H. R. 3590—208 
the demonstration project shall enter into an agreement with 
the State to participate in the project for not less than a 
3-year period. 
(d) INCENTIVE PAYMENT.—An accountable care organization 
that meets the performance guidelines established by the Secretary 
under subsection (c)(1) and achieves savings greater than the 
annual minimal savings level established by the State under sub-
section (c)(2) shall receive an incentive payment for such year 
equal to a portion (as determined appropriate by the Secretary) 
of the amount of such excess savings. The Secretary may establish 
an annual cap on incentive payments for an accountable care 
organization. 
(e) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated such sums as are necessary to carry out this 
section. 
SEC. 2707. MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION 
PROJECT. 
(a) AUTHORITY TO CONDUCT DEMONSTRATION PROJECT.—The 
Secretary of Health and Human Services (in this section referred 
to as the ‘‘Secretary’’) shall establish a demonstration project under 
which an eligible State (as described in subsection (c)) shall provide 
payment under the State Medicaid plan under title XIX of the 
Social Security Act to an institution for mental diseases that is 
not publicly owned or operated and that is subject to the require-
ments of section 1867 of the Social Security Act (42 U.S.C. 1395dd) 
for the provision of medical assistance available under such plan 
to individuals who— 
(1) have attained age 21, but have not attained age 65; 
(2) are eligible for medical assistance under such plan; 
and 
(3) require such medical assistance to stabilize an emer-
gency medical condition. 
(b) STABILIZATION REVIEW.—A State shall specify in its applica-
tion described in subsection (c)(1) establish a mechanism for how 
it will ensure that institutions participating in the demonstration 
will determine whether or not such individuals have been stabilized 
(as defined in subsection (h)(5)). This mechanism shall commence 
before the third day of the inpatient stay. States participating 
in the demonstration project may manage the provision of services 
for the stabilization of medical emergency conditions through utili-
zation review, authorization, or management practices, or the 
application of medical necessity and appropriateness criteria 
applicable to behavioral health. 
(c) ELIGIBLE STATE DEFINED.— 
(1) IN GENERAL.—An eligible State is a State that has 
made an application and has been selected pursuant to para-
graphs (2) and (3). 
(2) APPLICATION.—A State seeking to participate in the 
demonstration project under this section shall submit to the 
Secretary, at such time and in such format as the Secretary 
requires, an application that includes such information, provi-
sions, and assurances, as the Secretary may require. 
(3) SELECTION.—A State shall be determined eligible for 
the demonstration by the Secretary on a competitive basis 
among States with applications meeting the requirements of
H. R. 3590—209 
paragraph (1). In selecting State applications for the demonstra-
tion project, the Secretary shall seek to achieve an appropriate 
national balance in the geographic distribution of such projects. 
(d) LENGTH OF DEMONSTRATION PROJECT.—The demonstration 
project established under this section shall be conducted for a 
period of 3 consecutive years. 
(e) LIMITATIONS ON FEDERAL FUNDING.— 
(1) APPROPRIATION.— 
(A) IN GENERAL.—Out of any funds in the Treasury 
not otherwise appropriated, there is appropriated to carry 
out this section, $75,000,000 for fiscal year 2011. 
(B) BUDGET AUTHORITY.—Subparagraph (A) constitutes 
budget authority in advance of appropriations Act and rep-
resents the obligation of the Federal Government to provide 
for the payment of the amounts appropriated under that 
subparagraph. 
(2) 5-YEAR AVAILABILITY.—Funds appropriated under para-
graph (1) shall remain available for obligation through 
December 31, 2015. 
(3) LIMITATION ON PAYMENTS.—In no case may— 
(A) the aggregate amount of payments made by the 
Secretary to eligible States under this section exceed 
$75,000,000; or 
(B) payments be provided by the Secretary under this 
section after December 31, 2015. 
(4) FUNDS ALLOCATED TO STATES.—Funds shall be allocated 
to eligible States on the basis of criteria, including a State’s 
application and the availability of funds, as determined by 
the Secretary. 
(5) PAYMENTS TO STATES.—The Secretary shall pay to each 
eligible State, from its allocation under paragraph (4), an 
amount each quarter equal to the Federal medical assistance 
percentage of expenditures in the quarter for medical assistance 
described in subsection (a). As a condition of receiving payment, 
a State shall collect and report information, as determined 
necessary by the Secretary, for the purposes of providing Fed-
eral oversight and conducting an evaluation under subsection 
(f)(1). 
(f) EVALUATION AND REPORT TO CONGRESS.— 
(1) EVALUATION.—The Secretary shall conduct an evalua-
tion of the demonstration project in order to determine the 
impact on the functioning of the health and mental health 
service system and on individuals enrolled in the Medicaid 
program and shall include the following: 
(A) An assessment of access to inpatient mental health 
services under the Medicaid program; average lengths of 
inpatient stays; and emergency room visits. 
(B) An assessment of discharge planning by partici-
pating hospitals. 
(C) An assessment of the impact of the demonstration 
project on the costs of the full range of mental health 
services (including inpatient, emergency and ambulatory 
care). 
(D) An analysis of the percentage of consumers with 
Medicaid coverage who are admitted to inpatient facilities 
as a result of the demonstration project as compared to
H. R. 3590—210 
those admitted to these same facilities through other 
means. 
(E) A recommendation regarding whether the dem-
onstration project should be continued after December 31, 
2013, and expanded on a national basis. 
(2) REPORT.—Not later than December 31, 2013, the Sec-
retary shall submit to Congress and make available to the 
public a report on the findings of the evaluation under para-
graph (1). 
(g) WAIVER AUTHORITY.— 
(1) IN GENERAL.—The Secretary shall waive the limitation 
of subdivision (B) following paragraph (28) of section 1905(a) 
of the Social Security Act (42 U.S.C. 1396d(a)) (relating to 
limitations on payments for care or services for individuals 
under 65 years of age who are patients in an institution for 
mental diseases) for purposes of carrying out the demonstration 
project under this section. 
(2) LIMITED OTHER WAIVER AUTHORITY.—The Secretary may 
waive other requirements of titles XI and XIX of the Social 
Security Act (including the requirements of sections 1902(a)(1) 
(relating to statewideness) and 1902(1)(10)(B) (relating to com-
parability)) only to extent necessary to carry out the demonstra-
tion project under this section. 
(h) DEFINITIONS.—In this section: 
(1) EMERGENCY MEDICAL CONDITION.—The term ‘‘emergency 
medical condition’’ means, with respect to an individual, an 
individual who expresses suicidal or homicidal thoughts or ges-
tures, if determined dangerous to self or others. 
(2) FEDERAL MEDICAL ASSISTANCE PERCENTAGE.—The term 
‘‘Federal medical assistance percentage’’ has the meaning given 
that term with respect to a State under section 1905(b) of 
the Social Security Act (42 U.S.C. 1396d(b)). 
(3) INSTITUTION FOR MENTAL DISEASES.—The term ‘‘institu-
tion for mental diseases’’ has the meaning given to that term 
in section 1905(i) of the Social Security Act (42 U.S.C. 1396d(i)). 
(4) MEDICAL ASSISTANCE.—The term ‘‘medical assistance’’ 
has the meaning given that term in section 1905(a) of the 
Social Security Act (42 U.S.C. 1396d(a)). 
(5) STABILIZED.—The term ‘‘stabilized’’ means, with respect 
to an individual, that the emergency medical condition no longer 
exists with respect to the individual and the individual is 
no longer dangerous to self or others. 
(6) STATE.—The term ‘‘State’’ has the meaning given that 
term for purposes of title XIX of the Social Security Act (42 
U.S.C. 1396 et seq.). 
Subtitle J—Improvements to the Medicaid 
and CHIP Payment and Access Commis-
sion (MACPAC) 
SEC. 2801. MACPAC ASSESSMENT OF POLICIES AFFECTING ALL MED-
ICAID BENEFICIARIES. 
(a) IN GENERAL.—Section 1900 of the Social Security Act (42 
U.S.C. 1396) is amended— 
(1) in subsection (b)—
H. R. 3590—211 
(A) in paragraph (1)— 
(i) in the paragraph heading, by inserting ‘‘FOR 
ALL STATES’’ before ‘‘AND ANNUAL’’; and 
(ii) in subparagraph (A), by striking ‘‘children’s’’; 
(iii) in subparagraph (B), by inserting ‘‘, the Sec-
retary, and States’’ after ‘‘Congress’’; 
(iv) in subparagraph (C), by striking ‘‘March 1’’ 
and inserting ‘‘March 15’’; and 
(v) in subparagraph (D), by striking ‘‘June 1’’ and 
inserting ‘‘June 15’’; 
(B) in paragraph (2)— 
(i) in subparagraph (A)— 
(I) in clause (i)— 
(aa) by inserting ‘‘the efficient provision 
of’’ after ‘‘expenditures for’’; and 
(bb) by striking ‘‘hospital, skilled nursing 
facility, physician, Federally-qualified health 
center, rural health center, and other fees’’ 
and inserting ‘‘payments to medical, dental, 
and health professionals, hospitals, residential 
and long-term care providers, providers of 
home and community based services, Feder-
ally-qualified health centers and rural health 
clinics, managed care entities, and providers 
of other covered items and services’’; and 
(II) in clause (iii), by inserting ‘‘(including how 
such factors and methodologies enable such bene-
ficiaries to obtain the services for which they are 
eligible, affect provider supply, and affect providers 
that serve a disproportionate share of low-income 
and other vulnerable populations)’’ after ‘‘bene-
ficiaries’’; 
(ii) by redesignating subparagraphs (B) and (C) 
as subparagraphs (F) and (H), respectively; 
(iii) by inserting after subparagraph (A), the fol-
lowing: 
‘‘(B) ELIGIBILITY POLICIES.—Medicaid and CHIP eligi-
bility policies, including a determination of the degree to 
which Federal and State policies provide health care cov-
erage to needy populations. 
‘‘(C) ENROLLMENT AND RETENTION PROCESSES.—Med-
icaid and CHIP enrollment and retention processes, 
including a determination of the degree to which Federal 
and State policies encourage the enrollment of individuals 
who are eligible for such programs and screen out individ-
uals who are ineligible, while minimizing the share of 
program expenses devoted to such processes. 
‘‘(D) COVERAGE POLICIES.—Medicaid and CHIP benefit 
and coverage policies, including a determination of the 
degree to which Federal and State policies provide access 
to the services enrollees require to improve and maintain 
their health and functional status. 
‘‘(E) QUALITY OF CARE.—Medicaid and CHIP policies 
as they relate to the quality of care provided under those 
programs, including a determination of the degree to which 
Federal and State policies achieve their stated goals and
H. R. 3590—212 
interact with similar goals established by other purchasers 
of health care services.’’; 
(iv) by inserting after subparagraph (F) (as redesig-
nated by clause (ii) of this subparagraph), the following: 
‘‘(G) INTERACTIONS WITH MEDICARE AND MEDICAID.— 
Consistent with paragraph (11), the interaction of policies 
under Medicaid and the Medicare program under title 
XVIII, including with respect to how such interactions 
affect access to services, payments, and dual eligible 
individuals.’’ and 
(v) in subparagraph (H) (as so redesignated), by 
inserting ‘‘and preventive, acute, and long-term serv-
ices and supports’’ after ‘‘barriers’’; 
(C) by redesignating paragraphs (3) through (9) as 
paragraphs (4) through (10), respectively; 
(D) by inserting after paragraph (2), the following new 
paragraph: 
‘‘(3) RECOMMENDATIONS
AND
REPORTS
OF
STATE-SPECIFIC 
DATA.—MACPAC shall— 
‘‘(A) review national and State-specific Medicaid and 
CHIP data; and 
‘‘(B) submit reports and recommendations to Congress, 
the Secretary, and States based on such reviews.’’; 
(E) in paragraph (4), as redesignated by subparagraph 
(C), by striking ‘‘or any other problems’’ and all that follows 
through the period and inserting ‘‘, as well as other factors 
that adversely affect, or have the potential to adversely 
affect, access to care by, or the health care status of, 
Medicaid and CHIP beneficiaries. MACPAC shall include 
in the annual report required under paragraph (1)(D) a 
description of all such areas or problems identified with 
respect to the period addressed in the report.’’; 
(F) in paragraph (5), as so redesignated,— 
(i) in the paragraph heading, by inserting ‘‘AND 
REGULATIONS’’ after ‘‘REPORTS’’; and 
(ii) by striking ‘‘If’’ and inserting the following: 
‘‘(A) CERTAIN SECRETARIAL REPORTS.—If’’; and 
(iii) in the second sentence, by inserting ‘‘and the 
Secretary’’ after ‘‘appropriate committees of Congress’’; 
and 
(iv) by adding at the end the following: 
‘‘(B) REGULATIONS.—MACPAC shall review Medicaid 
and CHIP regulations and may comment through submis-
sion of a report to the appropriate committees of Congress 
and the Secretary, on any such regulations that affect 
access, quality, or efficiency of health care.’’; 
(G) in paragraph (10), as so redesignated, by inserting 
‘‘, and shall submit with any recommendations, a report 
on the Federal and State-specific budget consequences of 
the recommendations’’ before the period; and 
(H) by adding at the end the following: 
‘‘(11) CONSULTATION AND COORDINATION WITH MEDPAC.— 
‘‘(A) IN
GENERAL.—MACPAC shall consult with the 
Medicare Payment Advisory Commission (in this paragraph 
referred to as ‘MedPAC’) established under section 1805 
in carrying out its duties under this section, as appropriate 
and particularly with respect to the issues specified in
H. R. 3590—213 
paragraph (2) as they relate to those Medicaid beneficiaries 
who are dually eligible for Medicaid and the Medicare 
program under title XVIII, adult Medicaid beneficiaries 
(who are not dually eligible for Medicare), and beneficiaries 
under Medicare. Responsibility for analysis of and rec-
ommendations to change Medicare policy regarding Medi-
care beneficiaries, including Medicare beneficiaries who are 
dually eligible for Medicare and Medicaid, shall rest with 
MedPAC. 
‘‘(B) INFORMATION SHARING.—MACPAC and MedPAC 
shall have access to deliberations and records of the other 
such entity, respectively, upon the request of the other 
such entity. 
‘‘(12) CONSULTATION WITH STATES.—MACPAC shall regu-
larly consult with States in carrying out its duties under this 
section, including with respect to developing processes for car-
rying out such duties, and shall ensure that input from States 
is taken into account and represented in MACPAC’s rec-
ommendations and reports. 
‘‘(13) COORDINATE AND CONSULT WITH THE FEDERAL COORDI-
NATED HEALTH CARE OFFICE.—MACPAC shall coordinate and 
consult with the Federal Coordinated Health Care Office estab-
lished under section 2081 of the Patient Protection and Afford-
able Care Act before making any recommendations regarding 
dual eligible individuals. 
‘‘(14) PROGRAMMATIC
OVERSIGHT
VESTED
IN
THE
SEC-
RETARY.—MACPAC’s authority to make recommendations in 
accordance with this section shall not affect, or be considered 
to duplicate, the Secretary’s authority to carry out Federal 
responsibilities with respect to Medicaid and CHIP.’’; 
(2) in subsection (c)(2)— 
(A) by striking subparagraphs (A) and (B) and inserting 
the following: 
‘‘(A) IN GENERAL.—The membership of MACPAC shall 
include individuals who have had direct experience as 
enrollees or parents or caregivers of enrollees in Medicaid 
or CHIP and individuals with national recognition for their 
expertise in Federal safety net health programs, health 
finance and economics, actuarial science, health plans and 
integrated delivery systems, reimbursement for health care, 
health information technology, and other providers of 
health services, public health, and other related fields, 
who provide a mix of different professions, broad geographic 
representation, and a balance between urban and rural 
representation. 
‘‘(B) INCLUSION.—The membership of MACPAC shall 
include (but not be limited to) physicians, dentists, and 
other health professionals, employers, third-party payers, 
and individuals with expertise in the delivery of health 
services. Such membership shall also include representa-
tives of children, pregnant women, the elderly, individuals 
with disabilities, caregivers, and dual eligible individuals, 
current or former representatives of State agencies respon-
sible for administering Medicaid, and current or former 
representatives of State agencies responsible for admin-
istering CHIP.’’.
H. R. 3590—214 
(3) in subsection (d)(2), by inserting ‘‘and State’’ after ‘‘Fed-
eral’’; 
(4) in subsection (e)(1), in the first sentence, by inserting 
‘‘and, as a condition for receiving payments under sections 
1903(a) and 2105(a), from any State agency responsible for 
administering Medicaid or CHIP,’’ after ‘‘United States’’; and 
(5) in subsection (f)— 
(A) in the subsection heading, by striking ‘‘AUTHORIZA-
TION OF APPROPRIATIONS’’ and inserting ‘‘FUNDING’’; 
(B) in paragraph (1), by inserting ‘‘(other than for 
fiscal year 2010)’’ before ‘‘in the same manner’’; and 
(C) by adding at the end the following: 
‘‘(3) FUNDING FOR FISCAL YEAR 2010.— 
‘‘(A) IN GENERAL.—Out of any funds in the Treasury 
not otherwise appropriated, there is appropriated to 
MACPAC to carry out the provisions of this section for 
fiscal year 2010, $9,000,000. 
‘‘(B) TRANSFER
OF
FUNDS.—Notwithstanding section 
2104(a)(13), from the amounts appropriated in such section 
for fiscal year 2010, $2,000,000 is hereby transferred and 
made available in such fiscal year to MACPAC to carry 
out the provisions of this section. 
‘‘(4) AVAILABILITY.—Amounts made available under para-
graphs (2) and (3) to MACPAC to carry out the provisions 
of this section shall remain available until expended.’’. 
(b) CONFORMING MEDPAC AMENDMENTS.—Section 1805(b) of 
the Social Security Act (42 U.S.C. 1395b–6(b)), is amended— 
(1) in paragraph (1)(C), by striking ‘‘March 1 of each year 
(beginning with 1998)’’ and inserting ‘‘March 15’’; 
(2) in paragraph (1)(D), by inserting ‘‘, and (beginning 
with 2012) containing an examination of the topics described 
in paragraph (9), to the extent feasible’’ before the period; 
and 
(3) by adding at the end the following: 
‘‘(9) REVIEW
AND
ANNUAL
REPORT
ON
MEDICAID
AND 
COMMERCIAL TRENDS.—The Commission shall review and report 
on aggregate trends in spending, utilization, and financial 
performance under the Medicaid program under title XIX and 
the private market for health care services with respect to 
providers for which, on an aggregate national basis, a signifi-
cant portion of revenue or services is associated with the Med-
icaid program. Where appropriate, the Commission shall con-
duct such review in consultation with the Medicaid and CHIP 
Payment and Access Commission established under section 
1900 (in this section referred to as ‘MACPAC’). 
‘‘(10) COORDINATE AND CONSULT WITH THE FEDERAL COORDI-
NATED HEALTH CARE OFFICE.—The Commission shall coordinate 
and consult with the Federal Coordinated Health Care Office 
established under section 2081 of the Patient Protection and 
Affordable Care Act before making any recommendations 
regarding dual eligible individuals. 
‘‘(11) INTERACTION
OF
MEDICAID
AND
MEDICARE.—The 
Commission shall consult with MACPAC in carrying out its 
duties under this section, as appropriate. Responsibility for 
analysis of and recommendations to change Medicare policy 
regarding Medicare beneficiaries, including Medicare bene-
ficiaries who are dually eligible for Medicare and Medicaid,
H. R. 3590—215 
shall rest with the Commission. Responsibility for analysis 
of and recommendations to change Medicaid policy regarding 
Medicaid beneficiaries, including Medicaid beneficiaries who 
are dually eligible for Medicare and Medicaid, shall rest with 
MACPAC.’’. 
Subtitle K—Protections for American 
Indians and Alaska Natives 
SEC. 2901. SPECIAL RULES RELATING TO INDIANS. 
(a) NO COST-SHARING FOR INDIANS WITH INCOME AT OR BELOW 
300 PERCENT OF POVERTY ENROLLED IN COVERAGE THROUGH A 
STATE EXCHANGE.—For provisions prohibiting cost sharing for 
Indians enrolled in any qualified health plan in the individual 
market through an Exchange, see section 1402(d) of the Patient 
Protection and Affordable Care Act. 
(b) PAYER OF LAST RESORT.—Health programs operated by the 
Indian Health Service, Indian tribes, tribal organizations, and 
Urban Indian organizations (as those terms are defined in section 
4 of the Indian Health Care Improvement Act (25 U.S.C. 1603)) 
shall be the payer of last resort for services provided by such 
Service, tribes, or organizations to individuals eligible for services 
through such programs, notwithstanding any Federal, State, or 
local law to the contrary. 
(c) FACILITATING ENROLLMENT OF INDIANS UNDER THE EXPRESS 
LANE OPTION.—Section 1902(e)(13)(F)(ii) of the Social Security Act 
(42 U.S.C. 1396a(e)(13)(F)(ii)) is amended— 
(1) in the clause heading, by inserting ‘‘AND INDIAN TRIBES 
AND TRIBAL ORGANIZATIONS’’ after ‘‘AGENCIES’’; and 
(2) by adding at the end the following: 
‘‘(IV) The Indian Health Service, an Indian 
Tribe, Tribal Organization, or Urban Indian 
Organization (as defined in section 1139(c)).’’. 
(d) TECHNICAL CORRECTIONS.—Section 1139(c) of the Social 
Security Act (42 U.S.C. 1320b–9(c)) is amended by striking ‘‘In 
this section’’ and inserting ‘‘For purposes of this section, title XIX, 
and title XXI’’. 
SEC. 2902. ELIMINATION OF SUNSET FOR REIMBURSEMENT FOR ALL 
MEDICARE PART B SERVICES FURNISHED BY CERTAIN 
INDIAN HOSPITALS AND CLINICS. 
(a) REIMBURSEMENT FOR ALL MEDICARE PART B SERVICES FUR-
NISHED
BY
CERTAIN
INDIAN
HOSPITALS
AND
CLINICS.—Section 
1880(e)(1)(A) of the Social Security Act (42 U.S.C. 1395qq(e)(1)(A)) 
is amended by striking ‘‘during the 5-year period beginning on’’ 
and inserting ‘‘on or after’’. 
(b) EFFECTIVE DATE.—The amendments made by this section 
shall apply to items or services furnished on or after January 
1, 2010.
H. R. 3590—216 
Subtitle L—Maternal and Child Health 
Services 
SEC. 2951. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VIS-
ITING PROGRAMS. 
Title V of the Social Security Act (42 U.S.C. 701 et seq.) 
is amended by adding at the end the following new section: 
‘‘SEC. 511. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VIS-
ITING PROGRAMS. 
‘‘(a) PURPOSES.—The purposes of this section are— 
‘‘(1) to strengthen and improve the programs and activities 
carried out under this title; 
‘‘(2) to improve coordination of services for at risk commu-
nities; and 
‘‘(3) to identify and provide comprehensive services to 
improve outcomes for families who reside in at risk commu-
nities. 
‘‘(b) REQUIREMENT
FOR ALL STATES TO ASSESS STATEWIDE 
NEEDS AND IDENTIFY AT RISK COMMUNITIES.— 
‘‘(1) IN GENERAL.—Not later than 6 months after the date 
of enactment of this section, each State shall, as a condition 
of receiving payments from an allotment for the State under 
section 502 for fiscal year 2011, conduct a statewide needs 
assessment (which shall be separate from the statewide needs 
assessment required under section 505(a)) that identifies— 
‘‘(A) communities with concentrations of— 
‘‘(i) premature birth, low-birth weight infants, and 
infant mortality, including infant death due to neglect, 
or other indicators of at-risk prenatal, maternal, new-
born, or child health; 
‘‘(ii) poverty; 
‘‘(iii) crime; 
‘‘(iv) domestic violence; 
‘‘(v) high rates of high-school drop-outs; 
‘‘(vi) substance abuse; 
‘‘(vii) unemployment; or 
‘‘(viii) child maltreatment; 
‘‘(B) the quality and capacity of existing programs or 
initiatives for early childhood home visitation in the State 
including— 
‘‘(i) the number and types of individuals and fami-
lies who are receiving services under such programs 
or initiatives; 
‘‘(ii) the gaps in early childhood home visitation 
in the State; and 
‘‘(iii) the extent to which such programs or initia-
tives are meeting the needs of eligible families 
described in subsection (k)(2); and 
‘‘(C) the State’s capacity for providing substance abuse 
treatment and counseling services to individuals and fami-
lies in need of such treatment or services. 
‘‘(2) COORDINATION
WITH
OTHER
ASSESSMENTS.—In con-
ducting the statewide needs assessment required under para-
graph (1), the State shall coordinate with, and take into 
account, other appropriate needs assessments conducted by
H. R. 3590—217 
the State, as determined by the Secretary, including the needs 
assessment required under section 505(a) (both the most 
recently completed assessment and any such assessment in 
progress), the communitywide strategic planning and needs 
assessments conducted in accordance with section 640(g)(1)(C) 
of the Head Start Act, and the inventory of current unmet 
needs and current community-based and prevention-focused 
programs and activities to prevent child abuse and neglect, 
and other family resource services operating in the State 
required under section 205(3) of the Child Abuse Prevention 
and Treatment Act. 
‘‘(3) SUBMISSION
TO
THE
SECRETARY.—Each State shall 
submit to the Secretary, in such form and manner as the 
Secretary shall require— 
‘‘(A) the results of the statewide needs assessment 
required under paragraph (1); and 
‘‘(B) a description of how the State intends to address 
needs identified by the assessment, particularly with 
respect to communities identified under paragraph (1)(A), 
which may include applying for a grant to conduct an 
early childhood home visitation program in accordance with 
the requirements of this section. 
‘‘(c) GRANTS
FOR EARLY CHILDHOOD HOME VISITATION PRO-
GRAMS.— 
‘‘(1) AUTHORITY TO MAKE GRANTS.—In addition to any other 
payments made under this title to a State, the Secretary shall 
make grants to eligible entities to enable the entities to deliver 
services under early childhood home visitation programs that 
satisfy the requirements of subsection (d) to eligible families 
in order to promote improvements in maternal and prenatal 
health, infant health, child health and development, parenting 
related to child development outcomes, school readiness, and 
the socioeconomic status of such families, and reductions in 
child abuse, neglect, and injuries. 
‘‘(2) AUTHORITY TO USE INITIAL GRANT FUNDS FOR PLANNING 
OR IMPLEMENTATION.—An eligible entity that receives a grant 
under paragraph (1) may use a portion of the funds made 
available to the entity during the first 6 months of the period 
for which the grant is made for planning or implementation 
activities to assist with the establishment of early childhood 
home visitation programs that satisfy the requirements of sub-
section (d). 
‘‘(3) GRANT DURATION.—The Secretary shall determine the 
period of years for which a grant is made to an eligible entity 
under paragraph (1). 
‘‘(4) TECHNICAL ASSISTANCE.—The Secretary shall provide 
an eligible entity that receives a grant under paragraph (1) 
with technical assistance in administering programs or activi-
ties conducted in whole or in part with grant funds. 
‘‘(d) REQUIREMENTS.—The requirements of this subsection for 
an early childhood home visitation program conducted with a grant 
made under this section are as follows: 
‘‘(1) QUANTIFIABLE, MEASURABLE IMPROVEMENT IN BENCH-
MARK AREAS.— 
‘‘(A) IN GENERAL.—The eligible entity establishes, sub-
ject to the approval of the Secretary, quantifiable, measur-
able 3- and 5-year benchmarks for demonstrating that the
H. R. 3590—218 
program results in improvements for the eligible families 
participating in the program in each of the following areas: 
‘‘(i) Improved maternal and newborn health. 
‘‘(ii) Prevention of child injuries, child abuse, 
neglect, or maltreatment, and reduction of emergency 
department visits. 
‘‘(iii) Improvement in school readiness and achieve-
ment. 
‘‘(iv) Reduction in crime or domestic violence. 
‘‘(v) Improvements in family economic self-suffi-
ciency. 
‘‘(vi) Improvements in the coordination and refer-
rals for other community resources and supports. 
‘‘(B) DEMONSTRATION
OF
IMPROVEMENTS
AFTER
YEARS.— 
‘‘(i) REPORT TO THE SECRETARY.—Not later than 
30 days after the end of the 3rd year in which the 
eligible entity conducts the program, the entity submits 
to the Secretary a report demonstrating improvement 
in at least 4 of the areas specified in subparagraph 
(A). 
‘‘(ii) CORRECTIVE ACTION PLAN.—If the report sub-
mitted by the eligible entity under clause (i) fails to 
demonstrate improvement in at least 4 of the areas 
specified in subparagraph (A), the entity shall develop 
and implement a plan to improve outcomes in each 
of the areas specified in subparagraph (A), subject 
to approval by the Secretary. The plan shall include 
provisions for the Secretary to monitor implementation 
of the plan and conduct continued oversight of the 
program, including through submission by the entity 
of regular reports to the Secretary. 
‘‘(iii) TECHNICAL ASSISTANCE.— 
‘‘(I) IN GENERAL.—The Secretary shall provide 
an eligible entity required to develop and imple-
ment an improvement plan under clause (ii) with 
technical assistance to develop and implement the 
plan. The Secretary may provide the technical 
assistance directly or through grants, contracts, 
or cooperative agreements. 
‘‘(II) ADVISORY
PANEL.—The Secretary shall 
establish an advisory panel for purposes of 
obtaining recommendations regarding the tech-
nical assistance provided to entities in accordance 
with subclause (I). 
‘‘(iv) NO
IMPROVEMENT
OR
FAILURE
TO
SUBMIT 
REPORT.—If the Secretary determines after a period 
of time specified by the Secretary that an eligible entity 
implementing an improvement plan under clause (ii) 
has failed to demonstrate any improvement in the 
areas specified in subparagraph (A), or if the Secretary 
determines that an eligible entity has failed to submit 
the report required under clause (i), the Secretary shall 
terminate the entity’s grant and may include any unex-
pended grant funds in grants made to nonprofit 
organizations under subsection (h)(2)(B).
H. R. 3590—219 
‘‘(C) FINAL REPORT.—Not later than December 31, 2015, 
the eligible entity shall submit a report to the Secretary 
demonstrating improvements (if any) in each of the areas 
specified in subparagraph (A). 
‘‘(2) IMPROVEMENTS
IN
OUTCOMES
FOR
INDIVIDUAL
FAMI-
LIES.— 
‘‘(A) IN
GENERAL.—The program is designed, with 
respect to an eligible family participating in the program, 
to result in the participant outcomes described in subpara-
graph (B) that the eligible entity identifies on the basis 
of an individualized assessment of the family, are relevant 
for that family. 
‘‘(B) PARTICIPANT
OUTCOMES.—The participant out-
comes described in this subparagraph are the following: 
‘‘(i) Improvements in prenatal, maternal, and new-
born health, including improved pregnancy outcomes 
‘‘(ii) Improvements in child health and develop-
ment, including the prevention of child injuries and 
maltreatment and improvements in cognitive, lan-
guage, social-emotional, and physical developmental 
indicators. 
‘‘(iii) Improvements in parenting skills. 
‘‘(iv) Improvements in school readiness and child 
academic achievement. 
‘‘(v) Reductions in crime or domestic violence. 
‘‘(vi) Improvements in family economic self-suffi-
ciency. 
‘‘(vii) Improvements in the coordination of referrals 
for, and the provision of, other community resources 
and supports for eligible families, consistent with State 
child welfare agency training. 
‘‘(3) CORE
COMPONENTS.—The program includes the fol-
lowing core components: 
‘‘(A) SERVICE DELIVERY MODEL OR MODELS.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), the pro-
gram is conducted using 1 or more of the service 
delivery models described in item (aa) or (bb) of sub-
clause (I) or in subclause (II) selected by the eligible 
entity: 
‘‘(I) The model conforms to a clear consistent 
home visitation model that has been in existence 
for at least 3 years and is research-based, grounded 
in relevant empirically-based knowledge, linked to 
program determined outcomes, associated with a 
national organization or institution of higher edu-
cation that has comprehensive home visitation pro-
gram standards that ensure high quality service 
delivery and continuous program quality improve-
ment, and has demonstrated significant, (and in 
the case of the service delivery model described 
in item (aa), sustained) positive outcomes, as 
described in the benchmark areas specified in 
paragraph (1)(A) and the participant outcomes 
described in paragraph (2)(B), when evaluated 
using well-designed and rigorous—
H. R. 3590—220 
‘‘(aa) 
randomized 
controlled 
research 
designs, and the evaluation results have been 
published in a peer-reviewed journal; or 
‘‘(bb) quasi-experimental research designs. 
‘‘(II) The model conforms to a promising and 
new approach to achieving the benchmark areas 
specified in paragraph (1)(A) and the participant 
outcomes described in paragraph (2)(B), has been 
developed or identified by a national organization 
or institution of higher education, and will be 
evaluated through well-designed and rigorous 
process. 
‘‘(ii) MAJORITY
OF
GRANT
FUNDS
USED
FOR
EVI-
DENCE-BASED MODELS.—An eligible entity shall use not 
more than 25 percent of the amount of the grant paid 
to the entity for a fiscal year for purposes of conducting 
a program using the service delivery model described 
in clause (i)(II). 
‘‘(iii) CRITERIA FOR EVIDENCE OF EFFECTIVENESS 
OF MODELS.—The Secretary shall establish criteria for 
evidence of effectiveness of the service delivery models 
and shall ensure that the process for establishing the 
criteria is transparent and provides the opportunity 
for public comment. 
‘‘(B) ADDITIONAL REQUIREMENTS.— 
‘‘(i) The program adheres to a clear, consistent 
model that satisfies the requirements of being 
grounded in empirically-based knowledge related to 
home visiting and linked to the benchmark areas speci-
fied in paragraph (1)(A) and the participant outcomes 
described in paragraph (2)(B) related to the purposes 
of the program. 
‘‘(ii) The program employs well-trained and com-
petent staff, as demonstrated by education or training, 
such as nurses, social workers, educators, child 
development specialists, or other well-trained and com-
petent staff, and provides ongoing and specific training 
on the model being delivered. 
‘‘(iii) The program maintains high quality super-
vision to establish home visitor competencies. 
‘‘(iv) The program demonstrates strong organiza-
tional capacity to implement the activities involved. 
‘‘(v) The program establishes appropriate linkages 
and referral networks to other community resources 
and supports for eligible families. 
‘‘(vi) The program monitors the fidelity of program 
implementation to ensure that services are delivered 
pursuant to the specified model. 
‘‘(4) PRIORITY FOR SERVING HIGH-RISK POPULATIONS.—The 
eligible entity gives priority to providing services under the 
program to the following: 
‘‘(A) Eligible families who reside in communities in 
need of such services, as identified in the statewide needs 
assessment required under subsection (b)(1)(A). 
‘‘(B) Low-income eligible families. 
‘‘(C) Eligible families who are pregnant women who 
have not attained age 21.
H. R. 3590—221 
‘‘(D) Eligible families that have a history of child abuse 
or neglect or have had interactions with child welfare serv-
ices. 
‘‘(E) Eligible families that have a history of substance 
abuse or need substance abuse treatment. 
‘‘(F) Eligible families that have users of tobacco prod-
ucts in the home. 
‘‘(G) Eligible families that are or have children with 
low student achievement. 
‘‘(H) Eligible families with children with developmental 
delays or disabilities. 
‘‘(I) Eligible families who, or that include individuals 
who, are serving or formerly served in the Armed Forces, 
including such families that have members of the Armed 
Forces who have had multiple deployments outside of the 
United States. 
‘‘(e) APPLICATION REQUIREMENTS.—An eligible entity desiring 
a grant under this section shall submit an application to the Sec-
retary for approval, in such manner as the Secretary may require, 
that includes the following: 
‘‘(1) A description of the populations to be served by the 
entity, including specific information regarding how the entity 
will serve high risk populations described in subsection (d)(4). 
‘‘(2) An assurance that the entity will give priority to 
serving low-income eligible families and eligible families who 
reside in at risk communities identified in the statewide needs 
assessment required under subsection (b)(1)(A). 
‘‘(3) The service delivery model or models described in 
subsection (d)(3)(A) that the entity will use under the program 
and the basis for the selection of the model or models. 
‘‘(4) A statement identifying how the selection of the popu-
lations to be served and the service delivery model or models 
that the entity will use under the program for such populations 
is consistent with the results of the statewide needs assessment 
conducted under subsection (b). 
‘‘(5) The quantifiable, measurable benchmarks established 
by the State to demonstrate that the program contributes to 
improvements in the areas specified in subsection (d)(1)(A). 
‘‘(6) An assurance that the entity will obtain and submit 
documentation or other appropriate evidence from the organiza-
tion or entity that developed the service delivery model or 
models used under the program to verify that the program 
is implemented and services are delivered according to the 
model specifications. 
‘‘(7) Assurances that the entity will establish procedures 
to ensure that— 
‘‘(A) the participation of each eligible family in the 
program is voluntary; and 
‘‘(B) services are provided to an eligible family in 
accordance with the individual assessment for that family. 
‘‘(8) Assurances that the entity will— 
‘‘(A) submit annual reports to the Secretary regarding 
the program and activities carried out under the program 
that include such information and data as the Secretary 
shall require; and 
‘‘(B) participate in, and cooperate with, data and 
information collection necessary for the evaluation required
H. R. 3590—222 
under subsection (g)(2) and other research and evaluation 
activities carried out under subsection (h)(3). 
‘‘(9) A description of other State programs that include 
home visitation services, including, if applicable to the State, 
other programs carried out under this title with funds made 
available from allotments under section 502(c), programs 
funded under title IV, title II of the Child Abuse Prevention 
and Treatment Act (relating to community-based grants for 
the prevention of child abuse and neglect), and section 645A 
of the Head Start Act (relating to Early Head Start programs). 
‘‘(10) Other information as required by the Secretary. 
‘‘(f) MAINTENANCE OF EFFORT.—Funds provided to an eligible 
entity receiving a grant under this section shall supplement, and 
not supplant, funds from other sources for early childhood home 
visitation programs or initiatives. 
‘‘(g) EVALUATION.— 
‘‘(1) INDEPENDENT, EXPERT
ADVISORY
PANEL.—The Sec-
retary, in accordance with subsection (h)(1)(A), shall appoint 
an independent advisory panel consisting of experts in program 
evaluation and research, education, and early childhood 
development— 
‘‘(A) to review, and make recommendations on, the 
design and plan for the evaluation required under para-
graph (2) within 1 year after the date of enactment of 
this section; 
‘‘(B) to maintain and advise the Secretary regarding 
the progress of the evaluation; and 
‘‘(C) to comment, if the panel so desires, on the report 
submitted under paragraph (3). 
‘‘(2) AUTHORITY TO CONDUCT EVALUATION.—On the basis 
of the recommendations of the advisory panel under paragraph 
(1), the Secretary shall, by grant, contract, or interagency agree-
ment, conduct an evaluation of the statewide needs assessments 
submitted under subsection (b) and the grants made under 
subsections (c) and (h)(3)(B). The evaluation shall include— 
‘‘(A) an analysis, on a State-by-State basis, of the 
results of such assessments, including indicators of 
maternal and prenatal health and infant health and mor-
tality, and State actions in response to the assessments; 
and 
‘‘(B) an assessment of— 
‘‘(i) the effect of early childhood home visitation 
programs on child and parent outcomes, including with 
respect to each of the benchmark areas specified in 
subsection (d)(1)(A) and the participant outcomes 
described in subsection (d)(2)(B); 
‘‘(ii) the effectiveness of such programs on different 
populations, including the extent to which the ability 
of programs to improve participant outcomes varies 
across programs and populations; and 
‘‘(iii) the potential for the activities conducted 
under such programs, if scaled broadly, to improve 
health care practices, eliminate health disparities, and 
improve health care system quality, efficiencies, and 
reduce costs.
H. R. 3590—223 
‘‘(3) REPORT.—Not later than March 31, 2015, the Secretary 
shall submit a report to Congress on the results of the evalua-
tion conducted under paragraph (2) and shall make the report 
publicly available. 
‘‘(h) OTHER PROVISIONS.— 
‘‘(1) INTRA-AGENCY COLLABORATION.—The Secretary shall 
ensure that the Maternal and Child Health Bureau and the 
Administration for Children and Families collaborate with 
respect to carrying out this section, including with respect 
to— 
‘‘(A) reviewing and analyzing the statewide needs 
assessments required under subsection (b), the awarding 
and oversight of grants awarded under this section, the 
establishment of the advisory panels required under sub-
sections (d)(1)(B)(iii)(II) and (g)(1), and the evaluation and 
report required under subsection (g); and 
‘‘(B) consulting with other Federal agencies with 
responsibility for administering or evaluating programs 
that serve eligible families to coordinate and collaborate 
with respect to research related to such programs and 
families, including the Office of the Assistant Secretary 
for Planning and Evaluation of the Department of Health 
and Human Services, the Centers for Disease Control and 
Prevention, the National Institute of Child Health and 
Human Development of the National Institutes of Health, 
the Office of Juvenile Justice and Delinquency Prevention 
of the Department of Justice, and the Institute of Education 
Sciences of the Department of Education. 
‘‘(2) GRANTS TO ELIGIBLE ENTITIES THAT ARE NOT STATES.— 
‘‘(A) INDIAN TRIBES, TRIBAL ORGANIZATIONS, OR URBAN 
INDIAN
ORGANIZATIONS.—The 
Secretary 
shall 
specify 
requirements for eligible entities that are Indian Tribes 
(or a consortium of Indian Tribes), Tribal Organizations, 
or Urban Indian Organizations to apply for and conduct 
an early childhood home visitation program with a grant 
under this section. Such requirements shall, to the greatest 
extent practicable, be consistent with the requirements 
applicable to eligible entities that are States and shall 
require an Indian Tribe (or consortium), Tribal Organiza-
tion, or Urban Indian Organization to— 
‘‘(i) conduct a needs assessment similar to the 
assessment required for all States under subsection 
(b); and 
‘‘(ii) establish quantifiable, measurable 3- and 5- 
year benchmarks consistent with subsection (d)(1)(A). 
‘‘(B) NONPROFIT ORGANIZATIONS.—If, as of the begin-
ning of fiscal year 2012, a State has not applied or been 
approved for a grant under this section, the Secretary 
may use amounts appropriated under paragraph (1) of 
subsection (j) that are available for expenditure under para-
graph (3) of that subsection to make a grant to an eligible 
entity that is a nonprofit organization described in sub-
section (k)(1)(B) to conduct an early childhood home visita-
tion program in the State. The Secretary shall specify 
the requirements for such an organization to apply for 
and conduct the program which shall, to the greatest extent 
practicable, be consistent with the requirements applicable
H. R. 3590—368 
‘‘(I) for each of 2010 and 2011, 0.25 percentage 
point; and 
‘‘(II) subject to clause (ii), for each of 2012 
through 2019, 0.2 percentage point. 
‘‘(ii) REDUCTION OF OTHER ADJUSTMENT.—Clause 
(i)(II) shall be applied with respect to any of 2014 
through 2019 by substituting ‘0.0 percentage points’ 
for ‘0.2 percentage point’, if for such year— 
‘‘(I) the excess (if any) of— 
‘‘(aa) the total percentage of the non- 
elderly insured population for the preceding 
year (based on the most recent estimates avail-
able from the Director of the Congressional 
Budget Office before a vote in either House 
on the Patient Protection and Affordable Care 
Act that, if determined in the affirmative, 
would clear such Act for enrollment); over 
‘‘(bb) the total percentage of the non- 
elderly insured population for such preceding 
year (as estimated by the Secretary); exceeds 
‘‘(II) 5 percentage points.’’. 
(j) AMBULANCE SERVICES.—Section 1834(l)(3) of the Social Secu-
rity Act (42 U.S.C. 1395m(l)(3)) is amended— 
(1) in subparagraph (A), by striking ‘‘and’’ at the end; 
(2) in subparagraph (B)— 
(A) by inserting ‘‘, subject to subparagraph (C) and 
the 
succeeding 
sentence 
of 
this 
paragraph,’’ 
after 
‘‘increased’’; and 
(B) by striking the period at the end and inserting 
‘‘; and’’; 
(3) by adding at the end the following new subparagraph: 
‘‘(C) for 2011 and each subsequent year, after deter-
mining the percentage increase under subparagraph (B) 
for the year, reduce such percentage increase by the produc-
tivity adjustment described in section 1886(b)(3)(B)(xi)(II).’’; 
and 
(4) by adding at the end the following flush sentence: 
‘‘The application of subparagraph (C) may result in the percent-
age increase under subparagraph (B) being less than 0.0 for 
a year, and may result in payment rates under the fee schedule 
under this subsection for a year being less than such payment 
rates for the preceding year.’’. 
(k) 
AMBULATORY
SURGICAL
CENTER
SERVICES.—Section 
1833(i)(2)(D) of the Social Security Act (42 U.S.C. 1395l(i)(2)(D)) 
is amended— 
(1) by redesignating clause (v) as clause (vi); and 
(2) by inserting after clause (iv) the following new clause: 
‘‘(v) In implementing the system described in 
clause (i) for 2011 and each subsequent year, any 
annual update under such system for the year, after 
application of clause (iv), shall be reduced by the 
productivity 
adjustment 
described 
in 
section 
1886(b)(3)(B)(xi)(II). The application of the preceding 
sentence may result in such update being less than 
0.0 for a year, and may result in payment rates under 
the system described in clause (i) for a year being 
less than such payment rates for the preceding year.’’.
H. R. 3590—369 
(l) LABORATORY SERVICES.—Section 1833(h)(2)(A) of the Social 
Security Act (42 U.S.C. 1395l(h)(2)(A)) is amended— 
(1) in clause (i)— 
(A) by inserting ‘‘, subject to clause (iv),’’ after ‘‘year) 
by’’; and 
(B) by striking ‘‘through 2013’’ and inserting ‘‘and 
2010’’; and 
(2) by adding at the end the following new clause: 
‘‘(iv) After determining the adjustment to the fee 
schedules under clause (i), the Secretary shall reduce 
such adjustment— 
‘‘(I) for 2011 and each subsequent year, by 
the productivity adjustment described in section 
1886(b)(3)(B)(xi)(II); and 
‘‘(II) for each of 2011 through 2015, by 1.75 
percentage points. 
Subclause (I) shall not apply in a year where the 
adjustment to the fee schedules determined under 
clause (i) is 0.0 or a percentage decrease for a year. 
The application of the productivity adjustment under 
subclause (I) shall not result in an adjustment to the 
fee schedules under clause (i) being less than 0.0 for 
a year. The application of subclause (II) may result 
in an adjustment to the fee schedules under clause 
(i) being less than 0.0 for a year, and may result 
in payment rates for a year being less than such pay-
ment rates for the preceding year.’’. 
(m) 
CERTAIN
DURABLE
MEDICAL
EQUIPMENT.—Section 
1834(a)(14) of the Social Security Act (42 U.S.C. 1395m(a)(14)) 
is amended— 
(1) in subparagraph (K)— 
(A) by striking ‘‘2011, 2012, and 2013,’’; and 
(B) by inserting ‘‘and’’ after the semicolon at the end; 
(2) by striking subparagraphs (L) and (M) and inserting 
the following new subparagraph: 
‘‘(L) for 2011 and each subsequent year— 
‘‘(i) the percentage increase in the consumer price 
index for all urban consumers (United States city aver-
age) for the 12-month period ending with June of the 
previous year, reduced by— 
‘‘(ii) the productivity adjustment described in sec-
tion 1886(b)(3)(B)(xi)(II).’’; and 
(3) by adding at the end the following flush sentence: 
‘‘The application of subparagraph (L)(ii) may result in the cov-
ered item update under this paragraph being less than 0.0 
for a year, and may result in payment rates under this sub-
section for a year being less than such payment rates for 
the preceding year.’’. 
(n) PROSTHETIC DEVICES, ORTHOTICS, AND PROSTHETICS.—Sec-
tion 1834(h)(4) of the Social Security Act (42 U.S.C. 1395m(h)(4)) 
is amended— 
(1) in subparagraph (A)— 
(A) in clause (ix), by striking ‘‘and’’ at the end; 
(B) in clause (x)— 
(i) by striking ‘‘a subsequent year’’ and inserting 
‘‘for each of 2007 through 2010’’; and
H. R. 3590—370 
(ii) by inserting ‘‘and’’ after the semicolon at the 
end; 
(C) by adding at the end the following new clause: 
‘‘(xi) for 2011 and each subsequent year— 
‘‘(I) the percentage increase in the consumer 
price index for all urban consumers (United States 
city average) for the 12-month period ending with 
June of the previous year, reduced by— 
‘‘(II) the productivity adjustment described in 
section 1886(b)(3)(B)(xi)(II).’’; and 
(D) by adding at the end the following flush sentence: 
‘‘The application of subparagraph (A)(xi)(II) may result in the 
applicable percentage increase under subparagraph (A) being 
less than 0.0 for a year, and may result in payment rates 
under this subsection for a year being less than such payment 
rates for the preceding year.’’. 
(o) OTHER ITEMS.—Section 1842(s)(1) of the Social Security 
Act (42 U.S.C. 1395u(s)(1)) is amended— 
(1) in the first sentence, by striking ‘‘Subject to’’ and 
inserting ‘‘(A) Subject to’’; 
(2) by striking the second sentence and inserting the fol-
lowing new subparagraph: 
‘‘(B) Any fee schedule established under this paragraph 
for such item or service shall be updated— 
‘‘(i) for years before 2011— 
‘‘(I) subject to subclause (II), by the percentage 
increase in the consumer price index for all urban 
consumers (United States city average) for the 12- 
month period ending with June of the preceding 
year; and 
‘‘(II) for items and services described in para-
graph (2)(D) for 2009, section 1834(a)(14)(J) shall 
apply under this paragraph instead of the percent-
age increase otherwise applicable; and 
‘‘(ii) for 2011 and subsequent years— 
‘‘(I) the percentage increase in the consumer 
price index for all urban consumers (United States 
city average) for the 12-month period ending with 
June of the previous year, reduced by— 
‘‘(II) the productivity adjustment described in 
section 1886(b)(3)(B)(xi)(II).’’; and 
(3) by adding at the end the following flush sentence: 
‘‘The application of subparagraph (B)(ii)(II) may result in the 
update under this paragraph being less than 0.0 for a year, 
and may result in payment rates under any fee schedule estab-
lished under this paragraph for a year being less than such 
payment rates for the preceding year.’’. 
(p) NO APPLICATION PRIOR TO APRIL 1, 2010.—Notwithstanding 
the preceding provisions of this section, the amendments made 
by subsections (a), (c), and (d) shall not apply to discharges occurring 
before April 1, 2010. 
SEC. 3402. TEMPORARY ADJUSTMENT TO THE CALCULATION OF PART 
B PREMIUMS. 
Section 1839(i) of the Social Security Act (42 U.S.C. 1395r(i)) 
is amended—
H. R. 3590—376 
‘‘(II) take into account any delivery system 
reforms or other payment changes that have been 
enacted or published in final rules but not yet 
implemented as of the making of such calculation. 
‘‘(C) MEDICARE PER CAPITA TARGET GROWTH RATE.— 
For purposes of this section, the Medicare per capita target 
growth rate for an implementation year shall be calculated 
as the projected 5-year average (ending with such year) 
percentage increase in— 
‘‘(i) with respect to a determination year that is 
prior to 2018, the average of the projected percentage 
increase (if any) in— 
‘‘(I) the Consumer Price Index for All Urban 
Consumers (all items; United States city average); 
and 
‘‘(II) the medical care expenditure category of 
the Consumer Price Index for All Urban Con-
sumers (United States city average); and 
‘‘(ii) with respect to a determination year that is 
after 2017, the nominal gross domestic product per 
capita plus 1.0 percentage point. 
‘‘(7) SAVINGS REQUIREMENT.— 
‘‘(A) IN GENERAL.—If, with respect to a determination 
year, the Chief Actuary of the Centers for Medicare & 
Medicaid Services makes a determination under paragraph 
(6)(A) that the growth rate described in clause (i) of such 
paragraph exceeds the growth rate described in clause 
(ii) of such paragraph, the Chief Actuary shall establish 
an applicable savings target for the implementation year. 
‘‘(B) APPLICABLE SAVINGS TARGET.—For purposes of this 
section, the applicable savings target for an implementation 
year shall be an amount equal to the product of— 
‘‘(i) the total amount of projected Medicare program 
spending for the proposal year; and 
‘‘(ii) the applicable percent for the implementation 
year. 
‘‘(C) APPLICABLE PERCENT.—For purposes of subpara-
graph (B), the applicable percent for an implementation 
year is the lesser of— 
‘‘(i) in the case of— 
‘‘(I) implementation year 2015, 0.5 percent; 
‘‘(II) implementation year 2016, 1.0 percent; 
‘‘(III) implementation year 2017, 1.25 percent; 
and 
‘‘(IV) implementation year 2018 or any subse-
quent implementation year, 1.5 percent; and 
‘‘(ii) the projected excess for the implementation 
year (expressed as a percent) determined under 
subparagraph (A). 
‘‘(8) PER CAPITA RATE OF GROWTH IN NATIONAL HEALTH 
EXPENDITURES.—In each determination year (beginning in 
2018), the Chief Actuary of the Centers for Medicare & Med-
icaid Services shall project the per capita rate of growth in 
national health expenditures for the implementation year. Such 
rate of growth for an implementation year shall be calculated 
as the projected 5-year average (ending with such year) percent-
age increase in national health care expenditures.
H. R. 3590—377 
‘‘(d) CONGRESSIONAL CONSIDERATION.— 
‘‘(1) INTRODUCTION.— 
‘‘(A) IN GENERAL.—On the day on which a proposal 
is submitted by the President to the House of Representa-
tives and the Senate under subsection (c)(4), the legislative 
proposal (described in subsection (c)(3)(B)(iv)) contained in 
the proposal shall be introduced (by request) in the Senate 
by the majority leader of the Senate or by Members of 
the Senate designated by the majority leader of the Senate 
and shall be introduced (by request) in the House by the 
majority leader of the House or by Members of the House 
designated by the majority leader of the House. 
‘‘(B) NOT IN SESSION.—If either House is not in session 
on the day on which such legislative proposal is submitted, 
the legislative proposal shall be introduced in that House, 
as provided in subparagraph (A), on the first day thereafter 
on which that House is in session. 
‘‘(C) ANY MEMBER.—If the legislative proposal is not 
introduced in either House within 5 days on which that 
House is in session after the day on which the legislative 
proposal is submitted, then any Member of that House 
may introduce the legislative proposal. 
‘‘(D) REFERRAL.—The legislation introduced under this 
paragraph shall be referred by the Presiding Officers of 
the respective Houses to the Committee on Finance in 
the Senate and to the Committee on Energy and Commerce 
and the Committee on Ways and Means in the House 
of Representatives. 
‘‘(2) COMMITTEE CONSIDERATION OF PROPOSAL.— 
‘‘(A) REPORTING BILL.—Not later than April 1 of any 
proposal year in which a proposal is submitted by the 
President to Congress under this section, the Committee 
on Ways and Means and the Committee on Energy and 
Commerce of the House of Representatives and the Com-
mittee on Finance of the Senate may report the bill referred 
to the Committee under paragraph (1)(D) with committee 
amendments related to the Medicare program. 
‘‘(B) CALCULATIONS.—In determining whether a com-
mittee amendment meets the requirement of subparagraph 
(A), the reductions in Medicare program spending during 
the 3-month period immediately preceding the implementa-
tion year shall be counted to the extent that such reductions 
are a result of the implementation provisions in the com-
mittee amendment for a change in the payment rate for 
an item or service that was effective during such period 
pursuant to such amendment. 
‘‘(C) COMMITTEE JURISDICTION.—Notwithstanding rule 
XV of the Standing Rules of the Senate, a committee 
amendment described in subparagraph (A) may include 
matter not within the jurisdiction of the Committee on 
Finance if that matter is relevant to a proposal contained 
in the bill submitted under subsection (c)(3). 
‘‘(D) DISCHARGE.—If, with respect to the House 
involved, the committee has not reported the bill by the 
date required by subparagraph (A), the committee shall 
be discharged from further consideration of the proposal.
H. R. 3590—383 
resolution described in paragraph (1), it is at any time 
thereafter in order (even though a previous motion 
to the same effect has been disagreed to) for a motion 
to proceed to the consideration of the joint resolution 
to be made, and all points of order against the joint 
resolution (and against consideration of the joint reso-
lution) are waived, except for points of order under 
the Congressional Budget act of 1974 or under budget 
resolutions pursuant to that Act. The motion is not 
debatable. A motion to reconsider the vote by which 
the motion is agreed to or disagreed to shall not be 
in order. If a motion to proceed to the consideration 
of the joint resolution is agreed to, the joint resolution 
shall remain the unfinished business of the Senate 
until disposed of. 
‘‘(ii) DEBATE LIMITATION.—In the Senate, consider-
ation of the joint resolution, and on all debatable 
motions and appeals in connection therewith, shall 
be limited to not more than 10 hours, which shall 
be divided equally between the majority leader and 
the minority leader, or their designees. A motion fur-
ther to limit debate is in order and not debatable. 
An amendment to, or a motion to postpone, or a motion 
to proceed to the consideration of other business, or 
a motion to recommit the joint resolution is not in 
order. 
‘‘(iii) PASSAGE.—In the Senate, immediately fol-
lowing the conclusion of the debate on a joint resolution 
described in paragraph (1), and a single quorum call 
at the conclusion of the debate if requested in accord-
ance with the rules of the Senate, the vote on passage 
of the joint resolution shall occur. 
‘‘(iv) APPEALS.—Appeals from the decisions of the 
Chair relating to the application of the rules of the 
Senate to the procedure relating to a joint resolution 
described in paragraph (1) shall be decided without 
debate. 
‘‘(D) OTHER HOUSE ACTS FIRST.—If, before the passage 
by 1 House of a joint resolution of that House described 
in paragraph (1), that House receives from the other House 
a joint resolution described in paragraph (1), then the 
following procedures shall apply: 
‘‘(i) The joint resolution of the other House shall 
not be referred to a committee. 
‘‘(ii) With respect to a joint resolution described 
in paragraph (1) of the House receiving the joint resolu-
tion— 
‘‘(I) the procedure in that House shall be the 
same as if no joint resolution had been received 
from the other House; but 
‘‘(II) the vote on final passage shall be on 
the joint resolution of the other House. 
‘‘(E) EXCLUDED DAYS.—For purposes of determining the 
period specified in subparagraph (B), there shall be 
excluded any days either House of Congress is adjourned 
for more than 3 days during a session of Congress.
H. R. 3590—439 
(2) in paragraph (7), by striking ‘‘or (K)’’ and inserting 
‘‘(K), or (P)’’. 
(e) EFFECTIVE DATE.—The amendments made by this section 
shall apply to services furnished on or after January 1, 2011. 
SEC. 4104. REMOVAL OF BARRIERS TO PREVENTIVE SERVICES IN 
MEDICARE. 
(a) DEFINITION OF PREVENTIVE SERVICES.—Section 1861(ddd) 
of the Social Security Act (42 U.S.C. 1395x(ddd)) is amended— 
(1) in the heading, by inserting ‘‘; Preventive Services’’ 
after ‘‘Services’’; 
(2) in paragraph (1), by striking ‘‘not otherwise described 
in this title’’ and inserting ‘‘not described in subparagraph 
(A) or (C) of paragraph (3)’’; and 
(3) by adding at the end the following new paragraph: 
‘‘(3) The term ‘preventive services’ means the following: 
‘‘(A) The screening and preventive services described in 
subsection (ww)(2) (other than the service described in subpara-
graph (M) of such subsection). 
‘‘(B) An initial preventive physical examination (as defined 
in subsection (ww)). 
‘‘(C) Personalized prevention plan services (as defined in 
subsection (hhh)(1)).’’. 
(b) COINSURANCE.— 
(1) GENERAL APPLICATION.— 
(A) IN GENERAL.—Section 1833(a)(1) of the Social Secu-
rity Act (42 U.S.C. 1395l(a)(1)), as amended by section 
4103(c)(1), is amended— 
(i) in subparagraph (T), by inserting ‘‘(or 100 per-
cent if such services are recommended with a grade 
of A or B by the United States Preventive Services 
Task Force for any indication or population and are 
appropriate for the individual)’’ after ‘‘80 percent’’; 
(ii) in subparagraph (W)— 
(I) in clause (i), by inserting ‘‘(if such subpara-
graph were applied, by substituting ‘100 percent’ 
for ‘80 percent’)’’ after ‘‘subparagraph (D)’’; and 
(II) in clause (ii), by striking ‘‘80 percent’’ and 
inserting ‘‘100 percent’’; 
(iii) by striking ‘‘and’’ before ‘‘(X)’’; and 
(iv) by inserting before the semicolon at the end 
the following: ‘‘, and (Y) with respect to preventive 
services described in subparagraphs (A) and (B) of 
section 1861(ddd)(3) that are appropriate for the indi-
vidual and, in the case of such services described in 
subparagraph (A), are recommended with a grade of 
A or B by the United States Preventive Services Task 
Force for any indication or population, the amount 
paid shall be 100 percent of the lesser of the actual 
charge for the services or the amount determined under 
the fee schedule that applies to such services under 
this part’’. 
(2) ELIMINATION OF COINSURANCE IN OUTPATIENT HOSPITAL 
SETTINGS.— 
(A) EXCLUSION
FROM
OPD
FEE
SCHEDULE.—Section 
1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C.
H. R. 3590—440 
1395l(t)(1)(B)(iv)), as amended by section 4103(c)(3)(A), is 
amended— 
(i) by striking ‘‘or’’ before ‘‘personalized prevention 
plan services’’; and 
(ii) by inserting before the period the following: 
‘‘, or preventive services described in subparagraphs 
(A) and (B) of section 1861(ddd)(3) that are appropriate 
for the individual and, in the case of such services 
described in subparagraph (A), are recommended with 
a grade of A or B by the United States Preventive 
Services Task Force for any indication or population’’. 
(B) CONFORMING AMENDMENTS.—Section 1833(a)(2) of 
the Social Security Act (42 U.S.C. 1395l(a)(2)), as amended 
by section 4103(c)(3)(B), is amended— 
(i) in subparagraph (G)(ii), by striking ‘‘and’’ after 
the semicolon at the end; 
(ii) in subparagraph (H), by striking the comma 
at the end and inserting ‘‘; and’’; and 
(iii) by inserting after subparagraph (H) the fol-
lowing new subparagraph: 
‘‘(I) with respect to preventive services described in 
subparagraphs (A) and (B) of section 1861(ddd)(3) that 
are appropriate for the individual and are furnished by 
an outpatient department of a hospital and, in the case 
of such services described in subparagraph (A), are rec-
ommended with a grade of A or B by the United States 
Preventive Services Task Force for any indication or popu-
lation, the amount determined under paragraph (1)(W) or 
(1)(Y),’’. 
(c) WAIVER OF APPLICATION OF DEDUCTIBLE FOR PREVENTIVE 
SERVICES
AND COLORECTAL CANCER SCREENING TESTS.—Section 
1833(b) of the Social Security Act (42 U.S.C. 1395l(b)), as amended 
by section 4103(c)(4), is amended— 
(1) in paragraph (1), by striking ‘‘items and services 
described in section 1861(s)(10)(A)’’ and inserting ‘‘preventive 
services described in subparagraph (A) of section 1861(ddd)(3) 
that are recommended with a grade of A or B by the United 
States Preventive Services Task Force for any indication or 
population and are appropriate for the individual.’’; and 
(2) by adding at the end the following new sentence: ‘‘Para-
graph (1) of the first sentence of this subsection shall apply 
with respect to a colorectal cancer screening test regardless 
of the code that is billed for the establishment of a diagnosis 
as a result of the test, or for the removal of tissue or other 
matter or other procedure that is furnished in connection with, 
as a result of, and in the same clinical encounter as the 
screening test.’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall apply to items and services furnished on or after January 
1, 2011. 
SEC. 4105. EVIDENCE-BASED COVERAGE OF PREVENTIVE SERVICES 
IN MEDICARE. 
(a) AUTHORITY TO MODIFY OR ELIMINATE COVERAGE OF CERTAIN 
PREVENTIVE SERVICES.—Section 1834 of the Social Security Act 
(42 U.S.C. 1395m) is amended by adding at the end the following 
new subsection:
H. R. 3590—567 
(2) in subsection (d)(3)— 
(A) in subparagraph (B), by striking ‘‘and’’ at the end; 
(B) in subparagraph (C), by striking the period at 
the end and inserting ‘‘; and’’; and 
(C) by adding at the end the following new subpara-
graph: 
‘‘(D) the hospital meets the requirements described 
in subsection (i)(1) not later than 18 months after the 
date of the enactment of this subparagraph.’’; and 
(3) by adding at the end the following new subsection: 
‘‘(i) REQUIREMENTS
FOR HOSPITALS TO QUALIFY
FOR RURAL 
PROVIDER AND HOSPITAL EXCEPTION TO OWNERSHIP OR INVESTMENT 
PROHIBITION.— 
‘‘(1) REQUIREMENTS DESCRIBED.—For purposes of subsection 
(d)(3)(D), the requirements described in this paragraph for a 
hospital are as follows: 
‘‘(A) PROVIDER AGREEMENT.—The hospital had— 
‘‘(i) physician ownership or investment on Feb-
ruary 1, 2010; and 
‘‘(ii) a provider agreement under section 1866 in 
effect on such date. 
‘‘(B) LIMITATION ON EXPANSION OF FACILITY CAPACITY.— 
Except as provided in paragraph (3), the number of oper-
ating rooms, procedure rooms, and beds for which the hos-
pital is licensed at any time on or after the date of the 
enactment of this subsection is no greater than the number 
of operating rooms, procedure rooms, and beds for which 
the hospital is licensed as of such date. 
‘‘(C) PREVENTING CONFLICTS OF INTEREST.— 
‘‘(i) The hospital submits to the Secretary an 
annual report containing a detailed description of— 
‘‘(I) the identity of each physician owner or 
investor and any other owners or investors of the 
hospital; and 
‘‘(II) the nature and extent of all ownership 
and investment interests in the hospital. 
‘‘(ii) The hospital has procedures in place to require 
that any referring physician owner or investor discloses 
to the patient being referred, by a time that permits 
the patient to make a meaningful decision regarding 
the receipt of care, as determined by the Secretary— 
‘‘(I) the ownership or investment interest, as 
applicable, of such referring physician in the hos-
pital; and 
‘‘(II) if applicable, any such ownership or 
investment interest of the treating physician. 
‘‘(iii) The hospital does not condition any physician 
ownership or investment interests either directly or 
indirectly on the physician owner or investor making 
or influencing referrals to the hospital or otherwise 
generating business for the hospital. 
‘‘(iv) The hospital discloses the fact that the hos-
pital is partially owned or invested in by physicians— 
‘‘(I) on any public website for the hospital; 
and 
‘‘(II) in any public advertising for the hospital. 
‘‘(D) ENSURING BONA FIDE INVESTMENT.—
H. R. 3590—568 
‘‘(i) The percentage of the total value of the owner-
ship or investment interests held in the hospital, or 
in an entity whose assets include the hospital, by physi-
cian owners or investors in the aggregate does not 
exceed such percentage as of the date of enactment 
of this subsection. 
‘‘(ii) Any ownership or investment interests that 
the hospital offers to a physician owner or investor 
are not offered on more favorable terms than the terms 
offered to a person who is not a physician owner or 
investor. 
‘‘(iii) The hospital (or any owner or investor in 
the hospital) does not directly or indirectly provide 
loans or financing for any investment in the hospital 
by a physician owner or investor. 
‘‘(iv) The hospital (or any owner or investor in 
the hospital) does not directly or indirectly guarantee 
a loan, make a payment toward a loan, or otherwise 
subsidize a loan, for any individual physician owner 
or investor or group of physician owners or investors 
that is related to acquiring any ownership or invest-
ment interest in the hospital. 
‘‘(v) Ownership or investment returns are distrib-
uted to each owner or investor in the hospital in an 
amount that is directly proportional to the ownership 
or investment interest of such owner or investor in 
the hospital. 
‘‘(vi) Physician owners and investors do not receive, 
directly or indirectly, any guaranteed receipt of or right 
to purchase other business interests related to the 
hospital, including the purchase or lease of any prop-
erty under the control of other owners or investors 
in the hospital or located near the premises of the 
hospital. 
‘‘(vii) The hospital does not offer a physician owner 
or investor the opportunity to purchase or lease any 
property under the control of the hospital or any other 
owner or investor in the hospital on more favorable 
terms than the terms offered to an individual who 
is not a physician owner or investor. 
‘‘(E) PATIENT SAFETY.— 
‘‘(i) Insofar as the hospital admits a patient and 
does not have any physician available on the premises 
to provide services during all hours in which the hos-
pital is providing services to such patient, before admit-
ting the patient— 
‘‘(I) the hospital discloses such fact to a 
patient; and 
‘‘(II) following such disclosure, the hospital 
receives from the patient a signed acknowledgment 
that the patient understands such fact. 
‘‘(ii) The hospital has the capacity to— 
‘‘(I) provide assessment and initial treatment 
for patients; and 
‘‘(II) refer and transfer patients to hospitals 
with the capability to treat the needs of the patient 
involved.
H. R. 3590—569 
‘‘(F) LIMITATION
ON
APPLICATION
TO
CERTAIN
CON-
VERTED FACILITIES.—The hospital was not converted from 
an ambulatory surgical center to a hospital on or after 
the date of enactment of this subsection. 
‘‘(2) PUBLICATION
OF
INFORMATION
REPORTED.—The Sec-
retary shall publish, and update on an annual basis, the 
information submitted by hospitals under paragraph (1)(C)(i) 
on the public Internet website of the Centers for Medicare 
& Medicaid Services. 
‘‘(3) EXCEPTION TO PROHIBITION ON EXPANSION OF FACILITY 
CAPACITY.— 
‘‘(A) PROCESS.— 
‘‘(i) ESTABLISHMENT.—The Secretary shall estab-
lish and implement a process under which an 
applicable hospital (as defined in subparagraph (E)) 
may apply for an exception from the requirement under 
paragraph (1)(B). 
‘‘(ii) OPPORTUNITY
FOR
COMMUNITY
INPUT.—The 
process under clause (i) shall provide individuals and 
entities in the community in which the applicable hos-
pital applying for an exception is located with the 
opportunity to provide input with respect to the 
application. 
‘‘(iii) TIMING FOR IMPLEMENTATION.—The Secretary 
shall implement the process under clause (i) on August 
1, 2011. 
‘‘(iv) REGULATIONS.—Not later than July 1, 2011, 
the Secretary shall promulgate regulations to carry 
out the process under clause (i). 
‘‘(B) FREQUENCY.—The process described in subpara-
graph (A) shall permit an applicable hospital to apply for 
an exception up to once every 2 years. 
‘‘(C) PERMITTED INCREASE.— 
‘‘(i) IN
GENERAL.—Subject to clause (ii) and 
subparagraph (D), an applicable hospital granted an 
exception under the process described in subparagraph 
(A) may increase the number of operating rooms, proce-
dure rooms, and beds for which the applicable hospital 
is licensed above the baseline number of operating 
rooms, procedure rooms, and beds of the applicable 
hospital (or, if the applicable hospital has been granted 
a previous exception under this paragraph, above the 
number of operating rooms, procedure rooms, and beds 
for which the hospital is licensed after the application 
of the most recent increase under such an exception). 
‘‘(ii) 100 PERCENT INCREASE LIMITATION.—The Sec-
retary shall not permit an increase in the number 
of operating rooms, procedure rooms, and beds for 
which an applicable hospital is licensed under clause 
(i) to the extent such increase would result in the 
number of operating rooms, procedure rooms, and beds 
for which the applicable hospital is licensed exceeding 
200 percent of the baseline number of operating rooms, 
procedure rooms, and beds of the applicable hospital. 
‘‘(iii) BASELINE
NUMBER
OF
OPERATING
ROOMS, 
PROCEDURE ROOMS, AND BEDS.—In this paragraph, the 
term ‘baseline number of operating rooms, procedure
H. R. 3590—628 
‘‘SEC. 4377. DEFINITIONS AND SPECIAL RULES. 
‘‘(a) DEFINITIONS.—For purposes of this subchapter— 
‘‘(1) ACCIDENT AND HEALTH COVERAGE.—The term ‘accident 
and health coverage’ means any coverage which, if provided 
by an insurance policy, would cause such policy to be a specified 
health insurance policy (as defined in section 4375(c)). 
‘‘(2) INSURANCE POLICY.—The term ‘insurance policy’ means 
any policy or other instrument whereby a contract of insurance 
is issued, renewed, or extended. 
‘‘(3) UNITED
STATES.—The term ‘United States’ includes 
any possession of the United States. 
‘‘(b) TREATMENT OF GOVERNMENTAL ENTITIES.— 
‘‘(1) IN GENERAL.—For purposes of this subchapter— 
‘‘(A) the term ‘person’ includes any governmental 
entity, and 
‘‘(B) notwithstanding any other law or rule of law, 
governmental entities shall not be exempt from the fees 
imposed by this subchapter except as provided in paragraph 
(2). 
‘‘(2) TREATMENT OF EXEMPT GOVERNMENTAL PROGRAMS.— 
In the case of an exempt governmental program, no fee shall 
be imposed under section 4375 or section 4376 on any covered 
life under such program. 
‘‘(3) EXEMPT GOVERNMENTAL PROGRAM DEFINED.—For pur-
poses of this subchapter, the term ‘exempt governmental pro-
gram’ means— 
‘‘(A) any insurance program established under title 
XVIII of the Social Security Act, 
‘‘(B) the medical assistance program established by 
title XIX or XXI of the Social Security Act, 
‘‘(C) any program established by Federal law for pro-
viding medical care (other than through insurance policies) 
to individuals (or the spouses and dependents thereof) by 
reason of such individuals being members of the Armed 
Forces of the United States or veterans, and 
‘‘(D) any program established by Federal law for pro-
viding medical care (other than through insurance policies) 
to members of Indian tribes (as defined in section 4(d) 
of the Indian Health Care Improvement Act). 
‘‘(c) TREATMENT AS TAX.—For purposes of subtitle F, the fees 
imposed by this subchapter shall be treated as if they were taxes. 
‘‘(d) NO COVER OVER TO POSSESSIONS.—Notwithstanding any 
other provision of law, no amount collected under this subchapter 
shall be covered over to any possession of the United States.’’. 
(B) CLERICAL AMENDMENTS.— 
(i) Chapter 34 of such Code is amended by striking 
the chapter heading and inserting the following:
H. R. 3590—679 
as the eligible entity may require in order to conduct such 
evaluation; or 
‘‘(2) in the case of an applicant for a grant under section 
2041(b), to provide the Secretary with such information as 
the Secretary may require to conduct an evaluation or audit 
under subsection (c). 
‘‘(b) USE OF ELIGIBLE ENTITIES TO CONDUCT EVALUATIONS.— 
‘‘(1) EVALUATIONS REQUIRED.—Except as provided in para-
graph (2), the Secretary shall— 
‘‘(A) reserve a portion (not less than 2 percent) of 
the funds appropriated with respect to each program car-
ried out under this part; and 
‘‘(B) use the funds reserved under subparagraph (A) 
to provide assistance to eligible entities to conduct evalua-
tions of the activities funded under each program carried 
out under this part. 
‘‘(2) CERTIFIED
EHR
TECHNOLOGY
GRANT
PROGRAM
NOT 
INCLUDED.—The provisions of this subsection shall not apply 
to the certified EHR technology grant program under section 
2041(b). 
‘‘(3) AUTHORIZED
ACTIVITIES.—A recipient of assistance 
described in paragraph (1)(B) shall use the funds made avail-
able through the assistance to conduct a validated evaluation 
of the effectiveness of the activities funded under a program 
carried out under this part. 
‘‘(4) APPLICATIONS.—To be eligible to receive assistance 
under paragraph (1)(B), an entity shall submit an application 
to the Secretary at such time, in such manner, and containing 
such information as the Secretary may require, including a 
proposal for the evaluation. 
‘‘(5) REPORTS.—Not later than a date specified by the Sec-
retary, an eligible entity receiving assistance under paragraph 
(1)(B) shall submit to the Secretary, the Committee on Ways 
and Means and the Committee on Energy and Commerce of 
the House of Representatives, and the Committee on Finance 
of the Senate a report containing the results of the evaluation 
conducted using such assistance together with such rec-
ommendations as the entity determines to be appropriate. 
‘‘(c) EVALUATIONS AND AUDITS OF CERTIFIED EHR TECHNOLOGY 
GRANT PROGRAM BY THE SECRETARY.— 
‘‘(1) EVALUATIONS.—The Secretary shall conduct an evalua-
tion of the activities funded under the certified EHR technology 
grant program under section 2041(b). Such evaluation shall 
include an evaluation of whether the funding provided under 
the grant is expended only for the purposes for which it is 
made. 
‘‘(2) AUDITS.—The Secretary shall conduct appropriate 
audits of grants made under section 2041(b). 
‘‘SEC. 2045. REPORT. 
‘‘Not later than October 1, 2014, the Secretary shall submit 
to the Elder Justice Coordinating Council established under section 
2021, the Committee on Ways and Means and the Committee 
on Energy and Commerce of the House of Representatives, and 
the Committee on Finance of the Senate a report—
H. R. 3590—689 
such authority applies to biological products licensed under 
subsection (a). 
‘‘(6) EXCLUSIVITY FOR FIRST INTERCHANGEABLE BIOLOGICAL 
PRODUCT.—Upon review of an application submitted under this 
subsection relying on the same reference product for which 
a prior biological product has received a determination of inter-
changeability for any condition of use, the Secretary shall not 
make a determination under paragraph (4) that the second 
or subsequent biological product is interchangeable for any 
condition of use until the earlier of— 
‘‘(A) 1 year after the first commercial marketing of 
the first interchangeable biosimilar biological product to 
be approved as interchangeable for that reference product; 
‘‘(B) 18 months after— 
‘‘(i) a final court decision on all patents in suit 
in an action instituted under subsection (l)(6) against 
the applicant that submitted the application for the 
first approved interchangeable biosimilar biological 
product; or 
‘‘(ii) the dismissal with or without prejudice of 
an action instituted under subsection (l)(6) against the 
applicant that submitted the application for the first 
approved interchangeable biosimilar biological product; 
or 
‘‘(C)(i) 42 months after approval of the first inter-
changeable biosimilar biological product if the applicant 
that submitted such application has been sued under sub-
section (l)(6) and such litigation is still ongoing within 
such 42-month period; or 
‘‘(ii) 18 months after approval of the first interchange-
able biosimilar biological product if the applicant that sub-
mitted such application has not been sued under subsection 
(l)(6). 
For purposes of this paragraph, the term ‘final court decision’ 
means a final decision of a court from which no appeal (other 
than a petition to the United States Supreme Court for a 
writ of certiorari) has been or can be taken. 
‘‘(7) EXCLUSIVITY FOR REFERENCE PRODUCT.— 
‘‘(A) EFFECTIVE
DATE
OF
BIOSIMILAR
APPLICATION 
APPROVAL.—Approval of an application under this sub-
section may not be made effective by the Secretary until 
the date that is 12 years after the date on which the 
reference product was first licensed under subsection (a). 
‘‘(B) FILING PERIOD.—An application under this sub-
section may not be submitted to the Secretary until the 
date that is 4 years after the date on which the reference 
product was first licensed under subsection (a). 
‘‘(C) FIRST
LICENSURE.—Subparagraphs (A) and (B) 
shall not apply to a license for or approval of— 
‘‘(i) a supplement for the biological product that 
is the reference product; or 
‘‘(ii) a subsequent application filed by the same 
sponsor or manufacturer of the biological product that 
is the reference product (or a licensor, predecessor 
in interest, or other related entity) for— 
‘‘(I) a change (not including a modification to 
the structure of the biological product) that results
H. R. 3590—695 
‘‘(A) ACTION IF AGREEMENT ON PATENT LIST.—If the 
subsection (k) applicant and the reference product sponsor 
agree on patents as described in paragraph (4), not later 
than 30 days after such agreement, the reference product 
sponsor shall bring an action for patent infringement with 
respect to each such patent. 
‘‘(B) ACTION
IF
NO
AGREEMENT
ON
PATENT
LIST.—If 
the provisions of paragraph (5) apply to the parties as 
described in paragraph (4)(B), not later than 30 days after 
the exchange of lists under paragraph (5)(B), the reference 
product sponsor shall bring an action for patent infringe-
ment with respect to each patent that is included on such 
lists. 
‘‘(C) NOTIFICATION AND PUBLICATION OF COMPLAINT.— 
‘‘(i) NOTIFICATION TO SECRETARY.—Not later than 
30 days after a complaint is served to a subsection 
(k) applicant in an action for patent infringement 
described under this paragraph, the subsection (k) 
applicant shall provide the Secretary with notice and 
a copy of such complaint. 
‘‘(ii) PUBLICATION BY SECRETARY.—The Secretary 
shall publish in the Federal Register notice of a com-
plaint received under clause (i). 
‘‘(7) NEWLY
ISSUED
OR
LICENSED
PATENTS.—In the case 
of a patent that— 
‘‘(A) is issued to, or exclusively licensed by, the ref-
erence product sponsor after the date that the reference 
product sponsor provided the list to the subsection (k) 
applicant under paragraph (3)(A); and 
‘‘(B) the reference product sponsor reasonably believes 
that, due to the issuance of such patent, a claim of patent 
infringement could reasonably be asserted by the reference 
product sponsor if a person not licensed by the reference 
product sponsor engaged in the making, using, offering 
to sell, selling, or importing into the United States of 
the biological product that is the subject of the subsection 
(k) application, 
not later than 30 days after such issuance or licensing, the 
reference product sponsor shall provide to the subsection (k) 
applicant a supplement to the list provided by the reference 
product sponsor under paragraph (3)(A) that includes such 
patent, not later than 30 days after such supplement is pro-
vided, the subsection (k) applicant shall provide a statement 
to the reference product sponsor in accordance with paragraph 
(3)(B), and such patent shall be subject to paragraph (8). 
‘‘(8) NOTICE OF COMMERCIAL MARKETING AND PRELIMINARY 
INJUNCTION.— 
‘‘(A) NOTICE
OF
COMMERCIAL
MARKETING.—The sub-
section (k) applicant shall provide notice to the reference 
product sponsor not later than 180 days before the date 
of the first commercial marketing of the biological product 
licensed under subsection (k). 
‘‘(B) PRELIMINARY
INJUNCTION.—After receiving the 
notice under subparagraph (A) and before such date of 
the first commercial marketing of such biological product, 
the reference product sponsor may seek a preliminary 
injunction prohibiting the subsection (k) applicant from
H. R. 3590—696 
engaging in the commercial manufacture or sale of such 
biological product until the court decides the issue of patent 
validity, enforcement, and infringement with respect to 
any patent that is— 
‘‘(i) included in the list provided by the reference 
product sponsor under paragraph (3)(A) or in the list 
provided by the subsection (k) applicant under para-
graph (3)(B); and 
‘‘(ii) not included, as applicable, on— 
‘‘(I) the list of patents described in paragraph 
(4); or 
‘‘(II) the lists of patents described in paragraph 
(5)(B). 
‘‘(C) REASONABLE
COOPERATION.—If the reference 
product sponsor has sought a preliminary injunction under 
subparagraph (B), the reference product sponsor and the 
subsection (k) applicant shall reasonably cooperate to expe-
dite such further discovery as is needed in connection with 
the preliminary injunction motion. 
‘‘(9) LIMITATION ON DECLARATORY JUDGMENT ACTION.— 
‘‘(A) SUBSECTION (k) APPLICATION PROVIDED.—If a sub-
section (k) applicant provides the application and informa-
tion required under paragraph (2)(A), neither the reference 
product sponsor nor the subsection (k) applicant may, prior 
to the date notice is received under paragraph (8)(A), bring 
any action under section 2201 of title 28, United States 
Code, for a declaration of infringement, validity, or enforce-
ability of any patent that is described in clauses (i) and 
(ii) of paragraph (8)(B). 
‘‘(B) SUBSEQUENT FAILURE TO ACT BY SUBSECTION (k) 
APPLICANT.—If a subsection (k) applicant fails to complete 
an action required of the subsection (k) applicant under 
paragraph (3)(B)(ii), paragraph (5), paragraph (6)(C)(i), 
paragraph (7), or paragraph (8)(A), the reference product 
sponsor, but not the subsection (k) applicant, may bring 
an action under section 2201 of title 28, United States 
Code, for a declaration of infringement, validity, or enforce-
ability of any patent included in the list described in para-
graph (3)(A), including as provided under paragraph (7). 
‘‘(C) SUBSECTION (k) APPLICATION NOT PROVIDED.—If 
a subsection (k) applicant fails to provide the application 
and information required under paragraph (2)(A), the ref-
erence product sponsor, but not the subsection (k) 
applicant, may bring an action under section 2201 of title 
28, United States Code, for a declaration of infringement, 
validity, or enforceability of any patent that claims the 
biological product or a use of the biological product.’’. 
(b) DEFINITIONS.—Section 351(i) of the Public Health Service 
Act (42 U.S.C. 262(i)) is amended— 
(1) by striking ‘‘In this section, the term ‘biological product’ 
means’’ and inserting the following: ‘‘In this section: 
‘‘(1) The term ‘biological product’ means’’; 
(2) in paragraph (1), as so designated, by inserting ‘‘protein 
(except any chemically synthesized polypeptide),’’ after ‘‘aller-
genic product,’’; and 
(3) by adding at the end the following:
H. R. 3590—697 
‘‘(2) The term ‘biosimilar’ or ‘biosimilarity’, in reference 
to a biological product that is the subject of an application 
under subsection (k), means— 
‘‘(A) that the biological product is highly similar to 
the reference product notwithstanding minor differences 
in clinically inactive components; and 
‘‘(B) there are no clinically meaningful differences 
between the biological product and the reference product 
in terms of the safety, purity, and potency of the product. 
‘‘(3) The term ‘interchangeable’ or ‘interchangeability’, in 
reference to a biological product that is shown to meet the 
standards described in subsection (k)(4), means that the 
biological product may be substituted for the reference product 
without the intervention of the health care provider who pre-
scribed the reference product. 
‘‘(4) The term ‘reference product’ means the single biological 
product licensed under subsection (a) against which a biological 
product is evaluated in an application submitted under sub-
section (k).’’. 
(c) CONFORMING AMENDMENTS RELATING TO PATENTS.— 
(1) PATENTS.—Section 271(e) of title 35, United States Code, 
is amended— 
(A) in paragraph (2)— 
(i) in subparagraph (A), by striking ‘‘or’’ at the 
end; 
(ii) in subparagraph (B), by adding ‘‘or’’ at the 
end; and 
(iii) by inserting after subparagraph (B) the fol-
lowing: 
‘‘(C)(i) with respect to a patent that is identified in the 
list of patents described in section 351(l)(3) of the Public Health 
Service Act (including as provided under section 351(l)(7) of 
such Act), an application seeking approval of a biological 
product, or 
‘‘(ii) if the applicant for the application fails to provide 
the application and information required under section 
351(l)(2)(A) of such Act, an application seeking approval of 
a biological product for a patent that could be identified pursu-
ant to section 351(l)(3)(A)(i) of such Act,’’; and 
(iv) in the matter following subparagraph (C) (as 
added by clause (iii)), by striking ‘‘or veterinary 
biological product’’ and inserting ‘‘, veterinary biological 
product, or biological product’’; 
(B) in paragraph (4)— 
(i) in subparagraph (B), by— 
(I) striking ‘‘or veterinary biological product’’ 
and inserting ‘‘, veterinary biological product, or 
biological product’’; and 
(II) striking ‘‘and’’ at the end; 
(ii) in subparagraph (C), by— 
(I) striking ‘‘or veterinary biological product’’ 
and inserting ‘‘, veterinary biological product, or 
biological product’’; and 
(II) striking the period and inserting ‘‘, and’’; 
(iii) by inserting after subparagraph (C) the fol-
lowing:
H. R. 3590—738 
‘‘(A) IN
GENERAL.—This subsection shall apply to— 
‘‘(i) an organization which operates a facility which 
is required by a State to be licensed, registered, or 
similarly recognized as a hospital, and 
‘‘(ii) any other organization which the Secretary 
determines has the provision of hospital care as its 
principal function or purpose constituting the basis 
for its exemption under subsection (c)(3) (determined 
without regard to this subsection). 
‘‘(B) ORGANIZATIONS
WITH
MORE
THAN
HOSPITAL 
FACILITY.—If a hospital organization operates more than 
1 hospital facility— 
‘‘(i) the organization shall meet the requirements 
of this subsection separately with respect to each such 
facility, and 
‘‘(ii) the organization shall not be treated as 
described in subsection (c)(3) with respect to any such 
facility for which such requirements are not separately 
met. 
‘‘(3) COMMUNITY HEALTH NEEDS ASSESSMENTS.— 
‘‘(A) IN GENERAL.—An organization meets the require-
ments of this paragraph with respect to any taxable year 
only if the organization— 
‘‘(i) has conducted a community health needs 
assessment which meets the requirements of subpara-
graph (B) in such taxable year or in either of the 
2 taxable years immediately preceding such taxable 
year, and 
‘‘(ii) has adopted an implementation strategy to 
meet the community health needs identified through 
such assessment. 
‘‘(B) COMMUNITY
HEALTH
NEEDS
ASSESSMENT.—A 
community health needs assessment meets the require-
ments of this paragraph if such community health needs 
assessment— 
‘‘(i) takes into account input from persons who 
represent the broad interests of the community served 
by the hospital facility, including those with special 
knowledge of or expertise in public health, and 
‘‘(ii) is made widely available to the public. 
‘‘(4) FINANCIAL ASSISTANCE POLICY.—An organization meets 
the requirements of this paragraph if the organization estab-
lishes the following policies: 
‘‘(A) FINANCIAL ASSISTANCE POLICY.—A written finan-
cial assistance policy which includes— 
‘‘(i) eligibility criteria for financial assistance, and 
whether such assistance includes free or discounted 
care, 
‘‘(ii) the basis for calculating amounts charged to 
patients, 
‘‘(iii) the method for applying for financial assist-
ance, 
‘‘(iv) in the case of an organization which does 
not have a separate billing and collections policy, the 
actions the organization may take in the event of non- 
payment, including collections action and reporting to 
credit agencies, and
H. R. 3590—812 
(II) in the flush language after and below subpara-
graph (B)(ii), by striking ‘‘or fiscal year 2012’’ and 
inserting ‘‘, fiscal year 2012, or fiscal year 2014’’; and 
(vi) in paragraph (8)— 
(I) in the paragraph heading, by striking ‘‘2013’’ 
and inserting ‘‘2015’’; and 
(II) by striking ‘‘2013’’ and inserting ‘‘2015’’. 
(B) Section 2104(n) of such Act (42 U.S.C. 1397dd(n)) is 
amended— 
(i) in paragraph (2)— 
(I) in subparagraph (A)(ii)— 
(aa) by striking ‘‘2012’’ and inserting ‘‘2014’’; and 
(bb) by striking ‘‘2013’’ and inserting ‘‘2015’’; 
(II) in subparagraph (B)— 
(aa) by striking ‘‘2012’’ and inserting ‘‘2014’’; and 
(bb) by striking ‘‘2013’’ and inserting ‘‘2015’’; and 
(ii) in paragraph (3)(A), by striking ‘‘or a semi-annual allot-
ment period for fiscal year 2013’’ and inserting ‘‘fiscal year 
2013, fiscal year 2014, or a semi-annual allotment period for 
fiscal year 2015’’. 
(C) Section 2105(g)(4) of such Act (42 U.S.C. 1397ee(g)(4)) is 
amended— 
(i) in the paragraph heading, by striking ‘‘2013’’ and 
inserting ‘‘2015’’; and 
(ii) in subparagraph (A), by striking ‘‘2013’’ and inserting 
‘‘2015’’. 
(D) Section 2110(b) of such Act (42 U.S.C. 1397jj(b)) is 
amended— 
(i) in paragraph (2)(B), by inserting ‘‘except as provided 
in paragraph (6),’’ before ‘‘a child’’; and 
(ii) by adding at the end the following new paragraph: 
‘‘(6) EXCEPTIONS TO EXCLUSION OF CHILDREN OF EMPLOYEES 
OF A PUBLIC AGENCY IN THE STATE.— 
‘‘(A) IN GENERAL.—A child shall not be considered to 
be described in paragraph (2)(B) if— 
‘‘(i) the public agency that employs a member of 
the child’s family to which such paragraph applies 
satisfies subparagraph (B); or 
‘‘(ii) subparagraph (C) applies to such child. 
‘‘(B) MAINTENANCE OF EFFORT WITH RESPECT TO PER 
PERSON AGENCY CONTRIBUTION FOR FAMILY COVERAGE.— 
For purposes of subparagraph (A)(i), a public agency satis-
fies this subparagraph if the amount of annual agency 
expenditures made on behalf of each employee enrolled 
in health coverage paid for by the agency that includes 
dependent coverage for the most recent State fiscal year 
is not less than the amount of such expenditures made 
by the agency for the 1997 State fiscal year, increased 
by the percentage increase in the medical care expenditure 
category of the Consumer Price Index for All-Urban Con-
sumers (all items: U.S. City Average) for such preceding 
fiscal year. 
‘‘(C) HARDSHIP EXCEPTION.—For purposes of subpara-
graph (A)(ii), this subparagraph applies to a child if the 
State determines, on a case-by-case basis, that the annual 
aggregate amount of premiums and cost-sharing imposed
H. R. 3590—831 
‘‘(II) for each of fiscal years 2012 and 2013, 
0.1 percentage point; and’’; and 
(4) in subclause (III), as redesignated by paragraph (2), 
by striking ‘‘2012’’ and inserting ‘‘2014’’. 
(d) HOME HEALTH AGENCIES.—Section 1895(b)(3)(B)(vi)(II) of 
such Act, as added by section 3401(e), is amended by striking 
‘‘and 2012’’ and inserting ‘‘, 2012, and 2013’’. 
(e) PSYCHIATRIC HOSPITALS.—Section 1886(s)(3)(A) of the Social 
Security Act, as added by section 3401(f), is amended— 
(1) in clause (i), by striking ‘‘and’’ at the end; 
(2) by redesignating clause (ii) as clause (iii); 
(3) by inserting after clause (ii) the following new clause: 
‘‘(ii) for each of the rate years beginning in 2012 
and 2013, 0.1 percentage point; and’’; and 
(4) in clause (iii), as redesignated by paragraph (2), by 
striking ‘‘2012’’ and inserting ‘‘2014’’. 
(f) HOSPICE CARE.—Section 1814(i)(1)(C) of the Social Security 
Act (42 U.S.C. 1395f(i)(1)(C)), as amended by section 3401(g), is 
amended— 
(1) in clause (iv)(II), by striking ‘‘0.5’’ and inserting ‘‘0.3’’; 
and 
(2) in clause (v), in the matter preceding subclause (I), 
by striking ‘‘0.5’’ and inserting ‘‘0.3’’. 
(g) OUTPATIENT HOSPITALS.—Section 1833(t)(3)(G)(i) of the 
Social Security Act, as added by section 3401(i), is amended— 
(1) in subclause (I), by striking ‘‘and’’ at the end; 
(2) by redesignating subclause (II) as subclause (III); 
(3) by inserting after subclause (II) the following new sub-
clause: 
‘‘(II) for each of 2012 and 2013, 0.1 percentage 
point; and’’; and 
(4) in subclause (III), as redesignated by paragraph (2), 
by striking ‘‘2012’’ and inserting ‘‘2014’’. 
SEC. 10320. EXPANSION OF THE SCOPE OF, AND ADDITIONAL IMPROVE-
MENTS TO, THE INDEPENDENT MEDICARE ADVISORY 
BOARD. 
(a) IN GENERAL.—Section 1899A of the Social Security Act, 
as added by section 3403, is amended— 
(1) in subsection (c)— 
(A) in paragraph (1)(B), by adding at the end the 
following new sentence: ‘‘In any year (beginning with 2014) 
that the Board is not required to submit a proposal under 
this section, the Board shall submit to Congress an advisory 
report on matters related to the Medicare program.’’; 
(B) in paragraph (2)(A)— 
(i) in clause (iv), by inserting ‘‘or the full premium 
subsidy under section 1860D–14(a)’’ before the period 
at the end of the last sentence; and 
(ii) by adding at the end the following new clause: 
‘‘(vii) If the Chief Actuary of the Centers for Medi-
care & Medicaid Services has made a determination 
described in subsection (e)(3)(B)(i)(II) in the determina-
tion year, the proposal shall be designed to help reduce 
the growth rate described in paragraph (8) while 
maintaining or enhancing beneficiary access to quality 
care under this title.’’;
H. R. 3590—832 
(C) in paragraph (2)(B)— 
(i) in clause (v), by striking ‘‘and’’ at the end; 
(ii) in clause (vi), by striking the period at the 
end and inserting ‘‘; and’’; and 
(iii) by adding at the end the following new clause: 
‘‘(vii) take into account the data and findings con-
tained in the annual reports under subsection (n) in 
order to develop proposals that can most effectively 
promote the delivery of efficient, high quality care to 
Medicare beneficiaries.’’; 
(D) in paragraph (3)— 
(i) in the heading, by striking ‘‘TRANSMISSION OF 
BOARD PROPOSAL TO PRESIDENT’’ and inserting ‘‘SUBMIS-
SION OF BOARD PROPOSAL TO CONGRESS AND THE PRESI-
DENT’’; 
(ii) in subparagraph (A)(i), by striking ‘‘transmit 
a proposal under this section to the President’’ and 
insert ‘‘submit a proposal under this section to Con-
gress and the President’’; and 
(iii) in subparagraph (A)(ii)— 
(I) in subclause (I), by inserting ‘‘or’’ at the 
end; 
(II) in subclause (II), by striking ‘‘; or’’ and 
inserting a period; and 
(III) by striking subclause (III); 
(E) in paragraph (4)— 
(i) by striking ‘‘the Board under paragraph (3)(A)(i) 
or’’; and 
(ii) by striking ‘‘immediately’’ and inserting ‘‘within 
2 days’’; 
(F) in paragraph (5)— 
(i) by striking ‘‘to but’’ and inserting ‘‘but’’; and 
(ii) by inserting ‘‘Congress and’’ after ‘‘submit a 
proposal to’’; and 
(G) in paragraph (6)(B)(i), by striking ‘‘per unduplicated 
enrollee’’ and inserting ‘‘(calculated as the sum of per capita 
spending under each of parts A, B, and D)’’; 
(2) in subsection (d)— 
(A) in paragraph (1)(A)— 
(i) by inserting ‘‘the Board or’’ after ‘‘a proposal 
is submitted by’’; and 
(ii) by inserting ‘‘subsection (c)(3)(A)(i) or’’ after 
‘‘the Senate under’’; and 
(B) in paragraph (2)(A), by inserting ‘‘the Board or’’ 
after ‘‘a proposal is submitted by’’; 
(3) in subsection (e)— 
(A) in paragraph (1), by inserting ‘‘the Board or’’ after 
‘‘a proposal submitted by’’; and 
(B) in paragraph (3)— 
(i) by striking ‘‘EXCEPTION.—The Secretary shall 
not be required to implement the recommendations 
contained in a proposal submitted in a proposal year 
by’’ and inserting ‘‘EXCEPTIONS.— 
‘‘(A) IN GENERAL.—The Secretary shall not implement 
the recommendations contained in a proposal submitted 
in a proposal year by the Board or’’;