS.— 

6 ‘‘(1) IN GENERAL.—Payments under any con7 tracts or grants pursuant to this title, notwith8 standing any term or condition of such contract or 

9 grant— 

10 ‘‘(A) may be made in a single advance pay11 ment by the Secretary to the urban Indian or12 ganization by no later than the end of the first 

13 30 days of the funding period with respect to 

14 which the payments apply, unless the Secretary 

15 determines through an evaluation under section 

16 505 that the organization is not capable of ad17 ministering such a single advance payment; and 

18 ‘‘(B) if any portion thereof is unexpended 

19 by the urban Indian organization during the 

20 funding period with respect to which the pay21 ments initially apply, shall be carried forward 

22 for expenditure with respect to allowable or re23 imbursable costs incurred by the organization 

24 during 1 or more subsequent funding periods 

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1 tion by the organization as a condition of car2 rying forward the availability for expenditure of 

3 such funds. 

4 ‘‘(2) SEMIANNUAL AND QUARTERLY PAYMENTS

5 AND REIMBURSEMENTS.—If the Secretary deter6 mines under paragraph (1)(A) that an urban Indian 

7 organization is not capable of administering an en8 tire single advance payment, on request of the urban 

9 Indian organization, the payments may be made— 

10 ‘‘(A) in semiannual or quarterly payments 

11 by not later than 30 days after the date on 

12 which the funding period with respect to which 

13 the payments apply begins; or 

14 ‘‘(B) by way of reimbursement. 

15 ‘‘(c) REVISION OR AMENDMENT OF CONTRACTS.— 

16 Notwithstanding any provision of law to the contrary, the 

17 Secretary may, at the request and consent of an urban 

18 Indian organization, revise or amend any contract entered 

19 into by the Secretary with such organization under this 

20 title as necessary to carry out the purposes of this title. 

21 ‘‘(d) FAIR AND UNIFORM SERVICES AND ASSIST22 ANCE.—Contracts with or grants to urban Indian organi23 zations and regulations adopted pursuant to this title shall 

24 include provisions to assure the fair and uniform provision 


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1 to urban Indians of services and assistance under such 

2 contracts or grants by such organizations. 

3 ‘‘SEC. 508. REPORTS AND RECORDS. 

4 ‘‘(a) REPORTS.— 

5 ‘‘(1) IN GENERAL.—For each fiscal year during 

6 which an urban Indian organization receives or ex7 pends funds pursuant to a contract entered into or 

8 a grant received pursuant to this title, such urban 

9 Indian organization shall submit to the Secretary 

10 not more frequently than every 6 months, a report 

11 that includes the following: 

12 ‘‘(A) In the case of a contract or grant 

13 under section 503, recommendations pursuant 

14 to section 503(a)(5). 

15 ‘‘(B) Information on activities conducted 

16 by the organization pursuant to the contract or 

17 grant. 

18 ‘‘(C) An accounting of the amounts and 

19 purpose for which Federal funds were ex20 pended. 

21 ‘‘(D) A minimum set of data, using uni22 formly defined elements, as specified by the 

23 Secretary after consultation with urban Indian 

24 organizations. 

25 ‘‘(2) HEALTH STATUS AND SERVICES.— 


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1 ‘‘(A) IN GENERAL.—Not later than 18 

2 months after the date of enactment of the In3 dian Health Care Improvement Act Amend4 ments of 2009, the Secretary, acting through 

5 the Service, shall submit to Congress a report 

6 evaluating— 

7 ‘‘(i) the health status of urban Indi8 ans; 

9 ‘‘(ii) the services provided to Indians 

10 pursuant to this title; and 

11 ‘‘(iii) areas of unmet needs in the de12 livery of health services to urban Indians. 

13 ‘‘(B) CONSULTATION AND CONTRACTS.— 

14 In preparing the report under paragraph (1), 

15 the Secretary— 

16 ‘‘(i) shall consult with urban Indian 

17 organizations; and 

18 ‘‘(ii) may enter into a contract with a 

19 national organization representing urban 

20 Indian organizations to conduct any aspect 

21 of the report. 

22 ‘‘(b) AUDIT.—The reports and records of the urban 

23 Indian organization with respect to a contract or grant 

24 under this title shall be subject to audit by the Secretary 

25 and the Comptroller General of the United States. 


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1 ‘‘(c) COSTS OF AUDITS.—The Secretary shall allow 

2 as a cost of any contract or grant entered into or awarded 

3 under section 502 or 503 the cost of an annual inde4 pendent financial audit conducted by— 

5 ‘‘(1) a certified public accountant; or 

6 ‘‘(2) a certified public accounting firm qualified 

7 to conduct Federal compliance audits. 

8 ‘‘SEC. 509. LIMITATION ON CONTRACT AUTHORITY. 

9 ‘‘The authority of the Secretary to enter into con10 tracts or to award grants under this title shall be to the 

11 extent, and in an amount, provided for in appropriation 

12 Acts. 

13 ‘‘SEC. 510. FACILITIES. 

14 ‘‘(a) GRANTS.—The Secretary, acting through the 

15 Service, may make grants to contractors or grant recipi16 ents under this title for the lease, purchase, renovation, 

17 construction, or expansion of facilities, including leased fa18 cilities, in order to assist such contractors or grant recipi19 ents in complying with applicable licensure or certification 

20 requirements. 

21 ‘‘(b) LOAN FUND STUDY.—The Secretary, acting 

22 through the Service, may carry out a study to determine 

23 the feasibility of establishing a loan fund to provide to 

24 urban Indian organizations direct loans or guarantees for 

25 loans for the construction of health care facilities in a 


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1 manner consistent with section 309, including by submit2 ting a report in accordance with subsection (c) of that sec3 tion. 

4 ‘‘SEC. 511. DIVISION OF URBAN INDIAN HEALTH. 

5 ‘‘There is established within the Service a Division 

6 of Urban Indian Health, which shall be responsible for— 

7 ‘‘(1) carrying out the provisions of this title; 

8 ‘‘(2) providing central oversight of the pro9 grams and services authorized under this title; and 

10 ‘‘(3) providing technical assistance to urban In11 dian organizations. 

12 ‘‘SEC. 512. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE13 RELATED SERVICES. 

14 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

15 through the Service, may make grants for the provision 

16 of health-related services in prevention of, treatment of, 

17 rehabilitation of, or school- and community-based edu18 cation regarding, alcohol and substance abuse in Urban 

19 Centers to those urban Indian organizations with which 

20 the Secretary has entered into a contract under this title 

21 or under section 201. 

22 ‘‘(b) GOALS.—Each grant made pursuant to sub23 section (a) shall set forth the goals to be accomplished 

24 pursuant to the grant. The goals shall be specific to each 

25 grant as agreed to between the Secretary and the grantee. 


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1 ‘‘(c) CRITERIA.—The Secretary shall establish cri2 teria for the grants made under subsection (a), including 

3 criteria relating to the following: 

4 ‘‘(1) The size of the urban Indian population. 

5 ‘‘(2) Capability of the organization to ade6 quately perform the activities required under the 

7 grant. 

8 ‘‘(3) Satisfactory performance standards for the 

9 organization in meeting the goals set forth in such 

10 grant. The standards shall be negotiated and agreed 

11 to between the Secretary and the grantee on a 

12 grant-by-grant basis. 

13 ‘‘(4) Identification of the need for services. 

14 ‘‘(d) ALLOCATION OF GRANTS.—The Secretary shall 

15 develop a methodology for allocating grants made pursu16 ant to this section based on the criteria established pursu17 ant to subsection (c). 

18 ‘‘(e) GRANTS SUBJECT TO CRITERIA.—Any grant re19 ceived by an urban Indian organization under this Act for 

20 substance abuse prevention, treatment, and rehabilitation 

21 shall be subject to the criteria set forth in subsection (c). 


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1 ‘‘SEC. 513. TREATMENT OF CERTAIN DEMONSTRATION 

2 PROJECTS. 

3 ‘‘Notwithstanding any other provision of law, the 

4 Tulsa Clinic and Oklahoma City Clinic demonstration 

5 projects shall— 

6 ‘‘(1) be permanent programs within the Serv7 ice’s direct care program; 

8 ‘‘(2) continue to be treated as Service Units 

9 and Operating Units in the allocation of resources 

10 and coordination of care; and 

11 ‘‘(3) continue to meet the requirements and 

12 definitions of an urban Indian organization in this 

13 Act, and shall not be subject to the provisions of the 

14 Indian Self-Determination and Education Assistance 

15 Act (25 U.S.C. 450 et seq.). 

16 ‘‘SEC. 514. URBAN NIAAA TRANSFERRED PROGRAMS. 

17 ‘‘(a) GRANTS AND CONTRACTS.—The Secretary, 

18 through the Division of Urban Indian Health, shall make 

19 grants or enter into contracts with urban Indian organiza20 tions, to take effect not later than September 30, 2010, 

21 for the administration of urban Indian alcohol programs 

22 that were originally established under the National Insti23 tute on Alcoholism and Alcohol Abuse (hereafter in this 

24 section referred to as ‘NIAAA’) and transferred to the 

25 Service. 


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1 ‘‘(b) USE OF FUNDS.—Grants provided or contracts 

2 entered into under this section shall be used to provide 

3 support for the continuation of alcohol prevention and 

4 treatment services for urban Indian populations and such 

5 other objectives as are agreed upon between the Service 

6 and a recipient of a grant or contract under this section. 

7 ‘‘(c) ELIGIBILITY.—Urban Indian organizations that 

8 operate Indian alcohol programs originally funded under 

9 the NIAAA and subsequently transferred to the Service 

10 are eligible for grants or contracts under this section. 

11 ‘‘(d) REPORT.—The Secretary shall evaluate and re12 port to Congress on the activities of programs funded 

13 under this section not less than every 5 years. 

14 ‘‘SEC. 515. CONFERRING WITH URBAN INDIAN ORGANIZA15 TIONS. 

16 ‘‘(a) IN GENERAL.—The Secretary shall ensure that 

17 the Service confers or conferences, to the greatest extent 

18 practicable, with Urban Indian Organizations. 

19 ‘‘(b) DEFINITION OF CONFER; CONFERENCE.—In 

20 this section, the terms ‘confer’ and ‘conference’ mean an 

21 open and free exchange of information and opinions 

22 that— 

23 ‘‘(1) leads to mutual understanding and com24 prehension; and 


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1 ‘‘(2) emphasizes trust, respect, and shared re2 sponsibility. 

3 ‘‘SEC. 516. URBAN YOUTH TREATMENT CENTER DEM4 ONSTRATION. 

5 ‘‘(a) CONSTRUCTION AND OPERATION.— 

6 ‘‘(1) IN GENERAL.—The Secretary, acting 

7 through the Service, through grant or contract, shall 

8 fund the construction and operation of at least 1 

9 residential treatment center in each Service Area 

10 that meets the eligibility requirements set forth in 

11 subsection (b) to demonstrate the provision of alco12 hol and substance abuse treatment services to Urban 

13 Indian youth in a culturally competent residential 

14 setting. 

15 ‘‘(2) TREATMENT.—Each residential treatment 

16 center described in paragraph (1) shall be in addi17 tion to any facilities constructed under section 

18 707(b). 

19 ‘‘(b) ELIGIBILITY REQUIREMENTS.—To be eligible to 

20 obtain a facility under subsection (a)(1), a Service Area 

21 shall meet the following requirements: 

22 ‘‘(1) There is an Urban Indian Organization in 

23 the Service Area. 


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1 ‘‘(2) There reside in the Service Area Urban In2 dian youth with need for alcohol and substance 

3 abuse treatment services in a residential setting. 

4 ‘‘(3) There is a significant shortage of cul5 turally competent residential treatment services for 

6 Urban Indian youth in the Service Area. 

7 ‘‘SEC. 517. GRANTS FOR DIABETES PREVENTION, TREAT8 MENT, AND CONTROL. 

9 ‘‘(a) GRANTS AUTHORIZED.—The Secretary may 

10 make grants to those urban Indian organizations that 

11 have entered into a contract or have received a grant 

12 under this title for the provision of services for the preven13 tion and treatment of, and control of the complications 

14 resulting from, diabetes among urban Indians. 

15 ‘‘(b) GOALS.—Each grant made pursuant to sub16 section (a) shall set forth the goals to be accomplished 

17 under the grant. The goals shall be specific to each grant 

18 as agreed to between the Secretary and the grantee. 

19 ‘‘(c) ESTABLISHMENT OF CRITERIA.—The Secretary 

20 shall establish criteria for the grants made under sub21 section (a) relating to— 

22 ‘‘(1) the size and location of the urban Indian 

23 population to be served; 

24 ‘‘(2) the need for prevention of and treatment 

25 of, and control of the complications resulting from, 


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1 diabetes among the urban Indian population to be 

2 served; 

3 ‘‘(3) performance standards for the organiza4 tion in meeting the goals set forth in such grant 

5 that are negotiated and agreed to by the Secretary 

6 and the grantee; 

7 ‘‘(4) the capability of the organization to ade8 quately perform the activities required under the 

9 grant; and 

10 ‘‘(5) the willingness of the organization to col11 laborate with the registry, if any, established by the 

12 Secretary under section 203(e)(1)(B) in the Area 

13 Office of the Service in which the organization is lo14 cated. 

15 ‘‘(d) FUNDS SUBJECT TO CRITERIA.—Any funds re16 ceived by an urban Indian organization under this Act for 

17 the prevention, treatment, and control of diabetes among 

18 urban Indians shall be subject to the criteria developed 

19 by the Secretary under subsection (c). 

20 ‘‘SEC. 518. COMMUNITY HEALTH REPRESENTATIVES. 

21 ‘‘The Secretary, acting through the Service, may 

22 enter into contracts with, and make grants to, urban In23 dian organizations for the employment of Indians trained 

24 as health service providers through the Community Health 

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1 sion of health care, health promotion, and disease preven2 tion services to urban Indians. 

3 ‘‘SEC. 519. EFFECTIVE DATE. 

4 ‘‘The amendments made by the Indian Health Care 

5 Improvement Act Amendments of 2009 to this title shall 

6 take effect beginning on the date of enactment of that Act, 

7 regardless of whether the Secretary has promulgated regu8 lations implementing such amendments. 

9 ‘‘SEC. 520. ELIGIBILITY FOR SERVICES. 

10 ‘‘Urban Indians shall be eligible for, and the ultimate 

11 beneficiaries of, health care or referral services provided 

12 pursuant to this title. 

13 ‘‘SEC. 521. AUTHORIZATION OF APPROPRIATIONS. 

14 ‘‘(a) IN GENERAL.—There are authorized to be ap15 propriated such sums as may be necessary to carry out 

16 this title. 

17 ‘‘(b) URBAN INDIAN ORGANIZATIONS.—The Sec18 retary, acting through the Service, is authorized to estab19 lish programs, including programs for the awarding of 

20 grants, for urban Indian organizations that are identical 

21 to any programs established pursuant to section 126 (be22 havioral health training), section 209 (school health edu23 cation), section 211 (prevention of communicable dis24 eases), section 701 (behavioral health prevention and 


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1 treatment services), and section 707(g) (multidrug abuse 

2 program). 

3 ‘‘SEC. 522. HEALTH INFORMATION TECHNOLOGY. 

4 ‘‘The Secretary, acting through the Service, may 

5 make grants to urban Indian organizations under this title 

6 for the development, adoption, and implementation of 

7 health information technology (as defined in section 

8 3000(5) of the American Recovery and Reinvestment Act), 

9 telemedicine services development, and related infrastruc10 ture. 

11 ‘‘TITLE VI—ORGANIZATIONAL 

12 IMPROVEMENTS 

13 ‘‘SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERV14 ICE AS AN AGENCY OF THE PUBLIC HEALTH 

15 SERVICE. 

16 ‘‘(a) ESTABLISHMENT.— 

17 ‘‘(1) IN GENERAL.—In order to more effectively 

18 and efficiently carry out the responsibilities, authori19 ties, and functions of the United States to provide 

20 health care services to Indians and Indian Tribes, as 

21 are or may be hereafter provided by Federal statute 

22 or treaties, there is established within the Public 

23 Health Service of the Department the Indian Health 

24 Service. 


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1 ‘‘(2) ASSISTANT SECRETARY OF INDIAN

2 HEALTH.—The Service shall be administered by an 

3 Assistant Secretary of Indian Health, who shall be 

4 appointed by the President, by and with the advice 

5 and consent of the Senate. The Assistant Secretary 

6 shall report to the Secretary. Effective with respect 

7 to an individual appointed by the President, by and 

8 with the advice and consent of the Senate, after 

9 January 1, 2010, the term of service of the Assist10 ant Secretary shall be 4 years. An Assistant Sec11 retary may serve more than 1 term. 

12 ‘‘(3) INCUMBENT.—The individual serving in 

13 the position of Director of the Service on the day be14 fore the date of enactment of the Indian Health 

15 Care Improvement Act Amendments of 2009 shall 

16 serve as Assistant Secretary. 

17 ‘‘(4) ADVOCACY AND CONSULTATION.—The po18 sition of Assistant Secretary is established to, in a 

19 manner consistent with the government-to-govern20 ment relationship between the United States and In21 dian Tribes— 

22 ‘‘(A) facilitate advocacy for the develop23 ment of appropriate Indian health policy; and 

24 ‘‘(B) promote consultation on matters re25 lating to Indian health. 


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1 ‘‘(b) AGENCY.—The Service shall be an agency within 

2 the Public Health Service of the Department, and shall 

3 not be an office, component, or unit of any other agency 

4 of the Department. 

5 ‘‘(c) DUTIES.—The Assistant Secretary shall— 

6 ‘‘(1) perform all functions that were, on the day 

7 before the date of enactment of the Indian Health 

8 Care Improvement Act Amendments of 2009, car9 ried out by or under the direction of the individual 

10 serving as Director of the Service on that day; 

11 ‘‘(2) perform all functions of the Secretary re12 lating to the maintenance and operation of hospital 

13 and health facilities for Indians and the planning 

14 for, and provision and utilization of, health services 

15 for Indians; 

16 ‘‘(3) administer all health programs under 

17 which health care is provided to Indians based upon 

18 their status as Indians which are administered by 

19 the Secretary, including programs under— 

20 ‘‘(A) this Act; 

21 ‘‘(B) the Act of November 2, 1921 (25 

22 U.S.C. 13); 

23 ‘‘(C) the Act of August 5, 1954 (42 U.S.C. 

24 2001 et seq.); 


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1 ‘‘(D) the Act of August 16, 1957 (42 

2 U.S.C. 2005 et seq.); and 

3 ‘‘(E) the Indian Self-Determination and 

4 Education Assistance Act (25 U.S.C. 450 et 

5 seq.); 

6 ‘‘(4) administer all scholarship and loan func7 tions carried out under title I; 

8 ‘‘(5) report directly to the Secretary concerning 

9 all policy- and budget-related matters affecting In10 dian health; 

11 ‘‘(6) collaborate with the Assistant Secretary 

12 for Health concerning appropriate matters of Indian 

13 health that affect the agencies of the Public Health 

14 Service; 

15 ‘‘(7) advise each Assistant Secretary of the De16 partment concerning matters of Indian health with 

17 respect to which that Assistant Secretary has au18 thority and responsibility; 

19 ‘‘(8) advise the heads of other agencies and pro20 grams of the Department concerning matters of In21 dian health with respect to which those heads have 

22 authority and responsibility; 

23 ‘‘(9) coordinate the activities of the Department 

24 concerning matters of Indian health; and 


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1 ‘‘(10) perform such other functions as the Sec2 retary may designate. 

3 ‘‘(d) AUTHORITY.— 

4 ‘‘(1) IN GENERAL.—The Secretary, acting 

5 through the Assistant Secretary, shall have the au6 thority— 

7 ‘‘(A) except to the extent provided for in 

8 paragraph (2), to appoint and compensate em9 ployees for the Service in accordance with title 

10 5, United States Code; 

11 ‘‘(B) to enter into contracts for the pro12 curement of goods and services to carry out the 

13 functions of the Service; and 

14 ‘‘(C) to manage, expend, and obligate all 

15 funds appropriated for the Service. 

16 ‘‘(2) PERSONNEL ACTIONS.—Notwithstanding 

17 any other provision of law, the provisions of section 

18 12 of the Act of June 18, 1934 (48 Stat. 986; 25 

19 U.S.C. 472), shall apply to all personnel actions 

20 taken with respect to new positions created within 

21 the Service as a result of its establishment under 

22 subsection (a). 

23 ‘‘(e) REFERENCES.—Any reference to the Director of 

24 the Indian Health Service in any other Federal law, Exec25 utive order, rule, regulation, or delegation of authority, or 


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1 in any document of or relating to the Director of the In2 dian Health Service, shall be deemed to refer to the Assist3 ant Secretary. 

4 ‘‘SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYS5 TEM. 

6 ‘‘(a) ESTABLISHMENT.— 

7 ‘‘(1) IN GENERAL.—The Secretary shall estab8 lish an automated management information system 

9 for the Service. 

10 ‘‘(2) REQUIREMENTS OF SYSTEM.—The infor11 mation system established under paragraph (1) shall 

12 include— 

13 ‘‘(A) a financial management system; 

14 ‘‘(B) a patient care information system for 

15 each area served by the Service; 

16 ‘‘(C) privacy protections consistent with 

17 the regulations promulgated under section 

18 264(c) of the Health Insurance Portability and 

19 Accountability Act of 1996 or, to the extent 

20 consistent with such regulations, other Federal 

21 rules applicable to privacy of automated man22 agement information systems of a Federal 

23 agency; 

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1 sociated with the provision of specific medical 

2 treatments or services in each Area office of the 

3 Service; 

4 ‘‘(E) an interface mechanism for patient 

5 billing and accounts receivable system; and 

6 ‘‘(F) a training component. 

7 ‘‘(b) PROVISION OF SYSTEMS TO TRIBES AND ORGA8 NIZATIONS.—The Secretary shall provide each Tribal 

9 Health Program automated management information sys10 tems which— 

11 ‘‘(1) meet the management information needs 

12 of such Tribal Health Program with respect to the 

13 treatment by the Tribal Health Program of patients 

14 of the Service; and 

15 ‘‘(2) meet the management information needs 

16 of the Service. 

17 ‘‘(c) ACCESS TO RECORDS.—The Service shall pro18 vide access of patients to their medical or health records 

19 which are held by, or on behalf of, the Service in accord20 ance with the regulations promulgated under section 

21 264(c) of the Health Insurance Portability and Account22 ability Act of 1996 or, to the extent consistent with such 

23 regulations, other Federal rules applicable to access to 

24 health care records. 


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1 ‘‘(d) AUTHORITY TO ENHANCE INFORMATION TECH2 NOLOGY.—The Secretary, acting through the Assistant 

3 Secretary, shall have the authority to enter into contracts, 

4 agreements, or joint ventures with other Federal agencies, 

5 States, private and nonprofit organizations, for the pur6 pose of enhancing information technology in Indian 

7 Health Programs and facilities. 

8 ‘‘SEC. 603. AUTHORIZATION OF APPROPRIATIONS. 

9 ‘‘There is authorized to be appropriated such sums 

10 as may be necessary to carry out this title. 

11 ‘‘TITLE VII—BEHAVIORAL 

12 HEALTH PROGRAMS 

13 ‘‘SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREAT14 MENT SERVICES. 

15 ‘‘(a) PURPOSES.—The purposes of this section are as 

16 follows: 

17 ‘‘(1) To authorize and direct the Secretary, act18 ing through the Service, to develop a comprehensive 

19 behavioral health prevention and treatment program 

20 which emphasizes collaboration among alcohol and 

21 substance abuse, social services, and mental health 

22 programs. 

23 ‘‘(2) To provide information, direction, and 

24 guidance relating to mental illness and dysfunction 

25 and self-destructive behavior, including child abuse 


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1 and family violence, to those Federal, tribal, State, 

2 and local agencies responsible for programs in In3 dian communities in areas of health care, education, 

4 social services, child and family welfare, alcohol and 

5 substance abuse, law enforcement, and judicial serv6 ices. 

7 ‘‘(3) To assist Indian Tribes to identify services 

8 and resources available to address mental illness and 

9 dysfunctional and self-destructive behavior. 

10 ‘‘(4) To provide authority and opportunities for 

11 Indian Tribes and Tribal Organizations to develop, 

12 implement, and coordinate with community-based 

13 programs which include identification, prevention, 

14 education, referral, and treatment services, including 

15 through multidisciplinary resource teams. 

16 ‘‘(5) To ensure that Indians, as citizens of the 

17 United States and of the States in which they re18 side, have the same access to behavioral health serv19 ices to which all citizens have access. 

20 ‘‘(6) To modify or supplement existing pro21 grams and authorities in the areas identified in 

22 paragraph (2). 

23 ‘‘(b) PLANS.— 

24 ‘‘(1) DEVELOPMENT.—The Secretary, acting 

25 through the Service, shall encourage Indian Tribes 


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1 and Tribal Organizations to develop tribal plans, 

2 and urban Indian organizations to develop local 

3 plans, and for all such groups to participate in de4 veloping areawide plans for Indian Behavioral 

5 Health Services. The plans shall include, to the ex6 tent feasible, the following components: 

7 ‘‘(A) An assessment of the scope of alcohol 

8 or other substance abuse, mental illness, and 

9 dysfunctional and self-destructive behavior, in10 cluding suicide, child abuse, and family vio11 lence, among Indians, including— 

12 ‘‘(i) the number of Indians served who 

13 are directly or indirectly affected by such 

14 illness or behavior; or 

15 ‘‘(ii) an estimate of the financial and 

16 human cost attributable to such illness or 

17 behavior. 

18 ‘‘(B) An assessment of the existing and 

19 additional resources necessary for the preven20 tion and treatment of such illness and behavior, 

21 including an assessment of the progress toward 

22 achieving the availability of the full continuum 

23 of care described in subsection (c). 

24 ‘‘(C) An estimate of the additional funding 

25 needed by the Service, Indian Tribes, Tribal 


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1 Organizations, and urban Indian organizations 

2 to meet their responsibilities under the plans. 

3 ‘‘(2) NATIONAL CLEARINGHOUSE.—The Sec4 retary, acting through the Service, shall coordinate 

5 with existing national clearinghouses and informa6 tion centers to include at the clearinghouses and 

7 centers plans and reports on the outcomes of such 

8 plans developed by Indian Tribes, Tribal Organiza9 tions, urban Indian organizations, and Service Areas 

10 relating to behavioral health. The Secretary shall en11 sure access to these plans and outcomes by any In12 dian Tribe, Tribal Organization, urban Indian orga13 nization, or the Service. 

14 ‘‘(3) TECHNICAL ASSISTANCE.—The Secretary 

15 shall provide technical assistance to Indian Tribes, 

16 Tribal Organizations, and urban Indian organiza17 tions in preparation of plans under this section and 

18 in developing standards of care that may be used 

19 and adopted locally. 

20 ‘‘(c) PROGRAMS.—The Secretary, acting through the 

21 Service, shall provide, to the extent feasible and if funding 

22 is available, programs including the following: 

23 ‘‘(1) COMPREHENSIVE CARE.—A comprehensive 

24 continuum of behavioral health care which pro25 vides— 


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1 ‘‘(A) community-based prevention, inter2 vention, outpatient, and behavioral health 

3 aftercare; 

4 ‘‘(B) detoxification (social and medical); 

5 ‘‘(C) acute hospitalization; 

6 ‘‘(D) intensive outpatient/day treatment; 

7 ‘‘(E) residential treatment; 

8 ‘‘(F) transitional living for those needing a 

9 temporary, stable living environment that is 

10 supportive of treatment and recovery goals; 

11 ‘‘(G) emergency shelter; 

12 ‘‘(H) intensive case management; and 

13 ‘‘(I) diagnostic services. 

14 ‘‘(2) CHILD CARE.—Behavioral health services 

15 for Indians from birth through age 17, including— 

16 ‘‘(A) preschool and school age fetal alcohol 

17 disorder services, including assessment and be18 havioral intervention; 

19 ‘‘(B) mental health and substance abuse 

20 services (emotional, organic, alcohol, drug, in21 halant, and tobacco); 

22 ‘‘(C) identification and treatment of co-oc23 curring disorders and comorbidity; 

24 ‘‘(D) prevention of alcohol, drug, inhalant, 

25 and tobacco use; 


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1 ‘‘(E) early intervention, treatment, and 

2 aftercare; 

3 ‘‘(F) promotion of healthy approaches to 

4 risk and safety issues; and 

5 ‘‘(G) identification and treatment of ne6 glect and physical, mental, and sexual abuse. 

7 ‘‘(3) ADULT CARE.—Behavioral health services 

8 for Indians from age 18 through 55, including— 

9 ‘‘(A) early intervention, treatment, and 

10 aftercare; 

11 ‘‘(B) mental health and substance abuse 

12 services (emotional, alcohol, drug, inhalant, and 

13 tobacco), including sex specific services; 

14 ‘‘(C) identification and treatment of co-oc15 curring disorders (dual diagnosis) and comor16 bidity; 

17 ‘‘(D) promotion of healthy approaches for 

18 risk-related behavior; 

19 ‘‘(E) treatment services for women at risk 

20 of giving birth to a child with a fetal alcohol 

21 disorder; and 

22 ‘‘(F) sex specific treatment for sexual as23 sault and domestic violence. 

24 ‘‘(4) FAMILY CARE.—Behavioral health services 

25 for families, including— 


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1 ‘‘(A) early intervention, treatment, and 

2 aftercare for affected families; 

3 ‘‘(B) treatment for sexual assault and do4 mestic violence; and 

5 ‘‘(C) promotion of healthy approaches re6 lating to parenting, domestic violence, and other 

7 abuse issues. 

8 ‘‘(5) ELDER CARE.—Behavioral health services 

9 for Indians 56 years of age and older, including— 

10 ‘‘(A) early intervention, treatment, and 

11 aftercare; 

12 ‘‘(B) mental health and substance abuse 

13 services (emotional, alcohol, drug, inhalant, and 

14 tobacco), including sex specific services; 

15 ‘‘(C) identification and treatment of co-oc16 curring disorders (dual diagnosis) and comor17 bidity; 

18 ‘‘(D) promotion of healthy approaches to 

19 managing conditions related to aging; 

20 ‘‘(E) sex specific treatment for sexual as21 sault, domestic violence, neglect, physical and 

22 mental abuse and exploitation; and 

23 ‘‘(F) identification and treatment of de24 mentias regardless of cause. 

25 ‘‘(d) COMMUNITY BEHAVIORAL HEALTH PLAN.— 


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1 ‘‘(1) ESTABLISHMENT.—The governing body of 

2 any Indian Tribe, Tribal Organization, or urban In3 dian organization may adopt a resolution for the es4 tablishment of a community behavioral health plan 

5 providing for the identification and coordination of 

6 available resources and programs to identify, pre7 vent, or treat substance abuse, mental illness, or 

8 dysfunctional and self-destructive behavior, including 

9 child abuse and family violence, among its members 

10 or its service population. This plan should include 

11 behavioral health services, social services, intensive 

12 outpatient services, and continuing aftercare. 

13 ‘‘(2) TECHNICAL ASSISTANCE.—At the request 

14 of an Indian Tribe, Tribal Organization, or urban 

15 Indian organization, the Bureau of Indian Affairs 

16 and the Service shall cooperate with and provide 

17 technical assistance to the Indian Tribe, Tribal Or18 ganization, or urban Indian organization in the de19 velopment and implementation of such plan. 

20 ‘‘(3) FUNDING.—The Secretary, acting through 

21 the Service, may make funding available to Indian 

22 Tribes and Tribal Organizations which adopt a reso23 lution pursuant to paragraph (1) to obtain technical 

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1 havioral health plan and to provide administrative 

2 support in the implementation of such plan. 

3 ‘‘(e) COORDINATION FOR AVAILABILITY OF SERV4 ICES.—The Secretary, acting through the Service, shall 

5 coordinate behavioral health planning, to the extent fea6 sible, with other Federal agencies and with State agencies, 

7 to encourage comprehensive behavioral health services for 

8 Indians regardless of their place of residence. 

9 ‘‘(f) MENTAL HEALTH CARE NEED ASSESSMENT.— 

10 Not later than 1 year after the date of enactment of the 

11 Indian Health Care Improvement Act Amendments of 

12 2009, the Secretary, acting through the Service, shall 

13 make an assessment of the need for inpatient mental 

14 health care among Indians and the availability and cost 

15 of inpatient mental health facilities which can meet such 

16 need. In making such assessment, the Secretary shall con17 sider the possible conversion of existing, underused Service 

18 hospital beds into psychiatric units to meet such need. 

19 ‘‘SEC. 702. MEMORANDA OF AGREEMENT WITH THE DE20 PARTMENT OF THE INTERIOR. 

21 ‘‘(a) CONTENTS.—Not later than 12 months after the 

22 date of enactment of the Indian Health Care Improvement 

23 Act Amendments of 2009, the Secretary, acting through 

24 the Service, and the Secretary of the Interior shall develop 

25 and enter into a memoranda of agreement, or review and 


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1 update any existing memoranda of agreement, as required 

2 by section 4205 of the Indian Alcohol and Substance 

3 Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 

4 2411) under which the Secretaries address the following: 

5 ‘‘(1) The scope and nature of mental illness and 

6 dysfunctional and self-destructive behavior, including 

7 child abuse and family violence, among Indians. 

8 ‘‘(2) The existing Federal, tribal, State, local, 

9 and private services, resources, and programs avail10 able to provide behavioral health services for Indi11 ans. 

12 ‘‘(3) The unmet need for additional services, re13 sources, and programs necessary to meet the needs 

14 identified pursuant to paragraph (1). 

15 ‘‘(4)(A) The right of Indians, as citizens of the 

16 United States and of the States in which they re17 side, to have access to behavioral health services to 

18 which all citizens have access. 

19 ‘‘(B) The right of Indians to participate in, and 

20 receive the benefit of, such services. 

21 ‘‘(C) The actions necessary to protect the exer22 cise of such right. 

23 ‘‘(5) The responsibilities of the Bureau of In24 dian Affairs and the Service, including mental illness 

25 identification, prevention, education, referral, and 


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1 treatment services (including services through multi2 disciplinary resource teams), at the central, area, 

3 and agency and Service Unit, Service Area, and 

4 headquarters levels to address the problems identi5 fied in paragraph (1). 

6 ‘‘(6) A strategy for the comprehensive coordina7 tion of the behavioral health services provided by the 

8 Bureau of Indian Affairs and the Service to meet 

9 the problems identified pursuant to paragraph (1), 

10 including— 

11 ‘‘(A) the coordination of alcohol and sub12 stance abuse programs of the Service, the Bu13 reau of Indian Affairs, and Indian Tribes and 

14 Tribal Organizations (developed under the In15 dian Alcohol and Substance Abuse Prevention 

16 and Treatment Act of 1986 (25 U.S.C. 2401 et 

17 seq.)) with behavioral health initiatives pursu18 ant to this Act, particularly with respect to the 

19 referral and treatment of dually diagnosed indi20 viduals requiring behavioral health and sub21 stance abuse treatment; and 

22 ‘‘(B) ensuring that the Bureau of Indian 

23 Affairs and Service programs and services (in24 cluding multidisciplinary resource teams) ad25 dressing child abuse and family violence are coVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01894 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 ordinated with such non-Federal programs and 

2 services. 

3 ‘‘(7) Directing appropriate officials of the Bu4 reau of Indian Affairs and the Service, particularly 

5 at the agency and Service Unit levels, to cooperate 

6 fully with tribal requests made pursuant to commu7 nity behavioral health plans adopted under section 

8 701(c) and section 4206 of the Indian Alcohol and 

9 Substance Abuse Prevention and Treatment Act of 

10 1986 (25 U.S.C. 2412). 

11 ‘‘(8) Providing for an annual review of such 

12 agreement by the Secretaries which shall be provided 

13 to Congress and Indian Tribes and Tribal Organiza14 tions. 

15 ‘‘(b) SPECIFIC PROVISIONS REQUIRED.—The memo16 randa of agreement updated or entered into pursuant to 

17 subsection (a) shall include specific provisions pursuant to 

18 which the Service shall assume responsibility for— 

19 ‘‘(1) the determination of the scope of the prob20 lem of alcohol and substance abuse among Indians, 

21 including the number of Indians within the jurisdic22 tion of the Service who are directly or indirectly af23 fected by alcohol and substance abuse and the finan24 cial and human cost; 


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1 ‘‘(2) an assessment of the existing and needed 

2 resources necessary for the prevention of alcohol and 

3 substance abuse and the treatment of Indians af4 fected by alcohol and substance abuse; and 

5 ‘‘(3) an estimate of the funding necessary to 

6 adequately support a program of prevention of alco7 hol and substance abuse and treatment of Indians 

8 affected by alcohol and substance abuse. 

9 ‘‘(c) PUBLICATION.—Each memorandum of agree10 ment entered into or renewed (and amendments or modi11 fications thereto) under subsection (a) shall be published 

12 in the Federal Register. At the same time as publication 

13 in the Federal Register, the Secretary shall provide a copy 

14 of such memoranda, amendment, or modification to each 

15 Indian Tribe, Tribal Organization, and urban Indian orga16 nization. 

17 ‘‘SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PRE18 VENTION AND TREATMENT PROGRAM. 

19 ‘‘(a) ESTABLISHMENT.— 

20 ‘‘(1) IN GENERAL.—The Secretary, acting 

21 through the Service, shall provide a program of com22 prehensive behavioral health, prevention, treatment, 

23 and aftercare, including Systems of Care, which 

24 shall include— 


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1 ‘‘(A) prevention, through educational inter2 vention, in Indian communities; 

3 ‘‘(B) acute detoxification, psychiatric hos4 pitalization, residential, and intensive outpatient 

5 treatment; 

6 ‘‘(C) community-based rehabilitation and 

7 aftercare; 

8 ‘‘(D) community education and involve9 ment, including extensive training of health 

10 care, educational, and community-based per11 sonnel; 

12 ‘‘(E) specialized residential treatment pro13 grams for high-risk populations, including preg14 nant and postpartum women and their children; 

15 and 

16 ‘‘(F) diagnostic services. 

17 ‘‘(2) TARGET POPULATIONS.—The target popu18 lation of such programs shall be members of Indian 

19 Tribes. Efforts to train and educate key members of 

20 the Indian community shall also target employees of 

21 health, education, judicial, law enforcement, legal, 

22 and social service programs. 

23 ‘‘(b) CONTRACT HEALTH SERVICES.— 

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

25 through the Service, may enter into contracts with 


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1 public or private providers of behavioral health treat2 ment services for the purpose of carrying out the 

3 program required under subsection (a). 

4 ‘‘(2) PROVISION OF ASSISTANCE.—In carrying 

5 out this subsection, the Secretary shall provide as6 sistance to Indian Tribes and Tribal Organizations 

7 to develop criteria for the certification of behavioral 

8 health service providers and accreditation of service 

9 facilities which meet minimum standards for such 

10 services and facilities. 

11 ‘‘SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM. 

12 ‘‘(a) IN GENERAL.—Under the authority of the Act 

13 of November 2, 1921 (25 U.S.C. 13) (commonly known 

14 as the ‘Snyder Act’), the Secretary shall establish and 

15 maintain a mental health technician program within the 

16 Service which— 

17 ‘‘(1) provides for the training of Indians as 

18 mental health technicians; and 

19 ‘‘(2) employs such technicians in the provision 

20 of community-based mental health care that includes 

21 identification, prevention, education, referral, and 

22 treatment services. 

23 ‘‘(b) PARAPROFESSIONAL TRAINING.—In carrying 

24 out subsection (a), the Secretary, acting through the Serv25 ice, shall provide high-standard paraprofessional training 


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1 in mental health care necessary to provide quality care to 

2 the Indian communities to be served. Such training shall 

3 be based upon a curriculum developed or approved by the 

4 Secretary which combines education in the theory of men5 tal health care with supervised practical experience in the 

6 provision of such care. 

7 ‘‘(c) SUPERVISION AND EVALUATION OF TECHNI8 CIANS.—The Secretary, acting through the Service, shall 

9 supervise and evaluate the mental health technicians in 

10 the training program. 

11 ‘‘(d) TRADITIONAL HEALTH CARE PRACTICES.—The 

12 Secretary, acting through the Service, shall ensure that 

13 the program established pursuant to this subsection in14 volves the use and promotion of the traditional health care 

15 practices of the Indian Tribes to be served. 

16 ‘‘SEC. 705. LICENSING REQUIREMENT FOR MENTAL 

17 HEALTH CARE WORKERS. 

18 ‘‘(a) IN GENERAL.—Subject to the provisions of sec19 tion 221, and except as provided in subsection (b), any 

20 individual employed as a psychologist, social worker, or 

21 marriage and family therapist for the purpose of providing 

22 mental health care services to Indians in a clinical setting 

23 under this Act is required to be licensed as a psychologist, 

24 social worker, or marriage and family therapist, respec25 tively. 


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1 ‘‘(b) TRAINEES.—An individual may be employed as 

2 a trainee in psychology, social work, or marriage and fam3 ily therapy to provide mental health care services de4 scribed in subsection (a) if such individual— 

5 ‘‘(1) works under the direct supervision of a li6 censed psychologist, social worker, or marriage and 

7 family therapist, respectively; 

8 ‘‘(2) is enrolled in or has completed at least 2 

9 years of course work at a post-secondary, accredited 

10 education program for psychology, social work, mar11 riage and family therapy, or counseling; and 

12 ‘‘(3) meets such other training, supervision, and 

13 quality review requirements as the Secretary may es14 tablish. 

15 ‘‘SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS. 

16 ‘‘(a) GRANTS.—The Secretary, consistent with sec17 tion 701, may make grants to Indian Tribes, Tribal Orga18 nizations, and urban Indian organizations to develop and 

19 implement a comprehensive behavioral health program of 

20 prevention, intervention, treatment, and relapse preven21 tion services that specifically addresses the cultural, his22 torical, social, and child care needs of Indian women, re23 gardless of age. 

24 ‘‘(b) USE OF GRANT FUNDS.—A grant made pursu25 ant to this section may be used to— 


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1 ‘‘(1) develop and provide community training, 

2 education, and prevention programs for Indian 

3 women relating to behavioral health issues, including 

4 fetal alcohol disorders; 

5 ‘‘(2) identify and provide psychological services, 

6 counseling, advocacy, support, and relapse preven7 tion to Indian women and their families; and 

8 ‘‘(3) develop prevention and intervention models 

9 for Indian women which incorporate traditional 

10 health care practices, cultural values, and commu11 nity and family involvement. 

12 ‘‘(c) CRITERIA.—The Secretary, in consultation with 

13 Indian Tribes and Tribal Organizations, shall establish 

14 criteria for the review and approval of applications and 

15 proposals for funding under this section. 

16 ‘‘(d) ALLOCATION OF FUNDS FOR URBAN INDIAN

17 ORGANIZATIONS.—Twenty percent of the funds appro18 priated pursuant to this section shall be used to make 

19 grants to urban Indian organizations. 

20 ‘‘SEC. 707. INDIAN YOUTH PROGRAM. 

21 ‘‘(a) DETOXIFICATION AND REHABILITATION.—The 

22 Secretary, acting through the Service, consistent with sec23 tion 701, shall develop and implement a program for acute 

24 detoxification and treatment for Indian youths, including 

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1 gional treatment centers designed to include detoxification 

2 and rehabilitation for both sexes on a referral basis and 

3 programs developed and implemented by Indian Tribes or 

4 Tribal Organizations at the local level under the Indian 

5 Self-Determination and Education Assistance Act (25 

6 U.S.C. 450 et seq.). Regional centers shall be integrated 

7 with the intake and rehabilitation programs based in the 

8 referring Indian community. 

9 ‘‘(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT

10 CENTERS OR FACILITIES.— 

11 ‘‘(1) ESTABLISHMENT.— 

12 ‘‘(A) IN GENERAL.—The Secretary, acting 

13 through the Service, shall construct, renovate, 

14 or, as necessary, purchase, and appropriately 

15 staff and operate, at least 1 youth regional 

16 treatment center or treatment network in each 

17 area under the jurisdiction of an Area Office. 

18 ‘‘(B) AREA OFFICE IN CALIFORNIA.—For 

19 the purposes of this subsection, the Area Office 

20 in California shall be considered to be 2 Area 

21 Offices, 1 office whose jurisdiction shall be con22 sidered to encompass the northern area of the 

23 State of California, and 1 office whose jurisdic24 tion shall be considered to encompass the re25 mainder of the State of California for the purVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01902 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 pose of implementing California treatment net2 works. 

3 ‘‘(2) FUNDING.—For the purpose of staffing 

4 and operating such centers or facilities, funding 

5 shall be pursuant to the Act of November 2, 1921 

6 (25 U.S.C. 13). 

7 ‘‘(3) LOCATION.—A youth treatment center 

8 constructed or purchased under this subsection shall 

9 be constructed or purchased at a location within the 

10 area described in paragraph (1) agreed upon (by ap11 propriate tribal resolution) by a majority of the In12 dian Tribes to be served by such center. 

13 ‘‘(4) SPECIFIC PROVISION OF FUNDS.— 

14 ‘‘(A) IN GENERAL.—Notwithstanding any 

15 other provision of this title, the Secretary may, 

16 from amounts authorized to be appropriated for 

17 the purposes of carrying out this section, make 

18 funds available to— 

19 ‘‘(i) the Tanana Chiefs Conference, 

20 Incorporated, for the purpose of leasing, 

21 constructing, renovating, operating, and 

22 maintaining a residential youth treatment 

23 facility in Fairbanks, Alaska; and 

24 ‘‘(ii) the Southeast Alaska Regional 

25 Health Corporation to staff and operate a 


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1 residential youth treatment facility without 

2 regard to the proviso set forth in section 

3 4(l) of the Indian Self-Determination and 

4 Education Assistance Act (25 U.S.C. 

5 450b(l)). 

6 ‘‘(B) PROVISION OF SERVICES TO ELIGI7 BLE YOUTHS.—Until additional residential 

8 youth treatment facilities are established in 

9 Alaska pursuant to this section, the facilities 

10 specified in subparagraph (A) shall make every 

11 effort to provide services to all eligible Indian 

12 youths residing in Alaska. 

13 ‘‘(c) INTERMEDIATE ADOLESCENT BEHAVIORAL

14 HEALTH SERVICES.— 

15 ‘‘(1) IN GENERAL.—The Secretary, acting 

16 through the Service, may provide intermediate be17 havioral health services, which may incorporate Sys18 tems of Care, to Indian children and adolescents, in19 cluding— 

20 ‘‘(A) pretreatment assistance; 

21 ‘‘(B) inpatient, outpatient, and aftercare 

22 services; 

23 ‘‘(C) emergency care; 

24 ‘‘(D) suicide prevention and crisis interven25 tion; and 


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1 ‘‘(E) prevention and treatment of mental 

2 illness and dysfunctional and self-destructive 

3 behavior, including child abuse and family vio4 lence. 

5 ‘‘(2) USE OF FUNDS.—Funds provided under 

6 this subsection may be used— 

7 ‘‘(A) to construct or renovate an existing 

8 health facility to provide intermediate behav9 ioral health services; 

10 ‘‘(B) to hire behavioral health profes11 sionals; 

12 ‘‘(C) to staff, operate, and maintain an in13 termediate mental health facility, group home, 

14 sober housing, transitional housing or similar 

15 facilities, or youth shelter where intermediate 

16 behavioral health services are being provided; 

17 ‘‘(D) to make renovations and hire appro18 priate staff to convert existing hospital beds 

19 into adolescent psychiatric units; and 

20 ‘‘(E) for intensive home- and community21 based services. 

22 ‘‘(3) CRITERIA.—The Secretary, acting through 

23 the Service, shall, in consultation with Indian Tribes 

24 and Tribal Organizations, establish criteria for the 


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1 review and approval of applications or proposals for 

2 funding made available pursuant to this subsection. 

3 ‘‘(d) FEDERALLY OWNED STRUCTURES.— 

4 ‘‘(1) IN GENERAL.—The Secretary, in consulta5 tion with Indian Tribes and Tribal Organizations, 

6 shall— 

7 ‘‘(A) identify and use, where appropriate, 

8 federally owned structures suitable for local res9 idential or regional behavioral health treatment 

10 for Indian youths; and 

11 ‘‘(B) establish guidelines for determining 

12 the suitability of any such federally owned 

13 structure to be used for local residential or re14 gional behavioral health treatment for Indian 

15 youths. 

16 ‘‘(2) TERMS AND CONDITIONS FOR USE OF

17 STRUCTURE.—Any structure described in paragraph 

18 (1) may be used under such terms and conditions as 

19 may be agreed upon by the Secretary and the agency 

20 having responsibility for the structure and any In21 dian Tribe or Tribal Organization operating the pro22 gram. 

23 ‘‘(e) REHABILITATION AND AFTERCARE SERVICES.— 

24 ‘‘(1) IN GENERAL.—The Secretary, Indian 

25 Tribes, or Tribal Organizations, in cooperation with 


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1 the Secretary of the Interior, shall develop and im2 plement within each Service Unit, community-based 

3 rehabilitation and follow-up services for Indian 

4 youths who are having significant behavioral health 

5 problems, and require long-term treatment, commu6 nity reintegration, and monitoring to support the In7 dian youths after their return to their home commu8 nity. 

9 ‘‘(2) ADMINISTRATION.—Services under para10 graph (1) shall be provided by trained staff within 

11 the community who can assist the Indian youths in 

12 their continuing development of self-image, positive 

13 problem-solving skills, and nonalcohol or substance 

14 abusing behaviors. Such staff may include alcohol 

15 and substance abuse counselors, mental health pro16 fessionals, and other health professionals and para17 professionals, including community health represent18 atives. 

19 ‘‘(f) INCLUSION OF FAMILY IN YOUTH TREATMENT

20 PROGRAM.—In providing the treatment and other services 

21 to Indian youths authorized by this section, the Secretary, 

22 acting through the Service, shall provide for the inclusion 

23 of family members of such youths in the treatment pro24 grams or other services as may be appropriate. Not less 

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1 poses of carrying out subsection (e) shall be used for out2 patient care of adult family members related to the treat3 ment of an Indian youth under that subsection. 

4 ‘‘(g) MULTIDRUG ABUSE PROGRAM.—The Secretary, 

5 acting through the Service, shall provide, consistent with 

6 section 701, programs and services to prevent and treat 

7 the abuse of multiple forms of substances, including alco8 hol, drugs, inhalants, and tobacco, among Indian youths 

9 residing in Indian communities, on or near reservations, 

10 and in urban areas and provide appropriate mental health 

11 services to address the incidence of mental illness among 

12 such youths. 

13 ‘‘(h) INDIAN YOUTH MENTAL HEALTH.—The Sec14 retary, acting through the Service, shall collect data for 

15 the report under section 801 with respect to— 

16 ‘‘(1) the number of Indian youth who are being 

17 provided mental health services through the Service 

18 and Tribal Health Programs; 

19 ‘‘(2) a description of, and costs associated with, 

20 the mental health services provided for Indian youth 

21 through the Service and Tribal Health Programs; 

22 ‘‘(3) the number of youth referred to the Serv23 ice or Tribal Health Programs for mental health 

24 services; 


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1 ‘‘(4) the number of Indian youth provided resi2 dential treatment for mental health and behavioral 

3 problems through the Service and Tribal Health 

4 Programs, reported separately for on- and off-res5 ervation facilities; and 

6 ‘‘(5) the costs of the services described in para7 graph (4). 

8 ‘‘SEC. 708. INDIAN YOUTH TELEMENTAL HEALTH DEM9 ONSTRATION PROJECT. 

10 ‘‘(a) PURPOSE.—The purpose of this section is to au11 thorize the Secretary to carry out a demonstration project 

12 to test the use of telemental health services in suicide pre13 vention, intervention and treatment of Indian youth, in14 cluding through— 

15 ‘‘(1) the use of psychotherapy, psychiatric as16 sessments, diagnostic interviews, therapies for men17 tal health conditions predisposing to suicide, and al18 cohol and substance abuse treatment; 

19 ‘‘(2) the provision of clinical expertise to, con20 sultation services with, and medical advice and train21 ing for frontline health care providers working with 

22 Indian youth; 

23 ‘‘(3) training and related support for commu24 nity leaders, family members and health and edu25 cation workers who work with Indian youth; 


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1 ‘‘(4) the development of culturally relevant edu2 cational materials on suicide; and 

3 ‘‘(5) data collection and reporting. 

4 ‘‘(b) DEFINITIONS.—For the purpose of this section, 

5 the following definitions shall apply: 

6 ‘‘(1) DEMONSTRATION PROJECT.—The term 

7 ‘demonstration project’ means the Indian youth tele8 mental health demonstration project authorized 

9 under subsection (c). 

10 ‘‘(2) TELEMENTAL HEALTH.—The term ‘tele11 mental health’ means the use of electronic informa12 tion and telecommunications technologies to support 

13 long distance mental health care, patient and profes14 sional-related education, public health, and health 

15 administration. 

16 ‘‘(c) AUTHORIZATION.— 

17 ‘‘(1) IN GENERAL.—The Secretary is authorized 

18 to award grants under the demonstration project for 

19 the provision of telemental health services to Indian 

20 youth who— 

21 ‘‘(A) have expressed suicidal ideas; 

22 ‘‘(B) have attempted suicide; or 

23 ‘‘(C) have mental health conditions that in24 crease or could increase the risk of suicide. 


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1 ‘‘(2) ELIGIBILITY FOR GRANTS.—Such grants 

2 shall be awarded to Indian Tribes and Tribal Orga3 nizations that operate 1 or more facilities— 

4 ‘‘(A) located in Alaska and part of the 

5 Alaska Federal Health Care Access Network; 

6 ‘‘(B) reporting active clinical telehealth ca7 pabilities; or 

8 ‘‘(C) offering school-based telemental 

9 health services relating to psychiatry to Indian 

10 youth. 

11 ‘‘(3) GRANT PERIOD.—The Secretary shall 

12 award grants under this section for a period of up 

13 to 4 years. 

14 ‘‘(4) AWARDING OF GRANTS.—Not more than 5 

15 grants shall be provided under paragraph (1), with 

16 priority consideration given to Indian Tribes and 

17 Tribal Organizations that— 

18 ‘‘(A) serve a particular community or geo19 graphic area where there is a demonstrated 

20 need to address Indian youth suicide; 

21 ‘‘(B) enter in to collaborative partnerships 

22 with Indian Health Service or Tribal Health 

23 Programs or facilities to provide services under 

24 this demonstration project; 


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1 ‘‘(C) serve an isolated community or geo2 graphic area which has limited or no access to 

3 behavioral health services; or 

4 ‘‘(D) operate a detention facility at which 

5 Indian youth are detained. 

6 ‘‘(d) USE OF FUNDS.— 

7 ‘‘(1) IN GENERAL.—An Indian Tribe or Tribal 

8 Organization shall use a grant received under sub9 section (c) for the following purposes: 

10 ‘‘(A) To provide telemental health services 

11 to Indian youth, including the provision of— 

12 ‘‘(i) psychotherapy; 

13 ‘‘(ii) psychiatric assessments and di14 agnostic interviews, therapies for mental 

15 health conditions predisposing to suicide, 

16 and treatment; and 

17 ‘‘(iii) alcohol and substance abuse 

18 treatment. 

19 ‘‘(B) To provide clinician-interactive med20 ical advice, guidance and training, assistance in 

21 diagnosis and interpretation, crisis counseling 

22 and intervention, and related assistance to 

23 Service, tribal, or urban clinicians and health 

24 services providers working with youth being 

25 served under this demonstration project. 


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1 ‘‘(C) To assist, educate and train commu2 nity leaders, health education professionals and 

3 paraprofessionals, tribal outreach workers, and 

4 family members who work with the youth re5 ceiving telemental health services under this 

6 demonstration project, including with identifica7 tion of suicidal tendencies, crisis intervention 

8 and suicide prevention, emergency skill develop9 ment, and building and expanding networks 

10 among these individuals and with State and 

11 local health services providers. 

12 ‘‘(D) To develop and distribute culturally 

13 appropriate community educational materials 

14 on— 

15 ‘‘(i) suicide prevention; 

16 ‘‘(ii) suicide education; 

17 ‘‘(iii) suicide screening; 

18 ‘‘(iv) suicide intervention; and 

19 ‘‘(v) ways to mobilize communities 

20 with respect to the identification of risk 

21 factors for suicide. 

22 ‘‘(E) For data collection and reporting re23 lated to Indian youth suicide prevention efforts. 

24 ‘‘(2) TRADITIONAL HEALTH CARE PRAC25 TICES.—In carrying out the purposes described in 


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1 paragraph (1), an Indian Tribe or Tribal Organiza2 tion may use and promote the traditional health care 

3 practices of the Indian Tribes of the youth to be 

4 served. 

5 ‘‘(e) APPLICATIONS.—To be eligible to receive a grant 

6 under subsection (c), an Indian Tribe or Tribal Organiza7 tion shall prepare and submit to the Secretary an applica8 tion, at such time, in such manner, and containing such 

9 information as the Secretary may require, including— 

10 ‘‘(1) a description of the project that the Indian 

11 Tribe or Tribal Organization will carry out using the 

12 funds provided under the grant; 

13 ‘‘(2) a description of the manner in which the 

14 project funded under the grant would— 

15 ‘‘(A) meet the telemental health care needs 

16 of the Indian youth population to be served by 

17 the project; or 

18 ‘‘(B) improve the access of the Indian 

19 youth population to be served to suicide preven20 tion and treatment services; 

21 ‘‘(3) evidence of support for the project from 

22 the local community to be served by the project; 

23 ‘‘(4) a description of how the families and lead24 ership of the communities or populations to be 


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1 served by the project would be involved in the devel2 opment and ongoing operations of the project; 

3 ‘‘(5) a plan to involve the tribal community of 

4 the youth who are provided services by the project 

5 in planning and evaluating the mental health care 

6 and suicide prevention efforts provided, in order to 

7 ensure the integration of community, clinical, envi8 ronmental, and cultural components of the treat9 ment; and 

10 ‘‘(6) a plan for sustaining the project after Fed11 eral assistance for the demonstration project has ter12 minated. 

13 ‘‘(f) COLLABORATION; REPORTING TO NATIONAL

14 CLEARINGHOUSE.— 

15 ‘‘(1) COLLABORATION.—The Secretary, acting 

16 through the Service, shall encourage Indian Tribes 

17 and Tribal Organizations receiving grants under this 

18 section to collaborate to enable comparisons about 

19 best practices across projects. 

20 ‘‘(2) REPORTING TO NATIONAL CLEARING21 HOUSE.—The Secretary, acting through the Service, 

22 shall also encourage Indian Tribes and Tribal Orga23 nizations receiving grants under this section to sub24 mit relevant, declassified project information to the 

25 national clearinghouse authorized under section 


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1 701(b)(2) in order to better facilitate program per2 formance and improve suicide prevention, interven3 tion, and treatment services. 

4 ‘‘(g) ANNUAL REPORT.—Each grant recipient shall 

5 submit to the Secretary an annual report that— 

6 ‘‘(1) describes the number of telemental health 

7 services provided; and 

8 ‘‘(2) includes any other information that the 

9 Secretary may require. 

10 ‘‘(h) REPORT TO CONGRESS.—Not later than 270 

11 days after the termination of the demonstration project, 

12 the Secretary shall submit to the Committee on Indian Af13 fairs of the Senate and the Committee on Natural Re14 sources and Committee on Energy and Commerce of the 

15 House of Representatives a final report, based on the an16 nual reports provided by grant recipients under subsection 

17 (h), that— 

18 ‘‘(1) describes the results of the projects funded 

19 by grants awarded under this section, including any 

20 data available which indicates the number of at21 tempted suicides; 

22 ‘‘(2) evaluates the impact of the telemental 

23 health services funded by the grants in reducing the 

24 number of completed suicides among Indian youth; 


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1 ‘‘(3) evaluates whether the demonstration 

2 project should be— 

3 ‘‘(A) expanded to provide more than 5 

4 grants; and 

5 ‘‘(B) designated a permanent program; 

6 and 

7 ‘‘(4) evaluates the benefits of expanding the 

8 demonstration project to include urban Indian orga9 nizations. 

10 ‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There is 

11 authorized to be appropriated such sums as may be nec12 essary to carry out this section. 

13 ‘‘SEC. 709. INPATIENT AND COMMUNITY-BASED MENTAL 

14 HEALTH FACILITIES DESIGN, CONSTRUC15 TION, AND STAFFING. 

16 ‘‘Not later than 1 year after the date of enactment 

17 of the Indian Health Care Improvement Act Amendments 

18 of 2009, the Secretary, acting through the Service, may 

19 provide, in each area of the Service, not less than 1 inpa20 tient mental health care facility, or the equivalent, for In21 dians with behavioral health problems. For the purposes 

22 of this subsection, California shall be considered to be 2 

23 Area Offices, 1 office whose location shall be considered 

24 to encompass the northern area of the State of California 

25 and 1 office whose jurisdiction shall be considered to enVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01917 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 compass the remainder of the State of California. The Sec2 retary shall consider the possible conversion of existing, 

3 underused Service hospital beds into psychiatric units to 

4 meet such need. 

5 ‘‘SEC. 710. TRAINING AND COMMUNITY EDUCATION. 

6 ‘‘(a) PROGRAM.—The Secretary, in cooperation with 

7 the Secretary of the Interior, shall develop and implement 

8 or assist Indian Tribes and Tribal Organizations to de9 velop and implement, within each Service Unit or tribal 

10 program, a program of community education and involve11 ment which shall be designed to provide concise and timely 

12 information to the community leadership of each tribal 

13 community. Such program shall include education about 

14 behavioral health issues to political leaders, Tribal judges, 

15 law enforcement personnel, members of tribal health and 

16 education boards, health care providers including tradi17 tional practitioners, and other critical members of each 

18 tribal community. Such program may also include commu19 nity-based training to develop local capacity and tribal 

20 community provider training for prevention, intervention, 

21 treatment, and aftercare. 

22 ‘‘(b) INSTRUCTION.—The Secretary, acting through 

23 the Service, shall provide instruction in the area of behav24 ioral health issues, including instruction in crisis interven25 tion and family relations in the context of alcohol and subVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01918 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 stance abuse, child sexual abuse, youth alcohol and sub2 stance abuse, and the causes and effects of fetal alcohol 

3 disorders to appropriate employees of the Bureau of In4 dian Affairs and the Service, and to personnel in schools 

5 or programs operated under any contract with the Bureau 

6 of Indian Affairs or the Service, including supervisors of 

7 emergency shelters and halfway houses described in sec8 tion 4213 of the Indian Alcohol and Substance Abuse Pre9 vention and Treatment Act of 1986 (25 U.S.C. 2433). 

10 ‘‘(c) TRAINING MODELS.—In carrying out the edu11 cation and training programs required by this section, the 

12 Secretary, in consultation with Indian Tribes, Tribal Or13 ganizations, Indian behavioral health experts, and Indian 

14 alcohol and substance abuse prevention experts, shall de15 velop and provide community-based training models. Such 

16 models shall address— 

17 ‘‘(1) the elevated risk of alcohol and behavioral 

18 health problems faced by children of alcoholics; 

19 ‘‘(2) the cultural, spiritual, and 

20 multigenerational aspects of behavioral health prob21 lem prevention and recovery; and 

22 ‘‘(3) community-based and multidisciplinary 

23 strategies, including Systems of Care, for preventing 

24 and treating behavioral health problems. 


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1 ‘‘SEC. 711. BEHAVIORAL HEALTH PROGRAM. 

2 ‘‘(a) INNOVATIVE PROGRAMS.—The Secretary, acting 

3 through the Service, consistent with section 701, may 

4 plan, develop, implement, and carry out programs to de5 liver innovative community-based behavioral health serv6 ices to Indians. 

7 ‘‘(b) AWARDS; CRITERIA.—The Secretary may award 

8 a grant for a project under subsection (a) to an Indian 

9 Tribe or Tribal Organization and may consider the fol10 lowing criteria: 

11 ‘‘(1) The project will address significant unmet 

12 behavioral health needs among Indians. 

13 ‘‘(2) The project will serve a significant number 

14 of Indians. 

15 ‘‘(3) The project has the potential to deliver 

16 services in an efficient and effective manner. 

17 ‘‘(4) The Indian Tribe or Tribal Organization 

18 has the administrative and financial capability to ad19 minister the project. 

20 ‘‘(5) The project may deliver services in a man21 ner consistent with traditional health care practices. 

22 ‘‘(6) The project is coordinated with, and avoids 

23 duplication of, existing services. 

24 ‘‘(c) EQUITABLE TREATMENT.—For purposes of this 

25 subsection, the Secretary shall, in evaluating project appli26 cations or proposals, use the same criteria that the SecVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01920 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 retary uses in evaluating any other application or proposal 

2 for such funding. 

3 ‘‘SEC. 712. FETAL ALCOHOL DISORDER PROGRAMS. 

4 ‘‘(a) PROGRAMS.— 

5 ‘‘(1) ESTABLISHMENT.—The Secretary, con6 sistent with section 701 and acting through the 

7 Service, is authorized to establish and operate fetal 

8 alcohol disorder programs as provided in this section 

9 for the purposes of meeting the health status objec10 tives specified in section 3. 

11 ‘‘(2) USE OF FUNDS.— 

12 ‘‘(A) IN GENERAL.—Funding provided 

13 pursuant to this section shall be used for the 

14 following: 

15 ‘‘(i) To develop and provide for Indi16 ans community and in-school training, edu17 cation, and prevention programs relating 

18 to fetal alcohol disorders. 

19 ‘‘(ii) To identify and provide behav20 ioral health treatment to high-risk Indian 

21 women and high-risk women pregnant with 

22 an Indian’s child. 

23 ‘‘(iii) To identify and provide appro24 priate psychological services, educational 

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1 cacy, and information to fetal alcohol dis2 order affected Indians and their families or 

3 caretakers. 

4 ‘‘(iv) To develop and implement coun5 seling and support programs in schools for 

6 fetal alcohol disorder affected Indian chil7 dren. 

8 ‘‘(v) To develop prevention and inter9 vention models which incorporate practi10 tioners of traditional health care practices, 

11 cultural values, and community involve12 ment. 

13 ‘‘(vi) To develop, print, and dissemi14 nate education and prevention materials on 

15 fetal alcohol disorder. 

16 ‘‘(vii) To develop and implement, in 

17 consultation with Indian Tribes, Tribal Or18 ganizations, and urban Indian organiza19 tions, culturally sensitive assessment and 

20 diagnostic tools including dysmorphology 

21 clinics and multidisciplinary fetal alcohol 

22 disorder clinics for use in Indian commu23 nities and Urban Centers. 

24 ‘‘(B) ADDITIONAL USES.—In addition to 

25 any purpose under subparagraph (A), funding 


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1 provided pursuant to this section may be used 

2 for 1 or more of the following: 

3 ‘‘(i) Early childhood intervention 

4 projects from birth on to mitigate the ef5 fects of fetal alcohol disorder among Indi6 ans. 

7 ‘‘(ii) Community-based support serv8 ices for Indians and women pregnant with 

9 Indian children. 

10 ‘‘(iii) Community-based housing for 

11 adult Indians with fetal alcohol disorder. 

12 ‘‘(3) CRITERIA FOR APPLICATIONS.—The Sec13 retary shall establish criteria for the review and ap14 proval of applications for funding under this section. 

15 ‘‘(b) SERVICES.—The Secretary, acting through the 

16 Service, shall— 

17 ‘‘(1) develop and provide services for the pre18 vention, intervention, treatment, and aftercare for 

19 those affected by fetal alcohol disorder in Indian 

20 communities; and 

21 ‘‘(2) provide supportive services, including serv22 ices to meet the special educational, vocational, 

23 school-to-work transition, and independent living 

24 needs of adolescent and adult Indians with fetal al25 cohol disorder. 


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1 ‘‘(c) TASK FORCE.—The Secretary shall establish a 

2 task force to be known as the Fetal Alcohol Disorder Task 

3 Force to advise the Secretary in carrying out subsection 

4 (b). Such task force shall be composed of representatives 

5 from the following: 

6 ‘‘(1) The National Institute on Drug Abuse. 

7 ‘‘(2) The National Institute on Alcohol and Al8 coholism. 

9 ‘‘(3) The Office of Substance Abuse Prevention. 

10 ‘‘(4) The National Institute of Mental Health. 

11 ‘‘(5) The Service. 

12 ‘‘(6) The Office of Minority Health of the De13 partment of Health and Human Services. 

14 ‘‘(7) The Administration for Native Americans. 

15 ‘‘(8) The National Institute of Child Health 

16 and Human Development (NICHD). 

17 ‘‘(9) The Centers for Disease Control and Pre18 vention. 

19 ‘‘(10) The Bureau of Indian Affairs. 

20 ‘‘(11) Indian Tribes. 

21 ‘‘(12) Tribal Organizations. 

22 ‘‘(13) urban Indian organizations. 

23 ‘‘(14) Indian fetal alcohol spectrum disorders 

24 experts. 


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1 ‘‘(d) APPLIED RESEARCH PROJECTS.—The Sec2 retary, acting through the Substance Abuse and Mental 

3 Health Services Administration, shall make grants to In4 dian Tribes, Tribal Organizations, and urban Indian orga5 nizations for applied research projects which propose to 

6 elevate the understanding of methods to prevent, inter7 vene, treat, or provide rehabilitation and behavioral health 

8 aftercare for Indians and urban Indians affected by fetal 

9 alcohol spectrum disorders. 

10 ‘‘(e) FUNDING FOR URBAN INDIAN ORGANIZA11 TIONS.—Ten percent of the funds appropriated pursuant 

12 to this section shall be used to make grants to urban In13 dian organizations funded under title V. 

14 ‘‘SEC. 713. CHILD SEXUAL ABUSE AND PREVENTION TREAT15 MENT PROGRAMS. 

16 ‘‘(a) ESTABLISHMENT.—The Secretary, acting 

17 through the Service, shall establish, consistent with section 

18 701, in every Service Area, programs involving treatment 

19 for— 

20 ‘‘(1) victims of sexual abuse who are Indian 

21 children or children in an Indian household; and 

22 ‘‘(2) perpetrators of child sexual abuse who are 

23 Indian or members of an Indian household. 

24 ‘‘(b) USE OF FUNDS.—Funding provided pursuant to 

25 this section shall be used for the following: 


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1 ‘‘(1) To develop and provide community edu2 cation and prevention programs related to sexual 

3 abuse of Indian children or children in an Indian 

4 household. 

5 ‘‘(2) To identify and provide behavioral health 

6 treatment to victims of sexual abuse who are Indian 

7 children or children in an Indian household, and to 

8 their family members who are affected by sexual 

9 abuse. 

10 ‘‘(3) To develop prevention and intervention 

11 models which incorporate traditional health care 

12 practices, cultural values, and community involve13 ment. 

14 ‘‘(4) To develop and implement culturally sen15 sitive assessment and diagnostic tools for use in In16 dian communities and Urban Centers. 

17 ‘‘(5) To identify and provide behavioral health 

18 treatment to Indian perpetrators and perpetrators 

19 who are members of an Indian household— 

20 ‘‘(A) making efforts to begin offender and 

21 behavioral health treatment while the perpe22 trator is incarcerated or at the earliest possible 

23 date if the perpetrator is not incarcerated; and 


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1 ‘‘(B) providing treatment after the perpe2 trator is released, until it is determined that the 

3 perpetrator is not a threat to children. 

4 ‘‘(c) COORDINATION.—The programs established 

5 under subsection (a) shall be carried out in coordination 

6 with programs and services authorized under the Indian 

7 Child Protection and Family Violence Prevention Act (25 

8 U.S.C. 3201 et seq.). 

9 ‘‘SEC. 714. DOMESTIC AND SEXUAL VIOLENCE PREVENTION 

10 AND TREATMENT. 

11 ‘‘(a) IN GENERAL.—The Secretary, in accordance 

12 with section 701, is authorized to establish in each Service 

13 Area programs involving the prevention and treatment 

14 of— 

15 ‘‘(1) Indian victims of domestic violence or sex16 ual abuse; and 

17 ‘‘(2) perpetrators of domestic violence or sexual 

18 abuse who are Indian or members of an Indian 

19 household. 

20 ‘‘(b) USE OF FUNDS.—Funds made available to carry 

21 out this section shall be used— 

22 ‘‘(1) to develop and implement prevention pro23 grams and community education programs relating 

24 to domestic violence and sexual abuse; 


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1 ‘‘(2) to provide behavioral health services, in2 cluding victim support services, and medical treat3 ment (including examinations performed by sexual 

4 assault nurse examiners) to Indian victims of domes5 tic violence or sexual abuse; 

6 ‘‘(3) to purchase rape kits; 

7 ‘‘(4) to develop prevention and intervention 

8 models, which may incorporate traditional health 

9 care practices; and 

10 ‘‘(5) to identify and provide behavioral health 

11 treatment to perpetrators who are Indian or mem12 bers of an Indian household. 

13 ‘‘(c) TRAINING AND CERTIFICATION.— 

14 ‘‘(1) IN GENERAL.—Not later than 1 year after 

15 the date of enactment of the Indian Health Care Im16 provement Act Amendments of 2009, the Secretary 

17 shall establish appropriate protocols, policies, proce18 dures, standards of practice, and, if not available 

19 elsewhere, training curricula and training and cer20 tification requirements for services for victims of do21 mestic violence and sexual abuse. 

22 ‘‘(2) REPORT.—Not later than 18 months after 

23 the date of enactment of the Indian Health Care Im24 provement Act Amendments of 2008, the Secretary 

25 shall submit to the Committee on Indian Affairs of 


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1 the Senate and the Committee on Natural Resources 

2 of the House of Representatives a report that de3 scribes the means and extent to which the Secretary 

4 has carried out paragraph (1). 

5 ‘‘(d) COORDINATION.— 

6 ‘‘(1) IN GENERAL.—The Secretary, in coordina7 tion with the Attorney General, Federal and tribal 

8 law enforcement agencies, Indian Health Programs, 

9 and domestic violence or sexual assault victim orga10 nizations, shall develop appropriate victim services 

11 and victim advocate training programs— 

12 ‘‘(A) to improve domestic violence or sex13 ual abuse responses; 

14 ‘‘(B) to improve forensic examinations and 

15 collection; 

16 ‘‘(C) to identify problems or obstacles in 

17 the prosecution of domestic violence or sexual 

18 abuse; and 

19 ‘‘(D) to meet other needs or carry out 

20 other activities required to prevent, treat, and 

21 improve prosecutions of domestic violence and 

22 sexual abuse. 

23 ‘‘(2) REPORT.—Not later than 2 years after the 

24 date of enactment of the Indian Health Care Im25 provement Act Amendments of 2008, the Secretary 


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1 shall submit to the Committee on Indian Affairs of 

2 the Senate and the Committee on Natural Resources 

3 of the House of Representatives a report that de4 scribes, with respect to the matters described in 

5 paragraph (1), the improvements made and needed, 

6 problems or obstacles identified, and costs necessary 

7 to address the problems or obstacles, and any other 

8 recommendations that the Secretary determines to 

9 be appropriate. 

10 ‘‘SEC. 715. BEHAVIORAL HEALTH RESEARCH. 

11 ‘‘The Secretary, in consultation with appropriate 

12 Federal agencies, shall make grants to, or enter into con13 tracts with, Indian Tribes, Tribal Organizations, and 

14 urban Indian organizations or enter into contracts with, 

15 or make grants to appropriate institutions for, the conduct 

16 of research on the incidence and prevalence of behavioral 

17 health problems among Indians served by the Service, In18 dian Tribes, or Tribal Organizations and among Indians 

19 in urban areas. Research priorities under this section shall 

20 include— 

21 ‘‘(1) the multifactorial causes of Indian youth 

22 suicide, including— 

23 ‘‘(A) protective and risk factors and sci24 entific data that identifies those factors; and 


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1 ‘‘(B) the effects of loss of cultural identity 

2 and the development of scientific data on those 

3 effects; 

4 ‘‘(2) the interrelationship and interdependence 

5 of behavioral health problems with alcoholism and 

6 other substance abuse, suicide, homicides, other in7 juries, and the incidence of family violence; and 

8 ‘‘(3) the development of models of prevention 

9 techniques. 

10 The effect of the interrelationships and interdependencies 

11 referred to in paragraph (2) on children, and the develop12 ment of prevention techniques under paragraph (3) appli13 cable to children, shall be emphasized. 

14 ‘‘SEC. 716. DEFINITIONS. 

15 ‘‘For the purpose of this title, the following defini16 tions shall apply: 

17 ‘‘(1) ASSESSMENT.—The term ‘assessment’ 

18 means the systematic collection, analysis, and dis19 semination of information on health status, health 

20 needs, and health problems. 

21 ‘‘(2) ALCOHOL-RELATED

22 NEURODEVELOPMENTAL DISORDERS OR ARND.—The 

23 term ‘alcohol-related neurodevelopmental disorders’ 

24 or ‘ARND’ means, with a history of maternal alco25 hol consumption during pregnancy, central nervous 


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1 system involvement such as developmental delay, in2 tellectual deficit, or neurologic abnormalities. Behav3 iorally, there can be problems with irritability, and 

4 failure to thrive as infants. As children become older 

5 there will likely be hyperactivity, attention deficit, 

6 language dysfunction, and perceptual and judgment 

7 problems. 

8 ‘‘(3) BEHAVIORAL HEALTH AFTERCARE.—The 

9 term ‘behavioral health aftercare’ includes those ac10 tivities and resources used to support recovery fol11 lowing inpatient, residential, intensive substance 

12 abuse, or mental health outpatient or outpatient 

13 treatment. The purpose is to help prevent or deal 

14 with relapse by ensuring that by the time a client or 

15 patient is discharged from a level of care, such as 

16 outpatient treatment, an aftercare plan has been de17 veloped with the client. An aftercare plan may use 

18 such resources as a community-based therapeutic 

19 group, transitional living facilities, a 12-step spon20 sor, a local 12-step or other related support group, 

21 and other community-based providers. 

22 ‘‘(4) DUAL DIAGNOSIS.—The term ‘dual diag23 nosis’ means coexisting substance abuse and mental 

24 illness conditions or diagnosis. Such clients are 


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1 sometimes referred to as mentally ill chemical abus2 ers (MICAs). 

3 ‘‘(5) FETAL ALCOHOL SPECTRUM DIS4 ORDERS.— 

5 ‘‘(A) IN GENERAL.—The term ‘fetal alco6 hol spectrum disorders’ includes a range of ef7 fects that can occur in an individual whose 

8 mother drank alcohol during pregnancy, includ9 ing physical, mental, behavioral, and/or learning 

10 disabilities with possible lifelong implications. 

11 ‘‘(B) INCLUSIONS.—The term ‘fetal alcohol 

12 spectrum disorders’ may include— 

13 ‘‘(i) fetal alcohol syndrome (FAS); 

14 ‘‘(ii) fetal alcohol effect (FAE); 

15 ‘‘(iii) alcohol-related birth defects; and 

16 ‘‘(iv) alcohol-related 

17 neurodevelopmental disorders (ARND). 

18 ‘‘(6) FETAL ALCOHOL SYNDROME OR FAS.— 

19 The term ‘fetal alcohol syndrome’ or ‘FAS’ means 

20 any 1 of a spectrum of effects that may occur when 

21 a woman drinks alcohol during pregnancy, the diag22 nosis of which involves the confirmed presence of the 

23 following 3 criteria: 

24 ‘‘(A) Craniofacial abnormalities. 

25 ‘‘(B) Growth deficits. 


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1 ‘‘(C) Central nervous system abnormalities. 

2 ‘‘(7) REHABILITATION.—The term ‘rehabilita3 tion’ means medical and health care services that— 

4 ‘‘(A) are recommended by a physician or 

5 licensed practitioner of the healing arts within 

6 the scope of their practice under applicable law; 

7 ‘‘(B) are furnished in a facility, home, or 

8 other setting in accordance with applicable 

9 standards; and 

10 ‘‘(C) have as their purpose any of the fol11 lowing: 

12 ‘‘(i) The maximum attainment of 

13 physical, mental, and developmental func14 tioning. 

15 ‘‘(ii) Averting deterioration in physical 

16 or mental functional status. 

17 ‘‘(iii) The maintenance of physical or 

18 mental health functional status. 

19 ‘‘(8) SUBSTANCE ABUSE.—The term ‘substance 

20 abuse’ includes inhalant abuse. 

21 ‘‘(9) SYSTEMS OF CARE.—The term ‘Systems of 

22 Care’ means a system for delivering services to chil23 dren and their families that is child-centered, family24 focused and family-driven, community-based, and 

25 culturally competent and responsive to the needs of 


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1 the children and families being served. The systems 

2 of care approach values prevention and early identi3 fication, smooth transitions for children and fami4 lies, child and family participation and advocacy, 

5 comprehensive array of services, individualized serv6 ice planning, services in the least restrictive environ7 ment, and integrated services with coordinated plan8 ning across the child-serving systems. 

9 ‘‘SEC. 717. AUTHORIZATION OF APPROPRIATIONS. 

10 ‘‘There is authorized to be appropriated such sums 

11 as may be necessary to carry out the provisions of this 

12 title. 

13 ‘‘TITLE VIII—MISCELLANEOUS 

14 ‘‘SEC. 801. REPORTS. 

15 ‘‘For each fiscal year following the date of enactment 

16 of the Indian Health Care Improvement Act Amendments 

17 of 2009, the Secretary shall transmit to Congress a report 

18 containing the following: 

19 ‘‘(1) A report on the progress made in meeting 

20 the objectives of this Act, including a review of pro21 grams established or assisted pursuant to this Act 

22 and assessments and recommendations of additional 

23 programs or additional assistance necessary to, at a 

24 minimum, provide health services to Indians and en25 sure a health status for Indians, which are at a parVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01935 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 ity with the health services available to and the 

2 health status of the general population. 

3 ‘‘(2) A report on whether, and to what extent, 

4 new national health care programs, benefits, initia5 tives, or financing systems have had an impact on 

6 the purposes of this Act and any steps that the Sec7 retary may have taken to consult with Indian Tribes, 

8 Tribal Organizations, and urban Indian organiza9 tions to address such impact, including a report on 

10 proposed changes in allocation of funding pursuant 

11 to section 807. 

12 ‘‘(3) A report on the use of health services by 

13 Indians— 

14 ‘‘(A) on a national and area or other rel15 evant geographical basis; 

16 ‘‘(B) by gender and age; 

17 ‘‘(C) by source of payment and type of 

18 service; 

19 ‘‘(D) comparing such rates of use with 

20 rates of use among comparable non-Indian pop21 ulations; and 

22 ‘‘(E) provided under contracts. 

23 ‘‘(4) A report of contractors to the Secretary on 

24 Health Care Educational Loan Repayments every 6 

25 months required by section 110. 


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1 ‘‘(5) A general audit report of the Secretary on 

2 the Health Care Educational Loan Repayment Pro3 gram as required by section 110(m). 

4 ‘‘(6) A report of the findings and conclusions of 

5 demonstration programs on development of edu6 cational curricula for substance abuse counseling as 

7 required in section 125(f). 

8 ‘‘(7) A separate statement which specifies the 

9 amount of funds requested to carry out the provi10 sions of section 201. 

11 ‘‘(8) A report of the evaluations of health pro12 motion and disease prevention as required in section 

13 203(c). 

14 ‘‘(9) A biennial report to Congress on infectious 

15 diseases as required by section 212. 

16 ‘‘(10) A report on environmental and nuclear 

17 health hazards as required by section 215. 

18 ‘‘(11) An annual report on the status of all 

19 health care facilities needs as required by section 

20 301(c)(2)(B) and 301(d). 

21 ‘‘(12) Reports on safe water and sanitary waste 

22 disposal facilities as required by section 302(h). 

23 ‘‘(13) An annual report on the expenditure of 

24 non-Service funds for renovation as required by sec25 tions 304(b)(2). 


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1 ‘‘(14) A report identifying the backlog of main2 tenance and repair required at Service and tribal fa3 cilities required by section 313(a). 

4 ‘‘(15) A report providing an accounting of reim5 bursement funds made available to the Secretary 

6 under titles XVIII, XIX, and XXI of the Social Se7 curity Act. 

8 ‘‘(16) A report on any arrangements for the 

9 sharing of medical facilities or services, as author10 ized by section 406. 

11 ‘‘(17) A report on evaluation and renewal of 

12 urban Indian programs under section 505. 

13 ‘‘(18) A report on the evaluation of programs 

14 as required by section 513(d). 

15 ‘‘(19) A report on alcohol and substance abuse 

16 as required by section 701(f). 

17 ‘‘(20) A report on Indian youth mental health 

18 services as required by section 707(h). 

19 ‘‘(21) A report on the reallocation of base re20 sources if required by section 807. 

21 ‘‘(22) A report on the movement of patients be22 tween Service Units, including— 

23 ‘‘(A) a list of those Service Units that have 

24 a net increase and those that have a net de25 crease of patients due to patients assigned to 


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1 one Service Unit voluntarily choosing to receive 

2 service at another Service Unit; 

3 ‘‘(B) an analysis of the effect of patient 

4 movement on the quality of services for those 

5 Service Units experiencing an increase in the 

6 number of patients served; and 

7 ‘‘(C) what funding changes are necessary 

8 to maintain a consistent quality of service at 

9 Service Units that have an increase in the num10 ber of patients served. 

11 ‘‘(23) A report on the extent to which health 

12 care facilities of the Service, Indian Tribes, Tribal 

13 Organizations, and urban Indian organizations com14 ply with credentialing requirements of the Service or 

15 licensure requirements of States. 

16 ‘‘SEC. 802. REGULATIONS. 

17 ‘‘(a) DEADLINES.— 

18 ‘‘(1) PROCEDURES.—Not later than 90 days 

19 after the date of enactment of the Indian Health 

20 Care Improvement Act Amendments of 2009, the 

21 Secretary shall initiate procedures under subchapter 

22 III of chapter 5 of title 5, United States Code, to 

23 negotiate and promulgate such regulations or 

24 amendments thereto that are necessary to carry out 

25 this Act, except sections 105, 115, 117, 202, and 


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1 409 through 414. The Secretary may promulgate 

2 regulations to carry out such sections using the pro3 cedures required by chapter 5 of title 5, United 

4 States Code (commonly known as the ‘Administra5 tive Procedure Act’). 

6 ‘‘(2) PROPOSED REGULATIONS.—Proposed reg7 ulations to implement this Act shall be published in 

8 the Federal Register by the Secretary no later than 

9 2 years after the date of enactment of the Indian 

10 Health Care Improvement Act Amendments of 2009 

11 and shall have no less than a 120-day comment pe12 riod. 

13 ‘‘(3) FINAL REGULATIONS.—The Secretary 

14 shall publish in the Federal Register final regula15 tions to implement this Act by not later than 3 years 

16 after the date of enactment of the Indian Health 

17 Care Improvement Act Amendments of 2009. 

18 ‘‘(b) COMMITTEE.—A negotiated rulemaking com19 mittee established pursuant to section 565 of title 5, 

20 United States Code, to carry out this section shall have 

21 as its members only representatives of the Federal Gov22 ernment and representatives of Indian Tribes, and Tribal 

23 Organizations, a majority of whom shall be nominated by 

24 and be representatives of Indian Tribes and Tribal Orga25 nizations from each Service Area. 


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1 ‘‘(c) ADAPTATION OF PROCEDURES.—The Secretary 

2 shall adapt the negotiated rulemaking procedures to the 

3 unique context of self-governance and the government-to4 government relationship between the United States and 

5 Indian Tribes. 

6 ‘‘(d) LACK OF REGULATIONS.—The lack of promul7 gated regulations shall not limit the effect of this Act. 

8 ‘‘SEC. 803. PLAN OF IMPLEMENTATION. 

9 ‘‘(a) IN GENERAL.—Not later than 1 year after the 

10 date of enactment of the Indian Health Care Improvement 

11 Act Amendments of 2009, the Secretary, in consultation 

12 with Indian Tribes, Tribal Organizations, and urban In13 dian organizations, shall submit to Congress a plan ex14 plaining the manner and schedule, by title and section, 

15 by which the Secretary will implement the provisions of 

16 this Act. This consultation may be conducted jointly with 

17 the annual budget consultation pursuant to the Indian 

18 Self-Determination and Education Assistance Act (25 

19 U.S.C. 450 et seq.). 

20 ‘‘(b) LACK OF PLAN.—The lack of (or failure to sub21 mit) such a plan shall not limit the effect, or prevent the 

22 implementation, of this Act. 


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1 ‘‘SEC. 804. LIMITATION ON USE OF FUNDS APPROPRIATED 

2 TO INDIAN HEALTH SERVICE. 

3 ‘‘Any limitation on the use of funds contained in an 

4 Act providing appropriations for the Department for a pe5 riod with respect to the performance of abortions shall 

6 apply for that period with respect to the performance of 

7 abortions using funds contained in an Act providing ap8 propriations for the Service. 

9 ‘‘SEC. 805. ELIGIBILITY OF CALIFORNIA INDIANS. 

10 ‘‘(a) IN GENERAL.—The following California Indians 

11 shall be eligible for health services provided by the Service: 

12 ‘‘(1) Any member of a federally recognized In13 dian Tribe. 

14 ‘‘(2) Any descendant of an Indian who was re15 siding in California on June 1, 1852, if such de16 scendant— 

17 ‘‘(A) is a member of the Indian community 

18 served by a local program of the Service; and 

19 ‘‘(B) is regarded as an Indian by the com20 munity in which such descendant lives. 

21 ‘‘(3) Any Indian who holds trust interests in 

22 public domain, national forest, or reservation allot23 ments in California. 

24 ‘‘(4) Any Indian in California who is listed on 

25 the plans for distribution of the assets of rancherias 

26 and reservations located within the State of CaliVerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 01942 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962

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1 fornia under the Act of August 18, 1958 (72 Stat. 

2 619), and any descendant of such an Indian. 

3 ‘‘(b) CLARIFICATION.—Nothing in this section may 

4 be construed as expanding the eligibility of California Indi5 ans for health services provided by the Service beyond the 

6 scope of eligibility for such health services that applied on 

7 May 1, 1986. 

8 ‘‘SEC. 806. HEALTH SERVICES FOR INELIGIBLE PERSONS. 

9 ‘‘(a) CHILDREN.—Any individual who— 

10 ‘‘(1) has not attained 19 years of age; 

11 ‘‘(2) is the natural or adopted child, stepchild, 

12 foster child, legal ward, or orphan of an eligible In13 dian; and 

14 ‘‘(3) is not otherwise eligible for health services 

15 provided by the Service, 

16 shall be eligible for all health services provided by the 

17 Service on the same basis and subject to the same rules 

18 that apply to eligible Indians until such individual attains 

19 19 years of age. The existing and potential health needs 

20 of all such individuals shall be taken into consideration 

21 by the Service in determining the need for, or the alloca22 tion of, the health resources of the Service. If such an indi23 vidual has been determined to be legally incompetent prior 

24 to attaining 19 years of age, such individual shall remain 


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1 eligible for such services until 1 year after the date of a 

2 determination of competency. 

3 ‘‘(b) SPOUSES.—Any spouse of an eligible Indian who 

4 is not an Indian, or who is of Indian descent but is not 

5 otherwise eligible for the health services provided by the 

6 Service, shall be eligible for such health services if all such 

7 spouses or spouses who are married to members of each 

8 Indian Tribe being served are made eligible, as a class, 

9 by an appropriate resolution of the governing body of the 

10 Indian Tribe or Tribal Organization providing such serv11 ices. The health needs of persons made eligible under this 

12 paragraph shall not be taken into consideration by the 

13 Service in determining the need for, or allocation of, its 

14 health resources. 

15 ‘‘(c) PROVISION OF SERVICES TO OTHER INDIVID16 UALS.— 

17 ‘‘(1) IN GENERAL.—The Secretary is authorized 

18 to provide health services under this subsection 

19 through health programs operated directly by the 

20 Service to individuals who reside within the Service 

21 area of the Service Unit and who are not otherwise 

22 eligible for such health services if— 

23 ‘‘(A) the Indian Tribes served by such 

24 Service Unit request such provision of health 

25 services to such individuals; and 


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1 ‘‘(B) the Secretary and the served Indian 

2 Tribes have jointly determined that— 

3 ‘‘(i) the provision of such health serv4 ices will not result in a denial or diminu5 tion of health services to eligible Indians; 

6 and 

7 ‘‘(ii) there is no reasonable alternative 

8 health facilities or services, within or with9 out the Service Unit, available to meet the 

10 health needs of such individuals. 

11 ‘‘(2) ISDEAA PROGRAMS.—In the case of 

12 health programs and facilities operated under a con13 tract or compact entered into under the Indian Self14 Determination and Education Assistance Act (25 

15 U.S.C. 450 et seq.), the governing body of the In16 dian Tribe or Tribal Organization providing health 

17 services under such contract or compact is author18 ized to determine whether health services should be 

19 provided under such contract to individuals who are 

20 not eligible for such health services under any other 

21 subsection of this section or under any other provi22 sion of law. In making such determinations, the gov23 erning body of the Indian Tribe or Tribal Organiza24 tion shall take into account the considerations de25 scribed in paragraph (1)(B). 


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1 ‘‘(3) PAYMENT FOR SERVICES.— 

2 ‘‘(A) IN GENERAL.—Persons receiving 

3 health services provided by the Service under 

4 this subsection shall be liable for payment of 

5 such health services under a schedule of charges 

6 prescribed by the Secretary which, in the judg7 ment of the Secretary, results in reimbursement 

8 in an amount not less than the actual cost of 

9 providing the health services. Notwithstanding 

10 section 404 of this Act or any other provision 

11 of law, amounts collected under this subsection, 

12 including Medicare, Medicaid, or SCHIP reim13 bursements under titles XVIII, XIX, and XXI 

14 of the Social Security Act, shall be credited to 

15 the account of the program providing the serv16 ice and shall be used for the purposes listed in 

17 section 401(d)(2) and amounts collected under 

18 this subsection shall be available for expendi19 ture within such program. 

20 ‘‘(B) INDIGENT PEOPLE.—Health services 

21 may be provided by the Secretary through the 

22 Service under this subsection to an indigent in23 dividual who would not be otherwise eligible for 

24 such health services but for the provisions of 

25 paragraph (1) only if an agreement has been 


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1 entered into with a State or local government 

2 under which the State or local government 

3 agrees to reimburse the Service for the expenses 

4 incurred by the Service in providing such health 

5 services to such indigent individual. 

6 ‘‘(4) REVOCATION OF CONSENT FOR SERV7 ICES.— 

8 ‘‘(A) SINGLE TRIBE SERVICE AREA.—In 

9 the case of a Service Area which serves only 1 

10 Indian Tribe, the authority of the Secretary to 

11 provide health services under paragraph (1) 

12 shall terminate at the end of the fiscal year suc13 ceeding the fiscal year in which the governing 

14 body of the Indian Tribe revokes its concur15 rence to the provision of such health services. 

16 ‘‘(B) MULTITRIBAL SERVICE AREA.—In 

17 the case of a multitribal Service Area, the au18 thority of the Secretary to provide health serv19 ices under paragraph (1) shall terminate at the 

20 end of the fiscal year succeeding the fiscal year 

21 in which at least 51 percent of the number of 

22 Indian Tribes in the Service Area revoke their 

23 concurrence to the provisions of such health 

24 services. 


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1 ‘‘(d) OTHER SERVICES.—The Service may provide 

2 health services under this subsection to individuals who 

3 are not eligible for health services provided by the Service 

4 under any other provision of law in order to— 

5 ‘‘(1) achieve stability in a medical emergency; 

6 ‘‘(2) prevent the spread of a communicable dis7 ease or otherwise deal with a public health hazard; 

8 ‘‘(3) provide care to non-Indian women preg9 nant with an eligible Indian’s child for the duration 

10 of the pregnancy through postpartum; or 

11 ‘‘(4) provide care to immediate family members 

12 of an eligible individual if such care is directly re13 lated to the treatment of the eligible individual. 

14 ‘‘(e) HOSPITAL PRIVILEGES FOR PRACTITIONERS.— 

15 ‘‘(1) IN GENERAL.—Hospital privileges in 

16 health facilities operated and maintained by the 

17 Service or operated under a contract or compact 

18 pursuant to the Indian Self-Determination and Edu19 cation Assistance Act (25 U.S.C. 450 et seq.) may 

20 be extended to non-Service health care practitioners 

21 who provide services to individuals described in sub22 section (a), (b), (c), or (d). Such non-Service health 

23 care practitioners may, as part of the privileging 

24 process, be designated as employees of the Federal 

25 Government for purposes of section 1346(b) and 


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1 chapter 171 of title 28, United States Code (relating 

2 to Federal tort claims) only with respect to acts or 

3 omissions which occur in the course of providing 

4 services to eligible individuals as a part of the condi5 tions under which such hospital privileges are ex6 tended. 

7 ‘‘(2) DEFINITION.—For purposes of this sub8 section, the term ‘non-Service health care practi9 tioner’ means a practitioner who is not— 

10 ‘‘(A) an employee of the Service; or 

11 ‘‘(B) an employee of an Indian tribe or 

12 tribal organization operating a contract or com13 pact under the Indian Self-Determination and 

14 Education Assistance Act or an individual who 

15 provides health care services pursuant to a per16 sonal services contract with such Indian tribe or 

17 tribal organization. 

18 ‘‘(f) ELIGIBLE INDIAN.—For purposes of this sec19 tion, the term ‘eligible Indian’ means any Indian who is 

20 eligible for health services provided by the Service without 

21 regard to the provisions of this section. 

22 ‘‘SEC. 807. REALLOCATION OF BASE RESOURCES. 

23 ‘‘(a) REPORT REQUIRED.—Notwithstanding any 

24 other provision of law, any allocation of Service funds for 

25 a fiscal year that reduces by 5 percent or more from the 


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1 previous fiscal year the funding for any recurring pro2 gram, project, or activity of a Service Unit may be imple3 mented only after the Secretary has submitted to Con4 gress, under section 801, a report on the proposed change 

5 in allocation of funding, including the reasons for the 

6 change and its likely effects. 

7 ‘‘(b) EXCEPTION.—Subsection (a) shall not apply if 

8 the total amount appropriated to the Service for a fiscal 

9 year is at least 5 percent less than the amount appro10 priated to the Service for the previous fiscal year. 

11 ‘‘SEC. 808. RESULTS OF DEMONSTRATION PROJECTS. 

12 ‘‘The Secretary shall provide for the dissemination to 

13 Indian Tribes, Tribal Organizations, and urban Indian or14 ganizations of the findings and results of demonstration 

15 projects conducted under this Act. 

16 ‘‘SEC. 809. PROVISION OF SERVICES IN MONTANA. 

17 ‘‘(a) CONSISTENT WITH COURT DECISION.—The 

18 Secretary, acting through the Service, shall provide serv19 ices and benefits for Indians in Montana in a manner con20 sistent with the decision of the United States Court of Ap21 peals for the Ninth Circuit in McNabb for McNabb v. 

22 Bowen, 829 F.2d 787 (9th Cir. 1987). 

23 ‘‘(b) CLARIFICATION.—The provisions of subsection 

24 (a) shall not be construed to be an expression of the sense 

25 of Congress on the application of the decision described 


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1 in subsection (a) with respect to the provision of services 

2 or benefits for Indians living in any State other than Mon3 tana. 

4 ‘‘SEC. 810. MORATORIUM. 

5 ‘‘During the period of the moratorium imposed on 

6 implementation of the final rule published in the Federal 

7 Register on September 16, 1987, by the Department of 

8 Health and Human Services, relating to eligibility for the 

9 health care services of the Indian Health Service, the In10 dian Health Service shall provide services pursuant to the 

11 criteria for eligibility for such services that were in effect 

12 on September 15, 1987, subject to the provisions of sec13 tions 805 and 806, until the Service has submitted to the 

14 Committees on Appropriations of the Senate and the 

15 House of Representatives a budget request reflecting the 

16 increased costs associated with the proposed final rule, 

17 and the request has been included in an appropriations 

18 Act and enacted into law. 

19 ‘‘SEC. 811. SEVERABILITY PROVISIONS. 

20 ‘‘If any provision of this Act, any amendment made 

21 by the Act, or the application of such provision or amend22 ment to any person or circumstances is held to be invalid, 

23 the remainder of this Act, the remaining amendments 

24 made by this Act, and the application of such provisions 


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1 to persons or circumstances other than those to which it 

2 is held invalid, shall not be affected thereby. 

3 ‘‘SEC. 812. USE OF PATIENT SAFETY ORGANIZATIONS. 

4 ‘‘The Service, an Indian Tribe, Tribal Organization, 

5 or urban Indian organization may provide for quality as6 surance activities through the use of a patient safety orga7 nization in accordance with title IX of the Public Health 

8 Service Act. 

9 ‘‘SEC. 813. CONFIDENTIALITY OF MEDICAL QUALITY ASSUR10 ANCE RECORDS; QUALIFIED IMMUNITY FOR 

11 PARTICIPANTS. 

12 ‘‘(a) CONFIDENTIALITY OF RECORDS.—Medical qual13 ity assurance records created by or for any Indian Health 

14 Program or a health program of an Urban Indian Organi15 zation as part of a medical quality assurance program are 

16 confidential and privileged. Such records may not be dis17 closed to any person or entity, except as provided in sub18 section (c). 

19 ‘‘(b) PROHIBITION ON DISCLOSURE AND TESTI20 MONY.— 

21 ‘‘(1) IN GENERAL.—No part of any medical 

22 quality assurance record described in subsection (a) 

23 may be subject to discovery or admitted into evi24 dence in any judicial or administrative proceeding, 

25 except as provided in subsection (c). 


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1 ‘‘(2) TESTIMONY.—A person who reviews or 

2 creates medical quality assurance records for any In3 dian Health Program or Urban Indian Organization 

4 who participates in any proceeding that reviews or 

5 creates such records may not be permitted or re6 quired to testify in any judicial or administrative 

7 proceeding with respect to such records or with re8 spect to any finding, recommendation, evaluation, 

9 opinion, or action taken by such person or body in 

10 connection with such records except as provided in 

11 this section. 

12 ‘‘(c) AUTHORIZED DISCLOSURE AND TESTIMONY.— 

13 ‘‘(1) IN GENERAL.—Subject to paragraph (2), a 

14 medical quality assurance record described in sub15 section (a) may be disclosed, and a person referred 

16 to in subsection (b) may give testimony in connec17 tion with such a record, only as follows: 

18 ‘‘(A) To a Federal executive agency or pri19 vate organization, if such medical quality assur20 ance record or testimony is needed by such 

21 agency or organization to perform licensing or 

22 accreditation functions related to any Indian 

23 Health Program or to a health program of an 

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1 toring, required by law, of such program or or2 ganization. 

3 ‘‘(B) To an administrative or judicial pro4 ceeding commenced by a present or former In5 dian Health Program or Urban Indian Organi6 zation provider concerning the termination, sus7 pension, or limitation of clinical privileges of 

8 such health care provider. 

9 ‘‘(C) To a governmental board or agency 

10 or to a professional health care society or orga11 nization, if such medical quality assurance 

12 record or testimony is needed by such board, 

13 agency, society, or organization to perform li14 censing, credentialing, or the monitoring of pro15 fessional standards with respect to any health 

16 care provider who is or was an employee of any 

17 Indian Health Program or Urban Indian Orga18 nization. 

19 ‘‘(D) To a hospital, medical center, or 

20 other institution that provides health care serv21 ices, if such medical quality assurance record or 

22 testimony is needed by such institution to as23 sess the professional qualifications of any health 

24 care provider who is or was an employee of any 

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1 nization and who has applied for or been grant2 ed authority or employment to provide health 

3 care services in or on behalf of such program or 

4 organization. 

5 ‘‘(E) To an officer, employee, or contractor 

6 of the Indian Health Program or Urban Indian 

7 Organization that created the records or for 

8 which the records were created. If that officer, 

9 employee, or contractor has a need for such 

10 record or testimony to perform official duties. 

11 ‘‘(F) To a criminal or civil law enforce12 ment agency or instrumentality charged under 

13 applicable law with the protection of the public 

14 health or safety, if a qualified representative of 

15 such agency or instrumentality makes a written 

16 request that such record or testimony be pro17 vided for a purpose authorized by law. 

18 ‘‘(G) In an administrative or judicial pro19 ceeding commenced by a criminal or civil law 

20 enforcement agency or instrumentality referred 

21 to in subparagraph (F), but only with respect 

22 to the subject of such proceeding. 

23 ‘‘(2) IDENTITY OF PARTICIPANTS.—With the 

24 exception of the subject of a quality assurance ac25 tion, the identity of any person receiving health care 


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1 services from any Indian Health Program or Urban 

2 Indian Organization or the identity of any other per3 son associated with such program or organization 

4 for purposes of a medical quality assurance program 

5 that is disclosed in a medical quality assurance 

6 record described in subsection (a) shall be deleted 

7 from that record or document before any disclosure 

8 of such record is made outside such program or or9 ganization. 

10 ‘‘(d) DISCLOSURE FOR CERTAIN PURPOSES.— 

11 ‘‘(1) IN GENERAL.—Nothing in this section 

12 shall be construed as authorizing or requiring the 

13 withholding from any person or entity aggregate sta14 tistical information regarding the results of any In15 dian Health Program or Urban Indian 

16 Organizations’s medical quality assurance programs. 

17 ‘‘(2) WITHHOLDING FROM CONGRESS.—Noth18 ing in this section shall be construed as authority to 

19 withhold any medical quality assurance record from 

20 a committee of either House of Congress, any joint 

21 committee of Congress, or the Government Account22 ability Office if such record pertains to any matter 

23 within their respective jurisdictions. 

24 ‘‘(e) PROHIBITION ON DISCLOSURE OF RECORD OR

25 TESTIMONY.—A person or entity having possession of or 


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1 access to a record or testimony described by this section 

2 may not disclose the contents of such record or testimony 

3 in any manner or for any purpose except as provided in 

4 this section. 

5 ‘‘(f) EXEMPTION FROM FREEDOM OF INFORMATION

6 ACT.—Medical quality assurance records described in sub7 section (a) may not be made available to any person under 

8 section 552 of title 5, United States Code. 

9 ‘‘(g) LIMITATION ON CIVIL LIABILITY.—A person 

10 who participates in or provides information to a person 

11 or body that reviews or creates medical quality assurance 

12 records described in subsection (a) shall not be civilly lia13 ble for such participation or for providing such informa14 tion if the participation or provision of information was 

15 in good faith based on prevailing professional standards 

16 at the time the medical quality assurance program activity 

17 took place. 

18 ‘‘(h) APPLICATION TO INFORMATION IN CERTAIN

19 OTHER RECORDS.—Nothing in this section shall be con20 strued as limiting access to the information in a record 

21 created and maintained outside a medical quality assur22 ance program, including a patient’s medical records, on 

23 the grounds that the information was presented during 

24 meetings of a review body that are part of a medical qual25 ity assurance program. 


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1 ‘‘(i) REGULATIONS.—The Secretary, acting through 

2 the Service, shall promulgate regulations pursuant to sec3 tion 802. 

4 ‘‘(j) DEFINITIONS.—In this section: 

5 ‘‘(1) The term ‘health care provider’ means any 

6 health care professional, including community health 

7 aides and practitioners certified under section 121, 

8 who are granted clinical practice privileges or em9 ployed to provide health care services in an Indian 

10 Health Program or health program of an Urban In11 dian Organization, who is licensed or certified to 

12 perform health care services by a governmental 

13 board or agency or professional health care society 

14 or organization. 

15 ‘‘(2) The term ‘medical quality assurance pro16 gram’ means any activity carried out before, on, or 

17 after the date of enactment of this Act by or for any 

18 Indian Health Program or Urban Indian Organiza19 tion to assess the quality of medical care, including 

20 activities conducted by or on behalf of individuals, 

21 Indian Health Program or Urban Indian Organiza22 tion medical or dental treatment review committees, 

23 or other review bodies responsible for quality assur24 ance, credentials, infection control, patient safety, 

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1 dures, blood, drugs, and therapeutics), medical 

2 records, health resources management review and 

3 identification and prevention of medical or dental in4 cidents and risks. 

5 ‘‘(3) The term ‘medical quality assurance 

6 record’ means the proceedings, records, minutes, and 

7 reports that emanate from quality assurance pro8 gram activities described in paragraph (2) and are 

9 produced or compiled by or for an Indian Health 

10 Program or Urban Indian Organization as part of a 

11 medical quality assurance program. 

12 ‘‘(k) CONTINUED PROTECTION.—Disclosure under 

13 subsection (c) does not permit redisclosure except to the 

14 extent such further disclosure is authorized under sub15 section (c) or is otherwise authorized to be disclosed under 

16 this section. 

17 ‘‘(l) INCONSISTENCIES.—To the extent that the pro18 tections under the Patient Safety and Quality Improve19 ment Act of 2005 and this section are inconsistent, the 

20 provisions of whichever is more protective shall control. 

21 ‘‘(m) RELATIONSHIP TO OTHER LAW.—This section 

22 shall continue in force and effect, except as otherwise spe23 cifically provided in any Federal law enacted after the date 

24 of enactment of the Indian Health Care Improvement Act 

25 Amendments of 2009. 


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1 ‘‘SEC. 814. CLAREMORE INDIAN HOSPITAL. 

2 ‘‘The Claremore Indian Hospital shall be deemed to 

3 be a dependant Indian community for the purposes of sec4 tion 1151 of title 18, United States Code. 

5 ‘‘SEC. 815. SENSE OF CONGRESS REGARDING LAW EN6 FORCEMENT AND METHAMPHETAMINE 

7 ISSUES IN INDIAN COUNTRY. 

8 ‘‘It is the sense of Congress that Congress encourages 

9 State, local, and Indian tribal law enforcement agencies 

10 to enter into memoranda of agreement between and 

11 among those agencies for purposes of streamlining law en12 forcement activities and maximizing the use of limited re13 sources— 

14 ‘‘(1) to improve law enforcement services pro15 vided to Indian tribal communities; and 

16 ‘‘(2) to increase the effectiveness of measures to 

17 address problems relating to methamphetamine use 

18 in Indian country (as defined in section 1151 of title 

19 18, United States Code). 

20 ‘‘SEC. 816. PERMITTING IMPLEMENTATION THROUGH CON21 TRACTS WITH TRIBAL HEALTH PROGRAMS. 

22 ‘‘Nothing in this Act shall be construed as preventing 

23 the Secretary from— 

24 ‘‘(1) carrying out any section of this Act 

25 through contracts with Tribal Health Programs; and 


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1 ‘‘(2) carrying out sections through 214, 

2 701(a)(1), 701(b)(1), 701(c), 707(g), and 712(b), 

3 through contracts with urban Indian organizations. 

4 The previous sentence shall not affect the authority the 

5 Secretary may otherwise have to carry out other provisions 

6 of this Act through such contracts. 

7 ‘‘SEC. 817. AUTHORIZATION OF APPROPRIATIONS; AVAIL8 ABILITY. 

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

10 are authorized to be appropriated such sums as may be 

11 necessary to carry out this title. 

12 ‘‘(b) LIMITATION ON NEW SPENDING AUTHORITY.— 

13 Any new spending authority (described in subparagraph 

14 (A) or (B) of section 401(c)(2) of the Congressional Budg15 et Act of 1974 (Public Law 93–344; 88 Stat. 317)) which 

16 is provided under this Act shall be effective for any fiscal 

17 year only to such extent or in such amounts as are pro18 vided in appropriation Acts. 

19 ‘‘(c) AVAILABILITY.—The funds appropriated pursu20 ant to this Act shall remain available until expended.’’. 

21 (b) RATE OF PAY.— 

22 (1) POSITIONS AT LEVEL IV.—Section 5315 of 

23 title 5, United States Code, is amended by striking 

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1 ices (6).’’ and inserting ‘‘Assistant Secretaries of 

2 Health and Human Services (7)’’. 

3 (2) POSITIONS AT LEVEL V.—Section 5316 of 

4 title 5, United States Code, is amended by striking 

5 ‘‘Director, Indian Health Service, Department of 

6 Health and Human Services’’. 

7 (c) AMENDMENTS TO OTHER PROVISIONS OF LAW.— 

8 (1) Section 3307(b)(1)(C) of the Children’s 

9 Health Act of 2000 (25 U.S.C. 1671 note; Public 

10 Law 106–310) is amended by striking ‘‘Director of 

11 the Indian Health Service’’ and inserting ‘‘Assistant 

12 Secretary for Indian Health’’. 

13 (2) The Indian Lands Open Dump Cleanup Act 

14 of 1994 is amended— 

15 (A) in section 3 (25 U.S.C. 3902)— 

16 (i) by striking paragraph (2); 

17 (ii) by redesignating paragraphs (1), 

18 (3), (4), (5), and (6) as paragraphs (4), 

19 (5), (2), (6), and (1), respectively, and 

20 moving those paragraphs so as to appear 

21 in numerical order; and 

22 (iii) by inserting before paragraph (4) 

23 (as redesignated by subclause (II)) the fol24 lowing: 


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1 ‘‘(3) ASSISTANT SECRETARY.—The term ‘As2 sistant Secretary’ means the Assistant Secretary for 

3 Indian Health.’’; 

4 (B) in section 5 (25 U.S.C. 3904), by 

5 striking the section designation and heading 

6 and inserting the following: 

7 ‘‘SEC. 5. AUTHORITY OF ASSISTANT SECRETARY FOR IN8 DIAN HEALTH.’’; 

9 (C) in section 6(a) (25 U.S.C. 3905(a)), in 

10 the subsection heading, by striking ‘‘DIREC11 TOR’’ and inserting ‘‘ASSISTANT SECRETARY’’; 

12 (D) in section 9(a) (25 U.S.C. 3908(a)), in 

13 the subsection heading, by striking ‘‘DIREC14 TOR’’ and inserting ‘‘ASSISTANT SECRETARY’’; 

15 and 

16 (E) by striking ‘‘Director’’ each place it 

17 appears and inserting ‘‘Assistant Secretary’’. 

18 (3) Section 5504(d)(2) of the Augustus F. 

19 Hawkins-Robert T. Stafford Elementary and Sec20 ondary School Improvement Amendments of 1988 

21 (25 U.S.C. 2001 note; Public Law 100–297) is 

22 amended by striking ‘‘Director of the Indian Health 

23 Service’’ and inserting ‘‘Assistant Secretary for In24 dian Health’’. 


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1 (4) Section 203(a)(1) of the Rehabilitation Act 

2 of 1973 (29 U.S.C. 763(a)(1)) is amended by strik3 ing ‘‘Director of the Indian Health Service’’ and in4 serting ‘‘Assistant Secretary for Indian Health’’. 

5 (5) Subsections (b) and (e) of section 518 of 

6 the Federal Water Pollution Control Act (33 U.S.C. 

7 1377) are amended by striking ‘‘Director of the In8 dian Health Service’’ each place it appears and in9 serting ‘‘Assistant Secretary for Indian Health’’. 

10 (6) Section 317M(b) of the Public Health Serv11 ice Act (42 U.S.C. 247b–14(b)) is amended— 

12 (A) by striking ‘‘Director of the Indian 

13 Health Service’’ each place it appears and in14 serting ‘‘Assistant Secretary for Indian 

15 Health’’; and 

16 (B) in paragraph (2)(A), by striking ‘‘the 

17 Directors referred to in such paragraph’’ and 

18 inserting ‘‘the Director of the Centers for Dis19 ease Control and Prevention and the Assistant 

20 Secretary for Indian Health’’. 

21 (7) Section 417C(b) of the Public Health Serv22 ice Act (42 U.S.C. 285–9(b)) is amended by striking 

23 ‘‘Director of the Indian Health Service’’ and insert24 ing ‘‘Assistant Secretary for Indian Health’’. 


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1 (8) Section 1452(i) of the Safe Drinking Water 

2 Act (42 U.S.C. 300j–12(i)) is amended by striking 

3 ‘‘Director of the Indian Health Service’’ each place 

4 it appears and inserting ‘‘Assistant Secretary for In5 dian Health’’. 

6 (9) Section 803B(d)(1) of the Native American 

7 Programs Act of 1974 (42 U.S.C. 2991b–2(d)(1)) is 

8 amended in the last sentence by striking ‘‘Director 

9 of the Indian Health Service’’ and inserting ‘‘Assist10 ant Secretary for Indian Health’’. 

11 (10) Section 203(b) of the Michigan Indian 

12 Land Claims Settlement Act (Public Law 105–143; 

13 111 Stat. 2666) is amended by striking ‘‘Director of 

14 the Indian Health Service’’ and inserting ‘‘Assistant 

15 Secretary for Indian Health’’. 

16 SEC. 3102. SOBOBA SANITATION FACILITIES. 

17 The Act of December 17, 1970 (84 Stat. 1465), is 

18 amended by adding at the end the following: 

19 ‘‘SEC. 9. Nothing in this Act shall preclude the 

20 Soboba Band of Mission Indians and the Soboba Indian 

21 Reservation from being provided with sanitation facilities 

22 and services under the authority of section 7 of the Act 

23 of August 5, 1954 (68 Stat. 674), as amended by the Act 

24 of July 31, 1959 (73 Stat. 267).’’. 


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1 SEC. 3103. NATIVE AMERICAN HEALTH AND WELLNESS 

2 FOUNDATION. 

3 (a) IN GENERAL.—The Indian Self-Determination 

4 and Education Assistance Act (25 U.S.C. 450 et seq.) is 

5 amended by adding at the end the following: 

6 ‘‘TITLE VIII—NATIVE AMERICAN 

7 HEALTH AND WELLNESS 

8 FOUNDATION 

9 ‘‘SEC. 801. DEFINITIONS. 

10 ‘‘In this title: 

11 ‘‘(1) BOARD.—The term ‘Board’ means the 

12 Board of Directors of the Foundation. 

13 ‘‘(2) COMMITTEE.—The term ‘Committee’ 

14 means the Committee for the Establishment of Na15 tive American Health and Wellness Foundation es16 tablished under section 802(f). 

17 ‘‘(3) FOUNDATION.—The term ‘Foundation’ 

18 means the Native American Health and Wellness 

19 Foundation established under section 802. 

20 ‘‘(4) SECRETARY.—The term ‘Secretary’ means 

21 the Secretary of Health and Human Services. 

22 ‘‘(5) SERVICE.—The term ‘Service’ means the 

23 Indian Health Service of the Department of Health 

24 and Human Services. 


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1 ‘‘SEC. 802. NATIVE AMERICAN HEALTH AND WELLNESS 

2 FOUNDATION. 

3 ‘‘(a) ESTABLISHMENT.— 

4 ‘‘(1) IN GENERAL.—As soon as practicable 

5 after the date of enactment of this title, the Sec6 retary shall establish, under the laws of the District 

7 of Columbia and in accordance with this title, the 

8 Native American Health and Wellness Foundation. 

9 ‘‘(2) FUNDING DETERMINATIONS.—No funds, 

10 gift, property, or other item of value (including any 

11 interest accrued on such an item) acquired by the 

12 Foundation shall— 

13 ‘‘(A) be taken into consideration for pur14 poses of determining Federal appropriations re15 lating to the provision of health care and serv16 ices to Indians; or 

17 ‘‘(B) otherwise limit, diminish, or affect 

18 the Federal responsibility for the provision of 

19 health care and services to Indians. 

20 ‘‘(b) PERPETUAL EXISTENCE.—The Foundation 

21 shall have perpetual existence. 

22 ‘‘(c) NATURE OF CORPORATION.—The Foundation— 

23 ‘‘(1) shall be a charitable and nonprofit feder24 ally chartered corporation; and 

25 ‘‘(2) shall not be an agency or instrumentality 

26 of the United States. 


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1 ‘‘(d) PLACE OF INCORPORATION AND DOMICILE.— 

2 The Foundation shall be incorporated and domiciled in the 

3 District of Columbia. 

4 ‘‘(e) DUTIES.—The Foundation shall— 

5 ‘‘(1) encourage, accept, and administer private 

6 gifts of real and personal property, and any income 

7 from or interest in such gifts, for the benefit of, or 

8 in support of, the mission of the Service; 

9 ‘‘(2) undertake and conduct such other activi10 ties as will further the health and wellness activities 

11 and opportunities of Native Americans; and 

12 ‘‘(3) participate with and assist Federal, State, 

13 and tribal governments, agencies, entities, and indi14 viduals in undertaking and conducting activities that 

15 will further the health and wellness activities and op16 portunities of Native Americans. 

17 ‘‘(f) COMMITTEE FOR THE ESTABLISHMENT OF NA18 TIVE AMERICAN HEALTH AND WELLNESS FOUNDA19 TION.— 

20 ‘‘(1) IN GENERAL.—The Secretary shall estab21 lish the Committee for the Establishment of Native 

22 American Health and Wellness Foundation to assist 

23 the Secretary in establishing the Foundation. 


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1 ‘‘(2) DUTIES.—Not later than 180 days after 

2 the date of enactment of this section, the Committee 

3 shall— 

4 ‘‘(A) carry out such activities as are nec5 essary to incorporate the Foundation under the 

6 laws of the District of Columbia, including act7 ing as incorporators of the Foundation; 

8 ‘‘(B) ensure that the Foundation qualifies 

9 for and maintains the status required to carry 

10 out this section, until the Board is established; 

11 ‘‘(C) establish the constitution and initial 

12 bylaws of the Foundation; 

13 ‘‘(D) provide for the initial operation of 

14 the Foundation, including providing for tem15 porary or interim quarters, equipment, and 

16 staff; and 

17 ‘‘(E) appoint the initial members of the 

18 Board in accordance with the constitution and 

19 initial bylaws of the Foundation. 

20 ‘‘(g) BOARD OF DIRECTORS.— 

21 ‘‘(1) IN GENERAL.—The Board of Directors 

22 shall be the governing body of the Foundation. 

23 ‘‘(2) POWERS.—The Board may exercise, or 

24 provide for the exercise of, the powers of the Foun25 dation. 


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1 ‘‘(3) SELECTION.— 

2 ‘‘(A) IN GENERAL.—Subject to subpara3 graph (B), the number of members of the 

4 Board, the manner of selection of the members 

5 (including the filling of vacancies), and the 

6 terms of office of the members shall be as pro7 vided in the constitution and bylaws of the 

8 Foundation. 

9 ‘‘(B) REQUIREMENTS.— 

10 ‘‘(i) NUMBER OF MEMBERS.—The 

11 Board shall have at least 11 members, who 

12 shall have staggered terms. 

13 ‘‘(ii) INITIAL VOTING MEMBERS.—The 

14 initial voting members of the Board— 

15 ‘‘(I) shall be appointed by the 

16 Committee not later than 180 days 

17 after the date on which the Founda18 tion is established; and 

19 ‘‘(II) shall have staggered terms. 

20 ‘‘(iii) QUALIFICATION.—The members 

21 of the Board shall be United States citi22 zens who are knowledgeable or experienced 

23 in Native American health care and related 

24 matters. 


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1 ‘‘(C) COMPENSATION.—A member of the 

2 Board shall not receive compensation for service 

3 as a member, but shall be reimbursed for actual 

4 and necessary travel and subsistence expenses 

5 incurred in the performance of the duties of the 

6 Foundation. 

7 ‘‘(h) OFFICERS.— 

8 ‘‘(1) IN GENERAL.—The officers of the Founda9 tion shall be— 

10 ‘‘(A) a secretary, elected from among the 

11 members of the Board; and 

12 ‘‘(B) any other officers provided for in the 

13 constitution and bylaws of the Foundation. 

14 ‘‘(2) CHIEF OPERATING OFFICER.—The sec15 retary of the Foundation may serve, at the direction 

16 of the Board, as the chief operating officer of the 

17 Foundation, or the Board may appoint a chief oper18 ating officer, who shall serve at the direction of the 

19 Board. 

20 ‘‘(3) ELECTION.—The manner of election, term 

21 of office, and duties of the officers of the Founda22 tion shall be as provided in the constitution and by23 laws of the Foundation. 

24 ‘‘(i) POWERS.—The Foundation— 


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1 ‘‘(1) shall adopt a constitution and bylaws for 

2 the management of the property of the Foundation 

3 and the regulation of the affairs of the Foundation; 

4 ‘‘(2) may adopt and alter a corporate seal; 

5 ‘‘(3) may enter into contracts; 

6 ‘‘(4) may acquire (through a gift or otherwise), 

7 own, lease, encumber, and transfer real or personal 

8 property as necessary or convenient to carry out the 

9 purposes of the Foundation; 

10 ‘‘(5) may sue and be sued; and 

11 ‘‘(6) may perform any other act necessary and 

12 proper to carry out the purposes of the Foundation. 

13 ‘‘(j) PRINCIPAL OFFICE.— 

14 ‘‘(1) IN GENERAL.—The principal office of the 

15 Foundation shall be in the District of Columbia. 

16 ‘‘(2) ACTIVITIES; OFFICES.—The activities of 

17 the Foundation may be conducted, and offices may 

18 be maintained, throughout the United States in ac19 cordance with the constitution and bylaws of the 

20 Foundation. 

21 ‘‘(k) SERVICE OF PROCESS.—The Foundation shall 

22 comply with the law on service of process of each State 

23 in which the Foundation is incorporated and of each State 

24 in which the Foundation carries on activities. 


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1 ‘‘(l) LIABILITY OF OFFICERS, EMPLOYEES, AND

2 AGENTS.— 

3 ‘‘(1) IN GENERAL.—The Foundation shall be 

4 liable for the acts of the officers, employees, and 

5 agents of the Foundation acting within the scope of 

6 their authority. 

7 ‘‘(2) PERSONAL LIABILITY.—A member of the 

8 Board shall be personally liable only for gross neg9 ligence in the performance of the duties of the mem10 ber. 

11 ‘‘(m) RESTRICTIONS.— 

12 ‘‘(1) LIMITATION ON SPENDING.—Beginning 

13 with the fiscal year following the first full fiscal year 

14 during which the Foundation is in operation, the ad15 ministrative costs of the Foundation shall not exceed 

16 the percentage described in paragraph (2) of the 

17 sum of— 

18 ‘‘(A) the amounts transferred to the Foun19 dation under subsection (o) during the pre20 ceding fiscal year; and 

21 ‘‘(B) donations received from private 

22 sources during the preceding fiscal year. 

23 ‘‘(2) PERCENTAGES.—The percentages referred 

24 to in paragraph (1) are— 


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1 ‘‘(A) for the first fiscal year described in 

2 that paragraph, 20 percent; 

3 ‘‘(B) for the following fiscal year, 15 per4 cent; and 

5 ‘‘(C) for each fiscal year thereafter, 10 

6 percent. 

7 ‘‘(3) APPOINTMENT AND HIRING.—The ap8 pointment of officers and employees of the Founda9 tion shall be subject to the availability of funds. 

10 ‘‘(4) STATUS.—A member of the Board or offi11 cer, employee, or agent of the Foundation shall not 

12 by reason of association with the Foundation be con13 sidered to be an officer, employee, or agent of the 

14 United States. 

15 ‘‘(n) AUDITS.—The Foundation shall comply with 

16 section 10101 of title 36, United States Code, as if the 

17 Foundation were a corporation under part B of subtitle 

18 II of that title. 

19 ‘‘(o) FUNDING.— 

20 ‘‘(1) AUTHORIZATION OF APPROPRIATIONS.— 

21 There is authorized to be appropriated to carry out 

22 subsection (e)(1) $500,000 for each fiscal year, as 

23 adjusted to reflect changes in the Consumer Price 

24 Index for all-urban consumers published by the De25 partment of Labor. 


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1 ‘‘(2) TRANSFER OF DONATED FUNDS.—The 

2 Secretary shall transfer to the Foundation funds 

3 held by the Department of Health and Human Serv4 ices under the Act of August 5, 1954 (42 U.S.C. 

5 2001 et seq.), if the transfer or use of the funds is 

6 not prohibited by any term under which the funds 

7 were donated. 

8 ‘‘SEC. 803. ADMINISTRATIVE SERVICES AND SUPPORT. 

9 ‘‘(a) PROVISION OF SUPPORT BY SECRETARY.—Sub10 ject to subsection (b), during the 5-year period beginning 

11 on the date on which the Foundation is established, the 

12 Secretary— 

13 ‘‘(1) may provide personnel, facilities, and other 

14 administrative support services to the Foundation; 

15 ‘‘(2) may provide funds for initial operating 

16 costs and to reimburse the travel expenses of the 

17 members of the Board; and 

18 ‘‘(3) shall require and accept reimbursements 

19 from the Foundation for— 

20 ‘‘(A) services provided under paragraph 

21 (1); and 

22 ‘‘(B) funds provided under paragraph (2). 

23 ‘‘(b) REIMBURSEMENT.—Reimbursements accepted 

24 under subsection (a)(3)— 


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1 ‘‘(1) shall be deposited in the Treasury of the 

2 United States to the credit of the applicable appro3 priations account; and 

4 ‘‘(2) shall be chargeable for the cost of pro5 viding services described in subsection (a)(1) and 

6 travel expenses described in subsection (a)(2). 

7 ‘‘(c) CONTINUATION OF CERTAIN SERVICES.—The 

8 Secretary may continue to provide facilities and necessary 

9 support services to the Foundation after the termination 

10 of the 5-year period specified in subsection (a) if the facili11 ties and services— 

12 ‘‘(1) are available; and 

13 ‘‘(2) are provided on reimbursable cost basis.’’. 

14 (b) TECHNICAL AMENDMENTS.—The Indian Self-De15 termination and Education Assistance Act is amended— 

16 (1) by redesignating title V (25 U.S.C. 458bbb 

17 et seq.) as title VII; 

18 (2) by redesignating sections 501, 502, and 503 

19 (25 U.S.C. 458bbb, 458bbb–1, 458bbb–2) as sec20 tions 701, 702, and 703, respectively; and 

21 (3) in subsection (a)(2) of section 702 and 

22 paragraph (2) of section 703 (as redesignated by 

23 paragraph (2)), by striking ‘‘section 501’’ and in24 serting ‘‘section 701’’. 


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1 SEC. 3104. GAO STUDY AND REPORT ON PAYMENTS FOR 

2 CONTRACT HEALTH SERVICES. 

3 (a) STUDY.— 

4 (1) IN GENERAL.—The Comptroller General of 

5 the United States (in this section referred to as the 

6 ‘‘Comptroller General’’) shall conduct a study on the 

7 utilization of health care furnished by health care 

8 providers under the contract health services program 

9 funded by the Indian Health Service and operated 

10 by the Indian Health Service, an Indian Tribe, or a 

11 Tribal Organization (as those terms are defined in 

12 section 4 of the Indian Health Care Improvement 

13 Act). 

14 (2) ANALYSIS.—The study conducted under 

15 paragraph (1) shall include an analysis of— 

16 (A) the amounts reimbursed under the 

17 contract health services program described in 

18 paragraph (1) for health care furnished by enti19 ties, individual providers, and suppliers, includ20 ing a comparison of reimbursement for such 

21 health care through other public programs and 

22 in the private sector; 

23 (B) barriers to accessing care under such 

24 contract health services program, including, but 

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1 vate sector reluctance to furnish care to pa2 tients under such program; 

3 (C) the adequacy of existing Federal fund4 ing for health care under such contract health 

5 services program; and 

6 (D) any other items determined appro7 priate by the Comptroller General. 

8 (b) REPORT.—Not later than 18 months after the 

9 date of enactment of this Act, the Comptroller General 

10 shall submit to Congress a report on the study conducted 

11 under subsection (a), together with recommendations re12 garding— 

13 (1) the appropriate level of Federal funding 

14 that should be established for health care under the 

15 contract health services program described in sub16 section (a)(1); and 

17 (2) how to most efficiently utilize such funding. 

18 (c) CONSULTATION.—In conducting the study under 

19 subsection (a) and preparing the report under subsection 

20 (b), the Comptroller General shall consult with the Indian 

21 Health Service, Indian Tribes, and Tribal Organizations. 


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1 TITLE II—IMPROVEMENT OF IN2 DIAN HEALTH CARE PRO3 VIDED UNDER THE SOCIAL 

4 SECURITY ACT 

5 SEC. 3201. EXPANSION OF PAYMENTS UNDER MEDICARE, 

6 MEDICAID, AND SCHIP FOR ALL COVERED 

7 SERVICES FURNISHED BY INDIAN HEALTH 

8 PROGRAMS. 

9 (a) MEDICAID.— 

10 (1) EXPANSION TO ALL COVERED SERVICES.— 

11 Section 1911 of the Social Security Act (42 U.S.C. 

12 1396j) is amended— 

13 (A) by amending the heading to read as 

14 follows: 

15 ‘‘SEC. 1911. INDIAN HEALTH PROGRAMS.’’; 

16 and 

17 (B) by amending subsection (a) to read as 

18 follows: 

19 ‘‘(a) ELIGIBILITY FOR PAYMENT FOR MEDICAL AS20 SISTANCE.—An Indian Health Program shall be eligible 

21 for payment for medical assistance provided under a State 

22 plan or under waiver authority with respect to items and 

23 services furnished by the Program if the furnishing of 

24 such services meets all the conditions and requirements 

25 which are applicable generally to the furnishing of items 


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1 and services under this title and under such plan or waiver 

2 authority.’’. 

3 (2) REPEAL OF OBSOLETE PROVISION.—Sub4 section (b) of such section is repealed. 

5 (3) REVISION OF AUTHORITY TO ENTER INTO

6 AGREEMENTS.—Subsection (c) of such section is 

7 amended to read as follows: 

8 ‘‘(c) AUTHORITY TO ENTER INTO AGREEMENTS.— 

9 The Secretary may enter into an agreement with a State 

10 for the purpose of reimbursing the State for medical as11 sistance provided by the Indian Health Service, an Indian 

12 Tribe, Tribal Organization, or an Urban Indian Organiza13 tion (as so defined), directly, through referral, or under 

14 contracts or other arrangements between the Indian 

15 Health Service, an Indian Tribe, Tribal Organization, or 

16 an Urban Indian Organization and another health care 

17 provider to Indians who are eligible for medical assistance 

18 under the State plan or under waiver authority. This sub19 section shall not be construed to impair the entitlement 

20 of a State to reimbursement for such medical assistance 

21 under this title.’’. 

22 (4) CROSS-REFERENCES TO SPECIAL FUND FOR

23 IMPROVEMENT OF IHS FACILITIES; DIRECT BILLING

24 OPTION; DEFINITIONS.—Such section is further 


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1 amended by striking subsection (d) and adding at 

2 the end the following new subsections: 

3 ‘‘(c) SPECIAL FUND FOR IMPROVEMENT OF IHS FA4 CILITIES.—For provisions relating to the authority of the 

5 Secretary to place payments to which a facility of the In6 dian Health Service is eligible for payment under this title 

7 into a special fund established under section 401(c)(1) of 

8 the Indian Health Care Improvement Act, see subpara9 graphs (A) and (B) of section 401(c)(1) of such Act. 

10 ‘‘(d) DIRECT BILLING.—For provisions relating to 

11 the authority of an Tribal Health Program to elect to di12 rectly bill for, and receive payment for, health care items 

13 and services provided by such Program for which payment 

14 is made under this title, see section 401(d) of the Indian 

15 Health Care Improvement Act.’’. 

16 (5) DEFINITIONS.—Section 1101(a) of such Act 

17 (42 U.S.C. 1301(a)) is amended by adding at the 

18 end the following new paragraph: 

19 ‘‘(11) For purposes of this title and titles 

20 XVIII, XIX, and XXI, the terms ‘Indian Health 

21 Program’, ‘Indian Tribe’ (and ‘Indian tribe’), ‘Tribal 

22 Health Program’, ‘Tribal Organization’ (and ‘tribal 

23 organization’), and ‘urban Indian organization’ (and 

24 ‘urban Indian organization’) have the meanings 


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1 given those terms in section 4 of the Indian Health 

2 Care Improvement Act.’’. 

3 (b) MEDICARE.— 

4 (1) EXPANSION TO ALL COVERED SERVICES.— 

5 Section 1880 of such Act (42 U.S.C. 1395qq) is 

6 amended— 

7 (A) by amending the heading to read as 

8 follows: 

9 ‘‘SEC. 1880. INDIAN HEALTH PROGRAMS.’’; 

10 and 

11 (B) by amending subsection (a) to read as 

12 follows: 

13 ‘‘(a) ELIGIBILITY FOR PAYMENTS.—Subject to sub14 section (e), an Indian Health Program shall be eligible for 

15 payments under this title with respect to items and serv16 ices furnished by the Program if the furnishing of such 

17 services meets all the conditions and requirements which 

18 are applicable generally to the furnishing of items and 

19 services under this title.’’. 

20 (2) REPEAL OF OBSOLETE PROVISION.—Sub21 section (b) of such section is repealed. 

22 (3) CROSS-REFERENCES TO SPECIAL FUND FOR

23 IMPROVEMENT OF IHS FACILITIES; DIRECT BILLING

24 OPTION; DEFINITIONS.— 


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1 (A) IN GENERAL.—Such section is further 

2 amended by striking subsections (c) and (d) 

3 and inserting the following new subsections: 

4 ‘‘(b) SPECIAL FUND FOR IMPROVEMENT OF IHS FA5 CILITIES.—For provisions relating to the authority of the 

6 Secretary to place payments to which a facility of the In7 dian Health Service is eligible for payment under this title 

8 into a special fund established under section 401(c)(1) of 

9 the Indian Health Care Improvement Act, and the require10 ment to use amounts paid from such fund for making im11 provements in accordance with subsection (b), see sub12 paragraphs (A) and (B) of section 401(c)(1) of such Act. 

13 ‘‘(c) DIRECT BILLING.—For provisions relating to 

14 the authority of a Tribal Health Program to elect to di15 rectly bill for, and receive payment for, health care items 

16 and services provided by such Program for which payment 

17 is made under this title, see section 401(d) of the Indian 

18 Health Care Improvement Act.’’. 

19 (B) CONFORMING AMENDMENTS.—Such 

20 section is further amended— 

21 (i) in subsection (e)(3), by striking 

22 ‘‘Subsection (c)’’ and inserting ‘‘Subsection 

23 (b) and section 401(b)(1) of the Indian 

24 Health Care Improvement Act’’; 


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1 (ii) by redesignating subsection (e) as 

2 subsection (d); and 

3 (iii) by striking subsection (f). 

4 (4) DEFINITIONS.—Such section is further 

5 amended by amending adding at the end the fol6 lowing new subsection: 

7 ‘‘(e) DEFINITIONS.—In this section, the terms ‘In8 dian Health Program’, ‘Indian Tribe’, ‘Service Unit’, 

9 ‘Tribal Health Program’, ‘Tribal Organization’, and 

10 ‘Urban Indian Organization’ have the meanings given 

11 those terms in section 4 of the Indian Health Care Im12 provement Act.’’. 

13 (c) APPLICATION TO SCHIP.—Section 2107(e)(1) of 

14 the Social Security Act (42 U.S.C. 1397gg(e)(1)) is 

15 amended— 

16 (1) by redesignating subparagraphs (K) 

17 through (M) as subparagraphs (L) through (N), re18 spectively; and 

19 (2) by inserting after subparagraph (J), the fol20 lowing new subparagraph: 

21 ‘‘(K) Section 1911 (relating to Indian 

22 Health Programs, other than subsection (c) of 

23 such section).’’. 


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1 SEC. 3202. ADDITIONAL PROVISIONS TO INCREASE OUT2 REACH TO, AND ENROLLMENT OF, INDIANS 

3 IN SCHIP AND MEDICAID. 

4 (a) ASSURANCE OF PAYMENTS TO INDIAN HEALTH

5 CARE PROVIDERS FOR CHILD HEALTH ASSISTANCE.— 

6 Section 2102(b)(3)(D) of the Social Security Act (42 

7 U.S.C. 1397bb(b)(3)(D)) is amended by striking ‘‘(as de8 fined in section 4(c) of the Indian Health Care Improve9 ment Act, 25 U.S.C. 1603(c))’’ and inserting ‘‘, including 

10 how the State will ensure that payments are made to In11 dian Health Programs and urban Indian organizations op12 erating in the State for the provision of such assistance’’. 

13 (b) INCLUSION OF OTHER INDIAN FINANCED

14 HEALTH CARE PROGRAMS IN EXEMPTION FROM PROHI15 BITION ON CERTAIN PAYMENTS.—Section 2105(c)(6)(B) 

16 of such Act (42 U.S.C. 1397ee(c)(6)(B)) is amended by 

17 striking ‘‘insurance program, other than an insurance pro18 gram operated or financed by the Indian Health Service’’ 

19 and inserting ‘‘program, other than a health care program 

20 operated or financed by the Indian Health Service or by 

21 an Indian Tribe, Tribal Organization, or urban Indian or22 ganization’’. 

23 (c) DEFINITIONS.—Section 2110(c) of such Act (42 

24 U.S.C. 1397jj(c)) is amended by adding at the end the 

25 following new paragraph: 


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1 ‘‘(9) INDIAN; INDIAN HEALTH PROGRAM; IN2 DIAN TRIBE; ETC.—The terms ‘Indian’, ‘Indian 

3 Health Program’, ‘Indian Tribe’, ‘Tribal Organiza4 tion’, and ‘Urban Indian Organization’ have the 

5 meanings given those terms in section 4 of the In6 dian Health Care Improvement Act.’’. 

7 SEC. 3203. SOLICITATION OF PROPOSALS FOR SAFE HAR8 BORS UNDER THE SOCIAL SECURITY ACT 

9 FOR FACILITIES OF INDIAN HEALTH PRO10 GRAMS AND URBAN INDIAN ORGANIZATIONS. 

11 The Secretary of Health and Human Services, acting 

12 through the Office of the Inspector General of the Depart13 ment of Health and Human Services, shall publish a no14 tice, described in section 1128D(a)(1)(A) of the Social Se15 curity Act (42 U.S.C. 1320a–7d(a)(1)(A)), soliciting a 

16 proposal, not later than July 1, 2010, on the development 

17 of safe harbors described in such section relating to health 

18 care items and services provided by facilities of Indian 

19 Health Programs or an urban Indian organization (as 

20 such terms are defined in section 4 of the Indian Health 

21 Care Improvement Act). Such a safe harbor may relate 

22 to areas such as transportation, housing, or cost-sharing, 

23 assistance provided through such facilities or contract 

24 health services for Indians. 


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1 SEC. 3204. ANNUAL REPORT ON INDIANS SERVED BY SO2 CIAL SECURITY ACT HEALTH BENEFIT PRO3 GRAMS. 

4 Section 1139 of the Social Security Act (42 U.S.C. 

5 1320b–9), as amended by the sections 3203 and 3204, 

6 is amended by redesignating subsection (e) as subsection 

7 (f), and inserting after subsection (d) the following new 

8 subsection: 

9 ‘‘(e) ANNUAL REPORT ON INDIANS SERVED BY

10 HEALTH BENEFIT PROGRAMS FUNDED UNDER THIS

11 ACT.—Beginning January 1, 2011, and annually there12 after, the Secretary, acting through the Administrator of 

13 the Centers for Medicare & Medicaid Services and the Di14 rector of the Indian Health Service, shall submit a report 

15 to Congress regarding the enrollment and health status 

16 of Indians receiving items or services under health benefit 

17 programs funded under this Act during the preceding 

18 year. Each such report shall include the following: 

19 ‘‘(1) The total number of Indians enrolled in, or 

20 receiving items or services under, such programs, 

21 disaggregated with respect to each such program. 

22 ‘‘(2) The number of Indians described in para23 graph (1) that also received health benefits under 

24 programs funded by the Indian Health Service. 

25 ‘‘(3) General information regarding the health 

26 status of the Indians described in paragraph (1), 


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1 disaggregated with respect to specific diseases or 

2 conditions and presented in a manner that is con3 sistent with protections for privacy of individually 

4 identifiable health information under section 264(c) 

5 of the Health Insurance Portability and Account6 ability Act of 1996. 

7 ‘‘(4) A detailed statement of the status of facili8 ties of the Indian Health Service or an Indian Tribe, 

9 Tribal Organization, or an Urban Indian Organiza10 tion with respect to such facilities’ compliance with 

11 the applicable conditions and requirements of titles 

12 XVIII, XIX, and XXI, and, in the case of title XIX 

13 or XXI, under a State plan under such title or 

14 under waiver authority, and of the progress being 

15 made by such facilities (under plans submitted 

16 under 1911(b) or otherwise) toward the achievement 

17 and maintenance of such compliance. 

18 ‘‘(5) Such other information as the Secretary 

19 determines is appropriate.’’. 


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1 SEC. 3205. DEVELOPMENT OF RECOMMENDATIONS TO IM2 PROVE INTERSTATE COORDINATION OF MED3 ICAID AND SCHIP COVERAGE OF INDIAN 

4 CHILDREN AND OTHER CHILDREN WHO ARE 

5 OUTSIDE OF THEIR STATE OF RESIDENCY BE6 CAUSE OF EDUCATIONAL OR OTHER NEEDS. 

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

8 identify barriers to interstate coordination of enrollment 

9 and coverage under the Medicaid program under title XIX 

10 of the Social Security Act and the State Children’s Health 

11 Insurance Program under title XXI of such Act of chil12 dren who are eligible for medical assistance or child health 

13 assistance under such programs and who, because of edu14 cational needs, migration of families, emergency evacu15 ations, or otherwise, frequently change their State of resi16 dency or otherwise are temporarily present outside of the 

17 State of their residency. Such study shall include an exam18 ination of the enrollment and coverage coordination issues 

19 faced by Indian children who are eligible for medical as20 sistance or child health assistance under such programs 

21 in their State of residence and who temporarily reside in 

22 an out-of-State boarding school or peripheral dormitory 

23 funded by the Bureau of Indian Affairs. 

24 (b) REPORT.—Not later than 18 months after the 

25 date of enactment of this Act, the Secretary, in consulta26 tion with directors of State Medicaid programs under title 


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1 XIX of the Social Security Act and directors of State Chil2 dren’s Health Insurance Programs under title XXI of such 

3 Act, shall submit a report to Congress that contains rec4 ommendations for such legislative and administrative ac5 tions as the Secretary determines appropriate to address 

6 the enrollment and coverage coordination barriers identi7 fied through the study required under subsection (a). 

Æ 


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