1751 
oped partnerships with community 
organizations or with agencies with 
experience in language access. 
(C) VARIATION
IN
GRANTEES.—The 
Secretary shall also ensure that the 
grantees under this section represent, 
among other factors, variations in— 
(i) different types of language 
services provided and of service 
providers 
and 
organizations 
under parts A through D of title 
XVIII of the Social Security Act; 
(ii) 
languages 
needed 
and 
their frequency of use; 
(iii) urban and rural settings; 
(iv) at least two geographic 
regions, as defined by the Sec-
retary; and 
(v) at least two large metro-
politan statistical areas with di-
verse populations. 
(c) USE OF FUNDS.— 
(1) IN GENERAL.—A grantee shall use 
grant funds received under this section 
to pay for the provision of competent lan-
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guage services to Medicare beneficiaries 
who are limited English proficient. Com-
petent interpreter services may be pro-
vided through on-site interpretation, tele-
phonic interpretation, or video interpre-
tation or direct provision of health care 
or health care related services by a bilin-
gual health care provider. A grantee may 
use bilingual providers, staff, or contract 
interpreters. A grantee may use grant 
funds to pay for competent translation 
services. A grantee may use up to 10 per-
cent of the grant funds to pay for admin-
istrative costs associated with the provi-
sion of competent language services and 
for reporting required under subsection 
(e). 
(2) ORGANIZATIONS.—Grantees that are 
part C organizations or PDP sponsors 
must ensure that their network providers 
receive at least 50 percent of the grant 
funds to pay for the provision of com-
petent language services to Medicare 
beneficiaries who are limited English 
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proficient, 
including 
physicians 
and 
pharmacies. 
(3) DETERMINATION
OF
PAYMENTS
FOR 
LANGUAGE SERVICES.—Payments to grant-
ees shall be calculated based on the esti-
mated numbers of limited English pro-
ficient Medicare beneficiaries in a grant-
ee’s service area utilizing— 
(A) data on the numbers of lim-
ited English proficient individuals 
who speak English less than ‘‘very 
well’’ from the most recently available 
data from the Bureau of the Census 
or other State-based study the Sec-
retary determines likely to yield ac-
curate data regarding the number of 
such individuals served by the grant-
ee; or 
(B) the grantee’s own data if the 
grantee routinely collects data on 
Medicare beneficiaries’ primary lan-
guage in a manner determined by the 
Secretary to yield accurate data and 
such data shows greater numbers of 
limited English proficient individuals 
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than the data listed in subparagraph 
(A). 
(4) LIMITATIONS.— 
(A) REPORTING.—Payments shall 
only be provided under this section 
to grantees that report their costs of 
providing language services as re-
quired under subsection (e) and may 
be modified annually at the discre-
tion of the Secretary. If a grantee 
fails to provide the reports under 
such section for the first year of a 
grant, the Secretary may terminate 
the grant and solicit applications 
from new grantees to participate in 
the subsequent two years of the dem-
onstration program. 
(B) TYPE OF SERVICES.— 
(i) IN
GENERAL.—Subject to 
clause (ii), payments shall be pro-
vided under this section only to 
grantees that utilize competent 
bilingual staff or competent inter-
preter 
or 
translation 
services 
which— 
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(I) if the grantee operates 
in a State that has statewide 
health care interpreter stand-
ards, meet the State stand-
ards currently in effect; or 
(II) if the grantee operates 
in a State that does not have 
statewide health care inter-
preter 
standards, 
utilizes 
competent interpreters who 
follow the National Council 
on 
Interpreting 
in 
Health 
Care’s Code of Ethics and 
Standards of Practice. 
(ii) EXEMPTIONS.—The require-
ments of clause (i) shall not 
apply— 
(I) in the case of a Medi-
care beneficiary who is lim-
ited English proficient (who 
has been informed in the 
beneficiary’s 
primary 
lan-
guage of the availability of 
free interpreter and trans-
lation services) and who re-
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quests 
the 
use 
of 
family, 
friends, or other persons un-
trained in interpretation or 
translation and the grantee 
documents the request in the 
beneficiary’s record; and 
(II) in the case of a med-
ical 
emergency 
where 
the 
delay directly associated with 
obtaining a competent inter-
preter or translation services 
would jeopardize the health 
of the patient. 
Nothing in clause (ii)(II) shall be 
construed to exempt emergency 
rooms or similar entities that reg-
ularly provide health care serv-
ices in medical emergencies from 
having in place systems to pro-
vide competent interpreter and 
translation 
services 
without 
undue delay. 
(d) ASSURANCES.—Grantees under this sec-
tion shall— 
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(1) ensure that appropriate clinical 
and support staff receive ongoing edu-
cation and training in linguistically ap-
propriate service delivery; 
(2) ensure the linguistic competence 
of bilingual providers; 
(3) offer and provide appropriate lan-
guage services at no additional charge to 
each patient with limited English pro-
ficiency at all points of contact, in a time-
ly manner during all hours of operation; 
(4) notify Medicare beneficiaries of 
their right to receive language services in 
their primary language; 
(5) post signage in the languages of 
the commonly encountered group or 
groups present in the service area of the 
organization; and 
(6) ensure that— 
(A) primary language data are 
collected for recipients of language 
services; and 
(B) consistent with the privacy 
protections provided under the regu-
lations promulgated pursuant to sec-
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tion 264(c) of the Health Insurance 
Portability and Accountability Act of 
1996 (42 U.S.C. 1320d–2 note), if the 
recipient of language services is a 
minor or is incapacitated, the pri-
mary language of the parent or legal 
guardian is collected and utilized. 
(e) REPORTING REQUIREMENTS.—Grantees 
under this section shall provide the Secretary 
with reports at the conclusion of the each 
year of a grant under this section. Each re-
port shall include at least the following infor-
mation: 
(1) The number of Medicare bene-
ficiaries to whom language services are 
provided. 
(2) The languages of those Medicare 
beneficiaries. 
(3) The types of language services 
provided (such as provision of services 
directly in non-English language by a bi-
lingual health care provider or use of an 
interpreter). 
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(4) Type of interpretation (such as in- 
person, telephonic, or video interpreta-
tion). 
(5) The methods of providing lan-
guage services (such as staff or contract 
with external independent contractors or 
agencies). 
(6) The length of time for each inter-
pretation encounter. 
(7) The costs of providing language 
services (which may be actual or esti-
mated, as determined by the Secretary). 
(f) NO COST SHARING.—Limited English 
proficient Medicare beneficiaries shall not 
have to pay cost-sharing or co-pays for lan-
guage services provided through this dem-
onstration program. 
(g) EVALUATION
AND
REPORT.—The Sec-
retary shall conduct an evaluation of the dem-
onstration program under this section and 
shall submit to the appropriate committees of 
Congress a report not later than 1 year after 
the completion of the program. The report 
shall include the following: 
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(1) An analysis of the patient out-
comes and costs of furnishing care to the 
limited English proficient Medicare bene-
ficiaries participating in the project as 
compared to such outcomes and costs for 
limited English proficient Medicare bene-
ficiaries not participating. 
(2) The effect of delivering culturally 
and linguistically appropriate services on 
beneficiary access to care, utilization of 
services, efficiency and cost-effectiveness 
of health care delivery, patient satisfac-
tion, and select health outcomes. 
(3) Recommendations, if any, regard-
ing the extension of such project to the 
entire Medicare program. 
(h) GENERAL PROVISIONS.—Nothing in this 
section shall be construed to limit otherwise 
existing obligations of recipients of Federal fi-
nancial assistance under title VI of the Civil 
Rights Act of 1964 (42 U.S.C. 2000(d) et seq.) 
or any other statute. 
(i) AUTHORIZATION
OF APPROPRIATIONS.— 
There are authorized to be appropriated to 
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carry out this section $16,000,000 for each fis-
cal year of the demonstration program. 
SEC. 1223. IOM REPORT ON IMPACT OF LANGUAGE ACCESS 
SERVICES. 
(a) IN GENERAL.—The Secretary of Health 
and Human Services shall enter into an ar-
rangement with the Institute of Medicine 
under which the Institute will prepare and 
publish, not later than 3 years after the date 
of the enactment of this Act, a report on the 
impact of language access services on the 
health and health care of limited English pro-
ficient populations. 
(b) 
CONTENTS.—Such 
report 
shall 
in-
clude— 
(1) recommendations on the develop-
ment and implementation of policies and 
practices by health care organizations 
and providers for limited English pro-
ficient patient populations; 
(2) a description of the effect of pro-
viding language access services on qual-
ity of health care and access to care and 
reduced medical error; and 
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(3) a description of the costs associ-
ated with or savings related to provision 
of language access services. 
SEC. 1224. DEFINITIONS. 
In this subtitle: 
(1) BILINGUAL.—The term ‘‘bilingual’’ 
with respect to an individual means a 
person who has sufficient degree of pro-
ficiency in two languages and can ensure 
effective communication can occur in 
both languages. 
(2) 
COMPETENT
INTERPRETER
SERV-
ICES.—The term ‘‘competent interpreter 
services’’ means a trans-language ren-
dition of a spoken message in which the 
interpreter comprehends the source lan-
guage and can speak comprehensively in 
the target language to convey the mean-
ing intended in the source language. The 
interpreter knows health and health-re-
lated terminology and provides accurate 
interpretations by choosing equivalent 
expressions that convey the best match-
ing and meaning to the source language 
and captures, to the greatest possible ex-
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tent, all nuances intended in the source 
message. 
(3) 
COMPETENT
TRANSLATION
SERV-
ICES.—The term ‘‘competent translation 
services’’ means a trans-language ren-
dition of a written document in which 
the translator comprehends the source 
language and can write comprehensively 
in the target language to convey the 
meaning intended in the source language. 
The translator knows health and health- 
related terminology and provides accu-
rate translations by choosing equivalent 
expressions that convey the best match-
ing and meaning to the source language 
and captures, to the greatest possible ex-
tent, all nuances intended in the source 
document. 
(4) EFFECTIVE
COMMUNICATION.—The 
term ‘‘effective communication’’ means an 
exchange of information between the pro-
vider of health care or health care-re-
lated services and the limited English 
proficient recipient of such services that 
enables limited English proficient indi-
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1765 
(9) LANGUAGE
SERVICES.—The term 
‘‘language services’’ means provision of 
health care services directly in a non- 
English language, interpretation, trans-
lation, and non-English signage. 
(10) LIMITED
ENGLISH
PROFICIENT.— 
The term ‘‘limited English proficient’’ or 
‘‘LEP’’ with respect to an individual 
means an individual who speaks a pri-
mary language other than English and 
who cannot speak, read, write or under-
stand the English language at a level that 
permits the individual to effectively com-
municate with clinical or nonclinical 
staff at an entity providing health care or 
health care related services. 
(11) MEDICARE BENEFICIARY.—The term 
‘‘Medicare beneficiary’’ means an indi-
vidual entitled to benefits under part A of 
title XVIII of the Social Security Act or 
enrolled under part B of such title. 
(12) MEDICARE
PROGRAM.—The term 
‘‘Medicare program’’ means the programs 
under parts A through D of title XVIII of 
the Social Security Act. 
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(13) 
SERVICE
PROVIDER.—The 
term 
‘‘service provider’’ includes all suppliers, 
providers of services, or entities under 
contract to provide coverage, items or 
services under any part of title XVIII of 
the Social Security Act. 
Subtitle C—Miscellaneous 
Improvements 
SEC. 1231. EXTENSION OF THERAPY CAPS EXCEPTIONS 
PROCESS. 
Section 1833(g)(5) of the Social Security 
Act (42 U.S.C. 1395l(g)(5)), as amended by sec-
tion 141 of the Medicare Improvements for 
Patients and Providers Act of 2008 (Public 
Law 110–275), is amended by striking ‘‘Decem-
ber 31, 2009’’ and inserting ‘‘December 31, 
2011’’. 
SEC. 1232. EXTENDED MONTHS OF COVERAGE OF IMMUNO-
SUPPRESSIVE DRUGS FOR KIDNEY TRANS-
PLANT PATIENTS AND OTHER RENAL DIALY-
SIS PROVISIONS. 
(a) PROVISION OF APPROPRIATE COVERAGE 
OF
IMMUNOSUPPRESSIVE
DRUGS
UNDER
THE 
MEDICARE PROGRAM FOR KIDNEY TRANSPLANT 
RECIPIENTS.— 
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(1) CONTINUED
ENTITLEMENT
TO
IM-
MUNOSUPPRESSIVE DRUGS.— 
(A) KIDNEY
TRANSPLANT
RECIPI-
ENTS.—Section 226A(b)(2) of the Social 
Security Act (42 U.S.C. 426–1(b)(2)) is 
amended by inserting ‘‘(except for 
coverage 
of 
immunosuppressive 
drugs under section 1861(s)(2)(J))’’ be-
fore ‘‘, with the thirty-sixth month’’. 
(B) APPLICATION.—Section 1836 of 
such Act (42 U.S.C. 1395o) is amend-
ed— 
(i) by striking ‘‘Every indi-
vidual who’’ and inserting ‘‘(a) IN 
GENERAL.—Every individual who’’; 
and 
(ii) by adding at the end the 
following new subsection: 
‘‘(b) SPECIAL RULES APPLICABLE TO INDIVID-
UALS ONLY ELIGIBLE FOR COVERAGE OF IMMUNO-
SUPPRESSIVE DRUGS.— 
‘‘(1) IN GENERAL.—In the case of an in-
dividual whose eligibility for benefits 
under this title has ended on or after 
January 1, 2012, except for the coverage 
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of immunosuppressive drugs by reason of 
section 226A(b)(2), the following rules 
shall apply: 
‘‘(A) 
The 
individual 
shall 
be 
deemed to be enrolled under this part 
for purposes of receiving coverage of 
such drugs. 
‘‘(B) The individual shall be re-
sponsible for providing for payment 
of the portion of the premium under 
section 1839 which is not covered 
under the Medicare savings program 
(as defined in section 1144(c)(7)) in 
order to receive such coverage. 
‘‘(C) The provision of such drugs 
shall be subject to the application 
of— 
‘‘(i) the deductible under sec-
tion 1833(b); and 
‘‘(ii) the coinsurance amount 
applicable for such drugs (as de-
termined under this part). 
‘‘(D) If the individual is an inpa-
tient of a hospital or other entity, the 
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individual is entitled to receive cov-
erage of such drugs under this part. 
‘‘(2) ESTABLISHMENT OF PROCEDURES IN 
ORDER TO IMPLEMENT COVERAGE.—The Sec-
retary shall establish procedures for— 
‘‘(A) identifying individuals that 
are entitled to coverage of immuno-
suppressive drugs by reason of sec-
tion 226A(b)(2); and 
‘‘(B) distinguishing such individ-
uals from individuals that are en-
rolled under this part for the com-
plete package of benefits under this 
part.’’. 
(C) TECHNICAL AMENDMENT TO COR-
RECT
DUPLICATE
SUBSECTION
DESIGNA-
TION.—Subsection (c) of section 226A 
of such Act (42 U.S.C. 426–1), as added 
by section 201(a)(3)(D)(ii) of the So-
cial Security Independence and Pro-
gram Improvements Act of 1994 (Pub-
lic Law 103–296; 108 Stat. 1497), is re-
designated as subsection (d). 
(2) EXTENSION OF SECONDARY PAYER RE-
QUIREMENTS
FOR
ESRD
BENEFICIARIES.— 
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Section 1862(b)(1)(C) of such Act (42 
U.S.C. 1395y(b)(1)(C)) is amended by add-
ing at the end the following new sen-
tence: 
‘‘With 
regard 
to 
immuno-
suppressive drugs furnished on or after 
the date of the enactment of the Amer-
ica’s Affordable Health Choices Act of 
2009, this subparagraph shall be applied 
without regard to any time limitation.’’. 
(b) MEDICARE COVERAGE
FOR ESRD PA-
TIENTS.—Section 1881 of such Act is further 
amended— 
(1) in subsection (b)(14)(B)(iii), by in-
serting ‘‘, including oral drugs that are 
not the oral equivalent of an intravenous 
drug (such as oral phosphate binders and 
calcimimetics),’’ after ‘‘other drugs and 
biologicals’’; 
(2) in subsection (b)(14)(E)(ii)— 
(A) in the first sentence— 
(i) by striking ‘‘a one-time 
election to be excluded from the 
phase-in’’ and inserting ‘‘an elec-
tion, with respect to 2011, 2012, or 
2013, to be excluded from the 
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phase-in (or the remainder of the 
phase-in)’’; and 
(ii) by adding before the pe-
riod at the end the following: ‘‘for 
such year and for each subse-
quent year during the phase-in 
described in clause (i)’’; and 
(B) in the second sentence— 
(i) by striking ‘‘January 1, 
2011’’ and inserting ‘‘the first date 
of such year’’; and 
(ii) by inserting ‘‘and at a 
time’’ after ‘‘form and manner’’; 
and 
(3) in subsection (h)(4)(E), by striking 
‘‘lesser’’ and inserting ‘‘greater’’. 
SEC. 1233. ADVANCE CARE PLANNING CONSULTATION. 
(a) MEDICARE.— 
(1) IN GENERAL.—Section 1861 of the 
Social Security Act (42 U.S.C. 1395x) is 
amended— 
(A) in subsection (s)(2)— 
(i) by striking ‘‘and’’ at the 
end of subparagraph (DD); 
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(ii) by adding ‘‘and’’ at the end 
of subparagraph (EE); and 
(iii) by adding at the end the 
following new subparagraph: 
‘‘(FF) advance care planning con-
sultation 
(as 
defined 
in 
subsection 
(hhh)(1));’’; and 
(B) by adding at the end the fol-
lowing new subsection: 
‘‘Advance Care Planning Consultation 
‘‘(hhh)(1) Subject to paragraphs (3) and 
(4), the term ‘advance care planning consulta-
tion’ means a consultation between the indi-
vidual and a practitioner described in para-
graph (2) regarding advance care planning, if, 
subject to paragraph (3), the individual in-
volved has not had such a consultation within 
the last 5 years. Such consultation shall in-
clude the following: 
‘‘(A) An explanation by the practi-
tioner of advance care planning, includ-
ing key questions and considerations, im-
portant steps, and suggested people to 
talk to. 
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‘‘(B) An explanation by the practi-
tioner of advance directives, including 
living wills and durable powers of attor-
ney, and their uses. 
‘‘(C) An explanation by the practi-
tioner of the role and responsibilities of a 
health care proxy. 
‘‘(D) The provision by the practitioner 
of a list of national and State-specific re-
sources to assist consumers and their 
families with advance care planning, in-
cluding the national toll-free hotline, the 
advance care planning clearinghouses, 
and State legal service organizations (in-
cluding those funded through the Older 
Americans Act of 1965). 
‘‘(E) An explanation by the practi-
tioner of the continuum of end-of-life 
services and supports available, includ-
ing palliative care and hospice, and bene-
fits for such services and supports that 
are available under this title. 
‘‘(F)(i) Subject to clause (ii), an expla-
nation of orders regarding life sustaining 
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treatment or similar orders, which shall 
include— 
‘‘(I) the reasons why the develop-
ment of such an order is beneficial to 
the individual and the individual’s 
family and the reasons why such an 
order should be updated periodically 
as 
the 
health 
of 
the 
individual 
changes; 
‘‘(II) the information needed for 
an individual or legal surrogate to 
make informed decisions regarding 
the completion of such an order; and 
‘‘(III) the identification of re-
sources that an individual may use to 
determine the requirements of the 
State in which such individual re-
sides so that the treatment wishes of 
that individual will be carried out if 
the individual is unable to commu-
nicate those wishes, including re-
quirements regarding the designation 
of a surrogate decisionmaker (also 
known as a health care proxy). 
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‘‘(ii) The Secretary shall limit the re-
quirement for explanations under clause 
(i) to consultations furnished in a State— 
‘‘(I) in which all legal barriers 
have been addressed for enabling or-
ders for life sustaining treatment to 
constitute a set of medical orders re-
spected across all care settings; and 
‘‘(II) that has in effect a program 
for orders for life sustaining treat-
ment described in clause (iii). 
‘‘(iii) A program for orders for life 
sustaining treatment for a States de-
scribed in this clause is a program that— 
‘‘(I) 
ensures 
such 
orders 
are 
standardized and uniquely identifi-
able throughout the State; 
‘‘(II) distributes or makes acces-
sible such orders to physicians and 
other health professionals that (act-
ing within the scope of the profes-
sional’s authority under State law) 
may sign orders for life sustaining 
treatment; 
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‘‘(III) provides training for health 
care professionals across the con-
tinuum of care about the goals and 
use of orders for life sustaining treat-
ment; and 
‘‘(IV) is guided by a coalition of 
stakeholders includes representatives 
from 
emergency 
medical 
services, 
emergency department physicians or 
nurses, state long-term care associa-
tion, state medical association, state 
surveyors, agency responsible for sen-
ior 
services, 
state 
department 
of 
health, 
state 
hospital 
association, 
home health association, state bar as-
sociation, and state hospice associa-
tion. 
‘‘(2) A practitioner described in this para-
graph is— 
‘‘(A) a physician (as defined in sub-
section (r)(1)); and 
‘‘(B) a nurse practitioner or physician 
assistant who has the authority under 
State law to sign orders for life sus-
taining treatments. 
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‘‘(3)(A) An initial preventive physical ex-
amination under subsection (WW), including 
any related discussion during such examina-
tion, shall not be considered an advance care 
planning consultation for purposes of apply-
ing the 5-year limitation under paragraph (1). 
‘‘(B) An advance care planning consulta-
tion with respect to an individual may be con-
ducted more frequently than provided under 
paragraph (1) if there is a significant change 
in the health condition of the individual, in-
cluding diagnosis of a chronic, progressive, 
life-limiting disease, a life-threatening or ter-
minal diagnosis or life-threatening injury, or 
upon admission to a skilled nursing facility, 
a long-term care facility (as defined by the 
Secretary), or a hospice program. 
‘‘(4) A consultation under this subsection 
may include the formulation of an order re-
garding life sustaining treatment or a similar 
order. 
‘‘(5)(A) For purposes of this section, the 
term ‘order regarding life sustaining treat-
ment’ means, with respect to an individual, an 
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actionable medical order relating to the treat-
ment of that individual that— 
‘‘(i) is signed and dated by a physi-
cian (as defined in subsection (r)(1)) or 
another health care professional (as spec-
ified by the Secretary and who is acting 
within the scope of the professional’s au-
thority under State law in signing such 
an order, including a nurse practitioner 
or physician assistant) and is in a form 
that permits it to stay with the individual 
and be followed by health care profes-
sionals and providers across the con-
tinuum of care; 
‘‘(ii) effectively communicates the in-
dividual’s preferences regarding life sus-
taining treatment, including an indica-
tion of the treatment and care desired by 
the individual; 
‘‘(iii) is uniquely identifiable and 
standardized within a given locality, re-
gion, or State (as identified by the Sec-
retary); and 
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‘‘(iv) may incorporate any advance di-
rective (as defined in section 1866(f)(3)) if 
executed by the individual. 
‘‘(B) The level of treatment indicated 
under subparagraph (A)(ii) may range from 
an indication for full treatment to an indica-
tion to limit some or all or specified interven-
tions. Such indicated levels of treatment may 
include indications respecting, among other 
items— 
‘‘(i) the intensity of medical interven-
tion if the patient is pulse less, apneic, or 
has serious cardiac or pulmonary prob-
lems; 
‘‘(ii) the individual’s desire regarding 
transfer to a hospital or remaining at the 
current care setting; 
‘‘(iii) the use of antibiotics; and 
‘‘(iv) the use of artificially adminis-
tered nutrition and hydration.’’. 
(2) PAYMENT.—Section 1848(j)(3) of 
such Act (42 U.S.C. 1395w-4(j)(3)) is 
amended by inserting ‘‘(2)(FF),’’ after 
‘‘(2)(EE),’’. 
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(3) 
FREQUENCY
LIMITATION.—Section 
1862(a) of such Act (42 U.S.C. 1395y(a)) is 
amended— 
(A) in paragraph (1)— 
(i) in subparagraph (N), by 
striking ‘‘and’’ at the end; 
(ii) in subparagraph (O) by 
striking the semicolon at the end 
and inserting ‘‘, and’’; and 
(iii) by adding at the end the 
following new subparagraph: 
‘‘(P) in the case of advance care 
planning consultations (as defined in 
section 1861(hhh)(1)), which are per-
formed more frequently than is cov-
ered under such section;’’; and 
(B) in paragraph (7), by striking 
‘‘or (K)’’ and inserting ‘‘(K), or (P)’’. 
(4) EFFECTIVE DATE.—The amendments 
made by this subsection shall apply to 
consultations furnished on or after Janu-
ary 1, 2011. 
(b) EXPANSION OF PHYSICIAN QUALITY RE-
PORTING INITIATIVE FOR END OF LIFE CARE.— 
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(1) PHYSICIAN’S QUALITY REPORTING INI-
TIATIVE.—Section 1848(k)(2) of the Social 
Security Act (42 U.S.C. 1395w–4(k)(2)) is 
amended by adding at the end the fol-
lowing new subparagraph: 
‘‘(E) PHYSICIAN’S
QUALITY
REPORT-
ING INITIATIVE.— 
‘‘(i) IN GENERAL.—For purposes 
of reporting data on quality meas-
ures 
for 
covered 
professional 
services furnished during 2011 
and any subsequent year, to the 
extent that measures are avail-
able, the Secretary shall include 
quality measures on end of life 
care and advanced care planning 
that have been adopted or en-
dorsed by a consensus-based or-
ganization, if appropriate. Such 
measures shall measure both the 
creation of and adherence to or-
ders for life-sustaining treatment. 
‘‘(ii) PROPOSED
SET
OF
MEAS-
URES.—The Secretary shall pub-
lish in the Federal Register pro-
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posed quality measures on end of 
life care and advanced care plan-
ning that the Secretary deter-
mines are described in subpara-
graph (A) and would be appro-
priate for eligible professionals to 
use to submit data to the Sec-
retary. The Secretary shall pro-
vide for a period of public com-
ment on such set of measures be-
fore 
finalizing 
such 
proposed 
measures.’’. 
(c) INCLUSION OF INFORMATION IN MEDICARE 
& YOU HANDBOOK.— 
(1) MEDICARE & YOU HANDBOOK.— 
(A) IN GENERAL.—Not later than 1 
year after the date of the enactment 
of this Act, the Secretary of Health 
and Human Services shall update the 
online version of the Medicare & You 
Handbook to include the following: 
(i) An explanation of advance 
care planning and advance direc-
tives, including— 
(I) living wills; 
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(II) durable power of at-
torney; 
(III) 
orders 
of 
life-sus-
taining treatment; and 
(IV) health care proxies. 
(ii) A description of Federal 
and State resources available to 
assist individuals and their fami-
lies with advance care planning 
and advance directives, includ-
ing— 
(I) available State legal 
service organizations to assist 
individuals with advance care 
planning, including those or-
ganizations that receive fund-
ing pursuant to the Older 
Americans Act of 1965 (42 
U.S.C. 93001 et seq.); 
(II) website links or ad-
dresses for State-specific ad-
vance directive forms; and 
(III) any additional infor-
mation, as determined by the 
Secretary. 
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(B) UPDATE OF PAPER AND SUBSE-
QUENT VERSIONS.—The Secretary shall 
include the information described in 
subparagraph (A) in all paper and 
electronic versions of the Medicare & 
You Handbook that are published on 
or after the date that is 1 year after 
the date of the enactment of this Act. 
SEC. 1234. PART B SPECIAL ENROLLMENT PERIOD AND 
WAIVER OF LIMITED ENROLLMENT PENALTY 
FOR TRICARE BENEFICIARIES. 
(a) PART B SPECIAL ENROLLMENT PERIOD.— 
(1) IN GENERAL.—Section 1837 of the 
Social Security Act (42 U.S.C. 1395p) is 
amended by adding at the end the fol-
lowing new subsection: 
‘‘(l)(1) In the case of any individual who is 
a covered beneficiary (as defined in section 
1072(5) of title 10, United States Code) at the 
time the individual is entitled to hospital in-
surance benefits under part A under section 
226(b) or section 226A and who is eligible to 
enroll but who has elected not to enroll (or to 
be deemed enrolled) during the individual’s 
initial enrollment period, there shall be a spe-
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cial enrollment period described in para-
graph (2). 
‘‘(2) The special enrollment period de-
scribed in this paragraph, with respect to an 
individual, is the 12-month period beginning 
on the day after the last day of the initial en-
rollment period of the individual or, if later, 
the 12-month period beginning with the 
month the individual is notified of enrollment 
under this section. 
‘‘(3) In the case of an individual who en-
rolls during the special enrollment period 
provided under paragraph (1), the coverage 
period under this part shall begin on the first 
day of the month in which the individual en-
rolls or, at the option of the individual, on the 
first day of the second month following the 
last month of the individual’s initial enroll-
ment period. 
‘‘(4) The Secretary of Defense shall estab-
lish a method for identifying individuals de-
scribed in paragraph (1) and providing notice 
to them of their eligibility for enrollment dur-
ing the special enrollment period described in 
paragraph (2).’’. 
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(2) EFFECTIVE DATE.—The amendment 
made by paragraph (1) shall apply to 
elections made on or after the date of the 
enactment of this Act. 
(b) WAIVER OF INCREASE OF PREMIUM.— 
(1) IN
GENERAL.—Section 1839(b) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395r(b)) is amended by striking ‘‘section 
1837(i)(4)’’ and inserting ‘‘subsection (i)(4) 
or (l) of section 1837’’. 
(2) EFFECTIVE DATE.— 
(A) IN GENERAL.—The amendment 
made by paragraph (1) shall apply 
with respect to elections made on or 
after the date of the enactment of this 
Act. 
(B) REBATES FOR CERTAIN DISABLED 
AND ESRD BENEFICIARIES.— 
(i) IN GENERAL.—With respect 
to premiums for months on or 
after January 2005 and before the 
month of the enactment of this 
Act, no increase in the premium 
shall be effected for a month in 
the case of any individual who is 
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a covered beneficiary (as defined 
in section 1072(5) of title 10, 
United States Code) at the time 
the individual is entitled to hos-
pital insurance benefits under 
part A of title XVIII of the Social 
Security Act under section 226(b) 
or 226A of such Act, and who is el-
igible to enroll, but who has elect-
ed not to enroll (or to be deemed 
enrolled), during the individual’s 
initial 
enrollment 
period, 
and 
who enrolls under this part with-
in the 12-month period that be-
gins on the first day of the month 
after the month of notification of 
entitlement under this part. 
(ii) CONSULTATION
WITH
DE-
PARTMENT
OF
DEFENSE.—The Sec-
retary of Health and Human Serv-
ices shall consult with the Sec-
retary of Defense in identifying 
individuals 
described 
in 
this 
paragraph. 
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(iii) REBATES.—The Secretary 
of Health and Human Services 
shall establish a method for pro-
viding rebates of premium in-
creases paid for months on or 
after January 1, 2005, and before 
the month of the enactment of 
this Act for which a penalty was 
applied and collected. 
SEC. 1235. EXCEPTION FOR USE OF MORE RECENT TAX 
YEAR IN CASE OF GAINS FROM SALE OF PRI-
MARY RESIDENCE IN COMPUTING PART B IN-
COME-RELATED PREMIUM. 
(a) 
IN
GENERAL.—Section 
1839(i)(4)(C)(ii)(II) of the Social Security Act 
(42 U.S.C. 1395r(i)(4)(C)(ii)(II)) is amended by 
inserting ‘‘sale of primary residence,’’ after 
‘‘divorce of such individual,’’. 
(b) EFFECTIVE
DATE.—The amendment 
made by subsection (a) shall apply to pre-
miums and payments for years beginning 
with 2011. 
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SEC. 1236. DEMONSTRATION PROGRAM ON USE OF PA-
TIENT DECISIONS AIDS. 
(a) IN GENERAL.—The Secretary of Health 
and Human Services shall establish a shared 
decision making demonstration program (in 
this subsection referred to as the ‘‘program’’) 
under the Medicare program using patient de-
cision aids to meet the objective of improving 
the understanding by Medicare beneficiaries 
of their medical treatment options, as com-
pared to comparable Medicare beneficiaries 
who do not participate in a shared decision 
making process using patient decision aids. 
(b) SITES.— 
(1) ENROLLMENT.—The Secretary shall 
enroll in the program not more than 30 
eligible providers who have experience in 
implementing, and have invested in the 
necessary infrastructure to implement, 
shared decision making using patient de-
cision aids. 
(2) APPLICATION.—An eligible provider 
seeking to participate in the program 
shall submit to the Secretary an applica-
tion at such time and containing such in-
formation as the Secretary may require. 
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(3) PREFERENCE.—In enrolling eligible 
providers in the program, the Secretary 
shall give preference to eligible providers 
that— 
(A) have documented experience 
in using patient decision aids for the 
conditions identified by the Secretary 
and in using shared decision making; 
(B) have the necessary informa-
tion technology infrastructure to col-
lect the information required by the 
Secretary for reporting purposes; and 
(C) are trained in how to use pa-
tient decision aids and shared deci-
sion making. 
(c) FOLLOW-UP COUNSELING VISIT.— 
(1) IN GENERAL.—An eligible provider 
participating in the program shall rou-
tinely schedule Medicare beneficiaries 
for a counseling visit after the viewing of 
such a patient decision aid to answer any 
questions the beneficiary may have with 
respect to the medical care of the condi-
tion involved and to assist the bene-
ficiary in thinking through how their 
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preferences and concerns relate to their 
medical care. 
(2) PAYMENT
FOR
FOLLOW-UP
COUN-
SELING VISIT.—The Secretary shall estab-
lish procedures for making payments for 
such counseling visits provided to Medi-
care beneficiaries under the program. 
Such procedures shall provide for the es-
tablishment— 
(A) of a code (or codes) to rep-
resent such services; and 
(B) of a single payment amount 
for such service that includes the pro-
fessional time of the health care pro-
vider and a portion of the reasonable 
costs of the infrastructure of the eli-
gible provider such as would be made 
under the applicable payment sys-
tems to that provider for similar cov-
ered services. 
(d) COSTS OF AIDS.—An eligible provider 
participating in the program shall be respon-
sible for the costs of selecting, purchasing, 
and incorporating such patient decision aids 
into the provider’s practice, and reporting 
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data on quality and outcome measures under 
the program. 
(e) FUNDING.—The Secretary shall provide 
for the transfer from the Federal Supple-
mentary Medical Insurance Trust Fund estab-
lished under section 1841 of the Social Secu-
rity Act (42 U.S.C. 1395t) of such funds as are 
necessary for the costs of carrying out the 
program. 
(f) WAIVER
AUTHORITY.—The Secretary 
may waive such requirements of titles XI and 
XVIII of the Social Security Act (42 U.S.C. 1301 
et seq. and 1395 et seq.) as may be necessary 
for the purpose of carrying out the program. 
(g) REPORT.—Not later than 12 months 
after the date of completion of the program, 
the Secretary shall submit to Congress a re-
port on such program, together with rec-
ommendations for such legislation and ad-
ministrative action as the Secretary deter-
mines to be appropriate. The final report shall 
include an evaluation of the impact of the use 
of the program on health quality, utilization 
of health care services, and on improving the 
quality of life of such beneficiaries. 
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(h) DEFINITIONS.—In this section: 
(1) ELIGIBLE PROVIDER.—The term ‘‘eli-
gible provider’’ means the following: 
(A) A primary care practice. 
(B) A specialty practice. 
(C) A multispecialty group prac-
tice. 
(D) A hospital. 
(E) A rural health clinic. 
(F) A Federally qualified health 
center 
(as 
defined 
in 
section 
1861(aa)(4) of the Social Security Act 
(42 U.S.C. 1395x(aa)(4)). 
(G) An integrated delivery system. 
(H) A State cooperative entity 
that includes the State government 
and at least one other health care 
provider which is set up for the pur-
pose of testing shared decision mak-
ing and patient decision aids. 
(2) PATIENT
DECISION
AID.—The term 
‘‘patient decision aid’’ means an edu-
cational tool (such as the Internet, a 
video, or a pamphlet) that helps patients 
(or, if appropriate, the family caregiver of 
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the patient) understand and commu-
nicate their beliefs and preferences re-
lated to their treatment options, and to 
decide with their health care provider 
what treatments are best for them based 
on their treatment options, scientific evi-
dence, circumstances, beliefs, and pref-
erences. 
(3) 
SHARED
DECISION
MAKING.—The 
term ‘‘shared decision making’’ means a 
collaborative process between patient 
and clinician that engages the patient in 
decision making, provides patients with 
information about trade-offs among treat-
ment options, and facilitates the incorpo-
ration of patient preferences and values 
into the medical plan. 
TITLE 
III—PROMOTING 
PRI-
MARY 
CARE, 
MENTAL 
HEALTH SERVICES, AND CO-
ORDINATED CARE 
SEC. 1301. ACCOUNTABLE CARE ORGANIZATION PILOT 
PROGRAM. 
Title XVIII of the Social Security Act is 
amended by inserting after section 1866D, as 
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added by section 1152(f) of this Act, the fol-
lowing new section: 
‘‘ACCOUNTABLE CARE ORGANIZATION PILOT 
PROGRAM 
‘‘SEC. 1866E. (a) IN GENERAL.—The Sec-
retary shall conduct a pilot program (in this 
section referred to as the ‘pilot program’) to 
test different payment incentive models, in-
cluding (to the extent practicable) the specific 
payment incentive models described in sub-
section (c), designed to reduce the growth of 
expenditures and improve health outcomes in 
the provision of items and services under this 
title to applicable beneficiaries (as defined in 
subsection (d)) by qualifying accountable care 
organizations (as defined in subsection (b)(1)) 
in order to— 
‘‘(1) promote accountability for a pa-
tient population and coordinate items 
and services under parts A and B; 
‘‘(2) encourage investment in infra-
structure and redesigned care processes 
for high quality and efficient service de-
livery; and 
‘‘(3) reward physician practices and 
other physician organizational models for 
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the provision of high quality and efficient 
health care services. 
‘‘(b) QUALIFYING ACCOUNTABLE CARE ORGA-
NIZATIONS (ACOS).— 
‘‘(1) QUALIFYING ACO DEFINED.—In this 
section: 
‘‘(A) 
IN
GENERAL.—The 
terms 
‘qualifying accountable care organi-
zation’ and ‘qualifying ACO’ mean a 
group of physicians or other physi-
cian organizational model (as defined 
in subparagraph (D)) that— 
‘‘(i) is organized at least in 
part for the purpose of providing 
physicians’ services; and 
‘‘(ii) meets such criteria as the 
Secretary determines to be appro-
priate to participate in the pilot 
program, including the criteria 
specified in paragraph (2). 
‘‘(B) INCLUSION
OF
OTHER
PRO-
VIDERS.—Nothing in this subsection 
shall be construed as preventing a 
qualifying ACO from including a hos-
pital or any other provider of services 
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or supplier furnishing items or serv-
ices for which payment may be made 
under this title that is affiliated with 
the ACO under an arrangement struc-
tured so that such provider or sup-
plier participates in the pilot pro-
gram and shares in any incentive 
payments under the pilot program. 
‘‘(C) PHYSICIAN.—The term ‘physi-
cian’ includes, except as the Sec-
retary may otherwise provide, any in-
dividual who furnishes services for 
which payment may be made as phy-
sicians’ services. 
‘‘(D) OTHER
PHYSICIAN
ORGANIZA-
TIONAL MODEL.—The term ‘other phy-
sician organization model’ means, 
with respect to a qualifying ACO any 
model of organization under which 
physicians 
enter 
into 
agreements 
with other providers for the purposes 
of participation in the pilot program 
in order to provide high quality and 
efficient health care services and 
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share in any incentive payments 
under such program 
‘‘(E) OTHER SERVICES.—Nothing in 
this paragraph shall be construed as 
preventing a qualifying ACO from 
furnishing 
items 
or 
services, 
for 
which payment may not be made 
under this title, for purposes of 
achieving performance goals under 
the pilot program. 
‘‘(2) QUALIFYING
CRITERIA.—The fol-
lowing are criteria described in this para-
graph for an organized group of physi-
cians to be a qualifying ACO: 
‘‘(A) The group has a legal struc-
ture that would allow the group to re-
ceive and distribute incentive pay-
ments under this section. 
‘‘(B) The group includes a suffi-
cient number of primary care physi-
cians (regardless of specialty) for the 
applicable beneficiaries for whose 
care the group is accountable (as de-
termined by the Secretary). 
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‘‘(C) The group reports on quality 
measures in such form, manner, and 
frequency as specified by the Sec-
retary (which may be for the group, 
for providers of services and sup-
pliers, or both). 
‘‘(D) The group reports to the Sec-
retary (in a form, manner and fre-
quency as specified by the Secretary) 
such data as the Secretary deter-
mines appropriate to monitor and 
evaluate the pilot program. 
‘‘(E) The group provides notice to 
applicable beneficiaries regarding the 
pilot program (as determined appro-
priate by the Secretary). 
‘‘(F) The group contributes to a 
best practices network or website, 
that shall be maintained by the Sec-
retary for the purpose of sharing 
strategies on quality improvement, 
care coordination, and efficiency that 
the groups believe are effective. 
‘‘(G) The group utilizes patient- 
centered processes of care, including 
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those that emphasize patient and 
caregiver involvement in planning 
and monitoring of ongoing care man-
agement plan. 
‘‘(H) The group meets other cri-
teria determined to be appropriate by 
the Secretary. 
‘‘(c) SPECIFIC
PAYMENT
INCENTIVE
MOD-
ELS.—The specific payment incentive models 
described in this subsection are the following: 
‘‘(1) PERFORMANCE
TARGET
MODEL.— 
Under the performance target model 
under this paragraph (in this paragraph 
referred to as the ‘performance target 
model’): 
‘‘(A) IN
GENERAL.—A qualifying 
ACO qualifies to receive an incentive 
payment if expenditures for applica-
ble beneficiaries are less than a tar-
get spending level or a target rate of 
growth. The incentive payment shall 
be made only if savings are greater 
than would result from normal vari-
ation in expenditures for items and 
services covered under parts A and B. 
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‘‘(B) COMPUTATION
OF
PERFORM-
ANCE TARGET.— 
‘‘(i) 
IN
GENERAL.—The 
Sec-
retary shall establish a perform-
ance target for each qualifying 
ACO comprised of a base amount 
(described 
in 
clause 
(ii)) 
in-
creased to the current year by an 
adjustment factor (described in 
clause (iii)). Such a target may be 
established on a per capita basis, 
as the Secretary determines to be 
appropriate. 
‘‘(ii) BASE
AMOUNT.—For pur-
poses 
of 
clause 
(i), 
the 
base 
amount in this subparagraph is 
equal to the average total pay-
ments (or allowed charges) under 
parts A and B (and may include 
part D, if the Secretary deter-
mines appropriate) for applicable 
beneficiaries for whom the quali-
fying ACO furnishes items and 
services in a base period deter-
mined by the Secretary. Such 
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base amount may be determined 
on a per capita basis. 
‘‘(iii) 
ADJUSTMENT
FACTOR.— 
For purposes of clause (i), the ad-
justment factor in this clause may 
equal 
an 
annual 
per 
capita 
amount that reflects changes in 
expenditures from the period of 
the base amount to the current 
year that would represent an ap-
propriate performance target for 
applicable beneficiaries (as deter-
mined by the Secretary). Such ad-
justment factor may be deter-
mined as an amount or rate, may 
be determined on a national, re-
gional, local, or organization-spe-
cific basis, and may be deter-
mined on a per capita basis. Such 
adjustment factor also may be ad-
justed for risk as determined ap-
propriate by the Secretary. 
‘‘(iv) 
REBASING.—Under 
this 
model the Secretary shall periodi-
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cally rebase the base expenditure 
amount described in clause (ii). 
‘‘(C) MEETING TARGET.— 
‘‘(i) IN
GENERAL.—Subject to 
clause (ii), a qualifying ACO that 
meet or exceeds annual quality 
and performance targets for a 
year shall receive an incentive 
payment for such year equal to a 
portion (as determined appro-
priate by the Secretary) of the 
amount by which payments under 
this title for such year relative 
are estimated to be below the per-
formance target for such year, as 
determined by the Secretary. The 
Secretary may establish a cap on 
incentive payments for a year for 
a qualifying ACO. 
‘‘(ii) 
LIMITATION.—The 
Sec-
retary shall limit incentive pay-
ments to each qualifying ACO 
under this paragraph as nec-
essary to ensure that the aggre-
gate expenditures with respect to 
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applicable beneficiaries for such 
ACOs under this title (inclusive of 
incentive payments described in 
this subparagraph) do not exceed 
the amount that the Secretary es-
timates would be expended for 
such ACO for such beneficiaries if 
the pilot program under this sec-
tion were not implemented. 
‘‘(D) REPORTING
AND
OTHER
RE-
QUIREMENTS.—In carrying out such 
model, the Secretary may (as the Sec-
retary determines to be appropriate) 
incorporate reporting requirements, 
incentive payments, and penalties re-
lated to the physician quality report-
ing initiative (PQRI), electronic pre-
scribing, electronic health records, 
and other similar initiatives under 
section 1848, and may use alternative 
criteria than would otherwise apply 
under such section for determining 
whether to make such payments. The 
incentive payments described in this 
subparagraph shall not be included 
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in the limit described in subpara-
graph (C)(ii) or in the performance 
target model described in this para-
graph. 
‘‘(2) PARTIAL CAPITATION MODEL.— 
‘‘(A) IN GENERAL.—Subject to sub-
paragraph (B), a partial capitation 
model described in this paragraph (in 
this paragraph referred to as a ‘par-
tial capitation model’) is a model in 
which a qualifying ACO would be at 
financial risk for some, but not all, of 
the items and services covered under 
parts A and B, such as at risk for 
some or all physicians’ services or all 
items and services under part B. The 
Secretary may limit a partial capita-
tion model to ACOs that are highly 
integrated systems of care and to 
ACOs capable of bearing risk, as de-
termined to be appropriate by the 
Secretary. 
‘‘(B) NO
ADDITIONAL
PROGRAM
EX-
PENDITURES.—Payments to a quali-
fying 
ACO 
for 
applicable 
bene-
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ficiaries for a year under the partial 
capitation model shall be established 
in a manner that does not result in 
spending more for such ACO for such 
beneficiaries than would otherwise 
be expended for such ACO for such 
beneficiaries for such year if the pilot 
program were not implemented, as 
estimated by the Secretary. 
‘‘(3) OTHER PAYMENT MODELS.— 
‘‘(A) IN GENERAL.—Subject to sub-
paragraph (B), the Secretary may de-
velop other payment models that 
meet the goals of this pilot program 
to improve quality and efficiency. 
‘‘(B) NO
ADDITIONAL
PROGRAM
EX-
PENDITURES.—Subparagraph 
(B) 
of 
paragraph (2) shall apply to a pay-
ment model under subparagraph (A) 
in a similar manner as such subpara-
graph (B) applies to the payment 
model under paragraph (2). 
‘‘(d) APPLICABLE BENEFICIARIES.— 
‘‘(1) IN GENERAL.—In this section, the 
term ‘applicable beneficiary’ means, with 
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respect to a qualifying ACO, an indi-
vidual who— 
‘‘(A) is enrolled under part B and 
entitled to benefits under part A; 
‘‘(B) is not enrolled in a Medicare 
Advantage plan under part C or a 
PACE program under section 1894; 
and 
‘‘(C) meets such other criteria as 
the 
Secretary 
determines 
appro-
priate, which may include criteria re-
lating to frequency of contact with 
physicians in the ACO 
‘‘(2) 
FOLLOWING
APPLICABLE
BENE-
FICIARIES.—The Secretary may monitor 
data on expenditures and quality of serv-
ices under this title after an applicable 
beneficiary discontinues receiving serv-
ices under this title through a qualifying 
ACO. 
‘‘(e) IMPLEMENTATION.— 
‘‘(1) STARTING
DATE.—The pilot pro-
gram shall begin no later than January 1, 
2012. An agreement with a qualifying 
ACO under the pilot program may cover 
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(5) EXCLUSION OF MARRIAGE AND FAM-
ILY
THERAPIST
SERVICES
FROM
SKILLED 
NURSING
FACILITY
PROSPECTIVE
PAYMENT 
SYSTEM.—Section 1888(e)(2)(A)(ii) of the 
Social 
Security 
Act 
(42 
U.S.C. 
1395yy(e)(2)(A)(ii)), as amended by sec-
tion 1307(a), is amended by inserting 
‘‘marriage and family therapist services 
(as defined in subsection (jjj)(1)),’’ after 
‘‘clinical social worker services,’’. 
(6) COVERAGE OF MARRIAGE AND FAMILY 
THERAPIST
SERVICES
PROVIDED
IN
RURAL 
HEALTH CLINICS AND FEDERALLY QUALIFIED 
HEALTH
CENTERS.—Section 1861(aa)(1)(B) 
of the Social Security Act (42 U.S.C. 
1395x(aa)(1)(B)) is amended by striking 
‘‘or by a clinical social worker (as defined 
in subsection (hh)(1)),’’ and inserting ‘‘, by 
a clinical social worker (as defined in 
subsection (hh)(1)), or by a marriage and 
family therapist (as defined in subsection 
(jjj)(2)),’’. 
(7) INCLUSION OF MARRIAGE AND FAMILY 
THERAPISTS AS PRACTITIONERS FOR ASSIGN-
MENT
OF
CLAIMS.—Section 1842(b)(18)(C) 
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of the Social Security Act (42 U.S.C. 
1395u(b)(18)(C)) is amended by adding at 
the end the following new clause: 
‘‘(vii) A marriage and family therapist 
(as defined in section 1861(jjj)(2)).’’. 
(b) COVERAGE OF MENTAL HEALTH COUN-
SELOR SERVICES.— 
(1) COVERAGE
OF
SERVICES.—Section 
1861(s)(2) of the Social Security Act (42 
U.S.C. 1395x(s)(2)), as previously amend-
ed, is further amended— 
(A) in subparagraph (FF), by 
striking ‘‘and’’ at the end; 
(B) in subparagraph (GG), by in-
serting ‘‘and’’ at the end; and 
(C) by adding at the end the fol-
lowing new subparagraph: 
‘‘(HH) mental health counselor serv-
ices (as defined in subsection (kkk)(1));’’. 
(2) DEFINITION.—Section 1861 of the 
Social Security Act (42 U.S.C. 1395x), as 
previously amended, is amended by add-
ing at the end the following new sub-
section: 
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