VI 
Calendar No. 175 
AMENDMENT NO. 2786 
Purpose: In the nature of a substitute. 
IN THE SENATE OF THE UNITED STATES—111th Cong., 1st Sess. 
H. R. 3590 
To amend the Internal Revenue Code of 1986 to modify 
the first-time homebuyers credit in the case of members 
of the Armed Forces and certain other Federal employ-
ees, and for other purposes. 
November 19, 2009 
Ordered to lie on the table and to be printed 
Amendment in the nature of a substitute intended to be 
proposed by Mr. REID (for himself, Mr. BAUCUS, Mr. 
DODD, and Mr. HARKIN) 
Viz: 
Strike all after the enacting clause and insert the fol-
lowing: 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Patient Protection and Affordable Care Act’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
TITLE I—QUALITY, AFFORDABLE HEALTH CARE FOR ALL 
AMERICANS 
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•AMDT. NO. 2786 
Subtitle A—Immediate Improvements in Health Care Coverage for All 
Americans 
Sec. 1001. Amendments to the Public Health Service Act. 
‘‘PART A—INDIVIDUAL AND GROUP MARKET REFORMS 
‘‘SUBPART II—IMPROVING COVERAGE 
‘‘Sec. 2711. No lifetime or annual limits. 
‘‘Sec. 2712. Prohibition on rescissions. 
‘‘Sec. 2713. Coverage of preventive health services. 
‘‘Sec. 2714. Extension of dependent coverage. 
‘‘Sec. 2715. Development and utilization of uniform explanation of cov-
erage documents and standardized definitions. 
‘‘Sec. 2716. Prohibition of discrimination based on salary. 
‘‘Sec. 2717. Ensuring the quality of care. 
‘‘Sec. 2718. Bringing down the cost of health care coverage. 
‘‘Sec. 2719. Appeals process. 
Sec. 1002. Health insurance consumer information. 
Sec. 1003. Ensuring that consumers get value for their dollars. 
Sec. 1004. Effective dates. 
Subtitle B—Immediate Actions to Preserve and Expand Coverage 
Sec. 1101. Immediate access to insurance for uninsured individuals with a pre-
existing condition. 
Sec. 1102. Reinsurance for early retirees. 
Sec. 1103. Immediate information that allows consumers to identify affordable 
coverage options. 
Sec. 1104. Administrative simplification. 
Sec. 1105. Effective date. 
Subtitle C—Quality Health Insurance Coverage for All Americans 
PART I—HEALTH INSURANCE MARKET REFORMS 
Sec. 1201. Amendment to the Public Health Service Act. 
‘‘SUBPART I—GENERAL REFORM 
‘‘Sec. 2701. Fair health insurance premiums. 
‘‘Sec. 2702. Guaranteed availability of coverage. 
‘‘Sec. 2703. Guaranteed renewability of coverage. 
‘‘Sec. 2704. Prohibition of preexisting condition exclusions or other dis-
crimination based on health status. 
‘‘Sec. 2705. Prohibiting discrimination against individual participants and 
beneficiaries based on health status. 
‘‘Sec. 2706. Non-discrimination in health care. 
‘‘Sec. 2707. Comprehensive health insurance coverage. 
‘‘Sec. 2708. Prohibition on excessive waiting periods. 
PART II—OTHER PROVISIONS 
Sec. 1251. Preservation of right to maintain existing coverage. 
Sec. 1252. Rating reforms must apply uniformly to all health insurance issuers 
and group health plans. 
Sec. 1253. Effective dates. 
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Subtitle D—Available Coverage Choices for All Americans 
PART I—ESTABLISHMENT OF QUALIFIED HEALTH PLANS 
Sec. 1301. Qualified health plan defined. 
Sec. 1302. Essential health benefits requirements. 
Sec. 1303. Special rules. 
Sec. 1304. Related definitions. 
PART II—CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH 
HEALTH BENEFIT EXCHANGES 
Sec. 1311. Affordable choices of health benefit plans. 
Sec. 1312. Consumer choice. 
Sec. 1313. Financial integrity. 
PART III—STATE FLEXIBILITY RELATING TO EXCHANGES 
Sec. 1321. State flexibility in operation and enforcement of Exchanges and re-
lated requirements. 
Sec. 1322. Federal program to assist establishment and operation of nonprofit, 
member-run health insurance issuers. 
Sec. 1323. Community health insurance option. 
Sec. 1324. Level playing field. 
PART IV—STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS 
Sec. 1331. State flexibility to establish basic health programs for low-income in-
dividuals not eligible for Medicaid. 
Sec. 1332. Waiver for State innovation. 
Sec. 1333. Provisions relating to offering of plans in more than one State. 
PART V—REINSURANCE AND RISK ADJUSTMENT 
Sec. 1341. Transitional reinsurance program for individual and small group 
markets in each State. 
Sec. 1342. Establishment of risk corridors for plans in individual and small 
group markets. 
Sec. 1343. Risk adjustment. 
Subtitle E—Affordable Coverage Choices for All Americans 
PART I—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS 
SUBPART A—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS 
Sec. 1401. Refundable tax credit providing premium assistance for coverage 
under a qualified health plan. 
Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health 
plans. 
SUBPART B—ELIGIBILITY DETERMINATIONS 
Sec. 1411. Procedures for determining eligibility for Exchange participation, 
premium tax credits and reduced cost-sharing , and individual 
responsibility exemptions. 
Sec. 1412. Advance determination and payment of premium tax credits and 
cost-sharing reductions. 
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Sec. 1413. Streamlining of procedures for enrollment through an exchange and 
State Medicaid, CHIP, and health subsidy programs. 
Sec. 1414. Disclosures to carry out eligibility requirements for certain pro-
grams. 
Sec. 1415. Premium tax credit and cost-sharing reduction payments dis-
regarded for Federal and Federally-assisted programs. 
PART II—SMALL BUSINESS TAX CREDIT 
Sec. 1421. Credit for employee health insurance expenses of small businesses. 
Subtitle F—Shared Responsibility for Health Care 
PART I—INDIVIDUAL RESPONSIBILITY 
Sec. 1501. Requirement to maintain minimum essential coverage. 
Sec. 1502. Reporting of health insurance coverage. 
PART II—EMPLOYER RESPONSIBILITIES 
Sec. 1511. Automatic enrollment for employees of large employers. 
Sec. 1512. Employer requirement to inform employees of coverage options. 
Sec. 1513. Shared responsibility for employers. 
Sec. 1514. Reporting of employer health insurance coverage. 
Sec. 1515. Offering of Exchange-participating qualified health plans through 
cafeteria plans. 
Subtitle G—Miscellaneous Provisions 
Sec. 1551. Definitions. 
Sec. 1552. Transparency in government. 
Sec. 1553. Prohibition against discrimination on assisted suicide. 
Sec. 1554. Access to therapies. 
Sec. 1555. Freedom not to participate in Federal health insurance programs. 
Sec. 1556. Equity for certain eligible survivors. 
Sec. 1557. Nondiscrimination. 
Sec. 1558. Protections for employees. 
Sec. 1559. Oversight. 
Sec. 1560. Rules of construction. 
Sec. 1561. Health information technology enrollment standards and protocols. 
Sec. 1562. Conforming amendments. 
TITLE II—ROLE OF PUBLIC PROGRAMS 
Subtitle A—Improved Access to Medicaid 
Sec. 2001. Medicaid coverage for the lowest income populations. 
Sec. 2002. Income eligibility for nonelderly determined using modified gross in-
come. 
Sec. 2003. Requirement to offer premium assistance for employer-sponsored in-
surance. 
Sec. 2004. Medicaid coverage for former foster care children. 
Sec. 2005. Payments to territories. 
Sec. 2006. Special adjustment to FMAP determination for certain States recov-
ering from a major disaster. 
Sec. 2007. Medicaid Improvement Fund rescission. 
Subtitle B—Enhanced Support for the Children’s Health Insurance Program 
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Sec. 2101. Additional federal financial participation for CHIP. 
Sec. 2102. Technical corrections. 
Subtitle C—Medicaid and CHIP Enrollment Simplification 
Sec. 2201. Enrollment Simplification and coordination with State Health Insur-
ance Exchanges. 
Sec. 2202. Permitting hospitals to make presumptive eligibility determinations 
for all Medicaid eligible populations. 
Subtitle D—Improvements to Medicaid Services 
Sec. 2301. Coverage for freestanding birth center services. 
Sec. 2302. Concurrent care for children. 
Sec. 2303. State eligibility option for family planning services. 
Sec. 2304. Clarification of definition of medical assistance. 
Subtitle E—New Options for States to Provide Long-Term Services and 
Supports 
Sec. 2401. Community First Choice Option. 
Sec. 2402. Removal of barriers to providing home and community-based serv-
ices. 
Sec. 2403. Money Follows the Person Rebalancing Demonstration. 
Sec. 2404. Protection for recipients of home and community-based services 
against spousal impoverishment. 
Sec. 2405. Funding to expand State Aging and Disability Resource Centers. 
Sec. 2406. Sense of the Senate regarding long-term care. 
Subtitle F—Medicaid Prescription Drug Coverage 
Sec. 2501. Prescription drug rebates. 
Sec. 2502. Elimination of exclusion of coverage of certain drugs. 
Sec. 2503. Providing adequate pharmacy reimbursement. 
Subtitle G—Medicaid Disproportionate Share Hospital (DSH) Payments 
Sec. 2551. Disproportionate share hospital payments. 
Subtitle H—Improved Coordination for Dual Eligible Beneficiaries 
Sec. 2601. 5-year period for demonstration projects. 
Sec. 2602. Providing Federal coverage and payment coordination for dual eligi-
ble beneficiaries. 
Subtitle I—Improving the Quality of Medicaid for Patients and Providers 
Sec. 2701. Adult health quality measures. 
Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions. 
Sec. 2703. State option to provide health homes for enrollees with chronic con-
ditions. 
Sec. 2704. Demonstration project to evaluate integrated care around a hos-
pitalization. 
Sec. 2705. Medicaid Global Payment System Demonstration Project. 
Sec. 2706. Pediatric Accountable Care Organization Demonstration Project. 
Sec. 2707. Medicaid emergency psychiatric demonstration project. 
Subtitle J—Improvements to the Medicaid and CHIP Payment and Access 
Commission (MACPAC) 
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Sec. 2801. MACPAC assessment of policies affecting all Medicaid beneficiaries. 
Subtitle K—Protections for American Indians and Alaska Natives 
Sec. 2901. Special rules relating to Indians. 
Sec. 2902. Elimination of sunset for reimbursement for all medicare part B 
services furnished by certain indian hospitals and clinics. 
Subtitle L—Maternal and Child Health Services 
Sec. 2951. Maternal, infant, and early childhood home visiting programs. 
Sec. 2952. Support, education, and research for postpartum depression. 
Sec. 2953. Personal responsibility education. 
Sec. 2954. Restoration of funding for abstinence education. 
Sec. 2955. Inclusion of information about the importance of having a health 
care power of attorney in transition planning for children aging 
out of foster care and independent living programs. 
TITLE III—IMPROVING THE QUALITY AND EFFICIENCY OF 
HEALTH CARE 
Subtitle A—Transforming the Health Care Delivery System 
PART I—LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE 
MEDICARE PROGRAM 
Sec. 3001. Hospital Value-Based purchasing program. 
Sec. 3002. Improvements to the physician quality reporting system. 
Sec. 3003. Improvements to the physician feedback program. 
Sec. 3004. Quality reporting for long-term care hospitals, inpatient rehabilita-
tion hospitals, and hospice programs. 
Sec. 3005. Quality reporting for PPS-exempt cancer hospitals. 
Sec. 3006. Plans for a Value-Based purchasing program for skilled nursing fa-
cilities and home health agencies. 
Sec. 3007. Value-based payment modifier under the physician fee schedule. 
Sec. 3008. Payment adjustment for conditions acquired in hospitals. 
PART II—NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY 
Sec. 3011. National strategy. 
Sec. 3012. Interagency Working Group on Health Care Quality. 
Sec. 3013. Quality measure development. 
Sec. 3014. Quality measurement. 
Sec. 3015. Data collection; public reporting. 
PART III—ENCOURAGING DEVELOPMENT OF NEW PATIENT CARE MODELS 
Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation 
within CMS. 
Sec. 3022. Medicare shared savings program. 
Sec. 3023. National pilot program on payment bundling. 
Sec. 3024. Independence at home demonstration program. 
Sec. 3025. Hospital readmissions reduction program. 
Sec. 3026. Community-Based Care Transitions Program. 
Sec. 3027. Extension of gainsharing demonstration. 
Subtitle B—Improving Medicare for Patients and Providers 
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PART I—ENSURING BENEFICIARY ACCESS TO PHYSICIAN CARE AND OTHER 
SERVICES 
Sec. 3101. Increase in the physician payment update. 
Sec. 3102. Extension of the work geographic index floor and revisions to the 
practice expense geographic adjustment under the Medicare 
physician fee schedule. 
Sec. 3103. Extension of exceptions process for Medicare therapy caps. 
Sec. 3104. Extension of payment for technical component of certain physician 
pathology services. 
Sec. 3105. Extension of ambulance add-ons. 
Sec. 3106. Extension of certain payment rules for long-term care hospital serv-
ices and of moratorium on the establishment of certain hos-
pitals and facilities. 
Sec. 3107. Extension of physician fee schedule mental health add-on. 
Sec. 3108. Permitting physician assistants to order post-Hospital extended care 
services. 
Sec. 3109. Exemption of certain pharmacies from accreditation requirements. 
Sec. 3110. Part B special enrollment period for disabled TRICARE bene-
ficiaries. 
Sec. 3111. Payment for bone density tests. 
Sec. 3112. Revision to the Medicare Improvement Fund. 
Sec. 3113. Treatment of certain complex diagnostic laboratory tests. 
Sec. 3114. Improved access for certified nurse-midwife services. 
PART II—RURAL PROTECTIONS 
Sec. 3121. Extension of outpatient hold harmless provision. 
Sec. 3122. Extension of Medicare reasonable costs payments for certain clinical 
diagnostic laboratory tests furnished to hospital patients in cer-
tain rural areas. 
Sec. 3123. Extension of the Rural Community Hospital Demonstration Pro-
gram. 
Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program. 
Sec. 3125. Temporary improvements to the Medicare inpatient hospital pay-
ment adjustment for low-volume hospitals. 
Sec. 3126. Improvements to the demonstration project on community health in-
tegration models in certain rural counties. 
Sec. 3127. MedPAC study on adequacy of Medicare payments for health care 
providers serving in rural areas. 
Sec. 3128. Technical correction related to critical access hospital services. 
Sec. 3129. Extension of and revisions to Medicare rural hospital flexibility pro-
gram. 
PART III—IMPROVING PAYMENT ACCURACY 
Sec. 3131. Payment adjustments for home health care. 
Sec. 3132. Hospice reform. 
Sec. 3133. Improvement to medicare disproportionate share hospital (DSH) 
payments. 
Sec. 3134. Misvalued codes under the physician fee schedule. 
Sec. 3135. Modification of equipment utilization factor for advanced imaging 
services. 
Sec. 3136. Revision of payment for power-driven wheelchairs. 
Sec. 3137. Hospital wage index improvement. 
Sec. 3138. Treatment of certain cancer hospitals. 
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Sec. 3139. Payment for biosimilar biological products. 
Sec. 3140. Medicare hospice concurrent care demonstration program. 
Sec. 3141. Application of budget neutrality on a national basis in the calcula-
tion of the Medicare hospital wage index floor. 
Sec. 3142. HHS study on urban Medicare-dependent hospitals. 
Subtitle C—Provisions Relating to Part C 
Sec. 3201. Medicare Advantage payment. 
Sec. 3202. Benefit protection and simplification. 
Sec. 3203. Application of coding intensity adjustment during MA payment 
transition. 
Sec. 3204. Simplification of annual beneficiary election periods. 
Sec. 3205. Extension for specialized MA plans for special needs individuals. 
Sec. 3206. Extension of reasonable cost contracts. 
Sec. 3207. Technical correction to MA private fee-for-service plans. 
Sec. 3208. Making senior housing facility demonstration permanent. 
Sec. 3209. Authority to deny plan bids. 
Sec. 3210. Development of new standards for certain Medigap plans. 
Subtitle D—Medicare Part D Improvements for Prescription Drug Plans and 
MA–PD Plans 
Sec. 3301. Medicare coverage gap discount program. 
Sec. 3302. Improvement in determination of Medicare part D low-income 
benchmark premium. 
Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals under 
prescription drug plans and MA–PD plans. 
Sec. 3304. Special rule for widows and widowers regarding eligibility for low- 
income assistance. 
Sec. 3305. Improved information for subsidy eligible individuals reassigned to 
prescription drug plans and MA–PD plans. 
Sec. 3306. Funding outreach and assistance for low-income programs. 
Sec. 3307. Improving formulary requirements for prescription drug plans and 
MA–PD plans with respect to certain categories or classes of 
drugs. 
Sec. 3308. Reducing part D premium subsidy for high-income beneficiaries. 
Sec. 3309. Elimination of cost sharing for certain dual eligible individuals. 
Sec. 3310. Reducing wasteful dispensing of outpatient prescription drugs in 
long-term care facilities under prescription drug plans and 
MA–PD plans. 
Sec. 3311. Improved Medicare prescription drug plan and MA–PD plan com-
plaint system. 
Sec. 3312. Uniform exceptions and appeals process for prescription drug plans 
and MA–PD plans. 
Sec. 3313. Office of the Inspector General studies and reports. 
Sec. 3314. Including costs incurred by AIDS drug assistance programs and In-
dian Health Service in providing prescription drugs toward the 
annual out-of-pocket threshold under part D. 
Sec. 3315. Immediate reduction in coverage gap in 2010. 
Subtitle E—Ensuring Medicare Sustainability 
Sec. 3401. Revision of certain market basket updates and incorporation of pro-
ductivity improvements into market basket updates that do not 
already incorporate such improvements. 
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Sec. 3402. Temporary adjustment to the calculation of part B premiums. 
Sec. 3403. Independent Medicare Advisory Board. 
Subtitle F—Health Care Quality Improvements 
Sec. 3501. Health care delivery system research; Quality improvement technical 
assistance. 
Sec. 3502. Establishing community health teams to support the patient-cen-
tered medical home. 
Sec. 3503. Medication management services in treatment of chronic disease. 
Sec. 3504. Design and implementation of regionalized systems for emergency 
care. 
Sec. 3505. Trauma care centers and service availability. 
Sec. 3506. Program to facilitate shared decisionmaking. 
Sec. 3507. Presentation of prescription drug benefit and risk information. 
Sec. 3508. Demonstration program to integrate quality improvement and pa-
tient safety training into clinical education of health profes-
sionals. 
Sec. 3509. Improving women’s health. 
Sec. 3510. Patient navigator program. 
Sec. 3511. Authorization of appropriations. 
TITLE IV—PREVENTION OF CHRONIC DISEASE AND IMPROVING 
PUBLIC HEALTH 
Subtitle A—Modernizing Disease Prevention and Public Health Systems 
Sec. 4001. National Prevention, Health Promotion and Public Health Council. 
Sec. 4002. Prevention and Public Health Fund. 
Sec. 4003. Clinical and community preventive services. 
Sec. 4004. Education and outreach campaign regarding preventive benefits. 
Subtitle B—Increasing Access to Clinical Preventive Services 
Sec. 4101. School-based health centers. 
Sec. 4102. Oral healthcare prevention activities. 
Sec. 4103. Medicare coverage of annual wellness visit providing a personalized 
prevention plan. 
Sec. 4104. Removal of barriers to preventive services in Medicare. 
Sec. 4105. Evidence-based coverage of preventive services in Medicare. 
Sec. 4106. Improving access to preventive services for eligible adults in Med-
icaid. 
Sec. 4107. Coverage of comprehensive tobacco cessation services for pregnant 
women in Medicaid. 
Sec. 4108. Incentives for prevention of chronic diseases in medicaid. 
Subtitle C—Creating Healthier Communities 
Sec. 4201. Community transformation grants. 
Sec. 4202. Healthy aging, living well; evaluation of community-based prevention 
and wellness programs for Medicare beneficiaries. 
Sec. 4203. Removing barriers and improving access to wellness for individuals 
with disabilities. 
Sec. 4204. Immunizations. 
Sec. 4205. Nutrition labeling of standard menu items at chain restaurants. 
Sec. 4206. Demonstration project concerning individualized wellness plan. 
Sec. 4207. Reasonable break time for nursing mothers. 
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Subtitle D—Support for Prevention and Public Health Innovation 
Sec. 4301. Research on optimizing the delivery of public health services. 
Sec. 4302. Understanding health disparities: data collection and analysis. 
Sec. 4303. CDC and employer-based wellness programs. 
Sec. 4304. Epidemiology-Laboratory Capacity Grants. 
Sec. 4305. Advancing research and treatment for pain care management. 
Sec. 4306. Funding for Childhood Obesity Demonstration Project. 
Subtitle E—Miscellaneous Provisions 
Sec. 4401. Sense of the Senate concerning CBO scoring. 
Sec. 4402. Effectiveness of Federal health and wellness initiatives. 
TITLE V—HEALTH CARE WORKFORCE 
Subtitle A—Purpose and Definitions 
Sec. 5001. Purpose. 
Sec. 5002. Definitions. 
Subtitle B—Innovations in the Health Care Workforce 
Sec. 5101. National health care workforce commission. 
Sec. 5102. State health care workforce development grants. 
Sec. 5103. Health care workforce assessment. 
Subtitle C—Increasing the Supply of the Health Care Workforce 
Sec. 5201. Federally supported student loan funds. 
Sec. 5202. Nursing student loan program. 
Sec. 5203. Health care workforce loan repayment programs. 
Sec. 5204. Public health workforce recruitment and retention programs. 
Sec. 5205. Allied health workforce recruitment and retention programs. 
Sec. 5206. Grants for State and local programs. 
Sec. 5207. Funding for National Health Service Corps. 
Sec. 5208. Nurse-managed health clinics. 
Sec. 5209. Elimination of cap on commissioned corps. 
Sec. 5210. Establishing a Ready Reserve Corps. 
Subtitle D—Enhancing Health Care Workforce Education and Training 
Sec. 5301. Training in family medicine, general internal medicine, general pedi-
atrics, and physician assistantship. 
Sec. 5302. Training opportunities for direct care workers. 
Sec. 5303. Training in general, pediatric, and public health dentistry. 
Sec. 5304. Alternative dental health care providers demonstration project. 
Sec. 5305. Geriatric education and training; career awards; comprehensive geri-
atric education. 
Sec. 5306. Mental and behavioral health education and training grants. 
Sec. 5307. Cultural competency, prevention, and public health and individuals 
with disabilities training. 
Sec. 5308. Advanced nursing education grants. 
Sec. 5309. Nurse education, practice, and retention grants. 
Sec. 5310. Loan repayment and scholarship program. 
Sec. 5311. Nurse faculty loan program. 
Sec. 5312. Authorization of appropriations for parts B through D of title VIII. 
Sec. 5313. Grants to promote the community health workforce. 
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Sec. 5314. Fellowship training in public health. 
Sec. 5315. United States Public Health Sciences Track. 
Subtitle E—Supporting the Existing Health Care Workforce 
Sec. 5401. Centers of excellence. 
Sec. 5402. Health care professionals training for diversity. 
Sec. 5403. Interdisciplinary, community-based linkages. 
Sec. 5404. Workforce diversity grants. 
Sec. 5405. Primary care extension program. 
Subtitle F—Strengthening Primary Care and Other Workforce Improvements 
Sec. 5501. Expanding access to primary care services and general surgery serv-
ices. 
Sec. 5502. Medicare Federally qualified health center improvements. 
Sec. 5503. Distribution of additional residency positions. 
Sec. 5504. Counting resident time in outpatient settings and allowing flexibility 
for jointly operated residency training programs. 
Sec. 5505. Rules for counting resident time for didactic and scholarly activities 
and other activities. 
Sec. 5506. Preservation of resident cap positions from closed hospitals. 
Sec. 5507. Demonstration projects To address health professions workforce 
needs; extension of family-to-family health information centers. 
Sec. 5508. Increasing teaching capacity. 
Sec. 5509. Graduate nurse education demonstration. 
Subtitle G—Improving Access to Health Care Services 
Sec. 5601. Spending for Federally Qualified Health Centers (FQHCs). 
Sec. 5602. Negotiated rulemaking for development of methodology and criteria 
for designating medically underserved populations and health 
professions shortage areas. 
Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services for 
Children Program. 
Sec. 5604. Co-locating primary and specialty care in community-based mental 
health settings. 
Sec. 5605. Key National indicators. 
Subtitle H—General Provisions 
Sec. 5701. Reports. 
TITLE VI—TRANSPARENCY AND PROGRAM INTEGRITY 
Subtitle A—Physician Ownership and Other Transparency 
Sec. 6001. Limitation on Medicare exception to the prohibition on certain phy-
sician referrals for hospitals. 
Sec. 6002. Transparency reports and reporting of physician ownership or in-
vestment interests. 
Sec. 6003. Disclosure requirements for in-office ancillary services exception to 
the prohibition on physician self-referral for certain imaging 
services. 
Sec. 6004. Prescription drug sample transparency. 
Sec. 6005. Pharmacy benefit managers transparency requirements. 
Subtitle B—Nursing Home Transparency and Improvement 
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PART I—IMPROVING TRANSPARENCY OF INFORMATION 
Sec. 6101. Required disclosure of ownership and additional disclosable parties 
information. 
Sec. 6102. Accountability requirements for skilled nursing facilities and nursing 
facilities. 
Sec. 6103. Nursing home compare Medicare website. 
Sec. 6104. Reporting of expenditures. 
Sec. 6105. Standardized complaint form. 
Sec. 6106. Ensuring staffing accountability. 
Sec. 6107. GAO study and report on Five-Star Quality Rating System. 
PART II—TARGETING ENFORCEMENT 
Sec. 6111. Civil money penalties. 
Sec. 6112. National independent monitor demonstration project. 
Sec. 6113. Notification of facility closure. 
Sec. 6114. National demonstration projects on culture change and use of infor-
mation technology in nursing homes. 
PART III—IMPROVING STAFF TRAINING 
Sec. 6121. Dementia and abuse prevention training. 
Subtitle C—Nationwide Program for National and State Background Checks 
on Direct Patient Access Employees of Long-term Care Facilities and Pro-
viders 
Sec. 6201. Nationwide program for National and State background checks on 
direct patient access employees of long-term care facilities and 
providers. 
Subtitle D—Patient-Centered Outcomes Research 
Sec. 6301. Patient-Centered Outcomes Research. 
Sec. 6302. Federal coordinating council for comparative effectiveness research. 
Subtitle E—Medicare, Medicaid, and CHIP Program Integrity Provisions 
Sec. 6401. Provider screening and other enrollment requirements under Medi-
care, Medicaid, and CHIP. 
Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions. 
Sec. 6403. Elimination of duplication between the Healthcare Integrity and 
Protection Data Bank and the National Practitioner Data 
Bank. 
Sec. 6404. Maximum period for submission of Medicare claims reduced to not 
more than 12 months. 
Sec. 6405. Physicians who order items or services required to be Medicare en-
rolled physicians or eligible professionals. 
Sec. 6406. Requirement for physicians to provide documentation on referrals to 
programs at high risk of waste and abuse. 
Sec. 6407. Face to face encounter with patient required before physicians may 
certify eligibility for home health services or durable medical 
equipment under Medicare. 
Sec. 6408. Enhanced penalties. 
Sec. 6409. Medicare self-referral disclosure protocol. 
Sec. 6410. Adjustments to the Medicare durable medical equipment, pros-
thetics, orthotics, and supplies competitive acquisition program. 
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•AMDT. NO. 2786 
Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program. 
Subtitle F—Additional Medicaid Program Integrity Provisions 
Sec. 6501. Termination of provider participation under Medicaid if terminated 
under Medicare or other State plan. 
Sec. 6502. Medicaid exclusion from participation relating to certain ownership, 
control, and management affiliations. 
Sec. 6503. Billing agents, clearinghouses, or other alternate payees required to 
register under Medicaid. 
Sec. 6504. Requirement to report expanded set of data elements under MMIS 
to detect fraud and abuse. 
Sec. 6505. Prohibition on payments to institutions or entities located outside of 
the United States. 
Sec. 6506. Overpayments. 
Sec. 6507. Mandatory State use of national correct coding initiative. 
Sec. 6508. General effective date. 
Subtitle G—Additional Program Integrity Provisions 
Sec. 6601. Prohibition on false statements and representations. 
Sec. 6602. Clarifying definition. 
Sec. 6603. Development of model uniform report form. 
Sec. 6604. Applicability of State law to combat fraud and abuse. 
Sec. 6605. Enabling the Department of Labor to issue administrative summary 
cease and desist orders and summary seizures orders against 
plans that are in financially hazardous condition. 
Sec. 6607. Permitting 
evidentiary 
privilege 
and 
confidential 
cSec. 6606. MEWA plan registration with Department of 
Labor. 
ommunications. 
Subtitle H—Elder Justice Act 
Sec. 6701. Short title of subtitle. 
Sec. 6702. Definitions. 
Sec. 6703. Elder Justice. 
Subtitle I—Sense of the Senate Regarding Medical Malpractice 
Sec. 6801. Sense of the Senate regarding medical malpractice. 
TITLE VII—IMPROVING ACCESS TO INNOVATIVE MEDICAL 
THERAPIES 
Subtitle A—Biologics Price Competition and Innovation 
Sec. 7001. Short title. 
Sec. 7002. Approval pathway for biosimilar biological products. 
Sec. 7003. Savings. 
Subtitle B—More Affordable Medicines for Children and Underserved 
Communities 
Sec. 7101. Expanded participation in 340B program. 
Sec. 7102. Improvements to 340B program integrity. 
Sec. 7103. GAO study to make recommendations on improving the 340B pro-
gram. 
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•AMDT. NO. 2786 
TITLE VIII—CLASS ACT 
Sec. 8001. Short title of title. 
Sec. 8002. Establishment of national voluntary insurance program for pur-
chasing community living assistance services and support. 
TITLE IX—REVENUE PROVISIONS 
Subtitle A—Revenue Offset Provisions 
Sec. 9001. Excise tax on high cost employer-sponsored health coverage. 
Sec. 9002. Inclusion of cost of employer-sponsored health coverage on W–2. 
Sec. 9003. Distributions for medicine qualified only if for prescribed drug or in-
sulin. 
Sec. 9004. Increase in additional tax on distributions from HSAs and Archer 
MSAs not used for qualified medical expenses. 
Sec. 9005. Limitation on health flexible spending arrangements under cafeteria 
plans. 
Sec. 9006. Expansion of information reporting requirements. 
Sec. 9007. Additional requirements for charitable hospitals. 
Sec. 9008. Imposition of annual fee on branded prescription pharmaceutical 
manufacturers and importers. 
Sec. 9009. Imposition of annual fee on medical device manufacturers and im-
porters. 
Sec. 9010. Imposition of annual fee on health insurance providers. 
Sec. 9011. Study and report of effect on veterans health care. 
Sec. 9012. Elimination of deduction for expenses allocable to Medicare Part D 
subsidy. 
Sec. 9013. Modification of itemized deduction for medical expenses. 
Sec. 9014. Limitation on excessive remuneration paid by certain health insur-
ance providers. 
Sec. 9015. Additional hospital insurance tax on high-income taxpayers. 
Sec. 9016. Modification of section 833 treatment of certain health organiza-
tions. 
Sec. 9017. Excise tax on elective cosmetic medical procedures. 
Subtitle B—Other Provisions 
Sec. 9021. Exclusion of health benefits provided by Indian tribal governments. 
Sec. 9022. Establishment of simple cafeteria plans for small businesses. 
Sec. 9023. Qualifying therapeutic discovery project credit. 
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•AMDT. NO. 2786 
TITLE I—QUALITY, AFFORDABLE 
HEALTH 
CARE 
FOR 
ALL 
AMERICANS 
Subtitle 
A—Immediate 
Improve-
ments in Health Care Coverage 
for All Americans 
SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE 
ACT. 
Part A of title XXVII of the Public Health Service 
Act (42 U.S.C. 300gg et seq.) is amended— 
(1) by striking the part heading and inserting 
the following: 
‘‘PART A—INDIVIDUAL AND GROUP MARKET 
REFORMS’’; 
(2) by redesignating sections 2704 through 
2707 as sections 2725 through 2728, respectively; 
(3) by redesignating sections 2711 through 
2713 as sections 2731 through 2733, respectively; 
(4) by redesignating sections 2721 through 
2723 as sections 2735 through 2737, respectively; 
and 
(5) by inserting after section 2702, the fol-
lowing: 
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•AMDT. NO. 2786 
‘‘Subpart II—Improving Coverage 
‘‘SEC. 2711. NO LIFETIME OR ANNUAL LIMITS. 
‘‘(a) IN GENERAL.—A group health plan and a health 
insurance issuer offering group or individual health insur-
ance coverage may not establish— 
‘‘(1) lifetime limits on the dollar value of bene-
fits for any participant or beneficiary; or 
‘‘(2) unreasonable annual limits (within the 
meaning of section 223 of the Internal Revenue 
Code of 1986) on the dollar value of benefits for any 
participant or beneficiary. 
‘‘(b) PER BENEFICIARY LIMITS.—Subsection (a) 
shall not be construed to prevent a group health plan or 
health insurance coverage that is not required to provide 
essential health benefits under section 1302(b) of the Pa-
tient Protection and Affordable Care Act from placing an-
nual or lifetime per beneficiary limits on specific covered 
benefits to the extent that such limits are otherwise per-
mitted under Federal or State law. 
‘‘SEC. 2712. PROHIBITION ON RESCISSIONS. 
‘‘A group health plan and a health insurance issuer 
offering group or individual health insurance coverage 
shall not rescind such plan or coverage with respect to an 
enrollee once the enrollee is covered under such plan or 
coverage involved, except that this section shall not apply 
to a covered individual who has performed an act or prac-
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•AMDT. NO. 2786 
tice that constitutes fraud or makes an intentional mis-
representation of material fact as prohibited by the terms 
of the plan or coverage. Such plan or coverage may not 
be cancelled except with prior notice to the enrollee, and 
only as permitted under section 2702(c) or 2742(b). 
‘‘SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES. 
‘‘(a) IN GENERAL.—A group health plan and a health 
insurance issuer offering group or individual health insur-
ance coverage shall provide coverage for and shall not im-
pose any cost sharing requirements for— 
‘‘(1) evidence-based items or services that have 
in effect a rating of ‘A’ or ‘B’ in the current rec-
ommendations of the United States Preventive Serv-
ices Task Force; 
‘‘(2) immunizations that have in effect a rec-
ommendation from the Advisory Committee on Im-
munization Practices of the Centers for Disease 
Control and Prevention with respect to the indi-
vidual involved; and 
‘‘(3) with respect to infants, children, and ado-
lescents, evidence-informed preventive care and 
screenings provided for in the comprehensive guide-
lines supported by the Health Resources and Serv-
ices Administration. 
‘‘(b) INTERVAL.— 
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•AMDT. NO. 2786 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish a minimum interval between the date on which 
a recommendation described in subsection (a)(1) or 
(a)(2) or a guideline under subsection (a)(3) is 
issued and the plan year with respect to which the 
requirement described in subsection (a) is effective 
with respect to the service described in such rec-
ommendation or guideline. 
‘‘(2) MINIMUM.—The interval described in 
paragraph (1) shall not be less than 1 year. 
‘‘(c) VALUE-BASED INSURANCE DESIGN.—The Sec-
retary may develop guidelines to permit a group health 
plan and a health insurance issuer offering group or indi-
vidual health insurance coverage to utilize value-based in-
surance designs. 
‘‘SEC. 2714. EXTENSION OF DEPENDENT COVERAGE. 
‘‘(a) IN GENERAL.—A group health plan and a health 
insurance issuer offering group or individual health insur-
ance coverage that provides dependent coverage of chil-
dren shall continue to make such coverage available for 
an adult child (who is not married) until the child turns 
26 years of age. Nothing in this section shall require a 
health plan or a health insurance issuer described in the 
preceding sentence to make coverage available for a child 
of a child receiving dependent coverage. 
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•AMDT. NO. 2786 
‘‘(b) REGULATIONS.—The Secretary shall promul-
gate regulations to define the dependents to which cov-
erage shall be made available under subsection (a). 
‘‘(c) RULE OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed to modify the definition of ‘depend-
ent’ as used in the Internal Revenue Code of 1986 with 
respect to the tax treatment of the cost of coverage. 
‘‘SEC. 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM 
EXPLANATION OF COVERAGE DOCUMENTS 
AND STANDARDIZED DEFINITIONS. 
‘‘(a) IN GENERAL.—Not later than 12 months after 
the date of enactment of the Patient Protection and Af-
fordable Care Act, the Secretary shall develop standards 
for use by a group health plan and a health insurance 
issuer offering group or individual health insurance cov-
erage, in compiling and providing to enrollees a summary 
of benefits and coverage explanation that accurately de-
scribes the benefits and coverage under the applicable plan 
or coverage. In developing such standards, the Secretary 
shall consult with the National Association of Insurance 
Commissioners (referred to in this section as the ‘NAIC’), 
a working group composed of representatives of health in-
surance-related consumer advocacy organizations, health 
insurance issuers, health care professionals, patient advo-
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•AMDT. NO. 2786 
cates including those representing individuals with limited 
English proficiency, and other qualified individuals. 
‘‘(b) REQUIREMENTS.—The standards for the sum-
mary of benefits and coverage developed under subsection 
(a) shall provide for the following: 
‘‘(1) APPEARANCE.—The standards shall en-
sure that the summary of benefits and coverage is 
presented in a uniform format that does not exceed 
4 pages in length and does not include print smaller 
than 12-point font. 
‘‘(2) LANGUAGE.—The standards shall ensure 
that the summary is presented in a culturally and 
linguistically appropriate manner and utilizes termi-
nology understandable by the average plan enrollee. 
‘‘(3) CONTENTS.—The standards shall ensure 
that the summary of benefits and coverage in-
cludes— 
‘‘(A) uniform definitions of standard insur-
ance terms and medical terms (consistent with 
subsection (g)) so that consumers may compare 
health insurance coverage and understand the 
terms of coverage (or exception to such cov-
erage); 
‘‘(B) a description of the coverage, includ-
ing cost sharing for— 
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•AMDT. NO. 2786 
‘‘(i) each of the categories of the es-
sential health benefits described in sub-
paragraphs (A) through (J) of section 
1302(b)(1) of the Patient Protection and 
Affordable Care Act; and 
‘‘(ii) other benefits, as identified by 
the Secretary; 
‘‘(C) the exceptions, reductions, and limita-
tions on coverage; 
‘‘(D) the cost-sharing provisions, including 
deductible, coinsurance, and co-payment obliga-
tions; 
‘‘(E) the renewability and continuation of 
coverage provisions; 
‘‘(F) a coverage facts label that includes 
examples to illustrate common benefits sce-
narios, including pregnancy and serious or 
chronic medical conditions and related cost 
sharing, such scenarios to be based on recog-
nized clinical practice guidelines; 
‘‘(G) a statement of whether the plan or 
coverage— 
‘‘(i) provides minimum essential cov-
erage (as defined under section 5000A(f) 
of the Internal Revenue Code 1986); and 
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•AMDT. NO. 2786 
‘‘(ii) ensures that the plan or coverage 
share of the total allowed costs of benefits 
provided under the plan or coverage is not 
less than 60 percent of such costs; 
‘‘(H) a statement that the outline is a 
summary of the policy or certificate and that 
the coverage document itself should be con-
sulted to determine the governing contractual 
provisions; and 
‘‘(I) a contact number for the consumer to 
call with additional questions and an Internet 
web address where a copy of the actual indi-
vidual coverage policy or group certificate of 
coverage can be reviewed and obtained. 
‘‘(c) PERIODIC REVIEW AND UPDATING.—The Sec-
retary shall periodically review and update, as appropriate, 
the standards developed under this section. 
‘‘(d) REQUIREMENT TO PROVIDE.— 
‘‘(1) IN GENERAL.—Not later than 24 months 
after the date of enactment of the Patient Protection 
and Affordable Care Act, each entity described in 
paragraph (3) shall provide, prior to any enrollment 
restriction, a summary of benefits and coverage ex-
planation pursuant
to the standards developed by 
the Secretary under subsection (a) to— 
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•AMDT. NO. 2786 
‘‘(A) an applicant at the time of applica-
tion; 
‘‘(B) an enrollee prior to the time of enroll-
ment or reenrollment, as applicable; and 
‘‘(C) a policyholder or certificate holder at 
the time of issuance of the policy or delivery of 
the certificate. 
‘‘(2) COMPLIANCE.—An entity described in 
paragraph (3) is deemed to be in compliance with 
this section if the summary of benefits and coverage 
described in subsection (a) is provided in paper or 
electronic form. 
‘‘(3) ENTITIES
IN
GENERAL.—An entity de-
scribed in this paragraph is— 
‘‘(A) a health insurance issuer (including a 
group health plan that is not a self-insured 
plan) offering health insurance coverage within 
the United States; or 
‘‘(B) in the case of a self-insured group 
health plan, the plan sponsor or designated ad-
ministrator of the plan (as such terms are de-
fined in section 3(16) of the Employee Retire-
ment Income Security Act of 1974). 
‘‘(4) NOTICE OF MODIFICATIONS.—If a group 
health plan or health insurance issuer makes any 
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•AMDT. NO. 2786 
material modification in any of the terms of the plan 
or coverage involved (as defined for purposes of sec-
tion 102 of the Employee Retirement Income Secu-
rity Act of 1974) that is not reflected in the most 
recently provided summary of benefits and coverage, 
the plan or issuer shall provide notice of such modi-
fication to enrollees not later than 60 days prior to 
the date on which such modification will become ef-
fective. 
‘‘(e) PREEMPTION.—The standards developed under 
subsection (a) shall preempt any related State standards 
that require a summary of benefits and coverage that pro-
vides less information to consumers than that required to 
be provided under this section, as determined by the Sec-
retary. 
‘‘(f) FAILURE TO PROVIDE.—An entity described in 
subsection (d)(3) that willfully fails to provide the infor-
mation required under this section shall be subject to a 
fine of not more than $1,000 for each such failure. Such 
failure with respect to each enrollee shall constitute a sep-
arate offense for purposes of this subsection. 
‘‘(g) DEVELOPMENT OF STANDARD DEFINITIONS.— 
‘‘(1) IN
GENERAL.—The Secretary shall, by 
regulation, provide for the development of standards 
for the definitions of terms used in health insurance 
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•AMDT. NO. 2786 
coverage, including the insurance-related terms de-
scribed in paragraph (2) and the medical terms de-
scribed in paragraph (3). 
‘‘(2) INSURANCE-RELATED TERMS.—The insur-
ance-related terms described in this paragraph are 
premium, deductible, co-insurance, co-payment, out- 
of-pocket limit, preferred provider, non-preferred 
provider, out-of-network co-payments, UCR (usual, 
customary and reasonable) fees, excluded services, 
grievance and appeals, and such other terms as the 
Secretary determines are important to define so that 
consumers may compare health insurance coverage 
and understand the terms of their coverage. 
‘‘(3) MEDICAL TERMS.—The medical terms de-
scribed in this paragraph are hospitalization, hos-
pital outpatient care, emergency room care, physi-
cian services, prescription drug coverage, durable 
medical equipment, home health care, skilled nursing 
care, rehabilitation services, hospice services, emer-
gency medical transportation, and such other terms 
as the Secretary determines are important to define 
so that consumers may compare the medical benefits 
offered by health insurance and understand the ex-
tent of those medical benefits (or exceptions to those 
benefits). 
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•AMDT. NO. 2786 
‘‘SEC. 2716. PROHIBITION OF DISCRIMINATION BASED ON 
SALARY. 
‘‘(a) IN GENERAL.—The plan sponsor of a group 
health plan (other than a self-insured plan) may not estab-
lish rules relating to the health insurance coverage eligi-
bility (including continued eligibility) of any full-time em-
ployee under the terms of the plan that are based on the 
total hourly or annual salary of the employee or otherwise 
establish eligibility rules that have the effect of discrimi-
nating in favor of higher wage employees. 
‘‘(b) LIMITATION.—Subsection (a) shall not be con-
strued to prohibit a plan sponsor from establishing con-
tribution requirements for enrollment in the plan or cov-
erage that provide for the payment by employees with 
lower hourly or annual compensation of a lower dollar or 
percentage contribution than the payment required of 
similarly situated employees with a higher hourly or an-
nual compensation. 
‘‘SEC. 2717. ENSURING THE QUALITY OF CARE. 
‘‘(a) QUALITY REPORTING.— 
‘‘(1) IN
GENERAL.—Not later than 2 years 
after the date of enactment of the Patient Protection 
and Affordable Care Act, the Secretary, in consulta-
tion with experts in health care quality and stake-
holders, shall develop reporting requirements for use 
by a group health plan, and a health insurance 
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•AMDT. NO. 2786 
issuer offering group or individual health insurance 
coverage, with respect to plan or coverage benefits 
and health care provider reimbursement structures 
that— 
‘‘(A) improve health outcomes through the 
implementation of activities such as quality re-
porting, effective case management, care coordi-
nation, chronic disease management, and medi-
cation and care compliance initiatives, including 
through the use of the medical homes model as 
defined for purposes of section 3602 of the Pa-
tient Protection and Affordable Care Act, for 
treatment or services under the plan or cov-
erage; 
‘‘(B) implement activities to prevent hos-
pital readmissions through a comprehensive 
program for hospital discharge that includes pa-
tient-centered education and counseling, com-
prehensive discharge planning, and post dis-
charge reinforcement by an appropriate health 
care professional; 
‘‘(C) implement activities to improve pa-
tient safety and reduce medical errors through 
the appropriate use of best clinical practices, 
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•AMDT. NO. 2786 
a standard that is related to a health status factor 
(or if such a wellness program does not provide such 
a reward), the wellness program shall not violate 
this section if participation in the program is made 
available to all similarly situated individuals. The 
following programs shall not have to comply with the 
requirements of paragraph (3) if participation in the 
program is made available to all similarly situated 
individuals: 
‘‘(A) A program that reimburses all or 
part of the cost for memberships in a fitness 
center. 
‘‘(B) A diagnostic testing program that 
provides a reward for participation and does 
not base any part of the reward on outcomes. 
‘‘(C) A program that encourages preven-
tive care related to a health condition through 
the waiver of the copayment or deductible re-
quirement under group health plan for the costs 
of certain items or services related to a health 
condition (such as prenatal care or well-baby 
visits). 
‘‘(D) A program that reimburses individ-
uals for the costs of smoking cessation pro-
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