In the Senate of the United States, 
December 24, 2009. 
Resolved, That the bill from the House of Representa-
tives (H.R. 3590) entitled ‘‘An Act 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 cer-
tain other Federal employees, and for other purposes.’’, do 
pass with the following 
AMENDMENTS: 
Strike all after the enacting clause and insert the 
following: 
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SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the ‘‘Pa-
tient 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 
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 coverage 
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. 
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‘‘SUBPART I—GENERAL REFORM 
‘‘Sec. 2704. Prohibition of preexisting condition exclusions or other discrimi-
nation based on health status. 
‘‘Sec. 2701. Fair health insurance premiums. 
‘‘Sec. 2702. Guaranteed availability of coverage. 
‘‘Sec. 2703. Guaranteed renewability of coverage. 
‘‘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. 
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 indi-
viduals 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. 
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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, pre-
mium tax credits and reduced cost-sharing, and individual re-
sponsibility exemptions. 
Sec. 1412. Advance determination and payment of premium tax credits and cost- 
sharing reductions. 
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 programs. 
Sec. 1415. Premium tax credit and cost-sharing reduction payments disregarded 
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 cafe-
teria 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. 
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Sec. 1561. Health information technology enrollment standards and protocols. 
Sec. 1562. Conforming amendments. 
Sec. 1563. Sense of the Senate promoting fiscal responsibility. 
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 insur-
ance. 
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 
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 services. 
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. 
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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 eligible 
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 condi-
tions. 
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) 
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 serv-
ices 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 rehabilitation 
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 facili-
ties and home health agencies. 
Sec. 3007. Value-based payment modifier under the physician fee schedule. 
Sec. 3008. Payment adjustment for conditions acquired in hospitals. 
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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 
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 prac-
tice expense geographic adjustment under the Medicare physi-
cian fee schedule. 
Sec. 3103. Extension of exceptions process for Medicare therapy caps. 
Sec. 3104. Extension of payment for technical component of certain physician pa-
thology services. 
Sec. 3105. Extension of ambulance add-ons. 
Sec. 3106. Extension of certain payment rules for long-term care hospital services 
and of moratorium on the establishment of certain hospitals 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 beneficiaries. 
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 Program. 
Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program. 
Sec. 3125. Temporary improvements to the Medicare inpatient hospital payment 
adjustment for low-volume hospitals. 
Sec. 3126. Improvements to the demonstration project on community health inte-
gration models in certain rural counties. 
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Sec. 3127. MedPAC study on adequacy of Medicare payments for health care pro-
viders 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) pay-
ments. 
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. 
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 calculation 
of the Medicare hospital wage index floor. 
Sec. 3142. HHS study on urban Medicare-dependent hospitals. 
Sec. 3143. Protecting home health benefits. 
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 tran-
sition. 
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 bench-
mark 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-in-
come 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. 
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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. 
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-centered 
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 patient 
safety training into clinical education of health professionals. 
Sec. 3509. Improving women’s health. 
Sec. 3510. Patient navigator program. 
Sec. 3511. Authorization of appropriations. 
Subtitle G—Protecting and Improving Guaranteed Medicare Benefits 
Sec. 3601. Protecting and improving guaranteed Medicare benefits. 
Sec. 3602. No cuts in guaranteed benefits. 
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. 
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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 Medicaid. 
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. 
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. 
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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. 
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 nonprovider settings. 
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 pro-
fessions shortage areas. 
Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services for Chil-
dren Program. 
Sec. 5604. Co-locating primary and specialty care in community-based mental 
health settings. 
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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 physi-
cian referrals for hospitals. 
Sec. 6002. Transparency reports and reporting of physician ownership or invest-
ment interests. 
Sec. 6003. Disclosure requirements for in-office ancillary services exception to the 
prohibition on physician self-referral for certain imaging serv-
ices. 
Sec. 6004. Prescription drug sample transparency. 
Sec. 6005. Pharmacy benefit managers transparency requirements. 
Subtitle B—Nursing Home Transparency and Improvement 
PART I—IMPROVING TRANSPARENCY OF INFORMATION 
Sec. 6101. Required disclosure of ownership and additional disclosable parties in-
formation. 
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 informa-
tion 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 Providers 
Sec. 6201. Nationwide program for National and State background checks on di-
rect patient access employees of long-term care facilities and pro-
viders. 
Subtitle D—Patient-Centered Outcomes Research 
Sec. 6301. Patient-Centered Outcomes Research. 
Sec. 6302. Federal coordinating council for comparative effectiveness research. 
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Subtitle E—Medicare, Medicaid, and CHIP Program Integrity Provisions 
Sec. 6401. Provider screening and other enrollment requirements under Medicare, 
Medicaid, and CHIP. 
Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions. 
Sec. 6403. Elimination of duplication between the Healthcare Integrity and Pro-
tection 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 enrolled 
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, prosthetics, 
orthotics, and supplies competitive acquisition program. 
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. 6606. MEWA plan registration with Department of Labor. 
Sec. 6607. Permitting evidentiary privilege and confidential communications. 
Subtitle H—Elder Justice Act 
Sec. 6701. Short title of subtitle. 
Sec. 6702. Definitions. 
Sec. 6703. Elder Justice. 
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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. 
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 import-
ers. 
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 insurance 
providers. 
Sec. 9015. Additional hospital insurance tax on high-income taxpayers. 
Sec. 9016. Modification of section 833 treatment of certain health organizations. 
Sec. 9017. Excise tax on elective cosmetic medical procedures. 
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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. 
TITLE X—STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE 
FOR ALL AMERICANS 
Subtitle A—Provisions Relating to Title I 
Sec. 10101. Amendments to subtitle A. 
Sec. 10102. Amendments to subtitle B. 
Sec. 10103. Amendments to subtitle C. 
Sec. 10104. Amendments to subtitle D. 
Sec. 10105. Amendments to subtitle E. 
Sec. 10106. Amendments to subtitle F. 
Sec. 10107. Amendments to subtitle G. 
Sec. 10108. Free choice vouchers. 
Sec. 10109. Development of standards for financial and administrative trans-
actions. 
Subtitle B—Provisions Relating to Title II 
PART I—MEDICAID AND CHIP 
Sec. 10201. Amendments to the Social Security Act and title II of this Act. 
Sec. 10202. Incentives for States to offer home and community-based services as 
a long-term care alternative to nursing homes. 
Sec. 10203. Extension of funding for CHIP through fiscal year 2015 and other 
CHIP-related provisions. 
PART II—SUPPORT FOR PREGNANT AND PARENTING TEENS AND WOMEN 
Sec. 10211. Definitions. 
Sec. 10212. Establishment of pregnancy assistance fund. 
Sec. 10213. Permissible uses of Fund. 
Sec. 10214. Appropriations. 
PART III—INDIAN HEALTH CARE IMPROVEMENT 
Sec. 10221. Indian health care improvement. 
Subtitle C—Provisions Relating to Title III 
Sec. 10301. Plans for a Value-Based purchasing program for ambulatory surgical 
centers. 
Sec. 10302. Revision to national strategy for quality improvement in health care. 
Sec. 10303. Development of outcome measures. 
Sec. 10304. Selection of efficiency measures. 
Sec. 10305. Data collection; public reporting. 
Sec. 10306. Improvements under the Center for Medicare and Medicaid Innova-
tion. 
Sec. 10307. Improvements to the Medicare shared savings program. 
Sec. 10308. Revisions to national pilot program on payment bundling. 
Sec. 10309. Revisions to hospital readmissions reduction program. 
Sec. 10310. Repeal of physician payment update. 
Sec. 10311. Revisions to extension of ambulance add-ons. 
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Sec. 10312. Certain payment rules for long-term care hospital services and mora-
torium on the establishment of certain hospitals and facilities. 
Sec. 10313. Revisions to the extension for the rural community hospital dem-
onstration program. 
Sec. 10314. Adjustment to low-volume hospital provision. 
Sec. 10315. Revisions to home health care provisions. 
Sec. 10316. Medicare DSH. 
Sec. 10317. Revisions to extension of section 508 hospital provisions. 
Sec. 10318. Revisions to transitional extra benefits under Medicare Advantage. 
Sec. 10319. Revisions to market basket adjustments. 
Sec. 10320. Expansion of the scope of, and additional improvements to, the Inde-
pendent Medicare Advisory Board. 
Sec. 10321. Revision to community health teams. 
Sec. 10322. Quality reporting for psychiatric hospitals. 
Sec. 10323. Medicare coverage for individuals exposed to environmental health 
hazards. 
Sec. 10324. Protections for frontier States. 
Sec. 10325. Revision to skilled nursing facility prospective payment system. 
Sec. 10326. Pilot testing pay-for-performance programs for certain Medicare pro-
viders. 
Sec. 10327. Improvements to the physician quality reporting system. 
Sec. 10328. Improvement in part D medication therapy management (MTM) 
programs. 
Sec. 10329. Developing methodology to assess health plan value. 
Sec. 10330. Modernizing computer and data systems of the Centers for Medicare 
& Medicaid services to support improvements in care delivery. 
Sec. 10331. Public reporting of performance information. 
Sec. 10332. Availability of medicare data for performance measurement. 
Sec. 10333. Community-based collaborative care networks. 
Sec. 10334. Minority health. 
Sec. 10335. Technical correction to the hospital value-based purchasing program. 
Sec. 10336. GAO study and report on Medicare beneficiary access to high-quality 
dialysis services. 
Subtitle D—Provisions Relating to Title IV 
Sec. 10401. Amendments to subtitle A. 
Sec. 10402. Amendments to subtitle B. 
Sec. 10403. Amendments to subtitle C. 
Sec. 10404. Amendments to subtitle D. 
Sec. 10405. Amendments to subtitle E. 
Sec. 10406. Amendment relating to waiving coinsurance for preventive services. 
Sec. 10407. Better diabetes care. 
Sec. 10408. Grants for small businesses to provide comprehensive workplace 
wellness programs. 
Sec. 10409. Cures Acceleration Network. 
Sec. 10410. Centers of Excellence for Depression. 
Sec. 10411. Programs relating to congenital heart disease. 
Sec. 10412. Automated Defibrillation in Adam’s Memory Act. 
Sec. 10413. Young women’s breast health awareness and support of young women 
diagnosed with breast cancer. 
Subtitle E—Provisions Relating to Title V 
Sec. 10501. Amendments to the Public Health Service Act, the Social Security 
Act, and title V of this Act. 
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Sec. 10502. Infrastructure to Expand Access to Care. 
Sec. 10503. Community Health Centers and the National Health Service Corps 
Fund. 
Sec. 10504. Demonstration project to provide access to affordable care. 
Subtitle F—Provisions Relating to Title VI 
Sec. 10601. Revisions to limitation on medicare exception to the prohibition on 
certain physician referrals for hospitals. 
Sec. 10602. Clarifications to patient-centered outcomes research. 
Sec. 10603. Striking provisions relating to individual provider application fees. 
Sec. 10604. Technical correction to section 6405. 
Sec. 10605. Certain other providers permitted to conduct face to face encounter 
for home health services. 
Sec. 10606. Health care fraud enforcement. 
Sec. 10607. State demonstration programs to evaluate alternatives to current 
medical tort litigation. 
Sec. 10608. Extension of medical malpractice coverage to free clinics. 
Sec. 10609. Labeling changes. 
Subtitle G—Provisions Relating to Title VIII 
Sec. 10801. Provisions relating to title VIII. 
Subtitle H—Provisions Relating to Title IX 
Sec. 10901. Modifications to excise tax on high cost employer-sponsored health 
coverage. 
Sec. 10902. Inflation adjustment of limitation on health flexible spending ar-
rangements under cafeteria plans. 
Sec. 10903. Modification of limitation on charges by charitable hospitals. 
Sec. 10904. Modification of annual fee on medical device manufacturers and im-
porters. 
Sec. 10905. Modification of annual fee on health insurance providers. 
Sec. 10906. Modifications to additional hospital insurance tax on high-income 
taxpayers. 
Sec. 10907. Excise tax on indoor tanning services in lieu of elective cosmetic med-
ical procedures. 
Sec. 10908. Exclusion for assistance provided to participants in State student 
loan repayment programs for certain health professionals. 
Sec. 10909. Expansion of adoption credit and adoption assistance programs. 
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TITLE I—QUALITY, AFFORDABLE 
HEALTH CARE FOR ALL AMER-
ICANS 
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 following: 
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stitutes fraud or makes an intentional misrepresentation of 
material fact as prohibited by the terms of the plan or cov-
erage. 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, at a minimum provide coverage for and 
shall not impose 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 Con-
trol and Prevention with respect to the individual in-
volved; 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 Services 
Administration. 
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the service described in such recommendation or 
guideline. 
‘‘(2) MINIMUM.—The interval described in para-
graph (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 children 
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 sen-
tence to make coverage available for a child of a child re-
ceiving dependent coverage. 
‘‘(b) REGULATIONS.—The Secretary shall promulgate 
regulations to define the dependents to which coverage 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-
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ent’ as used in the Internal Revenue Code of 1986 with re-
spect 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 Affordable 
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 coverage, in com-
piling and providing to enrollees a summary of benefits and 
coverage explanation that accurately describes the benefits 
and coverage under the applicable plan or coverage. In de-
veloping such standards, the Secretary shall consult with 
the National Association of Insurance Commissioners (re-
ferred to in this section as the ‘NAIC’), a working group 
composed of representatives of health insurance-related con-
sumer advocacy organizations, health insurance issuers, 
health care professionals, patient advocates 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: 
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‘‘(1) APPEARANCE.—The standards shall ensure 
that the summary of benefits and coverage is pre-
sented 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 includes— 
‘‘(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 coverage); 
‘‘(B) a description of the coverage, includ-
ing cost sharing for— 
‘‘(i) each of the categories of the essen-
tial health benefits described in subpara-
graphs (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; 
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‘‘(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 ex-
amples to illustrate common benefits scenarios, 
including pregnancy and serious or chronic med-
ical conditions and related cost sharing, such 
scenarios to be based on recognized clinical prac-
tice guidelines; 
‘‘(G) a statement of whether the plan or cov-
erage— 
‘‘(i) provides minimum essential cov-
erage (as defined under section 5000A(f) of 
the Internal Revenue Code 1986); and 
‘‘(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 sum-
mary of the policy or certificate and that the 
coverage document itself should be consulted to 
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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 cov-
erage 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 expla-
nation pursuant
to the standards developed by the 
Secretary under subsection (a) to— 
‘‘(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. 
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‘‘(2) COMPLIANCE.—An entity described in para-
graph (3) is deemed to be in compliance with this sec-
tion 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 ma-
terial modification in any of the terms of the plan or 
coverage involved (as defined for purposes of section 
102 of the Employee Retirement Income Security Act 
of 1974) that is not reflected in the most recently pro-
vided summary of benefits and coverage, the plan or 
issuer shall provide notice of such modification to en-
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rollees not later than 60 days prior to the date on 
which such modification will become effective. 
‘‘(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 informa-
tion 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 separate of-
fense for purposes of this subsection. 
‘‘(g) DEVELOPMENT OF STANDARD DEFINITIONS.— 
‘‘(1) IN GENERAL.—The Secretary shall, by regu-
lation, provide for the development of standards for 
the definitions of terms used in health insurance cov-
erage, including the insurance-related terms described 
in paragraph (2) and the medical terms described 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 pro-
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vider, out-of-network co-payments, UCR (usual, cus-
tomary and reasonable) fees, excluded services, griev-
ance and appeals, and such other terms as the Sec-
retary determines are important to define so that con-
sumers 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, hospital 
outpatient care, emergency room care, physician serv-
ices, prescription drug coverage, durable medical 
equipment, home health care, skilled nursing care, re-
habilitation services, hospice services, emergency med-
ical transportation, and such other terms as the Sec-
retary determines are important to define so that con-
sumers may compare the medical benefits offered by 
health insurance and understand the extent of those 
medical benefits (or exceptions to those benefits). 
‘‘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 
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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 percent-
age contribution than the payment required of similarly sit-
uated employees with a higher hourly or annual compensa-
tion. 
‘‘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 consultation 
with experts in health care quality and stakeholders, 
shall develop reporting requirements for use by a 
group health plan, and a health insurance issuer of-
fering 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-
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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 coverage; 
‘‘(B) implement activities to prevent hos-
pital readmissions through a comprehensive pro-
gram 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, evi-
dence based medicine, and health information 
technology under the plan or coverage; and 
‘‘(D) implement wellness and health pro-
motion activities. 
‘‘(2) REPORTING REQUIREMENTS.— 
‘‘(A) IN GENERAL.—A group health plan 
and a health insurance issuer offering group or 
individual health insurance coverage shall annu-
ally submit to the Secretary, and to enrollees 
under the plan or coverage, a report on whether 
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the benefits under the plan or coverage satisfy 
the elements described in subparagraphs (A) 
through (D) of paragraph (1). 
‘‘(B) TIMING OF REPORTS.—A report under 
subparagraph (A) shall be made available to an 
enrollee under the plan or coverage during each 
open enrollment period. 
‘‘(C) AVAILABILITY OF REPORTS.—The Sec-
retary shall make reports submitted under sub-
paragraph (A) available to the public through an 
Internet website. 
‘‘(D) PENALTIES.—In developing the re-
porting requirements under paragraph (1), the 
Secretary may develop and impose appropriate 
penalties for non-compliance with such require-
ments. 
‘‘(E) EXCEPTIONS.—In developing the re-
porting requirements under paragraph (1), the 
Secretary may provide for exceptions to such re-
quirements for group health plans and health in-
surance issuers that substantially meet the goals 
of this section. 
‘‘(b) WELLNESS AND PREVENTION PROGRAMS.—For 
purposes of subsection (a)(1)(D), wellness and health pro-
motion activities may include personalized wellness and 
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prevention services, which are coordinated, maintained or 
delivered by a health care provider, a wellness and preven-
tion plan manager, or a health, wellness or prevention serv-
ices organization that conducts health risk assessments or 
offers ongoing face-to-face, telephonic or web-based interven-
tion efforts for each of the program’s participants, and 
which may include the following wellness and prevention 
efforts: 
‘‘(1) Smoking cessation. 
‘‘(2) Weight management. 
‘‘(3) Stress management. 
‘‘(4) Physical fitness. 
‘‘(5) Nutrition. 
‘‘(6) Heart disease prevention. 
‘‘(7) Healthy lifestyle support. 
‘‘(8) Diabetes prevention. 
‘‘(c) REGULATIONS.—Not later than 2 years after the 
date of enactment of the Patient Protection and Affordable 
Care Act, the Secretary shall promulgate regulations that 
provide criteria for determining whether a reimbursement 
structure is described in subsection (a). 
‘‘(d) STUDY AND REPORT.—Not later than 180 days 
after the date on which regulations are promulgated under 
subsection (c), the Government Accountability Office shall 
review such regulations and conduct a study and submit 
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to the Committee on Health, Education, Labor, and Pen-
sions of the Senate and the Committee on Energy and Com-
merce of the House of Representatives a report regarding 
the impact the activities under this section have had on the 
quality and cost of health care. 
‘‘SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE 
COVERAGE. 
‘‘(a) CLEAR ACCOUNTING FOR COSTS.—A health in-
surance issuer offering group or individual health insur-
ance coverage shall, with respect to each plan year, submit 
to the Secretary a report concerning the percentage of total 
premium revenue that such coverage expends— 
‘‘(1) on reimbursement for clinical services pro-
vided to enrollees under such coverage; 
‘‘(2) for activities that improve health care qual-
ity; and 
‘‘(3) on all other non-claims costs, including an 
explanation of the nature of such costs, and excluding 
State taxes and licensing or regulatory fees. 
The Secretary shall make reports received under this section 
available to the public on the Internet website of the Depart-
ment of Health and Human Services. 
‘‘(b) ENSURING THAT CONSUMERS RECEIVE VALUE 
FOR THEIR PREMIUM PAYMENTS.— 
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‘‘(1) REQUIREMENT
TO
PROVIDE
VALUE
FOR 
PREMIUM PAYMENTS.—A health insurance issuer of-
fering group or individual health insurance coverage 
shall, with respect to each plan year, provide an an-
nual rebate to each enrollee under such coverage, on 
a pro rata basis, in an amount that is equal to the 
amount by which premium revenue expended by the 
issuer on activities described in subsection (a)(3) ex-
ceeds— 
‘‘(A) with respect to a health insurance 
issuer offering coverage in the group market, 20 
percent, or such lower percentage as a State may 
by regulation determine; or 
‘‘(B) with respect to a health insurance 
issuer offering coverage in the individual market, 
25 percent, or such lower percentage as a State 
may by regulation determine, except that such 
percentage shall be adjusted to the extent the Sec-
retary determines that the application of such 
percentage with a State may destabilize the ex-
isting individual market in such State. 
‘‘(2) CONSIDERATION
IN
SETTING
PERCENT-
AGES.—In determining the percentages under para-
graph (1), a State shall seek to ensure adequate par-
ticipation by health insurance issuers, competition in 
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the health insurance market in the State, and value 
for consumers so that premiums are used for clinical 
services and quality improvements. 
‘‘(3) TERMINATION.—The provisions of this sub-
section shall have no force or effect after December 31, 
2013. 
‘‘(c) STANDARD HOSPITAL CHARGES.—Each hospital 
operating within the United States shall for each year es-
tablish (and update) and make public (in accordance with 
guidelines developed by the Secretary) a list of the hospital’s 
standard charges for items and services provided by the hos-
pital, including for diagnosis-related groups established 
under section 1886(d)(4) of the Social Security Act. 
‘‘(d) DEFINITIONS.—The Secretary, in consultation 
with the National Association of Insurance Commissions, 
shall establish uniform definitions for the activities reported 
under subsection (a). 
‘‘SEC. 2719. APPEALS PROCESS. 
‘‘A group health plan and a health insurance issuer 
offering group or individual health insurance coverage shall 
implement an effective appeals process for appeals of cov-
erage determinations and claims, under which the plan or 
issuer shall, at a minimum— 
‘‘(1) have in effect an internal claims appeal 
process; 
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‘‘(2) provide notice to enrollees, in a culturally 
and linguistically appropriate manner, of available 
internal and external appeals processes, and the 
availability of any applicable office of health insur-
ance consumer assistance or ombudsman established 
under section 2793 to assist such enrollees with the 
appeals processes; 
‘‘(3) allow an enrollee to review their file, to 
present evidence and testimony as part of the appeals 
process, and to receive continued coverage pending the 
outcome of the appeals process; and 
‘‘(4) provide an external review process for such 
plans and issuers that, at a minimum, includes the 
consumer protections set forth in the Uniform Exter-
nal Review Model Act promulgated by the National 
Association of Insurance Commissioners and is bind-
ing on such plans.’’. 
SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION. 
Part C of title XXVII of the Public Health Service Act 
(42 U.S.C. 300gg–91 et seq.) is amended by adding at the 
end the following: 
‘‘SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION. 
‘‘(a) IN GENERAL.—The Secretary shall award grants 
to States to enable such States (or the Exchanges operating 
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in such States) to establish, expand, or provide support 
for— 
‘‘(1) offices of health insurance consumer assist-
ance; or 
‘‘(2) health insurance ombudsman programs. 
‘‘(b) ELIGIBILITY.— 
‘‘(1) IN GENERAL.—To be eligible to receive a 
grant, a State shall designate an independent office of 
health insurance consumer assistance, or an ombuds-
man, that, directly or in coordination with State 
health insurance regulators and consumer assistance 
organizations, receives and responds to inquiries and 
complaints concerning health insurance coverage with 
respect to Federal health insurance requirements and 
under State law. 
‘‘(2) CRITERIA.—A State that receives a grant 
under this section shall comply with criteria estab-
lished by the Secretary for carrying out activities 
under such grant. 
‘‘(c) DUTIES.—The office of health insurance consumer 
assistance or health insurance ombudsman shall— 
‘‘(1) assist with the filing of complaints and ap-
peals, including filing appeals with the internal ap-
peal or grievance process of the group health plan or 
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health insurance issuer involved and providing infor-
mation about the external appeal process; 
‘‘(2) collect, track, and quantify problems and 
inquiries encountered by consumers; 
‘‘(3) educate consumers on their rights and re-
sponsibilities with respect to group health plans and 
health insurance coverage; 
‘‘(4) assist consumers with enrollment in a group 
health plan or health insurance coverage by providing 
information, referral, and assistance; and 
‘‘(5) resolve problems with obtaining premium 
tax credits under section 36B of the Internal Revenue 
Code of 1986. 
‘‘(d) DATA COLLECTION.—As a condition of receiving 
a grant under subsection (a), an office of health insurance 
consumer assistance or ombudsman program shall be re-
quired to collect and report data to the Secretary on the 
types of problems and inquiries encountered by consumers. 
The Secretary shall utilize such data to identify areas where 
more enforcement action is necessary and shall share such 
information with State insurance regulators, the Secretary 
of Labor, and the Secretary of the Treasury for use in the 
enforcement activities of such agencies. 
‘‘(e) FUNDING.— 
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‘‘(1) INITIAL FUNDING.—There is hereby appro-
priated to the Secretary, out of any funds in the 
Treasury not otherwise appropriated, $30,000,000 for 
the first fiscal year for which this section applies to 
carry out this section. Such amount shall remain 
available without fiscal year limitation. 
‘‘(2) 
AUTHORIZATION
FOR
SUBSEQUENT 
YEARS.—There is authorized to be appropriated to the 
Secretary for each fiscal year following the fiscal year 
described in paragraph (1), such sums as may be nec-
essary to carry out this section.’’. 
SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR 
THEIR DOLLARS. 
Part C of title XXVII of the Public Health Service Act 
(42 U.S.C. 300gg–91 et seq.), as amended by section 1002, 
is further amended by adding at the end the following: 
‘‘SEC. 2794. ENSURING THAT CONSUMERS GET VALUE FOR 
THEIR DOLLARS. 
‘‘(a) INITIAL PREMIUM REVIEW PROCESS.— 
‘‘(1) IN GENERAL.—The Secretary, in conjunc-
tion with States, shall establish a process for the an-
nual review, beginning with the 2010 plan year and 
subject to subsection (b)(2)(A), of unreasonable in-
creases in premiums for health insurance coverage. 
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‘‘(2) JUSTIFICATION
AND
DISCLOSURE.—The 
process established under paragraph (1) shall require 
health insurance issuers to submit to the Secretary 
and the relevant State a justification for an unrea-
sonable premium increase prior to the implementa-
tion of the increase. Such issuers shall prominently 
post such information on their Internet websites. The 
Secretary shall ensure the public disclosure of infor-
mation on such increases and justifications for all 
health insurance issuers. 
‘‘(b) CONTINUING PREMIUM REVIEW PROCESS.— 
‘‘(1) INFORMING
SECRETARY
OF
PREMIUM
IN-
CREASE PATTERNS.—As a condition of receiving a 
grant under subsection (c)(1), a State, through its 
Commissioner of Insurance, shall— 
‘‘(A) provide the Secretary with informa-
tion about trends in premium increases in health 
insurance coverage in premium rating areas in 
the State; and 
‘‘(B) make recommendations, as appro-
priate, to the State Exchange about whether par-
ticular health insurance issuers should be ex-
cluded from participation in the Exchange based 
on a pattern or practice of excessive or unjusti-
fied premium increases. 
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‘‘(2) MONITORING BY SECRETARY OF PREMIUM 
INCREASES.— 
‘‘(A) IN
GENERAL.—Beginning with plan 
years beginning in 2014, the Secretary, in con-
junction with the States and consistent with the 
provisions of subsection (a)(2), shall monitor 
premium increases of health insurance coverage 
offered through an Exchange and outside of an 
Exchange. 
‘‘(B) CONSIDERATION
IN
OPENING
EX-
CHANGE.—In 
determining 
under 
section 
1312(f)(2)(B) of the Patient Protection and Af-
fordable Care Act whether to offer qualified 
health plans in the large group market through 
an Exchange, the State shall take into account 
any excess of premium growth outside of the Ex-
change as compared to the rate of such growth 
inside the Exchange. 
‘‘(c) GRANTS IN SUPPORT OF PROCESS.— 
‘‘(1) PREMIUM
REVIEW
GRANTS
DURING
2010 
THROUGH 2014.—The Secretary shall carry out a pro-
gram to award grants to States during the 5-year pe-
riod beginning with fiscal year 2010 to assist such 
States in carrying out subsection (a), including— 
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‘‘(A) in reviewing and, if appropriate under 
State law, approving premium increases for 
health insurance coverage; and 
‘‘(B) in providing information and rec-
ommendations to the Secretary under subsection 
(b)(1). 
‘‘(2) FUNDING.— 
‘‘(A) IN GENERAL.—Out of all funds in the 
Treasury not otherwise appropriated, there are 
appropriated to the Secretary $250,000,000, to 
be available for expenditure for grants under 
paragraph (1) and subparagraph (B). 
‘‘(B) FURTHER AVAILABILITY FOR INSUR-
ANCE REFORM AND CONSUMER PROTECTION.—If 
the amounts appropriated under subparagraph 
(A) are not fully obligated under grants under 
paragraph (1) by the end of fiscal year 2014, 
any remaining funds shall remain available to 
the Secretary for grants to States for planning 
and implementing the insurance reforms and 
consumer protections under part A. 
‘‘(C) ALLOCATION.—The Secretary shall es-
tablish a formula for determining the amount of 
any grant to a State under this subsection. 
Under such formula— 
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‘‘(i) the Secretary shall consider the 
number of plans of health insurance cov-
erage offered in each State and the popu-
lation of the State; and 
‘‘(ii) no State qualifying for a grant 
under paragraph (1) shall receive less than 
$1,000,000, or more than $5,000,000 for a 
grant year.’’. 
SEC. 1004. EFFECTIVE DATES. 
(a) IN GENERAL.—Except as provided for in sub-
section (b), this subtitle (and the amendments made by this 
subtitle) shall become effective for plan years beginning on 
or after the date that is 6 months after the date of enactment 
of this Act, except that the amendments made by sections 
1002 and 1003 shall become effective for fiscal years begin-
ning with fiscal year 2010. 
(b) SPECIAL RULE.—The amendments made by sec-
tions 1002 and 1003 shall take effect on the date of enact-
ment of this Act. 
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Subtitle B—Immediate Actions to 
Preserve and Expand Coverage 
SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNIN-
SURED INDIVIDUALS WITH A PREEXISTING 
CONDITION. 
(a) IN GENERAL.—Not later than 90 days after the 
date of enactment of this Act, the Secretary shall establish 
a temporary high risk health insurance pool program to 
provide health insurance coverage for eligible individuals 
during the period beginning on the date on which such pro-
gram is established and ending on January 1, 2014. 
(b) ADMINISTRATION.— 
(1) IN GENERAL.—The Secretary may carry out 
the program under this section directly or through 
contracts to eligible entities. 
(2) ELIGIBLE ENTITIES.—To be eligible for a 
contract under paragraph (1), an entity shall— 
(A) be a State or nonprofit private entity; 
(B) submit to the Secretary an application 
at such time, in such manner, and containing 
such information as the Secretary may require; 
and 
(C) agree to utilize contract funding to es-
tablish and administer a qualified high risk pool 
for eligible individuals. 
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(3) MAINTENANCE OF EFFORT.—To be eligible to 
enter into a contract with the Secretary under this 
subsection, a State shall agree not to reduce the an-
nual amount the State expended for the operation of 
one or more State high risk pools during the year pre-
ceding the year in which such contract is entered into. 
(c) QUALIFIED HIGH RISK POOL.— 
(1) IN
GENERAL.—Amounts made available 
under this section shall be used to establish a quali-
fied high risk pool that meets the requirements of 
paragraph (2). 
(2) REQUIREMENTS.—A qualified high risk pool 
meets the requirements of this paragraph if such 
pool— 
(A) provides to all eligible individuals 
health insurance coverage that does not impose 
any preexisting condition exclusion with respect 
to such coverage; 
(B) provides health insurance coverage— 
(i) in which the issuer’s share of the 
total allowed costs of benefits provided 
under such coverage is not less than 65 per-
cent of such costs; and 
(ii) that has an out of pocket limit not 
greater than the applicable amount de-
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scribed in section 223(c)(2) of the Internal 
Revenue Code of 1986 for the year involved, 
except that the Secretary may modify such 
limit if necessary to ensure the pool meets 
the actuarial value limit under clause (i); 
(C) ensures that with respect to the pre-
mium rate charged for health insurance coverage 
offered to eligible individuals through the high 
risk pool, such rate shall— 
(i) except as provided in clause (ii), 
vary only as provided for under section 
2701 of the Public Health Service Act (as 
amended by this Act and notwithstanding 
the date on which such amendments take ef-
fect); 
(ii) vary on the basis of age by a factor 
of not greater than 4 to 1; and 
(iii) be established at a standard rate 
for a standard population; and 
(D) meets any other requirements deter-
mined appropriate by the Secretary. 
(d) ELIGIBLE INDIVIDUAL.—An individual shall be 
deemed to be an eligible individual for purposes of this sec-
tion if such individual— 
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(1) is a citizen or national of the United States 
or is lawfully present in the United States (as deter-
mined in accordance with section 1411); 
(2) has not been covered under creditable cov-
erage (as defined in section 2701(c)(1) of the Public 
Health Service Act as in effect on the date of enact-
ment of this Act) during the 6-month period prior to 
the date on which such individual is applying for 
coverage through the high risk pool; and 
(3) has a pre-existing condition, as determined 
in a manner consistent with guidance issued by the 
Secretary. 
(e) PROTECTION AGAINST DUMPING RISK BY INSUR-
ERS.— 
(1) IN GENERAL.—The Secretary shall establish 
criteria for determining whether health insurance 
issuers and employment-based health plans have dis-
couraged an individual from remaining enrolled in 
prior coverage based on that individual’s health sta-
tus. 
(2) SANCTIONS.—An issuer or employment-based 
health plan shall be responsible for reimbursing the 
program under this section for the medical expenses 
incurred by the program for an individual who, based 
on criteria established by the Secretary, the Secretary 
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finds was encouraged by the issuer to disenroll from 
health benefits coverage prior to enrolling in coverage 
through the program. The criteria shall include at 
least the following circumstances: 
(A) In the case of prior coverage obtained 
through an employer, the provision by the em-
ployer, group health plan, or the issuer of money 
or other financial consideration for disenrolling 
from the coverage. 
(B) In the case of prior coverage obtained 
directly from an issuer or under an employment- 
based health plan— 
(i) the provision by the issuer or plan 
of money or other financial consideration 
for disenrolling from the coverage; or 
(ii) in the case of an individual whose 
premium for the prior coverage exceeded the 
premium required by the program (adjusted 
based on the age factors applied to the prior 
coverage)— 
(I) the prior coverage is a policy 
that is no longer being actively mar-
keted (as defined by the Secretary) by 
the issuer; or 
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(II) the prior coverage is a policy 
for which duration of coverage form 
issue or health status are factors that 
can be considered in determining pre-
miums at renewal. 
(3) CONSTRUCTION.—Nothing in this subsection 
shall be construed as constituting exclusive remedies 
for violations of criteria established under paragraph 
(1) or as preventing States from applying or enforc-
ing such paragraph or other provisions under law 
with respect to health insurance issuers. 
(f) OVERSIGHT.—The Secretary shall establish— 
(1) an appeals process to enable individuals to 
appeal a determination under this section; and 
(2) procedures to protect against waste, fraud, 
and abuse. 
(g) FUNDING; TERMINATION OF AUTHORITY.— 
(1) IN GENERAL.—There is appropriated to the 
Secretary, out of any moneys in the Treasury not oth-
erwise appropriated, $5,000,000,000 to pay claims 
against (and the administrative costs of) the high risk 
pool under this section that are in excess of the 
amount of premiums collected from eligible individ-
uals enrolled in the high risk pool. Such funds shall 
be available without fiscal year limitation. 
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(2) INSUFFICIENT FUNDS.—If the Secretary esti-
mates for any fiscal year that the aggregate amounts 
available for the payment of the expenses of the high 
risk pool will be less than the actual amount of such 
expenses, the Secretary shall make such adjustments 
as are necessary to eliminate such deficit. 
(3) TERMINATION OF AUTHORITY.— 
(A) IN GENERAL.—Except as provided in 
subparagraph (B), coverage of eligible individ-
uals under a high risk pool in a State shall ter-
minate on January 1, 2014. 
(B) TRANSITION TO EXCHANGE.—The Sec-
retary shall develop procedures to provide for the 
transition of eligible individuals enrolled in 
health insurance coverage offered through a high 
risk pool established under this section into 
qualified health plans offered through an Ex-
change. Such procedures shall ensure that there 
is no lapse in coverage with respect to the indi-
vidual and may extend coverage after the termi-
nation of the risk pool involved, if the Secretary 
determines necessary to avoid such a lapse. 
(4) LIMITATIONS.—The Secretary has the au-
thority to stop taking applications for participation 
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in the program under this section to comply with the 
funding limitation provided for in paragraph (1). 
(5) RELATION TO STATE LAWS.—The standards 
established under this section shall supersede any 
State law or regulation (other than State licensing 
laws or State laws relating to plan solvency) with re-
spect to qualified high risk pools which are established 
in accordance with this section. 
SEC. 1102. REINSURANCE FOR EARLY RETIREES. 
(a) ADMINISTRATION.— 
(1) IN GENERAL.—Not later than 90 days after 
the date of enactment of this Act, the Secretary shall 
establish a temporary reinsurance program to provide 
reimbursement to participating employment-based 
plans for a portion of the cost of providing health in-
surance coverage to early retirees (and to the eligible 
spouses, surviving spouses, and dependents of such re-
tirees) during the period beginning on the date on 
which such program is established and ending on 
January 1, 2014. 
(2) REFERENCE.—In this section: 
(A) HEALTH BENEFITS.—The term ‘‘health 
benefits’’ means medical, surgical, hospital, pre-
scription drug, and such other benefits as shall 
be determined by the Secretary, whether self- 
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funded, or delivered through the purchase of in-
surance or otherwise. 
(B) EMPLOYMENT-BASED PLAN.—The term 
‘‘employment-based plan’’ means a group health 
benefits plan that— 
(i) is— 
(I) maintained by one or more 
current or former employers (including 
without limitation any State or local 
government or political subdivision 
thereof), employee organization, a vol-
untary employees’ beneficiary associa-
tion, or a committee or board of indi-
viduals appointed to administer such 
plan; or 
(II) a multiemployer plan (as de-
fined in section 3(37) of the Employee 
Retirement Income Security Act of 
1974); and 
(ii) provides health benefits to early re-
tirees. 
(C) EARLY RETIREES.—The term ‘‘early re-
tirees’’ means individuals who are age 55 and 
older but are not eligible for coverage under title 
XVIII of the Social Security Act, and who are 
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not active employees of an employer maintain-
ing, or currently contributing to, the employ-
ment-based plan or of any employer that has 
made substantial contributions to fund such 
plan. 
(b) PARTICIPATION.— 
(1) EMPLOYMENT-BASED PLAN ELIGIBILITY.—A 
participating employment-based plan is an employ-
ment-based plan that— 
(A) meets the requirements of paragraph (2) 
with respect to health benefits provided under the 
plan; and 
(B) submits to the Secretary an application 
for participation in the program, at such time, 
in such manner, and containing such informa-
tion as the Secretary shall require. 
(2) EMPLOYMENT-BASED
HEALTH
BENEFITS.— 
An employment-based plan meets the requirements of 
this paragraph if the plan— 
(A) implements programs and procedures to 
generate cost-savings with respect to participants 
with chronic and high-cost conditions; 
(B) provides documentation of the actual 
cost of medical claims involved; and 
(C) is certified by the Secretary. 
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(c) PAYMENTS.— 
(1) SUBMISSION OF CLAIMS.— 
(A) IN GENERAL.—A participating employ-
ment-based plan shall submit claims for reim-
bursement to the Secretary which shall contain 
documentation of the actual costs of the items 
and services for which each claim is being sub-
mitted. 
(B) BASIS FOR CLAIMS.—Claims submitted 
under subparagraph (A) shall be based on the ac-
tual amount expended by the participating em-
ployment-based plan involved within the plan 
year for the health benefits provided to an early 
retiree or the spouse, surviving spouse, or de-
pendent of such retiree. In determining the 
amount of a claim for purposes of this sub-
section, the participating employment-based plan 
shall take into account any negotiated price con-
cessions (such as discounts, direct or indirect 
subsidies, rebates, and direct or indirect remu-
nerations) obtained by such plan with respect to 
such health benefit. For purposes of determining 
the amount of any such claim, the costs paid by 
the early retiree or the retiree’s spouse, surviving 
spouse, or dependent in the form of deductibles, 
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co-payments, or co-insurance shall be included in 
the amounts paid by the participating employ-
ment-based plan. 
(2) PROGRAM PAYMENTS.—If the Secretary de-
termines that a participating employment-based plan 
has submitted a valid claim under paragraph (1), the 
Secretary shall reimburse such plan for 80 percent of 
that portion of the costs attributable to such claim 
that exceed $15,000, subject to the limits contained in 
paragraph (3). 
(3) LIMIT.—To be eligible for reimbursement 
under the program, a claim submitted by a partici-
pating employment-based plan shall not be less than 
$15,000 nor greater than $90,000. Such amounts 
shall be adjusted each fiscal year based on the per-
centage increase in the Medical Care Component of 
the Consumer Price Index for all urban consumers 
(rounded to the nearest multiple of $1,000) for the 
year involved. 
(4) USE OF PAYMENTS.—Amounts paid to a par-
ticipating employment-based plan under this sub-
section shall be used to lower costs for the plan. Such 
payments may be used to reduce premium costs for 
an entity described in subsection (a)(2)(B)(i) or to re-
duce 
premium 
contributions, 
co-payments, 
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deductibles, co-insurance, or other out-of-pocket costs 
for plan participants. Such payments shall not be 
used as general revenues for an entity described in 
subsection (a)(2)(B)(i). The Secretary shall develop a 
mechanism to monitor the appropriate use of such 
payments by such entities. 
(5) PAYMENTS NOT TREATED AS INCOME.—Pay-
ments received under this subsection shall not be in-
cluded in determining the gross income of an entity 
described in subsection (a)(2)(B)(i) that is maintain-
ing or currently contributing to a participating em-
ployment-based plan. 
(6) APPEALS.—The Secretary shall establish— 
(A) an appeals process to permit partici-
pating employment-based plans to appeal a de-
termination of the Secretary with respect to 
claims submitted under this section; and 
(B) procedures to protect against fraud, 
waste, and abuse under the program. 
(d) AUDITS.—The Secretary shall conduct annual au-
dits of claims data submitted by participating employment- 
based plans under this section to ensure that such plans 
are in compliance with the requirements of this section. 
(e) FUNDING.—There is appropriated to the Secretary, 
out of any moneys in the Treasury not otherwise appro-
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priated, $5,000,000,000 to carry out the program under this 
section. Such funds shall be available without fiscal year 
limitation. 
(f) LIMITATION.—The Secretary has the authority to 
stop taking applications for participation in the program 
based on the availability of funding under subsection (e). 
SEC. 1103. IMMEDIATE INFORMATION THAT ALLOWS CON-
SUMERS TO IDENTIFY AFFORDABLE COV-
ERAGE OPTIONS. 
(a) INTERNET PORTAL TO AFFORDABLE COVERAGE 
OPTIONS.— 
(1) IMMEDIATE
ESTABLISHMENT.—Not later 
than July 1, 2010, the Secretary, in consultation with 
the States, shall establish a mechanism, including an 
Internet website, through which a resident of any 
State may identify affordable health insurance cov-
erage options in that State. 
(2) CONNECTING TO AFFORDABLE COVERAGE.— 
An Internet website established under paragraph (1) 
shall, to the extent practicable, provide ways for resi-
dents of any State to receive information on at least 
the following coverage options: 
(A) Health insurance coverage offered by 
health insurance issuers, other than coverage that 
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provides reimbursement only for the treatment or 
mitigation of— 
(i) a single disease or condition; or 
(ii) an unreasonably limited set of dis-
eases or conditions (as determined by the 
Secretary); 
(B) Medicaid coverage under title XIX of 
the Social Security Act. 
(C) Coverage under title XXI of the Social 
Security Act. 
(D) A State health benefits high risk pool, 
to the extent that such high risk pool is offered 
in such State; and 
(E) Coverage under a high risk pool under 
section 1101. 
(b) ENHANCING
COMPARATIVE
PURCHASING
OP-
TIONS.— 
(1) IN GENERAL.—Not later than 60 days after 
the date of enactment of this Act, the Secretary shall 
develop a standardized format to be used for the pres-
entation of information relating to the coverage op-
tions described in subsection (a)(2). Such format 
shall, at a minimum, require the inclusion of infor-
mation on the percentage of total premium revenue 
expended on nonclinical costs (as reported under sec-
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‘‘health insurance issuer offering group or 
individual health insurance coverage’’; and 
(II) in paragraph (2)(A)— 
(aa) by inserting ‘‘or individual’’ 
after ‘‘employer’’; and 
(bb) by inserting ‘‘or individual 
health coverage, as the case may be’’ 
before the semicolon; and 
(iii) in subsection (e)— 
(I) by striking ‘‘(a)(1)(F)’’ and insert-
ing ‘‘(a)(6)’’; 
(II) by striking ‘‘2701’’ and inserting 
‘‘2704’’; and 
(III) by striking ‘‘2721(a)’’ and insert-
ing ‘‘2735(a)’’; and 
(B) by transferring such section (as amend-
ed by subparagraph (A)) to appear after section 
2705(a) as added by paragraph (4); and 
(4) by inserting after the subpart heading (as 
added by paragraph (1)) the following: 
‘‘SEC. 2701. FAIR HEALTH INSURANCE PREMIUMS. 
‘‘(a) 
PROHIBITING
DISCRIMINATORY
PREMIUM 
RATES.— 
‘‘(1) IN GENERAL.—With respect to the premium 
rate charged by a health insurance issuer for health 
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insurance coverage offered in the individual or small 
group market— 
‘‘(A) such rate shall vary with respect to the 
particular plan or coverage involved only by— 
‘‘(i) whether such plan or coverage cov-
ers an individual or family; 
‘‘(ii) rating area, as established in ac-
cordance with paragraph (2); 
‘‘(iii) age, except that such rate shall 
not vary by more than 3 to 1 for adults 
(consistent with section 2707(c)); and 
‘‘(iv) tobacco use, except that such rate 
shall not vary by more than 1.5 to 1; and 
‘‘(B) such rate shall not vary with respect 
to the particular plan or coverage involved by 
any other factor not described in subparagraph 
(A). 
‘‘(2) RATING AREA.— 
‘‘(A) IN GENERAL.—Each State shall estab-
lish 1 or more rating areas within that State for 
purposes of applying the requirements of this 
title. 
‘‘(B) 
SECRETARIAL
REVIEW.—The 
Sec-
retary shall review the rating areas established 
by each State under subparagraph (A) to ensure 
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reference product sponsor, but in no case 
later than 5 days after the subsection (k) 
applicant notifies the reference product 
sponsor under subparagraph (A), the sub-
section (k) applicant and the reference prod-
uct sponsor shall simultaneously exchange— 
‘‘(I) the list of patents that the 
subsection (k) applicant believes should 
be the subject of an action for patent 
infringement under paragraph (6); 
and 
‘‘(II) the list of patents, in accord-
ance with clause (ii), that the reference 
product sponsor believes should be the 
subject of an action for patent in-
fringement under paragraph (6). 
‘‘(ii) NUMBER OF PATENTS LISTED BY 
REFERENCE PRODUCT SPONSOR.— 
‘‘(I) IN
GENERAL.—Subject to 
subclause (II), the number of patents 
listed by the reference product sponsor 
under clause (i)(II) may not exceed the 
number of patents listed by the sub-
section (k) applicant under clause 
(i)(I). 
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