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‘‘(c) APPLICATION OF STATE AND FEDERAL LAWS RE-
GARDING ABORTION.— 
‘‘(1) NO PREEMPTION OF STATE LAWS REGARD-
ING ABORTION.—Nothing in this Act shall be con-
strued to preempt or otherwise have any effect on 
State laws regarding the prohibition of (or require-
ment of) coverage, funding, or procedural require-
ments on abortions, including parental notification or 
consent for the performance of an abortion on a 
minor. 
‘‘(2) NO EFFECT ON FEDERAL LAWS REGARDING 
ABORTION.— 
‘‘(A) IN
GENERAL.—Nothing in this Act 
shall be construed to have any effect on Federal 
laws regarding— 
‘‘(i) conscience protection; 
‘‘(ii) willingness or refusal to provide 
abortion; and 
‘‘(iii) discrimination on the basis of 
the willingness or refusal to provide, pay 
for, cover, or refer for abortion or to provide 
or participate in training to provide abor-
tion. 
‘‘(3) NO
EFFECT
ON
FEDERAL
CIVIL
RIGHTS 
LAW.—Nothing in this subsection shall alter the rights
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and obligations of employees and employers under 
title VII of the Civil Rights Act of 1964. 
‘‘(d) APPLICATION OF EMERGENCY SERVICES LAWS.— 
Nothing in this Act shall be construed to relieve any health 
care provider from providing emergency services as required 
by State or Federal law, including section 1867 of the So-
cial Security Act (popularly known as ‘EMTALA’).’’. 
(d) Section 1304 of this Act is amended by adding at 
the end the following: 
‘‘(e) EDUCATED HEALTH CARE CONSUMERS.—The 
term ‘educated health care consumer’ means an individual 
who is knowledgeable about the health care system, and has 
background or experience in making informed decisions re-
garding health, medical, and scientific matters.’’. 
(e) Section 1311(d) of this Act is amended— 
(1) in paragraph (3)(B), by striking clause (ii) 
and inserting the following: 
‘‘(ii) STATE MUST ASSUME COST.—A 
State shall make payments— 
‘‘(I) to an individual enrolled in 
a qualified health plan offered in such 
State; or 
‘‘(II) on behalf of an individual 
described in subclause (I) directly to
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the qualified health plan in which such 
individual is enrolled; 
to defray the cost of any additional benefits 
described in clause (i).’’; and 
(2) in paragraph (6)(A), by inserting ‘‘educated’’ 
before ‘‘health care’’. 
(f) Section 1311(e) of this Act is amended— 
(1) in paragraph (2), by striking ‘‘may’’ in the 
second sentence and inserting ‘‘shall’’; and 
(2) by adding at the end the following: 
‘‘(3) TRANSPARENCY IN COVERAGE.— 
‘‘(A) IN GENERAL.—The Exchange shall re-
quire health plans seeking certification as quali-
fied health plans to submit to the Exchange, the 
Secretary, the State insurance commissioner, 
and make available to the public, accurate and 
timely disclosure of the following information: 
‘‘(i) Claims payment policies and 
practices. 
‘‘(ii) Periodic financial disclosures. 
‘‘(iii) Data on enrollment. 
‘‘(iv) Data on disenrollment. 
‘‘(v) Data on the number of claims 
that are denied. 
‘‘(vi) Data on rating practices.
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‘‘(vii) Information on cost-sharing and 
payments with respect to any out-of-net-
work coverage. 
‘‘(viii) Information on enrollee and 
participant rights under this title. 
‘‘(ix) Other information as determined 
appropriate by the Secretary. 
‘‘(B) USE OF PLAIN LANGUAGE.—The infor-
mation required to be submitted under subpara-
graph (A) shall be provided in plain language. 
The term ‘plain language’ means language that 
the intended audience, including individuals 
with limited English proficiency, can readily 
understand and use because that language is 
concise, well-organized, and follows other best 
practices of plain language writing. The Sec-
retary and the Secretary of Labor shall jointly 
develop and issue guidance on best practices of 
plain language writing. 
‘‘(C) COST SHARING TRANSPARENCY.—The 
Exchange shall require health plans seeking cer-
tification as qualified health plans to permit in-
dividuals to learn the amount of cost-sharing 
(including deductibles, copayments, and coinsur-
ance) under the individual’s plan or coverage
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that the individual would be responsible for pay-
ing with respect to the furnishing of a specific 
item or service by a participating provider in a 
timely manner upon the request of the indi-
vidual. At a minimum, such information shall 
be made available to such individual through an 
Internet website and such other means for indi-
viduals without access to the Internet. 
‘‘(D) GROUP
HEALTH
PLANS.—The Sec-
retary of Labor shall update and harmonize the 
Secretary’s rules concerning the accurate and 
timely disclosure to participants by group health 
plans of plan disclosure, plan terms and condi-
tions, and periodic financial disclosure with the 
standards established by the Secretary under 
subparagraph (A).’’. 
(g) Section 1311(g)(1) of this Act is amended— 
(1) in subparagraph (C), by striking ‘‘; and’’ 
and inserting a semicolon; 
(2) in subparagraph (D), by striking the period 
and inserting ‘‘; and’’; and 
(3) by adding at the end the following: 
‘‘(E) the implementation of activities to re-
duce health and health care disparities, includ-
ing through the use of language services, commu-
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nity 
outreach, 
and 
cultural 
competency 
trainings.’’. 
(h) Section 1311(i)(2)((B) of this Act is amended by 
striking ‘‘small business development centers’’ and inserting 
‘‘resource partners of the Small Business Administration’’. 
(i) Section 1312 of this Act is amended— 
(1) in subsection (a)(1), by inserting ‘‘and for 
which such individual is eligible’’ before the period; 
(2) in subsection (e)— 
(A) in paragraph (1), by inserting ‘‘and 
employers’’ after ‘‘enroll individuals’’; and 
(B) by striking the flush sentence at the end; 
and 
(3) in subsection (f)(1)(A)(ii), by striking the 
parenthetical. 
(j)(1) Subparagraph (B) of section 1313(a)(6) of this 
Act is hereby deemed null, void, and of no effect. 
(2) Section 3730(e) of title 31, United States Code, is 
amended by striking paragraph (4) and inserting the fol-
lowing: 
‘‘(4)(A) The court shall dismiss an action or 
claim under this section, unless opposed by the Gov-
ernment, if substantially the same allegations or 
transactions as alleged in the action or claim were 
publicly disclosed—
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(3) by inserting after paragraph (3) the fol-
lowing: 
‘‘(4) a survey of the cost and affordability of 
health care insurance provided under the Exchanges 
for owners and employees of small business concerns 
(as defined under section 3 of the Small Business Act 
(15 U.S.C. 632)), including data on enrollees in Ex-
changes and individuals purchasing health insurance 
coverage outside of Exchanges; and’’. 
(l) Section 1322(b) of this Act is amended— 
(1) by redesignating paragraph (3) as para-
graph (4); and 
(2) by inserting after paragraph (2), the fol-
lowing: 
‘‘(3) REPAYMENT OF LOANS AND GRANTS.—Not 
later than July 1, 2013, and prior to awarding loans 
and grants under the CO–OP program, the Secretary 
shall promulgate regulations with respect to the re-
payment of such loans and grants in a manner that 
is consistent with State solvency regulations and 
other similar State laws that may apply. In promul-
gating such regulations, the Secretary shall provide 
that such loans shall be repaid within 5 years and 
such grants shall be repaid within 15 years, taking 
into consideration any appropriate State reserve re-
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quirements, solvency regulations, and requisite sur-
plus note arrangements that must be constructed in a 
State to provide for such repayment prior to award-
ing such loans and grants.’’. 
(m) Part III of subtitle D of title I of this Act is 
amended by striking section 1323. 
(n) Section 1324(a) of this Act is amended by striking 
‘‘, a community health’’ and all that follows through 
‘‘1333(b)’’ and inserting ‘‘, or a multi-State qualified health 
plan under section 1334’’. 
(o) Section 1331 of this Act is amended— 
(1) in subsection (d)(3)(A)(i), by striking ‘‘85’’ 
and inserting ‘‘95’’; and 
(2) in subsection (e)(1)(B), by inserting before 
the semicolon the following: ‘‘, or, in the case of an 
alien lawfully present in the United States, whose in-
come is not greater than 133 percent of the poverty 
line for the size of the family involved but who is not 
eligible for the Medicaid program under title XIX of 
the Social Security Act by reason of such alien sta-
tus’’. 
(p) Section 1333 of this Act is amended by striking 
subsection (b). 
(q) Part IV of subtitle D of title I of this Act is amend-
ed by adding at the end the following:
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‘‘SEC. 1334. MULTI-STATE PLANS. 
‘‘(a) OVERSIGHT BY THE OFFICE OF PERSONNEL MAN-
AGEMENT.— 
‘‘(1) IN GENERAL.—The Director of the Office of 
Personnel Management (referred to in this section as 
the ‘Director’) shall enter into contracts with health 
insurance issuers (which may include a group of 
health insurance issuers affiliated either by common 
ownership and control or by the common use of a na-
tionally licensed service mark), without regard to sec-
tion 5 of title 41, United States Code, or other stat-
utes requiring competitive bidding, to offer at least 2 
multi-State qualified health plans through each Ex-
change in each State. Such plans shall provide indi-
vidual, or in the case of small employers, group cov-
erage. 
‘‘(2) TERMS.—Each contract entered into under 
paragraph (1) shall be for a uniform term of at least 
1 year, but may be made automatically renewable 
from term to term in the absence of notice of termi-
nation by either party. In entering into such con-
tracts, the Director shall ensure that health benefits 
coverage is provided in accordance with the types of 
coverage provided for under section 2701(a)(1)(A)(i) 
of the Public Health Service Act.
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‘‘(3) NON-PROFIT
ENTITIES.—In entering into 
contracts under paragraph (1), the Director shall en-
sure that at least one contract is entered into with a 
non-profit entity. 
‘‘(4) ADMINISTRATION.—The Director shall im-
plement this subsection in a manner similar to the 
manner in which the Director implements the con-
tracting provisions with respect to carriers under the 
Federal employees health benefit program under chap-
ter 89 of title 5, United States Code, including 
(through negotiating with each multi-state plan)— 
‘‘(A) a medical loss ratio; 
‘‘(B) a profit margin; 
‘‘(C) the premiums to be charged; and 
‘‘(D) such other terms and conditions of 
coverage as are in the interests of enrollees in 
such plans. 
‘‘(5) AUTHORITY TO PROTECT CONSUMERS.—The 
Director may prohibit the offering of any multi-State 
health plan that does not meet the terms and condi-
tions defined by the Director with respect to the ele-
ments described in subparagraphs (A) through (D) of 
paragraph (4). 
‘‘(6) ASSURED
AVAILABILITY
OF
VARIED
COV-
ERAGE.—In entering into contracts under this sub-
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section, the Director shall ensure that with respect to 
multi-State qualified health plans offered in an Ex-
change, there is at least one such plan that does not 
provide coverage of services described in section 
1303(b)(1)(B)(i). 
‘‘(7) WITHDRAWAL.—Approval of a contract 
under this subsection may be withdrawn by the Direc-
tor only after notice and opportunity for hearing to 
the issuer concerned without regard to subchapter II 
of chapter 5 and chapter 7 of title 5, United States 
Code. 
‘‘(b) ELIGIBILITY.—A health insurance issuer shall be 
eligible to enter into a contract under subsection (a)(1) if 
such issuer— 
‘‘(1) agrees to offer a multi-State qualified health 
plan that meets the requirements of subsection (c) in 
each Exchange in each State; 
‘‘(2) is licensed in each State and is subject to 
all requirements of State law not inconsistent with 
this section, including the standards and require-
ments that a State imposes that do not prevent the 
application of a requirement of part A of title XXVII 
of the Public Health Service Act or a requirement of 
this title;
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‘‘(3) otherwise complies with the minimum 
standards prescribed for carriers offering health bene-
fits plans under section 8902(e) of title 5, United 
States Code, to the extent that such standards do not 
conflict with a provision of this title; and 
‘‘(4) meets such other requirements as determined 
appropriate by the Director, in consultation with the 
Secretary. 
‘‘(c) REQUIREMENTS FOR MULTI-STATE QUALIFIED 
HEALTH PLAN.— 
‘‘(1) IN
GENERAL.—A multi-State qualified 
health plan meets the requirements of this subsection 
if, in the determination of the Director— 
‘‘(A) the plan offers a benefits package that 
is uniform in each State and consists of the es-
sential benefits described in section 1302; 
‘‘(B) the plan meets all requirements of this 
title with respect to a qualified health plan, in-
cluding requirements relating to the offering of 
the bronze, silver, and gold levels of coverage and 
catastrophic coverage in each State Exchange; 
‘‘(C) except as provided in paragraph (5), 
the issuer provides for determinations of pre-
miums for coverage under the plan on the basis
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‘‘(1) MAINTENANCE
OF
EFFORT.—Nothing in 
this section shall be construed to permit the Director 
to allocate fewer financial or personnel resources to 
the functions of the Office of Personnel Management 
related to the administration of the Federal Employ-
ees Health Benefit Program under chapter 89 of title 
5, United States Code. 
‘‘(2) SEPARATE RISK POOL.—Enrollees in multi- 
State qualified health plans under this section shall 
be treated as a separate risk pool apart from enrollees 
in the Federal Employees Health Benefit Program 
under chapter 89 of title 5, United States Code. 
‘‘(3) AUTHORITY TO ESTABLISH SEPARATE ENTI-
TIES.—The Director may establish such separate 
units or offices within the Office of Personnel Man-
agement as the Director determines to be appropriate 
to ensure that the administration of multi-State 
qualified health plans under this section does not 
interfere with the effective administration of the Fed-
eral Employees Health Benefit Program under chap-
ter 89 of title 5, United States Code. 
‘‘(4) EFFECTIVE OVERSIGHT.—The Director may 
appoint such additional personnel as may be nec-
essary to enable the Director to carry out activities 
under this section.
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‘‘(5) ASSURANCE OF SEPARATE PROGRAM.—In 
carrying out this section, the Director shall ensure 
that the program under this section is separate from 
the Federal Employees Health Benefit Program under 
chapter 89 of title 5, United States Code. Premiums 
paid for coverage under a multi-State qualified health 
plan under this section shall not be considered to be 
Federal funds for any purposes. 
‘‘(6) FEHBP PLANS NOT REQUIRED TO PARTICI-
PATE.—Nothing in this section shall require that a 
carrier offering coverage under the Federal Employees 
Health Benefit Program under chapter 89 of title 5, 
United States Code, also offer a multi-State qualified 
health plan under this section. 
‘‘(h) ADVISORY BOARD.—The Director shall establish 
an advisory board to provide recommendations on the ac-
tivities described in this section. A significant percentage 
of the members of such board shall be comprised of enrollees 
in a multi-State qualified health plan, or representatives 
of such enrollees. 
‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There is 
authorized to be appropriated, such sums as may be nec-
essary to carry out this section.’’. 
(r) Section 1341 of this Act is amended—
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(1) in the section heading, by striking ‘‘AND 
SMALL GROUP MARKETS’’ and inserting ‘‘MAR-
KET’’; 
(2) in subsection (b)(2)(B), by striking ‘‘para-
graph (1)(A)’’ and inserting ‘‘paragraph (1)(B)’’; and 
(3) in subsection (c)(1)(A), by striking ‘‘and 
small group markets’’ and inserting ‘‘market’’. 
SEC. 10105. AMENDMENTS TO SUBTITLE E. 
(a) Section 36B(b)(3)(A)(ii) of the Internal Revenue 
Code of 1986, as added by section 1401(a) of this Act, is 
amended by striking ‘‘is in excess of’’ and inserting ‘‘equals 
or exceeds’’. 
(b) Section 36B(c)(1)(A) of the Internal Revenue Code 
of 1986, as added by section 1401(a) of this Act, is amended 
by inserting ‘‘equals or’’ before ‘‘exceeds’’. 
(c) Section 36B(c)(2)(C)(iv) of the Internal Revenue 
Code of 1986, as added by section 1401(a) of this Act, is 
amended by striking ‘‘subsection (b)(3)(A)(ii)’’ and insert-
ing ‘‘subsection (b)(3)(A)(iii)’’. 
(d) Section 1401(d) of this Act is amended by adding 
at the end the following: 
‘‘(3) Section 6211(b)(4)(A) of the Internal Rev-
enue Code of 1986 is amended by inserting ‘36B,’ 
after ‘36A,’.’’.
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(e)(1) Subparagraph (B) of section 45R(d)(3) of the 
Internal Revenue Code of 1986, as added by section 1421(a) 
of this Act, is amended to read as follows: 
‘‘(B) DOLLAR
AMOUNT.—For purposes of 
paragraph (1)(B) and subsection (c)(2)— 
‘‘(i) 2010, 2011, 2012, AND 2013.—The 
dollar amount in effect under this para-
graph for taxable years beginning in 2010, 
2011, 2012, or 2013 is $25,000. 
‘‘(ii) SUBSEQUENT
YEARS.—In the 
case of a taxable year beginning in a cal-
endar year after 2013, the dollar amount in 
effect under this paragraph shall be equal to 
$25,000, multiplied by the cost-of-living ad-
justment under section 1(f)(3) for the cal-
endar year, determined by substituting ‘cal-
endar year 2012’ for ‘calendar year 1992’ 
in subparagraph (B) thereof.’’. 
(2) Subsection (g) of section 45R of the Internal Rev-
enue Code of 1986, as added by section 1421(a) of this Act, 
is amended by striking ‘‘2011’’ both places it appears and 
inserting ‘‘2010, 2011’’. 
(3) Section 280C(h) of the Internal Revenue Code of 
1986, as added by section 1421(d)(1) of this Act, is amended 
by striking ‘‘2011’’ and inserting ‘‘2010, 2011’’.
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(4) Section 1421(f) of this Act is amended by striking 
‘‘2010’’ both places it appears and inserting ‘‘2009’’. 
(5) The amendments made by this subsection shall take 
effect as if included in the enactment of section 1421 of this 
Act. 
(f) Part I of subtitle E of title I of this Act is amended 
by adding at the end of subpart B, the following: 
‘‘SEC. 1416. STUDY OF GEOGRAPHIC VARIATION IN APPLICA-
TION OF FPL. 
‘‘(a) IN GENERAL.—The Secretary shall conduct a 
study to examine the feasibility and implication of adjust-
ing the application of the Federal poverty level under this 
subtitle (and the amendments made by this subtitle) for dif-
ferent geographic areas so as to reflect the variations in 
cost-of-living among different areas within the United 
States. If the Secretary determines that an adjustment is 
feasible, the study should include a methodology to make 
such an adjustment. Not later than January 1, 2013, the 
Secretary shall submit to Congress a report on such study 
and shall include such recommendations as the Secretary 
determines appropriate. 
‘‘(b) INCLUSION OF TERRITORIES.— 
‘‘(1) IN GENERAL.—The Secretary shall ensure 
that the study under subsection (a) covers the terri-
tories of the United States and that special attention
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is paid to the disparity that exists among poverty lev-
els and the cost of living in such territories and to the 
impact of such disparity on efforts to expand health 
coverage and ensure health care. 
‘‘(2) TERRITORIES DEFINED.—In this subsection, 
the term ‘territories of the United States’ includes the 
Commonwealth of Puerto Rico, the United States Vir-
gin Islands, Guam, the Northern Mariana Islands, 
and any other territory or possession of the United 
States.’’. 
SEC. 10106. AMENDMENTS TO SUBTITLE F. 
(a) Section 1501(a)(2) of this Act is amended to read 
as follows: 
‘‘(2) EFFECTS ON THE NATIONAL ECONOMY AND 
INTERSTATE
COMMERCE.—The effects described in 
this paragraph are the following: 
‘‘(A) The requirement regulates activity that 
is commercial and economic in nature: economic 
and financial decisions about how and when 
health care is paid for, and when health insur-
ance is purchased. In the absence of the require-
ment, some individuals would make an economic 
and financial decision to forego health insurance 
coverage and attempt to self-insure, which in-
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creases financial risks to households and medical 
providers. 
‘‘(B) Health insurance and health care serv-
ices are a significant part of the national econ-
omy. National health spending is projected to in-
crease from $2,500,000,000,000, or 17.6 percent 
of the economy, in 2009 to $4,700,000,000,000 in 
2019. Private health insurance spending is pro-
jected to be $854,000,000,000 in 2009, and pays 
for medical supplies, drugs, and equipment that 
are shipped in interstate commerce. Since most 
health insurance is sold by national or regional 
health insurance companies, health insurance is 
sold in interstate commerce and claims pay-
ments flow through interstate commerce. 
‘‘(C) The requirement, together with the 
other provisions of this Act, will add millions of 
new consumers to the health insurance market, 
increasing the supply of, and demand for, health 
care services, and will increase the number and 
share of Americans who are insured. 
‘‘(D) The requirement achieves near-uni-
versal coverage by building upon and strength-
ening the private employer-based health insur-
ance system, which covers 176,000,000 Ameri-
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cans nationwide. In Massachusetts, a similar re-
quirement has strengthened private employer- 
based coverage: despite the economic downturn, 
the number of workers offered employer-based 
coverage has actually increased. 
‘‘(E) 
The 
economy 
loses 
up 
to 
$207,000,000,000 a year because of the poorer 
health and shorter lifespan of the uninsured. By 
significantly reducing the number of the unin-
sured, the requirement, together with the other 
provisions of this Act, will significantly reduce 
this economic cost. 
‘‘(F) The cost of providing uncompensated 
care to the uninsured was $43,000,000,000 in 
2008. To pay for this cost, health care providers 
pass on the cost to private insurers, which pass 
on the cost to families. This cost-shifting in-
creases family premiums by on average over 
$1,000 a year. By significantly reducing the 
number of the uninsured, the requirement, to-
gether with the other provisions of this Act, will 
lower health insurance premiums. 
‘‘(G) 62 percent of all personal bankruptcies 
are caused in part by medical expenses. By sig-
nificantly increasing health insurance coverage,
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the requirement, together with the other provi-
sions of this Act, will improve financial security 
for families. 
‘‘(H) Under the Employee Retirement In-
come Security Act of 1974 (29 U.S.C. 1001 et 
seq.), the Public Health Service Act (42 U.S.C. 
201 et seq.), and this Act, the Federal Govern-
ment has a significant role in regulating health 
insurance. The requirement is an essential part 
of this larger regulation of economic activity, 
and the absence of the requirement would under-
cut Federal regulation of the health insurance 
market. 
‘‘(I) Under sections 2704 and 2705 of the 
Public Health Service Act (as added by section 
1201 of this Act), if there were no requirement, 
many individuals would wait to purchase health 
insurance until they needed care. By signifi-
cantly increasing health insurance coverage, the 
requirement, together with the other provisions of 
this Act, will minimize this adverse selection and 
broaden the health insurance risk pool to include 
healthy individuals, which will lower health in-
surance premiums. The requirement is essential 
to creating effective health insurance markets in
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which improved health insurance products that 
are guaranteed issue and do not exclude coverage 
of pre-existing conditions can be sold. 
‘‘(J) Administrative costs for private health 
insurance, which were $90,000,000,000 in 2006, 
are 26 to 30 percent of premiums in the current 
individual and small group markets. By signifi-
cantly increasing health insurance coverage and 
the size of purchasing pools, which will increase 
economies of scale, the requirement, together with 
the other provisions of this Act, will significantly 
reduce administrative costs and lower health in-
surance premiums. The requirement is essential 
to creating effective health insurance markets 
that do not require underwriting and eliminate 
its associated administrative costs.’’. 
(b)(1) Section 5000A(b)(1) of the Internal Revenue 
Code of 1986, as added by section 1501(b) of this Act, is 
amended to read as follows: 
‘‘(1) IN GENERAL.—If a taxpayer who is an ap-
plicable individual, or an applicable individual for 
whom the taxpayer is liable under paragraph (3), 
fails to meet the requirement of subsection (a) for 1 
or more months, then, except as provided in sub-
section (e), there is hereby imposed on the taxpayer
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a penalty with respect to such failures in the amount 
determined under subsection (c).’’. 
(2) Paragraphs (1) and (2) of section 5000A(c) 
of the Internal Revenue Code of 1986, as so added, 
are amended to read as follows: 
‘‘(1) IN GENERAL.—The amount of the penalty 
imposed by this section on any taxpayer for any tax-
able year with respect to failures described in sub-
section (b)(1) shall be equal to the lesser of— 
‘‘(A) the sum of the monthly penalty 
amounts determined under paragraph (2) for 
months in the taxable year during which 1 or 
more such failures occurred, or 
‘‘(B) an amount equal to the national aver-
age premium for qualified health plans which 
have a bronze level of coverage, provide coverage 
for the applicable family size involved, and are 
offered through Exchanges for plan years begin-
ning in the calendar year with or within which 
the taxable year ends. 
‘‘(2) MONTHLY
PENALTY
AMOUNTS.—For pur-
poses of paragraph (1)(A), the monthly penalty 
amount with respect to any taxpayer for any month 
during which any failure described in subsection
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(b)(1) occurred is an amount equal to 1⁄12 of the 
greater of the following amounts: 
‘‘(A) FLAT DOLLAR AMOUNT.—An amount 
equal to the lesser of— 
‘‘(i) the sum of the applicable dollar 
amounts for all individuals with respect to 
whom such failure occurred during such 
month, or 
‘‘(ii) 300 percent of the applicable dol-
lar amount (determined without regard to 
paragraph (3)(C)) for the calendar year 
with or within which the taxable year ends. 
‘‘(B) 
PERCENTAGE
OF
INCOME.—An 
amount equal to the following percentage of the 
taxpayer’s household income for the taxable year: 
‘‘(i) 0.5 percent for taxable years be-
ginning in 2014. 
‘‘(ii) 1.0 percent for taxable years be-
ginning in 2015. 
‘‘(iii) 2.0 percent for taxable years be-
ginning after 2015.’’. 
(3) Section 5000A(c)(3) of the Internal Revenue Code 
of 1986, as added by section 1501(b) of this Act, is amended 
by striking ‘‘$350’’ and inserting ‘‘$495’’.
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(c) Section 5000A(d)(2)(A) of the Internal Revenue 
Code of 1986, as added by section 1501(b) of this Act, is 
amended to read as follows: 
‘‘(A) 
RELIGIOUS
CONSCIENCE
EXEMP-
TION.—Such term shall not include any indi-
vidual for any month if such individual has in 
effect an exemption under section 1311(d)(4)(H) 
of the Patient Protection and Affordable Care 
Act which certifies that such individual is— 
‘‘(i) a member of a recognized religious 
sect or division thereof which is described in 
section 1402(g)(1), and 
‘‘(ii) an adherent of established tenets 
or teachings of such sect or division as de-
scribed in such section.’’. 
(d) Section 5000A(e)(1)(C) of the Internal Revenue 
Code of 1986, as added by section 1501(b) of this Act, is 
amended to read as follows: 
‘‘(C) SPECIAL RULES FOR INDIVIDUALS RE-
LATED
TO
EMPLOYEES.—For purposes of sub-
paragraph (B)(i), if an applicable individual is 
eligible for minimum essential coverage through 
an employer by reason of a relationship to an 
employee, the determination under subparagraph
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(A) shall be made by reference to required con-
tribution of the employee.’’. 
(e) Section 4980H(b) of the Internal Revenue Code of 
1986, as added by section 1513(a) of this Act, is amended 
to read as follows: 
‘‘(b) LARGE EMPLOYERS WITH WAITING PERIODS EX-
CEEDING 60 DAYS.— 
‘‘(1) IN GENERAL.—In the case of any applicable 
large employer which requires an extended waiting 
period to enroll in any minimum essential coverage 
under an employer-sponsored plan (as defined in sec-
tion 5000A(f)(2)), there is hereby imposed on the em-
ployer an assessable payment of $600 for each full- 
time employee of the employer to whom the extended 
waiting period applies. 
‘‘(2) EXTENDED
WAITING
PERIOD.—The term 
‘extended waiting period’ means any waiting period 
(as defined in section 2701(b)(4) of the Public Health 
Service Act) which exceeds 60 days.’’. 
(f)(1) Subparagraph (A) of section 4980H(d)(4) of the 
Internal Revenue Code of 1986, as added by section 1513(a) 
of this Act, is amended by inserting ‘‘, with respect to any 
month,’’ after ‘‘means’’.
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(2) Section 4980H(d)(2) of the Internal Revenue Code 
of 1986, as added by section 1513(a) of this Act, is amended 
by adding at the end the following: 
‘‘(D) APPLICATION
TO
CONSTRUCTION
IN-
DUSTRY EMPLOYERS.—In the case of any em-
ployer the substantial annual gross receipts of 
which are attributable to the construction indus-
try— 
‘‘(i) subparagraph (A) shall be applied 
by substituting ‘who employed an average of 
at least 5 full-time employees on business 
days during the preceding calendar year 
and whose annual payroll expenses exceed 
$250,000 for such preceding calendar year’ 
for ‘who employed an average of at least 50 
full-time employees on business days during 
the preceding calendar year’, and 
‘‘(ii) subparagraph (B) shall be ap-
plied by substituting ‘5’ for ‘50’.’’. 
(3) The amendment made by paragraph (2) shall 
apply to months beginning after December 31, 2013. 
(g) Section 6056(b) of the Internal Revenue Code of 
1986, as added by section 1514(a) of the Act, is amended 
by adding at the end the following new flush sentence:
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‘‘The Secretary shall have the authority to review the accu-
racy of the information provided under this subsection, in-
cluding the applicable large employer’s share under para-
graph (2)(C)(iv).’’. 
SEC. 10107. AMENDMENTS TO SUBTITLE G. 
(a) Section 1562 of this Act is amended, in the amend-
ment made by subsection (a)(2)(B)(iii), by striking ‘‘sub-
part 1’’ and inserting ‘‘subparts I and II’’; and 
(b) Subtitle G of title I of this Act is amended— 
(1) by redesignating section 1562 (as amended) 
as section 1563; and 
(2) by inserting after section 1561 the following: 
‘‘SEC. 1562. GAO STUDY REGARDING THE RATE OF DENIAL 
OF COVERAGE AND ENROLLMENT BY HEALTH 
INSURANCE ISSUERS AND GROUP HEALTH 
PLANS. 
‘‘(a) IN GENERAL.—The Comptroller General of the 
United States (referred to in this section as the ‘Comptroller 
General’) shall conduct a study of the incidence of denials 
of coverage for medical services and denials of applications 
to enroll in health insurance plans, as described in sub-
section (b), by group health plans and health insurance 
issuers. 
‘‘(b) DATA.—
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‘‘(1) IN GENERAL.—In conducting the study de-
scribed in subsection (a), the Comptroller General 
shall consider samples of data concerning the fol-
lowing: 
‘‘(A)(i) denials of coverage for medical serv-
ices to a plan enrollees, by the types of services 
for which such coverage was denied; and 
‘‘(ii) the reasons such coverage was denied; 
and 
‘‘(B)(i) incidents in which group health 
plans and health insurance issuers deny the ap-
plication of an individual to enroll in a health 
insurance plan offered by such group health plan 
or issuer; and 
‘‘(ii) the reasons such applications are de-
nied. 
‘‘(2) SCOPE OF DATA.— 
‘‘(A) FAVORABLY
RESOLVED
DISPUTES.— 
The data that the Comptroller General considers 
under paragraph (1) shall include data con-
cerning denials of coverage for medical services 
and denials of applications for enrollment in a 
plan by a group health plan or health insurance 
issuer, where such group health plan or health
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insurance issuer later approves such coverage or 
application. 
‘‘(B) ALL
HEALTH
PLANS.—The study 
under this section shall consider data from var-
ied group health plans and health insurance 
plans offered by health insurance issuers, includ-
ing qualified health plans and health plans that 
are not qualified health plans. 
‘‘(c) REPORT.—Not later than one year after the date 
of enactment of this Act, the Comptroller General shall sub-
mit to the Secretaries of Health and Human Services and 
Labor a report describing the results of the study conducted 
under this section. 
‘‘(d) PUBLICATION OF REPORT.—The Secretaries of 
Health and Human Services and Labor shall make the re-
port described in subsection (c) available to the public on 
an Internet website. 
‘‘SEC. 1563. SMALL BUSINESS PROCUREMENT. 
‘‘Part 19 of the Federal Acquisition Regulation, section 
15 of the Small Business Act (15 U.S.C. 644), and any 
other applicable laws or regulations establishing procure-
ment requirements relating to small business concerns (as 
defined in section 3 of the Small Business Act (15 U.S.C. 
632)) may not be waived with respect to any contract
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awarded under any program or other authority under this 
Act or an amendment made by this Act.’’. 
SEC. 10108. FREE CHOICE VOUCHERS. 
(a) IN GENERAL.—An offering employer shall provide 
free choice vouchers to each qualified employee of such em-
ployer. 
(b) OFFERING EMPLOYER.—For purposes of this sec-
tion, the term ‘‘offering employer’’ means any employer 
who— 
(1) offers minimum essential coverage to its em-
ployees consisting of coverage through an eligible em-
ployer-sponsored plan; and 
(2) pays any portion of the costs of such plan. 
(c) QUALIFIED EMPLOYEE.—For purposes of this sec-
tion— 
(1) IN
GENERAL.—The term ‘‘qualified em-
ployee’’ means, with respect to any plan year of an 
offering employer, any employee— 
(A) whose required contribution (as deter-
mined under section 5000A(e)(1)(B)) for min-
imum essential coverage through an eligible em-
ployer-sponsored plan— 
(i) exceeds 8 percent of such employee’s 
household income for the taxable year de-
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scribed in section 1412(b)(1)(B) which ends 
with or within in the plan year; and 
(ii) does not exceed 9.8 percent of such 
employee’s household income for such tax-
able year; 
(B) whose household income for such taxable 
year is not greater than 400 percent of the pov-
erty line for a family of the size involved; and 
(C) who does not participate in a health 
plan offered by the offering employer. 
(2) INDEXING.—In the case of any calendar year 
beginning after 2014, the Secretary shall adjust the 8 
percent under paragraph (1)(A)(i) and 9.8 percent 
under paragraph (1)(A)(ii) for the calendar year to 
reflect the rate of premium growth between the pre-
ceding calendar year and 2013 over the rate of in-
come growth for such period. 
(d) FREE CHOICE VOUCHER.— 
(1) AMOUNT.— 
(A) IN GENERAL.—The amount of any free 
choice voucher provided under subsection (a) 
shall be equal to the monthly portion of the cost 
of the eligible employer-sponsored plan which 
would have been paid by the employer if the em-
ployee were covered under the plan with respect
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to which the employer pays the largest portion of 
the cost of the plan. Such amount shall be equal 
to the amount the employer would pay for an 
employee with self-only coverage unless such em-
ployee elects family coverage (in which case such 
amount shall be the amount the employer would 
pay for family coverage). 
(B) DETERMINATION OF COST.—The cost of 
any health plan shall be determined under the 
rules similar to the rules of section 2204 of the 
Public Health Service Act, except that such 
amount shall be adjusted for age and category of 
enrollment in accordance with regulations estab-
lished by the Secretary. 
(2) USE
OF
VOUCHERS.—An Exchange shall 
credit the amount of any free choice voucher provided 
under subsection (a) to the monthly premium of any 
qualified health plan in the Exchange in which the 
qualified employee is enrolled and the offering em-
ployer shall pay any amounts so credited to the Ex-
change. 
(3) PAYMENT
OF
EXCESS
AMOUNTS.—If the 
amount of the free choice voucher exceeds the amount 
of the premium of the qualified health plan in which
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the qualified employee is enrolled for such month, 
such excess shall be paid to the employee. 
(e) OTHER DEFINITIONS.—Any term used in this sec-
tion which is also used in section 5000A of the Internal 
Revenue Code of 1986 shall have the meaning given such 
term under such section 5000A. 
(f) EXCLUSION FROM INCOME FOR EMPLOYEE.— 
(1) IN GENERAL.—Part III of subchapter B of 
chapter 1 of the Internal Revenue Code of 1986 is 
amended by inserting after section 139C the following 
new section: 
‘‘SEC. 139D. FREE CHOICE VOUCHERS. 
‘‘Gross income shall not include the amount of any free 
choice voucher provided by an employer under section 
10108 of the Patient Protection and Affordable Care Act 
to the extent that the amount of such voucher does not exceed 
the amount paid for a qualified health plan (as defined in 
section 1301 of such Act) by the taxpayer.’’. 
(2) CLERICAL AMENDMENT.—The table of sec-
tions for part III of subchapter B of chapter 1 of such 
Code is amended by inserting after the item relating 
to section 139C the following new item: 
‘‘Sec. 139D. Free choice vouchers.’’. 
(3) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply to vouchers provided 
after December 31, 2013.
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(g) DEDUCTION ALLOWED TO EMPLOYER.— 
(1) IN GENERAL.—Section 162(a) of the Internal 
Revenue Code of 1986 is amended by adding at the 
end the following new sentence: ‘‘For purposes of 
paragraph (1), the amount of a free choice voucher 
provided under section 10108 of the Patient Protec-
tion and Affordable Care Act shall be treated as an 
amount for compensation for personal services actu-
ally rendered.’’. 
(2) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply to vouchers provided 
after December 31, 2013. 
(h) VOUCHER TAKEN INTO ACCOUNT IN DETERMINING 
PREMIUM CREDIT.— 
(1) IN GENERAL.—Subsection (c)(2) of section 
36B of the Internal Revenue Code of 1986, as added 
by section 1401, is amended by adding at the end the 
following new subparagraph: 
‘‘(D) EXCEPTION FOR INDIVIDUAL RECEIV-
ING FREE CHOICE VOUCHERS.—The term ‘cov-
erage month’ shall not include any month in 
which such individual has a free choice voucher 
provided under section 10108 of the Patient Pro-
tection and Affordable Care Act.’’.
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(2) EFFECTIVE DATE.—The amendment made by 
this subsection shall apply to taxable years beginning 
after December 31, 2013. 
(i) COORDINATION WITH EMPLOYER RESPONSIBIL-
ITIES.— 
(1) SHARED RESPONSIBILITY PENALTY.— 
(A) IN GENERAL.—Subsection (c) of section 
4980H of the Internal Revenue Code of 1986, as 
added by section 1513, is amended by adding at 
the end the following new paragraph: 
‘‘(3) SPECIAL
RULES
FOR
EMPLOYERS
PRO-
VIDING FREE CHOICE VOUCHERS.—No assessable pay-
ment shall be imposed under paragraph (1) for any 
month with respect to any employee to whom the em-
ployer provides a free choice voucher under section 
10108 of the Patient Protection and Affordable Care 
Act for such month.’’. 
(B) EFFECTIVE
DATE.—The amendment 
made by this paragraph shall apply to months 
beginning after December 31, 2013. 
(2) 
NOTIFICATION
REQUIREMENT.—Section 
18B(a)(3) of the Fair Labor Standards Act of 1938, 
as added by section 1512, is amended—
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(A) by inserting ‘‘and the employer does not 
offer a free choice voucher’’ after ‘‘Exchange’’; 
and 
(B) by striking ‘‘will lose’’ and inserting 
‘‘may lose’’. 
(j) EMPLOYER REPORTING.— 
(1) IN GENERAL.—Subsection (a) of section 6056 
of the Internal Revenue Code of 1986, as added by 
section 1514, is amended by inserting ‘‘and every of-
fering employer’’ before ‘‘shall’’. 
(2) OFFERING
EMPLOYERS.—Subsection (f) of 
section 6056 of such Code, as added by section 1514, 
is amended to read as follows: 
‘‘(f) DEFINITIONS.—For purposes of this section— 
‘‘(1) OFFERING EMPLOYER.— 
‘‘(A) IN GENERAL.—The term ‘offering em-
ployer’ means any offering employer (as defined 
in section 10108(b) of the Patient Protection and 
Affordable Care Act) if the required contribution 
(within 
the 
meaning 
of 
section 
5000A(e)(1)(B)(i)) of any employee exceeds 8 
percent of the wages (as defined in section 
3121(a)) paid to such employee by such em-
ployer.
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‘‘(B) INDEXING.—In the case of any cal-
endar year beginning after 2014, the 8 percent 
under subparagraph (A) shall be adjusted for the 
calendar year to reflect the rate of premium 
growth between the preceding calendar year and 
2013 over the rate of income growth for such pe-
riod. 
‘‘(2) OTHER DEFINITIONS.—Any term used in 
this section which is also used in section 4980H shall 
have the meaning given such term by section 
4980H.’’. 
(3) CONFORMING AMENDMENTS.— 
(A) The heading of section 6056 of such 
Code, as added by section 1514, is amended by 
striking ‘‘LARGE’’ and inserting ‘‘CERTAIN’’. 
(B) Section 6056(b)(2)(C) of such Code is 
amended— 
(i) by inserting ‘‘in the case of an ap-
plicable large employer,’’ before ‘‘the length’’ 
in clause (i); 
(ii) by striking ‘‘and’’ at the end of 
clause (iii); 
(iii) by striking ‘‘applicable large em-
ployer’’ in clause (iv) and inserting ‘‘em-
ployer’’;
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(iv) by inserting ‘‘and’’ at the end of 
clause (iv); and 
(v) by inserting at the end the fol-
lowing new clause: 
‘‘(v) in the case of an offering em-
ployer, the option for which the employer 
pays the largest portion of the cost of the 
plan and the portion of the cost paid by the 
employer in each of the enrollment cat-
egories under such option,’’. 
(C) Section 6056(d)(2) of such Code is 
amended by inserting ‘‘or offering employer’’ 
after ‘‘applicable large employer’’. 
(D) Section 6056(e) of such Code is amend-
ed by inserting ‘‘or offering employer’’ after ‘‘ap-
plicable large employer’’. 
(E) Section 6724(d)(1)(B)(xxv) of such 
Code, as added by section 1514, is amended by 
striking ‘‘large’’ and inserting ‘‘certain’’. 
(F) Section 6724(d)(2)(HH) of such Code, 
as added by section 1514, is amended by striking 
‘‘large’’ and inserting ‘‘certain’’. 
(G) The table of sections for subpart D of 
part III of subchapter A of chapter 1 of such 
Code, as amended by section 1514, is amended
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by striking ‘‘Large employers’’ in the item relat-
ing to section 6056 and inserting ‘‘Certain em-
ployers’’. 
(4) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply to periods beginning 
after December 31, 2013. 
SEC. 10109. DEVELOPMENT OF STANDARDS FOR FINANCIAL 
AND ADMINISTRATIVE TRANSACTIONS. 
(a) ADDITIONAL TRANSACTION STANDARDS AND OP-
ERATING RULES.— 
(1) DEVELOPMENT OF ADDITIONAL TRANSACTION 
STANDARDS
AND
OPERATING
RULES.—Section 
1173(a) of the Social Security Act (42 U.S.C. 1320d– 
2(a)), as amended by section 1104(b)(2), is amend-
ed— 
(A) in paragraph (1)(B), by inserting before 
the period the following: ‘‘, and subject to the re-
quirements under paragraph (5)’’; and 
(B) by adding at the end the following new 
paragraph: 
‘‘(5) CONSIDERATION OF STANDARDIZATION OF 
ACTIVITIES AND ITEMS.— 
‘‘(A) IN GENERAL.—For purposes of car-
rying out paragraph (1)(B), the Secretary shall 
solicit, not later than January 1, 2012, and not
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less than every 3 years thereafter, input from en-
tities described in subparagraph (B) on— 
‘‘(i) whether there could be greater uni-
formity in financial and administrative ac-
tivities and items, as determined appro-
priate by the Secretary; and 
‘‘(ii) whether such activities should be 
considered financial and administrative 
transactions (as described in paragraph 
(1)(B)) for which the adoption of standards 
and operating rules would improve the op-
eration of the health care system and reduce 
administrative costs. 
‘‘(B) SOLICITATION
OF
INPUT.—For pur-
poses of subparagraph (A), the Secretary shall 
seek input from— 
‘‘(i) the National Committee on Vital 
and Health Statistics, the Health Informa-
tion Technology Policy Committee, and the 
Health Information Technology Standards 
Committee; and 
‘‘(ii) standard setting organizations 
and stakeholders, as determined appropriate 
by the Secretary.’’.
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(b) ACTIVITIES AND ITEMS FOR INITIAL CONSIDER-
ATION.—For purposes of section 1173(a)(5) of the Social 
Security Act, as added by subsection (a), the Secretary of 
Health and Human Services (in this section referred to as 
the ‘‘Secretary’’) shall, not later than January 1, 2012, seek 
input on activities and items relating to the following 
areas: 
(1) Whether the application process, including 
the use of a uniform application form, for enrollment 
of health care providers by health plans could be 
made electronic and standardized. 
(2) Whether standards and operating rules de-
scribed in section 1173 of the Social Security Act 
should apply to the health care transactions of auto-
mobile insurance, worker’s compensation, and other 
programs or persons not described in section 1172(a) 
of such Act (42 U.S.C. 1320d–1(a)). 
(3) Whether standardized forms could apply to 
financial audits required by health plans, Federal 
and State agencies (including State auditors, the Of-
fice of the Inspector General of the Department of 
Health and Human Services, and the Centers for 
Medicare & Medicaid Services), and other relevant 
entities as determined appropriate by the Secretary.
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(4) Whether there could be greater transparency 
and consistency of methodologies and processes used to 
establish claim edits used by health plans (as de-
scribed in section 1171(5) of the Social Security Act 
(42 U.S.C. 1320d(5))). 
(5) Whether health plans should be required to 
publish their timeliness of payment rules. 
(c) ICD CODING CROSSWALKS.— 
(1) ICD–9 TO
ICD–10
CROSSWALK.—The Sec-
retary shall task the ICD–9–CM Coordination and 
Maintenance Committee to convene a meeting, not 
later than January 1, 2011, to receive input from ap-
propriate stakeholders (including health plans, health 
care providers, and clinicians) regarding the cross-
walk between the Ninth and Tenth Revisions of the 
International Classification of Diseases (ICD–9 and 
ICD–10, respectively) that is posted on the website of 
the Centers for Medicare & Medicaid Services, and 
make recommendations about appropriate revisions to 
such crosswalk. 
(2) REVISION OF CROSSWALK.—For purposes of 
the crosswalk described in paragraph (1), the Sec-
retary shall make appropriate revisions and post any 
such revised crosswalk on the website of the Centers 
for Medicare & Medicaid Services.
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(3) USE OF REVISED CROSSWALK.—For purposes 
of paragraph (2), any revised crosswalk shall be treat-
ed as a code set for which a standard has been adopt-
ed by the Secretary for purposes of section 
1173(c)(1)(B) of the Social Security Act (42 U.S.C. 
1320d–2(c)(1)(B)). 
(4) SUBSEQUENT CROSSWALKS.—For subsequent 
revisions of the International Classification of Dis-
eases that are adopted by the Secretary as a standard 
code set under section 1173(c) of the Social Security 
Act (42 U.S.C. 1320d–2(c)), the Secretary shall, after 
consultation with the appropriate stakeholders, post 
on the website of the Centers for Medicare & Medicaid 
Services a crosswalk between the previous and subse-
quent version of the International Classification of 
Diseases not later than the date of implementation of 
such subsequent revision. 
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. 
(a)(1) Section 1902(a)(10)(A)(i)(IX) of the Social Se-
curity Act (42 U.S.C. 1396a(a)(10)(A)(i)(IX)), as added by 
section 2004(a), is amended to read as follows:
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‘‘(IX) who— 
‘‘(aa) are under 26 years of 
age; 
‘‘(bb) are not described in or 
enrolled under any of subclauses 
(I) through (VII) of this clause or 
are described in any of such sub-
clauses but have income that ex-
ceeds the level of income applica-
ble under the State plan for eligi-
bility to enroll for medical assist-
ance under such subclause; 
‘‘(cc) were in foster care 
under the responsibility of the 
State on the date of attaining 18 
years of age or such higher age as 
the State has elected under section 
475(8)(B)(iii); and 
‘‘(dd) were enrolled in the 
State plan under this title or 
under a waiver of the plan while 
in such foster care;’’. 
(2) Section 1902(a)(10) of the Social Security Act (42 
U.S.C. 1396a(a)(10), as amended by section 2001(a)(5)(A), 
is amended in the matter following subparagraph (G), by
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striking ‘‘and (XV)’’ and inserting ‘‘(XV)’’, and by insert-
ing ‘‘and (XVI) if an individual is described in subclause 
(IX) of subparagraph (A)(i) and is also described in sub-
clause (VIII) of that subparagraph, the medical assistance 
shall be made available to the individual through subclause 
(IX) instead of through subclause (VIII)’’ before the semi-
colon. 
(3) Section 2004(d) of this Act is amended by striking 
‘‘2019’’ and inserting ‘‘2014’’. 
(b) Section 1902(k)(2) of the Social Security Act (42 
U.S.C. 1396a(k)(2)), as added by section 2001(a)(4)(A), is 
amended by striking ‘‘January 1, 2011’’ and inserting 
‘‘April 1, 2010’’. 
(c) Section 1905 of the Social Security Act (42 U.S.C. 
1396d), as amended by sections 2001(a)(3), 2001(a)(5)(C), 
2006, and 4107(a)(2), is amended— 
(1) in subsection (a), in the matter preceding 
paragraph (1), by inserting in clause (xiv), ‘‘or 
1902(a)(10)(A)(i)(IX)’’ before the comma; 
(2) in subsection (b), in the first sentence, by in-
serting ‘‘, (z),’’ before ‘‘and (aa)’’; 
(3) in subsection (y)— 
(A) in paragraph (1)(B)(ii)(II), in the first 
sentence, by inserting ‘‘includes inpatient hos-
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pital services,’’ after ‘‘100 percent of the poverty 
line, that’’; and 
(B) in paragraph (2)(A), by striking ‘‘on 
the date of enactment of the Patient Protection 
and Affordable Care Act’’ and inserting ‘‘as of 
December 1, 2009’’; 
(4) by inserting after subsection (y) the fol-
lowing: 
‘‘(z) EQUITABLE SUPPORT FOR CERTAIN STATES.— 
‘‘(1)(A) During the period that begins on Janu-
ary 1, 2014, and ends on September 30, 2019, not-
withstanding subsection (b), the Federal medical as-
sistance percentage otherwise determined under sub-
section (b) with respect to a fiscal year occurring dur-
ing that period shall be increased by 2.2 percentage 
points for any State described in subparagraph (B) 
for amounts expended for medical assistance for indi-
viduals who are not newly eligible (as defined in sub-
section (y)(2)) individuals described in subclause 
(VIII) of section 1902(a)(10)(A)(i). 
‘‘(B) For purposes of subparagraph (A), a State 
described in this subparagraph is a State that— 
‘‘(i) is an expansion State described in sub-
section (y)(1)(B)(ii)(II);
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‘‘(ii) the Secretary determines will not re-
ceive any payments under this title on the basis 
of an increased Federal medical assistance per-
centage under subsection (y) for expenditures for 
medical assistance for newly eligible individuals 
(as so defined); and 
‘‘(iii) has not been approved by the Sec-
retary to divert a portion of the DSH allotment 
for a State to the costs of providing medical as-
sistance or other health benefits coverage under a 
waiver that is in effect on July 2009. 
‘‘(2)(A) During the period that begins on January 1, 
2014, and ends on December 31, 2016, notwithstanding sub-
section (b), the Federal medical assistance percentage other-
wise determined under subsection (b) with respect to all or 
any portion of a fiscal year occurring during that period 
shall be increased by .5 percentage point for a State de-
scribed in subparagraph (B) for amounts expended for med-
ical assistance under the State plan under this title or 
under a waiver of that plan during that period. 
‘‘(B) For purposes of subparagraph (A), a State de-
scribed in this subparagraph is a State that— 
‘‘(i) is described in clauses (i) and (ii) of para-
graph (1)(B); and
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‘‘(ii) is the State with the highest percentage of 
its population insured during 2008, based on the Cur-
rent Population Survey. 
‘‘(3) Notwithstanding subsection (b) and paragraphs 
(1) and (2) of this subsection, the Federal medical assist-
ance percentage otherwise determined under subsection (b) 
with respect to all or any portion of a fiscal year that begins 
on or after January 1, 2017, for the State of Nebraska, with 
respect to amounts expended for newly eligible individuals 
described in subclause (VIII) of section 1902(a)(10)(A)(i), 
shall be determined as provided for under subsection 
(y)(1)(A) (notwithstanding the period provided for in such 
paragraph). 
‘‘(4) The increase in the Federal medical assistance 
percentage for a State under paragraphs (1), (2), or (3) 
shall apply only for purposes of this title and shall not 
apply with respect to— 
‘‘(A) disproportionate share hospital payments 
described in section 1923; 
‘‘(B) payments under title IV; 
‘‘(C) payments under title XXI; and 
‘‘(D) payments under this title that are based on 
the enhanced FMAP described in section 2105(b).’’; 
(5) in subsection (aa), is amended by striking 
‘‘without regard to this subsection and subsection (y)’’
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and inserting ‘‘without regard to this subsection, sub-
section (y), subsection (z), and section 10202 of the 
Patient Protection and Affordable Care Act’’ each 
place it appears; 
(6) by adding after subsection (bb), the following: 
‘‘(cc) REQUIREMENT FOR CERTAIN STATES.—Notwith-
standing subsections (y), (z), and (aa), in the case of a State 
that requires political subdivisions within the State to con-
tribute toward the non-Federal share of expenditures re-
quired under the State plan under section 1902(a)(2), the 
State shall not be eligible for an increase in its Federal 
medical assistance percentage under such subsections if it 
requires that political subdivisions pay a greater percentage 
of the non-Federal share of such expenditures, or a greater 
percentage of the non-Federal share of payments under sec-
tion 1923, than the respective percentages that would have 
been required by the State under the State plan under this 
title, State law, or both, as in effect on December 31, 2009, 
and without regard to any such increase. Voluntary con-
tributions by a political subdivision to the non-Federal 
share of expenditures under the State plan under this title 
or to the non-Federal share of payments under section 1923, 
shall not be considered to be required contributions for pur-
poses of this subsection. The treatment of voluntary con-
tributions, and the treatment of contributions required by
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a State under the State plan under this title, or State law, 
as provided by this subsection, shall also apply to the in-
creases in the Federal medical assistance percentage under 
section 5001 of the American Recovery and Reinvestment 
Act of 2009.’’. 
(d) Section 1108(g)(4)(B) of the Social Security Act 
(42 U.S.C. 1308(g)(4)(B)), as added by section 2005(b), is 
amended by striking ‘‘income eligibility level in effect for 
that population under title XIX or under a waiver’’ and 
inserting ‘‘the highest income eligibility level in effect for 
parents under the commonwealth’s or territory’s State plan 
under title XIX or under a waiver of the plan’’. 
(e)(1) Section 1923(f) of the Social Security Act (42 
U.S.C. 1396r–4(f)), as amended by section 2551, is amend-
ed— 
(A) in paragraph (6)— 
(i) by striking the paragraph heading and 
inserting the following: ‘‘ALLOTMENT
ADJUST-
MENTS’’; and 
(ii) in subparagraph (B), by adding at the 
end the following: 
‘‘(iii) ALLOTMENT FOR 2D, 3RD, AND 
4TH QUARTER OF FISCAL YEAR 2012, FISCAL 
YEAR
2013, 
AND
SUCCEEDING
FISCAL
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YEARS.—Notwithstanding the table set forth 
in paragraph (2) or paragraph (7): 
‘‘(I) 2D, 3RD, AND 4TH QUARTER 
OF FISCAL YEAR 2012.—The DSH allot-
ment for Hawaii for the 2d, 3rd, and 
4th quarters of fiscal year 2012 shall 
be $7,500,000. 
‘‘(II) TREATMENT AS A LOW-DSH 
STATE FOR FISCAL YEAR 2013 AND SUC-
CEEDING FISCAL YEARS.—With respect 
to fiscal year 2013, and each fiscal 
year thereafter, the DSH allotment for 
Hawaii shall be increased in the same 
manner as allotments for low DSH 
States are increased for such fiscal 
year under clause (iii) of paragraph 
(5)(B). 
‘‘(III) CERTAIN
HOSPITAL
PAY-
MENTS.—The Secretary may not im-
pose a limitation on the total amount 
of payments made to hospitals under 
the QUEST section 1115 Demonstra-
tion Project except to the extent that 
such limitation is necessary to ensure 
that a hospital does not receive pay-
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ments in excess of the amounts de-
scribed in subsection (g), or as nec-
essary to ensure that such payments 
under the waiver and such payments 
pursuant to the allotment provided in 
this clause do not, in the aggregate in 
any year, exceed the amount that the 
Secretary determines is equal to the 
Federal medical assistance percentage 
component attributable to dispropor-
tionate share hospital payment adjust-
ments for such year that is reflected in 
the budget neutrality provision of the 
QUEST Demonstration Project.’’; and 
(B) in paragraph (7)— 
(i) in subparagraph (A), in the matter pre-
ceding clause (i), by striking ‘‘subparagraph 
(E)’’ and inserting ‘‘subparagraphs (E) and 
(G)’’; 
(ii) in subparagraph (B)— 
(I) in clause (i), by striking subclauses 
(I) and (II), and inserting the following: 
‘‘(I) if the State is a low DSH 
State described in paragraph (5)(B) 
and has spent not more than 99.90
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percent of the DSH allotments for the 
State on average for the period of fiscal 
years 2004 through 2008, as of Sep-
tember 30, 2009, the applicable per-
centage is equal to 25 percent; 
‘‘(II) if the State is a low DSH 
State described in paragraph (5)(B) 
and has spent more than 99.90 percent 
of the DSH allotments for the State on 
average for the period of fiscal years 
2004 through 2008, as of September 
30, 2009, the applicable percentage is 
equal to 17.5 percent; 
‘‘(III) if the State is not a low 
DSH State described in paragraph 
(5)(B) and has spent not more than 
99.90 percent of the DSH allotments 
for the State on average for the period 
of fiscal years 2004 through 2008, as of 
September 30, 2009, the applicable 
percentage is equal to 50 percent; and 
‘‘(IV) if the State is not a low 
DSH State described in paragraph 
(5)(B) and has spent more than 99.90 
percent of the DSH allotments for the
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State on average for the period of fiscal 
years 2004 through 2008, as of Sep-
tember 30, 2009, the applicable per-
centage is equal to 35 percent.’’; 
(II) in clause (ii), by striking sub-
clauses (I) and (II), and inserting the fol-
lowing: 
‘‘(I) if the State is a low DSH 
State described in paragraph (5)(B) 
and has spent not more than 99.90 
percent of the DSH allotments for the 
State on average for the period of fiscal 
years 2004 through 2008, as of Sep-
tember 30, 2009, the applicable per-
centage is equal to the product of the 
percentage reduction in uncovered in-
dividuals for the fiscal year from the 
preceding fiscal year and 27.5 percent; 
‘‘(II) if the State is a low DSH 
State described in paragraph (5)(B) 
and has spent more than 99.90 percent 
of the DSH allotments for the State on 
average for the period of fiscal years 
2004 through 2008, as of September 
30, 2009, the applicable percentage is
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equal to the product of the percentage 
reduction in uncovered individuals for 
the fiscal year from the preceding fiscal 
year and 20 percent; 
‘‘(III) if the State is not a low 
DSH State described in paragraph 
(5)(B) and has spent not more than 
99.90 percent of the DSH allotments 
for the State on average for the period 
of fiscal years 2004 through 2008, as of 
September 30, 2009, the applicable 
percentage is equal to the product of 
the percentage reduction in uncovered 
individuals for the fiscal year from the 
preceding fiscal year and 55 percent; 
and 
‘‘(IV) if the State is not a low 
DSH State described in paragraph 
(5)(B) and has spent more than 99.90 
percent of the DSH allotments for the 
State on average for the period of fiscal 
years 2004 through 2008, as of Sep-
tember 30, 2009, the applicable per-
centage is equal to the product of the 
percentage reduction in uncovered in-
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dividuals for the fiscal year from the 
preceding fiscal year and 40 percent.’’; 
(III) in subparagraph (E), by striking 
‘‘35 percent’’ and inserting ‘‘50 percent’’; 
and 
(IV) by adding at the end the fol-
lowing: 
‘‘(G) NONAPPLICATION.—The preceding pro-
visions of this paragraph shall not apply to the 
DSH allotment determined for the State of Ha-
waii for a fiscal year under paragraph (6).’’. 
(f) Section 2551 of this Act is amended by striking 
subsection (b). 
(g) Section 2105(d)(3)(B) of the Social Security Act 
(42 U.S.C. 1397ee(d)(3)(B)), 
as 
added 
by 
section 
2101(b)(1), is amended by adding at the end the following: 
‘‘For purposes of eligibility for premium assistance for the 
purchase of a qualified health plan under section 36B of 
the Internal Revenue Code of 1986 and reduced cost-sharing 
under section 1402 of the Patient Protection and Affordable 
Care Act, children described in the preceding sentence shall 
be deemed to be ineligible for coverage under the State child 
health plan.’’.
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(h) Clause (i) of subparagraph (C) of section 513(b)(2) 
of the Social Security Act, as added by section 2953 of this 
Act, is amended to read as follows: 
‘‘(i) Healthy relationships, including 
marriage and family interactions.’’. 
(i) Section 1115 of the Social Security Act (42 U.S.C. 
1315) is amended by inserting after subsection (c) the fol-
lowing: 
‘‘(d)(1) An application or renewal of any experi-
mental, pilot, or demonstration project undertaken under 
subsection (a) to promote the objectives of title XIX or XXI 
in a State that would result in an impact on eligibility, 
enrollment, benefits, cost-sharing, or financing with respect 
to a State program under title XIX or XXI (in this sub-
section referred to as a ‘demonstration project’) shall be con-
sidered by the Secretary in accordance with the regulations 
required to be promulgated under paragraph (2). 
‘‘(2) Not later than 180 days after the date of enact-
ment of this subsection, the Secretary shall promulgate reg-
ulations relating to applications for, and renewals of, a 
demonstration project that provide for— 
‘‘(A) a process for public notice and comment at 
the State level, including public hearings, sufficient to 
ensure a meaningful level of public input; 
‘‘(B) requirements relating to—
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‘‘(i) the goals of the program to be imple-
mented or renewed under the demonstration 
project; 
‘‘(ii) the expected State and Federal costs 
and coverage projections of the demonstration 
project; and 
‘‘(iii) the specific plans of the State to en-
sure that the demonstration project will be in 
compliance with title XIX or XXI; 
‘‘(C) a process for providing public notice and 
comment after the application is received by the Sec-
retary, that is sufficient to ensure a meaningful level 
of public input; 
‘‘(D) a process for the submission to the Sec-
retary of periodic reports by the State concerning the 
implementation of the demonstration project; and 
‘‘(E) a process for the periodic evaluation by the 
Secretary of the demonstration project. 
‘‘(3) The Secretary shall annually report to Congress 
concerning actions taken by the Secretary with respect to 
applications for demonstration projects under this section.’’. 
(j) Subtitle F of title III of this Act is amended by 
adding at the end the following:
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‘‘SEC. 3512. GAO STUDY AND REPORT ON CAUSES OF AC-
TION. 
‘‘(a) STUDY.— 
‘‘(1) IN GENERAL.—The Comptroller General of 
the United States shall conduct a study of whether the 
development, recognition, or implementation of any 
guideline or other standards under a provision de-
scribed in paragraph (2) would result in the estab-
lishment of a new cause of action or claim. 
‘‘(2) PROVISIONS
DESCRIBED.—The provisions 
described in this paragraph include the following: 
‘‘(A) Section 2701 (adult health quality 
measures). 
‘‘(B) Section 2702 (payment adjustments 
for health care acquired conditions). 
‘‘(C) Section 3001 (Hospital Value-Based 
Purchase Program). 
‘‘(D) Section 3002 (improvements to the 
Physician Quality Reporting Initiative). 
‘‘(E) Section 3003 (improvements to the 
Physician Feedback Program). 
‘‘(F) Section 3007 (value based payment 
modifier under physician fee schedule). 
‘‘(G) Section 3008 (payment adjustment for 
conditions acquired in hospitals).
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‘‘(H) Section 3013 (quality measure devel-
opment). 
‘‘(I) Section 3014 (quality measurement). 
‘‘(J) Section 3021 (Establishment of Center 
for Medicare and Medicaid Innovation). 
‘‘(K) Section 3025 (hospital readmission re-
duction program). 
‘‘(L) Section 3501 (health care delivery sys-
tem research, quality improvement). 
‘‘(M) Section 4003 (Task Force on Clinical 
and Preventive Services). 
‘‘(N) Section 4301 (research to optimize de-
liver of public health services). 
‘‘(b) REPORT.—Not later than 2 years after the date 
of enactment of this Act, the Comptroller General of the 
United States shall submit to the appropriate committees 
of Congress, a report containing the findings made by the 
Comptroller General under the study under subsection (a).’’. 
SEC. 10202. INCENTIVES FOR STATES TO OFFER HOME AND 
COMMUNITY-BASED SERVICES AS A LONG- 
TERM 
CARE 
ALTERNATIVE 
TO 
NURSING 
HOMES. 
(a) STATE BALANCING INCENTIVE PAYMENTS PRO-
GRAM.—Notwithstanding section 1905(b) of the Social Se-
curity Act (42 U.S.C. 1396d(b)), in the case of a balancing
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incentive payment State, as defined in subsection (b), that 
meets the conditions described in subsection (c), during the 
balancing incentive period, the Federal medical assistance 
percentage determined for the State under section 1905(b) 
of such Act and, if applicable, increased under subsection 
(z) or (aa) shall be increased by the applicable percentage 
points determined under subsection (d) with respect to eligi-
ble medical assistance expenditures described in subsection 
(e). 
(b) BALANCING INCENTIVE PAYMENT STATE.—A bal-
ancing incentive payment State is a State— 
(1) in which less than 50 percent of the total ex-
penditures for medical assistance under the State 
Medicaid program for a fiscal year for long-term 
services and supports (as defined by the Secretary 
under subsection (f))(1)) are for non-institutionally- 
based long-term services and supports described in 
subsection (f)(1)(B); 
(2) that submits an application and meets the 
conditions described in subsection (c); and 
(3) that is selected by the Secretary to partici-
pate in the State balancing incentive payment pro-
gram established under this section. 
(c) CONDITIONS.—The conditions described in this 
subsection are the following:
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(1) APPLICATION.—The State submits an appli-
cation to the Secretary that includes, in addition to 
such other information as the Secretary shall re-
quire— 
(A) a proposed budget that details the 
State’s plan to expand and diversify medical as-
sistance for non-institutionally-based long-term 
services and supports described in subsection 
(f)(1)(B) under the State Medicaid program dur-
ing the balancing incentive period and achieve 
the target spending percentage applicable to the 
State under paragraph (2), including through 
structural changes to how the State furnishes 
such assistance, such as through the establish-
ment of a ‘‘no wrong door—single entry point 
system’’, optional presumptive eligibility, case 
management services, and the use of core stand-
ardized assessment instruments, and that in-
cludes a description of the new or expanded of-
ferings of such services that the State will pro-
vide and the projected costs of such services; and 
(B) in the case of a State that proposes to 
expand the provision of home and community- 
based services under its State Medicaid program 
through a State plan amendment under section
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1915(i) of the Social Security Act, at the option 
of the State, an election to increase the income 
eligibility for such services from 150 percent of 
the poverty line to such higher percentage as the 
State may establish for such purpose, not to ex-
ceed 300 percent of the supplemental security in-
come 
benefit 
rate 
established 
by 
section 
1611(b)(1) of the Social Security Act (42 U.S.C. 
1382(b)(1)). 
(2) TARGET SPENDING PERCENTAGES.— 
(A) In the case of a balancing incentive 
payment State in which less than 25 percent of 
the total expenditures for long-term services and 
supports under the State Medicaid program for 
fiscal year 2009 are for home and community- 
based services, the target spending percentage for 
the State to achieve by not later than October 1, 
2015, is that 25 percent of the total expenditures 
for long-term services and supports under the 
State Medicaid program are for home and com-
munity-based services. 
(B) In the case of any other balancing in-
centive payment State, the target spending per-
centage for the State to achieve by not later than 
October 1, 2015, is that 50 percent of the total
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expenditures for long-term services and supports 
under the State Medicaid program are for home 
and community-based services. 
(3) MAINTENANCE
OF
ELIGIBILITY
REQUIRE-
MENTS.—The State does not apply eligibility stand-
ards, methodologies, or procedures for determining eli-
gibility for medical assistance for non-institutionally- 
based long-term services and supports described in 
subsection (f)(1)(B) under the State Medicaid pro-
gram that are more restrictive than the eligibility 
standards, methodologies, or procedures in effect for 
such purposes on December 31, 2010. 
(4) USE
OF
ADDITIONAL
FUNDS.—The State 
agrees to use the additional Federal funds paid to the 
State as a result of this section only for purposes of 
providing new or expanded offerings of non-institu-
tionally-based long-term services and supports de-
scribed in subsection (f)(1)(B) under the State Med-
icaid program. 
(5) STRUCTURAL CHANGES.—The State agrees to 
make, not later than the end of the 6-month period 
that begins on the date the State submits an applica-
tion under this section, the following changes: 
(A) ‘‘NO
WRONG
DOOR—SINGLE
ENTRY 
POINT
SYSTEM’’.—Development of a statewide
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system to enable consumers to access all long- 
term services and supports through an agency, 
organization, coordinated network, or portal, in 
accordance with such standards as the State 
shall establish and that shall provide informa-
tion regarding the availability of such services, 
how to apply for such services, referral services 
for services and supports otherwise available in 
the community, and determinations of financial 
and functional eligibility for such services and 
supports, or assistance with assessment processes 
for financial and functional eligibility. 
(B) CONFLICT-FREE
CASE
MANAGEMENT 
SERVICES.—Conflict-free case management serv-
ices to develop a service plan, arrange for serv-
ices and supports, support the beneficiary (and, 
if appropriate, the beneficiary’s caregivers) in 
directing the provision of services and supports 
for the beneficiary, and conduct ongoing moni-
toring to assure that services and supports are 
delivered to meet the beneficiary’s needs and 
achieve intended outcomes. 
(C) CORE STANDARDIZED ASSESSMENT IN-
STRUMENTS.—Development of core standardized 
assessment instruments for determining eligi-
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bility for non-institutionally-based long-term 
services and supports described in subsection 
(f)(1)(B), which shall be used in a uniform man-
ner throughout the State, to determine a bene-
ficiary’s needs for training, support services, 
medical care, transportation, and other services, 
and develop an individual service plan to ad-
dress such needs. 
(6) DATA COLLECTION.—The State agrees to col-
lect from providers of services and through such other 
means as the State determines appropriate the fol-
lowing data: 
(A) SERVICES
DATA.—Services data from 
providers of non-institutionally-based long-term 
services and supports described in subsection 
(f)(1)(B) on a per-beneficiary basis and in ac-
cordance with such standardized coding proce-
dures as the State shall establish in consultation 
with the Secretary. 
(B) QUALITY DATA.—Quality data on a se-
lected set of core quality measures agreed upon 
by the Secretary and the State that are linked to 
population-specific outcomes measures and acces-
sible to providers.
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(C) 
OUTCOMES
MEASURES.—Outcomes 
measures data on a selected set of core popu-
lation-specific outcomes measures agreed upon by 
the Secretary and the State that are accessible to 
providers and include— 
(i) measures of beneficiary and family 
caregiver experience with providers; 
(ii) measures of beneficiary and family 
caregiver satisfaction with services; and 
(iii) measures for achieving desired 
outcomes appropriate to a specific bene-
ficiary, including employment, participa-
tion in community life, health stability, and 
prevention of loss in function. 
(d) APPLICABLE PERCENTAGE POINTS INCREASE IN 
FMAP.—The applicable percentage points increase is— 
(1) in the case of a balancing incentive payment 
State subject to the target spending percentage de-
scribed in subsection (c)(2)(A), 5 percentage points; 
and 
(2) in the case of any other balancing incentive 
payment State, 2 percentage points. 
(e) 
ELIGIBLE
MEDICAL
ASSISTANCE
EXPENDI-
TURES.—
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(1) IN
GENERAL.—Subject to paragraph (2), 
medical assistance described in this subsection is med-
ical assistance for non-institutionally-based long-term 
services and supports described in subsection (f)(1)(B) 
that is provided by a balancing incentive payment 
State under its State Medicaid program during the 
balancing incentive payment period. 
(2) LIMITATION ON PAYMENTS.—In no case may 
the aggregate amount of payments made by the Sec-
retary to balancing incentive payment States under 
this section during the balancing incentive period ex-
ceed $3,000,000,000. 
(f) DEFINITIONS.—In this section: 
(1) LONG-TERM SERVICES AND SUPPORTS DE-
FINED.—The term ‘‘long-term services and supports’’ 
has the meaning given that term by Secretary and 
may include any of the following (as defined for pur-
poses of State Medicaid programs): 
(A) INSTITUTIONALLY-BASED
LONG-TERM 
SERVICES AND SUPPORTS.—Services provided in 
an institution, including the following: 
(i) Nursing facility services. 
(ii) Services in an intermediate care 
facility for the mentally retarded described
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in subsection (a)(15) of section 1905 of such 
Act. 
(B) 
NON-INSTITUTIONALLY-BASED
LONG- 
TERM SERVICES AND SUPPORTS.—Services not 
provided in an institution, including the fol-
lowing: 
(i) Home and community-based serv-
ices provided under subsection (c), (d), or 
(i) of section 1915 of such Act or under a 
waiver under section 1115 of such Act. 
(ii) Home health care services. 
(iii) Personal care services. 
(iv) Services described in subsection 
(a)(26) of section 1905 of such Act (relating 
to PACE program services). 
(v) Self-directed personal assistance 
services described in section 1915(j) of such 
Act. 
(2) BALANCING INCENTIVE PERIOD.—The term 
‘‘balancing incentive period’’ means the period that 
begins on October 1, 2011, and ends on September 30, 
2015. 
(3) POVERTY
LINE.—The term ‘‘poverty line’’ 
has the meaning given that term in section 2110(c)(5) 
of the Social Security Act (42 U.S.C. 1397jj(c)(5)).
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(4) STATE
MEDICAID
PROGRAM.—The term 
‘‘State Medicaid program’’ means the State program 
for medical assistance provided under a State plan 
under title XIX of the Social Security Act and under 
any waiver approved with respect to such State plan. 
SEC. 10203. EXTENSION OF FUNDING FOR CHIP THROUGH 
FISCAL YEAR 2015 AND OTHER CHIP-RELATED 
PROVISIONS. 
(a) Section 1311(c)(1) of this Act is amended by strik-
ing ‘‘and’’ at the end of subparagraph (G), by striking the 
period at the end of subparagraph (H) and inserting ‘‘; 
and’’, and by adding at the end the following: 
‘‘(I) report to the Secretary at least annu-
ally and in such manner as the Secretary shall 
require, pediatric quality reporting measures 
consistent with the pediatric quality reporting 
measures established under section 1139A of the 
Social Security Act.’’. 
(b) Effective as if included in the enactment of the 
Children’s Health Insurance Program Reauthorization Act 
of 2009 (Public Law 111–3): 
(1) Section 1906(e)(2) of the Social Security Act 
(42 U.S.C. 1396e(e)(2)) is amended by striking 
‘‘means’’ and all that follows through the period and
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inserting ‘‘has the meaning given that term in section 
2105(c)(3)(A).’’. 
(2)(A) Section 1906A(a) of the Social Security 
Act (42 U.S.C. 1396e–1(a)), is amended by inserting 
before the period the following: ‘‘and the offering of 
such a subsidy is cost-effective, as defined for purposes 
of section 2105(c)(3)(A)’’. 
(B) This Act shall be applied without regard to 
subparagraph (A) of section 2003(a)(1) of this Act 
and that subparagraph and the amendment made by 
that subparagraph are hereby deemed null, void, and 
of no effect. 
(3) Section 2105(c)(10) of the Social Security 
Act (42 U.S.C. 1397ee(c)(10)) is amended— 
(A) in subparagraph (A), in the first sen-
tence, by inserting before the period the fol-
lowing: ‘‘if the offering of such a subsidy is cost- 
effective, as defined for purposes of paragraph 
(3)(A)’’; 
(B) by striking subparagraph (M); and 
(C) by redesignating subparagraph (N) as 
subparagraph (M). 
(4) Section 2105(c)(3)(A) of the Social Security 
Act (42 U.S.C. 1397ee(c)(3)(A)) is amended—
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(A) in the matter preceding clause (i), by 
striking ‘‘to’’ and inserting ‘‘to—’’; and 
(B) in clause (ii), by striking the period 
and inserting a semicolon. 
(c) Section 2105 of the Social Security Act (42 U.S.C. 
1397ee), as amended by section 2101, is amended— 
(1) in subsection (b), in the second sentence, by 
striking ‘‘2013’’ and inserting ‘‘2015’’; and 
(2) in subsection (d)(3)— 
(A) in subparagraph (A)— 
(i) in the first sentence, by inserting 
‘‘as a condition of receiving payments 
under section 1903(a),’’ after ‘‘2019,’’; 
(ii) in clause (i), by striking ‘‘or’’ at 
the end; 
(iii) by redesignating clause (ii) as 
clause (iii); and 
(iv) by inserting after clause (i), the 
following: 
‘‘(ii) after September 30, 2015, enroll-
ing children eligible to be targeted low-in-
come children under the State child health 
plan in a qualified health plan that has 
been certified by the Secretary under sub-
paragraph (C); or’’;
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(B) in subparagraph (B), by striking ‘‘pro-
vided coverage’’ and inserting ‘‘screened for eligi-
bility for medical assistance under the State 
plan under title XIX or a waiver of that plan 
and, if found eligible, enrolled in such plan or a 
waiver. In the case of such children who, as a re-
sult of such screening, are determined to not be 
eligible for medical assistance under the State 
plan or a waiver under title XIX, the State shall 
establish procedures to ensure that the children 
are enrolled in a qualified health plan that has 
been certified by the Secretary under subpara-
graph (C) and is offered’’; and 
(C) by adding at the end the following: 
‘‘(C) CERTIFICATION OF COMPARABILITY OF 
PEDIATRIC COVERAGE OFFERED BY QUALIFIED 
HEALTH PLANS.—With respect to each State, the 
Secretary, not later than April 1, 2015, shall re-
view the benefits offered for children and the 
cost-sharing imposed with respect to such bene-
fits by qualified health plans offered through an 
Exchange established by the State under section 
1311 of the Patient Protection and Affordable 
Care Act and shall certify those plans that offer 
benefits for children and impose cost-sharing
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with respect to such benefits that the Secretary 
determines are at least comparable to the benefits 
offered and cost-sharing protections provided 
under the State child health plan.’’. 
(d)(1) Section 2104(a) of such Act (42 U.S.C. 
1397dd(a)) is amended— 
(A) in paragraph (15), by striking ‘‘and’’ at the 
end; and 
(B) by striking paragraph (16) and inserting the 
following: 
‘‘(16) for fiscal year 2013, $17,406,000,000; 
‘‘(17) for fiscal year 2014, $19,147,000,000; and 
‘‘(18) for fiscal year 2015, for purposes of mak-
ing 2 semi-annual allotments— 
‘‘(A) $2,850,000,000 for the period begin-
ning on October 1, 2014, and ending on March 
31, 2015, and 
‘‘(B) $2,850,000,000 for the period begin-
ning on April 1, 2015, and ending on September 
30, 2015.’’. 
(2)(A) Section 2104(m) of such Act (42 U.S.C. 
1397dd(m)), as amended by section 2102(a)(1), is amend-
ed— 
(i) in the subsection heading, by striking ‘‘2013’’ 
and inserting ‘‘2015’’;
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(ii) in paragraph (2)— 
(I) in the paragraph heading, by striking 
‘‘2012’’ and inserting ‘‘2014’’; and 
(II) by adding at the end the following: 
‘‘(B) FISCAL YEARS 2013 AND 2014.—Subject 
to paragraphs (4) and (6), from the amount 
made available under paragraphs (16) and (17) 
of subsection (a) for fiscal years 2013 and 2014, 
respectively, the Secretary shall compute a State 
allotment for each State (including the District 
of Columbia and each commonwealth and terri-
tory) for each such fiscal year as follows: 
‘‘(i) REBASING IN FISCAL YEAR 2013.— 
For fiscal year 2013, the allotment of the 
State is equal to the Federal payments to 
the State that are attributable to (and 
countable towards) the total amount of al-
lotments available under this section to the 
State in fiscal year 2012 (including pay-
ments made to the State under subsection 
(n) for fiscal year 2012 as well as amounts 
redistributed to the State in fiscal year 
2012), multiplied by the allotment increase 
factor under paragraph (5) for fiscal year 
2013.
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‘‘(ii) GROWTH
FACTOR
UPDATE
FOR 
FISCAL YEAR 2014.—For fiscal year 2014, 
the allotment of the State is equal to the 
sum of— 
‘‘(I) the amount of the State allot-
ment under clause (i) for fiscal year 
2013; and 
‘‘(II) the amount of any payments 
made to the State under subsection (n) 
for fiscal year 2013, 
multiplied by the allotment increase factor 
under paragraph (5) for fiscal year 2014.’’; 
(iii) in paragraph (3)— 
(I) in the paragraph heading, by strik-
ing ‘‘2013’’ and inserting ‘‘2015’’; 
(II) in subparagraphs (A) and (B), by 
striking ‘‘paragraph (16)’’ each place it ap-
pears and inserting ‘‘paragraph (18)’’; 
(III) in subparagraph (C)— 
(aa) by striking ‘‘2012’’ each 
place it appears and inserting ‘‘2014’’; 
and 
(bb) by striking ‘‘2013’’ and in-
serting ‘‘2015’’; and 
(IV) in subparagraph (D)—
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(aa) in clause (i)(I), by striking 
‘‘subsection (a)(16)(A)’’ and inserting 
‘‘subsection (a)(18)(A)’’; and 
(bb) in clause (ii)(II), by striking 
‘‘subsection (a)(16)(B)’’ and inserting 
‘‘subsection (a)(18)(B)’’; 
(iv) in paragraph (4), by striking ‘‘2013’’ 
and inserting ‘‘2015’’; 
(v) in paragraph (6)— 
(I) in subparagraph (A), by striking 
‘‘2013’’ and inserting ‘‘2015’’; and 
(II) in the flush language after and 
below subparagraph (B)(ii), by striking ‘‘or 
fiscal year 2012’’ and inserting ‘‘, fiscal 
year 2012, or fiscal year 2014’’; and 
(vi) in paragraph (8)— 
(I) in the paragraph heading, by strik-
ing ‘‘2013’’ and inserting ‘‘2015’’; and 
(II) by striking ‘‘2013’’ and inserting 
‘‘2015’’. 
(B) Section 2104(n) of such Act (42 U.S.C. 1397dd(n)) 
is amended— 
(i) in paragraph (2)— 
(I) in subparagraph (A)(ii)—
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(aa) by striking ‘‘2012’’ and inserting 
‘‘2014’’; and 
(bb) by striking ‘‘2013’’ and inserting 
‘‘2015’’; 
(II) in subparagraph (B)— 
(aa) by striking ‘‘2012’’ and inserting 
‘‘2014’’; and 
(bb) by striking ‘‘2013’’ and inserting 
‘‘2015’’; and 
(ii) in paragraph (3)(A), by striking ‘‘or a semi- 
annual allotment period for fiscal year 2013’’ and in-
serting ‘‘fiscal year 2013, fiscal year 2014, or a semi- 
annual allotment period for fiscal year 2015’’. 
(C) Section 2105(g)(4) of such Act (42 U.S.C. 
1397ee(g)(4)) is amended— 
(i) in the paragraph heading, by striking ‘‘2013’’ 
and inserting ‘‘2015’’; and 
(ii) in subparagraph (A), by striking ‘‘2013’’ 
and inserting ‘‘2015’’. 
(D) Section 2110(b) of such Act (42 U.S.C. 1397jj(b)) 
is amended— 
(i) in paragraph (2)(B), by inserting ‘‘except as 
provided in paragraph (6),’’ before ‘‘a child’’; and 
(ii) by adding at the end the following new 
paragraph:
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‘‘(6) EXCEPTIONS TO EXCLUSION OF CHILDREN 
OF
EMPLOYEES
OF
A
PUBLIC
AGENCY
IN
THE 
STATE.— 
‘‘(A) IN
GENERAL.—A child shall not be 
considered to be described in paragraph (2)(B) 
if— 
‘‘(i) the public agency that employs a 
member of the child’s family to which such 
paragraph applies satisfies subparagraph 
(B); or 
‘‘(ii) subparagraph (C) applies to such 
child. 
‘‘(B) MAINTENANCE OF EFFORT WITH RE-
SPECT TO PER PERSON AGENCY CONTRIBUTION 
FOR FAMILY COVERAGE.—For purposes of sub-
paragraph (A)(i), a public agency satisfies this 
subparagraph if the amount of annual agency 
expenditures made on behalf of each employee en-
rolled in health coverage paid for by the agency 
that includes dependent coverage for the most re-
cent State fiscal year is not less than the amount 
of such expenditures made by the agency for the 
1997 State fiscal year, increased by the percent-
age increase in the medical care expenditure cat-
egory of the Consumer Price Index for All-Urban
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Consumers (all items: U.S. City Average) for 
such preceding fiscal year. 
‘‘(C) HARDSHIP EXCEPTION.—For purposes 
of subparagraph (A)(ii), this subparagraph ap-
plies to a child if the State determines, on a 
case-by-case basis, that the annual aggregate 
amount of premiums and cost-sharing imposed 
for coverage of the family of the child would ex-
ceed 5 percent of such family’s income for the 
year involved.’’. 
(E) Section 2113 of such Act (42 U.S.C. 1397mm) is 
amended— 
(i) in subsection (a)(1), by striking ‘‘2013’’ and 
inserting ‘‘2015’’; and 
(ii) in subsection (g), by striking ‘‘$100,000,000 
for the period of fiscal years 2009 through 2013’’ and 
inserting ‘‘$140,000,000 for the period of fiscal years 
2009 through 2015’’. 
(F) Section 108 of Public Law 111–3 is amended by 
striking ‘‘$11,706,000,000’’ and all that follows through the 
second sentence and inserting ‘‘$15,361,000,000 to accom-
pany the allotment made for the period beginning on Octo-
ber 1, 2014, and ending on March 31, 2015, under section 
2104(a)(18)(A) of the Social Security Act (42 U.S.C. 
1397dd(a)(18)(A)), to remain available until expended.
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Such amount shall be used to provide allotments to States 
under paragraph (3) of section 2104(m) of the Social Secu-
rity Act (42 U.S.C. 1397dd(m)) for the first 6 months of 
fiscal year 2015 in the same manner as allotments are pro-
vided under subsection (a)(18)(A) of such section 2104 and 
subject to the same terms and conditions as apply to the 
allotments provided from such subsection (a)(18)(A).’’. 
PART II—SUPPORT FOR PREGNANT AND 
PARENTING TEENS AND WOMEN 
SEC. 10211. DEFINITIONS. 
In this part: 
(1) ACCOMPANIMENT.—The term ‘‘accompani-
ment’’ means assisting, representing, and accom-
panying a woman in seeking judicial relief for child 
support, child custody, restraining orders, and res-
titution for harm to persons and property, and in fil-
ing criminal charges, and may include the payment 
of court costs and reasonable attorney and witness 
fees associated therewith. 
(2) ELIGIBLE
INSTITUTION
OF
HIGHER
EDU-
CATION.—The term ‘‘eligible institution of higher edu-
cation’’ means an institution of higher education (as 
such term is defined in section 101 of the Higher 
Education Act of 1965 (20 U.S.C. 1001)) that has es-
tablished and operates, or agrees to establish and op-
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erate upon the receipt of a grant under this part, a 
pregnant and parenting student services office. 
(3) COMMUNITY
SERVICE
CENTER.—The term 
‘‘community service center’’ means a non-profit orga-
nization that provides social services to residents of a 
specific geographical area via direct service or by con-
tract with a local governmental agency. 
(4) HIGH
SCHOOL.—The term ‘‘high school’’ 
means any public or private school that operates 
grades 10 through 12, inclusive, grades 9 through 12, 
inclusive or grades 7 through 12, inclusive. 
(5) INTERVENTION SERVICES.—The term ‘‘inter-
vention services’’ means, with respect to domestic vio-
lence, sexual violence, sexual assault, or stalking, 24- 
hour telephone hotline services for police protection 
and referral to shelters. 
(6) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
(7) STATE.—The term ‘‘State’’ includes the Dis-
trict of Columbia, any commonwealth, possession, or 
other territory of the United States, and any Indian 
tribe or reservation. 
(8) SUPPORTIVE
SOCIAL
SERVICES.—The term 
‘‘supportive social services’’ means transitional and 
permanent housing, vocational counseling, and indi-
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vidual and group counseling aimed at preventing do-
mestic violence, sexual violence, sexual assault, or 
stalking. 
(9) VIOLENCE.—The term ‘‘violence’’ means ac-
tual violence and the risk or threat of violence. 
SEC. 10212. ESTABLISHMENT OF PREGNANCY ASSISTANCE 
FUND. 
(a) IN GENERAL.—The Secretary, in collaboration and 
coordination with the Secretary of Education (as appro-
priate), shall establish a Pregnancy Assistance Fund to be 
administered by the Secretary, for the purpose of awarding 
competitive grants to States to assist pregnant and par-
enting teens and women. 
(b) USE OF FUND.—A State may apply for a grant 
under subsection (a) to carry out any activities provided 
for in section 10213. 
(c) APPLICATIONS.—To be eligible to receive a grant 
under subsection (a), a State shall submit to the Secretary 
an application at such time, in such manner, and con-
taining such information as the Secretary may require, in-
cluding a description of the purposes for which the grant 
is being requested and the designation of a State agency 
for receipt and administration of funding received under 
this part.
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SEC. 10213. PERMISSIBLE USES OF FUND. 
(a) IN GENERAL.—A State shall use amounts received 
under a grant under section 10212 for the purposes de-
scribed in this section to assist pregnant and parenting 
teens and women. 
(b) INSTITUTIONS OF HIGHER EDUCATION.— 
(1) IN GENERAL.—A State may use amounts re-
ceived under a grant under section 10212 to make 
funding available to eligible institutions of higher 
education to enable the eligible institutions to estab-
lish, maintain, or operate pregnant and parenting 
student services. Such funding shall be used to supple-
ment, not supplant, existing funding for such services. 
(2) APPLICATION.—An eligible institution of 
higher education that desires to receive funding under 
this subsection shall submit an application to the des-
ignated State agency at such time, in such manner, 
and containing such information as the State agency 
may require. 
(3) MATCHING REQUIREMENT.—An eligible insti-
tution of higher education that receives funding under 
this subsection shall contribute to the conduct of the 
pregnant and parenting student services office sup-
ported by the funding an amount from non-Federal 
funds equal to 25 percent of the amount of the fund-
ing provided. The non-Federal share may be in cash
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or in-kind, fairly evaluated, including services, facili-
ties, supplies, or equipment. 
(4) USE OF FUNDS FOR ASSISTING PREGNANT 
AND PARENTING COLLEGE STUDENTS.—An eligible in-
stitution of higher education that receives funding 
under this subsection shall use such funds to establish, 
maintain or operate pregnant and parenting student 
services and may use such funding for the following 
programs and activities: 
(A) Conduct a needs assessment on campus 
and within the local community— 
(i) to assess pregnancy and parenting 
resources, located on the campus or within 
the local community, that are available to 
meet the needs described in subparagraph 
(B); and 
(ii) to set goals for— 
(I) improving such resources for 
pregnant, parenting, and prospective 
parenting students; and 
(II) improving access to such re-
sources. 
(B) Annually assess the performance of the 
eligible institution in meeting the following needs
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of students enrolled in the eligible institution 
who are pregnant or are parents: 
(i) The inclusion of maternity coverage 
and the availability of riders for additional 
family members in student health care. 
(ii) Family housing. 
(iii) Child care. 
(iv) Flexible or alternative academic 
scheduling, such as telecommuting pro-
grams, to enable pregnant or parenting stu-
dents to continue their education or stay in 
school. 
(v) Education to improve parenting 
skills for mothers and fathers and to 
strengthen marriages. 
(vi) Maternity and baby clothing, baby 
food (including formula), baby furniture, 
and similar items to assist parents and pro-
spective parents in meeting the material 
needs of their children. 
(vii) Post-partum counseling. 
(C) Identify public and private service pro-
viders, located on the campus of the eligible in-
stitution or within the local community, that are 
qualified to meet the needs described in subpara-
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graph (B), and establishes programs with quali-
fied providers to meet such needs. 
(D) Assist pregnant and parenting students, 
fathers or spouses in locating and obtaining serv-
ices that meet the needs described in subpara-
graph (B). 
(E) If appropriate, provide referrals for 
prenatal care and delivery, infant or foster care, 
or adoption, to a student who requests such in-
formation. An office shall make such referrals 
only to service providers that serve the following 
types of individuals: 
(i) Parents. 
(ii) 
Prospective 
parents 
awaiting 
adoption. 
(iii) Women who are pregnant and 
plan on parenting or placing the child for 
adoption. 
(iv) Parenting or prospective par-
enting couples. 
(5) REPORTING.— 
(A) ANNUAL REPORT BY INSTITUTIONS.— 
(i) IN GENERAL.—For each fiscal year 
that an eligible institution of higher edu-
cation receives funds under this subsection,
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the eligible institution shall prepare and 
submit to the State, by the date determined 
by the State, a report that— 
(I) itemizes the pregnant and par-
enting student services office’s expendi-
tures for the fiscal year; 
(II) contains a review and evalua-
tion of the performance of the office in 
fulfilling the requirements of this sec-
tion, using the specific performance 
criteria or standards established under 
subparagraph (B)(i); and 
(III) describes the achievement of 
the office in meeting the needs listed in 
paragraph (4)(B) of the students served 
by the eligible institution, and the fre-
quency of use of the office by such stu-
dents. 
(ii) 
PERFORMANCE
CRITERIA.—Not 
later than 180 days before the date the an-
nual report described in clause (i) is sub-
mitted, the State— 
(I) shall identify the specific per-
formance criteria or standards that 
shall be used to prepare the report; and
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(II) may establish the form or for-
mat of the report. 
(B) REPORT
BY
STATE.—The State shall 
annually prepare and submit a report on the 
findings under this subsection, including the 
number of eligible institutions of higher edu-
cation that were awarded funds and the number 
of students served by each pregnant and par-
enting student services office receiving funds 
under this section, to the Secretary. 
(c) SUPPORT
FOR
PREGNANT
AND
PARENTING 
TEENS.—A State may use amounts received under a grant 
under section 10212 to make funding available to eligible 
high schools and community service centers to establish, 
maintain or operate pregnant and parenting services in the 
same general manner and in accordance with all conditions 
and requirements described in subsection (b), except that 
paragraph (3) of such subsection shall not apply for pur-
poses of this subsection. 
(d) IMPROVING SERVICES
FOR PREGNANT WOMEN 
WHO ARE VICTIMS OF DOMESTIC VIOLENCE, SEXUAL VIO-
LENCE, SEXUAL ASSAULT, AND STALKING.— 
(1) IN GENERAL.—A State may use amounts re-
ceived under a grant under section 10212 to make
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funding available tp its State Attorney General to as-
sist Statewide offices in providing— 
(A) intervention services, accompaniment, 
and supportive social services for eligible preg-
nant women who are victims of domestic vio-
lence, sexual violence, sexual assault, or stalking. 
(B) technical assistance and training (as 
described in subsection (c)) relating to violence 
against eligible pregnant women to be made 
available to the following: 
(i) Federal, State, tribal, territorial, 
and local governments, law enforcement 
agencies, and courts. 
(ii) Professionals working in legal, so-
cial service, and health care settings. 
(iii) Nonprofit organizations. 
(iv) Faith-based organizations. 
(2) ELIGIBILITY.—To be eligible for a grant 
under paragraph (1), a State Attorney General shall 
submit an application to the designated State agency 
at such time, in such manner, and containing such 
information, as specified by the State. 
(3) TECHNICAL ASSISTANCE AND TRAINING DE-
SCRIBED.—For purposes of paragraph (1)(B), tech-
nical assistance and training is—
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(A) the identification of eligible pregnant 
women experiencing domestic violence, sexual vi-
olence, sexual assault, or stalking; 
(B) the assessment of the immediate and 
short-term safety of such a pregnant woman, the 
evaluation of the impact of the violence or stalk-
ing on the pregnant woman’s health, and the as-
sistance of the pregnant woman in developing a 
plan aimed at preventing further domestic vio-
lence, sexual violence, sexual assault, or stalking, 
as appropriate; 
(C) the maintenance of complete medical or 
forensic records that include the documentation 
of any examination, treatment given, and refer-
rals made, recording the location and nature of 
the pregnant woman’s injuries, and the establish-
ment of mechanisms to ensure the privacy and 
confidentiality of those medical records; and 
(D) the identification and referral of the 
pregnant woman to appropriate public and pri-
vate nonprofit entities that provide intervention 
services, accompaniment, and supportive social 
services. 
(4) ELIGIBLE PREGNANT WOMAN.—In this sub-
section, the term ‘‘eligible pregnant woman’’ means
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any woman who is pregnant on the date on which 
such woman becomes a victim of domestic violence, 
sexual violence, sexual assault, or stalking or who was 
pregnant during the one-year period before such date. 
(e) PUBLIC AWARENESS AND EDUCATION.—A State 
may use amounts received under a grant under section 
10212 to make funding available to increase public aware-
ness and education concerning any services available to 
pregnant and parenting teens and women under this part, 
or any other resources available to pregnant and parenting 
women in keeping with the intent and purposes of this part. 
The State shall be responsible for setting guidelines or limits 
as to how much of funding may be utilized for public 
awareness and education in any funding award. 
SEC. 10214. APPROPRIATIONS. 
There is authorized to be appropriated, and there are 
appropriated, $25,000,000 for each of fiscal years 2010 
through 2019, to carry out this part. 
PART III—INDIAN HEALTH CARE IMPROVEMENT 
SEC. 10221. INDIAN HEALTH CARE IMPROVEMENT. 
(a) IN GENERAL.—Except as provided in subsection 
(b), S. 1790 entitled ‘‘A bill to amend the Indian Health 
Care Improvement Act to revise and extend that Act, and 
for other purposes.’’, as reported by the Committee on In-
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dian Affairs of the Senate in December 2009, is enacted 
into law. 
(b) AMENDMENTS.— 
(1) Section 119 of the Indian Health Care Im-
provement Act (as amended by section 111 of the bill 
referred to in subsection (a)) is amended— 
(A) in subsection (d)— 
(i) in paragraph (2), by striking ‘‘In 
establishing’’ and inserting ‘‘Subject to 
paragraphs (3) and (4), in establishing’’; 
and 
(ii) by adding at the end the following: 
‘‘(3) ELECTION OF INDIAN TRIBE OR TRIBAL OR-
GANIZATION.— 
‘‘(A) IN GENERAL.—Subparagraph (B) of 
paragraph (2) shall not apply in the case of an 
election made by an Indian tribe or tribal orga-
nization located in a State (other than Alaska) 
in which the use of dental health aide therapist 
services or midlevel dental health provider serv-
ices is authorized under State law to supply such 
services in accordance with State law. 
‘‘(B) ACTION BY SECRETARY.—On an elec-
tion by an Indian tribe or tribal organization 
under subparagraph (A), the Secretary, acting
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through the Service, shall facilitate implementa-
tion of the services elected. 
‘‘(4) VACANCIES.—The Secretary shall not fill 
any vacancy for a certified dentist in a program op-
erated by the Service with a dental health aide thera-
pist.’’; and 
(B) by adding at the end the following: 
‘‘(e) EFFECT OF SECTION.—Nothing in this section 
shall restrict the ability of the Service, an Indian tribe, or 
a tribal organization to participate in any program or to 
provide any service authorized by any other Federal law.’’. 
(2) The Indian Health Care Improvement Act 
(as amended by section 134(b) of the bill referred to 
in subsection (a)) is amended by striking section 125 
(relating to treatment of scholarships for certain pur-
poses). 
(3) Section 806 of the Indian Health Care Im-
provement Act (25 U.S.C. 1676) is amended— 
(A) by striking ‘‘Any limitation’’ and in-
serting the following: 
‘‘(a) HHS APPROPRIATIONS.—Any limitation’’; and 
(B) by adding at the end the following: 
‘‘(b) LIMITATIONS PURSUANT TO OTHER FEDERAL 
LAW.—Any limitation pursuant to other Federal laws on 
the use of Federal funds appropriated to the Service shall
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apply with respect to the performance or coverage of abor-
tions.’’. 
(4) The bill referred to in subsection (a) is 
amended by striking section 201. 
Subtitle C—Provisions Relating to 
Title III 
SEC. 10301. PLANS FOR A VALUE-BASED PURCHASING PRO-
GRAM FOR AMBULATORY SURGICAL CEN-
TERS. 
(a) IN GENERAL.—Section 3006 is amended by adding 
at the end the following new subsection: 
‘‘(f) AMBULATORY SURGICAL CENTERS.— 
‘‘(1) IN GENERAL.—The Secretary shall develop 
a plan to implement a value-based purchasing pro-
gram for payments under the Medicare program 
under title XVIII of the Social Security Act for am-
bulatory surgical centers (as described in section 
1833(i) of the Social Security Act (42 U.S.C. 
1395l(i))). 
‘‘(2) DETAILS.—In developing the plan under 
paragraph (1), the Secretary shall consider the fol-
lowing issues: 
‘‘(A) The ongoing development, selection, 
and modification process for measures (including 
under section 1890 of the Social Security Act (42
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U.S.C. 1395aaa) and section 1890A of such Act, 
as added by section 3014), to the extent feasible 
and practicable, of all dimensions of quality and 
efficiency in ambulatory surgical centers. 
‘‘(B) The reporting, collection, and valida-
tion of quality data. 
‘‘(C) The structure of value-based payment 
adjustments, including the determination of 
thresholds or improvements in quality that 
would substantiate a payment adjustment, the 
size of such payments, and the sources of funding 
for the value-based bonus payments. 
‘‘(D) Methods for the public disclosure of in-
formation on the performance of ambulatory sur-
gical centers. 
‘‘(E) Any other issues determined appro-
priate by the Secretary. 
‘‘(3) CONSULTATION.—In developing the plan 
under paragraph (1), the Secretary shall— 
‘‘(A) consult with relevant affected parties; 
and 
‘‘(B) consider experience with such dem-
onstrations that the Secretary determines are rel-
evant to the value-based purchasing program de-
scribed in paragraph (1).
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‘‘(4) REPORT
TO
CONGRESS.—Not later than 
January 1, 2011, the Secretary shall submit to Con-
gress a report containing the plan developed under 
paragraph (1).’’. 
(b) TECHNICAL.—Section 3006(a)(2)(A) is amended 
by striking clauses (i) and (ii). 
SEC. 10302. REVISION TO NATIONAL STRATEGY FOR QUAL-
ITY IMPROVEMENT IN HEALTH CARE. 
Section 399HH(a)(2)(B)(iii) of the Public Health 
Service Act, as added by section 3011, is amended by insert-
ing ‘‘(taking into consideration the limitations set forth in 
subsections (c) and (d) of section 1182 of the Social Security 
Act)’’ after ‘‘information’’. 
SEC. 10303. DEVELOPMENT OF OUTCOME MEASURES. 
(a) DEVELOPMENT.—Section 931 of the Public Health 
Service Act, as added by section 3013(a), is amended by 
adding at the end the following new subsection: 
‘‘(f) DEVELOPMENT OF OUTCOME MEASURES.— 
‘‘(1) IN GENERAL.—The Secretary shall develop, 
and periodically update (not less than every 3 years), 
provider-level outcome measures for hospitals and 
physicians, as well as other providers as determined 
appropriate by the Secretary.
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‘‘(2) CATEGORIES OF MEASURES.—The measures 
developed under this subsection shall include, to the 
extent determined appropriate by the Secretary— 
‘‘(A) outcome measurement for acute and 
chronic diseases, including, to the extent feasible, 
the 5 most prevalent and resource-intensive acute 
and chronic medical conditions; and 
‘‘(B) outcome measurement for primary and 
preventative care, including, to the extent fea-
sible, measurements that cover provision of such 
care for distinct patient populations (such as 
healthy children, chronically ill adults, or infirm 
elderly individuals). 
‘‘(3) GOALS.—In developing such measures, the 
Secretary shall seek to— 
‘‘(A) address issues regarding risk adjust-
ment, accountability, and sample size; 
‘‘(B) include the full scope of services that 
comprise a cycle of care; and 
‘‘(C) include multiple dimensions. 
‘‘(4) TIMEFRAME.— 
‘‘(A) ACUTE AND CHRONIC DISEASES.—Not 
later than 24 months after the date of enactment 
of this Act, the Secretary shall develop not less 
than 10 measures described in paragraph (2)(A).
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‘‘(B) PRIMARY
AND
PREVENTIVE
CARE.— 
Not later than 36 months after the date of enact-
ment of this Act, the Secretary shall develop not 
less than 10 measures described in paragraph 
(2)(B).’’. 
(b) 
HOSPITAL-ACQUIRED
CONDITIONS.—Section 
1890A of the Social Security Act, as amended by section 
3013(b), is amended by adding at the end the following new 
subsection: 
‘‘(f) HOSPITAL ACQUIRED CONDITIONS.—The Sec-
retary shall, to the extent practicable, publicly report on 
measures for hospital-acquired conditions that are currently 
utilized by the Centers for Medicare & Medicaid Services 
for the adjustment of the amount of payment to hospitals 
based on rates of hospital-acquired infections.’’. 
(c) CLINICAL PRACTICE GUIDELINES.—Section 304(b) 
of the Medicare Improvements for Patients and Providers 
Act of 2008 (Public Law 110–275) is amended by adding 
at the end the following new paragraph: 
‘‘(4) IDENTIFICATION.— 
‘‘(A) IN GENERAL.—Following receipt of the 
report submitted under paragraph (2), and not 
less than every 3 years thereafter, the Secretary 
shall contract with the Institute to employ the 
results of the study performed under paragraph
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(1) and the best methods identified by the Insti-
tute for the purpose of identifying existing and 
new clinical practice guidelines that were devel-
oped using such best methods, including guide-
lines listed in the National Guideline Clearing-
house. 
‘‘(B) CONSULTATION.—In carrying out the 
identification process under subparagraph (A), 
the Secretary shall allow for consultation with 
professional societies, voluntary health care orga-
nizations, and expert panels.’’. 
SEC. 10304. SELECTION OF EFFICIENCY MEASURES. 
Sections 1890(b)(7) and 1890A of the Social Security 
Act, as added by section 3014, are amended by striking 
‘‘quality’’ each place it appears and inserting ‘‘quality and 
efficiency’’. 
SEC. 10305. DATA COLLECTION; PUBLIC REPORTING. 
Section 399II(a) of the Public Health Service Act, as 
added by section 3015, is amended to read as follows: 
‘‘(a) IN GENERAL.— 
‘‘(1) ESTABLISHMENT
OF
STRATEGIC
FRAME-
WORK.—The Secretary shall establish and implement 
an overall strategic framework to carry out the public 
reporting of performance information, as described in 
section 399JJ. Such strategic framework may include
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methods and related timelines for implementing na-
tionally consistent data collection, data aggregation, 
and analysis methods. 
‘‘(2) COLLECTION AND AGGREGATION OF DATA.— 
The Secretary shall collect and aggregate consistent 
data on quality and resource use measures from in-
formation systems used to support health care deliv-
ery, and may award grants or contracts for this pur-
pose. The Secretary shall align such collection and ag-
gregation efforts with the requirements and assistance 
regarding the expansion of health information tech-
nology systems, the interoperability of such technology 
systems, and related standards that are in effect on 
the date of enactment of the Patient Protection and 
Affordable Care Act. 
‘‘(3) SCOPE.—The Secretary shall ensure that 
the data collection, data aggregation, and analysis 
systems described in paragraph (1) involve an in-
creasingly broad range of patient populations, pro-
viders, and geographic areas over time.’’. 
SEC. 10306. IMPROVEMENTS UNDER THE CENTER FOR 
MEDICARE AND MEDICAID INNOVATION. 
Section 1115A of the Social Security Act, as added by 
section 3021, is amended—
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(1) in subsection (a), by inserting at the end the 
following new paragraph: 
‘‘(5) TESTING
WITHIN
CERTAIN
GEOGRAPHIC 
AREAS.—For purposes of testing payment and service 
delivery models under this section, the Secretary may 
elect to limit testing of a model to certain geographic 
areas.’’; 
(2) in subsection (b)(2)— 
(A) in subparagraph (A)— 
(i) in the second sentence, by striking 
‘‘the preceding sentence may include’’ and 
inserting ‘‘this subparagraph may include, 
but are not limited to,’’; and 
(ii) by inserting after the first sentence 
the following new sentence: ‘‘The Secretary 
shall focus on models expected to reduce pro-
gram costs under the applicable title while 
preserving or enhancing the quality of care 
received by individuals receiving benefits 
under such title.’’; 
(B) in subparagraph (B), by adding at the 
end the following new clauses: 
‘‘(xix) Utilizing, in particular in enti-
ties located in medically underserved areas 
and facilities of the Indian Health Service
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(whether operated by such Service or by an 
Indian tribe or tribal organization (as those 
terms are defined in section 4 of the Indian 
Health Care Improvement Act)), telehealth 
services— 
‘‘(I) in treating behavioral health 
issues (such as post-traumatic stress 
disorder) and stroke; and 
‘‘(II) to improve the capacity of 
non-medical providers and non-special-
ized medical providers to provide 
health services for patients with chron-
ic complex conditions. 
‘‘(xx) Utilizing a diverse network of 
providers of services and suppliers to im-
prove care coordination for applicable indi-
viduals described in subsection (a)(4)(A)(i) 
with 2 or more chronic conditions and a 
history 
of 
prior-year 
hospitalization 
through interventions developed under the 
Medicare Coordinated Care Demonstration 
Project under section 4016 of the Balanced 
Budget Act of 1997 (42 U.S.C. 1395b–1 
note).’’; and
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(C) in subparagraph (C), by adding at the 
end the following new clause: 
‘‘(viii) Whether the model demonstrates 
effective linkage with other public sector or 
private sector payers.’’; 
(3) in subsection (b)(4), by adding at the end the 
following new subparagraph: 
‘‘(C) MEASURE SELECTION.—To the extent 
feasible, the Secretary shall select measures under 
this paragraph that reflect national priorities for 
quality improvement and patient-centered care 
consistent with the measures described in 
1890(b)(7)(B).’’; and 
(4) in subsection (c)— 
(A) in paragraph (1)(B), by striking ‘‘care 
and reduce spending; and’’ and inserting ‘‘pa-
tient care without increasing spending;’’; 
(B) in paragraph (2), by striking ‘‘reduce 
program spending under applicable titles.’’ and 
inserting ‘‘reduce (or would not result in any in-
crease in) net program spending under applica-
ble titles; and’’; and 
(C) by adding at the end the following: 
‘‘(3) the Secretary determines that such expan-
sion would not deny or limit the coverage or provi-
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sion of benefits under the applicable title for applica-
ble individuals. 
In determining which models or demonstration projects to 
expand under the preceding sentence, the Secretary shall 
focus on models and demonstration projects that improve 
the quality of patient care and reduce spending.’’. 
SEC. 10307. IMPROVEMENTS TO THE MEDICARE SHARED 
SAVINGS PROGRAM. 
Section 1899 of the Social Security Act, as added by 
section 3022, is amended by adding at the end the following 
new subsections: 
‘‘(i) OPTION TO USE OTHER PAYMENT MODELS.— 
‘‘(1) IN GENERAL.—If the Secretary determines 
appropriate, the Secretary may use any of the pay-
ment models described in paragraph (2) or (3) for 
making payments under the program rather than the 
payment model described in subsection (d). 
‘‘(2) PARTIAL CAPITATION MODEL.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), a model described in this paragraph 
is a partial capitation model in which an ACO 
is at financial risk for some, but not all, of the 
items and services covered under parts A and B, 
such as at risk for some or all physicians’ serv-
ices or all items and services under part B. The
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Secretary may limit a partial capitation model 
to ACOs that are highly integrated systems of 
care and to ACOs capable of bearing risk, as de-
termined to be appropriate by the Secretary. 
‘‘(B) NO ADDITIONAL PROGRAM EXPENDI-
TURES.—Payments to an ACO for items and 
services under this title for beneficiaries for a 
year under the partial capitation model shall be 
established in a manner that does not result in 
spending more for such ACO for such bene-
ficiaries than would otherwise be expended for 
such ACO for such beneficiaries for such year if 
the model were not implemented, as estimated by 
the Secretary. 
‘‘(3) OTHER PAYMENT MODELS.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), a model described in this paragraph 
is any payment model that the Secretary deter-
mines will improve the quality and efficiency of 
items and services furnished under this title. 
‘‘(B) NO ADDITIONAL PROGRAM EXPENDI-
TURES.—Subparagraph (B) of paragraph (2) 
shall apply to a payment model under subpara-
graph (A) in a similar manner as such subpara-
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graph (B) applies to the payment model under 
paragraph (2). 
‘‘(j) INVOLVEMENT IN PRIVATE PAYER AND OTHER 
THIRD PARTY ARRANGEMENTS.—The Secretary may give 
preference to ACOs who are participating in similar ar-
rangements with other payers. 
‘‘(k) TREATMENT
OF PHYSICIAN GROUP PRACTICE 
DEMONSTRATION.—During the period beginning on the 
date of the enactment of this section and ending on the date 
the program is established, the Secretary may enter into 
an agreement with an ACO under the demonstration under 
section 1866A, subject to rebasing and other modifications 
deemed appropriate by the Secretary.’’. 
SEC. 10308. REVISIONS TO NATIONAL PILOT PROGRAM ON 
PAYMENT BUNDLING. 
(a) IN GENERAL.—Section 1866D of the Social Secu-
rity Act, as added by section 3023, is amended— 
(1) in paragraph (a)(2)(B), in the matter pre-
ceding clause (i), by striking ‘‘8 conditions’’ and in-
serting ‘‘10 conditions’’; 
(2) by striking subsection (c)(1)(B) and inserting 
the following: 
‘‘(B) EXPANSION.—The Secretary may, at 
any point after January 1, 2016, expand the du-
ration and scope of the pilot program, to the ex-
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tent determined appropriate by the Secretary, 
if— 
‘‘(i) the Secretary determines that such 
expansion is expected to— 
‘‘(I) reduce spending under title 
XVIII of the Social Security Act with-
out reducing the quality of care; or 
‘‘(II) improve the quality of care 
and reduce spending; 
‘‘(ii) the Chief Actuary of the Centers 
for Medicare & Medicaid Services certifies 
that such expansion would reduce program 
spending under such title XVIII; and 
‘‘(iii) the Secretary determines that 
such expansion would not deny or limit the 
coverage or provision of benefits under this 
title for individuals.’’; and 
(3) by striking subsection (g) and inserting the 
following new subsection: 
‘‘(g) APPLICATION
OF PILOT PROGRAM
TO CON-
TINUING CARE HOSPITALS.— 
‘‘(1) IN GENERAL.—In conducting the pilot pro-
gram, the Secretary shall apply the provisions of the 
program so as to separately pilot test the continuing 
care hospital model.
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‘‘(2) SPECIAL RULES.—In pilot testing the con-
tinuing care hospital model under paragraph (1), the 
following rules shall apply: 
‘‘(A) Such model shall be tested without the 
limitation to the conditions selected under sub-
section (a)(2)(B). 
‘‘(B) Notwithstanding subsection (a)(2)(D), 
an episode of care shall be defined as the full pe-
riod that a patient stays in the continuing care 
hospital plus the first 30 days following dis-
charge from such hospital. 
‘‘(3) CONTINUING CARE HOSPITAL DEFINED.—In 
this subsection, the term ‘continuing care hospital’ 
means an entity that has demonstrated the ability to 
meet patient care and patient safety standards and 
that provides under common management the medical 
and rehabilitation services provided in inpatient re-
habilitation hospitals and units (as defined in section 
1886(d)(1)(B)(ii)), long term care hospitals (as de-
fined in section 1886(d)(1)(B)(iv)(I)), and skilled 
nursing facilities (as defined in section 1819(a)) that 
are located in a hospital described in section 
1886(d).’’. 
(b) TECHNICAL AMENDMENTS.—
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(1) Section 3023 is amended by striking 
‘‘1886C’’ and inserting ‘‘1866C’’. 
(2) Title XVIII of the Social Security Act is 
amended by redesignating section 1866D, as added by 
section 3024, as section 1866E. 
SEC. 10309. REVISIONS TO HOSPITAL READMISSIONS RE-
DUCTION PROGRAM. 
Section 1886(q)(1) of the Social Security Act, as added 
by section 3025, in the matter preceding subparagraph (A), 
is amended by striking ‘‘the Secretary shall reduce the pay-
ments’’ and all that follows through ‘‘the product of’’ and 
inserting ‘‘the Secretary shall make payments (in addition 
to the payments described in paragraph (2)(A)(ii)) for such 
a discharge to such hospital under subsection (d) (or section 
1814(b)(3), as the case may be) in an amount equal to the 
product of’’. 
SEC. 10310. REPEAL OF PHYSICIAN PAYMENT UPDATE. 
The provisions of, and the amendment made by, sec-
tion 3101 are repealed. 
SEC. 10311. REVISIONS TO EXTENSION OF AMBULANCE 
ADD-ONS. 
(a) GROUND AMBULANCE.—Section 1834(l)(13)(A) of 
the Social Security Act (42 U.S.C. 1395m(l)(13)(A)), as 
amended by section 3105(a), is further amended— 
(1) in the matter preceding clause (i)—
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(A) by striking ‘‘2007, for’’ and inserting 
‘‘2007, and for’’; and 
(B) by striking ‘‘2010, and for such services 
furnished on or after April 1, 2010, and before 
January 1, 2011’’ and inserting ‘‘2011’’; and 
(2) in each of clauses (i) and (ii)— 
(A) by striking ‘‘, and on or after April 1, 
2010, and before January 1, 2011’’ each place it 
appears; and 
(B) by striking ‘‘January 1, 2010’’ and in-
serting ‘‘January 1, 2011’’ each place it appears. 
(b) AIR AMBULANCE.—Section 146(b)(1) of the Medi-
care Improvements for Patients and Providers Act of 2008 
(Public Law 110–275), as amended by section 3105(b), is 
further amended by striking ‘‘December 31, 2009, and dur-
ing the period beginning on April 1, 2010, and ending on 
January 1, 2011’’ and inserting ‘‘December 31, 2010’’. 
(c) 
SUPER
RURAL
AMBULANCE.—Section 
1834(l)(12)(A) of the Social Security Act (42 U.S.C. 
1395m(l)(12)(A)), as amended by section 3105(c), is further 
amended by striking ‘‘2010, and on or after April 1, 2010, 
and before January 1, 2011’’ and inserting ‘‘2011’’.
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SEC. 10312. CERTAIN PAYMENT RULES FOR LONG-TERM 
CARE HOSPITAL SERVICES AND MORATORIUM 
ON THE ESTABLISHMENT OF CERTAIN HOS-
PITALS AND FACILITIES. 
(a) CERTAIN PAYMENT RULES.—Section 114(c) of the 
Medicare, Medicaid, and SCHIP Extension Act of 2007 (42 
U.S.C. 1395ww note), as amended by section 4302(a) of the 
American Recovery and Reinvestment Act (Public Law 
111–5) and section 3106(a) of this Act, is further amended 
by striking ‘‘4-year period’’ each place it appears and in-
serting ‘‘5-year period’’. 
(b) MORATORIUM.—Section 114(d) of such Act (42 
U.S.C. 1395ww note), as amended by section 3106(b) of this 
Act, in the matter preceding subparagraph (A), is amended 
by striking ‘‘4-year period’’ and inserting ‘‘5-year period’’. 
SEC. 10313. REVISIONS TO THE EXTENSION FOR THE RURAL 
COMMUNITY 
HOSPITAL 
DEMONSTRATION 
PROGRAM. 
(a) IN GENERAL.—Subsection (g) of section 410A of 
the Medicare Prescription Drug, Improvement, and Mod-
ernization Act of 2003 (Public Law 108–173; 117 Stat. 
2272), as added by section 3123(a) of this Act, is amended 
to read as follows: 
‘‘(g) FIVE-YEAR EXTENSION OF DEMONSTRATION PRO-
GRAM.—
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‘‘(1) IN
GENERAL.—Subject to the succeeding 
provisions of this subsection, the Secretary shall con-
duct the demonstration program under this section for 
an additional 5-year period (in this section referred 
to as the ‘5-year extension period’) that begins on the 
date immediately following the last day of the initial 
5-year period under subsection (a)(5). 
‘‘(2) EXPANSION OF DEMONSTRATION STATES.— 
Notwithstanding subsection (a)(2), during the 5-year 
extension period, the Secretary shall expand the num-
ber of States with low population densities deter-
mined by the Secretary under such subsection to 20. 
In determining which States to include in such ex-
pansion, the Secretary shall use the same criteria and 
data that the Secretary used to determine the States 
under such subsection for purposes of the initial 5- 
year period. 
‘‘(3) INCREASE IN MAXIMUM NUMBER OF HOS-
PITALS PARTICIPATING IN THE DEMONSTRATION PRO-
GRAM.—Notwithstanding subsection (a)(4), during the 
5-year extension period, not more than 30 rural com-
munity hospitals may participate in the demonstra-
tion program under this section. 
‘‘(4) HOSPITALS IN DEMONSTRATION PROGRAM 
ON DATE OF ENACTMENT.—In the case of a rural
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community hospital that is participating in the dem-
onstration program under this section as of the last 
day of the initial 5-year period, the Secretary— 
‘‘(A) shall provide for the continued partici-
pation of such rural community hospital in the 
demonstration program during the 5-year exten-
sion period unless the rural community hospital 
makes an election, in such form and manner as 
the Secretary may specify, to discontinue such 
participation; and 
‘‘(B) in calculating the amount of payment 
under subsection (b) to the rural community hos-
pital for covered inpatient hospital services fur-
nished by the hospital during such 5-year exten-
sion period, shall substitute, under paragraph 
(1)(A) of such subsection— 
‘‘(i) the reasonable costs of providing 
such services for discharges occurring in the 
first cost reporting period beginning on or 
after the first day of the 5-year extension 
period, for 
‘‘(ii) the reasonable costs of providing 
such services for discharges occurring in the 
first cost reporting period beginning on or
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after the implementation of the demonstra-
tion program.’’. 
(b) CONFORMING AMENDMENTS.—Subsection (a)(5) of 
section 410A of the Medicare Prescription Drug, Improve-
ment, and Modernization Act of 2003 (Public Law 108– 
173; 117 Stat. 2272), as amended by section 3123(b) of this 
Act, is amended by striking ‘‘1-year extension’’ and insert-
ing ‘‘5-year extension’’. 
SEC. 10314. ADJUSTMENT TO LOW-VOLUME HOSPITAL PRO-
VISION. 
Section 1886(d)(12) of the Social Security Act (42 
U.S.C. 1395ww(d)(12), as amended by section 3125, is 
amended— 
(1) in subparagraph (C)(i), by striking ‘‘1,500 
discharges’’ and inserting ‘‘1,600 discharges’’; and 
(2) in subparagraph (D), by striking ‘‘1,500 dis-
charges’’ and inserting ‘‘1,600 discharges’’. 
SEC. 10315. REVISIONS TO HOME HEALTH CARE PROVI-
SIONS. 
(a) REBASING.—Section 1895(b)(3)(A)(iii) of the So-
cial Security Act, as added by section 3131, is amended— 
(1) in the clause heading, by striking ‘‘2013’’ and 
inserting ‘‘2014’’; 
(2) in subclause (I), by striking ‘‘2013’’ and in-
serting ‘‘2014’’; and
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(3) in subclause (II), by striking ‘‘2016’’ and in-
serting ‘‘2017’’. 
(b) REVISION OF HOME HEALTH STUDY AND RE-
PORT.—Section 3131(d) is amended to read as follows: 
‘‘(d) STUDY AND REPORT ON THE DEVELOPMENT OF 
HOME HEALTH PAYMENT REVISIONS IN ORDER TO EN-
SURE ACCESS TO CARE AND PAYMENT FOR SEVERITY OF 
ILLNESS.— 
‘‘(1) IN GENERAL.—The Secretary of Health and 
Human Services (in this section referred to as the 
‘Secretary’) shall conduct a study on home health 
agency costs involved with providing ongoing access 
to care to low-income Medicare beneficiaries or bene-
ficiaries in medically underserved areas, and in treat-
ing beneficiaries with varying levels of severity of ill-
ness. In conducting the study, the Secretary may ana-
lyze items such as the following: 
‘‘(A) Methods to potentially revise the home 
health prospective payment system under section 
1895 of the Social Security Act (42 U.S.C. 
1395fff) to account for costs related to patient se-
verity of illness or to improving beneficiary ac-
cess to care, such as—
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‘‘(i) payment adjustments for services 
that may involve additional or fewer re-
sources; 
‘‘(ii) changes to reflect resources in-
volved with providing home health services 
to low-income Medicare beneficiaries or 
Medicare beneficiaries residing in medically 
underserved areas; 
‘‘(iii) ways outlier payments might be 
revised to reflect costs of treating Medicare 
beneficiaries with high levels of severity of 
illness; and 
‘‘(iv) other issues determined appro-
priate by the Secretary. 
‘‘(B) Operational issues involved with po-
tential implementation of potential revisions to 
the home health payment system, including im-
pacts for both home health agencies and adminis-
trative and systems issues for the Centers for 
Medicare & Medicaid Services, and any possible 
payment vulnerabilities associated with imple-
menting potential revisions. 
‘‘(C) Whether additional research might be 
needed.
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‘‘(D) Other items determined appropriate 
by the Secretary. 
‘‘(2) CONSIDERATIONS.—In conducting the study 
under paragraph (1), the Secretary may consider 
whether patient severity of illness and access to care 
could be measured by factors, such as— 
‘‘(A) population density and relative pa-
tient access to care; 
‘‘(B) variations in service costs for pro-
viding care to individuals who are dually eligi-
ble under the Medicare and Medicaid programs; 
‘‘(C) the presence of severe or chronic dis-
eases, which might be measured by multiple, dis-
continuous home health episodes; 
‘‘(D) poverty status, such as evidenced by 
the receipt of Supplemental Security Income 
under title XVI of the Social Security Act; and 
‘‘(E) other factors determined appropriate 
by the Secretary. 
‘‘(3) REPORT.—Not later than March 1, 2014, 
the Secretary shall submit to Congress a report on the 
study conducted under paragraph (1), together with 
recommendations for such legislation and administra-
tive action as the Secretary determines appropriate.
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‘‘(4) CONSULTATIONS.—In conducting the study 
under paragraph (1), the Secretary shall consult with 
appropriate stakeholders, such as groups representing 
home health agencies and groups representing Medi-
care beneficiaries. 
‘‘(5) 
MEDICARE
DEMONSTRATION
PROJECT 
BASED ON THE RESULTS OF THE STUDY.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (D), taking into account the results of the 
study conducted under paragraph (1), the Sec-
retary may, as determined appropriate, provide 
for a demonstration project to test whether mak-
ing payment adjustments for home health serv-
ices under the Medicare program would substan-
tially improve access to care for patients with 
high severity levels of illness or for low-income or 
underserved Medicare beneficiaries. 
‘‘(B) WAIVING BUDGET NEUTRALITY.—The 
Secretary shall not reduce the standard prospec-
tive payment amount (or amounts) under section 
1895 of the Social Security Act (42 U.S.C. 
1395fff) applicable to home health services fur-
nished during a period to offset any increase in 
payments during such period resulting from the
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application of the payment adjustments under 
subparagraph (A). 
‘‘(C) NO
EFFECT
ON
SUBSEQUENT
PERI-
ODS.—A payment adjustment resulting from the 
application of subparagraph (A) for a period— 
‘‘(i) shall not apply to payments for 
home health services under title XVIII after 
such period; and 
‘‘(ii) shall not be taken into account in 
calculating the payment amounts applicable 
for such services after such period. 
‘‘(D) DURATION.—If the Secretary deter-
mines it appropriate to conduct the demonstra-
tion project under this subsection, the Secretary 
shall conduct the project for a four year period 
beginning not later than January 1, 2015. 
‘‘(E) FUNDING.—The Secretary shall pro-
vide for the transfer from the Federal Hospital 
Insurance Trust Fund under section 1817 of the 
Social Security Act (42 U.S.C. 1395i) and the 
Federal Supplementary Medical Insurance Trust 
Fund established under section 1841 of such Act 
(42 U.S.C. 1395t), in such proportion as the Sec-
retary determines appropriate, of $500,000,000 
for the period of fiscal years 2015 through 2018.
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Such funds shall be made available for the study 
described in paragraph (1) and the design, im-
plementation and evaluation of the demonstra-
tion described in this paragraph. Amounts avail-
able under this subparagraph shall be available 
until expended. 
‘‘(F) EVALUATION
AND
REPORT.—If the 
Secretary determines it appropriate to conduct 
the demonstration project under this subsection, 
the Secretary shall— 
‘‘(i) provide for an evaluation of the 
project; and 
‘‘(ii) submit to Congress, by a date 
specified by the Secretary, a report on the 
project. 
‘‘(G) ADMINISTRATION.—Chapter 35 of title 
44, United States Code, shall not apply with re-
spect to this subsection.’’. 
SEC. 10316. MEDICARE DSH. 
Section 1886(r)(2)(B) of the Social Security Act, as 
added by section 3133, is amended— 
(1) in clause (i)— 
(A) in the matter preceding subclause (I), 
by striking ‘‘(divided by 100)’’;
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(B) in subclause (I), by striking ‘‘2012’’ 
and inserting ‘‘2013’’; 
(C) in subclause (II), by striking the period 
at the end and inserting a comma; and 
(D) by adding at the end the following flush 
matter: 
‘‘minus 1.5 percentage points.’’. 
(2) in clause (ii)— 
(A) in the matter preceding subclause (I), 
by striking ‘‘(divided by 100)’’; 
(B) in subclause (I), by striking ‘‘2012’’ 
and inserting ‘‘2013’’; 
(C) in subclause (II), by striking the period 
at the end and inserting a comma; and 
(D) by adding at the end the following flush 
matter: 
‘‘and, for each of 2018 and 2019, minus 1.5 
percentage points.’’. 
SEC. 10317. REVISIONS TO EXTENSION OF SECTION 508 
HOSPITAL PROVISIONS. 
Section 3137(a) is amended to read as follows: 
‘‘(a) EXTENSION.— 
‘‘(1) IN GENERAL.—Subsection (a) of section 106 
of division B of the Tax Relief and Health Care Act 
of 2006 (42 U.S.C. 1395 note), as amended by section
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117 of the Medicare, Medicaid, and SCHIP Extension 
Act of 2007 (Public Law 110–173) and section 124 
of the Medicare Improvements for Patients and Pro-
viders Act of 2008 (Public Law 110–275), is amended 
by striking ‘September 30, 2009’ and inserting ‘Sep-
tember 30, 2010’. 
‘‘(2) SPECIAL RULE FOR FISCAL YEAR 2010.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), for purposes of implementation of the 
amendment made by paragraph (1), including 
(notwithstanding 
paragraph 
(3) 
of 
section 
117(a) of the Medicare, Medicaid and SCHIP 
Extension Act of 2007 (Public Law 110–173), as 
amended by section 124(b) of the Medicare Im-
provements for Patients and Providers Act of 
2008 (Public Law 110–275)) for purposes of the 
implementation of paragraph (2) of such section 
117(a), during fiscal year 2010, the Secretary of 
Health and Human Services (in this subsection 
referred to as the ‘Secretary’) shall use the hos-
pital wage index that was promulgated by the 
Secretary in the Federal Register on August 27, 
2009 (74 Fed. Reg. 43754), and any subsequent 
corrections.
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‘‘(B) EXCEPTION.—Beginning on April 1, 
2010, in determining the wage index applicable 
to hospitals that qualify for wage index reclassi-
fication, the Secretary shall include the average 
hourly wage data of hospitals whose reclassifica-
tion was extended pursuant to the amendment 
made by paragraph (1) only if including such 
data results in a higher applicable reclassified 
wage index. 
‘‘(3) ADJUSTMENT FOR CERTAIN HOSPITALS IN 
FISCAL YEAR 2010.— 
‘‘(A) IN GENERAL.—In the case of a sub-
section (d) hospital (as defined in subsection 
(d)(1)(B) of section 1886 of the Social Security 
Act (42 U.S.C. 1395ww)) with respect to 
which— 
‘‘(i) a reclassification of its wage index 
for purposes of such section was extended 
pursuant to the amendment made by para-
graph (1); and 
‘‘(ii) the wage index applicable for 
such hospital for the period beginning on 
October 1, 2009, and ending on March 31, 
2010, was lower than for the period begin-
ning on April 1, 2010, and ending on Sep-
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tember 30, 2010, by reason of the applica-
tion of paragraph (2)(B); 
the Secretary shall pay such hospital an addi-
tional payment that reflects the difference be-
tween the wage index for such periods. 
‘‘(B) TIMEFRAME
FOR
PAYMENTS.—The 
Secretary shall make payments required under 
subparagraph by not later than December 31, 
2010.’’. 
SEC. 10318. REVISIONS TO TRANSITIONAL EXTRA BENEFITS 
UNDER MEDICARE ADVANTAGE. 
Section 1853(p)(3)(A) of the Social Security Act, as 
added by section 3201(h), is amended by inserting ‘‘in 
2009’’ before the period at the end. 
SEC. 10319. REVISIONS TO MARKET BASKET ADJUSTMENTS. 
(a) 
INPATIENT
ACUTE
HOSPITALS.—Section 
1886(b)(3)(B)(xii) of the Social Security Act, as added by 
section 3401(a), is amended— 
(1) in subclause (I), by striking ‘‘and’’ at the 
end; 
(2) by redesignating subclause (II) as subclause 
(III); 
(3) by inserting after subclause (II) the following 
new subclause:
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‘‘(II) for each of fiscal years 2012 and 2013, by 
0.1 percentage point; and’’; and 
(4) in subclause (III), as redesignated by para-
graph (2), by striking ‘‘2012’’ and inserting ‘‘2014’’. 
(b) 
LONG-TERM
CARE
HOSPITALS.—Section 
1886(m)(4) of the Social Security Act, as added by section 
3401(c), is amended— 
(1) in subparagraph (A)— 
(A) in clause (i)— 
(i) by striking ‘‘each of rate years 2010 
and 2011’’ and inserting ‘‘rate year 2010’’; 
and 
(ii) by striking ‘‘and’’ at the end; 
(B) by redesignating clause (ii) as clause 
(iv); 
(C) by inserting after clause (i) the fol-
lowing new clauses: 
‘‘(ii) for rate year 2011, 0.50 percent-
age point; 
‘‘(iii) for each of the rate years begin-
ning in 2012 and 2013, 0.1 percentage 
point; and’’; and 
(D) in clause (iv), as redesignated by sub-
paragraph (B), by striking ‘‘2012’’ and inserting 
‘‘2014’’; and
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(2) in subparagraph (B), by striking ‘‘(A)(ii)’’ 
and inserting ‘‘(A)(iv)’’. 
(c) INPATIENT REHABILITATION FACILITIES.—Section 
1886(j)(3)(D)(i) of the Social Security Act, as added by sec-
tion 3401(d), is amended— 
(1) in subclause (I), by striking ‘‘and’’ at the 
end; 
(2) by redesignating subclause (II) as subclause 
(III); 
(3) by inserting after subclause (II) the following 
new subclause: 
‘‘(II) for each of fiscal years 2012 
and 2013, 0.1 percentage point; and’’; 
and 
(4) in subclause (III), as redesignated by para-
graph (2), by striking ‘‘2012’’ and inserting ‘‘2014’’. 
(d) 
HOME
HEALTH
AGENCIES.—Section 
1895(b)(3)(B)(vi)(II) of such Act, as added by section 
3401(e), is amended by striking ‘‘and 2012’’ and inserting 
‘‘, 2012, and 2013’’. 
(e) PSYCHIATRIC HOSPITALS.—Section 1886(s)(3)(A) 
of the Social Security Act, as added by section 3401(f), is 
amended— 
(1) in clause (i), by striking ‘‘and’’ at the end; 
(2) by redesignating clause (ii) as clause (iii);
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(3) by inserting after clause (ii) the following 
new clause: 
‘‘(ii) for each of the rate years begin-
ning in 2012 and 2013, 0.1 percentage 
point; and’’; and 
(4) in clause (iii), as redesignated by paragraph 
(2), by striking ‘‘2012’’ and inserting ‘‘2014’’. 
(f) HOSPICE CARE.—Section 1814(i)(1)(C) of the So-
cial Security Act (42 U.S.C. 1395f(i)(1)(C)), as amended 
by section 3401(g), is amended— 
(1) in clause (iv)(II), by striking ‘‘0.5’’ and in-
serting ‘‘0.3’’; and 
(2) in clause (v), in the matter preceding sub-
clause (I), by striking ‘‘0.5’’ and inserting ‘‘0.3’’. 
(g) 
OUTPATIENT
HOSPITALS.—Section 
1833(t)(3)(G)(i) of the Social Security Act, as added by sec-
tion 3401(i), is amended— 
(1) in subclause (I), by striking ‘‘and’’ at the 
end; 
(2) by redesignating subclause (II) as subclause 
(III); 
(3) by inserting after subclause (II) the following 
new subclause: 
‘‘(II) for each of 2012 and 2013, 
0.1 percentage point; and’’; and
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(4) in subclause (III), as redesignated by para-
graph (2), by striking ‘‘2012’’ and inserting ‘‘2014’’. 
SEC. 10320. EXPANSION OF THE SCOPE OF, AND ADDI-
TIONAL 
IMPROVEMENTS 
TO, 
THE 
INDE-
PENDENT MEDICARE ADVISORY BOARD. 
(a) IN GENERAL.—Section 1899A of the Social Secu-
rity Act, as added by section 3403, is amended— 
(1) in subsection (c)— 
(A) in paragraph (1)(B), by adding at the 
end the following new sentence: ‘‘In any year 
(beginning with 2014) that the Board is not re-
quired to submit a proposal under this section, 
the Board shall submit to Congress an advisory 
report on matters related to the Medicare pro-
gram.’’; 
(B) in paragraph (2)(A)— 
(i) in clause (iv), by inserting ‘‘or the 
full premium subsidy under section 1860D– 
14(a)’’ before the period at the end of the 
last sentence; and 
(ii) by adding at the end the following 
new clause: 
‘‘(vii) If the Chief Actuary of the Cen-
ters for Medicare & Medicaid Services has 
made a determination described in sub-
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section (e)(3)(B)(i)(II) in the determination 
year, the proposal shall be designed to help 
reduce the growth rate described in para-
graph (8) while maintaining or enhancing 
beneficiary access to quality care under this 
title.’’; 
(C) in paragraph (2)(B)— 
(i) in clause (v), by striking ‘‘and’’ at 
the end; 
(ii) in clause (vi), by striking the pe-
riod at the end and inserting ‘‘; and’’; and 
(iii) by adding at the end the following 
new clause: 
‘‘(vii) take into account the data and 
findings contained in the annual reports 
under subsection (n) in order to develop 
proposals that can most effectively promote 
the delivery of efficient, high quality care to 
Medicare beneficiaries.’’; 
(D) in paragraph (3)— 
(i) in the heading, by striking ‘‘TRANS-
MISSION
OF
BOARD
PROPOSAL
TO
PRESI-
DENT’’ and inserting ‘‘SUBMISSION
OF 
BOARD PROPOSAL TO CONGRESS AND THE 
PRESIDENT’’;
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(ii) in subparagraph (A)(i), by strik-
ing ‘‘transmit a proposal under this section 
to the President’’ and insert ‘‘submit a pro-
posal under this section to Congress and the 
President’’; and 
(iii) in subparagraph (A)(ii)— 
(I) in subclause (I), by inserting 
‘‘or’’ at the end; 
(II) in subclause (II), by striking 
‘‘; or’’ and inserting a period; and 
(III) by striking subclause (III); 
(E) in paragraph (4)— 
(i) by striking ‘‘the Board under para-
graph (3)(A)(i) or’’; and 
(ii) by striking ‘‘immediately’’ and in-
serting ‘‘within 2 days’’; 
(F) in paragraph (5)— 
(i) by striking ‘‘to but’’ and inserting 
‘‘but’’; and 
(ii) by inserting ‘‘Congress and’’ after 
‘‘submit a proposal to’’; and 
(G) in paragraph (6)(B)(i), by striking 
‘‘per unduplicated enrollee’’ and inserting ‘‘(cal-
culated as the sum of per capita spending under 
each of parts A, B, and D)’’;
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(2) in subsection (d)— 
(A) in paragraph (1)(A)— 
(i) by inserting ‘‘the Board or’’ after 
‘‘a proposal is submitted by’’; and 
(ii) 
by 
inserting 
‘‘subsection 
(c)(3)(A)(i) or’’ after ‘‘the Senate under’’; 
and 
(B) in paragraph (2)(A), by inserting ‘‘the 
Board or’’ after ‘‘a proposal is submitted by’’; 
(3) in subsection (e)— 
(A) in paragraph (1), by inserting ‘‘the 
Board or’’ after ‘‘a proposal submitted by’’; and 
(B) in paragraph (3)— 
(i) by striking ‘‘EXCEPTION.—The Sec-
retary shall not be required to implement 
the recommendations contained in a pro-
posal submitted in a proposal year by’’ and 
inserting ‘‘EXCEPTIONS.— 
‘‘(A) IN GENERAL.—The Secretary shall not 
implement the recommendations contained in a 
proposal submitted in a proposal year by the 
Board or’’; 
(ii) by redesignating subparagraphs 
(A) and (B) as clauses (i) and (ii), respec-
tively, and indenting appropriately; and
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(iii) by adding at the end the following 
new subparagraph: 
‘‘(B) LIMITED ADDITIONAL EXCEPTION.— 
‘‘(i) IN
GENERAL.—Subject to clause 
(ii), the Secretary shall not implement the 
recommendations contained in a proposal 
submitted by the Board or the President to 
Congress pursuant to this section in a pro-
posal year (beginning with proposal year 
2019) if— 
‘‘(I) the Board was required to 
submit a proposal to Congress under 
this section in the year preceding the 
proposal year; and 
‘‘(II) the Chief Actuary of the 
Centers for Medicare & Medicaid Serv-
ices makes a determination in the de-
termination year that the growth rate 
described in subsection (c)(8) exceeds 
the growth rate described in subsection 
(c)(6)(A)(i). 
‘‘(ii) LIMITED ADDITIONAL EXCEPTION 
MAY NOT BE APPLIED IN TWO CONSECUTIVE 
YEARS.—This subparagraph shall not apply 
if the recommendations contained in a pro-
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posal submitted by the Board or the Presi-
dent to Congress pursuant to this section in 
the year preceding the proposal year were 
not required to be implemented by reason of 
this subparagraph. 
‘‘(iii) NO AFFECT ON REQUIREMENT TO 
SUBMIT
PROPOSALS
OR
FOR
CONGRES-
SIONAL
CONSIDERATION
OF
PROPOSALS.— 
Clause (i) and (ii) shall not affect— 
‘‘(I) the requirement of the Board 
or the President to submit a proposal 
to Congress in a proposal year in ac-
cordance with the provisions of this 
section; or 
‘‘(II) Congressional consideration 
of a legislative proposal (described in 
subsection 
(c)(3)(B)(iv)) 
contained 
such a proposal in accordance with 
subsection (d).’’; 
(4) in subsection (f)(3)(B)— 
(A) by striking ‘‘or advisory reports to Con-
gress’’ and inserting ‘‘, advisory reports, or advi-
sory recommendations’’; and
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(B) by inserting ‘‘or produce the public re-
port under subsection (n)’’ after ‘‘this section’’; 
and 
(5) by adding at the end the following new sub-
sections: 
‘‘(n) ANNUAL PUBLIC REPORT.— 
‘‘(1) IN GENERAL.—Not later than July 1, 2014, 
and annually thereafter, the Board shall produce a 
public report containing standardized information on 
system-wide health care costs, patient access to care, 
utilization, and quality-of-care that allows for com-
parison by region, types of services, types of pro-
viders, and both private payers and the program 
under this title. 
‘‘(2) REQUIREMENTS.—Each report produced 
pursuant to paragraph (1) shall include information 
with respect to the following areas: 
‘‘(A) The quality and costs of care for the 
population at the most local level determined 
practical by the Board (with quality and costs 
compared to national benchmarks and reflecting 
rates of change, taking into account quality 
measures described in section 1890(b)(7)(B)). 
‘‘(B) Beneficiary and consumer access to 
care, patient and caregiver experience of care,
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and the cost-sharing or out-of-pocket burden on 
patients. 
‘‘(C) Epidemiological shifts and demo-
graphic changes. 
‘‘(D) The proliferation, effectiveness, and 
utilization of health care technologies, including 
variation in provider practice patterns and 
costs. 
‘‘(E) Any other areas that the Board deter-
mines affect overall spending and quality of care 
in the private sector. 
‘‘(o) ADVISORY RECOMMENDATIONS
FOR NON-FED-
ERAL HEALTH CARE PROGRAMS.— 
‘‘(1) IN GENERAL.—Not later than January 15, 
2015, and at least once every two years thereafter, the 
Board shall submit to Congress and the President rec-
ommendations to slow the growth in national health 
expenditures (excluding expenditures under this title 
and in other Federal health care programs) while pre-
serving or enhancing quality of care, such as rec-
ommendations— 
‘‘(A) that the Secretary or other Federal 
agencies can implement administratively; 
‘‘(B) that may require legislation to be en-
acted by Congress in order to be implemented;
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‘‘(C) that may require legislation to be en-
acted by State or local governments in order to 
be implemented; 
‘‘(D) that private sector entities can volun-
tarily implement; and 
‘‘(E) with respect to other areas determined 
appropriate by the Board. 
‘‘(2) COORDINATION.—In making recommenda-
tions under paragraph (1), the Board shall coordinate 
such recommendations with recommendations con-
tained in proposals and advisory reports produced by 
the Board under subsection (c). 
‘‘(3) AVAILABLE TO PUBLIC.—The Board shall 
make recommendations submitted to Congress and the 
President under this subsection available to the pub-
lic.’’. 
(b) NAME CHANGE.—Any reference in the provisions 
of, or amendments made by, section 3403 to the ‘‘Inde-
pendent Medicare Advisory Board’’ shall be deemed to be 
a reference to the ‘‘Independent Payment Advisory Board’’. 
(c) RULE OF CONSTRUCTION.—Nothing in the amend-
ments made by this section shall preclude the Independent 
Medicare Advisory Board, as established under section 
1899A of the Social Security Act (as added by section
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3403), from solely using data from public or private sources 
to carry out the amendments made by subsection (a)(4). 
SEC. 10321. REVISION TO COMMUNITY HEALTH TEAMS. 
Section 3502(c)(2)(A) is amended by inserting ‘‘or 
other primary care providers’’ after ‘‘physicians’’. 
SEC. 10322. QUALITY REPORTING FOR PSYCHIATRIC HOS-
PITALS. 
(a) IN GENERAL.—Section 1886(s) of the Social Secu-
rity Act, as added by section 3401(f), is amended by adding 
at the end the following new paragraph: 
‘‘(4) QUALITY REPORTING.— 
‘‘(A) REDUCTION IN UPDATE FOR FAILURE 
TO REPORT.— 
‘‘(i) IN GENERAL.—Under the system 
described in paragraph (1), for rate year 
2014 and each subsequent rate year, in the 
case of a psychiatric hospital or psychiatric 
unit that does not submit data to the Sec-
retary in accordance with subparagraph (C) 
with respect to such a rate year, any an-
nual update to a standard Federal rate for 
discharges for the hospital during the rate 
year, and after application of paragraph 
(2), shall be reduced by 2 percentage points.
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‘‘(ii) SPECIAL RULE.—The application 
of this subparagraph may result in such an-
nual update being less than 0.0 for a rate 
year, and may result in payment rates 
under the system described in paragraph 
(1) for a rate year being less than such pay-
ment rates for the preceding rate year. 
‘‘(B) NONCUMULATIVE APPLICATION.—Any 
reduction under subparagraph (A) shall apply 
only with respect to the rate year involved and 
the Secretary shall not take into account such re-
duction in computing the payment amount 
under the system described in paragraph (1) for 
a subsequent rate year. 
‘‘(C) SUBMISSION OF QUALITY DATA.—For 
rate year 2014 and each subsequent rate year, 
each psychiatric hospital and psychiatric unit 
shall submit to the Secretary data on quality 
measures specified under subparagraph (D). 
Such data shall be submitted in a form and 
manner, and at a time, specified by the Sec-
retary for purposes of this subparagraph. 
‘‘(D) QUALITY MEASURES.— 
‘‘(i) IN
GENERAL.—Subject to clause 
(ii), any measure specified by the Secretary
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under this subparagraph must have been 
endorsed by the entity with a contract 
under section 1890(a). 
‘‘(ii) EXCEPTION.—In the case of a 
specified area or medical topic determined 
appropriate by the Secretary for which a 
feasible and practical measure has not been 
endorsed by the entity with a contract 
under section 1890(a), the Secretary may 
specify a measure that is not so endorsed as 
long as due consideration is given to meas-
ures that have been endorsed or adopted by 
a consensus organization identified by the 
Secretary. 
‘‘(iii) TIME
FRAME.—Not later than 
October 1, 2012, the Secretary shall publish 
the measures selected under this subpara-
graph that will be applicable with respect to 
rate year 2014. 
‘‘(E) PUBLIC AVAILABILITY OF DATA SUB-
MITTED.—The Secretary shall establish proce-
dures for making data submitted under subpara-
graph (C) available to the public. Such proce-
dures shall ensure that a psychiatric hospital 
and a psychiatric unit has the opportunity to re-
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view the data that is to be made public with re-
spect to the hospital or unit prior to such data 
being made public. The Secretary shall report 
quality measures that relate to services furnished 
in inpatient settings in psychiatric hospitals and 
psychiatric units on the Internet website of the 
Centers for Medicare & Medicaid Services.’’. 
(b) 
CONFORMING
AMENDMENT.—Section 
1890(b)(7)(B)(i)(I) of the Social Security Act, as added by 
section 3014, is amended by inserting ‘‘1886(s)(4)(D),’’ 
after ‘‘1886(o)(2),’’. 
SEC. 10323. MEDICARE COVERAGE FOR INDIVIDUALS EX-
POSED TO ENVIRONMENTAL HEALTH HAZ-
ARDS. 
(a) IN GENERAL.—Title XVIII of the Social Security 
Act (42 U.S.C. 1395 et seq.) is amended by inserting after 
section 1881 the following new section: 
‘‘SEC. 1881A. MEDICARE COVERAGE FOR INDIVIDUALS EX-
POSED TO ENVIRONMENTAL HEALTH HAZ-
ARDS. 
‘‘(a) DEEMING
OF INDIVIDUALS
AS ELIGIBLE
FOR 
MEDICARE BENEFITS.— 
‘‘(1) IN GENERAL.—For purposes of eligibility 
for benefits under this title, an individual determined 
under subsection (c) to be an environmental exposure
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affected individual described in subsection (e)(2) shall 
be deemed to meet the conditions specified in section 
226(a). 
‘‘(2) DISCRETIONARY DEEMING.—For purposes of 
eligibility for benefits under this title, the Secretary 
may deem an individual determined under subsection 
(c) to be an environmental exposure affected indi-
vidual described in subsection (e)(3) to meet the con-
ditions specified in section 226(a). 
‘‘(3) EFFECTIVE DATE OF COVERAGE.—An Indi-
vidual who is deemed eligible for benefits under this 
title under paragraph (1) or (2) shall be— 
‘‘(A) entitled to benefits under the program 
under Part A as of the date of such deeming; and 
‘‘(B) eligible to enroll in the program under 
Part B beginning with the month in which such 
deeming occurs. 
‘‘(b) PILOT PROGRAM FOR CARE OF CERTAIN INDIVID-
UALS RESIDING IN EMERGENCY DECLARATION AREAS.— 
‘‘(1) PROGRAM; PURPOSE.— 
‘‘(A) PRIMARY PILOT PROGRAM.—The Sec-
retary shall establish a pilot program in accord-
ance with this subsection to provide innovative 
approaches to furnishing comprehensive, coordi-
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nated, and cost-effective care under this title to 
individuals described in paragraph (2)(A). 
‘‘(B) OPTIONAL
PILOT
PROGRAMS.—The 
Secretary may establish a separate pilot pro-
gram, in accordance with this subsection, with 
respect to each geographic area subject to an 
emergency declaration (other than the declara-
tion of June 17, 2009), in order to furnish such 
comprehensive, coordinated and cost-effective 
care to individuals described in subparagraph 
(2)(B) who reside in each such area. 
‘‘(2) INDIVIDUAL DESCRIBED.—For purposes of 
paragraph (1), an individual described in this para-
graph is an individual who enrolls in part B, sub-
mits to the Secretary an application to participate in 
the applicable pilot program under this subsection, 
and— 
‘‘(A) is an environmental exposure affected 
individual described in subsection (e)(2) who re-
sides in or around the geographic area subject to 
an emergency declaration made as of June 17, 
2009; or 
‘‘(B) is an environmental exposure affected 
individual described in subsection (e)(3) who—
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‘‘(i) is deemed under subsection (a)(2); 
and 
‘‘(ii) meets such other criteria or con-
ditions for participation in a pilot program 
under paragraph (1)(B) as the Secretary 
specifies. 
‘‘(3) FLEXIBLE
BENEFITS
AND
SERVICES.—A 
pilot program under this subsection may provide for 
the furnishing of benefits, items, or services not other-
wise covered or authorized under this title, if the Sec-
retary determines that furnishing such benefits, items, 
or services will further the purposes of such pilot pro-
gram (as described in paragraph (1)). 
‘‘(4) INNOVATIVE REIMBURSEMENT METHODOLO-
GIES.—For purposes of the pilot program under this 
subsection, the Secretary— 
‘‘(A) shall develop and implement appro-
priate methodologies to reimburse providers for 
furnishing benefits, items, or services for which 
payment is not otherwise covered or authorized 
under this title, if such benefits, items, or serv-
ices are furnished pursuant to paragraph (3); 
and 
‘‘(B) may develop and implement innova-
tive approaches to reimbursing providers for any
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benefits, items, or services furnished under this 
subsection. 
‘‘(5) 
LIMITATION.—Consistent 
with 
section 
1862(b), no payment shall be made under the pilot 
program under this subsection with respect to bene-
fits, items, or services furnished to an environmental 
exposure affected individual (as defined in subsection 
(e)) to the extent that such individual is eligible to re-
ceive such benefits, items, or services through any 
other public or private benefits plan or legal agree-
ment. 
‘‘(6) WAIVER AUTHORITY.—The Secretary may 
waive such provisions of this title and title XI as are 
necessary to carry out pilot programs under this sub-
section. 
‘‘(7) FUNDING.—For purposes of carrying out 
pilot programs under this subsection, the Secretary 
shall provide for the transfer, from the Federal Hos-
pital Insurance Trust Fund under section 1817 and 
the Federal Supplementary Medical Insurance Trust 
Fund under section 1841, in such proportion as the 
Secretary determines appropriate, of such sums as the 
Secretary determines necessary, to the Centers for 
Medicare & Medicaid Services Program Management 
Account.
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‘‘(8) WAIVER
OF
BUDGET
NEUTRALITY.—The 
Secretary shall not require that pilot programs under 
this subsection be budget neutral with respect to ex-
penditures under this title. 
‘‘(c) DETERMINATIONS.— 
‘‘(1) BY THE COMMISSIONER OF SOCIAL SECU-
RITY.—For purposes of this section, the Commissioner 
of Social Security, in consultation with the Secretary, 
and using the cost allocation method prescribed in 
section 201(g), shall determine whether individuals 
are environmental exposure affected individuals. 
‘‘(2) BY THE SECRETARY.—The Secretary shall 
determine eligibility for pilot programs under sub-
section (b). 
‘‘(d) EMERGENCY DECLARATION DEFINED.—For pur-
poses of this section, the term ‘emergency declaration’ means 
a declaration of a public health emergency under section 
104(a) of the Comprehensive Environmental Response, 
Compensation, and Liability Act of 1980. 
‘‘(e) ENVIRONMENTAL EXPOSURE AFFECTED INDI-
VIDUAL DEFINED.— 
‘‘(1) IN GENERAL.—For purposes of this section, 
the term ‘environmental exposure affected individual’ 
means—
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‘‘(A) an individual described in paragraph 
(2); and 
‘‘(B) an individual described in paragraph 
(3). 
‘‘(2) INDIVIDUAL DESCRIBED.— 
‘‘(A) IN
GENERAL.—An individual de-
scribed in this paragraph is any individual 
who— 
‘‘(i) is diagnosed with 1 or more condi-
tions described in subparagraph (B); 
‘‘(ii) as demonstrated in such manner 
as the Secretary determines appropriate, 
has been present for an aggregate total of 6 
months in the geographic area subject to an 
emergency declaration specified in sub-
section (b)(2)(A), during a period ending— 
‘‘(I) not less than 10 years prior 
to such diagnosis; and 
‘‘(II) prior to the implementation 
of all the remedial and removal actions 
specified in the Record of Decision for 
Operating Unit 4 and the Record of 
Decision for Operating Unit 7; 
‘‘(iii) files an application for benefits 
under this title (or has an application filed
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on behalf of the individual), including pur-
suant to this section; and 
‘‘(iv) is determined under this section 
to meet the criteria in this subparagraph. 
‘‘(B) CONDITIONS
DESCRIBED.—For pur-
poses of subparagraph (A), the following condi-
tions are described in this subparagraph: 
‘‘(i) Asbestosis, pleural thickening, or 
pleural plaques as established by— 
‘‘(I) interpretation by a ‘B Read-
er’ qualified physician of a plain chest 
x-ray or interpretation of a computed 
tomographic radiograph of the chest by 
a qualified physician, as determined 
by the Secretary; or 
‘‘(II) such other diagnostic stand-
ards as the Secretary specifies, 
except that this clause shall not apply to 
pleural thickening or pleural plaques unless 
there are symptoms or conditions requiring 
medical treatment as a result of these diag-
noses. 
‘‘(ii) Mesothelioma, or malignancies of 
the lung, colon, rectum, larynx, stomach,
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esophagus, pharynx, or ovary, as established 
by— 
‘‘(I) pathologic examination of bi-
opsy tissue; 
‘‘(II) 
cytology 
from 
bronchioalveolar lavage; or 
‘‘(III) 
such 
other 
diagnostic 
standards as the Secretary specifies. 
‘‘(iii) Any other diagnosis which the 
Secretary, in consultation with the Commis-
sioner of Social Security, determines is an 
asbestos-related medical condition, as estab-
lished by such diagnostic standards as the 
Secretary specifies. 
‘‘(3) OTHER INDIVIDUAL DESCRIBED.—An indi-
vidual described in this paragraph is any individual 
who— 
‘‘(A) is not an individual described in 
paragraph (2); 
‘‘(B) is diagnosed with a medical condition 
caused by the exposure of the individual to a 
public health hazard to which an emergency dec-
laration applies, based on such medical condi-
tions, diagnostic standards, and other criteria as 
the Secretary specifies;
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‘‘(C) as demonstrated in such manner as the 
Secretary determines appropriate, has been 
present for an aggregate total of 6 months in the 
geographic area subject to the emergency declara-
tion involved, during a period determined appro-
priate by the Secretary; 
‘‘(D) files an application for benefits under 
this title (or has an application filed on behalf 
of the individual), including pursuant to this 
section; and 
‘‘(E) is determined under this section to 
meet the criteria in this paragraph.’’. 
(b) PROGRAM FOR EARLY DETECTION OF CERTAIN 
MEDICAL
CONDITIONS
RELATED
TO
ENVIRONMENTAL 
HEALTH HAZARDS.—Title XX of the Social Security Act 
(42 U.S.C. 1397 et seq.), as amended by section 5507, is 
amended by adding at the end the following: 
‘‘SEC. 2009. PROGRAM FOR EARLY DETECTION OF CERTAIN 
MEDICAL CONDITIONS RELATED TO ENVI-
RONMENTAL HEALTH HAZARDS. 
‘‘(a) PROGRAM ESTABLISHMENT.—The Secretary shall 
establish a program in accordance with this section to make 
competitive grants to eligible entities specified in subsection 
(b) for the purpose of—
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‘‘(1) screening at-risk individuals (as defined in 
subsection (c)(1)) for environmental health conditions 
(as defined in subsection (c)(3)); and 
‘‘(2) developing and disseminating public infor-
mation and education concerning— 
‘‘(A) the availability of screening under the 
program under this section; 
‘‘(B) the detection, prevention, and treat-
ment of environmental health conditions; and 
‘‘(C) the availability of Medicare benefits 
for certain individuals diagnosed with environ-
mental health conditions under section 1881A. 
‘‘(b) ELIGIBLE ENTITIES.— 
‘‘(1) IN GENERAL.—For purposes of this section, 
an eligible entity is an entity described in paragraph 
(2) which submits an application to the Secretary in 
such form and manner, and containing such informa-
tion and assurances, as the Secretary determines ap-
propriate. 
‘‘(2) TYPES OF ELIGIBLE ENTITIES.—The enti-
ties described in this paragraph are the following: 
‘‘(A) A hospital or community health center. 
‘‘(B) A Federally qualified health center. 
‘‘(C) A facility of the Indian Health Serv-
ice.
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‘‘(D) A National Cancer Institute-des-
ignated cancer center. 
‘‘(E) An agency of any State or local gov-
ernment. 
‘‘(F) A nonprofit organization. 
‘‘(G) Any other entity the Secretary deter-
mines appropriate. 
‘‘(c) DEFINITIONS.—In this section: 
‘‘(1) AT-RISK INDIVIDUAL.—The term ‘at-risk in-
dividual’ means an individual who— 
‘‘(A)(i) as demonstrated in such manner as 
the Secretary determines appropriate, has been 
present for an aggregate total of 6 months in the 
geographic area subject to an emergency declara-
tion specified under paragraph (2), during a pe-
riod ending— 
‘‘(I) not less than 10 years prior to the 
date of such individual’s application under 
subparagraph (B); and 
‘‘(II) prior to the implementation of 
all the remedial and removal actions speci-
fied in the Record of Decision for Operating 
Unit 4 and the Record of Decision for Oper-
ating Unit 7; or
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‘‘(ii) meets such other criteria as the Sec-
retary determines appropriate considering the 
type of environmental health condition at issue; 
and 
‘‘(B) has submitted an application (or has 
an application submitted on the individual’s be-
half), to an eligible entity receiving a grant 
under this section, for screening under the pro-
gram under this section. 
‘‘(2) 
EMERGENCY
DECLARATION.—The 
term 
‘emergency declaration’ means a declaration of a pub-
lic health emergency under section 104(a) of the Com-
prehensive Environmental Response, Compensation, 
and Liability Act of 1980. 
‘‘(3) ENVIRONMENTAL HEALTH CONDITION.—The 
term ‘environmental health condition’ means— 
‘‘(A) asbestosis, pleural thickening, or pleu-
ral plaques, as established by— 
‘‘(i) interpretation by a ‘B Reader’ 
qualified physician of a plain chest x-ray or 
interpretation of a computed tomographic 
radiograph of the chest by a qualified physi-
cian, as determined by the Secretary; or 
‘‘(ii) such other diagnostic standards 
as the Secretary specifies;
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‘‘(B) mesothelioma, or malignancies of the 
lung, colon, rectum, larynx, stomach, esophagus, 
pharynx, or ovary, as established by— 
‘‘(i) pathologic examination of biopsy 
tissue; 
‘‘(ii) cytology from bronchioalveolar la-
vage; or 
‘‘(iii) such other diagnostic standards 
as the Secretary specifies; and 
‘‘(C) any other medical condition which the 
Secretary determines is caused by exposure to a 
hazardous substance or pollutant or contaminant 
at a Superfund site to which an emergency dec-
laration applies, based on such criteria and as 
established by such diagnostic standards as the 
Secretary specifies. 
‘‘(4) HAZARDOUS SUBSTANCE; POLLUTANT; CON-
TAMINANT.—The terms ‘hazardous substance’, ‘pollut-
ant’, and ‘contaminant’ have the meanings given 
those terms in section 101 of the Comprehensive Envi-
ronmental Response, Compensation, and Liability 
Act of 1980 (42 U.S.C. 9601). 
‘‘(5) SUPERFUND
SITE.—The term ‘Superfund 
site’ means a site included on the National Priorities 
List developed by the President in accordance with
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section 105(a)(8)(B) of the Comprehensive Environ-
mental 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 obliga-
tion of a governmental 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 ap-
propriated 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 pe-
riod thereafter. 
‘‘(2) AVAILABILITY.—Funds appropriated under 
paragraph (1) shall remain available until expended. 
‘‘(f) NONAPPLICATION.— 
‘‘(1) IN GENERAL.—Except as provided in para-
graph (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
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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 Security 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 sub-
paragraph to any hospital which is lo-
cated in a frontier State (as defined in 
subclause (II)) may not be less than 
1.00.
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‘‘(II) 
FRONTIER
STATE
DE-
FINED.—In this clause, the term ‘fron-
tier State’ means a State in which at 
least 50 percent of the counties in the 
State are frontier counties. 
‘‘(III) FRONTIER
COUNTY
DE-
FINED.—In this clause, the term ‘fron-
tier 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 re-
lated share adjustment under para-
graph (5)(H).’’. 
(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 Pa-
tient Protection and Affordable Care Act’’ after 
‘‘2003’’. 
(b) FLOOR ON AREA WAGE ADJUSTMENT FACTOR FOR 
HOSPITAL OUTPATIENT DEPARTMENT SERVICES IN FRON-
TIER STATES.—Section 1833(t) of the Social Security Act
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(42 U.S.C. 1395l(t)), as amended by section 3138, is 
amended— 
(1) in paragraph (2)(D), by striking ‘‘the Sec-
retary’’ and inserting ‘‘subject to paragraph (19), the 
Secretary’’; and 
(2) by adding at the end the following new para-
graph: 
‘‘(19) FLOOR ON AREA WAGE ADJUSTMENT FAC-
TOR FOR HOSPITAL OUTPATIENT DEPARTMENT SERV-
ICES IN FRONTIER STATES.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (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 preceding 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 re-
lated 
share 
adjustment 
under 
section 
1886(d)(5)(H).’’.
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(c) FLOOR FOR PRACTICE EXPENSE INDEX FOR PHY-
SICIANS’ SERVICES 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 sub-
paragraph: 
‘‘(I) FLOOR FOR PRACTICE EXPENSE INDEX 
FOR
SERVICES
FURNISHED
IN
FRONTIER 
STATES.— 
‘‘(i) IN
GENERAL.—Subject to clause 
(ii), for purposes 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 prac-
tice 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 sentence 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).’’.
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SEC. 10325. REVISION TO SKILLED NURSING FACILITY PRO-
SPECTIVE PAYMENT SYSTEM. 
(a) TEMPORARY
DELAY
OF
RUG–IV.—Notwith-
standing 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’’) pub-
lished in the Federal Register on August 11, 2009, entitled 
‘‘Prospective Payment System and Consolidated Billing for 
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 Oc-
tober 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 facil-
ity are used as factors in determining a case mix classifica-
tion 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.
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SEC. 10326. PILOT TESTING PAY-FOR-PERFORMANCE PRO-
GRAMS FOR CERTAIN MEDICARE PROVIDERS. 
(a) IN GENERAL.—Not later than January 1, 2016, 
the Secretary of Health and Human Services (in this sec-
tion referred to as the ‘‘Secretary’’) shall, for each provider 
described in subsection (b), conduct a separate pilot pro-
gram 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 psychiatric units (as de-
scribed in the matter following clause (v) of such sec-
tion). 
(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 Secu-
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HR 3590 EAS/PP 
rity Act as may be necessary solely for purposes of carrying 
out the pilot programs under this section. 
(d) NO ADDITIONAL PROGRAM EXPENDITURES.—Pay-
ments under this section under the separate pilot program 
for value based purchasing (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 pro-
vider type for such year if the pilot program were not im-
plemented, as estimated by the Secretary. 
(e) EXPANSION OF PILOT PROGRAM.—The Secretary 
may, at any point after January 1, 2018, expand the dura-
tion and scope of a pilot program conducted under this sub-
section, to the extent determined appropriate by the Sec-
retary, if— 
(1) the Secretary determines that such expansion 
is expected to— 
(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;
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(2) the Chief Actuary of the Centers for Medicare 
& Medicaid Services certifies that such expansion 
would reduce program 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 bene-
ficiaries. 
SEC. 10327. IMPROVEMENTS TO THE PHYSICIAN QUALITY 
REPORTING SYSTEM. 
(a) IN GENERAL.—Section 1848(m) of the Social Secu-
rity 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 subparagraph (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 pay-
ment described in subparagraph (A), an eligible 
professional shall meet the following require-
ments:
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‘‘(i) The eligible professional shall— 
‘‘(I) satisfactorily submit data on 
quality measures for purposes of para-
graph (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 reg-
istry (as described in subsection 
(k)(4)); or 
‘‘(bb) an alternative form 
and manner determined appro-
priate 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 Main-
tenance of Certification program for a 
year; and 
‘‘(II) 
successfully 
completes 
a 
qualified Maintenance of Certification 
Program practice assessment (as de-
fined in subparagraph (C)(ii)) for such 
year.
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‘‘(iii) A Maintenance of Certification 
program submits to the Secretary, on behalf 
of the eligible professional, information— 
‘‘(I) in a form and manner speci-
fied by the Secretary, that the eligible 
professional has successfully met the re-
quirements of clause (ii) (which may 
be in the form of a structural meas-
ure); 
‘‘(II) if requested by the Sec-
retary, on the survey of patient experi-
ence with care (as described in sub-
paragraph (C)(ii)(II)); and 
‘‘(III) as the Secretary may re-
quire, on the methods, measures, and 
data used under the Maintenance of 
Certification Program and the quali-
fied Maintenance of Certification Pro-
gram practice assessment. 
‘‘(C) DEFINITIONS.—For purposes of this 
paragraph: 
‘‘(i) The term ‘Maintenance of Certifi-
cation Program’ means a continuous assess-
ment program, such as qualified American 
Board of Medical Specialties Maintenance
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HR 3590 EAS/PP 
of Certification program or an equivalent 
program (as determined by the Secretary), 
that advances quality and the lifelong 
learning and self-assessment of board cer-
tified specialty physicians by focusing on 
the competencies of patient care, medical 
knowledge, practice-based learning, inter-
personal and communication skills and pro-
fessionalism. Such a program shall include 
the following: 
‘‘(I) The program requires the 
physician to maintain a valid, unre-
stricted medical license in the United 
States. 
‘‘(II) The program requires a 
physician to participate in educational 
and self-assessment programs that re-
quire an assessment of what was 
learned. 
‘‘(III) The program requires a 
physician to demonstrate, through a 
formalized, secure examination, that 
the physician has the fundamental di-
agnostic skills, medical knowledge, and
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HR 3590 EAS/PP 
clinical judgment to provide quality 
care in their respective specialty. 
‘‘(IV) The program requires suc-
cessful completion of a qualified Main-
tenance of Certification Program prac-
tice assessment as described in clause 
(ii). 
‘‘(ii) The term ‘qualified Maintenance 
of Certification Program practice assess-
ment’ means an assessment of a physician’s 
practice that— 
‘‘(I) includes an initial assess-
ment of an eligible professional’s prac-
tice that is designed to demonstrate the 
physician’s use of evidence-based medi-
cine; 
‘‘(II) includes a survey of patient 
experience with care; and 
‘‘(III) requires a physician to im-
plement a quality improvement inter-
vention to address a practice weakness 
identified in the initial assessment 
under subclause (I) and then to re-
measure to assess performance im-
provement after such intervention.’’.
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(b) AUTHORITY.—Section 3002(c) of this Act is 
amended by adding at the end the following new paragraph: 
‘‘(3) AUTHORITY.—For years after 2014, if the 
Secretary of Health and Human Services determines 
it to be appropriate, the Secretary may incorporate 
participation in a Maintenance of Certification Pro-
gram and successful completion of a qualified Mainte-
nance of Certification Program practice assessment 
into the composite of measures of quality of care fur-
nished pursuant to the physician fee schedule pay-
ment modifier, as described in section 1848(p)(2) of 
the Social Security Act (42 U.S.C. 1395w–4(p)(2)).’’. 
(c) ELIMINATION OF MA REGIONAL PLAN STABILIZA-
TION FUND.— 
(1) IN GENERAL.—Section 1858 of the Social Se-
curity Act (42 U.S.C. 1395w–27a) is amended by 
striking subsection (e). 
(2) TRANSITION.—Any amount contained in the 
MA Regional Plan Stabilization Fund as of the date 
of the enactment of this Act shall be transferred to the 
Federal Supplementary Medical Insurance Trust 
Fund.
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SEC. 10328. IMPROVEMENT IN PART D MEDICATION THER-
APY MANAGEMENT (MTM) PROGRAMS. 
(a) IN GENERAL.—Section 1860D–4(c)(2) of the So-
cial Security Act (42 U.S.C. 1395w–104(c)(2)) is amend-
ed— 
(1) by redesignating subparagraphs (C), (D), 
and (E) as subparagraphs (E), (F), and (G), respec-
tively; and 
(2) by inserting after subparagraph (B) the fol-
lowing new subparagraphs: 
‘‘(C) REQUIRED INTERVENTIONS.—For plan 
years beginning on or after the date that is 2 
years after the date of the enactment of the Pa-
tient Protection and Affordable Care Act, pre-
scription drug plan sponsors shall offer medica-
tion therapy management services to targeted 
beneficiaries described in subparagraph (A)(ii) 
that include, at a minimum, the following to in-
crease adherence to prescription medications or 
other goals deemed necessary by the Secretary: 
‘‘(i) An annual comprehensive medica-
tion review furnished person-to-person or 
using telehealth technologies (as defined by 
the Secretary) by a licensed pharmacist or 
other qualified provider. The comprehensive 
medication review—
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‘‘(I) shall include a review of the 
individual’s medications and may re-
sult in the creation of a recommended 
medication action plan or other ac-
tions in consultation with the indi-
vidual and with input from the pre-
scriber to the extent necessary and 
practicable; and 
‘‘(II) shall include providing the 
individual with a written or printed 
summary of the results of the review. 
The Secretary, in consultation with relevant 
stakeholders, shall develop a standardized 
format for the action plan under subclause 
(I) and the summary under subclause (II). 
‘‘(ii) Follow-up interventions as war-
ranted based on the findings of the annual 
medication review or the targeted medica-
tion enrollment and which may be provided 
person-to-person or using telehealth tech-
nologies (as defined by the Secretary). 
‘‘(D) ASSESSMENT.—The prescription drug 
plan sponsor shall have in place a process to as-
sess, at least on a quarterly basis, the medication 
use of individuals who are at risk but not en-
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HR 3590 EAS/PP 
rolled in the medication therapy management 
program, including individuals who have experi-
enced a transition in care, if the prescription 
drug plan sponsor has access to that informa-
tion. 
‘‘(E) AUTOMATIC ENROLLMENT WITH ABIL-
ITY TO OPT-OUT.—The prescription drug plan 
sponsor shall have in place a process to— 
‘‘(i) subject to clause (ii), automati-
cally enroll targeted beneficiaries described 
in subparagraph (A)(ii), including bene-
ficiaries identified under subparagraph (D), 
in the medication therapy management pro-
gram required under this subsection; and 
‘‘(ii) permit such beneficiaries to opt- 
out of enrollment in such program.’’. 
(b) RULE OF CONSTRUCTION.—Nothing in this section 
shall limit the authority of the Secretary of Health and 
Human Services to modify or broaden requirements for a 
medication therapy management program under part D of 
title XVIII of the Social Security Act or to study new mod-
els for medication therapy management through the Center 
for Medicare and Medicaid Innovation under section 1115A 
of such Act, as added by section 3021.
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SEC. 
10329. 
DEVELOPING 
METHODOLOGY 
TO 
ASSESS 
HEALTH PLAN VALUE. 
(a) DEVELOPMENT.—The Secretary of Health and 
Human Services (referred to in this section as the ‘‘Sec-
retary’’), in consultation with relevant stakeholders includ-
ing health insurance issuers, health care consumers, em-
ployers, health care providers, and other entities determined 
appropriate by the Secretary, shall develop a methodology 
to measure health plan value. Such methodology shall take 
into consideration, where applicable— 
(1) the overall cost to enrollees under the plan; 
(2) the quality of the care provided for under the 
plan; 
(3) the efficiency of the plan in providing care; 
(4) the relative risk of the plan’s enrollees as 
compared to other plans; 
(5) the actuarial value or other comparative 
measure of the benefits covered under the plan; and 
(6) other factors determined relevant by the Sec-
retary. 
(b) REPORT.—Not later than 18 months after the date 
of enactment of this Act, the Secretary shall submit to Con-
gress a report concerning the methodology developed under 
subsection (a).
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SEC. 10330. MODERNIZING COMPUTER AND DATA SYSTEMS 
OF THE CENTERS FOR MEDICARE & MED-
ICAID 
SERVICES 
TO 
SUPPORT 
IMPROVE-
MENTS IN CARE DELIVERY. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services (in this section referred to as the ‘‘Sec-
retary’’) shall develop a plan (and detailed budget for the 
resources needed to implement such plan) to modernize the 
computer and data systems of the Centers for Medicare & 
Medicaid Services (in this section referred to as ‘‘CMS’’). 
(b) CONSIDERATIONS.—In developing the plan, the 
Secretary shall consider how such modernized computer sys-
tem could— 
(1) in accordance with the regulations promul-
gated under section 264(c) of the Health Insurance 
Portability and Accountability Act of 1996, make 
available data in a reliable and timely manner to 
providers of services and suppliers to support their ef-
forts to better manage and coordinate care furnished 
to beneficiaries of CMS programs; and 
(2) support consistent evaluations of payment 
and delivery system reforms under CMS programs. 
(c) POSTING OF PLAN.—By not later than 9 months 
after the date of the enactment of this Act, the Secretary 
shall post on the website of the Centers for Medicare & Med-
icaid Services the plan described in subsection (a).
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SEC. 10331. PUBLIC REPORTING OF PERFORMANCE INFOR-
MATION. 
(a) IN GENERAL.— 
(1) DEVELOPMENT.—Not later than January 1, 
2011, the Secretary shall develop a Physician Com-
pare Internet website with information on physicians 
enrolled in the Medicare program under section 
1866(j) of the Social Security Act (42 U.S.C. 
1395cc(j)) and other eligible professionals who par-
ticipate in the Physician Quality Reporting Initia-
tive under section 1848 of such Act (42 U.S.C. 
1395w–4). 
(2) PLAN.—Not later than January 1, 2013, and 
with respect to reporting periods that begin no earlier 
than January 1, 2012, the Secretary shall also imple-
ment a plan for making publicly available through 
Physician Compare, consistent with subsection (c), 
information on physician performance that provides 
comparable information for the public on quality and 
patient experience measures with respect to physi-
cians enrolled in the Medicare program under such 
section 1866(j). To the extent scientifically sound 
measures that are developed consistent with the re-
quirements of this section are available, such informa-
tion, to the extent practicable, shall include—
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HR 3590 EAS/PP 
(A) measures collected under the Physician 
Quality Reporting Initiative; 
(B) an assessment of patient health out-
comes and the functional status of patients; 
(C) an assessment of the continuity and co-
ordination of care and care transitions, includ-
ing episodes of care and risk-adjusted resource 
use; 
(D) an assessment of efficiency; 
(E) an assessment of patient experience and 
patient, caregiver, and family engagement; 
(F) an assessment of the safety, effectiveness, 
and timeliness of care; and 
(G) other information as determined appro-
priate by the Secretary. 
(b) OTHER REQUIRED CONSIDERATIONS.—In devel-
oping and implementing the plan described in subsection 
(a)(2), the Secretary shall, to the extent practicable, in-
clude— 
(1) processes to assure that data made public, ei-
ther by the Centers for Medicare & Medicaid Services 
or by other entities, is statistically valid and reliable, 
including risk adjustment mechanisms used by the 
Secretary;
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(2) processes by which a physician or other eligi-
ble professional whose performance on measures is 
being publicly reported has a reasonable opportunity, 
as determined by the Secretary, to review his or her 
individual results before they are made public; 
(3) processes by the Secretary to assure that the 
implementation of the plan and the data made avail-
able on Physician Compare provide a robust and ac-
curate portrayal of a physician’s performance; 
(4) data that reflects the care provided to all pa-
tients seen by physicians, under both the Medicare 
program and, to the extent practicable, other payers, 
to the extent such information would provide a more 
accurate portrayal of physician performance; 
(5) processes to ensure appropriate attribution of 
care when multiple physicians and other providers 
are involved in the care of a patient; 
(6) processes to ensure timely statistical perform-
ance feedback is provided to physicians concerning 
the data reported under any program subject to pub-
lic reporting under this section; and 
(7) implementation of computer and data sys-
tems of the Centers for Medicare & Medicaid Services 
that support valid, reliable, and accurate public re-
porting activities authorized under this section.
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(c) ENSURING PATIENT PRIVACY.—The Secretary shall 
ensure that information on physician performance and pa-
tient experience is not disclosed under this section in a 
manner that violates sections 552 or 552a of title 5, United 
States Code, with regard to the privacy of individually 
identifiable health information. 
(d) 
FEEDBACK
FROM
MULTI-STAKEHOLDER 
GROUPS.—The Secretary shall take into consideration 
input provided by multi-stakeholder groups, consistent with 
sections 1890(b)(7) and 1890A of the Social Security Act, 
as added by section 3014 of this Act, in selecting quality 
measures for use under this section. 
(e) CONSIDERATION OF TRANSITION TO VALUE-BASED 
PURCHASING.—In developing the plan under this sub-
section (a)(2), the Secretary shall, as the Secretary deter-
mines appropriate, consider the plan to transition to a 
value-based purchasing program for physicians and other 
practitioners developed under section 131 of the Medicare 
Improvements for Patients and Providers Act of 2008 (Pub-
lic Law 110–275). 
(f) REPORT TO CONGRESS.—Not later than January 
1, 2015, the Secretary shall submit to Congress a report 
on the Physician Compare Internet website developed under 
subsection (a)(1). Such report shall include information on 
the efforts of and plans made by the Secretary to collect
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and publish data on physician quality and efficiency and 
on patient experience of care in support of value-based pur-
chasing and consumer choice, together with recommenda-
tions for such legislation and administrative action as the 
Secretary determines appropriate. 
(g) EXPANSION.—At any time before the date on which 
the report is submitted under subsection (f), the Secretary 
may expand (including expansion to other providers of 
services and suppliers under title XVIII of the Social Secu-
rity Act) the information made available on such website. 
(h) FINANCIAL INCENTIVES TO ENCOURAGE CON-
SUMERS TO CHOOSE HIGH QUALITY PROVIDERS.—The 
Secretary may establish a demonstration program, not later 
than January 1, 2019, to provide financial incentives to 
Medicare beneficiaries who are furnished services by high 
quality physicians, as determined by the Secretary based 
on factors in subparagraphs (A) through (G) of subsection 
(a)(2). In no case may Medicare beneficiaries be required 
to pay increased premiums or cost sharing or be subject 
to a reduction in benefits under title XVIII of the Social 
Security Act as a result of such demonstration program. 
The Secretary shall ensure that any such demonstration 
program does not disadvantage those beneficiaries without 
reasonable access to high performing physicians or create 
financial inequities under such title.
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(i) DEFINITIONS.—In this section: 
(1) ELIGIBLE PROFESSIONAL.—The term ‘‘eligi-
ble professional’’ has the meaning given that term for 
purposes of the Physician Quality Reporting Initia-
tive under section 1848 of the Social Security Act (42 
U.S.C. 1395w–4). 
(2) PHYSICIAN.—The term ‘‘physician’’ has the 
meaning given that term in section 1861(r) of such 
Act (42 U.S.C. 1395x(r)). 
(3) PHYSICIAN COMPARE.—The term ‘‘Physician 
Compare’’ means the Internet website developed under 
subsection (a)(1). 
(4) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services. 
SEC. 10332. AVAILABILITY OF MEDICARE DATA FOR PER-
FORMANCE MEASUREMENT. 
(a) IN GENERAL.—Section 1874 of the Social Security 
Act (42 U.S.C. 1395kk) is amended by adding at the end 
the following new subsection: 
‘‘(e) AVAILABILITY OF MEDICARE DATA.— 
‘‘(1) IN GENERAL.—Subject to paragraph (4), the 
Secretary shall make available to qualified entities 
(as defined in paragraph (2)) data described in para-
graph (3) for the evaluation of the performance of 
providers of services and suppliers.
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‘‘(2) QUALIFIED ENTITIES.—For purposes of this 
subsection, the term ‘qualified entity’ means a public 
or private entity that— 
‘‘(A) is qualified (as determined by the Sec-
retary) to use claims data to evaluate the per-
formance of providers of services and suppliers 
on measures of quality, efficiency, effectiveness, 
and resource use; and 
‘‘(B) agrees to meet the requirements de-
scribed in paragraph (4) and meets such other 
requirements as the Secretary may specify, such 
as ensuring security of data. 
‘‘(3) DATA DESCRIBED.—The data described in 
this paragraph are standardized extracts (as deter-
mined by the Secretary) of claims data under parts 
A, B, and D for items and services furnished under 
such parts for one or more specified geographic areas 
and time periods requested by a qualified entity. The 
Secretary shall take such actions as the Secretary 
deems necessary to protect the identity of individuals 
entitled to or enrolled for benefits under such parts. 
‘‘(4) REQUIREMENTS.— 
‘‘(A) FEE.—Data described in paragraph 
(3) shall be made available to a qualified entity 
under this subsection at a fee equal to the cost
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of making such data available. Any fee collected 
pursuant to the preceding sentence shall be de-
posited into the Federal Supplementary Medical 
Insurance Trust Fund under section 1841. 
‘‘(B) SPECIFICATION OF USES AND METH-
ODOLOGIES.—A qualified entity requesting data 
under this subsection shall— 
‘‘(i) submit to the Secretary a descrip-
tion of the methodologies that such qualified 
entity will use to evaluate the performance 
of providers of services and suppliers using 
such data; 
‘‘(ii)(I) except as provided in subclause 
(II), if available, use standard measures, 
such as measures endorsed by the entity 
with a contract under section 1890(a) and 
measures developed pursuant to section 931 
of the Public Health Service Act; or 
‘‘(II) use alternative measures if the 
Secretary, in consultation with appropriate 
stakeholders, determines that use of such al-
ternative measures would be more valid, re-
liable, responsive to consumer preferences, 
cost-effective, or relevant to dimensions of
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quality and resource use not addressed by 
such standard measures; 
‘‘(iii) include data made available 
under this subsection with claims data from 
sources other than claims data under this 
title in the evaluation of performance of 
providers of services and suppliers; 
‘‘(iv) only include information on the 
evaluation of performance of providers and 
suppliers in reports described in subpara-
graph (C); 
‘‘(v) make available to providers of 
services and suppliers, upon their request, 
data made available under this subsection; 
and 
‘‘(vi) prior to their release, submit to 
the Secretary the format of reports under 
subparagraph (C). 
‘‘(C) REPORTS.—Any report by a qualified 
entity evaluating the performance of providers of 
services and suppliers using data made available 
under this subsection shall— 
‘‘(i) include an understandable descrip-
tion of the measures, which shall include 
quality measures and the rationale for use
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of other measures described in subparagraph 
(B)(ii)(II), risk adjustment methods, physi-
cian attribution methods, other applicable 
methods, data specifications and limita-
tions, and the sponsors, so that consumers, 
providers of services and suppliers, health 
plans, researchers, and other stakeholders 
can assess such reports; 
‘‘(ii) be made available confidentially, 
to any provider of services or supplier to be 
identified in such report, prior to the public 
release of such report, and provide an op-
portunity to appeal and correct errors; 
‘‘(iii) only include information on a 
provider of services or supplier in an aggre-
gate form as determined appropriate by the 
Secretary; and 
‘‘(iv) except as described in clause (ii), 
be made available to the public. 
‘‘(D) 
APPROVAL
AND
LIMITATION
OF 
USES.—The Secretary shall not make data de-
scribed in paragraph (3) available to a qualified 
entity unless the qualified entity agrees to release 
the information on the evaluation of performance 
of providers of services and suppliers. Such enti-
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ty shall only use such data, and information de-
rived from such evaluation, for the reports under 
subparagraph (C). Data released to a qualified 
entity under this subsection shall not be subject 
to discovery or admission as evidence in judicial 
or administrative proceedings without consent of 
the applicable provider of services or supplier.’’. 
(b) EFFECTIVE DATE.—The amendment made by sub-
section (a) shall take effect on January 1, 2012. 
SEC. 10333. COMMUNITY-BASED COLLABORATIVE CARE 
NETWORKS. 
Part D of title III of the Public Health Service Act 
(42 U.S.C. 254b et seq.) is amended by adding at the end 
the following new subpart: 
‘‘Subpart XI—Community-Based Collaborative Care 
Network Program 
‘‘SEC. 340H. COMMUNITY-BASED COLLABORATIVE CARE 
NETWORK PROGRAM. 
‘‘(a) IN GENERAL.—The Secretary may award grants 
to eligible entities to support community-based collaborative 
care networks that meet the requirements of subsection (b). 
‘‘(b) COMMUNITY-BASED COLLABORATIVE CARE NET-
WORKS.— 
‘‘(1) DESCRIPTION.—A community-based collabo-
rative care network (referred to in this section as a