H. R. 3590—841 
Comprehensive Environmental Response, Compensation, and 
Liability Act of 1980 (42 U.S.C. 9605(a)(8)(B)). 
‘‘(d) HEALTH COVERAGE UNAFFECTED.—Nothing in this section 
shall be construed to affect any coverage obligation of a govern-
mental or private health plan or program relating to an at-risk 
individual. 
‘‘(e) FUNDING.— 
‘‘(1) IN GENERAL.—Out of any funds in the Treasury not 
otherwise appropriated, there are appropriated to the Secretary, 
to carry out the program under this section— 
‘‘(A) $23,000,000 for the period of fiscal years 2010 
through 2014; and 
‘‘(B) $20,000,000 for each 5-fiscal year period there-
after. 
‘‘(2) AVAILABILITY.—Funds appropriated under paragraph 
(1) shall remain available until expended. 
‘‘(f) NONAPPLICATION.— 
‘‘(1) IN GENERAL.—Except as provided in paragraph (2), 
the preceding sections of this title shall not apply to grants 
awarded under this section. 
‘‘(2) LIMITATIONS ON USE OF GRANTS.—Section 2005(a) shall 
apply to a grant awarded under this section to the same extent 
and in the same manner as such section applies to payments 
to States under this title, except that paragraph (4) of such 
section shall not be construed to prohibit grantees from con-
ducting screening for environmental health conditions as 
authorized under this section.’’. 
SEC. 10324. PROTECTIONS FOR FRONTIER STATES. 
(a) FLOOR ON AREA WAGE INDEX FOR HOSPITALS IN FRONTIER 
STATES.— 
(1) IN GENERAL.—Section 1886(d)(3)(E) of the Social Secu-
rity Act (42 U.S.C. 1395ww(d)(3)(E)) is amended— 
(A) in clause (i), by striking ‘‘clause (ii)’’ and inserting 
‘‘clause (ii) or (iii)’’; and 
(B) by adding at the end the following new clause: 
‘‘(iii) FLOOR ON AREA WAGE INDEX FOR HOSPITALS 
IN FRONTIER STATES.— 
‘‘(I) IN GENERAL.—Subject to subclause (IV), 
for discharges occurring on or after October 1, 
2010, the area wage index applicable under this 
subparagraph to any hospital which is located in 
a frontier State (as defined in subclause (II)) may 
not be less than 1.00. 
‘‘(II) FRONTIER STATE DEFINED.—In this clause, 
the term ‘frontier State’ means a State in which 
at least 50 percent of the counties in the State 
are frontier counties. 
‘‘(III) FRONTIER
COUNTY
DEFINED.—In this 
clause, the term ‘frontier county’ means a county 
in which the population per square mile is less 
than 6. 
‘‘(IV) LIMITATION.—This clause shall not apply 
to any hospital located in a State that receives 
a non-labor related share adjustment under para-
graph (5)(H).’’.
H. R. 3590—842 
(2) WAIVING BUDGET NEUTRALITY.—Section 1886(d)(3)(E) of 
the Social Security Act (42 U.S.C. 1395ww(d)(3)(E)), as amended 
by subsection (a), is amended in the third sentence by inserting 
‘‘and the amendments made by section 10324(a)(1) of the 
Patient Protection and Affordable Care Act’’ after ‘‘2003’’. 
(b) FLOOR ON AREA WAGE ADJUSTMENT FACTOR FOR HOSPITAL 
OUTPATIENT DEPARTMENT SERVICES IN FRONTIER STATES.—Section 
1833(t) of the Social Security Act (42 U.S.C. 1395l(t)), as amended 
by section 3138, is amended— 
(1) in paragraph (2)(D), by striking ‘‘the Secretary’’ and 
inserting ‘‘subject to paragraph (19), the Secretary’’; and 
(2) by adding at the end the following new paragraph: 
‘‘(19) FLOOR ON AREA WAGE ADJUSTMENT FACTOR FOR HOS-
PITAL OUTPATIENT DEPARTMENT SERVICES IN FRONTIER STATES.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), with 
respect to covered OPD services furnished on or after 
January 1, 2011, the area wage adjustment factor 
applicable under the payment system established under 
this subsection to any hospital outpatient department 
which is located in a frontier State (as defined in section 
1886(d)(3)(E)(iii)(II)) may not be less than 1.00. The pre-
ceding sentence shall not be applied in a budget neutral 
manner. 
‘‘(B) LIMITATION.—This paragraph shall not apply to 
any hospital outpatient department located in a State that 
receives a non-labor related share adjustment under section 
1886(d)(5)(H).’’. 
(c) FLOOR FOR PRACTICE EXPENSE INDEX FOR PHYSICIANS’ SERV-
ICES FURNISHED IN FRONTIER STATES.—Section 1848(e)(1) of the 
Social Security Act (42 U.S.C. 1395w–4(e)(1)), as amended by section 
3102, is amended— 
(1) in subparagraph (A), by striking ‘‘and (H)’’ and inserting 
‘‘(H), and (I)’’; and 
(2) by adding at the end the following new subparagraph: 
‘‘(I) FLOOR FOR PRACTICE EXPENSE INDEX FOR SERVICES 
FURNISHED IN FRONTIER STATES.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), for pur-
poses of payment for services furnished in a frontier 
State (as defined in section 1886(d)(3)(E)(iii)(II)) on 
or after January 1, 2011, after calculating the practice 
expense index in subparagraph (A)(i), the Secretary 
shall increase any such index to 1.00 if such index 
would otherwise be less that 1.00. The preceding sen-
tence shall not be applied in a budget neutral manner. 
‘‘(ii) LIMITATION.—This subparagraph shall not 
apply to services furnished in a State that receives 
a non-labor related share adjustment under section 
1886(d)(5)(H).’’. 
SEC. 10325. REVISION TO SKILLED NURSING FACILITY PROSPECTIVE 
PAYMENT SYSTEM. 
(a) TEMPORARY DELAY OF RUG–IV.—Notwithstanding any other 
provision of law, the Secretary of Health and Human Services 
shall not, prior to October 1, 2011, implement Version 4 of the 
Resource Utilization Groups (in this subsection refereed to as 
‘‘RUG–IV’’) published in the Federal Register on August 11, 2009, 
entitled ‘‘Prospective Payment System and Consolidated Billing for
H. R. 3590—843 
Skilled Nursing Facilities for FY 2010; Minimum Data Set, Version 
3.0 for Skilled Nursing Facilities and Medicaid Nursing Facilities’’ 
(74 Fed. Reg. 40288). Beginning on October 1, 2010, the Secretary 
of Health and Human Services shall implement the change specific 
to therapy furnished on a concurrent basis that is a component 
of RUG–IV and changes to the lookback period to ensure that 
only those services furnished after admission to a skilled nursing 
facility are used as factors in determining a case mix classification 
under the skilled nursing facility prospective payment system under 
section 1888(e) of the Social Security Act (42 U.S.C. 1395yy(e)). 
(b) CONSTRUCTION.—Nothing in this section shall be interpreted 
as delaying the implementation of Version 3.0 of the Minimum 
Data Sets (MDS 3.0) beyond the planned implementation date 
of October 1, 2010. 
SEC. 10326. PILOT TESTING PAY-FOR-PERFORMANCE PROGRAMS FOR 
CERTAIN MEDICARE PROVIDERS. 
(a) IN GENERAL.—Not later than January 1, 2016, the Secretary 
of Health and Human Services (in this section referred to as the 
‘‘Secretary’’) shall, for each provider described in subsection (b), 
conduct a separate pilot program under title XVIII of the Social 
Security Act to test the implementation of a value-based purchasing 
program for payments under such title for the provider. 
(b) PROVIDERS DESCRIBED.—The providers described in this 
paragraph are the following: 
(1) Psychiatric hospitals (as described in clause (i) of section 
1886(d)(1)(B) of such Act (42 U.S.C. 1395ww(d)(1)(B))) and psy-
chiatric units (as described in the matter following clause (v) 
of such section). 
(2) Long-term care hospitals (as described in clause (iv) 
of such section). 
(3) Rehabilitation hospitals (as described in clause (ii) of 
such section). 
(4) PPS-exempt cancer hospitals (as described in clause 
(v) of such section). 
(5) Hospice programs (as defined in section 1861(dd)(2) 
of such Act (42 U.S.C. 1395x(dd)(2))). 
(c) WAIVER
AUTHORITY.—The Secretary may waive such 
requirements of titles XI and XVIII of the Social Security Act 
as may be necessary solely for purposes of carrying out the pilot 
programs under this section. 
(d) NO ADDITIONAL PROGRAM EXPENDITURES.—Payments under 
this section under the separate pilot program for value based pur-
chasing (as described in subsection (a)) for each provider type 
described in paragraphs (1) through (5) of subsection (b) for 
applicable items and services under title XVIII of the Social Security 
Act for a year shall be established in a manner that does not 
result in spending more under each such value based purchasing 
program for such year than would otherwise be expended for such 
provider type for such year if the pilot program were not imple-
mented, as estimated by the Secretary. 
(e) EXPANSION
OF PILOT PROGRAM.—The Secretary may, at 
any point after January 1, 2018, expand the duration and scope 
of a pilot program conducted under this subsection, to the extent 
determined appropriate by the Secretary, if— 
(1) the Secretary determines that such expansion is 
expected to—
H. R. 3590—844 
(A) reduce spending under title XVIII of the Social 
Security Act without reducing the quality of care; or 
(B) improve the quality of care and reduce spending; 
(2) the Chief Actuary of the Centers for Medicare & Med-
icaid Services certifies that such expansion would reduce pro-
gram spending under such title XVIII; and 
(3) the Secretary determines that such expansion would 
not deny or limit the coverage or provision of benefits under 
such title XIII for Medicare beneficiaries. 
SEC. 10327. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING 
SYSTEM. 
(a) IN GENERAL.—Section 1848(m) of the Social Security Act 
(42 U.S.C. 1395w–4(m)) is amended by adding at the end the 
following new paragraph: 
‘‘(7) ADDITIONAL INCENTIVE PAYMENT.— 
‘‘(A) IN GENERAL.—For 2011 through 2014, if an eligible 
professional meets the requirements described in subpara-
graph (B), the applicable quality percent for such year, 
as described in clauses (iii) and (iv) of paragraph (1)(B), 
shall be increased by 0.5 percentage points. 
‘‘(B) REQUIREMENTS DESCRIBED.—In order to qualify 
for the additional incentive payment described in subpara-
graph (A), an eligible professional shall meet the following 
requirements: 
‘‘(i) The eligible professional shall— 
‘‘(I) satisfactorily submit data on quality meas-
ures for purposes of paragraph (1) for a year; and 
‘‘(II) have such data submitted on their behalf 
through a Maintenance of Certification Program 
(as defined in subparagraph (C)(i)) that meets— 
‘‘(aa) the criteria for a registry (as 
described in subsection (k)(4)); or 
‘‘(bb) an alternative form and manner 
determined appropriate by the Secretary. 
‘‘(ii) The eligible professional, more frequently than 
is required to qualify for or maintain board certification 
status— 
‘‘(I) participates in such a Maintenance of Cer-
tification program for a year; and 
‘‘(II) successfully completes a qualified Mainte-
nance of Certification Program practice assessment 
(as defined in subparagraph (C)(ii)) for such year. 
‘‘(iii) A Maintenance of Certification program sub-
mits to the Secretary, on behalf of the eligible profes-
sional, information— 
‘‘(I) in a form and manner specified by the 
Secretary, that the eligible professional has 
successfully met the requirements of clause (ii) 
(which may be in the form of a structural 
measure); 
‘‘(II) if requested by the Secretary, on the 
survey of patient experience with care (as 
described in subparagraph (C)(ii)(II)); and 
‘‘(III) as the Secretary may require, on the 
methods, measures, and data used under the 
Maintenance of Certification Program and the