IB 

Union Calendar No. 3 

111TH CONGRESS 

1ST SESSION H. R. 629 

[Report No. 111–7, Part I] 

To provide energy and commerce provisions of the American Recovery and 

Reinvestment Act of 2009. 

IN THE HOUSE OF REPRESENTATIVES 

JANUARY 22, 2009 

Mr. WAXMAN introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on 

Ways and Means, Education and Labor, and Science and Technology, 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 

JANUARY 26, 2009 

Reported from the Committee on Energy and Commerce with an amendment 

[Strike out all after the enacting clause and insert the part printed in italic] 

JANUARY 27, 2009 

The Committees on Ways and Means, Education and Labor, and Science and 

Technology discharged; committed to the Committee of the Whole House 

on the State of the Union and ordered to be printed 

[For text of introduced bill, see copy of bill as introduced on January 22, 2009] 

A BILL 

To provide energy and commerce provisions of the American 

Recovery and Reinvestment Act of 2009. 


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

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Energy and Commerce 

5 Recovery and Reinvestment Act’’. 

6 SEC. 2. TABLE OF CONTENTS. 

7 The table of contents of this Act is as follows: 

Sec. 1. Short title. 

Sec. 2. Table of contents. 

TITLE I—BROADBAND COMMUNICATIONS 

Sec. 1001. Inventory of Broadband Service Capability and Availability. 

Sec. 1002. Wireless and Broadband Deployment Grant Programs. 

Sec. 1003. National broadband plan. 

TITLE II—ENERGY 

Sec. 2001. Technical corrections to the Energy Independence and Security Act of 

2007. 

Sec. 2002. Amendments to title XIII of the Energy Independence and Security 

Act of 2007. 

Sec. 2003. Renewable energy and electric power transmission loan guarantee program. 

Sec. 2004. Weatherization Assistance Program amendments. 

Sec. 2005. Renewable electricity transmission study. 

Sec. 2006. Additional State energy grants. 

Sec. 2007. Inapplicability of limitation. 

TITLE III—HEALTH INSURANCE ASSISTANCE FOR THE 

UNEMPLOYED 

Sec. 3001. Short title and table of contents of title. 

Sec. 3002. Premium assistance for COBRA benefits and extension of COBRA benefits for older or long-term employees. 

Sec. 3003. Temporary optional Medicaid coverage for the unemployed. 

TITLE IV—HEALTH INFORMATION TECHNOLOGY 

Sec. 4001. Short title; table of contents of title. 

Subtitle A—Promotion of Health Information Technology 

PART 1—IMPROVING HEALTH CARE QUALITY, SAFETY, AND EFFICIENCY

Sec. 4101. ONCHIT; standards development and adoption. 

Sec. 4102. Technical amendment. 

Sec. 4103. American technology required. 


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PART 2—APPLICATION AND USE OF ADOPTED HEALTH INFORMATION

TECHNOLOGY STANDARDS; REPORTS

Sec. 4111. Coordination of Federal activities with adopted standards and implementation specifications. 

Sec. 4112. Application to private entities. 

Sec. 4113. Study and reports. 

Subtitle B—Testing of Health Information Technology 

Sec. 4201. National Institute for Standards and Technology testing. 

Sec. 4202. Research and development programs. 

Subtitle C—Incentives for the Use of Health Information Technology 

PART I—GRANTS AND LOANS FUNDING

Sec. 4301. Grant, loan, and demonstration programs. 

PART II—MEDICARE PROGRAM

Sec. 4311. Incentives for eligible professionals. 

Sec. 4312. Incentives for hospitals. 

Sec. 4313. Treatment of payments and savings; implementation funding. 

Sec. 4314. Study on application of EHR payment incentives for providers not receiving other incentive payments. 

PART III—MEDICAID FUNDING

Sec. 4321. Medicaid provider HIT adoption and operation payments; implementation funding. 

Subtitle D—Privacy 

Sec. 4400. Definitions. 

PART I—IMPROVED PRIVACY PROVISIONS AND SECURITY PROVISIONS

Sec. 4401. Application of security provisions and penalties to business associates 

of covered entities; annual guidance on security provisions. 

Sec. 4402. Notification in the case of breach. 

Sec. 4403. Education on Health Information Privacy. 

Sec. 4404. Application of privacy provisions and penalties to business associates 

of covered entities. 

Sec. 4405. Restrictions on certain disclosures and sales of health information; accounting of certain protected health information disclosures; access to certain information in electronic format. 

Sec. 4406. Conditions on certain contacts as part of health care operations. 

Sec. 4407. Temporary breach notification requirement for vendors of personal 

health records and other non-HIPAA covered entities. 

Sec. 4408. Business associate contracts required for certain entities. 

Sec. 4409. Clarification of application of wrongful disclosures criminal penalties. 

Sec. 4410. Improved enforcement. 

Sec. 4411. Audits. 

Sec. 4412. Securing individually identifiable health information. 

Sec. 4413. Special rule for information to reduce medication errors and improve 

patient safety. 


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PART II—RELATIONSHIP TO OTHER LAWS; REGULATORY REFERENCES; 

EFFECTIVE DATE; REPORTS

Sec. 4421. Relationship to other laws. 

Sec. 4422. Regulatory references. 

Sec. 4423. Effective date. 

Sec. 4424. Studies, reports, guidance. 

TITLE V—MEDICAID PROVISIONS 

Sec. 5000. Table of contents of title. 

Sec. 5001. Temporary increase of Medicaid FMAP. 

Sec. 5002. Moratoria on certain regulations. 

Sec. 5003. Transitional Medicaid assistance (TMA). 

Sec. 5004. State eligibility option for family planning services. 

Sec. 5005. Protections for Indians under Medicaid and CHIP. 

Sec. 5006. Consultation on Medicaid and CHIP. 

Sec. 5007. Temporary increase in DSH allotments during recession. 

1 TITLE I—BROADBAND 

2 COMMUNICATIONS 

3 SEC. 1001. INVENTORY OF BROADBAND SERVICE CAPA4 BILITY AND AVAILABILITY. 

5 (a) ESTABLISHMENT.—To provide a comprehensive 

6 nationwide inventory of existing broadband service capa7 bility and availability, the National Telecommunications 

8 and Information Administration (‘‘NTIA’’) shall develop 

9 and maintain a broadband inventory map of the United 

10 States that identifies and depicts the geographic extent to 

11 which broadband service capability is deployed and avail12 able from a commercial provider or public provider 

13 throughout each State. 

14 (b) PUBLIC AVAILABILITY AND INTERACTIVITY.—Not 

15 later than 2 years after the date of enactment of this Act, 

16 the NTIA shall make the broadband inventory map devel17 oped and maintained pursuant to this section accessible by 


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1 the public on a World Wide website of the NTIA in a form 

2 that is interactive and searchable. 

3 SEC. 1002. WIRELESS AND BROADBAND DEPLOYMENT 

4 GRANT PROGRAMS. 

5 (a) GRANTS AUTHORIZED.— 

6 (1) IN GENERAL.—The National Telecommuni7 cations and Information Administration (‘‘NTIA’’) is 

8 authorized to carry out a program to award grants 

9 to eligible entities for the non-recurring costs associ10 ated with the deployment of broadband infrastructure 

11 in rural, suburban, and urban areas, in accordance 

12 with the requirements of this section. 

13 (2) PROGRAM WEBSITE.—The NTIA shall de14 velop and maintain a website to make publicly avail15 able information about the program described in 

16 paragraph (1), including— 

17 (A) each prioritization report submitted by 

18 a State under subsection (b); 

19 (B) a list of eligible entities that have ap20 plied for a grant under this section, and the area 

21 or areas the entity proposes to serve; and 

22 (C) the status of each such application, 

23 whether approved, denied, or pending. 

24 (b) STATE PRIORITIES.— 


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1 (1) PRIORITIES REPORT SUBMISSION.—Not later 

2 than 75 days after the date of enactment of this sec3 tion, each State intending to participate in the pro4 gram under this section shall submit to the NTIA a 

5 report indicating the geographic areas of the State 

6 which— 

7 (A) for the purposes of determining the need 

8 for Wireless Deployment Grants under subsection 

9 (c), the State considers to have the greatest pri10 ority for— 

11 (i) wireless voice service in unserved 

12 areas; and 

13 (ii) advanced wireless broadband serv14 ice in underserved areas; and 

15 (B) for the purposes of determining the need 

16 for Broadband Deployment Grants under sub17 section (d), the State considers to have the great18 est priority for— 

19 (i) basic broadband service in unserved 

20 areas; and 

21 (ii) advanced broadband service in un22 derserved areas. 

23 (2) LIMITATION.—The unserved and underserved 

24 areas identified by a State in the report required by 


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1 this subsection shall not represent, in the aggregate, 

2 more than 20 percent of the population of such State. 

3 (c) WIRELESS DEPLOYMENT GRANTS.— 

4 (1) AUTHORIZED ACTIVITY.—The NTIA shall 

5 award Wireless Deployment Grants in accordance 

6 with this subsection from amounts authorized for 

7 Wireless Deployment Grants by this subtitle to eligi8 ble entities to deploy necessary infrastructure for the 

9 provision of wireless voice service or advanced wire10 less broadband service to end users in designated 

11 areas. 

12 (2) GRANT DISTRIBUTION.—The NTIA shall seek 

13 to distribute grants, to the extent possible, so that 25 

14 percent of the grants awarded under this subsection 

15 shall be awarded to eligible entities for providing 

16 wireless voice service to unserved areas and 75 per17 cent of grants awarded under this subsection shall be 

18 awarded to eligible entities for providing advanced 

19 wireless broadband service to underserved areas. 

20 (d) BROADBAND DEPLOYMENT GRANTS.— 

21 (1) AUTHORIZED ACTIVITY.—The NTIA shall 

22 award Broadband Deployment Grants in accordance 

23 with this subsection from amounts authorized for 

24 Broadband Deployment Grants by this subtitle to eli25 gible entities to deploy necessary infrastructure for 


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1 the provision of basic broadband service or advanced 

2 broadband service to end users in designated areas. 

3 (2) GRANT DISTRIBUTION.—The NTIA shall seek 

4 to distribute grants, to the extent possible, so that 25 

5 percent of the grants awarded under this subsection 

6 shall be awarded to eligible entities for providing 

7 basic broadband service to unserved areas and 75 per8 cent of grants awarded under this subsection shall be 

9 awarded to eligible entities for providing advanced 

10 broadband service to underserved areas. 

11 (e) GRANT REQUIREMENTS.—The NTIA shall— 

12 (1) adopt rules to protect against unjust enrich13 ment; and 

14 (2) ensure that grant recipients— 

15 (A) meet buildout requirements; 

16 (B) maximize use of the supported infra17 structure by the public; 

18 (C) operate basic and advanced broadband 

19 service networks on an open access basis; 

20 (D) operate advanced wireless broadband 

21 service on a wireless open access basis; and 

22 (E) adhere to the principles contained in 

23 the Federal Communications Commission’s 

24 broadband policy statement (FCC 05–151, 

25 adopted August 5, 2005). 


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1 (f) APPLICATIONS.— 

2 (1) SUBMISSION.—To be considered for a grant 

3 awarded under subsection (c) or (d), an eligible entity 

4 shall submit to the NTIA an application at such 

5 time, in such manner, and containing such informa6 tion and assurances as the NTIA may require. Such 

7 an application shall include— 

8 (A) a cost-study estimate for serving the 

9 particular geographic area to be served by the 

10 entity; 

11 (B) a proposed build-out schedule to resi12 dential households and small businesses in the 

13 area; 

14 (C) for applicants for Wireless Deployment 

15 Grants under subsection (c), a build-out schedule 

16 for geographic coverage of such areas; and 

17 (D) any other requirements the NTIA deems 

18 necessary. 

19 (2) SELECTION.— 

20 (A) NOTIFICATION.—The NTIA shall notify 

21 each eligible entity that has submitted a complete 

22 application whether the entity has been approved 

23 or denied for a grant under this section in a 

24 timely fashion. 


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1 (B) GRANT DISTRIBUTION CONSIDER2 ATIONS.—In awarding grants under this section, 

3 the NTIA shall, to the extent practical— 

4 (i) award not less than one grant in 

5 each State; 

6 (ii) give substantial weight to whether 

7 an application is from an eligible entity to 

8 deploy infrastructure in an area that is an 

9 area— 

10 (I) identified by a State in a re11 port submitted under subsection (b); or 

12 (II) in which the NTIA deter13 mines there will be a significant 

14 amount of public safety or emergency 

15 response use of the infrastructure; 

16 (iii) consider whether an application 

17 from an eligible entity to deploy infrastruc18 ture in an area— 

19 (I) will, if approved, increase the 

20 affordability of, or subscribership to, 

21 service to the greatest population of 

22 underserved users in the area; 

23 (II) will, if approved, enhance 

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1 ulation of underserved users in the 

2 area; 

3 (III) contains concrete plans for 

4 enhancing computer ownership or com5 puter literacy in the area; 

6 (IV) is from a recipient of more 

7 than 20 percent matching grants from 

8 State, local, or private entities for serv9 ice in the area and the extent of such 

10 commitment; 

11 (V) will, if approved, result in 

12 unjust enrichment because the eligible 

13 entity has applied for, or intends to 

14 apply for, support for the non-recur15 ring costs through another Federal pro16 gram for service in the area; and 

17 (VI) will, if approved, signifi18 cantly improve interoperable 

19 broadband communications systems 

20 available for use by public safety and 

21 emergency response; and 

22 (iv) consider whether the eligible entity 

23 is a socially and economically disadvan24 taged small business concern, as defined 


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1 under section 8(a) of the Small Business 

2 Act (15 U.S.C. 637). 

3 (g) COORDINATION AND CONSULTATION.—The NTIA 

4 shall coordinate with the Federal Communications Commis5 sion and shall consult with other appropriate Federal agen6 cies in implementing this section. 

7 (h) REPORT REQUIRED.—The NTIA shall submit an 

8 annual report to the Committee on Energy and Commerce 

9 of the House of Representatives and the Committee on Com10 merce, Science, and Transportation of the Senate for 5 

11 years assessing the impact of the grants funded under this 

12 section on the basis of the objectives and criteria described 

13 in subsection (f)(2)(B)(iii). 

14 (i) RULEMAKING AUTHORITY.—The NTIA shall have 

15 the authority to prescribe such rules as necessary to carry 

16 out the purposes of this section. 

17 (j) DEFINITIONS.—For the purpose of this section— 

18 (1) the term ‘‘advanced broadband service’’ 

19 means a service delivering data to the end user trans20 mitted at a speed of at least 45 megabits per second 

21 downstream and at least 15 megabits per second up22 stream; 

23 (2) the term ‘‘advanced wireless broadband serv24 ice’’ means a wireless service delivering to the end 

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1 bits per second downstream and at least 1 megabit 

2 per second upstream over an end-to-end internet pro3 tocol wireless network; 

4 (3) the term ‘‘basic broadband service’’ means a 

5 service delivering data to the end user transmitted at 

6 a speed of at least 5 megabits per second downstream 

7 and at least 1 megabit per second upstream; 

8 (4) the term ‘‘eligible entity’’ means— 

9 (A) a provider of wireless voice service, ad10 vanced wireless broadband service, basic 

11 broadband service, or advanced broadband serv12 ice, including a satellite carrier that provides 

13 any such service; 

14 (B) a State or unit of local government, or 

15 agency or instrumentality thereof, that is or in16 tends to be a provider of any such service; and 

17 (C) any other entity, including construction 

18 companies, tower companies, backhaul compa19 nies, or other service providers, that the NTIA 

20 authorizes by rule to participate in the programs 

21 under this section, if such other entity is re22 quired to provide access to the supported infra23 structure on a neutral, reasonable basis to maxi24 mize use; 


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1 (5) the term ‘‘interoperable broadband commu2 nications systems’’ means communications systems 

3 which enable public safety agencies to share informa4 tion among local, State, Federal, and tribal public 

5 safety agencies in the same area using voice or data 

6 signals via advanced wireless broadband service; 

7 (6) the term ‘‘open access’’ shall be defined by the 

8 Federal Communications Commission not later than 

9 45 days after the date of enactment of this section; 

10 (7) the term ‘‘State’’ includes the District of Co11 lumbia and the territories and possessions; 

12 (8) the term ‘‘underserved area’’ shall be defined 

13 by the Federal Communications Commission not later 

14 than 45 days after the date of enactment of this sec15 tion; 

16 (9) the term ‘‘unserved area’’ shall be defined by 

17 the Federal Communications Commission not later 

18 than 45 days after the date of enactment of this sec19 tion; 

20 (10) the term ‘‘wireless open access’’ shall be de21 fined by the Federal Communications Commission 

22 not later than 45 days after the date of enactment of 

23 this section; and 


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1 (11) the term ‘‘wireless voice service’’ means the 

2 provision of two-way, real-time, voice communica3 tions using a mobile service. 

4 (k) REVIEW OF DEFINITIONS.—Not later than 3 

5 months after the date the NTIA makes a broadband inven6 tory map of the United States accessible to the public pursu7 ant to section 1001(b), the Federal Communications Com8 mission shall review the definitions of ‘‘underserved area’’ 

9 and ‘‘unserved area’’, as defined by the Commission within 

10 45 days after the date of enactment of this Act (as required 

11 by paragraphs (8) and (9) of subsection (j)), and shall re12 vise such definitions based on the data used by the NTIA 

13 to develop and maintain such map. 

14 SEC. 1003. NATIONAL BROADBAND PLAN. 

15 (a) REPORT REQUIRED.—Not later than 1 year after 

16 the date of enactment of this section, the Federal Commu17 nications Commission shall submit to the Committee on 

18 Energy and Commerce of the House of Representatives and 

19 the Committee on Commerce, Science, and Transportation 

20 of the Senate, a report containing a national broadband 

21 plan. 

22 (b) CONTENTS OF PLAN.—The national broadband 

23 plan required by this section shall seek to ensure that all 

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1 bility and shall establish benchmarks for meeting that goal. 

2 The plan shall also include— 

3 (1) an analysis of the most effective and efficient 

4 mechanisms for ensuring broadband access by all peo5 ple of the United States; 

6 (2) a detailed strategy for achieving affordability 

7 of such service and maximum utilization of 

8 broadband infrastructure and service by the public; 

9 and 

10 (3) a plan for use of broadband infrastructure 

11 and services in advancing consumer welfare, civic 

12 participation, public safety and homeland security, 

13 community development, health care delivery, energy 

14 independence and efficiency, education, worker train15 ing, private sector investment, entrepreneurial activ16 ity, job creation and economic growth, and other na17 tional purposes. 

18 TITLE II—ENERGY 

19 SEC. 2001. TECHNICAL CORRECTIONS TO THE ENERGY 

20 INDEPENDENCE AND SECURITY ACT OF 2007. 

21 (a) Section 543(a) of the Energy Independence and Se22 curity Act of 2007 (42 U.S.C. 17153(a)) is amended— 

23 (1) by redesignating paragraphs (2) through (4) 

24 as paragraphs (3) through (5), respectively; and 


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1 (2) by striking paragraph (1) and inserting the 

2 following: 

3 ‘‘(1) 34 percent to eligible units of local govern4 ment–alternative 1, in accordance with subsection (b); 

5 ‘‘(2) 34 percent to eligible units of local govern6 ment–alternative 2, in accordance with subsection 

7 (b);’’. 

8 (b) Section 543(b) of the Energy Independence and Se9 curity Act of 2007 (42 U.S.C. 17153(b)) is amended by 

10 striking ‘‘subsection (a)(1)’’ and inserting ‘‘subsection 

11 (a)(1) or (2)’’. 

12 (c) Section 548(a)(1) of the Energy Independence and 

13 Security Act of 2007 (42 U.S.C. 17158(a)(1)) is amending 

14 by striking ‘‘; provided’’ and all that follows through 

15 ‘‘541(3)(B)’’. 

16 SEC. 2002. AMENDMENTS TO TITLE XIII OF THE ENERGY 

17 INDEPENDENCE AND SECURITY ACT OF 2007. 

18 Title XIII of the Energy Independence and Security 

19 Act of 2007 (42 U.S.C. 17381 and following) is amended 

20 as follows: 

21 (1) By amending subparagraph (A) of section 

22 1304(b)(3) to read as follows: 

23 ‘‘(A) IN GENERAL.—In carrying out the ini24 tiative, the Secretary shall provide financial sup25 port to smart grid demonstration projects in 


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1 urban, suburban, and rural areas, including 

2 areas where electric system assets are controlled 

3 by tax-exempt entities and areas where electric 

4 system assets are controlled by investor-owned 

5 utilities.’’. 

6 (2) By amending subparagraph (C) of section 

7 1304(b)(3) to read as follows: 

8 ‘‘(C) FEDERAL SHARE OF COST OF TECH9 NOLOGY INVESTMENTS.—The Secretary shall pro10 vide to an electric utility described in subpara11 graph (B) or to other parties financial assistance 

12 for use in paying an amount equal to not more 

13 than 50 percent of the cost of qualifying ad14 vanced grid technology investments made by the 

15 electric utility or other party to carry out a 

16 demonstration project.’’. 

17 (3) By inserting after section 1304(b)(3)(D) the 

18 following new subparagraphs: 

19 ‘‘(E) AVAILABILITY OF DATA.—The Sec20 retary shall establish and maintain a smart grid 

21 information clearinghouse in a timely manner 

22 which will make data from smart grid dem23 onstration projects and other sources available to 

24 the public. As a condition of receiving financial 

25 assistance under this subsection, a utility or 


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1 other participant in a smart grid demonstration 

2 project shall provide such information as the 

3 Secretary may require to become available 

4 through the smart grid information clearing5 house in the form and within the timeframes as 

6 directed by the Secretary. The Secretary shall as7 sure that business proprietary information and 

8 individual customer information is not included 

9 in the information made available through the 

10 clearinghouse. 

11 ‘‘(F) OPEN INTERNET-BASED PROTOCOLS

12 AND STANDARDS.—The Secretary shall require as 

13 a condition of receiving funding under this sub14 section that demonstration projects utilize open 

15 Internet-based protocols and standards if avail16 able.’’. 

17 (4) By amending paragraph (2) of section 

18 1304(c) to read as follows: 

19 ‘‘(2) to carry out subsection (b), such sums as 

20 may be necessary.’’. 

21 (5) By amending subsection (a) of section 1306 

22 by striking ‘‘reimbursement of one-fifth (20 percent)’’ 

23 and inserting ‘‘grants of up to one-half (50 percent)’’. 

24 (6) By striking the last sentence of subsection 

25 (b)(9) of section 1306. 


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1 (7) By striking ‘‘are eligible for’’ in subsection 

2 (c)(1) of section 1306 and inserting ‘‘utilize’’. 

3 (8) By amending subsection (e) of section 1306 

4 to read as follows: 

5 ‘‘(e) PROCEDURES AND RULES.—The Secretary 

6 shall— 

7 ‘‘(1) establish within 60 days after the enactment 

8 of the Energy and Commerce Recovery and Reinvest9 ment Act procedures by which applicants can obtain 

10 grants of not more than one-half of their documented 

11 costs; 

12 ‘‘(2) require as a condition of receiving a grant 

13 under this section that grant recipients utilize open 

14 Internet-based protocols and standards if available; 

15 ‘‘(3) establish procedures to ensure that there is 

16 no duplication or multiple payment or recovery for 

17 the same investment or costs, that the grant goes to 

18 the party making the actual expenditures for quali19 fying smart grid investments, and that the grants 

20 made have significant effect in encouraging and fa21 cilitating the development of a smart grid; 

22 ‘‘(4) maintain public records of grants made, re23 cipients, and qualifying smart grid investments 

24 which have received grants; 


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1 ‘‘(5) establish procedures to provide advance 

2 payment of moneys up to the full amount of the grant 

3 award; and 

4 ‘‘(6) have and exercise the discretion to deny 

5 grants for investments that do not qualify in the rea6 sonable judgment of the Secretary.’’. 

7 SEC. 2003. RENEWABLE ENERGY AND ELECTRIC POWER 

8 TRANSMISSION LOAN GUARANTEE PROGRAM. 

9 (a) AMENDMENT.—Title XVII of the Energy Policy 

10 Act of 2005 (42 U.S.C. 16511 et seq.) is amended by adding 

11 the following at the end: 

12 ‘‘SEC. 1705. TEMPORARY PROGRAM FOR RAPID DEPLOY13 MENT OF RENEWABLE ENERGY AND ELEC14 TRIC POWER TRANSMISSION PROJECTS. 

15 ‘‘(a) IN GENERAL.—Notwithstanding section 1703, the 

16 Secretary may make guarantees under this section only for 

17 commercial technology projects under subsection (b) that 

18 will commence construction not later than September 30, 

19 2011. 

20 ‘‘(b) CATEGORIES.—Projects from only the following 

21 categories shall be eligible for support under this section: 

22 ‘‘(1) Renewable energy systems, including incre23 mental hydropower, that generate electricity. 

24 ‘‘(2) Electric power transmission systems, in25 cluding upgrading and reconductoring projects. 


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1 ‘‘(3) Leading edge biofuel projects that will use 

2 technologies performing at the pilot or demonstration 

3 scale that the Secretary determines are likely to be4 come commercial technologies and will produce trans5 portation fuels that substantially reduce life-cycle 

6 greenhouse gas emissions compared to other transpor7 tation fuels. 

8 ‘‘(c) FACTORS RELATING TO ELECTRIC POWER TRANS9 MISSION SYSTEMS.—In determining to make guarantees to 

10 projects described in subsection (b)(2), the Secretary shall 

11 consider the following factors: 

12 ‘‘(1) The viability of the project without guaran13 tees. 

14 ‘‘(2) The availability of other Federal and State 

15 incentives. 

16 ‘‘(3) The importance of the project in meeting re17 liability needs. 

18 ‘‘(4) The effect of the project in meeting a State 

19 or region’s environment (including climate change) 

20 and energy goals. 

21 ‘‘(d) WAGE RATE REQUIREMENTS.—The Secretary 

22 shall require that each recipient of support under this sec23 tion provide reasonable assurance that all laborers and me24 chanics employed in the performance of the project for 

25 which the assistance is provided, including those employed 


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1 by contractors or subcontractors, will be paid wages at rates 

2 not less than those prevailing on similar work in the local3 ity as determined by the Secretary of Labor in accordance 

4 with subchapter IV of chapter 31 of part A of subtitle II 

5 of title 40, United States Code (commonly referred to as 

6 the ‘Davis-Bacon Act’). 

7 ‘‘(e) LIMITATION.—Funding under this section for 

8 projects described in subsection (b)(3) shall not exceed 

9 $500,000,000. 

10 ‘‘(f) SUNSET.—The authority to enter into guarantees 

11 under this section shall expire on September 30, 2011.’’. 

12 (b) TABLE OF CONTENTS AMENDMENT.—The table of 

13 contents for the Energy Policy Act of 2005 is amended by 

14 inserting after the item relating to section 1704 the fol15 lowing new item: 

‘‘Sec. 1705. Temporary program for rapid deployment of renewable energy and 

electric power transmission projects.’’. 

16 SEC. 2004. WEATHERIZATION ASSISTANCE PROGRAM 

17 AMENDMENTS. 

18 (a) INCOME LEVEL.—Section 412(7) of the Energy 

19 Conservation and Production Act (42 U.S.C. 6862(7)) is 

20 amended by striking ‘‘150 percent’’ both places it appears 

21 and inserting ‘‘200 percent’’. 

22 (b) ASSISTANCE LEVEL PER DWELLING UNIT.— Sec23 tion 415(c)(1) of the Energy Conservation and Production 


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1 Act (42 U.S.C. 6865(c)(1)) is amended by striking ‘‘$2,500’’ 

2 and inserting ‘‘$5,000’’. 

3 (c) EFFECTIVE USE OF FUNDS.—In providing funds 

4 made available by this Act for the Weatherization Assist5 ance Program, the Secretary may encourage States to give 

6 priority to using such funds for the most cost-effective effi7 ciency activities, which may include insulation of attics, 

8 if, in the Secretary’s view, such use of funds would increase 

9 the effectiveness of the program. 

10 SEC. 2005. RENEWABLE ELECTRICITY TRANSMISSION 

11 STUDY. 

12 In completing the 2009 National Electric Trans13 mission Congestion Study, the Secretary of Energy shall 

14 include— 

15 (1) an analysis of the significant potential 

16 sources of renewable energy that are constrained in 

17 accessing appropriate market areas by lack of ade18 quate transmission capacity; 

19 (2) an analysis of the reasons for failure to de20 velop the adequate transmission capacity; 

21 (3) recommendations for achieving adequate 

22 transmission capacity; 

23 (4) an analysis of the extent to which legal chal24 lenges filed at the State and Federal level are delayVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00024 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 ing the construction of transmission necessary to ac2 cess renewable energy; and 

3 (5) an explanation of assumptions and projec4 tions made in the Study, including— 

5 (A) assumptions and projections relating to 

6 energy efficiency improvements in each load cen7 ter; 

8 (B) assumptions and projections regarding 

9 the location and type of projected new generation 

10 capacity; and 

11 (C) assumptions and projections regarding 

12 projected deployment of distributed generation 

13 infrastructure. 

14 SEC. 2006. ADDITIONAL STATE ENERGY GRANTS. 

15 (a) IN GENERAL.—Amounts appropriated for the 

16 State Energy Program under the American Recovery and 

17 Reinvestment Act of 2009 shall be available to the Secretary 

18 of Energy for making additional grants under part D of 

19 title III of the Energy Policy and Conservation Act (42 

20 U.S.C. 6321 et seq.). The Secretary shall make grants under 

21 this section in excess of the base allocation established for 

22 a State under regulations issued pursuant to the authoriza23 tion provided in section 365(f) of such Act only if the gov24 ernor of the recipient State notifies the Secretary of Energy 


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1 that the governor will seek, to the extent of his or her author2 ity, to ensure that each of the following will occur: 

3 (1) The applicable State regulatory authority 

4 will implement the following regulatory policies for 

5 each electric and gas utility with respect to which the 

6 State regulatory authority has ratemaking authority: 

7 (A) Policies that ensure that a utility’s re8 covery of prudent fixed costs of service is timely 

9 and independent of its retail sales, without in 

10 the process shifting prudent costs from variable 

11 to fixed charges. This cost shifting constraint 

12 shall not apply to rate designs adopted prior to 

13 the date of enactment of this Act. 

14 (B) Cost recovery for prudent investments 

15 by utilities in energy efficiency. 

16 (C) An earnings opportunity for utilities 

17 associated with cost-effective energy efficiency 

18 savings. 

19 (2) The State, or the applicable units of local 

20 government that have authority to adopt building 

21 codes, will implement the following: 

22 (A) A building energy code (or codes) for 

23 residential buildings that meets or exceeds the 

24 most recently published International Energy 


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1 Conservation Code, or achieves equivalent or 

2 greater energy savings. 

3 (B) A building energy code (or codes) for 

4 commercial buildings throughout the State that 

5 meets or exceeds the ANSI/ASHRAE/IESNA 

6 Standard 90.1–2007, or achieves equivalent or 

7 greater energy savings. 

8 (C) A plan for the jurisdiction achieving 

9 compliance with the building energy code or 

10 codes described in subparagraphs (A) and (B) 

11 within 8 years of the date of enactment of this 

12 Act in at least 90 percent of new and renovated 

13 residential and commercial building space. Such 

14 plan shall include active training and enforce15 ment programs and measurement of the rate of 

16 compliance each year. 

17 (3) The State will to the extent practicable 

18 prioritize the grants toward funding energy efficiency 

19 and renewable energy programs, including— 

20 (A) the expansion of existing energy effi21 ciency programs approved by the State or the 

22 appropriate regulatory authority, including en23 ergy efficiency retrofits of buildings and indus24 trial facilities, that are funded— 

25 (i) by the State; or 


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1 (ii) through rates under the oversight 

2 of the applicable regulatory authority, to 

3 the extent applicable; 

4 (B) the expansion of existing programs, ap5 proved by the State or the appropriate regu6 latory authority, to support renewable energy 

7 projects and deployment activities, including 

8 programs operated by entities which have the au9 thority and capability to manage and distribute 

10 grants, loans, performance incentives, and other 

11 forms of financial assistance; and 

12 (C) cooperation and joint activities between 

13 States to advance more efficient and effective use 

14 of this funding to support the priorities described 

15 in this paragraph. 

16 (b) STATE MATCH.—The State cost share requirement 

17 under the item relating to ‘‘DEPARTMENT OF ENERGY; 

18 energy conservation’’ in title II of the Department of the 

19 Interior and Related Agencies Appropriations Act, 1985 

20 (42 U.S.C. 6323a; 98 Stat. 1861) shall not apply to assist21 ance provided under this section. 

22 (c) EQUIPMENT AND MATERIALS FOR ENERGY EFFI23 CIENCY MEASURES.—No limitation on the percentage of 

24 funding that may be used for the purchase and installation 

25 of equipment and materials for energy efficiency measures 


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1 under grants provided under part D of title III of the En2 ergy Policy and Conservation Act (42 U.S.C. 6321 et seq.) 

3 shall apply to assistance provided under this section. 

4 SEC. 2007. INAPPLICABILITY OF LIMITATION. 

5 The limitations in section 399A(f)(2), (3), and (4) of 

6 the Energy Policy and Conservation Act (42 U.S.C. 6371h– 

7 1(f)(2), (3), and (4)) shall not apply to grants funded with 

8 appropriations provided by this Act, except that such grant 

9 funds shall be available for not more than an amount equal 

10 to 80 percent of the costs of the project for which the grant 

11 is provided. 

12 TITLE III—HEALTH INSURANCE 

13 ASSISTANCE FOR THE UNEM14 PLOYED 

15 SEC. 3001. SHORT TITLE AND TABLE OF CONTENTS OF 

16 TITLE. 

17 (a) SHORT TITLE OF TITLE.—This title may be cited 

18 as the ‘‘Health Insurance Assistance for the Unemployed 

19 Act of 2009’’. 

20 (b) TABLE OF CONTENTS OF TITLE.—The table of con21 tents of this title is as follows: 

Sec. 3001. Short title and table of contents of title. 

Sec. 3002. Premium assistance for COBRA benefits and extension of COBRA benefits for older or long-term employees. 

Sec. 3003. Temporary optional Medicaid coverage for the unemployed. 


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1 SEC. 3002. PREMIUM ASSISTANCE FOR COBRA BENEFITS 

2 AND EXTENSION OF COBRA BENEFITS FOR 

3 OLDER OR LONG-TERM EMPLOYEES. 

4 (a) PREMIUM ASSISTANCE FOR COBRA CONTINU5 ATION COVERAGE FOR INDIVIDUALS AND THEIR FAMI6 LIES.— 

7 (1) PROVISION OF PREMIUM ASSISTANCE.— 

8 (A) REDUCTION OF PREMIUMS PAYABLE.— 

9 In the case of any premium for a period of cov10 erage beginning on or after the date of the enact11 ment of this Act for COBRA continuation cov12 erage with respect to any assistance eligible indi13 vidual, such individual shall be treated for pur14 poses of any COBRA continuation provision as 

15 having paid the amount of such premium if such 

16 individual pays 35 percent of the amount of such 

17 premium (as determined without regard to this 

18 subsection). 

19 (B) PREMIUM REIMBURSEMENT.—For pro20 visions providing the balance of such premium, 

21 see section 6431 of the Internal Revenue Code of 

22 1986, as added by paragraph (12). 

23 (2) LIMITATION OF PERIOD OF PREMIUM ASSIST24 ANCE.— 

25 (A) IN GENERAL.—Paragraph (1)(A) shall 

26 not apply with respect to any assistance eligible 


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1 individual for months of coverage beginning on 

2 or after the earlier of— 

3 (i) the first date that such individual 

4 is eligible for coverage under any other 

5 group health plan (other than coverage con6 sisting of only dental, vision, counseling, or 

7 referral services (or a combination thereof), 

8 coverage under a health reimbursement ar9 rangement or a health flexible spending ar10 rangement, or coverage of treatment that is 

11 furnished in an on-site medical facility 

12 maintained by the employer and that con13 sists primarily of first-aid services, preven14 tion and wellness care, or similar care (or 

15 a combination thereof)) or is eligible for 

16 benefits under title XVIII of the Social Se17 curity Act, or 

18 (ii) the earliest of— 

19 (I) the date which is 12 months 

20 after the first day of the first month 

21 that paragraph (1)(A) applies with re22 spect to such individual, 

23 (II) the date following the expira24 tion of the maximum period of con25 tinuation coverage required under the 


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1 applicable COBRA continuation cov2 erage provision, or 

3 (III) the date following the expi4 ration of the period of continuation 

5 coverage allowed under paragraph 

6 (4)(B)(ii). 

7 (B) TIMING OF ELIGIBILITY FOR ADDI8 TIONAL COVERAGE.—For purposes of subpara9 graph (A)(i), an individual shall not be treated 

10 as eligible for coverage under a group health 

11 plan before the first date on which such indi12 vidual could be covered under such plan. 

13 (C) NOTIFICATION REQUIREMENT.—An as14 sistance eligible individual shall notify in writ15 ing the group health plan with respect to which 

16 paragraph (1)(A) applies if such paragraph 

17 ceases to apply by reason of subparagraph 

18 (A)(i). Such notice shall be provided to the group 

19 health plan in such time and manner as may be 

20 specified by the Secretary of Labor. 

21 (3) ASSISTANCE ELIGIBLE INDIVIDUAL.—For 

22 purposes of this section, the term ‘‘assistance eligible 

23 individual’’ means any qualified beneficiary if— 

24 (A) at any time during the period that be25 gins with September 1, 2008, and ends with DeVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00032 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 cember 31, 2009, such qualified beneficiary is el2 igible for COBRA continuation coverage, 

3 (B) such qualified beneficiary elects such 

4 coverage, 

5 (C) the qualifying event with respect to the 

6 COBRA continuation coverage consists of the in7 voluntary termination of the covered employee’s 

8 employment and occurred during such period, 

9 and 

10 (D) at the time of the election such qualified 

11 beneficiary’s annual income is less than 

12 $1,000,000. 

13 (4) EXTENSION OF ELECTION PERIOD AND EF14 FECT ON COVERAGE.— 

15 (A) IN GENERAL.—Notwithstanding section 

16 605(a) of the Employee Retirement Income Secu17 rity Act of 1974, section 4980B(f)(5)(A) of the 

18 Internal Revenue Code of 1986, section 2205(a) 

19 of the Public Health Service Act, and section 

20 8905a(c)(2) of title 5, United States Code, in the 

21 case of an individual who is a qualified bene22 ficiary described in paragraph (3)(A) as of the 

23 date of the enactment of this Act and has not 

24 made the election referred to in paragraph 

25 (3)(B) as of such date, such individual may elect 


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1 the COBRA continuation coverage under the 

2 COBRA continuation coverage provisions con3 taining such sections during the 60-day period 

4 commencing with the date on which the notifica5 tion required under paragraph (7)(C) is pro6 vided to such individual. 

7 (B) COMMENCEMENT OF COVERAGE; NO

8 REACH-BACK.—Any COBRA continuation cov9 erage elected by a qualified beneficiary during 

10 an extended election period under subparagraph 

11 (A)— 

12 (i) shall commence on the date of the 

13 enactment of this Act, and 

14 (ii) shall not extend beyond the period 

15 of COBRA continuation coverage that 

16 would have been required under the applica17 ble COBRA continuation coverage provision 

18 if the coverage had been elected as required 

19 under such provision. 

20 (C) PREEXISTING CONDITIONS.—With re21 spect to a qualified beneficiary who elects 

22 COBRA continuation coverage pursuant to sub23 paragraph (A), the period— 

24 (i) beginning on the date of the quali25 fying event, and 


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1 (ii) ending with the day before the date 

2 of the enactment of this Act, 

3 shall be disregarded for purposes of determining 

4 the 63-day periods referred to in section 701)(2) 

5 of the Employee Retirement Income Security Act 

6 of 1974, section 9801(c)(2) of the Internal Rev7 enue Code of 1986, and section 2701(c)(2) of the 

8 Public Health Service Act. 

9 (5) EXPEDITED REVIEW OF DENIALS OF PRE10 MIUM ASSISTANCE.—In any case in which an indi11 vidual requests treatment as an assistance eligible in12 dividual and is denied such treatment by the group 

13 health plan by reason of such individual’s ineligi14 bility for COBRA continuation coverage, the Sec15 retary of Labor (or the Secretary of Health and 

16 Human services in connection with COBRA continu17 ation coverage which is provided other than pursuant 

18 to part 6 of subtitle B of title I of the Employee Re19 tirement Income Security Act of 1974), in consulta20 tion with the Secretary of the Treasury, shall provide 

21 for expedited review of such denial. An individual 

22 shall be entitled to such review upon application to 

23 such Secretary in such form and manner as shall be 

24 provided by such Secretary. Such Secretary shall 

25 make a determination regarding such individual’s eliVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00035 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 gibility within 10 business days after receipt of such 

2 individual’s application for review under this para3 graph. 

4 (6) DISREGARD OF SUBSIDIES FOR PURPOSES OF

5 FEDERAL AND STATE PROGRAMS.—Notwithstanding 

6 any other provision of law, any premium reduction 

7 with respect to an assistance eligible individual under 

8 this subsection shall not be considered income or re9 sources in determining eligibility for, or the amount 

10 of assistance or benefits provided under, any other 

11 public benefit provided under Federal law or the law 

12 of any State or political subdivision thereof. 

13 (7) NOTICES TO INDIVIDUALS.— 

14 (A) GENERAL NOTICE.— 

15 (i) IN GENERAL.—In the case of notices 

16 provided under section 606(4) of the Em17 ployee Retirement Income Security Act of 

18 1974 (29 U.S.C. 1166(4)), section 

19 4980B(f)(6)(D) of the Internal Revenue 

20 Code of 1986, section 2206(4) of the Public 

21 Health Service Act (42 U.S.C. 300bb–6(4)), 

22 or section 8905a(f)(2)(A) of title 5, United 

23 States Code, with respect to individuals 

24 who, during the period described in para25 graph (3)(A), become entitled to elect 


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1 COBRA continuation coverage, such notices 

2 shall include an additional notification to 

3 the recipient of the availability of premium 

4 reduction with respect to such coverage 

5 under this subsection. 

6 (ii) ALTERNATIVE NOTICE.—In the 

7 case of COBRA continuation coverage to 

8 which the notice provision under such sec9 tions does not apply, the Secretary of 

10 Labor, in consultation with the Secretary of 

11 the Treasury and the Secretary of Health 

12 and Human Services, shall, in coordination 

13 with administrators of the group health 

14 plans (or other entities) that provide or ad15 minister the COBRA continuation coverage 

16 involved, provide rules requiring the provi17 sion of such notice. 

18 (iii) FORM.—The requirement of the 

19 additional notification under this subpara20 graph may be met by amendment of exist21 ing notice forms or by inclusion of a sepa22 rate document with the notice otherwise re23 quired. 


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1 (B) SPECIFIC REQUIREMENTS.—Each addi2 tional notification under subparagraph (A) shall 

3 include— 

4 (i) the forms necessary for establishing 

5 eligibility for premium reduction under this 

6 subsection, 

7 (ii) the name, address, and telephone 

8 number necessary to contact the plan ad9 ministrator and any other person main10 taining relevant information in connection 

11 with such premium reduction, 

12 (iii) a description of the extended elec13 tion period provided for in paragraph 

14 (4)(A), 

15 (iv) a description of the obligation of 

16 the qualified beneficiary under paragraph 

17 (2)(C) to notify the plan providing continu18 ation coverage of eligibility for subsequent 

19 coverage under another group health plan 

20 or eligibility for benefits under title XVIII 

21 of the Social Security Act and the penalty 

22 provided for failure to so notify the plan, 

23 and 

24 (v) a description, displayed in a 

25 prominent manner, of the qualified beneVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00038 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 ficiary’s right to a reduced premium and 

2 any conditions on entitlement to the re3 duced premium. 

4 (C) NOTICE RELATING TO RETROACTIVE

5 COVERAGE.—In the case of an individual de6 scribed in paragraph (3)(A) who has elected 

7 COBRA continuation coverage as of the date of 

8 enactment of this Act or an individual described 

9 in paragraph (4)(A), the administrator of the 

10 group health plan (or other entity) involved shall 

11 provide (within 60 days after the date of enact12 ment of this Act) for the additional notification 

13 required to be provided under subparagraph (A). 

14 (D) MODEL NOTICES.—Not later than 30 

15 days after the date of enactment of this Act, the 

16 Secretary of the Labor, in consultation with the 

17 Secretary of the Treasury and the Secretary of 

18 Health and Human Services, shall prescribe 

19 models for the additional notification required 

20 under this paragraph. 

21 (8) SAFEGUARDS.—The Secretary of the Treas22 ury shall provide such rules, procedures, regulations, 

23 and other guidance as may be necessary and appro24 priate to prevent fraud and abuse under this sub25 section. 


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1 (9) OUTREACH.—The Secretary of Labor, in con2 sultation with the Secretary of the Treasury and the 

3 Secretary of Health and Human Services, shall pro4 vide outreach consisting of public education and en5 rollment assistance relating to premium reduction 

6 provided under this subsection. Such outreach shall 

7 target employers, group health plan administrators, 

8 public assistance programs, States, insurers, and 

9 other entities as determined appropriate by such Sec10 retaries. Such outreach shall include an initial focus 

11 on those individuals electing continuation coverage 

12 who are referred to in paragraph (7)(C). Information 

13 on such premium reduction, including enrollment, 

14 shall also be made available on website of the Depart15 ments of Labor, Treasury, and Health and Human 

16 Services. 

17 (10) DEFINITIONS.—For purposes of this sub18 section— 

19 (A) ADMINISTRATOR.—The term ‘‘adminis20 trator’’ has the meaning given such term in sec21 tion 3(16) of the Employee Retirement Income 

22 Security Act of 1974. 

23 (B) COBRA CONTINUATION COVERAGE.— 

24 The term ‘‘COBRA continuation coverage’’ 

25 means continuation coverage provided pursuant 


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1 to part 6 of subtitle B of title I of the Employee 

2 Retirement Income Security Act of 1974 (other 

3 than under section 609), title XXII of the Public 

4 Health Service Act, section 4980B of the Internal 

5 Revenue Code of 1986 (other than subsection 

6 (f)(1) of such section insofar as it relates to pedi7 atric vaccines), or section 8905a of title 5, 

8 United States Code, or under a State program 

9 that provides continuation coverage comparable 

10 to such continuation coverage. Such term does 

11 not include coverage under a health flexible 

12 spending arrangement. 

13 (C) COBRA CONTINUATION PROVISION.— 

14 The term ‘‘COBRA continuation provision’’ 

15 means the provisions of law described in sub16 paragraph (B). 

17 (D) COVERED EMPLOYEE.—The term ‘‘cov18 ered employee’’ has the meaning given such term 

19 in section 607(2) of the Employee Retirement In20 come Security Act of 1974. 

21 (E) QUALIFIED BENEFICIARY.—The term 

22 ‘‘qualified beneficiary’’ has the meaning given 

23 such term in section 607(3) of the Employee Re24 tirement Income Security Act of 1974. 


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1 (F) GROUP HEALTH PLAN.—The term 

2 ‘‘group health plan’’ has the meaning given such 

3 term in section 607(1) of the Employee Retire4 ment Income Security Act of 1974. 

5 (G) STATE.—The term ‘‘State’’ includes the 

6 District of Columbia, the Commonwealth of 

7 Puerto Rico, the Virgin Islands, Guam, Amer8 ican Samoa, and the Commonwealth of the 

9 Northern Mariana Islands. 

10 (11) REPORTS.— 

11 (A) INTERIM REPORT.—The Secretary of the 

12 Treasury shall submit an interim report to the 

13 Committee on Education and Labor, the Com14 mittee on Ways and Means, and the Committee 

15 on Energy and Commerce of the House of Rep16 resentatives and the Committee on Health, Edu17 cation, Labor, and Pensions and the Committee 

18 on Finance of the Senate regarding the premium 

19 reduction provided under this subsection that in20 cludes— 

21 (i) the number of individuals provided 

22 such assistance as of the date of the report; 

23 and 

24 (ii) the total amount of expenditures 

25 incurred (with administrative expenditures 


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1 noted separately) in connection with such 

2 assistance as of the date of the report. 

3 (B) FINAL REPORT.—As soon as practicable 

4 after the last period of COBRA continuation cov5 erage for which premium reduction is provided 

6 under this section, the Secretary of the Treasury 

7 shall submit a final report to each Committee re8 ferred to in subparagraph (A) that includes— 

9 (i) the number of individuals provided 

10 premium reduction under this section; 

11 (ii) the average dollar amount (month12 ly and annually) of premium reductions 

13 provided to such individuals; and 

14 (iii) the total amount of expenditures 

15 incurred (with administrative expenditures 

16 noted separately) in connection with pre17 mium reduction under this section. 

18 (12) COBRA PREMIUM ASSISTANCE.— 

19 (A) IN GENERAL.—Subchapter B of chapter 

20 65 of the Internal Revenue Code of 1986 is 

21 amended by adding at the end the following new 

22 section: 

23 ‘‘SEC. 6431. COBRA PREMIUM ASSISTANCE. 

24 ‘‘(a) IN GENERAL.—The entity to whom premiums are 

25 payable under COBRA continuation coverage shall be reimVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00043 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 bursed for the amount of premiums not paid by plan bene2 ficiaries by reason of section 3002(a) of the Health Insur3 ance Assistance for the Unemployed Act of 2009. Such 

4 amount shall be treated as a credit against the requirement 

5 of such entity to make deposits of payroll taxes. To the ex6 tent that such amount exceeds the amount of such taxes, 

7 the Secretary shall pay to such entity the amount of such 

8 excess. No payment may be made under this subsection to 

9 an entity with respect to any assistance eligible individual 

10 until after such entity has received the reduced premium 

11 from such individual required under section 3002(a)(1)(A) 

12 of such Act. 

13 ‘‘(b) PAYROLL TAXES.—For purposes of this section, 

14 the term ‘payroll taxes’ means— 

15 ‘‘(1) amounts required to be deducted and with16 held for the payroll period under section 3401 (relat17 ing to wage withholding), 

18 ‘‘(2) amounts required to be deducted for the 

19 payroll period under section 3102 (relating to FICA 

20 employee taxes), and 

21 ‘‘(3) amounts of the taxes imposed for the payroll 

22 period under section 3111 (relating to FICA employer 

23 taxes). 

24 ‘‘(c) TREATMENT OF CREDIT.—Except as otherwise 

25 provided by the Secretary, the credit described in subsection 


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1 (a) shall be applied as though the employer had paid to 

2 the Secretary, on the day that the qualified beneficiary’s 

3 premium payment is received, an amount equal to such 

4 credit. 

5 ‘‘(d) TREATMENT OF PAYMENT.—For purposes of sec6 tion 1324(b)(2) of title 31, United States Code, any pay7 ment under this section shall be treated in the same manner 

8 as a refund of the credit under section 35. 

9 ‘‘(e) REPORTING.— 

10 ‘‘(1) IN GENERAL.—Each entity entitled to reim11 bursement under subsection (a) for any period shall 

12 submit such reports as the Secretary may require, in13 cluding— 

14 ‘‘(A) an attestation of involuntary termi15 nation of employment for each covered employee 

16 on the basis of whose termination entitlement to 

17 reimbursement is claimed under subsection (a), 

18 and 

19 ‘‘(B) a report of the amount of payroll taxes 

20 offset under subsection (a) for the reporting pe21 riod and the estimated offsets of such taxes for 

22 the subsequent reporting period in connection 

23 with reimbursements under subsection (a). 

24 ‘‘(2) TIMING OF REPORTS RELATING TO AMOUNT

25 OF PAYROLL TAXES.—Reports required under paraVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00045 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 graph (1)(B) shall be submitted at the same time as 

2 deposits of taxes imposed by chapters 21, 22, and 24 

3 or at such time as is specified by the Secretary. 

4 ‘‘(f) REGULATIONS.—The Secretary may issue such 

5 regulations or other guidance as may be necessary or appro6 priate to carry out this section, including the requirement 

7 to report information or the establishment of other methods 

8 for verifying the correct amounts of payments and credits 

9 under this section.’’. 

10 (B) SOCIAL SECURITY TRUST FUNDS HELD

11 HARMLESS.—In determining any amount trans12 ferred or appropriated to any fund under the So13 cial Security Act, section 6431 of the Internal 

14 Revenue Code of 1986 shall not be taken into ac15 count. 

16 (C) CLERICAL AMENDMENT.—The table of 

17 sections for subchapter B of chapter 65 of the In18 ternal Revenue Code of 1986 is amended by add19 ing at the end the following new item: 

‘‘Sec. 6431. COBRA premium assistance.’’. 

20 (D) EFFECTIVE DATE.—The amendments 

21 made by this paragraph shall apply to pre22 miums to which subsection (a)(1)(A) applies. 

23 (13) PENALTY FOR FAILURE TO NOTIFY HEALTH

24 PLAN OF CESSATION OF ELIGIBILITY FOR PREMIUM

25 ASSISTANCE.— 


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1 (A) IN GENERAL.—Part I of subchapter B 

2 of chapter 68 of the Internal Revenue Code of 

3 1986 is amended by adding at the end the fol4 lowing new section: 

5 ‘‘SEC. 6720C. PENALTY FOR FAILURE TO NOTIFY HEALTH 

6 PLAN OF CESSATION OF ELIGIBILITY FOR 

7 COBRA PREMIUM ASSISTANCE. 

8 ‘‘(a) IN GENERAL.—Any person required to notify a 

9 group health plan under section 3002(a)(2)(C)) of the 

10 Health Insurance Assistance for the Unemployed Act of 

11 2009 who fails to make such a notification at such time 

12 and in such manner as the Secretary of Labor may require 

13 shall pay a penalty of 110 percent of the premium reduction 

14 provided under such section after termination of eligibility 

15 under such subsection. 

16 ‘‘(b) REASONABLE CAUSE EXCEPTION.—No penalty 

17 shall be imposed under subsection (a) with respect to any 

18 failure if it is shown that such failure is due to reasonable 

19 cause and not to willful neglect.’’. 

20 (B) CLERICAL AMENDMENT.—The table of 

21 sections of part I of subchapter B of chapter 68 

22 of such Code is amended by adding at the end 

23 the following new item: 

‘‘Sec. 6720C. Penalty for failure to notify health plan of cessation of eligibility 

for COBRA premium assistance.’’. 


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1 (C) EFFECTIVE DATE.—The amendments 

2 made by this paragraph shall apply to failures 

3 occurring after the date of the enactment of this 

4 Act. 

5 (14) COORDINATION WITH HCTC.— 

6 (A) IN GENERAL.—Subsection (g) of section 

7 35 of the Internal Revenue Code of 1986 is 

8 amended by redesignating paragraph (9) as 

9 paragraph (10) and inserting after paragraph 

10 (8) the following new paragraph: 

11 ‘‘(9) COBRA PREMIUM ASSISTANCE.—In the 

12 case of an assistance eligible individual who receives 

13 premium reduction for COBRA continuation coverage 

14 under section 3002(a) of the Health Insurance Assist15 ance for the Unemployed Act of 2009 for any month 

16 during the taxable year, such individual shall not be 

17 treated as an eligible individual, a certified indi18 vidual, or a qualifying family member for purposes 

19 of this section or section 7527 with respect to such 

20 month.’’. 

21 (B) EFFECTIVE DATE.—The amendment 

22 made by subparagraph (A) shall apply to tax23 able years ending after the date of the enactment 

24 of this Act. 


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1 (15) EXCLUSION OF COBRA PREMIUM ASSIST2 ANCE FROM GROSS INCOME.— 

3 (A) IN GENERAL.—Part III of subchapter B 

4 of chapter 1 of the Internal Revenue Code of 

5 1986 is amended by inserting after section 139B 

6 the following new section: 

7 ‘‘SEC. 139C. COBRA PREMIUM ASSISTANCE. 

8 ‘‘In the case of an assistance eligible individual (as 

9 defined in section 3002 of the Health Insurance Assistance 

10 for the Unemployed Act of 2009), gross income does not in11 clude any premium reduction provided under subsection (a) 

12 of such section.’’. 

13 (B) CLERICAL AMENDMENT.—The table of 

14 sections for part III of subchapter B of chapter 

15 1 of such Code is amended by inserting after the 

16 item relating to section 139B the following new 

17 item: 

‘‘Sec. 139C. COBRA premium assistance.’’. 

18 (C) EFFECTIVE DATE.—The amendments 

19 made by this paragraph shall apply to taxable 

20 years ending after the date of the enactment of 

21 this Act. 

22 (b) EXTENSION OF COBRA BENEFITS FOR OLDER OR

23 LONG-TERM EMPLOYEES.— 

24 (1) ERISA AMENDMENT.—Section 602(2)(A) of 

25 the Employee Retirement Income Security Act of 


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1 1974 is amended by adding at the end the following 

2 new clauses: 

3 ‘‘(x) SPECIAL RULE FOR OLDER OR

4 LONG-TERM EMPLOYEES GENERALLY.—In 

5 the case of a qualifying event described in 

6 section 603(2) with respect to a covered em7 ployee who (as of such qualifying event) has 

8 attained age 55 or has completed 10 or 

9 more years of service with the entity that is 

10 the employer at the time of the qualifying 

11 event, clauses (i) and (ii) shall not apply. 

12 ‘‘(xi) YEAR OF SERVICE.— For pur13 poses of this subparagraph, the term ‘year 

14 of service’ shall have the meaning provided 

15 in section 202(a)(3).’’. 

16 (2) IRC AMENDMENT.—Clause (i) of section 

17 4980B(f)(2)(B) of the Internal Revenue Code of 1986 

18 is amended by adding at the end the following new 

19 subclauses: 

20 ‘‘(X) SPECIAL RULE FOR OLDER

21 OR LONG-TERM EMPLOYEES GEN22 ERALLY.—In the case of a qualifying 

23 event described in paragraph (3)(B) 

24 with respect to a covered employee who 

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1 tained age 55 or has completed 10 or 

2 more years of service with the entity 

3 that is the employer at the time of the 

4 qualifying event, subclauses (I) and 

5 (II) shall not apply. 

6 ‘‘(XI) YEAR OF SERVICE.— For 

7 purposes of this clause, the term ‘year 

8 of service’ shall have the meaning pro9 vided in section 202(a)(3) of the Em10 ployee Retirement Income Security Act 

11 of 1974.’’. 

12 (3) PHSA AMENDMENT.—Section 2202(2)(A) of 

13 the Public Health Service Act is amended by adding 

14 at the end the following new clauses: 

15 ‘‘(viii) SPECIAL RULE FOR OLDER OR

16 LONG-TERM EMPLOYEES GENERALLY.—In 

17 the case of a qualifying event described in 

18 section 2203(2) with respect to a covered 

19 employee who (as of such qualifying event) 

20 has attained age 55 or has completed 10 or 

21 more years of service with the entity that is 

22 the employer at the time of the qualifying 

23 event, clauses (i) and (ii) shall not apply. 

24 ‘‘(ix) YEAR OF SERVICE.— For pur25 poses of this subparagraph, the term ‘year 


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1 of service’ shall have the meaning provided 

2 in section 202(a)(3) of the Employee Retire3 ment Income Security Act of 1974.’’. 

4 (4) EFFECTIVE DATE OF AMENDMENTS.—The 

5 amendments made by this subsection shall apply to 

6 periods of coverage which would (without regard to 

7 the amendments made by this section) end on or after 

8 the date of the enactment of this Act. 

9 SEC. 3003. TEMPORARY OPTIONAL MEDICAID COVERAGE 

10 FOR THE UNEMPLOYED. 

11 (a) IN GENERAL.—Section 1902 of the Social Security 

12 Act (42 U.S.C. 1396b) is amended— 

13 (1) in subsection (a)(10)(A)(ii)— 

14 (A) by striking ‘‘or’’ at the end of subclause 

15 (XVIII); 

16 (B) by adding ‘‘or’’ at the end of subclause 

17 (XIX); and 

18 (C) by adding at the end the following new 

19 subclause: 

20 ‘‘(XX) who are described in sub21 section (dd)(1) (relating to certain un22 employed individuals and their fami23 lies);’’; and 

24 (2) by adding at the end the following new sub25 section: 


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1 ‘‘(dd)(1) Individuals described in this paragraph 

2 are— 

3 ‘‘(A) individuals who— 

4 ‘‘(i) are within one or more of the categories de5 scribed in paragraph (2), as elected under the State 

6 plan; and 

7 ‘‘(ii) meet the applicable requirements of para8 graph (3); and 

9 ‘‘(B) individuals who— 

10 ‘‘(i) are the spouse, or dependent child under 19 

11 years of age, of an individual described in subpara12 graph (A); and 

13 ‘‘(ii) meet the requirement of paragraph (3)(B). 

14 ‘‘(2) The categories of individuals described in this 

15 paragraph are each of the following: 

16 ‘‘(A) Individuals who are receiving unemploy17 ment compensation benefits. 

18 ‘‘(B) Individuals who were receiving, but have 

19 exhausted, unemployment compensation benefits on or 

20 after July 1, 2008. 

21 ‘‘(C) Individuals who are involuntarily unem22 ployed and were involuntarily separated from em23 ployment on or after September 1, 2008, and before 

24 January 1, 2011, whose family gross income does not 

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1 ceed 200 percent) of the income official poverty line 

2 (as defined by the Office of Management and Budget, 

3 and revised annually in accordance with section 

4 673(2) of the Omnibus Budget Reconciliation Act of 

5 1981) applicable to a family of the size involved, and 

6 who, but for subsection (a)(10)(A)(ii)(XX), are not el7 igible for medical assistance under this title or health 

8 assistance under title XXI. 

9 ‘‘(D) Individuals who are involuntarily unem10 ployed and were involuntarily separated from em11 ployment on or after September 1, 2008, and before 

12 January 1, 2011, who are members of households par13 ticipating in the supplemental nutrition assistance 

14 program established under the Food and Nutrition 

15 Act of 2008 (7 U.S.C. 2011 et seq), and who, but for 

16 subsection (a)(10)(A)(ii)(XX), are not eligible for 

17 medical assistance under this title or health assistance 

18 under title XXI. 

19 A State plan may elect one or more of the categories de20 scribed in this paragraph but may not elect the category 

21 described in subparagraph (B) unless the State plan also 

22 elects the category described in subparagraph (A). 

23 ‘‘(3) The requirements of this paragraph with respect 

24 to an individual are the following: 


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1 ‘‘(A) In the case of individuals within a category 

2 described in subparagraph (A) or (B) of paragraph 

3 (2), the individual was involuntarily separated from 

4 employment on or after September 1, 2008, and before 

5 January 1, 2011, or meets such comparable require6 ment as the Secretary specifies through rule, guid7 ance, or otherwise in the case of an individual who 

8 was an independent contractor. 

9 ‘‘(B) The individual is not otherwise covered 

10 under creditable coverage, as defined in section 

11 2701(c) of the Public Health Service Act (42 U.S.C. 

12 300gg(c)), but applied without regard to paragraph 

13 (1)(F) of such section and without regard to coverage 

14 provided by reason of the application of subsection 

15 (a)(10)(A)(ii)(XX). 

16 ‘‘(4)(A) No income or resources test shall be applied 

17 with respect to any category of individuals described in sub18 paragraph (A), (B), or (D) of paragraph (2) who are eligi19 ble for medical assistance only by reason of the application 

20 of subsection (a)(10)(A)(ii)(XX). 

21 ‘‘(B) Nothing in this subsection shall be construed to 

22 prevent a State from imposing a resource test for the cat23 egory of individuals described in paragraph (2)(C)). 

24 ‘‘(C) In the case of individuals provided medical as25 sistance by reason of the application of subsection 


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1 (a)(10)(A)(ii)(XX), the requirements of subsections (i)(22) 

2 and (x) shall not apply.’’. 

3 (b) 100 PERCENT FEDERAL MATCHING RATE.— 

4 (1) FMAP FOR TIME-LIMITED PERIOD.—The 

5 third sentence of section 1905(b) of such Act (42 

6 U.S.C. 1396d(b)) is amended by inserting before the 

7 period at the end the following: ‘‘and for items and 

8 services furnished on or after the date of enactment of 

9 this Act and before January 1, 2011, to individuals 

10 who are eligible for medical assistance only by reason 

11 of the application of section 1902(a)(10)(A)(ii)(XX)’’. 

12 (2) CERTAIN ENROLLMENT-RELATED ADMINIS13 TRATIVE COSTS.—Notwithstanding any other provi14 sion of law, for purposes of applying section 1903(a) 

15 of the Social Security Act (42 U.S.C. 1396b(a)), with 

16 respect to expenditures incurred on or after the date 

17 of the enactment of this Act and before January 1, 

18 2011, for costs of administration (including outreach 

19 and the modification and operation of eligibility in20 formation systems) attributable to eligibility deter21 mination and enrollment of individuals who are eligi22 ble for medical assistance only by reason of the appli23 cation of section 1902(a)(10)(A)(ii)(XX) of such Act, 

24 as added by subsection (a)(1), the Federal matching 


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1 percentage shall be 100 percent instead of the match2 ing percentage otherwise applicable. 

3 (c) CONFORMING AMENDMENTS.—(1) Section 

4 1903(f)(4) of such Act (42 U.S.C. 1396c(f)(4)) is amended 

5 by inserting ‘‘1902(a)(10)(A)(ii)(XX), or’’ after 

6 ‘‘1902(a)(10)(A)(ii)(XIX),’’. 

7 (2) Section 1905(a) of such Act (42 U.S.C. 1396d(a)) 

8 is amended, in the matter preceding paragraph (1)— 

9 (A) by striking ‘‘or’’ at the end of clause (xii); 

10 (B) by adding ‘‘or’’ at the end of clause (xiii); 

11 and 

12 (C) by inserting after clause (xiii) the following 

13 new clause: 

14 ‘‘(xiv) individuals described in section 

15 1902(dd)(1),’’. 

16 TITLE IV—HEALTH 

17 INFORMATION TECHNOLOGY 

18 SEC. 4001. SHORT TITLE; TABLE OF CONTENTS OF TITLE. 

19 (a) SHORT TITLE.—This title may be cited as the 

20 ‘‘Health Information Technology for Economic and Clinical 

21 Health Act’’ or the ‘‘HITECH Act’’. 

22 (b) TABLE OF CONTENTS OF TITLE.—The table of con23 tents of this title is as follows: 

Sec. 4001. Short title; table of contents of title. 


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Subtitle A—Promotion of Health Information Technology 

PART I—IMPROVING HEALTH CARE QUALITY, SAFETY, AND EFFICIENCY

Sec. 4101. ONCHIT; standards development and adoption. 

‘‘TITLE XXX—HEALTH INFORMATION TECHNOLOGY AND QUALITY 

‘‘Sec. 3000. Definitions. 

‘‘Subtitle A—Promotion of Health Information Technology 

‘‘Sec. 3001. Office of the National Coordinator for Health Information Technology. 

‘‘Sec. 3002. HIT Policy Committee. 

‘‘Sec. 3003. HIT Standards Committee. 

‘‘Sec. 3004. Process for adoption of endorsed recommendations; adoption of 

initial set of standards, implementation specifications, and 

certification criteria. 

‘‘Sec. 3005. Application and use of adopted standards and implementation 

specifications by Federal agencies. 

‘‘Sec. 3006. Voluntary application and use of adopted standards and implementation specifications by private entities. 

‘‘Sec. 3007. Federal health information technology. 

‘‘Sec. 3008. Transitions. 

‘‘Sec. 3009. Relation to HIPAA privacy and security law. 

‘‘Sec. 3010. Authorization for appropriations. 

Sec. 4102. Technical amendment. 

Sec. 4103. American technology required. 

PART II—APPLICATION AND USE OF ADOPTED HEALTH INFORMATION

TECHNOLOGY STANDARDS; REPORTS

Sec. 4111. Coordination of Federal activities with adopted standards and implementation specifications. 

Sec. 4112. Application to private entities. 

Sec. 4113. Study and reports. 

Subtitle B—Testing of Health Information Technology 

Sec. 4201. National Institute for Standards and Technology testing. 

Sec. 4202. Research and development programs. 

Subtitle C—Incentives for the Use of Health Information Technology 

PART I—GRANTS AND LOANS FUNDING

Sec. 4301. Grant, loan, and demonstration programs. 

‘‘Subtitle B—Incentives for the Use of Health Information Technology 

‘‘Sec. 3011. Immediate funding to strengthen the health information technology infrastructure. 

‘‘Sec. 3012. Health information technology implementation assistance. 

‘‘Sec. 3013. State grants to promote health information technology. 

‘‘Sec. 3014. Competitive grants to States and Indian tribes for the development of loan programs to facilitate the widespread adoption 

of certified EHR technology. 


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‘‘Sec. 3015. Demonstration program to integrate information technology into 

clinical education. 

‘‘Sec. 3016. Information technology professionals on health care. 

‘‘Sec. 3017. General grant and loan provisions. 

‘‘Sec. 3018. Authorization for appropriations. 

PART II—MEDICARE PROGRAM

Sec. 4311. Incentives for eligible professionals. 

Sec. 4312. Incentives for hospitals. 

Sec. 4313. Treatment of payments and savings; implementation funding. 

Sec. 4314. Study on application of EHR payment incentives for providers not receiving other incentive payments. 

PART III—MEDICAID FUNDING

Sec. 4321. Medicaid provider HIT adoption and operation payments; implementation funding. 

Subtitle D—Privacy 

Sec. 4400. Definitions. 

PART I—IMPROVED PRIVACY PROVISIONS AND SECURITY PROVISIONS

Sec. 4401. Application of security provisions and penalties to business associates 

of covered entities; annual guidance on security provisions. 

Sec. 4402. Notification in the case of breach. 

Sec. 4403. Education on Health Information Privacy. 

Sec. 4404. Application of privacy provisions and penalties to business associates 

of covered entities. 

Sec. 4405. Restrictions on certain disclosures and sales of health information; accounting of certain protected health information disclosures; access to certain information in electronic format. 

Sec. 4406. Conditions on certain contacts as part of health care operations. 

Sec. 4407. Temporary breach notification requirement for vendors of personal 

health records and other non-HIPAA covered entities. 

Sec. 4408. Business associate contracts required for certain entities. 

Sec. 4409. Clarification of application of wrongful disclosures criminal penalties. 

Sec. 4410. Improved enforcement. 

Sec. 4411. Audits. 

Sec. 4412. Securing individually identifiable health information. 

Sec. 4413. Special rule for information to reduce medication errors and improve 

patient safety. 

PART II—RELATIONSHIP TO OTHER LAWS; REGULATORY REFERENCES; 

EFFECTIVE DATE; REPORTS

Sec. 4421. Relationship to other laws. 

Sec. 4422. Regulatory references. 

Sec. 4423. Effective date. 

Sec. 4424. Studies, reports, guidance. 


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1 Subtitle A—Promotion of Health 

2 Information Technology 

3 PART 1—IMPROVING HEALTH CARE QUALITY, 

4 SAFETY, AND EFFICIENCY 

5 SEC. 4101. ONCHIT; STANDARDS DEVELOPMENT AND ADOP6 TION. 

7 The Public Health Service Act (42 U.S.C. 201 et seq.) 

8 is amended by adding at the end the following: 

9 ‘‘TITLE XXX—HEALTH INFORMA10 TION TECHNOLOGY AND 

11 QUALITY 

12 ‘‘SEC. 3000. DEFINITIONS. 

13 ‘‘In this title: 

14 ‘‘(1) CERTIFIED EHR TECHNOLOGY.—The term 

15 ‘certified EHR technology’ means a qualified elec16 tronic health record that is certified pursuant to sec17 tion 3001(c)(5) as meeting standards adopted under 

18 section 3004 that are applicable to the type of record 

19 involved (as determined by the Secretary, such as an 

20 ambulatory electronic health record for office-based 

21 physicians or an inpatient hospital electronic health 

22 record for hospitals). 

23 ‘‘(2) ENTERPRISE INTEGRATION.—The term ‘en24 terprise integration’ means the electronic linkage of 

25 health care providers, health plans, the government, 


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1 and other interested parties, to enable the electronic 

2 exchange and use of health information among all the 

3 components in the health care infrastructure in ac4 cordance with applicable law, and such term includes 

5 related application protocols and other related stand6 ards. 

7 ‘‘(3) HEALTH CARE PROVIDER.—The term 

8 ‘health care provider’ means a hospital, skilled nurs9 ing facility, nursing facility, home health entity or 

10 other long term care facility, health care clinic, Feder11 ally qualified health center, group practice (as defined 

12 in section 1877(h)(4) of the Social Security Act), a 

13 pharmacist, a pharmacy, a laboratory, a physician 

14 (as defined in section 1861(r) of the Social Security 

15 Act), a practitioner (as described in section 

16 1842(b)(18)(C) of the Social Security Act), a provider 

17 operated by, or under contract with, the Indian 

18 Health Service or by an Indian tribe (as defined in 

19 the Indian Self-Determination and Education Assist20 ance Act), tribal organization, or urban Indian orga21 nization (as defined in section 4 of the Indian Health 

22 Care Improvement Act), a rural health clinic, a cov23 ered entity under section 340B, an ambulatory sur24 gical center described in section 1833(i) of the Social 


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1 Security Act, and any other category of facility or 

2 clinician determined appropriate by the Secretary. 

3 ‘‘(4) HEALTH INFORMATION.—The term ‘health 

4 information’ has the meaning given such term in sec5 tion 1171(4) of the Social Security Act. 

6 ‘‘(5) HEALTH INFORMATION TECHNOLOGY.—The 

7 term ‘health information technology’ means hardware, 

8 software, integrated technologies and related licenses, 

9 intellectual property, upgrades, and packaged solu10 tions sold as services that are specifically designed for 

11 use by health care entities for the electronic creation, 

12 maintenance, or exchange of health information. 

13 ‘‘(6) HEALTH PLAN.—The term ‘health plan’ has 

14 the meaning given such term in section 1171(5) of the 

15 Social Security Act. 

16 ‘‘(7) HIT POLICY COMMITTEE.—The term ‘HIT 

17 Policy Committee’ means such Committee established 

18 under section 3002(a). 

19 ‘‘(8) HIT STANDARDS COMMITTEE.—The term 

20 ‘HIT Standards Committee’ means such Committee 

21 established under section 3003(a). 

22 ‘‘(9) INDIVIDUALLY IDENTIFIABLE HEALTH IN23 FORMATION.—The term ‘individually identifiable 

24 health information’ has the meaning given such term 

25 in section 1171(6) of the Social Security Act. 


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1 ‘‘(10) LABORATORY.—The term ‘laboratory’ has 

2 the meaning given such term in section 353(a). 

3 ‘‘(11) NATIONAL COORDINATOR.—The term ‘Na4 tional Coordinator’ means the head of the Office of the 

5 National Coordinator for Health Information Tech6 nology established under section 3001(a). 

7 ‘‘(12) PHARMACIST.—The term ‘pharmacist’ has 

8 the meaning given such term in section 804(2) of the 

9 Federal Food, Drug, and Cosmetic Act. 

10 ‘‘(13) QUALIFIED ELECTRONIC HEALTH

11 RECORD.—The term ‘qualified electronic health 

12 record’ means an electronic record of health-related 

13 information on an individual that— 

14 ‘‘(A) includes patient demographic and 

15 clinical health information, such as medical his16 tory and problem lists; and 

17 ‘‘(B) has the capacity— 

18 ‘‘(i) to provide clinical decision sup19 port; 

20 ‘‘(ii) to support physician order entry; 

21 ‘‘(iii) to capture and query informa22 tion relevant to health care quality; and 

23 ‘‘(iv) to exchange electronic health in24 formation with, and integrate such infor25 mation from other sources. 


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1 ‘‘(14) STATE.—The term ‘State’ means each of 

2 the several States, the District of Columbia, Puerto 

3 Rico, the Virgin Islands, Guam, American Samoa, 

4 and the Northern Mariana Islands. 

5 ‘‘Subtitle A—Promotion of Health 

6 Information Technology 

7 ‘‘SEC. 3001. OFFICE OF THE NATIONAL COORDINATOR FOR 

8 HEALTH INFORMATION TECHNOLOGY. 

9 ‘‘(a) ESTABLISHMENT.—There is established within 

10 the Department of Health and Human Services an Office 

11 of the National Coordinator for Health Information Tech12 nology (referred to in this section as the ‘Office’). The Office 

13 shall be headed by a National Coordinator who shall be ap14 pointed by the Secretary and shall report directly to the 

15 Secretary. 

16 ‘‘(b) PURPOSE.—The National Coordinator shall per17 form the duties under subsection (c) in a manner consistent 

18 with the development of a nationwide health information 

19 technology infrastructure that allows for the electronic use 

20 and exchange of information and that— 

21 ‘‘(1) ensures that each patient’s health informa22 tion is secure and protected, in accordance with ap23 plicable law; 


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1 ‘‘(2) improves health care quality, reduces med2 ical errors, reduces health disparities, and advances 

3 the delivery of patient-centered medical care; 

4 ‘‘(3) reduces health care costs resulting from inef5 ficiency, medical errors, inappropriate care, duplica6 tive care, and incomplete information; 

7 ‘‘(4) provides appropriate information to help 

8 guide medical decisions at the time and place of care; 

9 ‘‘(5) ensures the inclusion of meaningful public 

10 input in such development of such infrastructure; 

11 ‘‘(6) improves the coordination of care and infor12 mation among hospitals, laboratories, physician of13 fices, and other entities through an effective infra14 structure for the secure and authorized exchange of 

15 health care information; 

16 ‘‘(7) improves public health activities and facili17 tates the early identification and rapid response to 

18 public health threats and emergencies, including bio19 terror events and infectious disease outbreaks; 

20 ‘‘(8) facilitates health and clinical research and 

21 health care quality; 

22 ‘‘(9) promotes prevention of chronic diseases; 

23 ‘‘(10) promotes a more effective marketplace, 

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1 creased consumer choice, and improved outcomes in 

2 health care services; and 

3 ‘‘(11) improves efforts to reduce health dispari4 ties. 

5 ‘‘(c) DUTIES OF THE NATIONAL COORDINATOR.— 

6 ‘‘(1) STANDARDS.—The National Coordinator 

7 shall review and determine whether to endorse each 

8 standard, implementation specification, and certifi9 cation criterion for the electronic exchange and use of 

10 health information that is recommended by the HIT 

11 Standards Committee under section 3003 for purposes 

12 of adoption under section 3004. The Coordinator shall 

13 make such determination, and report to the Secretary 

14 such determination, not later than 45 days after the 

15 date the recommendation is received by the Coordi16 nator. 

17 ‘‘(2) HIT POLICY COORDINATION.— 

18 ‘‘(A) IN GENERAL.—The National Coordi19 nator shall coordinate health information tech20 nology policy and programs of the Department 

21 with those of other relevant executive branch 

22 agencies with a goal of avoiding duplication of 

23 efforts and of helping to ensure that each agency 

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1 pertise and technical capability and in a man2 ner towards a coordinated national goal. 

3 ‘‘(B) HIT POLICY AND STANDARDS COMMIT4 TEES.—The National Coordinator shall be a 

5 leading member in the establishment and oper6 ations of the HIT Policy Committee and the 

7 HIT Standards Committee and shall serve as a 

8 liaison among those two Committees and the 

9 Federal Government. 

10 ‘‘(3) STRATEGIC PLAN.— 

11 ‘‘(A) IN GENERAL.—The National Coordi12 nator shall, in consultation with other appro13 priate Federal agencies (including the National 

14 Institute of Standards and Technology), update 

15 the Federal Health IT Strategic Plan (developed 

16 as of June 3, 2008) to include specific objectives, 

17 milestones, and metrics with respect to the fol18 lowing: 

19 ‘‘(i) The electronic exchange and use of 

20 health information and the enterprise inte21 gration of such information. 

22 ‘‘(ii) The utilization of an electronic 

23 health record for each person in the United 

24 States by 2014. 


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1 ‘‘(iii) The incorporation of privacy 

2 and security protections for the electronic 

3 exchange of an individual’s individually 

4 identifiable health information. 

5 ‘‘(iv) Ensuring security methods to en6 sure appropriate authorization and elec7 tronic authentication of health information 

8 and specifying technologies or methodologies 

9 for rendering health information unusable, 

10 unreadable, or indecipherable. 

11 ‘‘(v) Specifying a framework for co12 ordination and flow of recommendations 

13 and policies under this subtitle among the 

14 Secretary, the National Coordinator, the 

15 HIT Policy Committee, the HIT Standards 

16 Committee, and other health information 

17 exchanges and other relevant entities. 

18 ‘‘(vi) Methods to foster the public un19 derstanding of health information tech20 nology. 

21 ‘‘(vii) Strategies to enhance the use of 

22 health information technology in improving 

23 the quality of health care, reducing medical 

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1 ing public health, and improving the con2 tinuity of care among health care settings. 

3 ‘‘(B) COLLABORATION.—The strategic plan 

4 shall be updated through collaboration of public 

5 and private entities. 

6 ‘‘(C) MEASURABLE OUTCOME GOALS.—The 

7 strategic plan update shall include measurable 

8 outcome goals. 

9 ‘‘(D) PUBLICATION.—The National Coordi10 nator shall republish the strategic plan, includ11 ing all updates. 

12 ‘‘(4) WEBSITE.—The National Coordinator shall 

13 maintain and frequently update an Internet website 

14 on which there is posted information on the work, 

15 schedules, reports, recommendations, and other infor16 mation to ensure transparency in promotion of a na17 tionwide health information technology infrastruc18 ture. 

19 ‘‘(5) CERTIFICATION.— 

20 ‘‘(A) IN GENERAL.—The National Coordi21 nator, in consultation with the Director of the 

22 National Institute of Standards and Technology, 

23 shall develop a program (either directly or by 

24 contract) for the voluntary certification of health 

25 information technology as being in compliance 


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1 with applicable certification criteria adopted 

2 under this subtitle. Such program shall include 

3 testing of the technology in accordance with sec4 tion 4201(b) of the HITECH Act. 

5 ‘‘(B) CERTIFICATION CRITERIA DE6 SCRIBED.—In this title, the term ‘certification 

7 criteria’ means, with respect to standards and 

8 implementation specifications for health infor9 mation technology, criteria to establish that the 

10 technology meets such standards and implemen11 tation specifications. 

12 ‘‘(6) REPORTS AND PUBLICATIONS.— 

13 ‘‘(A) REPORT ON ADDITIONAL FUNDING OR

14 AUTHORITY NEEDED.—Not later than 12 months 

15 after the date of the enactment of this title, the 

16 National Coordinator shall submit to the appro17 priate committees of jurisdiction of the House of 

18 Representatives and the Senate a report on any 

19 additional funding or authority the Coordinator 

20 or the HIT Policy Committee or HIT Standards 

21 Committee requires to evaluate and develop 

22 standards, implementation specifications, and 

23 certification criteria, or to achieve full participa24 tion of stakeholders in the adoption of a nation25 wide health information technology infrastrucVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00070 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 ture that allows for the electronic use and ex2 change of health information. 

3 ‘‘(B) IMPLEMENTATION REPORT.—The Na4 tional Coordinator shall prepare a report that 

5 identifies lessons learned from major public and 

6 private health care systems in their implementa7 tion of health information technology, including 

8 information on whether the technologies and 

9 practices developed by such systems may be ap10 plicable to and usable in whole or in part by 

11 other health care providers. 

12 ‘‘(C) ASSESSMENT OF IMPACT OF HIT ON

13 COMMUNITIES WITH HEALTH DISPARITIES AND

14 UNINSURED, UNDERINSURED, AND MEDICALLY

15 UNDERSERVED AREAS.—The National Coordi16 nator shall assess and publish the impact of 

17 health information technology in communities 

18 with health disparities and in areas with a high 

19 proportion of individuals who are uninsured, 

20 underinsured, and medically underserved indi21 viduals (including urban and rural areas) and 

22 identify practices to increase the adoption of 

23 such technology by health care providers in such 

24 communities. 


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1 ‘‘(D) EVALUATION OF BENEFITS AND COSTS

2 OF THE ELECTRONIC USE AND EXCHANGE OF

3 HEALTH INFORMATION.—The National Coordi4 nator shall evaluate and publish evidence on the 

5 benefits and costs of the electronic use and ex6 change of health information and assess to whom 

7 these benefits and costs accrue. 

8 ‘‘(E) RESOURCE REQUIREMENTS.—The Na9 tional Coordinator shall estimate and publish re10 sources required annually to reach the goal of 

11 utilization of an electronic health record for each 

12 person in the United States by 2014, including 

13 the required level of Federal funding, expecta14 tions for regional, State, and private investment, 

15 and the expected contributions by volunteers to 

16 activities for the utilization of such records. 

17 ‘‘(7) ASSISTANCE.—The National Coordinator 

18 may provide financial assistance to consumer advo19 cacy groups and not-for-profit entities that work in 

20 the public interest for purposes of defraying the cost 

21 to such groups and entities to participate under, 

22 whether in whole or in part, the National Technology 

23 Transfer Act of 1995 (15 U.S.C. 272 note). 

24 ‘‘(8) GOVERNANCE FOR NATIONWIDE HEALTH IN25 FORMATION NETWORK.—The National Coordinator 


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1 shall establish a governance mechanism for the na2 tionwide health information network. 

3 ‘‘(d) DETAIL OF FEDERAL EMPLOYEES.— 

4 ‘‘(1) IN GENERAL.—Upon the request of the Na5 tional Coordinator, the head of any Federal agency is 

6 authorized to detail, with or without reimbursement 

7 from the Office, any of the personnel of such agency 

8 to the Office to assist it in carrying out its duties 

9 under this section. 

10 ‘‘(2) EFFECT OF DETAIL.—Any detail of per11 sonnel under paragraph (1) shall— 

12 ‘‘(A) not interrupt or otherwise affect the 

13 civil service status or privileges of the Federal 

14 employee; and 

15 ‘‘(B) be in addition to any other staff of the 

16 Department employed by the National Coordi17 nator. 

18 ‘‘(3) ACCEPTANCE OF DETAILEES.—Notwith19 standing any other provision of law, the Office may 

20 accept detailed personnel from other Federal agencies 

21 without regard to whether the agency described under 

22 paragraph (1) is reimbursed. 

23 ‘‘(e) CHIEF PRIVACY OFFICER OF THE OFFICE OF THE

24 NATIONAL COORDINATOR.—Not later than 12 months after 

25 the date of the enactment of this title, the Secretary shall 


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1 appoint a Chief Privacy Officer of the Office of the National 

2 Coordinator, whose duty it shall be to advise the National 

3 Coordinator on privacy, security, and data stewardship of 

4 electronic health information and to coordinate with other 

5 Federal agencies (and similar privacy officers in such agen6 cies), with State and regional efforts, and with foreign 

7 countries with regard to the privacy, security, and data 

8 stewardship of electronic individually identifiable health 

9 information. 

10 ‘‘SEC. 3002. HIT POLICY COMMITTEE. 

11 ‘‘(a) ESTABLISHMENT.—There is established a HIT 

12 Policy Committee to make policy recommendations to the 

13 National Coordinator relating to the implementation of a 

14 nationwide health information technology infrastructure, 

15 including implementation of the strategic plan described in 

16 section 3001(c)(3). 

17 ‘‘(b) DUTIES.— 

18 ‘‘(1) RECOMMENDATIONS ON HEALTH INFORMA19 TION TECHNOLOGY INFRASTRUCTURE.—The HIT Pol20 icy Committee shall recommend a policy framework 

21 for the development and adoption of a nationwide 

22 health information technology infrastructure that per23 mits the electronic exchange and use of health infor24 mation as is consistent with the strategic plan under 

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1 tions under paragraph (2). The Committee shall up2 date such recommendations and make new rec3 ommendations as appropriate. 

4 ‘‘(2) SPECIFIC AREAS OF STANDARD DEVELOP5 MENT.— 

6 ‘‘(A) IN GENERAL.—The HIT Policy Com7 mittee shall recommend the areas in which 

8 standards, implementation specifications, and 

9 certification criteria are needed for the electronic 

10 exchange and use of health information for pur11 poses of adoption under section 3004 and shall 

12 recommend an order of priority for the develop13 ment, harmonization, and recognition of such 

14 standards, specifications, and certification cri15 teria among the areas so recommended. Such 

16 standards and implementation specifications 

17 shall include named standards, architectures, 

18 and software schemes for the authentication and 

19 security of individually identifiable health infor20 mation and other information as needed to en21 sure the reproducible development of common so22 lutions across disparate entities. 

23 ‘‘(B) AREAS REQUIRED FOR CONSIDER24 ATION.—For purposes of subparagraph (A), the 


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1 HIT Policy Committee shall make recommenda2 tions for at least the following areas: 

3 ‘‘(i) Technologies that protect the pri4 vacy of health information and promote se5 curity in a qualified electronic health 

6 record, including for the segmentation and 

7 protection from disclosure of specific and 

8 sensitive individually identifiable health in9 formation with the goal of minimizing the 

10 reluctance of patients to seek care (or dis11 close information about a condition) be12 cause of privacy concerns, in accordance 

13 with applicable law, and for the use and 

14 disclosure of limited data sets of such infor15 mation. 

16 ‘‘(ii) A nationwide health information 

17 technology infrastructure that allows for the 

18 electronic use and accurate exchange of 

19 health information. 

20 ‘‘(iii) The utilization of a certified elec21 tronic health record for each person in the 

22 United States by 2014. 

23 ‘‘(iv) Technologies that as a part of a 

24 qualified electronic health record allow for 

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1 ered entity (as defined for purposes of regu2 lations promulgated under section 264(c) of 

3 the Health Insurance Portability and Ac4 countability Act of 1996) for purposes of 

5 treatment, payment, and health care oper6 ations (as such terms are defined for pur7 poses of such regulations). 

8 ‘‘(v) The use of certified electronic 

9 health records to improve the quality of 

10 health care, such as by promoting the co11 ordination of health care and improving 

12 continuity of health care among health care 

13 providers, by reducing medical errors, by 

14 improving population health, by reducing 

15 health disparities, and by advancing re16 search and education. 

17 ‘‘(C) OTHER AREAS FOR CONSIDERATION.— 

18 In making recommendations under subpara19 graph (A), the HIT Policy Committee may con20 sider the following additional areas: 

21 ‘‘(i) The appropriate uses of a nation22 wide health information infrastructure, in23 cluding for purposes of— 

24 ‘‘(I) the collection of quality data 

25 and public reporting; 


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1 ‘‘(II) biosurveillance and public 

2 health; 

3 ‘‘(III) medical and clinical re4 search; and 

5 ‘‘(IV) drug safety. 

6 ‘‘(ii) Self-service technologies that fa7 cilitate the use and exchange of patient in8 formation and reduce wait times. 

9 ‘‘(iii) Telemedicine technologies, in 

10 order to reduce travel requirements for pa11 tients in remote areas. 

12 ‘‘(iv) Technologies that facilitate home 

13 health care and the monitoring of patients 

14 recuperating at home. 

15 ‘‘(v) Technologies that help reduce med16 ical errors. 

17 ‘‘(vi) Technologies that facilitate the 

18 continuity of care among health settings. 

19 ‘‘(vii) Technologies that meet the needs 

20 of diverse populations. 

21 ‘‘(viii) Any other technology that the 

22 HIT Policy Committee finds to be among 

23 the technologies with the greatest potential 

24 to improve the quality and efficiency of 

25 health care. 


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1 ‘‘(3) FORUM.—The HIT Policy Committee shall 

2 serve as a forum for broad stakeholder input with spe3 cific expertise in policies relating to the matters de4 scribed in paragraphs (1) and (2). 

5 ‘‘(c) MEMBERSHIP AND OPERATIONS.— 

6 ‘‘(1) IN GENERAL.—The National Coordinator 

7 shall provide leadership in the establishment and op8 erations of the HIT Policy Committee. 

9 ‘‘(2) MEMBERSHIP.—The membership of the HIT 

10 Policy Committee shall at least reflect providers, an11 cillary healthcare workers, consumers, purchasers, 

12 health plans, technology vendors, researchers, relevant 

13 Federal agencies, and individuals with technical ex14 pertise on health care quality, privacy and security, 

15 and on the electronic exchange and use of health in16 formation. 

17 ‘‘(3) CONSIDERATION.—The National Coordi18 nator shall ensure that the relevant recommendations 

19 and comments from the National Committee on Vital 

20 and Health Statistics are considered in the develop21 ment of policies. 

22 ‘‘(d) APPLICATION OF FACA.—The Federal Advisory 

23 Committee Act (5 U.S.C. App.), other than section 14 of 

24 such Act, shall apply to the HIT Policy Committee. 


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1 ‘‘(e) PUBLICATION.—The Secretary shall provide for 

2 publication in the Federal Register and the posting on the 

3 Internet website of the Office of the National Coordinator 

4 for Health Information Technology of all policy rec5 ommendations made by the HIT Policy Committee under 

6 this section. 

7 ‘‘SEC. 3003. HIT STANDARDS COMMITTEE. 

8 ‘‘(a) ESTABLISHMENT.—There is established a com9 mittee to be known as the HIT Standards Committee to 

10 recommend to the National Coordinator standards, imple11 mentation specifications, and certification criteria for the 

12 electronic exchange and use of health information for pur13 poses of adoption under section 3004, consistent with the 

14 implementation of the strategic plan described in section 

15 3001(c)(3) and beginning with the areas listed in section 

16 3002(b)(2)(B) in accordance with policies developed by the 

17 HIT Policy Committee. 

18 ‘‘(b) DUTIES.— 

19 ‘‘(1) STANDARDS DEVELOPMENT.— 

20 ‘‘(A) IN GENERAL.—The HIT Standards 

21 Committee shall recommend to the National Co22 ordinator standards, implementation specifica23 tions, and certification criteria described in sub24 section (a) that have been developed, harmonized, 

25 or recognized by the HIT Standards Committee. 


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1 The HIT Standards Committee shall update 

2 such recommendations and make new rec3 ommendations as appropriate, including in re4 sponse to a notification sent under section 

5 3004(b)(2). Such recommendations shall be con6 sistent with the latest recommendations made by 

7 the HIT Policy Committee. 

8 ‘‘(B) PILOT TESTING OF STANDARDS AND

9 IMPLEMENTATION SPECIFICATIONS.—In the de10 velopment, harmonization, or recognition of 

11 standards and implementation specifications, the 

12 HIT Standards Committee shall, as appropriate, 

13 provide for the testing of such standards and 

14 specifications by the National Institute for 

15 Standards and Technology under section 4201 of 

16 the HITECH Act. 

17 ‘‘(C) CONSISTENCY.—The standards, imple18 mentation specifications, and certification cri19 teria recommended under this subsection shall be 

20 consistent with the standards for information 

21 transactions and data elements adopted pursu22 ant to section 1173 of the Social Security Act. 

23 ‘‘(2) FORUM.—The HIT Standards Committee 

24 shall serve as a forum for the participation of a broad 

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1 ment, harmonization, and recognition of standards, 

2 implementation specifications, and certification cri3 teria necessary for the development and adoption of 

4 a nationwide health information technology infra5 structure that allows for the electronic use and ex6 change of health information. 

7 ‘‘(3) SCHEDULE.—Not later than 90 days after 

8 the date of the enactment of this title, the HIT Stand9 ards Committee shall develop a schedule for the assess10 ment of policy recommendations developed by the 

11 HIT Policy Committee under section 3002. The HIT 

12 Standards Committee shall update such schedule an13 nually. The Secretary shall publish such schedule in 

14 the Federal Register. 

15 ‘‘(4) PUBLIC INPUT.—The HIT Standards Com16 mittee shall conduct open public meetings and develop 

17 a process to allow for public comment on the schedule 

18 described in paragraph (3) and recommendations de19 scribed in this subsection. Under such process com20 ments shall be submitted in a timely manner after the 

21 date of publication of a recommendation under this 

22 subsection. 

23 ‘‘(c) MEMBERSHIP AND OPERATIONS.— 


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1 ‘‘(1) IN GENERAL.—The National Coordinator 

2 shall provide leadership in the establishment and op3 erations of the HIT Standards Committee. 

4 ‘‘(2) MEMBERSHIP.—The membership of the HIT 

5 Standards Committee shall at least reflect providers, 

6 ancillary healthcare workers, consumers, purchasers, 

7 health plans, technology vendors, researchers, relevant 

8 Federal agencies, and individuals with technical ex9 pertise on health care quality, privacy and security, 

10 and on the electronic exchange and use of health in11 formation. 

12 ‘‘(3) CONSIDERATION.—The National Coordi13 nator shall ensure that the relevant recommendations 

14 and comments from the National Committee on Vital 

15 and Health Statistics are considered in the develop16 ment of standards. 

17 ‘‘(4) ASSISTANCE.—For the purposes of carrying 

18 out this section, the Secretary may provide or ensure 

19 that financial assistance is provided by the HIT 

20 Standards Committee to defray in whole or in part 

21 any membership fees or dues charged by such Com22 mittee to those consumer advocacy groups and not for 

23 profit entities that work in the public interest as a 

24 part of their mission. 


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1 ‘‘(d) APPLICATION OF FACA.—The Federal Advisory 

2 Committee Act (5 U.S.C. App.), other than section 14, shall 

3 apply to the HIT Standards Committee. 

4 ‘‘(e) PUBLICATION.—The Secretary shall provide for 

5 publication in the Federal Register and the posting on the 

6 Internet website of the Office of the National Coordinator 

7 for Health Information Technology of all recommendations 

8 made by the HIT Standards Committee under this section. 

9 ‘‘SEC. 3004. PROCESS FOR ADOPTION OF ENDORSED REC10 OMMENDATIONS; ADOPTION OF INITIAL SET 

11 OF STANDARDS, IMPLEMENTATION SPECI12 FICATIONS, AND CERTIFICATION CRITERIA. 

13 ‘‘(a) PROCESS FOR ADOPTION OF ENDORSED REC14 OMMENDATIONS.— 

15 ‘‘(1) REVIEW OF ENDORSED STANDARDS, IMPLE16 MENTATION SPECIFICATIONS, AND CERTIFICATION CRI17 TERIA.—Not later than 90 days after the date of re18 ceipt of standards, implementation specifications, or 

19 certification criteria endorsed under section 3001(c), 

20 the Secretary, in consultation with representatives of 

21 other relevant Federal agencies, shall jointly review 

22 such standards, implementation specifications, or cer23 tification criteria and shall determine whether or not 

24 to propose adoption of such standards, implementa25 tion specifications, or certification criteria. 


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1 ‘‘(2) DETERMINATION TO ADOPT STANDARDS, IM2 PLEMENTATION SPECIFICATIONS, AND CERTIFICATION

3 CRITERIA.—If the Secretary determines— 

4 ‘‘(A) to propose adoption of any grouping of 

5 such standards, implementation specifications, 

6 or certification criteria, the Secretary shall, by 

7 regulation, determine whether or not to adopt 

8 such grouping of standards, implementation 

9 specifications, or certification criteria; or 

10 ‘‘(B) not to propose adoption of any group11 ing of standards, implementation specifications, 

12 or certification criteria, the Secretary shall no13 tify the National Coordinator and the HIT 

14 Standards Committee in writing of such deter15 mination and the reasons for not proposing the 

16 adoption of such recommendation. 

17 ‘‘(3) PUBLICATION.—The Secretary shall provide 

18 for publication in the Federal Register of all deter19 minations made by the Secretary under paragraph 

20 (1). 

21 ‘‘(b) ADOPTION OF INITIAL SET OF STANDARDS, IM22 PLEMENTATION SPECIFICATIONS, AND CERTIFICATION CRI23 TERIA.— 

24 ‘‘(1) IN GENERAL.—Not later than December 31, 

25 2009, the Secretary shall, through the rulemaking 


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1 process described in section 3003, adopt an initial set 

2 of standards, implementation specifications, and cer3 tification criteria for the areas required for consider4 ation under section 3002(b)(2)(B). 

5 ‘‘(2) APPLICATION OF CURRENT STANDARDS, IM6 PLEMENTATION SPECIFICATIONS, AND CERTIFICATION

7 CRITERIA.—The standards, implementation specifica8 tions, and certification criteria adopted before the 

9 date of the enactment of this title through the process 

10 existing through the Office of the National Coordi11 nator for Health Information Technology may be ap12 plied towards meeting the requirement of paragraph 

13 (1). 

14 ‘‘SEC. 3005. APPLICATION AND USE OF ADOPTED STAND15 ARDS AND IMPLEMENTATION SPECIFICA16 TIONS BY FEDERAL AGENCIES. 

17 ‘‘For requirements relating to the application and use 

18 by Federal agencies of the standards and implementation 

19 specifications adopted under section 3004, see section 4111 

20 of the HITECH Act. 

21 ‘‘SEC. 3006. VOLUNTARY APPLICATION AND USE OF ADOPT22 ED STANDARDS AND IMPLEMENTATION SPEC23 IFICATIONS BY PRIVATE ENTITIES. 

24 ‘‘(a) IN GENERAL.—Except as provided under section 

25 4112 of the HITECH Act, any standard or implementation 


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1 specification adopted under section 3004 shall be voluntary 

2 with respect to private entities. 

3 ‘‘(b) RULE OF CONSTRUCTION.—Nothing in this sub4 title shall be construed to require that a private entity that 

5 enters into a contract with the Federal Government apply 

6 or use the standards and implementation specifications 

7 adopted under section 3004 with respect to activities not 

8 related to the contract. 

9 ‘‘SEC. 3007. FEDERAL HEALTH INFORMATION TECHNOLOGY. 

10 ‘‘(a) IN GENERAL.—The National Coordinator shall 

11 support the development, routine updating, and provision 

12 of qualified EHR technology (as defined in section 3000) 

13 consistent with subsections (b) and (c) unless the Secretary 

14 determines that the needs and demands of providers are 

15 being substantially and adequately met through the market16 place. 

17 ‘‘(b) CERTIFICATION.—In making such EHR tech18 nology publicly available, the National Coordinator shall 

19 ensure that the qualified EHR technology described in sub20 section (a) is certified under the program developed under 

21 section 3001(c)(3) to be in compliance with applicable 

22 standards adopted under section 3003(a). 

23 ‘‘(c) AUTHORIZATION TO CHARGE A NOMINAL FEE.— 

24 The National Coordinator may impose a nominal fee for 

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1 mation technology system developed or approved under sub2 section (a) and (b). Such fee shall take into account the 

3 financial circumstances of smaller providers, low income 

4 providers, and providers located in rural or other medically 

5 underserved areas. 

6 ‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec7 tion shall be construed to require that a private or govern8 ment entity adopt or use the technology provided under this 

9 section. 

10 ‘‘SEC. 3008. TRANSITIONS. 

11 ‘‘(a) ONCHIT.—To the extent consistent with section 

12 3001, all functions, personnel, assets, liabilities, and ad13 ministrative actions applicable to the National Coordinator 

14 for Health Information Technology appointed under Execu15 tive Order 13335 or the Office of such National Coordinator 

16 on the date before the date of the enactment of this title 

17 shall be transferred to the National Coordinator appointed 

18 under section 3001(a) and the Office of such National Coor19 dinator as of the date of the enactment of this title. 

20 ‘‘(b) AHIC.— 

21 ‘‘(1) To the extent consistent with sections 3002 

22 and 3003, all functions, personnel, assets, and liabil23 ities applicable to the AHIC Successor, Inc. doing 

24 business as the National eHealth Collaborative as of 

25 the day before the date of the enactment of this title 


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1 shall be transferred to the HIT Policy Committee or 

2 the HIT Standards Committee, established under sec3 tion 3002(a) or 3003(a), as appropriate, as of the 

4 date of the enactment of this title. 

5 ‘‘(2) In carrying out section 3003(b)(1)(A), until 

6 recommendations are made by the HIT Policy Com7 mittee, recommendations of the HIT Standards Com8 mittee shall be consistent with the most recent rec9 ommendations made by such AHIC Successor, Inc. 

10 ‘‘(c) RULES OF CONSTRUCTION.— 

11 ‘‘(1) ONCHIT.—Nothing in section 3001 or sub12 section (a) shall be construed as requiring the cre13 ation of a new entity to the extent that the Office of 

14 the National Coordinator for Health Information 

15 Technology established pursuant to Executive Order 

16 13335 is consistent with the provisions of section 

17 3001. 

18 ‘‘(2) AHIC.—Nothing in sections 3002 or 3003 

19 or subsection (b) shall be construed as prohibiting the 

20 AHIC Successor, Inc. doing business as the National 

21 eHealth Collaborative from modifying its charter, du22 ties, membership, and any other structure or function 

23 required to be consistent with section 3002 and 3003 

24 in a manner that would permit the Secretary to 

25 choose to recognize such AHIC Successor, Inc. as the 


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1 HIT Policy Committee or the HIT Standards Com2 mittee. 

3 ‘‘SEC. 3009. RELATION TO HIPAA PRIVACY AND SECURITY 

4 LAW. 

5 ‘‘(a) IN GENERAL.—With respect to the relation of this 

6 title to HIPAA privacy and security law: 

7 ‘‘(1) This title may not be construed as having 

8 any effect on the authorities of the Secretary under 

9 HIPAA privacy and security law. 

10 ‘‘(2) The purposes of this title include ensuring 

11 that the health information technology standards and 

12 implementation specifications adopted under section 

13 3004 take into account the requirements of HIPAA 

14 privacy and security law. 

15 ‘‘(b) DEFINITION.—For purposes of this section, the 

16 term ‘HIPAA privacy and security law’ means— 

17 ‘‘(1) the provisions of part C of title XI of the 

18 Social Security Act, section 264 of the Health Insur19 ance Portability and Accountability Act of 1996, and 

20 subtitle D of title IV of the HITECH Act; and 

21 ‘‘(2) regulations under such provisions. 

22 ‘‘SEC. 3010. AUTHORIZATION FOR APPROPRIATIONS. 

23 ‘‘There is authorized to be appropriated to the Office 

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1 nology to carry out this subtitle $250,000,000 for fiscal year 

2 2009.’’. 

3 SEC. 4102. TECHNICAL AMENDMENT. 

4 Section 1171(5) of the Social Security Act (42 U.S.C. 

5 1320d) is amended by striking ‘‘or C’’ and inserting ‘‘C, 

6 or D’’. 

7 SEC. 4103. AMERICAN TECHNOLOGY REQUIRED. 

8 (a) REQUIREMENT.—Any funds made available to 

9 carry out this title and the amendments made by this title 

10 (including through grants, contracts, loans, payments 

11 under title XVIII or XIX of the Social Security Act, or other 

12 assistance) may be used to purchase health information 

13 technology only if such technology is manufactured, includ14 ing the engineering and programming of any software, in 

15 the United States substantially all from articles, materials, 

16 or supplies mined, produced, or manufactured, as the case 

17 may be, in the United States. 

18 (b) DEFINITION.—In this section, the term ‘‘health in19 formation technology’’ has the meaning given to that term 

20 in section 3000 of the Public Health Service Act, as added 

21 by section 4101. 


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1 PART 2—APPLICATION AND USE OF ADOPTED 

2 HEALTH INFORMATION TECHNOLOGY 

3 STANDARDS; REPORTS 

4 SEC. 4111. COORDINATION OF FEDERAL ACTIVITIES WITH 

5 ADOPTED STANDARDS AND IMPLEMENTA6 TION SPECIFICATIONS. 

7 (a) SPENDING ON HEALTH INFORMATION TECH8 NOLOGY SYSTEMS.—As each agency (as defined in the Exec9 utive Order issued on August 22, 2006, relating to pro10 moting quality and efficient health care in Federal govern11 ment administered or sponsored health care programs) im12 plements, acquires, or upgrades health information tech13 nology systems used for the direct exchange of individually 

14 identifiable health information between agencies and with 

15 non-Federal entities, it shall utilize, where available, health 

16 information technology systems and products that meet 

17 standards and implementation specifications adopted under 

18 section 3004 of the Public Health Service Act, as added by 

19 section 4101. 

20 (b) FEDERAL INFORMATION COLLECTION ACTIVI21 TIES.—With respect to a standard or implementation speci22 fication adopted under section 3004 of the Public Health 

23 Service Act, as added by section 4101, the President shall 

24 take measures to ensure that Federal activities involving 

25 the broad collection and submission of health information 

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1 fication, respectively, within three years after the date of 

2 such adoption. 

3 (c) APPLICATION OF DEFINITIONS.—The definitions 

4 contained in section 3000 of the Public Health Service Act, 

5 as added by section 4101, shall apply for purposes of this 

6 part. 

7 SEC. 4112. APPLICATION TO PRIVATE ENTITIES. 

8 Each agency (as defined in such Executive Order 

9 issued on August 22, 2006, relating to promoting quality 

10 and efficient health care in Federal government adminis11 tered or sponsored health care programs) shall require in 

12 contracts or agreements with health care providers, health 

13 plans, or health insurance issuers that as each provider, 

14 plan, or issuer implements, acquires, or upgrades health in15 formation technology systems, it shall utilize, where avail16 able, health information technology systems and products 

17 that meet standards and implementation specifications 

18 adopted under section 3004 of the Public Health Service 

19 Act, as added by section 4101. 

20 SEC. 4113. STUDY AND REPORTS. 

21 (a) REPORT ON ADOPTION OF NATIONWIDE SYSTEM.— 

22 Not later than 2 years after the date of the enactment of 

23 this Act and annually thereafter, the Secretary of Health 

24 and Human Services shall submit to the appropriate comVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00093 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 mittees of jurisdiction of the House of Representatives and 

2 the Senate a report that— 

3 (1) describes the specific actions that have been 

4 taken by the Federal Government and private entities 

5 to facilitate the adoption of a nationwide system for 

6 the electronic use and exchange of health information; 

7 (2) describes barriers to the adoption of such a 

8 nationwide system; and 

9 (3) contains recommendations to achieve full im10 plementation of such a nationwide system. 

11 (b) REIMBURSEMENT INCENTIVE STUDY AND RE12 PORT.— 

13 (1) STUDY.—The Secretary of Health and 

14 Human Services shall carry out, or contract with a 

15 private entity to carry out, a study that examines 

16 methods to create efficient reimbursement incentives 

17 for improving health care quality in Federally quali18 fied health centers, rural health clinics, and free clin19 ics. 

20 (2) REPORT.—Not later than 2 years after the 

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

22 Health and Human Services shall submit to the ap23 propriate committees of jurisdiction of the House of 

24 Representatives and the Senate a report on the study 

25 carried out under paragraph (1). 


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1 (c) AGING SERVICES TECHNOLOGY STUDY AND RE2 PORT.— 

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

4 Human Services shall carry out, or contract with a 

5 private entity to carry out, a study of matters relat6 ing to the potential use of new aging services tech7 nology to assist seniors, individuals with disabilities, 

8 and their caregivers throughout the aging process. 

9 (2) MATTERS TO BE STUDIED.—The study under 

10 paragraph (1) shall include— 

11 (A) an evaluation of— 

12 (i) methods for identifying current, 

13 emerging, and future health technology that 

14 can be used to meet the needs of seniors and 

15 individuals with disabilities and their care16 givers across all aging services settings, as 

17 specified by the Secretary; 

18 (ii) methods for fostering scientific in19 novation with respect to aging services tech20 nology within the business and academic 

21 communities; and 

22 (iii) developments in aging services 

23 technology in other countries that may be 

24 applied in the United States; and 

25 (B) identification of— 


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1 (i) barriers to innovation in aging 

2 services technology and devising strategies 

3 for removing such barriers; and 

4 (ii) barriers to the adoption of aging 

5 services technology by health care providers 

6 and consumers and devising strategies to re7 moving such barriers. 

8 (3) REPORT.—Not later than 24 months after the 

9 date of the enactment of this Act, the Secretary shall 

10 submit to the appropriate committees of jurisdiction 

11 of the House of Representatives and of the Senate a 

12 report on the study carried out under paragraph (1). 

13 (4) DEFINITIONS.—For purposes of this sub14 section: 

15 (A) AGING SERVICES TECHNOLOGY.—The 

16 term ‘‘aging services technology’’ means health 

17 technology that meets the health care needs of 

18 seniors, individuals with disabilities, and the 

19 caregivers of such seniors and individuals. 

20 (B) SENIOR.—The term ‘‘senior’’ has such 

21 meaning as specified by the Secretary. 


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1 Subtitle B—Testing of Health 

2 Information Technology 

3 SEC. 4201. NATIONAL INSTITUTE FOR STANDARDS AND 

4 TECHNOLOGY TESTING. 

5 (a) PILOT TESTING OF STANDARDS AND IMPLEMENTA6 TION SPECIFICATIONS.—In coordination with the HIT 

7 Standards Committee established under section 3003 of the 

8 Public Health Service Act, as added by section 4101, with 

9 respect to the development of standards and implementation 

10 specifications under such section, the Director of the Na11 tional Institute for Standards and Technology shall test 

12 such standards and implementation specifications, as ap13 propriate, in order to assure the efficient implementation 

14 and use of such standards and implementation specifica15 tions. 

16 (b) VOLUNTARY TESTING PROGRAM.—In coordination 

17 with the HIT Standards Committee established under sec18 tion 3003 of the Public Health Service Act, as added by 

19 section 4101, with respect to the development of standards 

20 and implementation specifications under such section, the 

21 Director of the National Institute of Standards and Tech22 nology shall support the establishment of a conformance 

23 testing infrastructure, including the development of tech24 nical test beds. The development of this conformance testing 


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1 infrastructure may include a program to accredit inde2 pendent, non-Federal laboratories to perform testing. 

3 SEC. 4202. RESEARCH AND DEVELOPMENT PROGRAMS. 

4 (a) HEALTH CARE INFORMATION ENTERPRISE INTE5 GRATION RESEARCH CENTERS.— 

6 (1) IN GENERAL.—The Director of the National 

7 Institute of Standards and Technology, in consulta8 tion with the Director of the National Science Foun9 dation and other appropriate Federal agencies, shall 

10 establish a program of assistance to institutions of 

11 higher education (or consortia thereof which may in12 clude nonprofit entities and Federal Government lab13 oratories) to establish multidisciplinary Centers for 

14 Health Care Information Enterprise Integration. 

15 (2) REVIEW; COMPETITION.—Grants shall be 

16 awarded under this subsection on a merit-reviewed, 

17 competitive basis. 

18 (3) PURPOSE.—The purposes of the Centers de19 scribed in paragraph (1) shall be— 

20 (A) to generate innovative approaches to 

21 health care information enterprise integration by 

22 conducting cutting-edge, multidisciplinary re23 search on the systems challenges to health care 

24 delivery; and 


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1 (B) the development and use of health infor2 mation technologies and other complementary 

3 fields. 

4 (4) RESEARCH AREAS.—Research areas may in5 clude— 

6 (A) interfaces between human information 

7 and communications technology systems; 

8 (B) voice-recognition systems; 

9 (C) software that improves interoperability 

10 and connectivity among health information sys11 tems; 

12 (D) software dependability in systems crit13 ical to health care delivery; 

14 (E) measurement of the impact of informa15 tion technologies on the quality and productivity 

16 of health care; 

17 (F) health information enterprise manage18 ment; 

19 (G) health information technology security 

20 and integrity; and 

21 (H) relevant health information technology 

22 to reduce medical errors. 

23 (5) APPLICATIONS.—An institution of higher 

24 education (or a consortium thereof) seeking funding 

25 under this subsection shall submit an application to 


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1 the Director of the National Institute of Standards 

2 and Technology at such time, in such manner, and 

3 containing such information as the Director may re4 quire. The application shall include, at a minimum, 

5 a description of— 

6 (A) the research projects that will be under7 taken by the Center established pursuant to as8 sistance under paragraph (1) and the respective 

9 contributions of the participating entities; 

10 (B) how the Center will promote active col11 laboration among scientists and engineers from 

12 different disciplines, such as information tech13 nology, biologic sciences, management, social 

14 sciences, and other appropriate disciplines; 

15 (C) technology transfer activities to dem16 onstrate and diffuse the research results, tech17 nologies, and knowledge; and 

18 (D) how the Center will contribute to the 

19 education and training of researchers and other 

20 professionals in fields relevant to health informa21 tion enterprise integration. 

22 (b) NATIONAL INFORMATION TECHNOLOGY RESEARCH

23 AND DEVELOPMENT PROGRAM.—The National High-Per24 formance Computing Program established by section 101 of 

25 the High-Performance Computing Act of 1991 (15 U.S.C. 


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1 5511) shall coordinate Federal research and development 

2 programs related to the development and deployment of 

3 health information technology, including activities related 

4 to— 

5 (1) computer infrastructure; 

6 (2) data security; 

7 (3) development of large-scale, distributed, reli8 able computing systems; 

9 (4) wired, wireless, and hybrid high-speed net10 working; 

11 (5) development of software and software-inten12 sive systems; 

13 (6) human-computer interaction and informa14 tion management technologies; and 

15 (7) the social and economic implications of in16 formation technology. 

17 Subtitle C—Incentives for the Use of 

18 Health Information Technology 

19 PART I—GRANTS AND LOANS FUNDING 

20 SEC. 4301. GRANT, LOAN, AND DEMONSTRATION PRO21 GRAMS. 

22 Title XXX of the Public Health Service Act, as added 

23 by section 4101, is amended by adding at the end the fol24 lowing new subtitle: 


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1 ‘‘Subtitle B—Incentives for the Use 

2 of Health Information Technology 

3 ‘‘SEC. 3011. IMMEDIATE FUNDING TO STRENGTHEN THE 

4 HEALTH INFORMATION TECHNOLOGY INFRA5 STRUCTURE. 

6 ‘‘(a) IN GENERAL.—The Secretary shall, using 

7 amounts appropriated under section 3018, invest in the in8 frastructure necessary to allow for and promote the elec9 tronic exchange and use of health information for each indi10 vidual in the United States consistent with the goals out11 lined in the strategic plan developed by the National Coor12 dinator (and as available) under section 3001. To the great13 est extent practicable, the Secretary shall ensure that any 

14 funds so appropriated shall be used for the acquisition of 

15 health information technology that meets standards and 

16 certification criteria adopted before the date of the enact17 ment of this title until such date as the standards are adopt18 ed under section 3004. The Secretary shall invest funds 

19 through the different agencies with expertise in such goals, 

20 such as the Office of the National Coordinator for Health 

21 Information Technology, the Health Resources and Services 

22 Administration, the Agency for Healthcare Research and 

23 Quality, the Centers of Medicare & Medicaid Services, the 

24 Centers for Disease Control and Prevention, and the Indian 

25 Health Service to support the following: 


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1 ‘‘(1) Health information technology architecture 

2 that will support the nationwide electronic exchange 

3 and use of health information in a secure, private, 

4 and accurate manner, including connecting health in5 formation exchanges, and which may include updat6 ing and implementing the infrastructure necessary 

7 within different agencies of the Department of Health 

8 and Human Services to support the electronic use 

9 and exchange of health information. 

10 ‘‘(2) Development and adoption of appropriate 

11 certified electronic health records for categories of pro12 viders, as defined in section 3000, not eligible for sup13 port under title XVIII or XIX of the Social Security 

14 Act for the adoption of such records. 

15 ‘‘(3) Training on and dissemination of informa16 tion on best practices to integrate health information 

17 technology, including electronic health records, into a 

18 provider’s delivery of care, consistent with best prac19 tices learned from the Health Information Technology 

20 Research Center developed under section 3012(b), in21 cluding community health centers receiving assistance 

22 under section 330, covered entities under section 

23 340B, and providers participating in one or more of 

24 the programs under titles XVIII, XIX, and XXI of the 


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1 Social Security Act (relating to Medicare, Medicaid, 

2 and the State Children’s Health Insurance Program). 

3 ‘‘(4) Infrastructure and tools for the promotion 

4 of telemedicine, including coordination among Fed5 eral agencies in the promotion of telemedicine. 

6 ‘‘(5) Promotion of the interoperability of clinical 

7 data repositories or registries. 

8 ‘‘(6) Promotion of technologies and best practices 

9 that enhance the protection of health information by 

10 all holders of individually identifiable health informa11 tion. 

12 ‘‘(7) Improvement and expansion of the use of 

13 health information technology by public health de14 partments. 

15 ‘‘(8) Provision of $300 million to support re16 gional or sub-national efforts towards health informa17 tion exchange. 

18 ‘‘(b) COORDINATION.—The Secretary shall ensure 

19 funds under this section are used in a coordinated manner 

20 with other health information promotion activities. 

21 ‘‘(c) ADDITIONAL USE OF FUNDS.—In addition to 

22 using funds as provided in subsection (a), the Secretary 

23 may use amounts appropriated under section 3018 to carry 

24 out health information technology activities that are proVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00104 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 vided for under laws in effect on the date of the enactment 

2 of this title. 

3 ‘‘SEC. 3012. HEALTH INFORMATION TECHNOLOGY IMPLE4 MENTATION ASSISTANCE. 

5 ‘‘(a) HEALTH INFORMATION TECHNOLOGY EXTENSION

6 PROGRAM.—To assist health care providers to adopt, imple7 ment, and effectively use certified EHR technology that al8 lows for the electronic exchange and use of health informa9 tion, the Secretary, acting through the Office of the National 

10 Coordinator, shall establish a health information technology 

11 extension program to provide health information technology 

12 assistance services to be carried out through the Department 

13 of Health and Human Services. The National Coordinator 

14 shall consult with other Federal agencies with demonstrated 

15 experience and expertise in information technology services, 

16 such as the National Institute of Standards and Tech17 nology, in developing and implementing this program. 

18 ‘‘(b) HEALTH INFORMATION TECHNOLOGY RESEARCH

19 CENTER.— 

20 ‘‘(1) IN GENERAL.—The Secretary shall create a 

21 Health Information Technology Research Center (in 

22 this section referred to as the ‘Center’) to provide tech23 nical assistance and develop or recognize best prac24 tices to support and accelerate efforts to adopt, imple25 ment, and effectively utilize health information techVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00105 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 nology that allows for the electronic exchange and use 

2 of information in compliance with standards, imple3 mentation specifications, and certification criteria 

4 adopted under section 3004. 

5 ‘‘(2) INPUT.—The Center shall incorporate input 

6 from— 

7 ‘‘(A) other Federal agencies with dem8 onstrated experience and expertise in informa9 tion technology services such as the National In10 stitute of Standards and Technology; 

11 ‘‘(B) users of health information technology, 

12 such as providers and their support and clerical 

13 staff and others involved in the care and care co14 ordination of patients, from the health care and 

15 health information technology industry; and 

16 ‘‘(C) others as appropriate. 

17 ‘‘(3) PURPOSES.—The purposes of the Center are 

18 to— 

19 ‘‘(A) provide a forum for the exchange of 

20 knowledge and experience; 

21 ‘‘(B) accelerate the transfer of lessons 

22 learned from existing public and private sector 

23 initiatives, including those currently receiving 

24 Federal financial support; 


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1 ‘‘(C) assemble, analyze, and widely dissemi2 nate evidence and experience related to the adop3 tion, implementation, and effective use of health 

4 information technology that allows for the elec5 tronic exchange and use of information includ6 ing through the regional centers described in sub7 section (c); 

8 ‘‘(D) provide technical assistance for the es9 tablishment and evaluation of regional and local 

10 health information networks to facilitate the elec11 tronic exchange of information across health care 

12 settings and improve the quality of health care; 

13 ‘‘(E) provide technical assistance for the de14 velopment and dissemination of solutions to bar15 riers to the exchange of electronic health informa16 tion; and 

17 ‘‘(F) learn about effective strategies to adopt 

18 and utilize health information technology in 

19 medically underserved communities. 

20 ‘‘(c) HEALTH INFORMATION TECHNOLOGY REGIONAL

21 EXTENSION CENTERS.— 

22 ‘‘(1) IN GENERAL.—The Secretary shall provide 

23 assistance for the creation and support of regional 

24 centers (in this subsection referred to as ‘regional cen25 ters’) to provide technical assistance and disseminate 


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1 best practices and other information learned from the 

2 Center to support and accelerate efforts to adopt, im3 plement, and effectively utilize health information 

4 technology that allows for the electronic exchange and 

5 use of information in compliance with standards, im6 plementation specifications, and certification criteria 

7 adopted under section 3004. Activities conducted 

8 under this subsection shall be consistent with the stra9 tegic plan developed by the National Coordinator, 

10 (and, as available) under section 3001. 

11 ‘‘(2) AFFILIATION.—Regional centers shall be af12 filiated with any United States-based nonprofit insti13 tution or organization, or group thereof, that applies 

14 and is awarded financial assistance under this sec15 tion. Individual awards shall be decided on the basis 

16 of merit. 

17 ‘‘(3) OBJECTIVE.—The objective of the regional 

18 centers is to enhance and promote the adoption of 

19 health information technology through— 

20 ‘‘(A) assistance with the implementation, ef21 fective use, upgrading, and ongoing maintenance 

22 of health information technology, including elec23 tronic health records, to healthcare providers na24 tionwide; 


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1 ‘‘(B) broad participation of individuals 

2 from industry, universities, and State govern3 ments; 

4 ‘‘(C) active dissemination of best practices 

5 and research on the implementation, effective 

6 use, upgrading, and ongoing maintenance of 

7 health information technology, including elec8 tronic health records, to health care providers in 

9 order to improve the quality of healthcare and 

10 protect the privacy and security of health infor11 mation; 

12 ‘‘(D) participation, to the extent prac13 ticable, in health information exchanges; and 

14 ‘‘(E) utilization, when appropriate, of the 

15 expertise and capability that exists in Federal 

16 agencies other than the Department; and 

17 ‘‘(F) integration of health information tech18 nology, including electronic health records, into 

19 the initial and ongoing training of health profes20 sionals and others in the healthcare industry 

21 that would be instrumental to improving the 

22 quality of healthcare through the smooth and ac23 curate electronic use and exchange of health in24 formation. 


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1 ‘‘(4) REGIONAL ASSISTANCE.—Each regional 

2 center shall aim to provide assistance and education 

3 to all providers in a region, but shall prioritize any 

4 direct assistance first to the following: 

5 ‘‘(A) Public or not-for-profit hospitals or 

6 critical access hospitals. 

7 ‘‘(B) Federally qualified health centers (as 

8 defined in section 1861(aa)(4) of the Social Se9 curity Act). 

10 ‘‘(C) Entities that are located in rural and 

11 other areas that serve uninsured, underinsured, 

12 and medically underserved individuals (regard13 less of whether such area is urban or rural). 

14 ‘‘(D) Individual or small group practices 

15 (or a consortium thereof) that are primarily fo16 cused on primary care. 

17 ‘‘(5) FINANCIAL SUPPORT.—The Secretary may 

18 provide financial support to any regional center cre19 ated under this subsection for a period not to exceed 

20 four years. The Secretary may not provide more than 

21 50 percent of the capital and annual operating and 

22 maintenance funds required to create and maintain 

23 such a center, except in an instance of national eco24 nomic conditions which would render this cost-share 

25 requirement detrimental to the program and upon noVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00110 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 tification to Congress as to the justification to waive 

2 the cost-share requirement. 

3 ‘‘(6) NOTICE OF PROGRAM DESCRIPTION AND

4 AVAILABILITY OF FUNDS.—The Secretary shall pub5 lish in the Federal Register, not later than 90 days 

6 after the date of the enactment of this title, a draft 

7 description of the program for establishing regional 

8 centers under this subsection. Such description shall 

9 include the following: 

10 ‘‘(A) A detailed explanation of the program 

11 and the programs goals. 

12 ‘‘(B) Procedures to be followed by the appli13 cants. 

14 ‘‘(C) Criteria for determining qualified ap15 plicants. 

16 ‘‘(D) Maximum support levels expected to be 

17 available to centers under the program. 

18 ‘‘(7) APPLICATION REVIEW.—The Secretary shall 

19 subject each application under this subsection to 

20 merit review. In making a decision whether to ap21 prove such application and provide financial support, 

22 the Secretary shall consider at a minimum the merits 

23 of the application, including those portions of the ap24 plication regarding— 


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1 ‘‘(A) the ability of the applicant to provide 

2 assistance under this subsection and utilization 

3 of health information technology appropriate to 

4 the needs of particular categories of health care 

5 providers; 

6 ‘‘(B) the types of service to be provided to 

7 health care providers; 

8 ‘‘(C) geographical diversity and extent of 

9 service area; and 

10 ‘‘(D) the percentage of funding and amount 

11 of in-kind commitment from other sources. 

12 ‘‘(8) BIENNIAL EVALUATION.—Each regional cen13 ter which receives financial assistance under this sub14 section shall be evaluated biennially by an evaluation 

15 panel appointed by the Secretary. Each evaluation 

16 panel shall be composed of private experts, none of 

17 whom shall be connected with the center involved, and 

18 of Federal officials. Each evaluation panel shall meas19 ure the involved center’s performance against the ob20 jective specified in paragraph (3). The Secretary shall 

21 not continue to provide funding to a regional center 

22 unless its evaluation is overall positive. 

23 ‘‘(9) CONTINUING SUPPORT.—After the second 

24 year of assistance under this subsection, a regional 

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1 section if it has received positive evaluations and a 

2 finding by the Secretary that continuation of Federal 

3 funding to the center was in the best interest of provi4 sion of health information technology extension serv5 ices. 

6 ‘‘SEC. 3013. STATE GRANTS TO PROMOTE HEALTH INFORMA7 TION TECHNOLOGY. 

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

9 National Coordinator, shall establish a program in accord10 ance with this section to facilitate and expand the electronic 

11 movement and use of health information among organiza12 tions according to nationally recognized standards. 

13 ‘‘(b) PLANNING GRANTS.—The Secretary may award 

14 a grant to a State or qualified State-designated entity (as 

15 described in subsection (f)) that submits an application to 

16 the Secretary at such time, in such manner, and containing 

17 such information as the Secretary may specify, for the pur18 pose of planning activities described in subsection (d). 

19 ‘‘(c) IMPLEMENTATION GRANTS.—The Secretary may 

20 award a grant to a State or qualified State designated enti21 ty that— 

22 ‘‘(1) has submitted, and the Secretary has ap23 proved, a plan described in subsection (e) (regardless 

24 of whether such plan was prepared using amounts 

25 awarded under subsection (b); and 


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1 ‘‘(2) submits an application at such time, in 

2 such manner, and containing such information as the 

3 Secretary may specify. 

4 ‘‘(d) USE OF FUNDS.—Amounts received under a 

5 grant under subsection (c) shall be used to conduct activities 

6 to facilitate and expand the electronic movement and use 

7 of health information among organizations according to na8 tionally recognized standards through activities that in9 clude— 

10 ‘‘(1) enhancing broad and varied participation 

11 in the authorized and secure nationwide electronic use 

12 and exchange of health information; 

13 ‘‘(2) identifying State or local resources available 

14 towards a nationwide effort to promote health infor15 mation technology; 

16 ‘‘(3) complementing other Federal grants, pro17 grams, and efforts towards the promotion of health 

18 information technology; 

19 ‘‘(4) providing technical assistance for the devel20 opment and dissemination of solutions to barriers to 

21 the exchange of electronic health information; 

22 ‘‘(5) promoting effective strategies to adopt and 

23 utilize health information technology in medically un24 derserved communities; 


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1 ‘‘(6) assisting patients in utilizing health infor2 mation technology; 

3 ‘‘(7) encouraging clinicians to work with Health 

4 Information Technology Regional Extension Centers 

5 as described in section 3012, to the extent they are 

6 available and valuable; 

7 ‘‘(8) supporting public health agencies’ author8 ized use of and access to electronic health information; 

9 ‘‘(9) promoting the use of electronic health 

10 records for quality improvement including through 

11 quality measures reporting; and 

12 ‘‘(10) such other activities as the Secretary may 

13 specify. 

14 ‘‘(e) PLAN.— 

15 ‘‘(1) IN GENERAL.—A plan described in this sub16 section is a plan that describes the activities to be 

17 carried out by a State or by the qualified State-des18 ignated entity within such State to facilitate and ex19 pand the electronic movement and use of health infor20 mation among organizations according to nationally 

21 recognized standards and implementation specifica22 tions. 

23 ‘‘(2) REQUIRED ELEMENTS.—A plan described 

24 in paragraph (1) shall— 

25 ‘‘(A) be pursued in the public interest; 


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1 ‘‘(B) be consistent with the strategic plan 

2 developed by the National Coordinator, (and, as 

3 available) under section 3001; 

4 ‘‘(C) include a description of the ways the 

5 State or qualified State-designated entity will 

6 carry out the activities described in subsection 

7 (b); and 

8 ‘‘(D) contain such elements as the Secretary 

9 may require. 

10 ‘‘(f) QUALIFIED STATE-DESIGNATED ENTITY.—For 

11 purposes of this section, to be a qualified State-designated 

12 entity, with respect to a State, an entity shall— 

13 ‘‘(1) be designated by the State as eligible to re14 ceive awards under this section; 

15 ‘‘(2) be a not-for-profit entity with broad stake16 holder representation on its governing board; 

17 ‘‘(3) demonstrate that one of its principal goals 

18 is to use information technology to improve health 

19 care quality and efficiency through the authorized 

20 and secure electronic exchange and use of health in21 formation; 

22 ‘‘(4) adopt nondiscrimination and conflict of in23 terest policies that demonstrate a commitment to 

24 open, fair, and nondiscriminatory participation by 

25 stakeholders; and 


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1 ‘‘(5) conform to such other requirements as the 

2 Secretary may establish. 

3 ‘‘(g) REQUIRED CONSULTATION.—In carrying out ac4 tivities described in subsections (b) and (c), a State or 

5 qualified State-designated entity shall consult with and 

6 consider the recommendations of— 

7 ‘‘(1) health care providers (including providers 

8 that provide services to low income and underserved 

9 populations); 

10 ‘‘(2) health plans; 

11 ‘‘(3) patient or consumer organizations that rep12 resent the population to be served; 

13 ‘‘(4) health information technology vendors; 

14 ‘‘(5) health care purchasers and employers; 

15 ‘‘(6) public health agencies; 

16 ‘‘(7) health professions schools, universities and 

17 colleges; 

18 ‘‘(8) clinical researchers; 

19 ‘‘(9) other users of health information technology 

20 such as the support and clerical staff of providers and 

21 others involved in the care and care coordination of 

22 patients; and 

23 ‘‘(10) such other entities, as may be determined 

24 appropriate by the Secretary. 


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1 ‘‘(h) CONTINUOUS IMPROVEMENT.—The Secretary 

2 shall annually evaluate the activities conducted under this 

3 section and shall, in awarding grants under this section, 

4 implement the lessons learned from such evaluation in a 

5 manner so that awards made subsequent to each such eval6 uation are made in a manner that, in the determination 

7 of the Secretary, will lead towards the greatest improvement 

8 in quality of care, decrease in costs, and the most effective 

9 authorized and secure electronic exchange of health informa10 tion. 

11 ‘‘(i) REQUIRED MATCH.— 

12 ‘‘(1) IN GENERAL.—For a fiscal year (beginning 

13 with fiscal year 2011), the Secretary may not make 

14 a grant under this section to a State unless the State 

15 agrees to make available non-Federal contributions 

16 (which may include in-kind contributions) toward the 

17 costs of a grant awarded under subsection (c) in an 

18 amount equal to— 

19 ‘‘(A) for fiscal year 2011, not less than $1 

20 for each $10 of Federal funds provided under the 

21 grant; 

22 ‘‘(B) for fiscal year 2012, not less than $1 

23 for each $7 of Federal funds provided under the 

24 grant; and 


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1 ‘‘(C) for fiscal year 2013 and each subse2 quent fiscal year, not less than $1 for each $3 of 

3 Federal funds provided under the grant. 

4 ‘‘(2) AUTHORITY TO REQUIRE STATE MATCH FOR

5 FISCAL YEARS BEFORE FISCAL YEAR 2011.—For any 

6 fiscal year during the grant program under this sec7 tion before fiscal year 2011, the Secretary may deter8 mine the extent to which there shall be required a 

9 non-Federal contribution from a State receiving a 

10 grant under this section. 

11 ‘‘SEC. 3014. COMPETITIVE GRANTS TO STATES AND INDIAN 

12 TRIBES FOR THE DEVELOPMENT OF LOAN 

13 PROGRAMS TO FACILITATE THE WIDESPREAD 

14 ADOPTION OF CERTIFIED EHR TECHNOLOGY. 

15 ‘‘(a) IN GENERAL.—The National Coordinator may 

16 award competitive grants to eligible entities for the estab17 lishment of programs for loans to health care providers to 

18 conduct the activities described in subsection (e). 

19 ‘‘(b) ELIGIBLE ENTITY DEFINED.—For purposes of 

20 this subsection, the term ‘eligible entity’ means a State or 

21 Indian tribe (as defined in the Indian Self-Determination 

22 and Education Assistance Act) that— 

23 ‘‘(1) submits to the National Coordinator an ap24 plication at such time, in such manner, and conVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00119 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 taining such information as the National Coordinator 

2 may require; 

3 ‘‘(2) submits to the National Coordinator a stra4 tegic plan in accordance with subsection (d) and pro5 vides to the National Coordinator assurances that the 

6 entity will update such plan annually in accordance 

7 with such subsection; 

8 ‘‘(3) provides assurances to the National Coordi9 nator that the entity will establish a Loan Fund in 

10 accordance with subsection (c); 

11 ‘‘(4) provides assurances to the National Coordi12 nator that the entity will not provide a loan from the 

13 Loan Fund to a health care provider unless the pro14 vider agrees to— 

15 ‘‘(A) submit reports on quality measures 

16 adopted by the Federal Government (by not later 

17 than 90 days after the date on which such meas18 ures are adopted), to— 

19 ‘‘(i) the Administrator of the Centers 

20 for Medicare & Medicaid Services (or his or 

21 her designee), in the case of an entity par22 ticipating in the Medicare program under 

23 title XVIII of the Social Security Act or the 

24 Medicaid program under title XIX of such 

25 Act; or 


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1 ‘‘(ii) the Secretary in the case of other 

2 entities; 

3 ‘‘(B) demonstrate to the satisfaction of the 

4 Secretary (through criteria established by the 

5 Secretary) that any certified EHR technology 

6 purchased, improved, or otherwise financially 

7 supported under a loan under this section is 

8 used to exchange health information in a man9 ner that, in accordance with law and standards 

10 (as adopted under section 3004) applicable to the 

11 exchange of information, improves the quality of 

12 health care, such as promoting care coordination; 

13 ‘‘(C) comply with such other requirements 

14 as the entity or the Secretary may require; 

15 ‘‘(D) include a plan on how health care pro16 viders involved intend to maintain and support 

17 the certified EHR technology over time; and 

18 ‘‘(E) include a plan on how the health care 

19 providers involved intend to maintain and sup20 port the certified EHR technology that would be 

21 purchased with such loan, including the type of 

22 resources expected to be involved and any such 

23 other information as the State or Indian Tribe, 

24 respectively, may require; and 


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1 ‘‘(5) agrees to provide matching funds in accord2 ance with subsection (h). 

3 ‘‘(c) ESTABLISHMENT OF FUND.—For purposes of sub4 section (b)(3), an eligible entity shall establish a certified 

5 EHR technology loan fund (referred to in this subsection 

6 as a ‘Loan Fund’) and comply with the other requirements 

7 contained in this section. A grant to an eligible entity under 

8 this section shall be deposited in the Loan Fund established 

9 by the eligible entity. No funds authorized by other provi10 sions of this title to be used for other purposes specified in 

11 this title shall be deposited in any Loan Fund. 

12 ‘‘(d) STRATEGIC PLAN.— 

13 ‘‘(1) IN GENERAL.—For purposes of subsection 

14 (b)(2), a strategic plan of an eligible entity under this 

15 subsection shall identify the intended uses of amounts 

16 available to the Loan Fund of such entity. 

17 ‘‘(2) CONTENTS.—A strategic plan under para18 graph (1), with respect to a Loan Fund of an eligible 

19 entity, shall include for a year the following: 

20 ‘‘(A) A list of the projects to be assisted 

21 through the Loan Fund during such year. 

22 ‘‘(B) A description of the criteria and meth23 ods established for the distribution of funds from 

24 the Loan Fund during the year. 


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1 ‘‘(C) A description of the financial status of 

2 the Loan Fund as of the date of submission of 

3 the plan. 

4 ‘‘(D) The short-term and long-term goals of 

5 the Loan Fund. 

6 ‘‘(e) USE OF FUNDS.—Amounts deposited in a Loan 

7 Fund, including loan repayments and interest earned on 

8 such amounts, shall be used only for awarding loans or loan 

9 guarantees, making reimbursements described in subsection 

10 (g)(4)(A), or as a source of reserve and security for lever11 aged loans, the proceeds of which are deposited in the Loan 

12 Fund established under subsection (c). Loans under this sec13 tion may be used by a health care provider to— 

14 ‘‘(1) facilitate the purchase of certified EHR 

15 technology; 

16 ‘‘(2) enhance the utilization of certified EHR 

17 technology; 

18 ‘‘(3) train personnel in the use of such tech19 nology; or 

20 ‘‘(4) improve the secure electronic exchange of 

21 health information. 

22 ‘‘(f) TYPES OF ASSISTANCE.—Except as otherwise lim23 ited by applicable State law, amounts deposited into a 

24 Loan Fund under this section may only be used for the fol25 lowing: 


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1 ‘‘(1) To award loans that comply with the fol2 lowing: 

3 ‘‘(A) The interest rate for each loan shall 

4 not exceed the market interest rate. 

5 ‘‘(B) The principal and interest payments 

6 on each loan shall commence not later than 1 

7 year after the date the loan was awarded, and 

8 each loan shall be fully amortized not later than 

9 10 years after the date of the loan. 

10 ‘‘(C) The Loan Fund shall be credited with 

11 all payments of principal and interest on each 

12 loan awarded from the Loan Fund. 

13 ‘‘(2) To guarantee, or purchase insurance for, a 

14 local obligation (all of the proceeds of which finance 

15 a project eligible for assistance under this subsection) 

16 if the guarantee or purchase would improve credit 

17 market access or reduce the interest rate applicable to 

18 the obligation involved. 

19 ‘‘(3) As a source of revenue or security for the 

20 payment of principal and interest on revenue or gen21 eral obligation bonds issued by the eligible entity if 

22 the proceeds of the sale of the bonds will be deposited 

23 into the Loan Fund. 

24 ‘‘(4) To earn interest on the amounts deposited 

25 into the Loan Fund. 


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1 ‘‘(5) To make reimbursements described in sub2 section (g)(4)(A). 

3 ‘‘(g) ADMINISTRATION OF LOAN FUNDS.— 

4 ‘‘(1) COMBINED FINANCIAL ADMINISTRATION.— 

5 An eligible entity may (as a convenience and to avoid 

6 unnecessary administrative costs) combine, in accord7 ance with applicable State law, the financial admin8 istration of a Loan Fund established under this sub9 section with the financial administration of any other 

10 revolving fund established by the entity if otherwise 

11 not prohibited by the law under which the Loan Fund 

12 was established. 

13 ‘‘(2) COST OF ADMINISTERING FUND.—Each eli14 gible entity may annually use not to exceed 4 percent 

15 of the funds provided to the entity under a grant 

16 under this section to pay the reasonable costs of the 

17 administration of the programs under this section, in18 cluding the recovery of reasonable costs expended to 

19 establish a Loan Fund which are incurred after the 

20 date of the enactment of this title. 

21 ‘‘(3) GUIDANCE AND REGULATIONS.—The Na22 tional Coordinator shall publish guidance and pro23 mulgate regulations as may be necessary to carry out 

24 the provisions of this section, including— 


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1 ‘‘(A) provisions to ensure that each eligible 

2 entity commits and expends funds allotted to the 

3 entity under this section as efficiently as possible 

4 in accordance with this title and applicable 

5 State laws; and 

6 ‘‘(B) guidance to prevent waste, fraud, and 

7 abuse. 

8 ‘‘(4) PRIVATE SECTOR CONTRIBUTIONS.— 

9 ‘‘(A) IN GENERAL.—A Loan Fund estab10 lished under this section may accept contribu11 tions from private sector entities, except that 

12 such entities may not specify the recipient or re13 cipients of any loan issued under this subsection. 

14 An eligible entity may agree to reimburse a pri15 vate sector entity for any contribution made 

16 under this subparagraph, except that the amount 

17 of such reimbursement may not be greater than 

18 the principal amount of the contribution made. 

19 ‘‘(B) AVAILABILITY OF INFORMATION.—An 

20 eligible entity shall make publicly available the 

21 identity of, and amount contributed by, any pri22 vate sector entity under subparagraph (A) and 

23 may issue letters of commendation or make other 

24 awards (that have no financial value) to any 

25 such entity. 


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1 ‘‘(h) MATCHING REQUIREMENTS.— 

2 ‘‘(1) IN GENERAL.—The National Coordinator 

3 may not make a grant under subsection (a) to an eli4 gible entity unless the entity agrees to make available 

5 (directly or through donations from public or private 

6 entities) non-Federal contributions in cash to the costs 

7 of carrying out the activities for which the grant is 

8 awarded in an amount equal to not less than $1 for 

9 each $5 of Federal funds provided under the grant. 

10 ‘‘(2) DETERMINATION OF AMOUNT OF NON-FED11 ERAL CONTRIBUTION.—In determining the amount of 

12 non-Federal contributions that an eligible entity has 

13 provided pursuant to subparagraph (A), the National 

14 Coordinator may not include any amounts provided 

15 to the entity by the Federal Government. 

16 ‘‘(i) EFFECTIVE DATE.—The Secretary may not make 

17 an award under this section prior to January 1, 2010. 

18 ‘‘SEC. 3015. DEMONSTRATION PROGRAM TO INTEGRATE IN19 FORMATION TECHNOLOGY INTO CLINICAL 

20 EDUCATION. 

21 ‘‘(a) IN GENERAL.—The Secretary may award grants 

22 under this section to carry out demonstration projects to 

23 develop academic curricula integrating certified EHR tech24 nology in the clinical education of health professionals. 


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1 Such awards shall be made on a competitive basis and pur2 suant to peer review. 

3 ‘‘(b) ELIGIBILITY.—To be eligible to receive a grant 

4 under subsection (a), an entity shall— 

5 ‘‘(1) submit to the Secretary an application at 

6 such time, in such manner, and containing such in7 formation as the Secretary may require; 

8 ‘‘(2) submit to the Secretary a strategic plan for 

9 integrating certified EHR technology in the clinical 

10 education of health professionals to reduce medical er11 rors and enhance health care quality; 

12 ‘‘(3) be— 

13 ‘‘(A) a school of medicine, osteopathic medi14 cine, dentistry, or pharmacy, a graduate pro15 gram in behavioral or mental health, or any 

16 other graduate health professions school; 

17 ‘‘(B) a graduate school of nursing or physi18 cian assistant studies; 

19 ‘‘(C) a consortium of two or more schools 

20 described in subparagraph (A) or (B); or 

21 ‘‘(D) an institution with a graduate med22 ical education program in medicine, osteopathic 

23 medicine, dentistry, pharmacy, nursing, or phy24 sician assistance studies; 


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1 ‘‘(4) provide for the collection of data regarding 

2 the effectiveness of the demonstration project to be 

3 funded under the grant in improving the safety of pa4 tients, the efficiency of health care delivery, and in 

5 increasing the likelihood that graduates of the grantee 

6 will adopt and incorporate certified EHR technology, 

7 in the delivery of health care services; and 

8 ‘‘(5) provide matching funds in accordance with 

9 subsection (d). 

10 ‘‘(c) USE OF FUNDS.— 

11 ‘‘(1) IN GENERAL.—With respect to a grant 

12 under subsection (a), an eligible entity shall— 

13 ‘‘(A) use grant funds in collaboration with 

14 2 or more disciplines; and 

15 ‘‘(B) use grant funds to integrate certified 

16 EHR technology into community-based clinical 

17 education. 

18 ‘‘(2) LIMITATION.—An eligible entity shall not 

19 use amounts received under a grant under subsection 

20 (a) to purchase hardware, software, or services. 

21 ‘‘(d) FINANCIAL SUPPORT.—The Secretary may not 

22 provide more than 50 percent of the costs of any activity 

23 for which assistance is provided under subsection (a), except 

24 in an instance of national economic conditions which would 

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1 rimental to the program and upon notification to Congress 

2 as to the justification to waive the cost-share requirement. 

3 ‘‘(e) EVALUATION.—The Secretary shall take such ac4 tion as may be necessary to evaluate the projects funded 

5 under this section and publish, make available, and dis6 seminate the results of such evaluations on as wide a basis 

7 as is practicable. 

8 ‘‘(f) REPORTS.—Not later than 1 year after the date 

9 of enactment of this title, and annually thereafter, the Sec10 retary shall submit to the Committee on Health, Education, 

11 Labor, and Pensions and the Committee on Finance of the 

12 Senate, and the Committee on Energy and Commerce of 

13 the House of Representatives a report that— 

14 ‘‘(1) describes the specific projects established 

15 under this section; and 

16 ‘‘(2) contains recommendations for Congress 

17 based on the evaluation conducted under subsection 

18 (e). 

19 ‘‘SEC. 3016. INFORMATION TECHNOLOGY PROFESSIONALS 

20 ON HEALTH CARE. 

21 ‘‘(a) IN GENERAL.—The Secretary, in consultation 

22 with the Director of the National Science Foundation, shall 

23 provide assistance to institutions of higher education (or 

24 consortia thereof) to establish or expand medical health 

25 informatics education programs, including certification, 


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1 undergraduate, and masters degree programs, for both 

2 health care and information technology students to ensure 

3 the rapid and effective utilization and development of 

4 health information technologies (in the United States health 

5 care infrastructure). 

6 ‘‘(b) ACTIVITIES.—Activities for which assistance may 

7 be provided under subsection (a) may include the following: 

8 ‘‘(1) Developing and revising curricula in med9 ical health informatics and related disciplines. 

10 ‘‘(2) Recruiting and retaining students to the 

11 program involved. 

12 ‘‘(3) Acquiring equipment necessary for student 

13 instruction in these programs, including the installa14 tion of testbed networks for student use. 

15 ‘‘(4) Establishing or enhancing bridge programs 

16 in the health informatics fields between community 

17 colleges and universities. 

18 ‘‘(c) PRIORITY.—In providing assistance under sub19 section (a), the Secretary shall give preference to the fol20 lowing: 

21 ‘‘(1) Existing education and training programs. 

22 ‘‘(2) Programs designed to be completed in less 

23 than six months. 

24 ‘‘(d) FINANCIAL SUPPORT.—The Secretary may not 

25 provide more than 50 percent of the costs of any activity 


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1 for which assistance is provided under subsection (a), except 

2 in an instance of national economic conditions which would 

3 render the cost-share requirement under this subsection det4 rimental to the program and upon notification to Congress 

5 as to the justification to waive the cost-share requirement. 

6 ‘‘SEC. 3017. GENERAL GRANT AND LOAN PROVISIONS. 

7 ‘‘(a) REPORTS.—The Secretary may require that an 

8 entity receiving assistance under this subtitle shall submit 

9 to the Secretary, not later than the date that is 1 year after 

10 the date of receipt of such assistance, a report that in11 cludes— 

12 ‘‘(1) an analysis of the effectiveness of the activi13 ties for which the entity receives such assistance, as 

14 compared to the goals for such activities; and 

15 ‘‘(2) an analysis of the impact of the project on 

16 health care quality and safety. 

17 ‘‘(b) REQUIREMENT TO IMPROVE QUALITY OF CARE

18 AND DECREASE IN COSTS.—The National Coordinator shall 

19 annually evaluate the activities conducted under this sub20 title and shall, in awarding grants, implement the lessons 

21 learned from such evaluation in a manner so that awards 

22 made subsequent to each such evaluation are made in a 

23 manner that, in the determination of the National Coordi24 nator, will result in the greatest improvement in the quality 

25 and efficiency of health care. 


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1 ‘‘SEC. 3018. AUTHORIZATION FOR APPROPRIATIONS. 

2 ‘‘For the purposes of carrying out this subtitle, there 

3 is authorized to be appropriated such sums as may be nec4 essary for each of the fiscal years 2009 through 2013. 

5 Amounts so appropriated shall remain available until ex6 pended.’’. 

7 PART II—MEDICARE PROGRAM 

8 SEC. 4311. INCENTIVES FOR ELIGIBLE PROFESSIONALS. 

9 (a) INCENTIVE PAYMENTS.—Section 1848 of the Social 

10 Security Act (42 U.S.C. 1395w–4) is amended by adding 

11 at the end the following new subsection: 

12 ‘‘(o) INCENTIVES FOR ADOPTION AND MEANINGFUL

13 USE OF CERTIFIED EHR TECHNOLOGY.— 

14 ‘‘(1) INCENTIVE PAYMENTS.— 

15 ‘‘(A) IN GENERAL.—Subject to the suc16 ceeding subparagraphs of this paragraph, with 

17 respect to covered professional services furnished 

18 by an eligible professional during a payment 

19 year (as defined in subparagraph (E)), if the eli20 gible professional is a meaningful EHR user (as 

21 determined under paragraph (2)) for the report22 ing period with respect to such year, in addition 

23 to the amount otherwise paid under this part, 

24 there also shall be paid to the eligible profes25 sional (or to an employer or facility in the cases 

26 described in clause (A) of section 1842(b)(6)), 


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1 from the Federal Supplementary Medical Insur2 ance Trust Fund established under section 1841 

3 an amount equal to 75 percent of the Secretary’s 

4 estimate (based on claims submitted not later 

5 than 2 months after the end of the payment 

6 year) of the allowed charges under this part for 

7 all such covered professional services furnished 

8 by the eligible professional during such year. 

9 ‘‘(B) LIMITATIONS ON AMOUNTS OF INCEN10 TIVE PAYMENTS.— 

11 ‘‘(i) IN GENERAL.—In no case shall the 

12 amount of the incentive payment provided 

13 under this paragraph for an eligible profes14 sional for a payment year exceed the appli15 cable amount specified under this subpara16 graph with respect to such eligible profes17 sional and such year. 

18 ‘‘(ii) AMOUNT.—Subject to clause (iii), 

19 the applicable amount specified in this sub20 paragraph for an eligible professional is as 

21 follows: 

22 ‘‘(I) For the first payment year 

23 for such professional, $15,000. 

24 ‘‘(II) For the second payment 

25 year for such professional, $12,000. 


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1 ‘‘(III) For the third payment year 

2 for such professional, $8,000. 

3 ‘‘(IV) For the fourth payment 

4 year for such professional, $4,000. 

5 ‘‘(V) For the fifth payment year 

6 for such professional, $2,000. 

7 ‘‘(VI) For any succeeding pay8 ment year for such professional, $0. 

9 ‘‘(iii) PHASE DOWN FOR ELIGIBLE

10 PROFESSIONALS FIRST ADOPTING EHR

11 AFTER 2013.—If the first payment year for 

12 an eligible professional is after 2013, then 

13 the amount specified in this subparagraph 

14 for a payment year for such professional is 

15 the same as the amount specified in clause 

16 (ii) for such payment year for an eligible 

17 professional whose first payment year is 

18 2013. If the first payment year for an eligi19 ble professional is after 2015 then the appli20 cable amount specified in this subparagraph 

21 for such professional for such year and any 

22 subsequent year shall be $0. 

23 ‘‘(C) NON-APPLICATION TO HOSPITAL-BASED

24 ELIGIBLE PROFESSIONALS.— 


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1 ‘‘(i) IN GENERAL.—No incentive pay2 ment may be made under this paragraph in 

3 the case of a hospital-based eligible profes4 sional. 

5 ‘‘(ii) HOSPITAL-BASED ELIGIBLE PRO6 FESSIONAL.—For purposes of clause (i), the 

7 term ‘hospital-based eligible professional’ 

8 means, with respect to covered professional 

9 services furnished by an eligible professional 

10 during the reporting period for a payment 

11 year, an eligible professional, such as a pa12 thologist, anesthesiologist, or emergency 

13 physician, who furnishes substantially all of 

14 such services in a hospital setting (whether 

15 inpatient or outpatient) and through the 

16 use of the facilities and equipment, includ17 ing computer equipment, of the hospital. 

18 ‘‘(D) PAYMENT.— 

19 ‘‘(i) FORM OF PAYMENT.—The pay20 ment under this paragraph may be in the 

21 form of a single consolidated payment or in 

22 the form of such periodic installments as the 

23 Secretary may specify. 

24 ‘‘(ii) COORDINATION OF APPLICATION

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1 FERENT PRACTICES.—In the case of an eli2 gible professional furnishing covered profes3 sional services in more than one practice 

4 (as specified by the Secretary), the Sec5 retary shall establish rules to coordinate the 

6 incentive payments, including the applica7 tion of the limitation on amounts of such 

8 incentive payments under this paragraph, 

9 among such practices. 

10 ‘‘(iii) COORDINATION WITH MED11 ICAID.—The Secretary shall seek, to the 

12 maximum extent practicable, to avoid du13 plicative requirements from Federal and 

14 State Governments to demonstrate meaning15 ful use of certified EHR technology under 

16 this title and title XIX. In doing so, the 

17 Secretary may deem satisfaction of State 

18 requirements for such meaningful use for a 

19 payment year under title XIX to be suffi20 cient to qualify as meaningful use under 

21 this subsection and subsection (a)(7) and 

22 vice versa. The Secretary may also adjust 

23 the reporting periods under such title and 

24 such subsections in order to carry out this 

25 clause. 


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1 ‘‘(E) PAYMENT YEAR DEFINED.— 

2 ‘‘(i) IN GENERAL.—For purposes of 

3 this subsection, the term ‘payment year’ 

4 means a year beginning with 2011. 

5 ‘‘(ii) FIRST, SECOND, ETC. PAYMENT

6 YEAR.—The term ‘first payment year’ 

7 means, with respect to covered professional 

8 services furnished by an eligible profes9 sional, the first year for which an incentive 

10 payment is made for such services under 

11 this subsection. The terms ‘second payment 

12 year’, ‘third payment year’, ‘fourth pay13 ment year’, and ‘fifth payment year’ mean, 

14 with respect to covered professional services 

15 furnished by such eligible professional, each 

16 successive year immediately following the 

17 first payment year for such professional. 

18 ‘‘(2) MEANINGFUL EHR USER.— 

19 ‘‘(A) IN GENERAL.—For purposes of para20 graph (1), an eligible professional shall be treat21 ed as a meaningful EHR user for a reporting 

22 period for a payment year (or, for purposes of 

23 subsection (a)(7), for a reporting period under 

24 such subsection for a year) if each of the fol25 lowing requirements is met: 


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1 ‘‘(i) MEANINGFUL USE OF CERTIFIED

2 EHR TECHNOLOGY.—The eligible profes3 sional demonstrates to the satisfaction of the 

4 Secretary, in accordance with subparagraph 

5 (C)(i), that during such period the profes6 sional is using certified EHR technology in 

7 a meaningful manner, which shall include 

8 the use of electronic prescribing as deter9 mined to be appropriate by the Secretary. 

10 ‘‘(ii) INFORMATION EXCHANGE.—The 

11 eligible professional demonstrates to the sat12 isfaction of the Secretary, in accordance 

13 with subparagraph (C)(i), that during such 

14 period such certified EHR technology is 

15 connected in a manner that provides, in ac16 cordance with law and standards applicable 

17 to the exchange of information, for the elec18 tronic exchange of health information to im19 prove the quality of health care, such as 

20 promoting care coordination. 

21 ‘‘(iii) REPORTING ON MEASURES USING

22 EHR.—Subject to subparagraph (B)(ii) and 

23 using such certified EHR technology, the el24 igible professional submits information for 

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1 fied by the Secretary, on such clinical qual2 ity measures and such other measures as se3 lected by the Secretary under subparagraph 

4 (B)(i). 

5 The Secretary may provide for the use of alter6 native means for meeting the requirements of 

7 clauses (i), (ii), and (iii) in the case of an eligi8 ble professional furnishing covered professional 

9 services in a group practice (as defined by the 

10 Secretary). The Secretary shall seek to improve 

11 the use of electronic health records and health 

12 care quality over time by requiring more strin13 gent measures of meaningful use selected under 

14 this paragraph. 

15 ‘‘(B) REPORTING ON MEASURES.— 

16 ‘‘(i) SELECTION.—The Secretary shall 

17 select measures for purposes of subpara18 graph (A)(iii) but only consistent with the 

19 following: 

20 ‘‘(I) The Secretary shall provide 

21 preference to clinical quality measures 

22 that have been endorsed by the entity 

23 with a contract with the Secretary 

24 under section 1890(a). 


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1 ‘‘(II) Prior to any measure being 

2 selected under this subparagraph, the 

3 Secretary shall publish in the Federal 

4 Register such measure and provide for 

5 a period of public comment on such 

6 measure. 

7 ‘‘(ii) LIMITATION.—The Secretary may 

8 not require the electronic reporting of infor9 mation on clinical quality measures under 

10 subparagraph (A)(iii) unless the Secretary 

11 has the capacity to accept the information 

12 electronically, which may be on a pilot 

13 basis. 

14 ‘‘(iii) COORDINATION OF REPORTING

15 OF INFORMATION.—In selecting such meas16 ures, and in establishing the form and man17 ner for reporting measures under subpara18 graph (A)(iii), the Secretary shall seek to 

19 avoid redundant or duplicative reporting 

20 otherwise required, including reporting 

21 under subsection (k)(2)(C). 

22 ‘‘(C) DEMONSTRATION OF MEANINGFUL USE

23 OF CERTIFIED EHR TECHNOLOGY AND INFORMA24 TION EXCHANGE.— 


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1 ‘‘(i) IN GENERAL.—A professional may 

2 satisfy the demonstration requirement of 

3 clauses (i) and (ii) of subparagraph (A) 

4 through means specified by the Secretary, 

5 which may include— 

6 ‘‘(I) an attestation; 

7 ‘‘(II) the submission of claims 

8 with appropriate coding (such as a 

9 code indicating that a patient encoun10 ter was documented using certified 

11 EHR technology); 

12 ‘‘(III) a survey response; 

13 ‘‘(IV) reporting under subpara14 graph (A)(iii); and 

15 ‘‘(V) other means specified by the 

16 Secretary. 

17 ‘‘(ii) USE OF PART D DATA.—Notwith18 standing sections 1860D–15(d)(2)(B) and 

19 1860D–15(f)(2), the Secretary may use data 

20 regarding drug claims submitted for pur21 poses of section 1860D–15 that are nec22 essary for purposes of subparagraph (A). 

23 ‘‘(3) APPLICATION.— 

24 ‘‘(A) PHYSICIAN REPORTING SYSTEM

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1 section (k) shall apply for purposes of this sub2 section in the same manner as they apply for 

3 purposes of such subsection. 

4 ‘‘(B) COORDINATION WITH OTHER PAY5 MENTS.—The provisions of this subsection shall 

6 not be taken into account in applying the provi7 sions of subsection (m) of this section and of sec8 tion 1833(m) and any payment under such pro9 visions shall not be taken into account in com10 puting allowable charges under this subsection. 

11 ‘‘(C) LIMITATIONS ON REVIEW.—There shall 

12 be no administrative or judicial review under 

13 section 1869, section 1878, or otherwise of the de14 termination of any incentive payment under this 

15 subsection and the payment adjustment under 

16 subsection (a)(7), including the determination of 

17 a meaningful EHR user under paragraph (2), a 

18 limitation under paragraph (1)(B), and the ex19 ception under subsection (a)(7)(B). 

20 ‘‘(D) POSTING ON WEBSITE.—The Secretary 

21 shall post on the Internet website of the Centers 

22 for Medicare & Medicaid Services, in an easily 

23 understandable format, a list of the names, busi24 ness addresses, and business phone numbers of 

25 the eligible professionals who are meaningful 


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1 EHR users and, as determined appropriate by 

2 the Secretary, of group practices receiving incen3 tive payments under paragraph (1). 

4 ‘‘(4) CERTIFIED EHR TECHNOLOGY DEFINED.— 

5 For purposes of this section, the term ‘certified EHR 

6 technology’ means a qualified electronic health record 

7 (as defined in 3000(13) of the Public Health Service 

8 Act) that is certified pursuant to section 3001(c)(5) of 

9 such Act as meeting standards adopted under section 

10 3004 of such Act that are applicable to the type of 

11 record involved (as determined by the Secretary, such 

12 as an ambulatory electronic health record for office13 based physicians or an inpatient hospital electronic 

14 health record for hospitals). 

15 ‘‘(5) DEFINITIONS.—For purposes of this sub16 section: 

17 ‘‘(A) COVERED PROFESSIONAL SERVICES.— 

18 The term ‘covered professional services’ has the 

19 meaning given such term in subsection (k)(3). 

20 ‘‘(B) ELIGIBLE PROFESSIONAL.—The term 

21 ‘eligible professional’ means a physician, as de22 fined in section 1861(r). 

23 ‘‘(C) REPORTING PERIOD.—The term ‘re24 porting period’ means any period (or periods), 


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1 with respect to a payment year, as specified by 

2 the Secretary.’’. 

3 (b) INCENTIVE PAYMENT ADJUSTMENT.—Section 

4 1848(a) of the Social Security Act (42 U.S.C. 1395w–4(a)) 

5 is amended by adding at the end the following new para6 graph: 

7 ‘‘(7) INCENTIVES FOR MEANINGFUL USE OF CER8 TIFIED EHR TECHNOLOGY.— 

9 ‘‘(A) ADJUSTMENT.— 

10 ‘‘(i) IN GENERAL.—Subject to subpara11 graphs (B) and (D), with respect to covered 

12 professional services furnished by an eligible 

13 professional during 2016 or any subsequent 

14 payment year, if the eligible professional is 

15 not a meaningful EHR user (as determined 

16 under subsection (o)(2)) for a reporting pe17 riod for the year, the fee schedule amount 

18 for such services furnished by such profes19 sional during the year (including the fee 

20 schedule amount for purposes of deter21 mining a payment based on such amount) 

22 shall be equal to the applicable percent of 

23 the fee schedule amount that would other24 wise apply to such services under this sub25 section (determined after application of 


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1 paragraph (3) but without regard to this 

2 paragraph). 

3 ‘‘(ii) APPLICABLE PERCENT.—Subject 

4 to clause (iii), for purposes of clause (i), the 

5 term ‘applicable percent’ means— 

6 ‘‘(I) for 2016, 99 percent; 

7 ‘‘(II) for 2017, 98 percent; and 

8 ‘‘(III) for 2018 and each subse9 quent year, 97 percent. 

10 ‘‘(iii) AUTHORITY TO DECREASE AP11 PLICABLE PERCENTAGE FOR 2019 AND SUB12 SEQUENT YEARS.—For 2019 and each sub13 sequent year, if the Secretary finds that the 

14 proportion of eligible professionals who are 

15 meaningful EHR users (as determined 

16 under subsection (o)(2)) is less than 75 per17 cent, the applicable percent shall be de18 creased by 1 percentage point from the ap19 plicable percent in the preceding year, but 

20 in no case shall the applicable percent be 

21 less than 95 percent. 

22 ‘‘(B) SIGNIFICANT HARDSHIP EXCEPTION.— 

23 The Secretary may, on a case-by-case basis, ex24 empt an eligible professional from the applica25 tion of the payment adjustment under subparaVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00146 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 graph (A) if the Secretary determines, subject to 

2 annual renewal, that compliance with the re3 quirement for being a meaningful EHR user 

4 would result in a significant hardship, such as 

5 in the case of an eligible professional who prac6 tices in a rural area without sufficient Internet 

7 access. In no case may an eligible professional be 

8 granted an exemption under this subparagraph 

9 for more than 5 years. 

10 ‘‘(C) APPLICATION OF PHYSICIAN REPORT11 ING SYSTEM RULES.—Paragraphs (5), (6), and 

12 (8) of subsection (k) shall apply for purposes of 

13 this paragraph in the same manner as they 

14 apply for purposes of such subsection. 

15 ‘‘(D) NON-APPLICATION TO HOSPITAL16 BASED ELIGIBLE PROFESSIONALS.—No payment 

17 adjustment may be made under subparagraph 

18 (A) in the case of hospital-based eligible profes19 sionals (as defined in subsection (o)(1)(C)(ii)). 

20 ‘‘(E) DEFINITIONS.—For purposes of this 

21 paragraph: 

22 ‘‘(i) COVERED PROFESSIONAL SERV23 ICES.—The term ‘covered professional serv24 ices’ has the meaning given such term in 

25 subsection (k)(3). 


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1 ‘‘(ii) ELIGIBLE PROFESSIONAL.—The 

2 term ‘eligible professional’ means a physi3 cian, as defined in section 1861(r). 

4 ‘‘(iii) REPORTING PERIOD.—The term 

5 ‘reporting period’ means, with respect to a 

6 year, a period specified by the Secretary.’’. 

7 (c) APPLICATION TO CERTAIN HMO-AFFILIATED ELI8 GIBLE PROFESSIONALS.—Section 1853 of the Social Secu9 rity Act (42 U.S.C. 1395w–23) is amended by adding at 

10 the end the following new subsection: 

11 ‘‘(l) APPLICATION OF ELIGIBLE PROFESSIONAL INCEN12 TIVES FOR CERTAIN MA ORGANIZATIONS FOR ADOPTION

13 AND MEANINGFUL USE OF CERTIFIED EHR TECH14 NOLOGY.— 

15 ‘‘(1) IN GENERAL.—Subject to paragraphs (3) 

16 and (4), in the case of a qualifying MA organization, 

17 the provisions of sections 1848(o) and 1848(a)(7) 

18 shall apply with respect to eligible professionals de19 scribed in paragraph (2) of the organization who the 

20 organization attests under paragraph (6) to be mean21 ingful EHR users in a similar manner as they apply 

22 to eligible professionals under such sections. Incentive 

23 payments under paragraph (3) shall be made to and 

24 payment adjustments under paragraph (4) shall 

25 apply to such qualifying organizations. 


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1 ‘‘(2) ELIGIBLE PROFESSIONAL DESCRIBED.— 

2 With respect to a qualifying MA organization, an eli3 gible professional described in this paragraph is an 

4 eligible professional (as defined for purposes of section 

5 1848(o)) who— 

6 ‘‘(A)(i) is employed by the organization; or 

7 ‘‘(ii)(I) is employed by, or is a partner of, 

8 an entity that through contract with the organi9 zation furnishes at least 80 percent of the enti10 ty’s patient care services to enrollees of such or11 ganization; and 

12 ‘‘(II) furnishes at least 75 percent of the 

13 professional services of the eligible professional to 

14 enrollees of the organization; and 

15 ‘‘(B) furnishes, on average, at least 20 hours 

16 per week of patient care services. 

17 ‘‘(3) ELIGIBLE PROFESSIONAL INCENTIVE PAY18 MENTS.— 

19 ‘‘(A) IN GENERAL.—In applying section 

20 1848(o) under paragraph (1), instead of the ad21 ditional payment amount under section 

22 1848(o)(1)(A) and subject to subparagraph (B), 

23 the Secretary may substitute an amount deter24 mined by the Secretary to the extent feasible and 

25 practical to be similar to the estimated amount 


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1 in the aggregate that would be payable if pay2 ment for services furnished by such professionals 

3 was payable under part B instead of this part. 

4 ‘‘(B) AVOIDING DUPLICATION OF PAY5 MENTS.— 

6 ‘‘(i) IN GENERAL.—If an eligible pro7 fessional described in paragraph (2) is eligi8 ble for the maximum incentive payment 

9 under section 1848(o)(1)(A) for the same 

10 payment period, the payment incentive 

11 shall be made only under such section and 

12 not under this subsection. 

13 ‘‘(ii) METHODS.—In the case of an eli14 gible professional described in paragraph 

15 (2) who is eligible for an incentive payment 

16 under section 1848(o)(1)(A) but is not de17 scribed in clause (i) for the same payment 

18 period, the Secretary shall develop a proc19 ess— 

20 ‘‘(I) to ensure that duplicate pay21 ments are not made with respect to an 

22 eligible professional both under this 

23 subsection and under section 

24 1848(o)(1)(A); and 


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1 ‘‘(II) to collect data from Medi2 care Advantage organizations to ensure 

3 against such duplicate payments. 

4 ‘‘(C) FIXED SCHEDULE FOR APPLICATION

5 OF LIMITATION ON INCENTIVE PAYMENTS FOR

6 ALL ELIGIBLE PROFESSIONALS.—In applying 

7 section 1848(o)(1)(B)(ii) under subparagraph 

8 (A), in accordance with rules specified by the 

9 Secretary, a qualifying MA organization shall 

10 specify a year (not earlier than 2011) that shall 

11 be treated as the first payment year for all eligi12 ble professionals with respect to such organiza13 tion. 

14 ‘‘(4) PAYMENT ADJUSTMENT.— 

15 ‘‘(A) IN GENERAL.—In applying section 

16 1848(a)(7) under paragraph (1), instead of the 

17 payment adjustment being an applicable percent 

18 of the fee schedule amount for a year under such 

19 section, subject to subparagraph (D), the pay20 ment adjustment under paragraph (1) shall be 

21 equal to the percent specified in subparagraph 

22 (B) for such year of the payment amount other23 wise provided under this section for such year. 

24 ‘‘(B) SPECIFIED PERCENT.—The percent 

25 specified under this subparagraph for a year is 


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1 100 percent minus a number of percentage 

2 points equal to the product of— 

3 ‘‘(i) the number of percentage points by 

4 which the applicable percent (under section 

5 1848(a)(7)(A)(ii)) for the year is less than 

6 100 percent; and 

7 ‘‘(ii) the Medicare physician expendi8 ture proportion specified in subparagraph 

9 (C) for the year. 

10 ‘‘(C) MEDICARE PHYSICIAN EXPENDITURE

11 PROPORTION.—The Medicare physician expendi12 ture proportion under this subparagraph for a 

13 year is the Secretary’s estimate of the propor14 tion, of the expenditures under parts A and B 

15 that are not attributable to this part, that are 

16 attributable to expenditures for physicians’ serv17 ices. 

18 ‘‘(D) APPLICATION OF PAYMENT ADJUST19 MENT.—In the case that a qualifying MA orga20 nization attests that not all eligible professionals 

21 are meaningful EHR users with respect to a 

22 year, the Secretary shall apply the payment ad23 justment under this paragraph based on the pro24 portion of such eligible professionals that are not 

25 meaningful EHR users for such year. 


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1 ‘‘(5) QUALIFYING MA ORGANIZATION DEFINED.— 

2 In this subsection and subsection (m), the term ‘quali3 fying MA organization’ means a Medicare Advantage 

4 organization that is organized as a health mainte5 nance organization (as defined in section 2791(b)(3) 

6 of the Public Health Service Act). 

7 ‘‘(6) MEANINGFUL EHR USER ATTESTATION.— 

8 For purposes of this subsection and subsection (m), a 

9 qualifying MA organization shall submit an attesta10 tion, in a form and manner specified by the Secretary 

11 which may include the submission of such attestation 

12 as part of submission of the initial bid under section 

13 1854(a)(1)(A)(iv), identifying— 

14 ‘‘(A) whether each eligible professional de15 scribed in paragraph (2), with respect to such 

16 organization is a meaningful EHR user (as de17 fined in section 1848(o)(2)) for a year specified 

18 by the Secretary; and 

19 ‘‘(B) whether each eligible hospital described 

20 in subsection (m)(1), with respect to such organi21 zation, is a meaningful EHR user (as defined in 

22 section 1886(n)(3)) for an applicable period 

23 specified by the Secretary.’’. 

24 (d) CONFORMING AMENDMENTS.—Section 1853 of the 

25 Social Security Act (42 U.S.C. 1395w–23) is amended— 


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1 (1) in subsection (a)(1)(A), by striking ‘‘and (i)’’ 

2 and inserting ‘‘(i), and (l)’’; 

3 (2) in subsection (c)— 

4 (A) in paragraph (1)(D)(i), by striking 

5 ‘‘section 1886(h)’’ and inserting ‘‘sections 

6 1848(o) and 1886(h)’’; and 

7 (B) in paragraph (6)(A), by inserting after 

8 ‘‘under part B,’’ the following: ‘‘excluding ex9 penditures attributable to subsections (a)(7) and 

10 (o) of section 1848,’’; and 

11 (3) in subsection (f), by inserting ‘‘and for pay12 ments under subsection (l)’’ after ‘‘with the organiza13 tion’’. 

14 (e) CONFORMING AMENDMENTS TO E-PRESCRIBING.— 

15 (1) Section 1848(a)(5)(A) of the Social Security 

16 Act (42 U.S.C. 1395w–4(a)(5)(A)) is amended— 

17 (A) in clause (i), by striking ‘‘or any subse18 quent year’’ and inserting ‘‘, 2013, 2014, or 

19 2015’’; and 

20 (B) in clause (ii), by striking ‘‘and each 

21 subsequent year’’ and inserting ‘‘and 2015’’. 

22 (2) Section 1848(m)(2) of such Act (42 U.S.C. 

23 1395w–4(m)(2)) is amended— 


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1 (A) in subparagraph (A), by striking ‘‘For 

2 2009’’ and inserting ‘‘Subject to subparagraph 

3 (D), for 2009’’; and 

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

5 subparagraph: 

6 ‘‘(D) LIMITATION WITH RESPECT TO EHR

7 INCENTIVE PAYMENTS.—The provisions of this 

8 paragraph shall not apply to an eligible profes9 sional (or, in the case of a group practice under 

10 paragraph (3)(C), to the group practice) if, for 

11 the reporting period the eligible professional (or 

12 group practice) receives an incentive payment 

13 under subsection (o)(1)(A) with respect to a cer14 tified EHR technology (as defined in subsection 

15 (o)(4)) that has the capability of electronic pre16 scribing.’’. 

17 SEC. 4312. INCENTIVES FOR HOSPITALS. 

18 (a) INCENTIVE PAYMENT.—Section 1886 of the Social 

19 Security Act (42 U.S.C. 1395ww) is amended by adding 

20 at the end the following new subsection: 

21 ‘‘(n) INCENTIVES FOR ADOPTION AND MEANINGFUL

22 USE OF CERTIFIED EHR TECHNOLOGY.— 

23 ‘‘(1) IN GENERAL.—Subject to the succeeding 

24 provisions of this subsection, with respect to inpatient 

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1 ing a payment year (as defined in paragraph 

2 (2)(G)), if the eligible hospital is a meaningful EHR 

3 user (as determined under paragraph (3)) for the re4 porting period with respect to such year, in addition 

5 to the amount otherwise paid under this section, there 

6 also shall be paid to the eligible hospital, from the 

7 Federal Hospital Insurance Trust Fund established 

8 under section 1817, an amount equal to the applica9 ble amount specified in paragraph (2)(A) for the hos10 pital for such payment year. 

11 ‘‘(2) PAYMENT AMOUNT.— 

12 ‘‘(A) IN GENERAL.—Subject to the suc13 ceeding subparagraphs of this paragraph, the ap14 plicable amount specified in this subparagraph 

15 for an eligible hospital for a payment year is 

16 equal to the product of the following: 

17 ‘‘(i) INITIAL AMOUNT.—The sum of— 

18 ‘‘(I) the base amount specified in 

19 subparagraph (B); plus 

20 ‘‘(II) the discharge related amount 

21 specified in subparagraph (C) for a 12- 

22 month period selected by the Secretary 

23 with respect to such payment year. 

24 ‘‘(ii) MEDICARE SHARE.—The Medi25 care share as specified in subparagraph (D) 


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1 for the hospital for a period selected by the 

2 Secretary with respect to such payment 

3 year. 

4 ‘‘(iii) TRANSITION FACTOR.—The tran5 sition factor specified in subparagraph (E) 

6 for the hospital for the payment year. 

7 ‘‘(B) BASE AMOUNT.—The base amount 

8 specified in this subparagraph is $2,000,000. 

9 ‘‘(C) DISCHARGE RELATED AMOUNT.—The 

10 discharge related amount specified in this sub11 paragraph for a 12-month period selected by the 

12 Secretary shall be determined as the sum of the 

13 amount, based upon total discharges (regardless 

14 of any source of payment) for the period, for 

15 each discharge up to the 23,000th discharge as 

16 follows: 

17 ‘‘(i) For the 1,150th through the 

18 9,200th discharge, $200. 

19 ‘‘(ii) For the 9,201st through the 

20 13,800th discharge, 50 percent of the 

21 amount specified in clause (i). 

22 ‘‘(iii) For the 13,801st through the 

23 23,000th discharge, 30 percent of the 

24 amount specified in clause (i). 


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1 ‘‘(D) MEDICARE SHARE.—The Medicare 

2 share specified under this subparagraph for a 

3 hospital for a period selected by the Secretary for 

4 a payment year is equal to the fraction— 

5 ‘‘(i) the numerator of which is the sum 

6 (for such period and with respect to the hos7 pital) of— 

8 ‘‘(I) the number of inpatient-bed9 days (as established by the Secretary) 

10 which are attributable to individuals 

11 with respect to whom payment may be 

12 made under part A; and 

13 ‘‘(II) the number of inpatient-bed14 days (as so established) which are at15 tributable to individuals who are en16 rolled with a Medicare Advantage or17 ganization under part C; and 

18 ‘‘(ii) the denominator of which is the 

19 product of— 

20 ‘‘(I) the total number of inpa21 tient-bed-days with respect to the hos22 pital during such period; and 

23 ‘‘(II) the total amount of the hos24 pital’s charges during such period, not 

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1 utable to charity care (as such term is 

2 used for purposes of hospital cost re3 porting under this title), divided by the 

4 total amount of the hospital’s charges 

5 during such period. 

6 Insofar as the Secretary determines that data are 

7 not available on charity care necessary to cal8 culate the portion of the formula specified in 

9 clause (ii)(II), the Secretary shall use data on 

10 uncompensated care and may adjust such data 

11 so as to be an appropriate proxy for charity care 

12 including a downward adjustment to eliminate 

13 bad debt data from uncompensated care data. In 

14 the absence of the data necessary, with respect to 

15 a hospital, for the Secretary to compute the 

16 amount described in clause (ii)(II), the amount 

17 under such clause shall be deemed to be 1. In the 

18 absence of data, with respect to a hospital, nec19 essary to compute the amount described in clause 

20 (i)(II), the amount under such clause shall be 

21 deemed to be 0. 

22 ‘‘(E) TRANSITION FACTOR SPECIFIED.— 

23 ‘‘(i) IN GENERAL.—Subject to clause 

24 (ii), the transition factor specified in this 


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1 subparagraph for an eligible hospital for a 

2 payment year is as follows: 

3 ‘‘(I) For the first payment year 

4 for such hospital, 1. 

5 ‘‘(II) For the second payment 

year for such hospital, 3 6 ⁄4. 

7 ‘‘(III) For the third payment year 

for such hospital, 1 8 ⁄2. 

9 ‘‘(IV) For the fourth payment 

year for such hospital, 1 10 ⁄4. 

11 ‘‘(V) For any succeeding payment 

12 year for such hospital, 0. 

13 ‘‘(ii) PHASE DOWN FOR ELIGIBLE HOS14 PITALS FIRST ADOPTING EHR AFTER 2013.— 

15 If the first payment year for an eligible hos16 pital is after 2013, then the transition fac17 tor specified in this subparagraph for a 

18 payment year for such hospital is the same 

19 as the amount specified in clause (i) for 

20 such payment year for an eligible hospital 

21 for which the first payment year is 2013. If 

22 the first payment year for an eligible hos23 pital is after 2015 then the transition factor 

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1 pital and for such year and any subsequent 

2 year shall be 0. 

3 ‘‘(F) FORM OF PAYMENT.—The payment 

4 under this subsection for a payment year may be 

5 in the form of a single consolidated payment or 

6 in the form of such periodic installments as the 

7 Secretary may specify. 

8 ‘‘(G) PAYMENT YEAR DEFINED.— 

9 ‘‘(i) IN GENERAL.—For purposes of 

10 this subsection, the term ‘payment year’ 

11 means a fiscal year beginning with fiscal 

12 year 2011. 

13 ‘‘(ii) FIRST, SECOND, ETC. PAYMENT

14 YEAR.—The term ‘first payment year’ 

15 means, with respect to inpatient hospital 

16 services furnished by an eligible hospital, 

17 the first fiscal year for which an incentive 

18 payment is made for such services under 

19 this subsection. The terms ‘second payment 

20 year’, ‘third payment year’, and ‘fourth 

21 payment year’ mean, with respect to an eli22 gible hospital, each successive year imme23 diately following the first payment year for 

24 that hospital. 

25 ‘‘(3) MEANINGFUL EHR USER.— 


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1 ‘‘(A) IN GENERAL.—For purposes of para2 graph (1), an eligible hospital shall be treated as 

3 a meaningful EHR user for a reporting period 

4 for a payment year (or, for purposes of sub5 section (b)(3)(B)(ix), for a reporting period 

6 under such subsection for a fiscal year) if each 

7 of the following requirements are met: 

8 ‘‘(i) MEANINGFUL USE OF CERTIFIED

9 EHR TECHNOLOGY.—The eligible hospital 

10 demonstrates to the satisfaction of the Sec11 retary, in accordance with subparagraph 

12 (C)(i), that during such period the hospital 

13 is using certified EHR technology in a 

14 meaningful manner. 

15 ‘‘(ii) INFORMATION EXCHANGE.—The 

16 eligible hospital demonstrates to the satis17 faction of the Secretary, in accordance with 

18 subparagraph (C)(i), that during such pe19 riod such certified EHR technology is con20 nected in a manner that provides, in ac21 cordance with law and standards applicable 

22 to the exchange of information, for the elec23 tronic exchange of health information to im24 prove the quality of health care, such as 

25 promoting care coordination. 


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1 ‘‘(iii) REPORTING ON MEASURES USING

2 EHR.—Subject to subparagraph (B)(ii) and 

3 using such certified EHR technology, the el4 igible hospital submits information for such 

5 period, in a form and manner specified by 

6 the Secretary, on such clinical quality 

7 measures and such other measures as se8 lected by the Secretary under subparagraph 

9 (B)(i). 

10 The Secretary shall seek to improve the use of 

11 electronic health records and health care quality 

12 over time by requiring more stringent measures 

13 of meaningful use selected under this paragraph. 

14 ‘‘(B) REPORTING ON MEASURES.— 

15 ‘‘(i) SELECTION.—The Secretary shall 

16 select measures for purposes of subpara17 graph (A)(iii) but only consistent with the 

18 following: 

19 ‘‘(I) The Secretary shall provide 

20 preference to clinical quality measures 

21 that have been selected for purposes of 

22 applying subsection (b)(3)(B)(viii) or 

23 that have been endorsed by the entity 

24 with a contract with the Secretary 

25 under section 1890(a). 


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1 ‘‘(II) Prior to any measure (other 

2 than a clinical quality measure that 

3 has been selected for purposes of apply4 ing subsection (b)(3)(B)(viii)) being se5 lected under this subparagraph, the 

6 Secretary shall publish in the Federal 

7 Register such measure and provide for 

8 a period of public comment on such 

9 measure. 

10 ‘‘(ii) LIMITATIONS.—The Secretary 

11 may not require the electronic reporting of 

12 information on clinical quality measures 

13 under subparagraph (A)(iii) unless the Sec14 retary has the capacity to accept the infor15 mation electronically, which may be on a 

16 pilot basis. 

17 ‘‘(iii) COORDINATION OF REPORTING

18 OF INFORMATION.—In selecting such meas19 ures, and in establishing the form and man20 ner for reporting measures under subpara21 graph (A)(iii), the Secretary shall seek to 

22 avoid redundant or duplicative reporting 

23 with reporting otherwise required, including 

24 reporting under subsection (b)(3)(B)(viii). 


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1 ‘‘(C) DEMONSTRATION OF MEANINGFUL USE

2 OF CERTIFIED EHR TECHNOLOGY AND INFORMA3 TION EXCHANGE.— 

4 ‘‘(i) IN GENERAL.—A hospital may 

5 satisfy the demonstration requirement of 

6 clauses (i) and (ii) of subparagraph (A) 

7 through means specified by the Secretary, 

8 which may include— 

9 ‘‘(I) an attestation; 

10 ‘‘(II) the submission of claims 

11 with appropriate coding (such as a 

12 code indicating that inpatient care 

13 was documented using certified EHR 

14 technology); 

15 ‘‘(III) a survey response; 

16 ‘‘(IV) reporting under subpara17 graph (A)(iii); and 

18 ‘‘(V) other means specified by the 

19 Secretary. 

20 ‘‘(ii) USE OF PART D DATA.—Notwith21 standing sections 1860D–15(d)(2)(B) and 

22 1860D–15(f)(2), the Secretary may use data 

23 regarding drug claims submitted for pur24 poses of section 1860D–15 that are nec25 essary for purposes of subparagraph (A). 


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1 ‘‘(4) APPLICATION.— 

2 ‘‘(A) LIMITATIONS ON REVIEW.—There shall 

3 be no administrative or judicial review under 

4 section 1869, section 1878, or otherwise of the de5 termination of any incentive payment under this 

6 subsection and the payment adjustment under 

7 subsection (b)(3)(B)(ix), including the deter8 mination of a meaningful EHR user under 

9 paragraph (3), determination of measures appli10 cable to services furnished by eligible hospitals 

11 under this subsection, and the exception under 

12 subsection (b)(3)(B)(ix)(II). 

13 ‘‘(B) POSTING ON WEBSITE.—The Secretary 

14 shall post on the Internet website of the Centers 

15 for Medicare & Medicaid Services, in an easily 

16 understandable format, a list of the names of the 

17 eligible hospitals that are meaningful EHR users 

18 under this subsection or subsection (b)(3)(B)(ix) 

19 and other relevant data as determined appro20 priate by the Secretary. The Secretary shall en21 sure that a hospital has the opportunity to re22 view the other relevant data that are to be made 

23 public with respect to the hospital prior to such 

24 data being made public. 


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1 ‘‘(5) CERTIFIED EHR TECHNOLOGY DEFINED.— 

2 The term ‘certified EHR technology’ has the meaning 

3 given such term in section 1848(o)(4). 

4 ‘‘(6) DEFINITIONS.—For purposes of this sub5 section: 

6 ‘‘(A) ELIGIBLE HOSPITAL.—The term ‘eligi7 ble hospital’ means a subsection (d) hospital. 

8 ‘‘(B) REPORTING PERIOD.—The term ‘re9 porting period’ means any period (or periods), 

10 with respect to a payment year, as specified by 

11 the Secretary.’’. 

12 (b) INCENTIVE MARKET BASKET ADJUSTMENT.—Sec13 tion 1886(b)(3)(B) of the Social Security Act (42 U.S.C. 

14 1395ww(b)(3)(B)) is amended— 

15 (1) in clause (viii)(I), by inserting ‘‘(or, begin16 ning with fiscal year 2016, by one-quarter)’’ after 

17 ‘‘2.0 percentage points’’; and 

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

19 clause: 

20 ‘‘(ix)(I) For purposes of clause (i) for fiscal year 2016 

21 and each subsequent fiscal year, in the case of an eligible 

22 hospital (as defined in subsection (n)(6)(A)) that is not a 

23 meaningful EHR user (as defined in subsection (n)(3)) for 

24 the reporting period for such fiscal year, three-quarters of 

25 the applicable percentage increase otherwise applicable 


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1 under clause (i) for such fiscal year shall be reduced by 

331⁄3 percent for fiscal year 2016, 662 2 ⁄3 percent for fiscal 

3 year 2017, and 100 percent for fiscal year 2018 and each 

4 subsequent fiscal year. Such reduction shall apply only with 

5 respect to the fiscal year involved and the Secretary shall 

6 not take into account such reduction in computing the ap7 plicable percentage increase under clause (i) for a subse8 quent fiscal year. 

9 ‘‘(II) The Secretary may, on a case-by-case basis, ex10 empt a subsection (d) hospital from the application of sub11 clause (I) with respect to a fiscal year if the Secretary deter12 mines, subject to annual renewal, that requiring such hos13 pital to be a meaningful EHR user during such fiscal year 

14 would result in a significant hardship, such as in the case 

15 of a hospital in a rural area without sufficient Internet ac16 cess. In no case may a hospital be granted an exemption 

17 under this subclause for more than 5 years. 

18 ‘‘(III) For fiscal year 2016 and each subsequent fiscal 

19 year, a State in which hospitals are paid for services under 

20 section 1814(b)(3) shall adjust the payments to each sub21 section (d) hospital in the State that is not a meaningful 

22 EHR user (as defined in subsection (n)(3)) in a manner 

23 that is designed to result in an aggregate reduction in pay24 ments to hospitals in the State that is equivalent to the ag25 gregate reduction that would have occurred if payments had 


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1 been reduced to each subsection (d) hospital in the State 

2 in a manner comparable to the reduction under the pre3 vious provisions of this clause. The State shall report to 

4 the Secretary the methodology it will use to make the pay5 ment adjustment under the previous sentence. 

6 ‘‘(IV) For purposes of this clause, the term ‘reporting 

7 period’ means, with respect to a fiscal year, any period (or 

8 periods), with respect to the fiscal year, as specified by the 

9 Secretary.’’. 

10 (c) APPLICATION TO CERTAIN HMO-AFFILIATED ELI11 GIBLE HOSPITALS.—Section 1853 of the Social Security 

12 Act (42 U.S.C. 1395w–23), as amended by section 4311(c), 

13 is further amended by adding at the end the following new 

14 subsection: 

15 ‘‘(m) APPLICATION OF ELIGIBLE HOSPITAL INCEN16 TIVES FOR CERTAIN MA ORGANIZATIONS FOR ADOPTION

17 AND MEANINGFUL USE OF CERTIFIED EHR TECH18 NOLOGY.— 

19 ‘‘(1) APPLICATION.—Subject to paragraphs (3) 

20 and (4), in the case of a qualifying MA organization, 

21 the provisions of sections 1886(n) and 

22 1886(b)(3)(B)(ix) shall apply with respect to eligible 

23 hospitals described in paragraph (2) of the organiza24 tion which the organization attests under subsection 

25 (l)(6) to be meaningful EHR users in a similar manVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00169 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 ner as they apply to eligible hospitals under such sec2 tions. Incentive payments under paragraph (3) shall 

3 be made to and payment adjustments under para4 graph (4) shall apply to such qualifying organiza5 tions. 

6 ‘‘(2) ELIGIBLE HOSPITAL DESCRIBED.—With re7 spect to a qualifying MA organization, an eligible 

8 hospital described in this paragraph is an eligible 

9 hospital that is under common corporate governance 

10 with such organization and serves individuals en11 rolled under an MA plan offered by such organiza12 tion. 

13 ‘‘(3) ELIGIBLE HOSPITAL INCENTIVE PAY14 MENTS.— 

15 ‘‘(A) IN GENERAL.—In applying section 

16 1886(n)(2) under paragraph (1), instead of the 

17 additional payment amount under section 

18 1886(n)(2), there shall be substituted an amount 

19 determined by the Secretary to be similar to the 

20 estimated amount in the aggregate that would be 

21 payable if payment for services furnished by 

22 such hospitals was payable under part A instead 

23 of this part. In implementing the previous sen24 tence, the Secretary— 


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1 ‘‘(i) shall, insofar as data to determine 

2 the discharge related amount under section 

3 1886(n)(2)(C) for an eligible hospital are 

4 not available to the Secretary, use such al5 ternative data and methodology to estimate 

6 such discharge related amount as the Sec7 retary determines appropriate; and 

8 ‘‘(ii) shall, insofar as data to deter9 mine the medicare share described in sec10 tion 1886(n)(2)(D) for an eligible hospital 

11 are not available to the Secretary, use such 

12 alternative data and methodology to esti13 mate such share, which data and method14 ology may include use of the inpatient bed 

15 days (or discharges) with respect to an eli16 gible hospital during the appropriate period 

17 which are attributable to both individuals 

18 for whom payment may be made under 

19 part A or individuals enrolled in an MA 

20 plan under a Medicare Advantage organiza21 tion under this part as a proportion of the 

22 total number of patient-bed-days (or dis23 charges) with respect to such hospital dur24 ing such period. 


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1 ‘‘(B) AVOIDING DUPLICATION OF PAY2 MENTS.— 

3 ‘‘(i) IN GENERAL.—In the case of a 

4 hospital that for a payment year is an eli5 gible hospital described in paragraph (2), is 

6 an eligible hospital under section 1886(n), 

7 and for which at least one-third of their dis8 charges (or bed-days) of Medicare patients 

9 for the year are covered under part A, pay10 ment for the payment year shall be made 

11 only under section 1886(n) and not under 

12 this subsection. 

13 ‘‘(ii) METHODS.—In the case of a hos14 pital that is an eligible hospital described 

15 in paragraph (2) and also is eligible for an 

16 incentive payment under section 1886(n) 

17 but is not described in clause (i) for the 

18 same payment period, the Secretary shall 

19 develop a process— 

20 ‘‘(I) to ensure that duplicate pay21 ments are not made with respect to an 

22 eligible hospital both under this sub23 section and under section 1886(n); and 


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1 ‘‘(II) to collect data from Medi2 care Advantage organizations to ensure 

3 against such duplicate payments. 

4 ‘‘(4) PAYMENT ADJUSTMENT.— 

5 ‘‘(A) Subject to paragraph (3), in the case 

6 of a qualifying MA organization (as defined in 

7 section 1853(l)(5)), if, according to the attesta8 tion of the organization submitted under sub9 section (l)(6) for an applicable period, one or 

10 more eligible hospitals (as defined in section 

11 1886(n)(6)(A)) that are under common corporate 

12 governance with such organization and that 

13 serve individuals enrolled under a plan offered 

14 by such organization are not meaningful EHR 

15 users (as defined in section 1886(n)(3)) with re16 spect to a period, the payment amount payable 

17 under this section for such organization for such 

18 period shall be the percent specified in subpara19 graph (B) for such period of the payment 

20 amount otherwise provided under this section for 

21 such period. 

22 ‘‘(B) SPECIFIED PERCENT.—The percent 

23 specified under this subparagraph for a year is 

24 100 percent minus a number of percentage 

25 points equal to the product of— 


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1 ‘‘(i) the number of the percentage point 

2 reduction effected under section 

3 1886(b)(3)(B)(ix)(I) for the period; and 

4 ‘‘(ii) the Medicare hospital expenditure 

5 proportion specified in subparagraph (C) 

6 for the year. 

7 ‘‘(C) MEDICARE HOSPITAL EXPENDITURE

8 PROPORTION.—The Medicare hospital expendi9 ture proportion under this subparagraph for a 

10 year is the Secretary’s estimate of the propor11 tion, of the expenditures under parts A and B 

12 that are not attributable to this part, that are 

13 attributable to expenditures for inpatient hos14 pital services. 

15 ‘‘(D) APPLICATION OF PAYMENT ADJUST16 MENT.—In the case that a qualifying MA orga17 nization attests that not all eligible hospitals are 

18 meaningful EHR users with respect to an appli19 cable period, the Secretary shall apply the pay20 ment adjustment under this paragraph based on 

21 a methodology specified by the Secretary, taking 

22 into account the proportion of such eligible hos23 pitals, or discharges from such hospitals, that are 

24 not meaningful EHR users for such period.’’. 

25 (d) CONFORMING AMENDMENTS.— 


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1 (1) Section 1814(b) of the Social Security Act 

2 (42 U.S.C. 1395f(b)) is amended— 

3 (A) in paragraph (3), in the matter pre4 ceding subparagraph (A), by inserting ‘‘, subject 

5 to section 1886(d)(3)(B)(ix)(III),’’ after ‘‘then’’; 

6 and 

7 (B) by adding at the end the following: 

8 ‘‘For purposes of applying paragraph (3), there 

9 shall be taken into account incentive payments, 

10 and payment adjustments under subsection 

11 (b)(3)(B)(ix) or (n) of section 1886.’’. 

12 (2) Section 1851(i)(1) of the Social Security Act 

13 (42 U.S.C. 1395w–21(i)(1)) is amended by striking 

14 ‘‘and 1886(h)(3)(D)’’ and inserting ‘‘1886(h)(3)(D), 

15 and 1853(m)’’. 

16 (3) Section 1853 of the Social Security Act (42 

17 U.S.C. 1395w–23), as amended by section 4311(d)(1), 

18 is amended— 

19 (A) in subsection (c)— 

20 (i) in paragraph (1)(D)(i), by striking 

21 ‘‘1848(o)’’ and inserting ‘‘, 1848(o), and 

22 1886(n)’’; and 

23 (ii) in paragraph (6)(A), by inserting 

24 ‘‘and subsections (b)(3)(B)(ix) and (n) of 

25 section 1886’’ after ‘‘section 1848’’; and 


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1 (B) in subsection (f), by inserting ‘‘and sub2 section (m)’’ after ‘‘under subsection (l)’’. 

3 SEC. 4313. TREATMENT OF PAYMENTS AND SAVINGS; IMPLE4 MENTATION FUNDING. 

5 (a) PREMIUM HOLD HARMLESS.— 

6 (1) IN GENERAL.—Section 1839(a)(1) of the So7 cial Security Act (42 U.S.C. 1395r(a)(1)) is amended 

8 by adding at the end the following: ‘‘In applying this 

9 paragraph there shall not be taken into account addi10 tional payments under section 1848(o) and section 

11 1853(l)(3) and the Government contribution under 

12 section 1844(a)(3).’’. 

13 (2) PAYMENT.—Section 1844(a) of such Act (42 

14 U.S.C. 1395w(a)) is amended— 

15 (A) in paragraph (2), by striking the period 

16 at the end and inserting ‘‘; plus’’; and 

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

18 paragraph: 

19 ‘‘(3) a Government contribution equal to the 

20 amount of payment incentives payable under sections 

21 1848(o) and 1853(l)(3).’’. 

22 (b) MEDICARE IMPROVEMENT FUND.—Section 1898 of 

23 the Social Security Act (42 U.S.C. 1395iii), as added by 

24 section 7002(a) of the Supplemental Appropriations Act, 

25 2008 (Public Law 110–252) and as amended by section 


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1 188(a)(2) of the Medicare Improvements for Patients and 

2 Providers Act of 2008 (Public Law 110–275; 122 Stat. 

3 2589) and by section 6 of the QI Program Supplemental 

4 Funding Act of 2008, is amended— 

5 (1) in subsection (a)— 

6 (A) by inserting ‘‘medicare’’ before ‘‘fee-for7 service’’; and 

8 (B) by inserting before the period at the end 

9 the following: ‘‘including, but not limited to, an 

10 increase in the conversion factor under section 

11 1848(d) to address, in whole or in part, any pro12 jected shortfall in the conversion factor for 2014 

13 relative to the conversion factor for 2008 and ad14 justments to payments for items and services fur15 nished by providers of services and suppliers 

16 under such original medicare fee-for-service pro17 gram’’; and 

18 (2) in subsection (b)— 

19 (A) in paragraph (1), by striking ‘‘during 

20 fiscal year 2014,’’ and all that follows and in21 serting the following: ‘‘during— 

22 ‘‘(A) fiscal year 2014, $22,290,000,000; and 

23 ‘‘(B) fiscal year 2020 and each subsequent 

24 fiscal year, the Secretary’s estimate, as of July 

25 1 of the fiscal year, of the aggregate reduction in 


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1 expenditures under this title during the pre2 ceding fiscal year directly resulting from the re3 duction in payment amounts under sections 

4 1848(a)(7), 1853(l)(4), 1853(m)(4), and 

5 1886(b)(3)(B)(ix).’’; and 

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

7 paragraph: 

8 ‘‘(4) NO EFFECT ON PAYMENTS IN SUBSEQUENT

9 YEARS.—In the case that expenditures from the Fund 

10 are applied to, or otherwise affect, a payment rate for 

11 an item or service under this title for a year, the pay12 ment rate for such item or service shall be computed 

13 for a subsequent year as if such application or effect 

14 had never occurred.’’. 

15 (c) IMPLEMENTATION FUNDING.—In addition to funds 

16 otherwise available, out of any funds in the Treasury not 

17 otherwise appropriated, there are appropriated to the Sec18 retary of Health and Human Services for the Center for 

19 Medicare & Medicaid Services Program Management Ac20 count, $60,000,000 for each of fiscal years 2009 through 

21 2015 and $30,000,000 for each succeeding fiscal year 

22 through fiscal year 2019, which shall be available for pur23 poses of carrying out the provisions of (and amendments 

24 made by) this part. Amounts appropriated under this sub25 section for a fiscal year shall be available until expended. 


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1 SEC. 4314. STUDY ON APPLICATION OF EHR PAYMENT IN2 CENTIVES FOR PROVIDERS NOT RECEIVING 

3 OTHER INCENTIVE PAYMENTS. 

4 (a) STUDY.— 

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

6 Human Services shall conduct a study to determine 

7 the extent to which and manner in which payment 

8 incentives (such as under title XVIII or XIX of the 

9 Social Security Act) and other funding for purposes 

10 of implementing and using certified EHR technology 

11 (as defined in section 3000 of the Public Health Serv12 ice Act) should be made available to health care pro13 viders who are receiving minimal or no payment in14 centives or other funding under this Act, under title 

15 XVIII or XIX of the Social Security Act, or otherwise, 

16 for such purposes. 

17 (2) DETAILS OF STUDY.—Such study shall in18 clude an examination of— 

19 (A) the adoption rates of certified EHR 

20 technology by such health care providers; 

21 (B) the clinical utility of such technology by 

22 such health care providers; 

23 (C) whether the services furnished by such 

24 health care providers are appropriate for or 

25 would benefit from the use of such technology; 


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1 (D) the extent to which such health care 

2 providers work in settings that might otherwise 

3 receive an incentive payment or other funding 

4 under this Act, title XVIII or XIX of the Social 

5 Security Act, or otherwise; 

6 (E) the potential costs and the potential 

7 benefits of making payment incentives and other 

8 funding available to such health care providers; 

9 and 

10 (F) any other issues the Secretary deems to 

11 be appropriate. 

12 (b) REPORT.—Not later than June 30, 2010, the Sec13 retary shall submit to Congress a report on the findings 

14 and conclusions of the study conducted under subsection (a). 

15 PART III—MEDICAID FUNDING 

16 SEC. 4321. MEDICAID PROVIDER HIT ADOPTION AND OPER17 ATION PAYMENTS; IMPLEMENTATION FUND18 ING. 

19 (a) IN GENERAL.—Section 1903 of the Social Security 

20 Act (42 U.S.C. 1396b) is amended— 

21 (1) in subsection (a)(3)— 

22 (A) by striking ‘‘and’’ at the end of sub23 paragraph (D); 

24 (B) by striking ‘‘plus’’ at the end of sub25 paragraph (E) and inserting ‘‘and’’; and 


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

2 subparagraph: 

3 ‘‘(F)(i) 100 percent of so much of the sums 

4 expended during such quarter as are attributable 

5 to payments for certified EHR technology (and 

6 support services including maintenance and 

7 training that is for, or is necessary for the adop8 tion and operation of, such technology) by Med9 icaid providers described in subsection (t)(1); 

10 and 

11 ‘‘(ii) 90 percent of so much of the sums ex12 pended during such quarter as are attributable 

13 to payments for reasonable administrative ex14 penses related to the administration of payments 

15 described in clause (i) if the State meets the con16 dition described in subsection (t)(9); plus’’; and 

17 (2) by inserting after subsection (s) the following 

18 new subsection: 

19 ‘‘(t)(1) For purposes of subsection (a)(3)(F), the pay20 ments for certified EHR technology (and support services 

21 including maintenance that is for, or is necessary for the 

22 operation of, such technology) by Medicaid providers de23 scribed in this paragraph are payments made by the State 

24 in accordance with this subsection of 85 percent of the net 


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1 allowable costs of Medicaid providers (as defined in para2 graph (2)) for such technology (and support services). 

3 ‘‘(2) In this subsection and subsection (a)(3)(F), the 

4 term ‘Medicaid provider’ means— 

5 ‘‘(A) an eligible professional (as defined in para6 graph (3)(B)) who is not hospital-based and has at 

7 least 30 percent of the professional’s patient volume 

8 (as estimated in accordance with standards estab9 lished by the Secretary) attributable to individuals 

10 who are receiving medical assistance under this title; 

11 and 

12 ‘‘(B)(i) a children’s hospital, (ii) an acute-care 

13 hospital that is not described in clause (i) and that 

14 has at least 10 percent of the hospital’s patient vol15 ume (as estimated in accordance with standards es16 tablished by the Secretary) attributable to individuals 

17 who are receiving medical assistance under this title, 

18 or (iii) a Federally-qualified health center or rural 

19 health clinic that has at least 30 percent of the cen20 ter’s or clinic’s patient volume (as estimated in ac21 cordance with standards established by the Secretary) 

22 attributable to individuals who are receiving medical 

23 assistance under this title. 

24 An eligible professional shall not qualify as a Medicaid pro25 vider under this subsection unless the eligible professional 


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1 has waived, in a manner specified by the Secretary, any 

2 right to payment under section 1848(o) with respect to the 

3 adoption or support of certified EHR technology by the pro4 fessional. In applying clauses (ii) and (iii) of subparagraph 

5 (B), the standards established by the Secretary for patient 

6 volume shall include individuals enrolled in a Medicaid 

7 managed care plan (under section 1903(m) or section 

8 1932). 

9 ‘‘(3) In this subsection and subsection (a)(3)(F): 

10 ‘‘(A) The term ‘certified EHR technology’ means 

11 a qualified electronic health record (as defined in 

12 3000(13) of the Public Health Service Act) that is cer13 tified pursuant to section 3001(c)(5) of such Act as 

14 meeting standards adopted under section 3004 of such 

15 Act that are applicable to the type of record involved 

16 (as determined by the Secretary, such as an ambula17 tory electronic health record for office-based physi18 cians or an inpatient hospital electronic health record 

19 for hospitals). 

20 ‘‘(B) The term ‘eligible professional’ means a 

21 physician as defined in paragraphs (1) and (2) of 

22 section 1861(r), and includes a nurse mid-wife and a 

23 nurse practitioner. 

24 ‘‘(C) The term ‘hospital-based’ means, with re25 spect to an eligible professional, a professional (such 


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1 as a pathologist, anesthesiologist, or emergency physi2 cian) who furnishes substantially all of the individ3 ual’s professional services in a hospital setting 

4 (whether inpatient or outpatient) and through the use 

5 of the facilities and equipment, including computer 

6 equipment, of the hospital. 

7 ‘‘(4)(A) The term ‘allowable costs’ means, with respect 

8 to certified EHR technology of a Medicaid provider, costs 

9 of such technology (and support services including mainte10 nance and training that is for, or is necessary for the adop11 tion and operation of, such technology) as determined by 

12 the Secretary to be reasonable. 

13 ‘‘(B) The term ‘net allowable costs’ means allowable 

14 costs reduced by any payment that is made to the Medicaid 

15 provider involved from any other source that is directly at16 tributable to payment for certified EHR technology or serv17 ices described in subparagraph (A). 

18 ‘‘(C) In no case shall— 

19 ‘‘(i) the aggregate allowable costs under this sub20 section (covering one or more years) with respect to 

21 a Medicaid provider described in paragraph (2)(A) 

22 for purchase and initial implementation of certified 

23 EHR technology (and services described in subpara24 graph (A)) exceed $25,000 or include costs over a pe25 riod of longer than 5 years; 


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1 ‘‘(ii) for costs not described in clause (i) relating 

2 to the operation, maintenance, or use of certified 

3 EHR technology, the annual allowable costs under 

4 this subsection with respect to such a Medicaid pro5 vider for costs not described in clause (i) for any year 

6 exceed $10,000; 

7 ‘‘(iii) payment described in paragraph (1) for 

8 costs described in clause (ii) be made with respect to 

9 such a Medicaid provider over a period of more than 

10 5 years; 

11 ‘‘(iv) the aggregate allowable costs under this 

12 subsection with respect to such a Medicaid provider 

13 for all costs exceed $75,000; or 

14 ‘‘(v) the allowable costs, whether for purchase 

15 and initial implementation, maintenance, or other16 wise, for a Medicaid provider described in paragraph 

17 (2)(B) exceed such aggregate or annual limitation as 

18 the Secretary shall establish, based on an amount de19 termined by the Secretary as being adequate to adopt 

20 and maintain certified EHR technology, consistent 

21 with paragraph (6). 

22 ‘‘(5) Payments described in paragraph (1) are not in 

23 accordance with this subsection unless the following require24 ments are met: 


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1 ‘‘(A) The State provides assurances satisfactory 

2 to the Secretary that amounts received under sub3 section (a)(3)(F) with respect to costs of a Medicaid 

4 provider are paid directly to such provider without 

5 any deduction or rebate. 

6 ‘‘(B) Such Medicaid provider is responsible for 

7 payment of the costs described in such paragraph that 

8 are not provided under this title. 

9 ‘‘(C) With respect to payments to such Medicaid 

10 provider for costs other than costs related to the ini11 tial adoption of certified EHR technology, the Med12 icaid provider demonstrates meaningful use of cer13 tified EHR technology through a means that is ap14 proved by the State and acceptable to the Secretary, 

15 and that may be based upon the methodologies ap16 plied under section 1848(o) or 1886(n). 

17 ‘‘(D) To the extent specified by the Secretary, the 

18 certified EHR technology is compatible with State or 

19 Federal administrative management systems. 

20 ‘‘(6)(A) In no case shall the payments described in 

21 paragraph (1), with respect to a hospital, exceed in the ag22 gregate the product of— 

23 ‘‘(i) the overall hospital EHR amount for the 

24 hospital computed under subparagraph (B); and 


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1 ‘‘(ii) the Medicaid share for such hospital com2 puted under subparagraph (C). 

3 ‘‘(B) For purposes of this paragraph, the overall hos4 pital EHR amount, with respect to a hospital, is the sum 

5 of the applicable amounts specified in section 1886(n)(2)(A) 

6 for such hospital for the first 4 payment years (as estimated 

7 by the Secretary) determined as if the Medicare share speci8 fied in clause (ii) of such section were 1. The Secretary shall 

9 publish in the Federal Register the overall hospital EHR 

10 amount for each hospital eligible for payments under this 

11 subsection. In computing amounts under clause (ii) for 

12 payment years after the first payment year, the Secretary 

13 shall assume that in subsequent payment years discharges 

14 increase at the average annual rate of growth of the most 

15 recent 3 years for which discharge data are available per 

16 year. 

17 ‘‘(C) The Medicaid share computed under this sub18 paragraph, for a hospital for a period specified by the Sec19 retary, shall be calculated in the same manner as the Medi20 care share under section 1886(n)(2)(D) for such a hospital 

21 and period, except that there shall be substituted for the nu22 merator under clause (i) of such section the amount that 

23 is equal to the number of inpatient-bed-days (as established 

24 by the Secretary) which are attributable to individuals who 

25 are receiving medical assistance under this title and who 


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1 are not described in section 1886(n)(2)(D)(i). In computing 

2 inpatient-bed-days under the previous sentence, the Sec3 retary shall take into account inpatient-bed-days attrib4 utable to inpatient-bed-days that are paid for individuals 

5 enrolled in a Medicaid managed care plan (under section 

6 1903(m) or section 1932). 

7 ‘‘(7) With respect to health care providers other than 

8 hospitals, the Secretary shall ensure coordination of the dif9 ferent programs for payment of such health care providers 

10 for adoption or use of health information technology (in11 cluding certified EHR technology), as well as payments for 

12 such health care providers provided under this title or title 

13 XVIII, to assure no duplication of funding. 

14 ‘‘(8) In carrying out paragraph (5)(C), the State and 

15 Secretary shall seek, to the maximum extent practicable, to 

16 avoid duplicative requirements from Federal and State 

17 Governments to demonstrate meaningful use of certified 

18 EHR technology under this title and title XVIII. In doing 

19 so, the Secretary may deem satisfaction of requirements for 

20 such meaningful use for a payment year under title XVIII 

21 to be sufficient to qualify as meaningful use under this sub22 section. The Secretary may also specify the reporting peri23 ods under this subsection in order to carry out this para24 graph. 


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1 ‘‘(9) In order to be provided Federal financial partici2 pation under subsection (a)(3)(F)(ii), a State must dem3 onstrate to the satisfaction of the Secretary, that the State— 

4 ‘‘(A) is using the funds provided for the purposes 

5 of administering payments under this subsection, in6 cluding tracking of meaningful use by Medicaid pro7 viders; 

8 ‘‘(B) is conducting adequate oversight of the pro9 gram under this subsection, including routine track10 ing of meaningful use attestations and reporting 

11 mechanisms; and 

12 ‘‘(C) is pursuing initiatives to encourage the 

13 adoption of certified EHR technology to promote 

14 health care quality and the exchange of health care 

15 information under this title, subject to applicable 

16 laws and regulations governing such exchange. 

17 ‘‘(10) The Secretary shall periodically submit reports 

18 to the Committee on Energy and Commerce of the House 

19 of Representatives and the Committee on Finance of the 

20 Senate on status, progress, and oversight of payments under 

21 paragraph (1).’’. 

22 (b) IMPLEMENTATION FUNDING.—In addition to funds 

23 otherwise available, out of any funds in the Treasury not 

24 otherwise appropriated, there are appropriated to the Sec25 retary of Health and Human Services for the Center for 


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1 Medicare & Medicaid Services Program Management Ac2 count, $40,000,000 for each of fiscal years 2009 through 

3 2015 and $20,000,000 for each succeeding fiscal year 

4 through fiscal year 2019, which shall be available for pur5 poses of carrying out the provisions of (and the amendments 

6 made by) this part. Amounts appropriated under this sub7 section for a fiscal year shall be available until expended. 

8 Subtitle D—Privacy 

9 SEC. 4400. DEFINITIONS. 

10 In this subtitle, except as specified otherwise: 

11 (1) BREACH.—The term ‘‘breach’’ means the un12 authorized acquisition, access, use, or disclosure of 

13 protected health information which compromises the 

14 security, privacy, or integrity of protected health in15 formation maintained by or on behalf of a person. 

16 Such term does not include any unintentional acqui17 sition, access, use, or disclosure of such information 

18 by an employee or agent of the covered entity or busi19 ness associate involved if such acquisition, access, use, 

20 or disclosure, respectively, was made in good faith 

21 and within the course and scope of the employment 

22 or other contractual relationship of such employee or 

23 agent, respectively, with the covered entity or business 

24 associate and if such information is not further acVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00190 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 quired, accessed, used, or disclosed by such employee 

2 or agent. 

3 (2) BUSINESS ASSOCIATE.—The term ‘‘business 

4 associate’’ has the meaning given such term in section 

5 160.103 of title 45, Code of Federal Regulations. 

6 (3) COVERED ENTITY.—The term ‘‘covered enti7 ty’’ has the meaning given such term in section 

8 160.103 of title 45, Code of Federal Regulations. 

9 (4) DISCLOSE.—The terms ‘‘disclose’’ and ‘‘dis10 closure’’ have the meaning given the term ‘‘disclosure’’ 

11 in section 160.103 of title 45, Code of Federal Regula12 tions. 

13 (5) ELECTRONIC HEALTH RECORD.—The term 

14 ‘‘electronic health record’’ means an electronic record 

15 of health-related information on an individual that is 

16 created, gathered, managed, and consulted by author17 ized health care clinicians and staff. 

18 (6) HEALTH CARE OPERATIONS.—The term 

19 ‘‘health care operation’’ has the meaning given such 

20 term in section 164.501 of title 45, Code of Federal 

21 Regulations. 

22 (7) HEALTH CARE PROVIDER.—The term ‘‘health 

23 care provider’’ has the meaning given such term in 

24 section 160.103 of title 45, Code of Federal Regula25 tions. 


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1 (8) HEALTH PLAN.—The term ‘‘health plan’’ has 

2 the meaning given such term in section 1171(5) of the 

3 Social Security Act. 

4 (9) NATIONAL COORDINATOR.—The term ‘‘Na5 tional Coordinator’’ means the head of the Office of 

6 the National Coordinator for Health Information 

7 Technology established under section 3001(a) of the 

8 Public Health Service Act, as added by section 4101. 

9 (10) PAYMENT.—The term ‘‘payment’’ has the 

10 meaning given such term in section 164.501 of title 

11 45, Code of Federal Regulations. 

12 (11) PERSONAL HEALTH RECORD.—The term 

13 ‘‘personal health record’’ means an electronic record of 

14 individually identifiable health information on an in15 dividual that can be drawn from multiple sources and 

16 that is managed, shared, and controlled by or for the 

17 individual. 

18 (12) PROTECTED HEALTH INFORMATION.—The 

19 term ‘‘protected health information’’ has the meaning 

20 given such term in section 160.103 of title 45, Code 

21 of Federal Regulations. 

22 (13) SECRETARY.—The term ‘‘Secretary’’ means 

23 the Secretary of Health and Human Services. 


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1 (14) SECURITY.—The term ‘‘security’’ has the 

2 meaning given such term in section 164.304 of title 

3 45, Code of Federal Regulations. 

4 (15) STATE.—The term ‘‘State’’ means each of 

5 the several States, the District of Columbia, Puerto 

6 Rico, the Virgin Islands, Guam, American Samoa, 

7 and the Northern Mariana Islands. 

8 (16) TREATMENT.—The term ‘‘treatment’’ has 

9 the meaning given such term in section 164.501 of 

10 title 45, Code of Federal Regulations. 

11 (17) USE.—The term ‘‘use’’ has the meaning 

12 given such term in section 160.103 of title 45, Code 

13 of Federal Regulations. 

14 (18) VENDOR OF PERSONAL HEALTH

15 RECORDS.—The term ‘‘vendor of personal health 

16 records’’ means an entity, other than a covered entity 

17 (as defined in paragraph (3)), that offers or main18 tains a personal health record. 


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1 PART I—IMPROVED PRIVACY PROVISIONS AND 

2 SECURITY PROVISIONS 

3 SEC. 4401. APPLICATION OF SECURITY PROVISIONS AND 

4 PENALTIES TO BUSINESS ASSOCIATES OF 

5 COVERED ENTITIES; ANNUAL GUIDANCE ON 

6 SECURITY PROVISIONS. 

7 (a) APPLICATION OF SECURITY PROVISIONS.—Sections 

8 164.308, 164.310, 164.312, and 164.316 of title 45, Code 

9 of Federal Regulations, shall apply to a business associate 

10 of a covered entity in the same manner that such sections 

11 apply to the covered entity. The additional requirements of 

12 this title that relate to security and that are made applica13 ble with respect to covered entities shall also be applicable 

14 to such a business associate and shall be incorporated into 

15 the business associate agreement between the business asso16 ciate and the covered entity. 

17 (b) APPLICATION OF CIVIL AND CRIMINAL PEN18 ALTIES.—In the case of a business associate that violates 

19 any security provision specified in subsection (a), sections 

20 1176 and 1177 of the Social Security Act (42 U.S.C. 

21 1320d–5, 1320d–6) shall apply to the business associate 

22 with respect to such violation in the same manner such sec23 tions apply to a covered entity that violates such security 

24 provision. 

25 (c) ANNUAL GUIDANCE.—For the first year beginning 

26 after the date of the enactment of this Act and annually 


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1 thereafter, the Secretary of Health and Human Services 

2 shall, in consultation with industry stakeholders, annually 

3 issue guidance on the most effective and appropriate tech4 nical safeguards for use in carrying out the sections referred 

5 to in subsection (a) and the security standards in subpart 

6 C of part 164 of title 45, Code of Federal Regulations, as 

7 such provisions are in effect as of the date before the enact8 ment of this Act. 

9 SEC. 4402. NOTIFICATION IN THE CASE OF BREACH. 

10 (a) IN GENERAL.—A covered entity that accesses, 

11 maintains, retains, modifies, records, stores, destroys, or 

12 otherwise holds, uses, or discloses unsecured protected health 

13 information (as defined in subsection (h)(1)) shall, in the 

14 case of a breach of such information that is discovered by 

15 the covered entity, notify each individual whose unsecured 

16 protected health information has been, or is reasonably be17 lieved by the covered entity to have been, accessed, acquired, 

18 or disclosed as a result of such breach. 

19 (b) NOTIFICATION OF COVERED ENTITY BY BUSINESS

20 ASSOCIATE.—A business associate of a covered entity that 

21 accesses, maintains, retains, modifies, records, stores, de22 stroys, or otherwise holds, uses, or discloses unsecured pro23 tected health information shall, following the discovery of 

24 a breach of such information, notify the covered entity of 

25 such breach. Such notice shall include the identification of 


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1 each individual whose unsecured protected health informa2 tion has been, or is reasonably believed by the business asso3 ciate to have been, accessed, acquired, or disclosed during 

4 such breach. 

5 (c) BREACHES TREATED AS DISCOVERED.—For pur6 poses of this section, a breach shall be treated as discovered 

7 by a covered entity or by a business associate as of the first 

8 day on which such breach is known to such entity or asso9 ciate, respectively, (including any person, other than the in10 dividual committing the breach, that is an employee, officer, 

11 or other agent of such entity or associate, respectively) or 

12 should reasonably have been known to such entity or asso13 ciate (or person) to have occurred. 

14 (d) TIMELINESS OF NOTIFICATION.— 

15 (1) IN GENERAL.—Subject to subsection (g), all 

16 notifications required under this section shall be made 

17 without unreasonable delay and in no case later than 

18 60 calendar days after the discovery of a breach by 

19 the covered entity involved (or business associate in20 volved in the case of a notification required under 

21 subsection (b)). 

22 (2) BURDEN OF PROOF.—The covered entity in23 volved (or business associate involved in the case of a 

24 notification required under subsection (b)), shall have 

25 the burden of demonstrating that all notifications 


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1 were made as required under this part, including evi2 dence demonstrating the necessity of any delay. 

3 (e) METHODS OF NOTICE.— 

4 (1) INDIVIDUAL NOTICE.—Notice required under 

5 this section to be provided to an individual, with re6 spect to a breach, shall be provided promptly and in 

7 the following form: 

8 (A) Written notification by first-class mail 

9 to the individual (or the next of kin of the indi10 vidual if the individual is deceased) at the last 

11 known address of the individual or the next of 

12 kin, respectively, or, if specified as a preference 

13 by the individual, by electronic mail. The notifi14 cation may be provided in one or more mailings 

15 as information is available. 

16 (B) In the case in which there is insuffi17 cient, or out-of-date contact information (includ18 ing a phone number, email address, or any other 

19 form of appropriate communication) that pre20 cludes direct written (or, if specified by the indi21 vidual under subparagraph (A), electronic) noti22 fication to the individual, a substitute form of 

23 notice shall be provided, including, in the case 

24 that there are 10 or more individuals for which 

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1 mation, a conspicuous posting for a period deter2 mined by the Secretary on the home page of the 

3 website of the covered entity involved or notice in 

4 major print or broadcast media, including major 

5 media in geographic areas where the individuals 

6 affected by the breach likely reside. Such a notice 

7 in media or web posting will include a toll-free 

8 phone number where an individual can learn 

9 whether or not the individual’s unsecured pro10 tected health information is possibly included in 

11 the breach. 

12 (C) In any case deemed by the covered enti13 ty involved to require urgency because of possible 

14 imminent misuse of unsecured protected health 

15 information, the covered entity, in addition to 

16 notice provided under subparagraph (A), may 

17 provide information to individuals by telephone 

18 or other means, as appropriate. 

19 (2) MEDIA NOTICE.—Notice shall be provided to 

20 prominent media outlets serving a State or jurisdic21 tion, following the discovery of a breach described in 

22 subsection (a), if the unsecured protected health infor23 mation of more than 500 residents of such State or 

24 jurisdiction is, or is reasonably believed to have been, 

25 accessed, acquired, or disclosed during such breach. 


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1 (3) NOTICE TO SECRETARY.—Notice shall be pro2 vided to the Secretary by covered entities of unsecured 

3 protected health information that has been acquired 

4 or disclosed in a breach. If the breach was with re5 spect to 500 or more individuals than such notice 

6 must be provided immediately. If the breach was with 

7 respect to less than 500 individuals, the covered entity 

8 involved may maintain a log of any such breach oc9 curring and annually submit such a log to the Sec10 retary documenting such breaches occurring during 

11 the year involved. 

12 (4) POSTING ON HHS PUBLIC WEBSITE.—The 

13 Secretary shall make available to the public on the 

14 Internet website of the Department of Health and 

15 Human Services a list that identifies each covered en16 tity involved in a breach described in subsection (a) 

17 in which the unsecured protected health information 

18 of more than 500 individuals is acquired or disclosed. 

19 (f) CONTENT OF NOTIFICATION.—Regardless of the 

20 method by which notice is provided to individuals under 

21 this section, notice of a breach shall include, to the extent 

22 possible, the following: 

23 (1) A brief description of what happened, includ24 ing the date of the breach and the date of the dis25 covery of the breach, if known. 


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1 (2) A description of the types of unsecured pro2 tected health information that were involved in the 

3 breach (such as full name, Social Security number, 

4 date of birth, home address, account number, or dis5 ability code). 

6 (3) The steps individuals should take to protect 

7 themselves from potential harm resulting from the 

8 breach. 

9 (4) A brief description of what the covered entity 

10 involved is doing to investigate the breach, to mitigate 

11 losses, and to protect against any further breaches. 

12 (5) Contact procedures for individuals to ask 

13 questions or learn additional information, which shall 

14 include a toll-free telephone number, an e-mail ad15 dress, website, or postal address. 

16 (g) DELAY OF NOTIFICATION AUTHORIZED FOR LAW

17 ENFORCEMENT PURPOSES.—If a law enforcement official 

18 determines that a notification, notice, or posting required 

19 under this section would impede a criminal investigation 

20 or cause damage to national security, such notification, no21 tice, or posting shall be delayed in the same manner as pro22 vided under section 164.528(a)(2) of title 45, Code of Fed23 eral Regulations, in the case of a disclosure covered under 

24 such section. 


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1 (h) UNSECURED PROTECTED HEALTH INFORMA2 TION.— 

3 (1) DEFINITION.— 

4 (A) IN GENERAL.—Subject to subparagraph 

5 (B), for purposes of this section, the term ‘‘unse6 cured protected health information’’ means pro7 tected health information that is not secured 

8 through the use of a technology or methodology 

9 specified by the Secretary in the guidance issued 

10 under paragraph (2). 

11 (B) EXCEPTION IN CASE TIMELY GUIDANCE

12 NOT ISSUED.—In the case that the Secretary does 

13 not issue guidance under paragraph (2) by the 

14 date specified in such paragraph, for purposes of 

15 this section, the term ‘‘unsecured protected health 

16 information’’ shall mean protected health infor17 mation that is not secured by a technology 

18 standard that renders protected health informa19 tion unusable, unreadable, or indecipherable to 

20 unauthorized individuals and is developed or en21 dorsed by a standards developing organization 

22 that is accredited by the American National 

23 Standards Institute. 

24 (2) GUIDANCE.—For purposes of paragraph (1) 

25 and section 407(f)(3), not later than the date that is 


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1 60 days after the date of the enactment of this Act, 

2 the Secretary shall, after consultation with stake3 holders, issue (and annually update) guidance speci4 fying the technologies and methodologies that render 

5 protected health information unusable, unreadable, or 

6 indecipherable to unauthorized individuals. 

7 (i) REPORT TO CONGRESS ON BREACHES.— 

8 (1) IN GENERAL.—Not later than 12 months 

9 after the date of the enactment of this Act and annu10 ally thereafter, the Secretary shall prepare and sub11 mit to the Committee on Finance and the Committee 

12 on Health, Education, Labor, and Pensions of the 

13 Senate and the Committee on Ways and Means and 

14 the Committee on Energy and Commerce of the House 

15 of Representatives a report containing the informa16 tion described in paragraph (2) regarding breaches 

17 for which notice was provided to the Secretary under 

18 subsection (e)(3). 

19 (2) INFORMATION.—The information described 

20 in this paragraph regarding breaches specified in 

21 paragraph (1) shall include— 

22 (A) the number and nature of such breaches; 

23 and 

24 (B) actions taken in response to such 

25 breaches. 


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1 (j) REGULATIONS; EFFECTIVE DATE.—To carry out 

2 this section, the Secretary of Health and Human Services 

3 shall promulgate interim final regulations by not later than 

4 the date that is 180 days after the date of the enactment 

5 of this title. The provisions of this section shall apply to 

6 breaches that are discovered on or after the date that is 30 

7 days after the date of publication of such interim final regu8 lations. 

9 SEC. 4403. EDUCATION ON HEALTH INFORMATION PRIVACY. 

10 (a) REGIONAL OFFICE PRIVACY ADVISORS.—Not later 

11 than 6 months after the date of the enactment of this Act, 

12 the Secretary shall designate an individual in each regional 

13 office of the Department of Health and Human Services to 

14 offer guidance and education to covered entities, business 

15 associates, and individuals on their rights and responsibil16 ities related to Federal privacy and security requirements 

17 for protected health information. 

18 (b) EDUCATION INITIATIVE ON USES OF HEALTH IN19 FORMATION.—Not later than 12 months after the date of 

20 the enactment of this Act, the Office for Civil Rights within 

21 the Department of Health and Human Services shall de22 velop and maintain a multi-faceted national education ini23 tiative to enhance public transparency regarding the uses 

24 of protected health information, including programs to edu25 cate individuals about the potential uses of their protected 


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1 health information, the effects of such uses, and the rights 

2 of individuals with respect to such uses. Such programs 

3 shall be conducted in a variety of languages and present 

4 information in a clear and understandable manner. 

5 SEC. 4404. APPLICATION OF PRIVACY PROVISIONS AND 

6 PENALTIES TO BUSINESS ASSOCIATES OF 

7 COVERED ENTITIES. 

8 (a) APPLICATION OF CONTRACT REQUIREMENTS.—In 

9 the case of a business associate of a covered entity that ob10 tains or creates protected health information pursuant to 

11 a written contract (or other written arrangement) described 

12 in section 164.502(e)(2) of title 45, Code of Federal Regula13 tions, with such covered entity, the business associate may 

14 use and disclose such protected health information only if 

15 such use or disclosure, respectively, is in compliance with 

16 each applicable requirement of section 164.504(e) of such 

17 title. The additional requirements of this subtitle that relate 

18 to privacy and that are made applicable with respect to 

19 covered entities shall also be applicable to such a business 

20 associate and shall be incorporated into the business asso21 ciate agreement between the business associate and the cov22 ered entity. 

23 (b) APPLICATION OF KNOWLEDGE ELEMENTS ASSOCI24 ATED WITH CONTRACTS.—Section 164.504(e)(1)(ii) of title 

25 45, Code of Federal Regulations, shall apply to a business 


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1 associate described in subsection (a), with respect to compli2 ance with such subsection, in the same manner that such 

3 section applies to a covered entity, with respect to compli4 ance with the standards in sections 164.502(e) and 

5 164.504(e) of such title, except that in applying such section 

6 164.504(e)(1)(ii) each reference to the business associate, 

7 with respect to a contract, shall be treated as a reference 

8 to the covered entity involved in such contract. 

9 (c) APPLICATION OF CIVIL AND CRIMINAL PEN10 ALTIES.—In the case of a business associate that violates 

11 any provision of subsection (a) or (b), the provisions of sec12 tions 1176 and 1177 of the Social Security Act (42 U.S.C. 

13 1320d–5, 1320d–6) shall apply to the business associate 

14 with respect to such violation in the same manner as such 

15 provisions apply to a person who violates a provision of 

16 part C of title XI of such Act. 

17 SEC. 4405. RESTRICTIONS ON CERTAIN DISCLOSURES AND 

18 SALES OF HEALTH INFORMATION; ACCOUNT19 ING OF CERTAIN PROTECTED HEALTH INFOR20 MATION DISCLOSURES; ACCESS TO CERTAIN 

21 INFORMATION IN ELECTRONIC FORMAT. 

22 (a) REQUESTED RESTRICTIONS ON CERTAIN DISCLO23 SURES OF HEALTH INFORMATION.—In the case that an in24 dividual requests under paragraph (a)(1)(i)(A) of section 

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1 ered entity restrict the disclosure of the protected health in2 formation of the individual, notwithstanding paragraph 

3 (a)(1)(ii) of such section, the covered entity must comply 

4 with the requested restriction if— 

5 (1) except as otherwise required by law, the dis6 closure is to a health plan for purposes of carrying 

7 out payment or health care operations (and is not for 

8 purposes of carrying out treatment); and 

9 (2) the protected health information pertains 

10 solely to a health care item or service for which the 

11 health care provider involved has been paid out of 

12 pocket in full. 

13 (b) DISCLOSURES REQUIRED TO BE LIMITED TO THE

14 LIMITED DATA SET OR THE MINIMUM NECESSARY.— 

15 (1) IN GENERAL.— 

16 (A) IN GENERAL.—Subject to subparagraph 

17 (B), a covered entity shall be treated as being in 

18 compliance with section 164.502(b)(1) of title 45, 

19 Code of Federal Regulations, with respect to the 

20 use, disclosure, or request of protected health in21 formation described in such section, only if the 

22 covered entity limits such protected health infor23 mation, to the extent practicable, to the limited 

24 data set (as defined in section 164.514(e)(2) of 

25 such title) or, if needed by such entity, to the 


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1 minimum necessary to accomplish the intended 

2 purpose of such use, disclosure, or request, re3 spectively. 

4 (B) GUIDANCE.—Not later than 18 months 

5 after the date of the enactment of this section, the 

6 Secretary shall issue guidance on what con7 stitutes ‘‘minimum necessary’’ for purposes of 

8 subpart E of part 164 of title 45, Code of Fed9 eral Regulation. In issuing such guidance the 

10 Secretary shall take into consideration the guid11 ance under section 4424(c). 

12 (C) SUNSET.—Subparagraph (A) shall not 

13 apply on and after the effective date on which 

14 the Secretary issues the guidance under subpara15 graph (B). 

16 (2) DETERMINATION OF MINIMUM NECESSARY.— 

17 For purposes of paragraph (1), in the case of the dis18 closure of protected health information, the covered 

19 entity or business associate disclosing such informa20 tion shall determine what constitutes the minimum 

21 necessary to accomplish the intended purpose of such 

22 disclosure. 

23 (3) APPLICATION OF EXCEPTIONS.—The excep24 tions described in section 164.502(b)(2) of title 45, 

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1 quirement under paragraph (1) as of the effective date 

2 described in section 4423 in the same manner that 

3 such exceptions apply to section 164.502(b)(1) of such 

4 title before such date. 

5 (4) RULE OF CONSTRUCTION.—Nothing in this 

6 subsection shall be construed as affecting the use, dis7 closure, or request of protected health information 

8 that has been de-identified. 

9 (c) ACCOUNTING OF CERTAIN PROTECTED HEALTH IN10 FORMATION DISCLOSURES REQUIRED IF COVERED ENTITY

11 USES ELECTRONIC HEALTH RECORD.— 

12 (1) IN GENERAL.—In applying section 164.528 

13 of title 45, Code of Federal Regulations, in the case 

14 that a covered entity uses or maintains an electronic 

15 health record with respect to protected health informa16 tion— 

17 (A) the exception under paragraph (a)(1)(i) 

18 of such section shall not apply to disclosures 

19 through an electronic health record made by such 

20 entity of such information; and 

21 (B) an individual shall have a right to re22 ceive an accounting of disclosures described in 

23 such paragraph of such information made by 

24 such covered entity during only the three years 


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1 prior to the date on which the accounting is re2 quested. 

3 (2) REGULATIONS.—The Secretary shall promul4 gate regulations on what information shall be col5 lected about each disclosure referred to in paragraph 

6 (1)(A) not later than 18 months after the date on 

7 which the Secretary adopts standards on accounting 

8 for disclosure described in the section 

9 3002(b)(2)(B)(iv) of the Public Health Service Act, as 

10 added by section 4101. Such regulations shall only re11 quire such information to be collected through an elec12 tronic health record in a manner that takes into ac13 count the interests of individuals in learning the cir14 cumstances under which their protected health infor15 mation is being disclosed and takes into account the 

16 administrative burden of accounting for such disclo17 sures. 

18 (3) CONSTRUCTION.—Nothing in this subsection 

19 shall be construed as requiring a covered entity to ac20 count for disclosures of protected health information 

21 that are not made by such covered entity or by a 

22 business associate acting on behalf of the covered enti23 ty. 

24 (4) EFFECTIVE DATE.— 


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1 (A) CURRENT USERS OF ELECTRONIC

2 RECORDS.—In the case of a covered entity inso3 far as it acquired an electronic health record as 

4 of January 1, 2009, paragraph (1) shall apply 

5 to disclosures, with respect to protected health in6 formation, made by the covered entity from such 

7 a record on and after January 1, 2014. 

8 (B) OTHERS.—In the case of a covered enti9 ty insofar as it acquires an electronic health 

10 record after January 1, 2009, paragraph (1) 

11 shall apply to disclosures, with respect to pro12 tected health information, made by the covered 

13 entity from such record on and after the later of 

14 the following: 

15 (i) January 1, 2011; or 

16 (ii) the date that it acquires an elec17 tronic health record. 

18 (d) REVIEW OF HEALTH CARE OPERATIONS.—Not 

19 later than 18 months after the date of the enactment of this 

20 title, the Secretary shall promulgate regulations to elimi21 nate from the definition of health care operations under sec22 tion 164.501 of title 45, Code of Federal Regulations, those 

23 activities that can reasonably and efficiently be conducted 

24 through the use of information that is de-identified (in ac25 cordance with the requirements of section 164.514(b) of such 


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1 title) or that should require a valid authorization for use 

2 or disclosure. In promulgating such regulations, the Sec3 retary may choose to narrow or clarify activities that the 

4 Secretary chooses to retain in the definition of health care 

5 operations and the Secretary shall take into account the re6 port under section 424(d). In such regulations the Secretary 

7 shall specify the date on which such regulations shall apply 

8 to disclosures made by a covered entity, but in no case 

9 would such date be sooner than the date that is 24 months 

10 after the date of the enactment of this section. 

11 (e) PROHIBITION ON SALE OF ELECTRONIC HEALTH

12 RECORDS OR PROTECTED HEALTH INFORMATION.— 

13 (1) IN GENERAL.—Except as provided in para14 graph (2), a covered entity or business associate shall 

15 not directly or indirectly receive remuneration in ex16 change for any protected health information of an in17 dividual unless the covered entity obtained from the 

18 individual, in accordance with section 164.508 of title 

19 45, Code of Federal Regulations, a valid authoriza20 tion that includes, in accordance with such section, a 

21 specification of whether the protected health informa22 tion can be further exchanged for remuneration by the 

23 entity receiving protected health information of that 

24 individual. 


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1 (2) EXCEPTIONS.—Paragraph (1) shall not 

2 apply in the following cases: 

3 (A) The purpose of the exchange is for re4 search or public health activities (as described in 

5 sections 164.501, 164.512(i), and 164.512(b) of 

6 title 45, Code of Federal Regulations) and the 

7 price charged reflects the costs of preparation 

8 and transmittal of the data for such purpose. 

9 (B) The purpose of the exchange is for the 

10 treatment of the individual and the price charges 

11 reflects not more than the costs of preparation 

12 and transmittal of the data for such purpose. 

13 (C) The purpose of the exchange is the 

14 health care operation specifically described in 

15 subparagraph (iv) of paragraph (6) of the defini16 tion of health care operations in section 164.501 

17 of title 45, Code of Federal Regulations. 

18 (D) The purpose of the exchange is for re19 muneration that is provided by a covered entity 

20 to a business associate for activities involving the 

21 exchange of protected health information that the 

22 business associate undertakes on behalf of and at 

23 the specific request of the covered entity pursuant 

24 to a business associate agreement. 


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1 (E) The purpose of the exchange is to pro2 vide an individual with a copy of the individ3 ual’s protected health information pursuant to 

4 section 164.524 of title 45, Code of Federal Regu5 lations. 

6 (F) The purpose of the exchange is otherwise 

7 determined by the Secretary in regulations to be 

8 similarly necessary and appropriate as the ex9 ceptions provided in subparagraphs (A) through 

10 (E). 

11 (3) REGULATIONS.—The Secretary shall promul12 gate regulations to carry out paragraph (this sub13 section, including exceptions described in paragraph 

14 (2), not later than 18 months after the date of the en15 actment of this title. 

16 (4) EFFECTIVE DATE.—Paragraph (1) shall 

17 apply to exchanges occurring on or after the date that 

18 is 6 months after the date of the promulgation of final 

19 regulations implementing this subsection. 

20 (f) ACCESS TO CERTAIN INFORMATION IN ELECTRONIC

21 FORMAT.—In applying section 164.524 of title 45, Code of 

22 Federal Regulations, in the case that a covered entity uses 

23 or maintains an electronic health record with respect to 

24 protected health information of an individual— 


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1 (1) the individual shall have a right to obtain 

2 from such covered entity a copy of such information 

3 in an electronic format; and 

4 (2) notwithstanding paragraph (c)(4) of such 

5 section, any fee that the covered entity may impose 

6 for providing such individual with a copy of such in7 formation (or a summary or explanation of such in8 formation) if such copy (or summary or explanation) 

9 is in an electronic form shall not be greater than the 

10 entity’s labor costs in responding to the request for the 

11 copy (or summary or explanation). 

12 SEC. 4406. CONDITIONS ON CERTAIN CONTACTS AS PART 

13 OF HEALTH CARE OPERATIONS. 

14 (a) MARKETING.— 

15 (1) IN GENERAL.—A communication by a cov16 ered entity or business associate that is about a prod17 uct or service and that encourages recipients of the 

18 communication to purchase or use the product or 

19 service shall not be considered a health care operation 

20 for purposes of subpart E of part 164 of title 45, Code 

21 of Federal Regulations, unless the communication is 

22 made as described in subparagraph (i), (ii), or (iii) 

23 of paragraph (1) of the definition of marketing in sec24 tion 164.501 of such title. 


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1 (2) PAYMENT FOR CERTAIN COMMUNICATIONS.— 

2 A covered entity or business associate may not receive 

3 direct or indirect payment in exchange for making 

4 any communication described in subparagraph (i), 

5 (ii), or (iii) of paragraph (1) of the definition of mar6 keting in section 164.501 of title 45, Code of Federal 

7 Regulations, except— 

8 (A) a business associate of a covered entity 

9 may receive payment from the covered entity for 

10 making any such communication on behalf of the 

11 covered entity that is consistent with the written 

12 contract (or other written arrangement) de13 scribed in section 164.502(e)(2) of such title be14 tween such business associate and covered entity; 

15 or 

16 (B) a covered entity may receive payment 

17 in exchange for making any such communication 

18 if the entity obtains from the recipient of the 

19 communication, in accordance with section 

20 164.508 of title 45, Code of Federal Regulations, 

21 a valid authorization (as described in paragraph 

22 (b) of such section) with respect to such commu23 nication. 

24 (b) FUNDRAISING.—Fundraising for the benefit of a 

25 covered entity shall not be considered a health care operVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00215 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 ation for purposes of section 164.501 of title 45, Code of 

2 Federal Regulations. 

3 (c) EFFECTIVE DATE.—This section shall apply to 

4 contracting occurring on or after the effective date specified 

5 under section 4423. 

6 SEC. 4407. TEMPORARY BREACH NOTIFICATION REQUIRE7 MENT FOR VENDORS OF PERSONAL HEALTH 

8 RECORDS AND OTHER NON-HIPAA COVERED 

9 ENTITIES. 

10 (a) IN GENERAL.—In accordance with subsection (c), 

11 each vendor of personal health records, following the dis12 covery of a breach of security of unsecured PHR identifiable 

13 health information that is in a personal health record 

14 maintained or offered by such vendor, and each entity de15 scribed in clause (ii) or (iii) of section 4424(b)(1)(A), fol16 lowing the discovery of a breach of security of such informa17 tion that is obtained through a product or service provided 

18 by such entity, shall— 

19 (1) notify each individual who is a citizen or 

20 resident of the United States whose unsecured PHR 

21 identifiable health information was acquired by an 

22 unauthorized person as a result of such a breach of 

23 security; and 

24 (2) notify the Federal Trade Commission. 


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1 (b) NOTIFICATION BY THIRD PARTY SERVICE PRO2 VIDERS.—A third party service provider that provides serv3 ices to a vendor of personal health records or to an entity 

4 described in clause (ii) or (iii) of section 4424(b)(1)(A) in 

5 connection with the offering or maintenance of a personal 

6 health record or a related product or service and that ac7 cesses, maintains, retains, modifies, records, stores, destroys, 

8 or otherwise holds, uses, or discloses unsecured PHR identi9 fiable health information in such a record as a result of 

10 such services shall, following the discovery of a breach of 

11 security of such information, notify such vendor or entity, 

12 respectively, of such breach. Such notice shall include the 

13 identification of each individual whose unsecured PHR 

14 identifiable health information has been, or is reasonably 

15 believed to have been, accessed, acquired, or disclosed during 

16 such breach. 

17 (c) APPLICATION OF REQUIREMENTS FOR TIMELINESS, 

18 METHOD, AND CONTENT OF NOTIFICATIONS.—Subsections 

19 (c), (d), (e), and (f) of section 402 shall apply to a notifica20 tion required under subsection (a) and a vendor of personal 

21 health records, an entity described in subsection (a) and 

22 a third party service provider described in subsection (b), 

23 with respect to a breach of security under subsection (a) 

24 of unsecured PHR identifiable health information in such 


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1 records maintained or offered by such vendor, in a manner 

2 specified by the Federal Trade Commission. 

3 (d) NOTIFICATION OF THE SECRETARY.—Upon receipt 

4 of a notification of a breach of security under subsection 

5 (a)(2), the Federal Trade Commission shall notify the Sec6 retary of such breach. 

7 (e) ENFORCEMENT.—A violation of subsection (a) or 

8 (b) shall be treated as an unfair and deceptive act or prac9 tice in violation of a regulation under section 18(a)(1)(B) 

10 of the Federal Trade Commission Act (15 U.S.C. 

11 57a(a)(1)(B)) regarding unfair or deceptive acts or prac12 tices. 

13 (f) DEFINITIONS.—For purposes of this section: 

14 (1) BREACH OF SECURITY.—The term ‘‘breach of 

15 security’’ means, with respect to unsecured PHR 

16 identifiable health information of an individual in a 

17 personal health record, acquisition of such informa18 tion without the authorization of the individual. 

19 (2) PHR IDENTIFIABLE HEALTH INFORMA20 TION.—The term ‘‘PHR identifiable health informa21 tion’’ means individually identifiable health informa22 tion, as defined in section 1171(6) of the Social Secu23 rity Act (42 U.S.C. 1320d(6)), and includes, with re24 spect to an individual, information— 


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1 (A) that is provided by or on behalf of the 

2 individual; and 

3 (B) that identifies the individual or with 

4 respect to which there is a reasonable basis to be5 lieve that the information can be used to identify 

6 the individual. 

7 (3) UNSECURED PHR IDENTIFIABLE HEALTH IN8 FORMATION.— 

9 (A) IN GENERAL.—Subject to subparagraph 

10 (B), the term ‘‘unsecured PHR identifiable 

11 health information’’ means PHR identifiable 

12 health information that is not protected through 

13 the use of a technology or methodology specified 

14 by the Secretary in the guidance issued under 

15 section 4402(h)(2). 

16 (B) EXCEPTION IN CASE TIMELY GUIDANCE

17 NOT ISSUED.—In the case that the Secretary does 

18 not issue guidance under section 4402(h)(2) by 

19 the date specified in such section, for purposes of 

20 this section, the term ‘‘unsecured PHR identifi21 able health information’’ shall mean PHR iden22 tifiable health information that is not secured by 

23 a technology standard that renders protected 

24 health information unusable, unreadable, or in25 decipherable to unauthorized individuals and 


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1 that is developed or endorsed by a standards de2 veloping organization that is accredited by the 

3 American National Standards Institute. 

4 (g) REGULATIONS; EFFECTIVE DATE; SUNSET.— 

5 (1) REGULATIONS; EFFECTIVE DATE.—To carry 

6 out this section, the Secretary of Health and Human 

7 Services shall promulgate interim final regulations by 

8 not later than the date that is 180 days after the date 

9 of the enactment of this section. The provisions of this 

10 section shall apply to breaches of security that are 

11 discovered on or after the date that is 30 days after 

12 the date of publication of such interim final regula13 tions. 

14 (2) SUNSET.—The provisions of this section shall 

15 not apply to breaches of security occurring on or after 

16 the earlier of the following the dates: 

17 (A) The date on which a standard relating 

18 to requirements for entities that are not covered 

19 entities that includes requirements relating to 

20 breach notification has been promulgated by the 

21 Secretary. 

22 (B) The date on which a standard relating 

23 to requirements for entities that are not covered 

24 entities that includes requirements relating to 


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1 breach notification has been promulgated by the 

2 Federal Trade Commission and has taken effect. 

3 SEC. 4408. BUSINESS ASSOCIATE CONTRACTS REQUIRED 

4 FOR CERTAIN ENTITIES. 

5 Each organization, with respect to a covered entity, 

6 that provides data transmission of protected health infor7 mation to such entity (or its business associate) and that 

8 requires access on a routine basis to such protected health 

9 information, such as a Health Information Exchange Orga10 nization, Regional Health Information Organization, E11 prescribing Gateway, or each vendor that contracts with a 

12 covered entity to allow that covered entity to offer a per13 sonal health record to patients as part of its electronic 

14 health record, is required to enter into a written contract 

15 (or other written arrangement) described in section 

16 164.502(e)(2) of title 45, Code of Federal Regulations and 

17 a written contract (or other arrangement) described in sec18 tion 164.308(b) of such title, with such entity and shall be 

19 treated as a business associate of the covered entity for pur20 poses of the provisions of this subtitle and subparts C and 

21 E of part 164 of title 45, Code of Federal Regulations, as 

22 such provisions are in effect as of the date of enactment 

23 of this title. 


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1 SEC. 4409. CLARIFICATION OF APPLICATION OF WRONGFUL 

2 DISCLOSURES CRIMINAL PENALTIES. 

3 Section 1177(a) of the Social Security Act (42 U.S.C. 

4 1320d–6(a)) is amended by adding at the end the following 

5 new sentence: ‘‘For purposes of the previous sentence, a per6 son (including an employee or other individual) shall be 

7 considered to have obtained or disclosed individually identi8 fiable health information in violation of this part if the in9 formation is maintained by a covered entity (as defined in 

10 the HIPAA privacy regulation described in section 

11 1180(b)(3)) and the individual obtained or disclosed such 

12 information without authorization.’’. 

13 SEC. 4410. IMPROVED ENFORCEMENT. 

14 (a) IN GENERAL.—Section 1176 of the Social Security 

15 Act (42 U.S.C. 1320d–5) is amended— 

16 (1) in subsection (b)(1), by striking ‘‘the act con17 stitutes an offense punishable under section 1177’’ 

18 and inserting ‘‘a penalty has been imposed under sec19 tion 1177 with respect to such act’’; and 

20 (2) by adding at the end the following new sub21 section: 

22 ‘‘(c) NONCOMPLIANCE DUE TO WILLFUL NEGLECT.— 

23 ‘‘(1) IN GENERAL.—A violation of a provision of 

24 this part due to willful neglect is a violation for 

25 which the Secretary is required to impose a penalty 

26 under subsection (a)(1). 


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1 ‘‘(2) REQUIRED INVESTIGATION.—For purposes 

2 of paragraph (1), the Secretary shall formally inves3 tigate any complaint of a violation of a provision of 

4 this part if a preliminary investigation of the facts 

5 of the complaint indicate such a possible violation 

6 due to willful neglect.’’. 

7 (b) EFFECTIVE DATE; REGULATIONS.— 

8 (1) The amendments made by subsection (a) 

9 shall apply to penalties imposed on or after the date 

10 that is 24 months after the date of the enactment of 

11 this title. 

12 (2) Not later than 18 months after the date of the 

13 enactment of this title, the Secretary of Health and 

14 Human Services shall promulgate regulations to im15 plement such amendments. 

16 (c) DISTRIBUTION OF CERTAIN CIVIL MONETARY PEN17 ALTIES COLLECTED.— 

18 (1) IN GENERAL.—Subject to the regulation pro19 mulgated pursuant to paragraph (3), any civil mone20 tary penalty or monetary settlement collected with re21 spect to an offense punishable under this subtitle or 

22 section 1176 of the Social Security Act (42 U.S.C. 

23 1320d–5) insofar as such section relates to privacy or 

24 security shall be transferred to the Office of Civil 

25 Rights of the Department of Health and Human 


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1 Services to be used for purposes of enforcing the pro2 visions of this subtitle and subparts C and E of part 

3 164 of title 45, Code of Federal Regulations, as such 

4 provisions are in effect as of the date of enactment of 

5 this Act. 

6 (2) GAO REPORT.—Not later than 18 months 

7 after the date of the enactment of this title, the Comp8 troller General shall submit to the Secretary a report 

9 including recommendations for a methodology under 

10 which an individual who is harmed by an act that 

11 constitutes an offense referred to in paragraph (1) 

12 may receive a percentage of any civil monetary pen13 alty or monetary settlement collected with respect to 

14 such offense. 

15 (3) ESTABLISHMENT OF METHODOLOGY TO DIS16 TRIBUTE PERCENTAGE OF CMPS COLLECTED TO

17 HARMED INDIVIDUALS.—Not later than 3 years after 

18 the date of the enactment of this title, the Secretary 

19 shall establish by regulation and based on the rec20 ommendations submitted under paragraph (2), a 

21 methodology under which an individual who is 

22 harmed by an act that constitutes an offense referred 

23 to in paragraph (1) may receive a percentage of any 

24 civil monetary penalty or monetary settlement col25 lected with respect to such offense. 


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1 (4) APPLICATION OF METHODOLOGY.—The meth2 odology under paragraph (3) shall be applied with re3 spect to civil monetary penalties or monetary settle4 ments imposed on or after the effective date of the reg5 ulation. 

6 (d) TIERED INCREASE IN AMOUNT OF CIVIL MONE7 TARY PENALTIES.— 

8 (1) IN GENERAL.—Section 1176(a)(1) of the So9 cial Security Act (42 U.S.C. 1320d–5(a)(1)) is 

10 amended by striking ‘‘who violates a provision of this 

11 part a penalty of not more than’’ and all that follows 

12 and inserting the following: ‘‘who violates a provision 

13 of this part— 

14 ‘‘(A) in the case of a violation of such pro15 vision in which it is established that the person 

16 did not know (and by exercising reasonable dili17 gence would not have known) that such person 

18 violated such provision, a penalty for each such 

19 violation of an amount that is at least the 

20 amount described in paragraph (3)(A) but not to 

21 exceed the amount described in paragraph 

22 (3)(D); 

23 ‘‘(B) in the case of a violation of such pro24 vision in which it is established that the viola25 tion was due to reasonable cause and not to willVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00225 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 ful neglect, a penalty for each such violation of 

2 an amount that is at least the amount described 

3 in paragraph (3)(B) but not to exceed the 

4 amount described in paragraph (3)(D); and 

5 ‘‘(C) in the case of a violation of such provi6 sion in which it is established that the violation 

7 was due to willful neglect— 

8 ‘‘(i) if the violation is corrected as de9 scribed in subsection (b)(3)(A), a penalty in 

10 an amount that is at least the amount de11 scribed in paragraph (3)(C) but not to ex12 ceed the amount described in paragraph 

13 (3)(D); and 

14 ‘‘(ii) if the violation is not corrected as 

15 described in such subsection, a penalty in 

16 an amount that is at least the amount de17 scribed in paragraph (3)(D). 

18 In determining the amount of a penalty under 

19 this section for a violation, the Secretary shall 

20 base such determination on the nature and ex21 tent of the violation and the nature and extent 

22 of the harm resulting from such violation.’’. 

23 (2) TIERS OF PENALTIES DESCRIBED.—Section 

24 1176(a) of such Act (42 U.S.C. 1320d–5(a)) is further 


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1 amended by adding at the end the following new 

2 paragraph: 

3 ‘‘(3) TIERS OF PENALTIES DESCRIBED.—For 

4 purposes of paragraph (1), with respect to a violation 

5 by a person of a provision of this part— 

6 ‘‘(A) the amount described in this subpara7 graph is $100 for each such violation, except that 

8 the total amount imposed on the person for all 

9 such violations of an identical requirement or 

10 prohibition during a calendar year may not ex11 ceed $25,000; 

12 ‘‘(B) the amount described in this subpara13 graph is $1,000 for each such violation, except 

14 that the total amount imposed on the person for 

15 all such violations of an identical requirement or 

16 prohibition during a calendar year may not ex17 ceed $100,000; 

18 ‘‘(C) the amount described in this subpara19 graph is $10,000 for each such violation, except 

20 that the total amount imposed on the person for 

21 all such violations of an identical requirement or 

22 prohibition during a calendar year may not ex23 ceed $250,000; and 

24 ‘‘(D) the amount described in this subpara25 graph is $50,000 for each such violation, except 


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1 that the total amount imposed on the person for 

2 all such violations of an identical requirement or 

3 prohibition during a calendar year may not ex4 ceed $1,500,000.’’. 

5 (3) CONFORMING AMENDMENTS.—Section 

6 1176(b) of such Act (42 U.S.C. 1320d–5(b)) is amend7 ed— 

8 (A) by striking paragraph (2) and redesig9 nating paragraphs (3) and (4) as paragraphs 

10 (2) and (3), respectively; and 

11 (B) in paragraph (2), as so redesignated— 

12 (i) in subparagraph (A), by striking 

13 ‘‘in subparagraph (B), a penalty may not 

14 be imposed under subsection (a) if’’ and all 

15 that follows through ‘‘the failure to comply 

16 is corrected’’ and inserting ‘‘in subpara17 graph (B) or subsection (a)(1)(C), a penalty 

18 may not be imposed under subsection (a) if 

19 the failure to comply is corrected’’; and 

20 (ii) in subparagraph (B), by striking 

21 ‘‘(A)(ii)’’ and inserting ‘‘(A)’’ each place it 

22 appears. 

23 (4) EFFECTIVE DATE.—The amendments made 

24 by this subsection shall apply to violations occurring 

25 after the date of the enactment of this title. 


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1 (e) ENFORCEMENT THROUGH STATE ATTORNEYS GEN2 ERAL.— 

3 (1) IN GENERAL.—Section 1176 of the Social Se4 curity Act (42 U.S.C. 1320d–5) is amended by add5 ing at the end the following new subsection: 

6 ‘‘(c) ENFORCEMENT BY STATE ATTORNEYS GEN7 ERAL.— 

8 ‘‘(1) CIVIL ACTION.—Except as provided in sub9 section (b), in any case in which the attorney general 

10 of a State has reason to believe that an interest of one 

11 or more of the residents of that State has been or is 

12 threatened or adversely affected by any person who 

13 violates a provision of this part, the attorney general 

14 of the State, as parens patriae, may bring a civil ac15 tion on behalf of such residents of the State in a dis16 trict court of the United States of appropriate juris17 diction— 

18 ‘‘(A) to enjoin further such violation by the 

19 defendant; or 

20 ‘‘(B) to obtain damages on behalf of such 

21 residents of the State, in an amount equal to the 

22 amount determined under paragraph (2). 

23 ‘‘(2) STATUTORY DAMAGES.— 

24 ‘‘(A) IN GENERAL.—For purposes of para25 graph (1)(B), the amount determined under this 


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1 paragraph is the amount calculated by multi2 plying the number of violations by up to $100. 

3 For purposes of the preceding sentence, in the 

4 case of a continuing violation, the number of vio5 lations shall be determined consistent with the 

6 HIPAA privacy regulations (as defined in sec7 tion 1180(b)(3)) for violations of subsection (a). 

8 ‘‘(B) LIMITATION.—The total amount of 

9 damages imposed on the person for all violations 

10 of an identical requirement or prohibition dur11 ing a calendar year may not exceed $25,000. 

12 ‘‘(C) REDUCTION OF DAMAGES.—In assess13 ing damages under subparagraph (A), the court 

14 may consider the factors the Secretary may con15 sider in determining the amount of a civil 

16 money penalty under subsection (a) under the 

17 HIPAA privacy regulations. 

18 ‘‘(3) ATTORNEY FEES.—In the case of any suc19 cessful action under paragraph (1), the court, in its 

20 discretion, may award the costs of the action and rea21 sonable attorney fees to the State. 

22 ‘‘(4) NOTICE TO SECRETARY.—The State shall 

23 serve prior written notice of any action under para24 graph (1) upon the Secretary and provide the Sec25 retary with a copy of its complaint, except in any 


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1 case in which such prior notice is not feasible, in 

2 which case the State shall serve such notice imme3 diately upon instituting such action. The Secretary 

4 shall have the right— 

5 ‘‘(A) to intervene in the action; 

6 ‘‘(B) upon so intervening, to be heard on all 

7 matters arising therein; and 

8 ‘‘(C) to file petitions for appeal. 

9 ‘‘(5) CONSTRUCTION.—For purposes of bringing 

10 any civil action under paragraph (1), nothing in this 

11 section shall be construed to prevent an attorney gen12 eral of a State from exercising the powers conferred 

13 on the attorney general by the laws of that State. 

14 ‘‘(6) VENUE; SERVICE OF PROCESS.— 

15 ‘‘(A) VENUE.—Any action brought under 

16 paragraph (1) may be brought in the district 

17 court of the United States that meets applicable 

18 requirements relating to venue under section 

19 1391 of title 28, United States Code. 

20 ‘‘(B) SERVICE OF PROCESS.—In an action 

21 brought under paragraph (1), process may be 

22 served in any district in which the defendant— 

23 ‘‘(i) is an inhabitant; or 

24 ‘‘(ii) maintains a physical place of 

25 business. 


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1 ‘‘(7) LIMITATION ON STATE ACTION WHILE FED2 ERAL ACTION IS PENDING.—If the Secretary has insti3 tuted an action against a person under subsection (a) 

4 with respect to a specific violation of this part, no 

5 State attorney general may bring an action under 

6 this subsection against the person with respect to such 

7 violation during the pendency of that action. 

8 ‘‘(8) APPLICATION OF CMP STATUTE OF LIMITA9 TION.—A civil action may not be instituted with re10 spect to a violation of this part unless an action to 

11 impose a civil money penalty may be instituted 

12 under subsection (a) with respect to such violation 

13 consistent with the second sentence of section 

14 1128A(c)(1).’’. 

15 (2) CONFORMING AMENDMENTS.—Subsection (b) 

16 of such section, as amended by subsection (d)(3), is 

17 amended— 

18 (A) in paragraph (1), by striking ‘‘A pen19 alty may not be imposed under subsection (a)’’ 

20 and inserting ‘‘No penalty may be imposed 

21 under subsection (a) and no damages obtained 

22 under subsection (c)’’; 

23 (B) in paragraph (2)(A)— 

24 (i) in the matter before clause (i), by 

25 striking ‘‘a penalty may not be imposed 


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1 under subsection (a)’’ and inserting ‘‘no 

2 penalty may be imposed under subsection 

3 (a) and no damages obtained under sub4 section (c)’’; and 

5 (ii) in clause (ii), by inserting ‘‘or 

6 damages’’ after ‘‘the penalty’’; 

7 (C) in paragraph (2)(B)(i), by striking 

8 ‘‘The period’’ and inserting ‘‘With respect to the 

9 imposition of a penalty by the Secretary under 

10 subsection (a), the period’’; and 

11 (D) in paragraph (3), by inserting ‘‘and 

12 any damages under subsection (c)’’ after ‘‘any 

13 penalty under subsection (a)’’. 

14 (3) EFFECTIVE DATE.—The amendments made 

15 by this subsection shall apply to violations occurring 

16 after the date of the enactment of this Act. 

17 (f) ALLOWING CONTINUED USE OF CORRECTIVE AC18 TION.—Such section is further amended by adding at the 

19 end the following new subsection: 

20 ‘‘(d) ALLOWING CONTINUED USE OF CORRECTIVE AC21 TION.—Nothing in this section shall be construed as pre22 venting the Office of Civil Rights of the Department of 

23 Health and Human Services from continuing, in its discre24 tion, to use corrective action without a penalty in cases 

25 where the person did not know (and by exercising reasonVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00233 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 able diligence would not have known) of the violation in2 volved.’’. 

3 SEC. 4411. AUDITS. 

4 The Secretary shall provide for periodic audits to en5 sure that covered entities and business associates that are 

6 subject to the requirements of this subtitle and subparts C 

7 and E of part 164 of title 45, Code of Federal Regulations, 

8 as such provisions are in effect as of the date of enactment 

9 of this Act, comply with such requirements. 

10 SEC. 4412. SECURING INDIVIDUALLY IDENTIFIABLE 

11 HEALTH INFORMATION. 

12 Notwithstanding the previous provisions of this title, 

13 a covered entity or business associate must use a technology 

14 standard that renders protected health information unus15 able, unreadable, or indecipherable to unauthorized individ16 uals and is developed or endorsed by a standards developing 

17 organization that is accredited by the American National 

18 Standards Institute to secure individually identifiable 

19 health information that is transmitted in the nationwide 

20 health information network supported in this title or phys21 ically transported outside of a covered entity’s or business 

22 associate’s secured, physical perimeter, including informa23 tion transported on removable media and on portable de24 vices. The Secretary may establish implementation criteria 

25 such that smaller covered entities with fewer resources are 


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1 granted a longer period of time to comply with these re2 quirements. 

3 SEC. 4413. SPECIAL RULE FOR INFORMATION TO REDUCE 

4 MEDICATION ERRORS AND IMPROVE PATIENT 

5 SAFETY. 

6 Nothing under this subtitle shall prevent a pharmacist 

7 from collecting and sharing information with patients in 

8 order to reduce medication errors and improve patient safe9 ty as long as any renumeration received for making such 

10 communication is reasonable and cost-based. Within 180 

11 days of the date of the enactment of this Act, the Secretary 

12 shall promulgate regulations implementing this section. 

13 PART II—RELATIONSHIP TO OTHER LAWS; REGU14 LATORY REFERENCES; EFFECTIVE DATE; RE15 PORTS 

16 SEC. 4421. RELATIONSHIP TO OTHER LAWS. 

17 (a) APPLICATION OF HIPAA STATE PREEMPTION.— 

18 Section 1178 of the Social Security Act (42 U.S.C. 1320d– 

19 7) shall apply to a provision or requirement under this sub20 title in the same manner that such section applies to a pro21 vision or requirement under part C of title XI of such Act 

22 or a standard or implementation specification adopted or 

23 established under sections 1172 through 1174 of such Act. 

24 (b) HEALTH INSURANCE PORTABILITY AND ACCOUNT25 ABILITY ACT.—The standards governing the privacy and 


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1 security of individually identifiable health information pro2 mulgated by the Secretary under sections 262(a) and 264 

3 of the Health Insurance Portability and Accountability Act 

4 of 1996 shall remain in effect to the extent that they are 

5 consistent with this subtitle. The Secretary shall by rule 

6 amend such Federal regulations as required to make such 

7 regulations consistent with this subtitle. 

8 SEC. 4422. REGULATORY REFERENCES. 

9 Each reference in this subtitle to a provision of the 

10 Code of Federal Regulations refers to such provision as in 

11 effect on the date of the enactment of this title (or to the 

12 most recent update of such provision). 

13 SEC. 4423. EFFECTIVE DATE. 

14 Except as otherwise specifically provided, the provi15 sions of part I shall take effect on the date that is 12 months 

16 after the date of the enactment of this title. 

17 SEC. 4424. STUDIES, REPORTS, GUIDANCE. 

18 (a) REPORT ON COMPLIANCE.— 

19 (1) IN GENERAL.—For the first year beginning 

20 after the date of the enactment of this Act and annu21 ally thereafter, the Secretary shall prepare and sub22 mit to the Committee on Health, Education, Labor, 

23 and Pensions of the Senate and the Committee on 

24 Ways and Means and the Committee on Energy and 

25 Commerce of the House of Representatives a report 


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1 concerning complaints of alleged violations of law, in2 cluding the provisions of this subtitle as well as the 

3 provisions of subparts C and E of part 164 of title 

4 45, Code of Federal Regulations, (as such provisions 

5 are in effect as of the date of enactment of this Act) 

6 relating to privacy and security of health information 

7 that are received by the Secretary during the year for 

8 which the report is being prepared. Each such report 

9 shall include, with respect to such complaints received 

10 during the year— 

11 (A) the number of such complaints; 

12 (B) the number of such complaints resolved 

13 informally, a summary of the types of such com14 plaints so resolved, and the number of covered 

15 entities that received technical assistance from 

16 the Secretary during such year in order to 

17 achieve compliance with such provisions and the 

18 types of such technical assistance provided; 

19 (C) the number of such complaints that 

20 have resulted in the imposition of civil monetary 

21 penalties or have been resolved through monetary 

22 settlements, including the nature of the com23 plaints involved and the amount paid in each 

24 penalty or settlement; 


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1 (D) the number of compliance reviews con2 ducted and the outcome of each such review; 

3 (E) the number of subpoenas or inquiries 

4 issued; 

5 (F) the Secretary’s plan for improving com6 pliance with and enforcement of such provisions 

7 for the following year; and 

8 (G) the number of audits performed and a 

9 summary of audit findings pursuant to section 

10 4411. 

11 (2) AVAILABILITY TO PUBLIC.—Each report 

12 under paragraph (1) shall be made available to the 

13 public on the Internet website of the Department of 

14 Health and Human Services. 

15 (b) STUDY AND REPORT ON APPLICATION OF PRIVACY

16 AND SECURITY REQUIREMENTS TO NON-HIPAA COVERED

17 ENTITIES.— 

18 (1) STUDY.—Not later than one year after the 

19 date of the enactment of this title, the Secretary, in 

20 consultation with the Federal Trade Commission, 

21 shall conduct a study, and submit a report under 

22 paragraph (2), on privacy and security requirements 

23 for entities that are not covered entities or business 

24 associates as of the date of the enactment of this title, 

25 including— 


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1 (A) requirements relating to security, pri2 vacy, and notification in the case of a breach of 

3 security or privacy (including the applicability 

4 of an exemption to notification in the case of in5 dividually identifiable health information that 

6 has been rendered unusable, unreadable, or inde7 cipherable through technologies or methodologies 

8 recognized by appropriate professional organiza9 tion or standard setting bodies to provide effec10 tive security for the information) that should be 

11 applied to— 

12 (i) vendors of personal health records; 

13 (ii) entities that offer products or serv14 ices through the website of a vendor of per15 sonal health records; 

16 (iii) entities that are not covered enti17 ties and that offer products or services 

18 through the websites of covered entities that 

19 offer individuals personal health records; 

20 (iv) entities that are not covered enti21 ties and that access information in a per22 sonal health record or send information to 

23 a personal health record; and 

24 (v) third party service providers used 

25 by a vendor or entity described in clause 


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1 (i), (ii), (iii), or (iv) to assist in providing 

2 personal health record products or services; 

3 (B) a determination of which Federal gov4 ernment agency is best equipped to enforce such 

5 requirements recommended to be applied to such 

6 vendors, entities, and service providers under 

7 subparagraph (A); and 

8 (C) a timeframe for implementing regula9 tions based on such findings. 

10 (2) REPORT.—The Secretary shall submit to the 

11 Committee on Finance, the Committee on Health, 

12 Education, Labor, and Pensions, and the Committee 

13 on Commerce of the Senate and the Committee on 

14 Ways and Means and the Committee on Energy and 

15 Commerce of the House of Representatives a report on 

16 the findings of the study under paragraph (1) and 

17 shall include in such report recommendations on the 

18 privacy and security requirements described in such 

19 paragraph. 

20 (c) GUIDANCE ON IMPLEMENTATION SPECIFICATION

21 TO DE-IDENTIFY PROTECTED HEALTH INFORMATION.— 

22 Not later than 12 months after the date of the enactment 

23 of this title, the Secretary shall, in consultation with stake24 holders, issue guidance on how best to implement the re25 quirements for the de-identification of protected health inVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00240 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 formation under section 164.514(b) of title 45, Code of Fed2 eral Regulations. 

3 (d) GAO REPORT ON TREATMENT DISCLOSURES.— 

4 Not later than one year after the date of the enactment of 

5 this title, the Comptroller General of the United States shall 

6 submit to the Committee on Health, Education, Labor, and 

7 Pensions of the Senate and the Committee on Ways and 

8 Means and the Committee on Energy and Commerce of the 

9 House of Representatives a report on the best practices re10 lated to the disclosure among health care providers of pro11 tected health information of an individual for purposes of 

12 treatment of such individual. Such report shall include an 

13 examination of the best practices implemented by States 

14 and by other entities, such as health information exchanges 

15 and regional health information organizations, an exam16 ination of the extent to which such best practices are suc17 cessful with respect to the quality of the resulting health 

18 care provided to the individual and with respect to the abil19 ity of the health care provider to manage such best prac20 tices, and an examination of the use of electronic informed 

21 consent for disclosing protected health information for treat22 ment, payment, and health care operations. 

23 TITLE V—MEDICAID PROVISIONS 

24 SEC. 5000. TABLE OF CONTENTS OF TITLE. 

25 The table of contents of this title is as follows: 

Sec. 5000. Table of contents of title. 


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Sec. 5001. Temporary increase of Medicaid FMAP. 

Sec. 5002. Moratoria on certain regulations. 

Sec. 5003. Transitional Medicaid assistance (TMA). 

Sec. 5004. State eligibility option for family planning services. 

Sec. 5005. Protections for Indians under Medicaid and CHIP. 

Sec. 5006. Consultation on Medicaid and CHIP. 

Sec. 5007. Temporary increase in DSH allotments during recession. 

1 SEC. 5001. TEMPORARY INCREASE OF MEDICAID FMAP. 

2 (a) PERMITTING MAINTENANCE OF FMAP.—Subject to 

3 subsections (e), (f), and (g), if the FMAP determined with4 out regard to this section for a State for— 

5 (1) fiscal year 2009 is less than the FMAP as so 

6 determined for fiscal year 2008, the FMAP for the 

7 State for fiscal year 2008 shall be substituted for the 

8 State’s FMAP for fiscal year 2009, before the applica9 tion of this section; 

10 (2) fiscal year 2010 is less than the FMAP as so 

11 determined for fiscal year 2008 or fiscal year 2009 

12 (after the application of paragraph (1)), the greater 

13 of such FMAP for the State for fiscal year 2008 or 

14 fiscal year 2009 shall be substituted for the State’s 

15 FMAP for fiscal year 2010, before the application of 

16 this section; and 

17 (3) fiscal year 2011 is less than the FMAP as so 

18 determined for fiscal year 2008, fiscal year 2009 

19 (after the application of paragraph (1)), or fiscal 

20 year 2010 (after the application of paragraph (2)), 

21 the greatest of such FMAP for the State for fiscal year 

22 2008, fiscal year 2009, or fiscal year 2010 shall be 


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1 substituted for the State’s FMAP for fiscal year 2011, 

2 before the application of this section, but only for the 

3 first calendar quarter in fiscal year 2011. 

4 (b) GENERAL 4.9 PERCENTAGE POINT INCREASE.— 

5 (1) IN GENERAL.—Subject to subsections (e), (f), 

6 and (g) and paragraph (2), for each State for cal7 endar quarters during the recession adjustment period 

8 (as defined in subsection (h)(2)), the FMAP (after the 

9 application of subsection (a)) shall be increased 

10 (without regard to any limitation otherwise specified 

11 in section 1905(b) of the Social Security Act) by 4.9 

12 percentage points. 

13 (2) SPECIAL ELECTION FOR TERRITORIES.—In 

14 the case of a State that is not one of the 50 States 

15 or the District of Columbia, paragraph (1) shall only 

16 apply if the State makes a one-time election, in a 

17 form and manner specified by the Secretary and for 

18 the entire recession adjustment period, to apply the 

19 increase in FMAP under paragraph (1) and a 10 

20 percent increase under subsection (d) instead of ap21 plying a 20 percent increase under subsection (d). 

22 (c) ADDITIONAL ADJUSTMENT TO REFLECT INCREASE

23 IN UNEMPLOYMENT.— 

24 (1) IN GENERAL.—Subject to subsections (e), (f), 

25 and (g), in the case of a State that is a high unemVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00243 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 ployment State (as defined in paragraph (2)) for a 

2 calendar quarter during the recession adjustment pe3 riod, the FMAP (taking into account the application 

4 of subsections (a) and (b)) for such quarter shall be 

5 further increased by the high unemployment percent6 age point adjustment specified in paragraph (3) for 

7 the State for the quarter. 

8 (2) HIGH UNEMPLOYMENT STATE.— 

9 (A) IN GENERAL.—In this subsection, sub10 ject to subparagraph (B), the term ‘‘high unem11 ployment State’’ means, with respect to a cal12 endar quarter in the recession adjustment period, 

13 a State that is 1 of the 50 States or the District 

14 of Columbia and for which the State unemploy15 ment increase percentage (as computed under 

16 paragraph (5)) for the quarter is not less than 

17 1.5 percentage points. 

18 (B) MAINTENANCE OF STATUS.—If a State 

19 is a high unemployment State for a calendar 

20 quarter, it shall remain a high unemployment 

21 State for each subsequent calendar quarter end22 ing before July 1, 2010. 

23 (3) HIGH UNEMPLOYMENT PERCENTAGE POINT

24 ADJUSTMENT.— 


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1 (A) IN GENERAL.—The high unemployment 

2 percentage point adjustment specified in this 

3 paragraph for a high unemployment State for a 

4 quarter is equal to the product of— 

5 (i) the SMAP for such State and quar6 ter (determined after the application of sub7 section (a) and before the application of 

8 subsection (b)); and 

9 (ii) subject to subparagraph (B), the 

10 State unemployment reduction factor speci11 fied in paragraph (4) for the State and 

12 quarter. 

13 (B) MAINTENANCE OF ADJUSTMENT LEVEL

14 FOR CERTAIN QUARTERS.—In no case shall the 

15 State unemployment reduction factor applied 

16 under subparagraph (A)(ii) for a State for a 

17 quarter (beginning on or after January 1, 2009, 

18 and ending before July 1, 2010) be less than the 

19 State unemployment reduction factor applied to 

20 the State for the previous quarter (taking into 

21 account the application of this subparagraph). 

22 (4) STATE UNEMPLOYMENT REDUCTION FAC23 TOR.—In the case of a high unemployment State for 

24 which the State unemployment increase percentage 


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1 (as computed under paragraph (5)) with respect to a 

2 calendar quarter is— 

3 (A) not less than 1.5, but is less than 2.5, 

4 percentage points, the State unemployment re5 duction factor for the State and quarter is 6 per6 cent; 

7 (B) not less than 2.5, but is less than 3.5, 

8 percentage points, the State unemployment re9 duction factor for the State and quarter is 12 

10 percent; or 

11 (C) not less than 3.5 percentage points, the 

12 State unemployment reduction factor for the 

13 State and quarter is 14 percent. 

14 (5) COMPUTATION OF STATE UNEMPLOYMENT IN15 CREASE PERCENTAGE.— 

16 (A) IN GENERAL.—In this subsection, the 

17 ‘‘State unemployment increase percentage’’ for a 

18 State for a calendar quarter is equal to the num19 ber of percentage points (if any) by which— 

20 (i) the average monthly unemployment 

21 rate for the State for months in the most re22 cent previous 3-consecutive-month period for 

23 which data are available, subject to sub24 paragraph (C); exceeds 


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1 (ii) the lowest average monthly unem2 ployment rate for the State for any 3-con3 secutive-month period preceding the period 

4 described in clause (i) and beginning on or 

5 after January 1, 2006. 

6 (B) AVERAGE MONTHLY UNEMPLOYMENT

7 RATE DEFINED.—In this paragraph, the term 

8 ‘‘average monthly unemployment rate’’ means 

9 the average of the monthly number unemployed, 

10 divided by the average of the monthly civilian 

11 labor force, seasonally adjusted, as determined 

12 based on the most recent monthly publications of 

13 the Bureau of Labor Statistics of the Department 

14 of Labor. 

15 (C) SPECIAL RULE.—With respect to— 

16 (i) the first 2 calendar quarters of the 

17 recession adjustment period, the most recent 

18 previous 3-consecutive-month period de19 scribed in subparagraph (A)(i) shall be the 

20 3-consecutive-month period beginning with 

21 October 2008; and 

22 (ii) the last 2 calendar quarters of the 

23 recession adjustment period, the most recent 

24 previous 3-consecutive-month period de25 scribed in such subparagraph shall be the 3- 


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1 consecutive-month period beginning with 

2 December 2009. 

3 (d) INCREASE IN CAP ON MEDICAID PAYMENTS TO

4 TERRITORIES.—Subject to subsections (f) and (g) , with re5 spect to entire fiscal years occurring during the recession 

6 adjustment period and with respect to fiscal years only a 

7 portion of which occurs during such period (and in propor8 tion to the portion of the fiscal year that occurs during such 

9 period), the amounts otherwise determined for Puerto Rico, 

10 the Virgin Islands, Guam, the Northern Mariana Islands, 

11 and American Samoa under subsections (f) and (g) of sec12 tion 1108 of the Social Security Act (42 U.S.C. 1308) shall 

13 each be increased by 20 percent (or, in the case of an elec14 tion under subsection (b)(2), 10 percent). 

15 (e) SCOPE OF APPLICATION.—The increases in the 

16 FMAP for a State under this section shall apply for pur17 poses of title XIX of the Social Security Act and— 

18 (1) the increases applied under subsections (a), 

19 (b), and (c) shall not apply with respect— 

20 (A) to payments under parts A, B, and D 

21 of title IV or title XXI of such Act (42 U.S.C. 

22 601 et seq. and 1397aa et seq.); 

23 (B) to payments under title XIX of such Act 

24 that are based on the enhanced FMAP described 


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1 in section 2105(b) of such Act (42 U.S.C. 

2 1397ee(b)); and 

3 (C) to payments for disproportionate share 

4 hospital (DSH) payment adjustments under sec5 tion 1923 of such Act (42 U.S.C. 1396r–4); and 

6 (2) the increase provided under subsection (c) 

7 shall not apply with respect to payments under part 

8 E of title IV of such Act. 

9 (f) STATE INELIGIBILITY AND LIMITATION.— 

10 (1) IN GENERAL.—Subject to paragraphs (2) and 

11 (3), a State is not eligible for an increase in its 

12 FMAP under subsection (a), (b), or (c), or an increase 

13 in a cap amount under subsection (d), if eligibility 

14 standards, methodologies, or procedures under its 

15 State plan under title XIX of the Social Security Act 

16 (including any waiver under such title or under sec17 tion 1115 of such Act (42 U.S.C. 1315)) are more re18 strictive than the eligibility standards, methodologies, 

19 or procedures, respectively, under such plan (or waiv20 er) as in effect on July 1, 2008. 

21 (2) STATE REINSTATEMENT OF ELIGIBILITY PER22 MITTED.—Subject to paragraph (3), a State that has 

23 restricted eligibility standards, methodologies, or pro24 cedures under its State plan under title XIX of the 

25 Social Security Act (including any waiver under such 


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1 title or under section 1115 of such Act (42 U.S.C. 

2 1315)) after July 1, 2008, is no longer ineligible 

3 under paragraph (1) beginning with the first cal4 endar quarter in which the State has reinstated eligi5 bility standards, methodologies, or procedures that are 

6 no more restrictive than the eligibility standards, 

7 methodologies, or procedures, respectively, under such 

8 plan (or waiver) as in effect on July 1, 2008. 

9 (3) SPECIAL RULES.—A State shall not be ineli10 gible under paragraph (1)— 

11 (A) before July 1, 2009, on the basis of a 

12 restriction that was applied after July 1, 2008, 

13 and before the date of the enactment of this Act; 

14 or 

15 (B) on the basis of a restriction that was ef16 fective under State law as of July 1, 2008, and 

17 would have been in effect as of such date, but for 

18 a delay (of not longer than 1 calendar quarter) 

19 in the approval of a request for a new waiver 

20 under section 1115 of such Act with respect to 

21 such restriction. 

22 (4) STATE’S APPLICATION TOWARD RAINY DAY

23 FUND.—A State is not eligible for an increase in its 

24 FMAP under subsection (b) or (c), or an increase in 

25 a cap amount under subsection (d), if any amounts 


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1 attributable (directly or indirectly) to such increase 

2 are deposited or credited into any reserve or rainy 

3 day fund of the State. 

4 (5) RULE OF CONSTRUCTION.—Nothing in para5 graph (1) or (2) shall be construed as affecting a 

6 State’s flexibility with respect to benefits offered 

7 under the State Medicaid program under title XIX of 

8 the Social Security Act (42 U.S.C. 1396 et seq.) (in9 cluding any waiver under such title or under section 

10 1115 of such Act (42 U.S.C. 1315)). 

11 (6) NO WAIVER AUTHORITY.—The Secretary may 

12 not waive the application of this subsection or sub13 section (g) under section 1115 of the Social Security 

14 Act or otherwise. 

15 (g) REQUIREMENT FOR CERTAIN STATES.—In the case 

16 of a State that requires political subdivisions within the 

17 State to contribute toward the non-Federal share of expend18 itures under the State Medicaid plan required under section 

19 1902(a)(2) of the Social Security Act (42 U.S.C. 

20 1396a(a)(2)), the State is not eligible for an increase in 

21 its FMAP under subsection (a), (b), or (c), or an increase 

22 in a cap amount under subsection (d), if it requires that 

23 such political subdivisions pay a greater percentage of the 

24 non-Federal share of such expenditures for quarters during 

25 the recession adjustment period, than the percentage that 


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1 would have been required by the State under such plan on 

2 September 30, 2008, prior to application of this section. 

3 (h) DEFINITIONS.—In this section, except as otherwise 

4 provided: 

5 (1) FMAP.—The term ‘‘FMAP’’ means the Fed6 eral medical assistance percentage, as defined in sec7 tion 1905(b) of the Social Security Act (42 U.S.C. 

8 1396d(b)), as determined without regard to this sec9 tion except as otherwise specified. 

10 (2) RECESSION ADJUSTMENT PERIOD.—The term 

11 ‘‘recession adjustment period’’ means the period be12 ginning on October 1, 2008, and ending on December 

13 31, 2010. 

14 (3) SECRETARY.—The term ‘‘Secretary’’ means 

15 the Secretary of Health and Human Services. 

16 (4) SMAP.—The term ‘‘SMAP’’ means, for a 

17 State, 100 percent minus the Federal medical assist18 ance percentage. 

19 (5) STATE.—The term ‘‘State’’ has the meaning 

20 given such term in section 1101(a)(1) of the Social 

21 Security Act (42 U.S.C. 1301(a)(1)) for purposes of 

22 title XIX of the Social Security Act (42 U.S.C. 1396 

23 et seq.). 


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1 (i) SUNSET.—This section shall not apply to items and 

2 services furnished after the end of the recession adjustment 

3 period. 

4 SEC. 5002. MORATORIA ON CERTAIN REGULATIONS. 

5 (a) EXTENSION OF MORATORIA ON CERTAIN MEDICAID

6 REGULATIONS.—The following sections are each amended 

7 by striking ‘‘April 1, 2009’’ and inserting ‘‘July 1, 2009’’: 

8 (1) Section 7002(a)(1) of the U.S. Troop Readi9 ness, Veterans’ Care, Katrina Recovery, and Iraq Ac10 countability Appropriations Act, 2007 (Public Law 

11 110–28), as amended by section 7001(a)(1) of the 

12 Supplemental Appropriations Act, 2008 (Public Law 

13 110–252). 

14 (2) Section 206 of the Medicare, Medicaid, and 

15 SCHIP Extension Act of 2007 (Public Law 110–173), 

16 as amended by section 7001(a)(2) of the Supple17 mental Appropriations Act, 2008 (Public Law 110– 

18 252). 

19 (3) Section 7001(a)(3)(A) of the Supplemental 

20 Appropriations Act, 2008 (Public Law 110–252). 

21 (b) ADDITIONAL MEDICAID MORATORIUM.—Notwith22 standing any other provision of law, with respect to expend23 itures for services furnished during the period beginning on 

24 December 8, 2008 and ending on June 30, 2009, the Sec25 retary of Health and Human Services shall not take any 


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1 action (through promulgation of regulation, issuance of reg2 ulatory guidance, use of Federal payment audit procedures, 

3 or other administrative action, policy, or practice, includ4 ing a Medical Assistance Manual transmittal or letter to 

5 State Medicaid directors) to implement the final regulation 

6 relating to clarification of the definition of outpatient hos7 pital facility services under the Medicaid program pub8 lished on November 7, 2008 (73 Federal Register 66187). 

9 SEC. 5003. TRANSITIONAL MEDICAID ASSISTANCE (TMA). 

10 (a) 18-MONTH EXTENSION.— 

11 (1) IN GENERAL.—Sections 1902(e)(1)(B) and 

12 1925(f) of the Social Security Act (42 U.S.C. 

13 1396a(e)(1)(B), 1396r–6(f)) are each amended by 

14 striking ‘‘September 30, 2003’’ and inserting ‘‘Decem15 ber 31, 2010’’. 

16 (2) EFFECTIVE DATE.—The amendments made 

17 by this subsection shall take effect on July 1, 2009. 

18 (b) STATE OPTION OF INITIAL 12-MONTH ELIGI19 BILITY.—Section 1925 of the Social Security Act (42 U.S.C. 

20 1396r–6) is amended— 

21 (1) in subsection (a)(1), by inserting ‘‘but subject 

22 to paragraph (5)’’ after ‘‘Notwithstanding any other 

23 provision of this title’’; 

24 (2) by adding at the end of subsection (a) the fol25 lowing: 


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1 ‘‘(5) OPTION OF 12-MONTH INITIAL ELIGIBILITY

2 PERIOD.—A State may elect to treat any reference in 

3 this subsection to a 6-month period (or 6 months) as 

4 a reference to a 12-month period (or 12 months). In 

5 the case of such an election, subsection (b) shall not 

6 apply.’’; and 

7 (3) in subsection (b)(1), by inserting ‘‘but subject 

8 to subsection (a)(5)’’ after ‘‘Notwithstanding any 

9 other provision of this title’’. 

10 (c) REMOVAL OF REQUIREMENT FOR PREVIOUS RE11 CEIPT OF MEDICAL ASSISTANCE.—Section 1925(a)(1) of 

12 such Act (42 U.S.C. 1396r–6(a)(1)), as amended by sub13 section (b)(1), is further amended— 

14 (1) by inserting ‘‘subparagraph (B) and’’ before 

15 ‘‘paragraph (5)’’; 

16 (2) by redesignating the matter after ‘‘REQUIRE17 MENT.—’’ as a subparagraph (A) with the heading 

18 ‘‘IN GENERAL.—’’ and with the same indentation as 

19 subparagraph (B) (as added by paragraph (3)); and 

20 (3) by adding at the end the following: 

21 ‘‘(B) STATE OPTION TO WAIVE REQUIRE22 MENT FOR 3 MONTHS BEFORE RECEIPT OF MED23 ICAL ASSISTANCE.—A State may, at its option, 

24 elect also to apply subparagraph (A) in the case 

25 of a family that was receiving such aid for fewer 


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1 than three months or that had applied for and 

2 was eligible for such aid for fewer than 3 months 

3 during the 6 immediately preceding months de4 scribed in such subparagraph.’’. 

5 (d) CMS REPORT ON ENROLLMENT AND PARTICIPA6 TION RATES UNDER TMA.—Section 1925 of such Act (42 

7 U.S.C. 1396r–6), as amended by this section, is further 

8 amended by adding at the end the following new subsection: 

9 ‘‘(g) COLLECTION AND REPORTING OF PARTICIPATION

10 INFORMATION.— 

11 ‘‘(1) COLLECTION OF INFORMATION FROM

12 STATES.—Each State shall collect and submit to the 

13 Secretary (and make publicly available), in a format 

14 specified by the Secretary, information on average 

15 monthly enrollment and average monthly participa16 tion rates for adults and children under this section 

17 and of the number and percentage of children who be18 come ineligible for medical assistance under this sec19 tion whose medical assistance is continued under an20 other eligibility category or who are enrolled under 

21 the State’s child health plan under title XXI. Such 

22 information shall be submitted at the same time and 

23 frequency in which other enrollment information 

24 under this title is submitted to the Secretary. 


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1 ‘‘(2) ANNUAL REPORTS TO CONGRESS.—Using 

2 the information submitted under paragraph (1), the 

3 Secretary shall submit to Congress annual reports 

4 concerning enrollment and participation rates de5 scribed in such paragraph.’’. 

6 (e) EFFECTIVE DATE.—The amendments made by sub7 sections (b) through (d) shall take effect on July 1, 2009. 

8 SEC. 5004. STATE ELIGIBILITY OPTION FOR FAMILY PLAN9 NING SERVICES. 

10 (a) COVERAGE AS OPTIONAL CATEGORICALLY NEEDY

11 GROUP.— 

12 (1) IN GENERAL.—Section 1902(a)(10)(A)(ii) of 

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

14 1396a(a)(10)(A)(ii)), as amended by section 3003(a) 

15 of the Health Insurance Assistance for the Unem16 ployed Act of 2009, is amended— 

17 (A) in subclause (XIX), by striking ‘‘or’’ at 

18 the end; 

19 (B) in subclause (XX), by adding ‘‘or’’ at 

20 the end; and 

21 (C) by adding at the end the following new 

22 subclause: 

23 ‘‘(XXI) who are described in subsection (ee) (re24 lating to individuals who meet certain income stand25 ards);’’. 


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1 (2) GROUP DESCRIBED.—Section 1902 of such 

2 Act (42 U.S.C. 1396a), as amended by section 

3 3003(a) of the Health Insurance Assistance for the 

4 Unemployed Act of 2009, is amended by adding at 

5 the end the following new subsection: 

6 ‘‘(ee)(1) Individuals described in this subsection are 

7 individuals— 

8 ‘‘(A) whose income does not exceed an in9 come eligibility level established by the State that 

10 does not exceed the highest income eligibility 

11 level established under the State plan under this 

12 title (or under its State child health plan under 

13 title XXI) for pregnant women; and 

14 ‘‘(B) who are not pregnant. 

15 ‘‘(2) At the option of a State, individuals de16 scribed in this subsection may include individuals 

17 who, had individuals applied on or before January 1, 

18 2007, would have been made eligible pursuant to the 

19 standards and processes imposed by that State for 

20 benefits described in clause (XV) of the matter fol21 lowing subparagraph (G) of section subsection (a)(10) 

22 pursuant to a waiver granted under section 1115. 

23 ‘‘(3) At the option of a State, for purposes of 

24 subsection (a)(17)(B), in determining eligibility for 


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1 services under this subsection, the State may consider 

2 only the income of the applicant or recipient.’’. 

3 (3) LIMITATION ON BENEFITS.—Section 

4 1902(a)(10) of the Social Security Act (42 U.S.C. 

5 1396a(a)(10)) is amended in the matter following 

6 subparagraph (G)— 

7 (A) by striking ‘‘and (XIV)’’ and inserting 

8 ‘‘(XIV)’’; and 

9 (B) by inserting ‘‘, and (XV) the medical 

10 assistance made available to an individual de11 scribed in subsection (ee) shall be limited to fam12 ily planning services and supplies described in 

13 section 1905(a)(4)(C) including medical diag14 nosis and treatment services that are provided 

15 pursuant to a family planning service in a fam16 ily planning setting’’ after ‘‘cervical cancer’’. 

17 (4) CONFORMING AMENDMENTS.—Section 

18 1905(a) of the Social Security Act (42 U.S.C. 

19 1396d(a)), as amended by section 3003(c)(2) of the 

20 Health Insurance Assistance for the Unemployed Act 

21 of 2009, is amended in the matter preceding para22 graph (1)— 

23 (A) in clause (xiii), by striking ‘‘or’’ at the 

24 end; 


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1 (B) in clause (xiv), by adding ‘‘or’’ at the 

2 end; and 

3 (C) by inserting after clause (xiii) the fol4 lowing: 

5 ‘‘(xv) individuals described in section 

6 1902(ee),’’. 

7 (b) PRESUMPTIVE ELIGIBILITY.— 

8 (1) IN GENERAL.—Title XIX of the Social Secu9 rity Act (42 U.S.C. 1396 et seq.) is amended by in10 serting after section 1920B the following: 

11 ‘‘PRESUMPTIVE ELIGIBILITY FOR FAMILY PLANNING

12 SERVICES

13 ‘‘SEC. 1920C. (a) STATE OPTION.—State plan ap14 proved under section 1902 may provide for making medical 

15 assistance available to an individual described in section 

16 1902(ee) (relating to individuals who meet certain income 

17 eligibility standard) during a presumptive eligibility pe18 riod. In the case of an individual described in section 

19 1902(ee), such medical assistance shall be limited to family 

20 planning services and supplies described in 1905(a)(4)(C) 

21 and, at the State’s option, medical diagnosis and treatment 

22 services that are provided in conjunction with a family 

23 planning service in a family planning setting. 

24 ‘‘(b) DEFINITIONS.—For purposes of this section: 

25 ‘‘(1) PRESUMPTIVE ELIGIBILITY PERIOD.—The 

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1 spect to an individual described in subsection (a), the 

2 period that— 

3 ‘‘(A) begins with the date on which a quali4 fied entity determines, on the basis of prelimi5 nary information, that the individual is de6 scribed in section 1902(ee); and 

7 ‘‘(B) ends with (and includes) the earlier 

8 of— 

9 ‘‘(i) the day on which a determination 

10 is made with respect to the eligibility of 

11 such individual for services under the State 

12 plan; or 

13 ‘‘(ii) in the case of such an individual 

14 who does not file an application by the last 

15 day of the month following the month dur16 ing which the entity makes the determina17 tion referred to in subparagraph (A), such 

18 last day. 

19 ‘‘(2) QUALIFIED ENTITY.— 

20 ‘‘(A) IN GENERAL.—Subject to subpara21 graph (B), the term ‘qualified entity’ means any 

22 entity that— 

23 ‘‘(i) is eligible for payments under a 

24 State plan approved under this title; and 


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1 ‘‘(ii) is determined by the State agency 

2 to be capable of making determinations of 

3 the type described in paragraph (1)(A). 

4 ‘‘(B) RULE OF CONSTRUCTION.—Nothing in 

5 this paragraph shall be construed as preventing 

6 a State from limiting the classes of entities that 

7 may become qualified entities in order to prevent 

8 fraud and abuse. 

9 ‘‘(c) ADMINISTRATION.— 

10 ‘‘(1) IN GENERAL.—The State agency shall pro11 vide qualified entities with— 

12 ‘‘(A) such forms as are necessary for an ap13 plication to be made by an individual described 

14 in subsection (a) for medical assistance under 

15 the State plan; and 

16 ‘‘(B) information on how to assist such in17 dividuals in completing and filing such forms. 

18 ‘‘(2) NOTIFICATION REQUIREMENTS.—A quali19 fied entity that determines under subsection (b)(1)(A) 

20 that an individual described in subsection (a) is pre21 sumptively eligible for medical assistance under a 

22 State plan shall— 

23 ‘‘(A) notify the State agency of the deter24 mination within 5 working days after the date 

25 on which determination is made; and 


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1 ‘‘(B) inform such individual at the time the 

2 determination is made that an application for 

3 medical assistance is required to be made by not 

4 later than the last day of the month following the 

5 month during which the determination is made. 

6 ‘‘(3) APPLICATION FOR MEDICAL ASSISTANCE.— 

7 In the case of an individual described in subsection 

8 (a) who is determined by a qualified entity to be pre9 sumptively eligible for medical assistance under a 

10 State plan, the individual shall apply for medical as11 sistance by not later than the last day of the month 

12 following the month during which the determination 

13 is made. 

14 ‘‘(d) PAYMENT.—Notwithstanding any other provision 

15 of law, medical assistance that— 

16 ‘‘(1) is furnished to an individual described in 

17 subsection (a)— 

18 ‘‘(A) during a presumptive eligibility pe19 riod; and 

20 ‘‘(B) by a entity that is eligible for pay21 ments under the State plan; and 

22 ‘‘(2) is included in the care and services covered 

23 by the State plan, 


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1 shall be treated as medical assistance provided by such plan 

2 for purposes of clause (4) of the first sentence of section 

3 1905(b).’’. 

4 (2) CONFORMING AMENDMENTS.— 

5 (A) Section 1902(a)(47) of the Social Secu6 rity Act (42 U.S.C. 1396a(a)(47)) is amended by 

7 inserting before the semicolon at the end the fol8 lowing: ‘‘and provide for making medical assist9 ance available to individuals described in sub10 section (a) of section 1920C during a presump11 tive eligibility period in accordance with such 

12 section’’. 

13 (B) Section 1903(u)(1)(D)(v) of such Act 

14 (42 U.S.C. 1396b(u)(1)(D)(v)) is amended— 

15 (i) by striking ‘‘or for’’ and inserting 

16 ‘‘for’’; and 

17 (ii) by inserting before the period the 

18 following: ‘‘, or for medical assistance pro19 vided to an individual described in sub20 section (a) of section 1920C during a pre21 sumptive eligibility period under such sec22 tion’’. 

23 (c) CLARIFICATION OF COVERAGE OF FAMILY PLAN24 NING SERVICES AND SUPPLIES.—Section 1937(b) of the SoVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00264 Fmt 6652 Sfmt 6203 E:\BILLS\H629.RH H629

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1 cial Security Act (42 U.S.C. 1396u–7(b)) is amended by 

2 adding at the end the following: 

3 ‘‘(5) COVERAGE OF FAMILY PLANNING SERVICES

4 AND SUPPLIES.—Notwithstanding the previous provi5 sions of this section, a State may not provide for 

6 medical assistance through enrollment of an indi7 vidual with benchmark coverage or benchmark-equiva8 lent coverage under this section unless such coverage 

9 includes for any individual described in section 

10 1905(a)(4)(C), medical assistance for family planning 

11 services and supplies in accordance with such sec12 tion.’’. 

13 (d) EFFECTIVE DATE.—The amendments made by this 

14 section take effect on the date of the enactment of this Act 

15 and shall apply to items and services furnished on or after 

16 such date. 

17 SEC. 5005. PROTECTIONS FOR INDIANS UNDER MEDICAID 

18 AND CHIP. 

19 (a) PREMIUMS AND COST SHARING PROTECTION

20 UNDER MEDICAID.— 

21 (1) IN GENERAL.—Section 1916 of the Social Se22 curity Act (42 U.S.C. 1396o) is amended— 

23 (A) in subsection (a), in the matter pre24 ceding paragraph (1), by striking ‘‘and (i)’’ and 

25 inserting ‘‘, (i), and (j)’’; and 


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

2 subsection: 

3 ‘‘(j) NO PREMIUMS OR COST SHARING FOR INDIANS

4 FURNISHED ITEMS OR SERVICES DIRECTLY BY INDIAN

5 HEALTH PROGRAMS OR THROUGH REFERRAL UNDER CON6 TRACT HEALTH SERVICES.— 

7 ‘‘(1) NO COST SHARING FOR ITEMS OR SERVICES

8 FURNISHED TO INDIANS THROUGH INDIAN HEALTH

9 PROGRAMS.— 

10 ‘‘(A) IN GENERAL.—No enrollment fee, pre11 mium, or similar charge, and no deduction, co12 payment, cost sharing, or similar charge shall be 

13 imposed against an Indian who is furnished an 

14 item or service directly by the Indian Health 

15 Service, an Indian Tribe, Tribal Organization, 

16 or Urban Indian Organization or through refer17 ral under contract health services for which pay18 ment may be made under this title. 

19 ‘‘(B) NO REDUCTION IN AMOUNT OF PAY20 MENT TO INDIAN HEALTH PROVIDERS.—Payment 

21 due under this title to the Indian Health Service, 

22 an Indian Tribe, Tribal Organization, or Urban 

23 Indian Organization, or a health care provider 

24 through referral under contract health services 

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1 dian who is eligible for assistance under such 

2 title, may not be reduced by the amount of any 

3 enrollment fee, premium, or similar charge, or 

4 any deduction, copayment, cost sharing, or simi5 lar charge that would be due from the Indian but 

6 for the operation of subparagraph (A). 

7 ‘‘(2) RULE OF CONSTRUCTION.—Nothing in this 

8 subsection shall be construed as restricting the appli9 cation of any other limitations on the imposition of 

10 premiums or cost sharing that may apply to an indi11 vidual receiving medical assistance under this title 

12 who is an Indian.’’. 

13 (2) CONFORMING AMENDMENT.—Section 

14 1916A(b)(3) of such Act (42 U.S.C. 1396o–1(b)(3)) is 

15 amended— 

16 (A) in subparagraph (A), by adding at the 

17 end the following new clause: 

18 ‘‘(vi) An Indian who is furnished an 

19 item or service directly by the Indian 

20 Health Service, an Indian Tribe, Tribal Or21 ganization or Urban Indian Organization 

22 or through referral under contract health 

23 services.’’; and 

24 (B) in subparagraph (B), by adding at the 

25 end the following new clause: 


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1 ‘‘(ix) Items and services furnished to 

2 an Indian directly by the Indian Health 

3 Service, an Indian Tribe, Tribal Organiza4 tion or Urban Indian Organization or 

5 through referral under contract health serv6 ices.’’. 

7 (3) EFFECTIVE DATE.—The amendments made 

8 by this subsection shall take effect on October 1, 2009. 

9 (b) TREATMENT OF CERTAIN PROPERTY FROM RE10 SOURCES FOR MEDICAID AND CHIP ELIGIBILITY.— 

11 (1) MEDICAID.—Section 1902 of the Social Secu12 rity Act (42 U.S.C. 1396a), as amended by section 

13 3003(a) of the Health Insurance Assistance for the 

14 Unemployed Act of 2009 and section 5004, is amend15 ed by adding at the end the following new subsection: 

16 ‘‘(ff) Notwithstanding any other requirement of this 

17 title or any other provision of Federal or State law, a State 

18 shall disregard the following property from resources for 

19 purposes of determining the eligibility of an individual who 

20 is an Indian for medical assistance under this title: 

21 ‘‘(1) Property, including real property and im22 provements, that is held in trust, subject to Federal 

23 restrictions, or otherwise under the supervision of the 

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1 ervation, pueblo, or colony, including former reserva2 tions in Oklahoma, Alaska Native regions established 

3 by the Alaska Native Claims Settlement Act, and In4 dian allotments on or near a reservation as des5 ignated and approved by the Bureau of Indian Af6 fairs of the Department of the Interior. 

7 ‘‘(2) For any federally recognized Tribe not de8 scribed in paragraph (1), property located within the 

9 most recent boundaries of a prior Federal reservation. 

10 ‘‘(3) Ownership interests in rents, leases, royal11 ties, or usage rights related to natural resources (in12 cluding extraction of natural resources or harvesting 

13 of timber, other plants and plant products, animals, 

14 fish, and shellfish) resulting from the exercise of feder15 ally protected rights. 

16 ‘‘(4) Ownership interests in or usage rights to 

17 items not covered by paragraphs (1) through (3) that 

18 have unique religious, spiritual, traditional, or cul19 tural significance or rights that support subsistence or 

20 a traditional lifestyle according to applicable tribal 

21 law or custom.’’. 

22 (2) APPLICATION TO CHIP.—Section 2107(e)(1) 

23 of such Act (42 U.S.C. 1397gg(e)(1)) is amended by 

24 adding at the end the following new subparagraph: 


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1 ‘‘(E) Section 1902(ff) (relating to disregard 

2 of certain property for purposes of making eligi3 bility determinations).’’. 

4 (c) CONTINUATION OF CURRENT LAW PROTECTIONS OF

5 CERTAIN INDIAN PROPERTY FROM MEDICAID ESTATE RE6 COVERY.—Section 1917(b)(3) of the Social Security Act (42 

7 U.S.C. 1396p(b)(3)) is amended— 

8 (1) by inserting ‘‘(A)’’ after ‘‘(3)’’; and 

9 (2) by adding at the end the following new sub10 paragraph: 

11 ‘‘(B) The standards specified by the Sec12 retary under subparagraph (A) shall require that 

13 the procedures established by the State agency 

14 under subparagraph (A) exempt income, re15 sources, and property that are exempt from the 

16 application of this subsection as of April 1, 

17 2003, under manual instructions issued to carry 

18 out this subsection (as in effect on such date) be19 cause of the Federal responsibility for Indian 

20 Tribes and Alaska Native Villages. Nothing in 

21 this subparagraph shall be construed as pre22 venting the Secretary from providing additional 

23 estate recovery exemptions under this title for In24 dians.’’. 


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1 SEC. 5006. CONSULTATION ON MEDICAID AND CHIP. 

2 (a) IN GENERAL.—Section 1139 of the Social Security 

3 Act (42 U.S.C. 1320b–9) is amended to read as follows: 

4 ‘‘CONSULTATION WITH TRIBAL TECHNICAL ADVISORY

5 GROUP (TTAG)

6 ‘‘SEC. 1139. 

7 ‘‘The Secretary shall maintain within the Centers for 

8 Medicaid & Medicare Services (CMS) a Tribal Technical 

9 Advisory Group, which was first established in accordance 

10 with requirements of the charter dated September 30, 2003, 

11 and the Secretary shall include in such Group a representa12 tive of the Urban Indian Organizations and the Service. 

13 The representative of the Urban Indian Organization shall 

14 be deemed to be an elected officer of a tribal government 

15 for purposes of applying section 204(b) of the Unfunded 

16 Mandates Reform Act of 1995 (2 U.S.C. 1534(b)).’’. 

17 (b) SOLICITATION OF ADVICE UNDER MEDICAID AND

18 CHIP.— 

19 (1) MEDICAID STATE PLAN AMENDMENT.—Sec20 tion 1902(a) of the Social Security Act (42 U.S.C. 

21 1396a(a)) is amended— 

22 (A) in paragraph (70), by striking ‘‘and’’ 

23 at the end; 

24 (B) in paragraph (71), by striking the pe25 riod at the end and inserting ‘‘; and’’; and 


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1 (C) by inserting after paragraph (71), the 

2 following new paragraph: 

3 ‘‘(72) in the case of any State in which 1 or 

4 more Indian Health Programs or Urban Indian Or5 ganizations furnishes health care services, provide for 

6 a process under which the State seeks advice on a reg7 ular, ongoing basis from designees of such Indian 

8 Health Programs and Urban Indian Organizations 

9 on matters relating to the application of this title 

10 that are likely to have a direct effect on such Indian 

11 Health Programs and Urban Indian Organizations 

12 and that— 

13 ‘‘(A) shall include solicitation of advice 

14 prior to submission of any plan amendments, 

15 waiver requests, and proposals for demonstration 

16 projects likely to have a direct effect on Indians, 

17 Indian Health Programs, or Urban Indian Or18 ganizations; and 

19 ‘‘(B) may include appointment of an advi20 sory committee and of a designee of such Indian 

21 Health Programs and Urban Indian Organiza22 tions to the medical care advisory committee ad23 vising the State on its State plan under this 

24 title.’’. 


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1 (2) APPLICATION TO CHIP.—Section 2107(e)(1) 

2 of such Act (42 U.S.C. 1397gg(e)(1)), as amended by 

3 section 5005(b), is amended by adding at the end the 

4 following new subparagraph: 

5 ‘‘(F) Section 1902(a)(72) (relating to re6 quiring certain States to seek advice from des7 ignees of Indian Health Programs and Urban 

8 Indian Organizations).’’. 

9 (c) RULE OF CONSTRUCTION.—Nothing in the amend10 ments made by this section shall be construed as super11 seding existing advisory committees, working groups, guid12 ance, or other advisory procedures established by the Sec13 retary of Health and Human Services or by any State with 

14 respect to the provision of health care to Indians. 

15 SEC. 5007. TEMPORARY INCREASE IN DSH ALLOTMENTS 

16 DURING RECESSION. 

17 Section 1923(f)(3) of the Social Security Act (42 

18 U.S.C. 1396r–4(f)(3)) is amended— 

19 (1) in subparagraph (A), by striking ‘‘paragraph 

20 (6)’’ and inserting ‘‘paragraph (6) and subparagraph 

21 (E)’’; and 

22 (2) by adding at the end the following new sub23 paragraph: 

24 ‘‘(E) TEMPORARY INCREASE IN ALLOT25 MENTS DURING RECESSION.— 


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1 ‘‘(i) IN GENERAL.—Subject to clause 

2 (ii), the DSH allotment for any State— 

3 ‘‘(I) for fiscal year 2009 is equal 

4 to 102.5 percent of the DSH allotment 

5 that would be determined under this 

6 paragraph for the State for fiscal year 

7 2009 without application of this sub8 paragraph, notwithstanding subpara9 graph (B); 

10 ‘‘(II) for fiscal year 2010 is equal 

11 to 102.5 percent of the the DSH allot12 ment for the State for fiscal year 2009, 

13 as determined under subclause (I); and 

14 ‘‘(III) for each succeeding fiscal 

15 year is equal to the DSH allotment for 

16 the State under this paragraph deter17 mined without applying subclauses (I) 

18 and (II). 

19 ‘‘(ii) APPLICATION.—Clause (i) shall 

20 not apply to a State for a year in the case 

21 that the DSH allotment for such State for 

22 such year under this paragraph determined 

23 without applying clause (i) would grow 

24 higher than the DSH allotment specified 


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1 under clause (i) for the State for such 

2 year.’’. 


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Union Calendar No. 3 

111TH CONGRESS 

1ST SESSION H. R. 629 

[Report No. 111–7, Part I] 

A BILL 

American Recovery and Reinvestment Act of 2009. 

To provide energy and commerce provisions of the 

JANUARY 27, 2009 

The Committees on Ways and Means, Education and 

State of the Union and ordered to be printed mitted to the Committee of the Whole House on the Labor, and Science and Technology discharged; comVerDate Nov 24 2008 01:50 Jan 28, 2009 Jkt 079200 PO 00000 Frm 00276 Fmt 6651 Sfmt 6651 E:\BILLS\H629.RH H629

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