H. R. 3590—623 
‘‘(i) limit the application of differential copayments under 
title XVIII based on factors such as cost or type of service; 
or 
‘‘(ii) prevent the Secretary from using evidence or findings 
from such comparative clinical effectiveness research in deter-
mining coverage, reimbursement, or incentive programs under 
such title based upon a comparison of the difference in the 
effectiveness of alternative health care treatments in extending 
an individual’s life due to that individual’s age, disability, or 
terminal illness. 
‘‘(3) Nothing in the provisions of, or amendments made by 
the Patient Protection and Affordable Care Act, shall be construed 
to limit comparative clinical effectiveness research or any other 
research, evaluation, or dissemination of information concerning 
the likelihood that a health care treatment will result in disability. 
‘‘(e) The Patient-Centered Outcomes Research Institute estab-
lished under section 1181(b)(1) shall not develop or employ a dollars- 
per-quality adjusted life year (or similar measure that discounts 
the value of a life because of an individual’s disability) as a 
threshold to establish what type of health care is cost effective 
or recommended. The Secretary shall not utilize such an adjusted 
life year (or such a similar measure) as a threshold to determine 
coverage, reimbursement, or incentive programs under title XVIII.’’. 
(d) IN GENERAL.—Part D of title XI of the Social Security 
Act, as added by subsection (a) and amended by subsection (c), 
is amended by adding at the end the following new section: 
‘‘TRUST FUND TRANSFERS TO PATIENT-CENTERED OUTCOMES 
RESEARCH TRUST FUND 
‘‘SEC. 1183. (a) IN GENERAL.—The Secretary shall provide for 
the transfer, from the Federal Hospital Insurance Trust Fund under 
section 1817 and the Federal Supplementary Medical Insurance 
Trust Fund under section 1841, in proportion (as estimated by 
the Secretary) to the total expenditures during such fiscal year 
that are made under title XVIII from the respective trust fund, 
to the Patient-Centered Outcomes Research Trust Fund (referred 
to in this section as the ‘PCORTF’) under section 9511 of the 
Internal Revenue Code of 1986, of the following: 
‘‘(1) For fiscal year 2013, an amount equal to $1 multiplied 
by the average number of individuals entitled to benefits under 
part A, or enrolled under part B, of title XVIII during such 
fiscal year. 
‘‘(2) For each of fiscal years 2014, 2015, 2016, 2017, 2018, 
and 2019, an amount equal to $2 multiplied by the average 
number of individuals entitled to benefits under part A, or 
enrolled under part B, of title XVIII during such fiscal year. 
‘‘(b) ADJUSTMENTS FOR INCREASES IN HEALTH CARE SPENDING.— 
In the case of any fiscal year beginning after September 30, 2014, 
the dollar amount in effect under subsection (a)(2) for such fiscal 
year shall be equal to the sum of such dollar amount for the 
previous fiscal year (determined after the application of this sub-
section), plus an amount equal to the product of— 
‘‘(1) such dollar amount for the previous fiscal year, multi-
plied by 
‘‘(2) the percentage increase in the projected per capita 
amount of National Health Expenditures, as most recently pub-
lished by the Secretary before the beginning of the fiscal year.’’.
H. R. 3590—624 
(e) PATIENT-CENTERED OUTCOMES RESEARCH TRUST FUND; 
FINANCING FOR TRUST FUND.— 
(1) ESTABLISHMENT OF TRUST FUND.— 
(A) IN GENERAL.—Subchapter A of chapter 98 of the 
Internal Revenue Code of 1986 (relating to establishment 
of trust funds) is amended by adding at the end the fol-
lowing new section: 
‘‘SEC. 9511. PATIENT-CENTERED OUTCOMES RESEARCH TRUST FUND. 
‘‘(a) CREATION OF TRUST FUND.—There is established in the 
Treasury of the United States a trust fund to be known as the 
‘Patient-Centered Outcomes Research Trust Fund’ (hereafter in this 
section referred to as the ‘PCORTF’), consisting of such amounts 
as may be appropriated or credited to such Trust Fund as provided 
in this section and section 9602(b). 
‘‘(b) TRANSFERS TO FUND.— 
‘‘(1) APPROPRIATION.—There are hereby appropriated to the 
Trust Fund the following: 
‘‘(A) For fiscal year 2010, $10,000,000. 
‘‘(B) For fiscal year 2011, $50,000,000. 
‘‘(C) For fiscal year 2012, $150,000,000. 
‘‘(D) For fiscal year 2013— 
‘‘(i) an amount equivalent to the net revenues 
received in the Treasury from the fees imposed under 
subchapter B of chapter 34 (relating to fees on health 
insurance and self-insured plans) for such fiscal year; 
and 
‘‘(ii) $150,000,000. 
‘‘(E) For each of fiscal years 2014, 2015, 2016, 2017, 
2018, and 2019— 
‘‘(i) an amount equivalent to the net revenues 
received in the Treasury from the fees imposed under 
subchapter B of chapter 34 (relating to fees on health 
insurance and self-insured plans) for such fiscal year; 
and 
‘‘(ii) $150,000,000. 
The amounts appropriated under subparagraphs (A), (B), 
(C), (D)(ii), and (E)(ii) shall be transferred from the general 
fund of the Treasury, from funds not otherwise appro-
priated. 
‘‘(2) TRUST FUND TRANSFERS.—In addition to the amounts 
appropriated under paragraph (1), there shall be credited to 
the PCORTF the amounts transferred under section 1183 of 
the Social Security Act. 
‘‘(3) LIMITATION
ON
TRANSFERS
TO
PCORTF.—No amount 
may be appropriated or transferred to the PCORTF on and 
after the date of any expenditure from the PCORTF which 
is not an expenditure permitted under this section. The deter-
mination of whether an expenditure is so permitted shall be 
made without regard to— 
‘‘(A) any provision of law which is not contained or 
referenced in this chapter or in a revenue Act, and 
‘‘(B) whether such provision of law is a subsequently 
enacted provision or directly or indirectly seeks to waive 
the application of this paragraph. 
‘‘(c) TRUSTEE.—The Secretary of the Treasury shall be a trustee 
of the PCORTF.
H. R. 3590—625 
‘‘(d) EXPENDITURES FROM FUND.— 
‘‘(1) AMOUNTS AVAILABLE TO THE PATIENT-CENTERED OUT-
COMES
RESEARCH
INSTITUTE.—Subject 
to 
paragraph 
(2), 
amounts in the PCORTF are available, without further appro-
priation, to the Patient-Centered Outcomes Research Institute 
established under section 1181(b) of the Social Security Act 
for carrying out part D of title XI of the Social Security Act 
(as in effect on the date of enactment of such Act). 
‘‘(2) TRANSFER OF FUNDS.— 
‘‘(A) IN GENERAL.—The trustee of the PCORTF shall 
provide for the transfer from the PCORTF of 20 percent 
of the amounts appropriated or credited to the PCORTF 
for each of fiscal years 2011 through 2019 to the Secretary 
of Health and Human Services to carry out section 937 
of the Public Health Service Act. 
‘‘(B) 
AVAILABILITY.—Amounts 
transferred 
under 
subparagraph (A) shall remain available until expended. 
‘‘(C) REQUIREMENTS.—Of the amounts transferred 
under subparagraph (A) with respect to a fiscal year, the 
Secretary of Health and Human Services shall distribute— 
‘‘(i) 80 percent to the Office of Communication 
and Knowledge Transfer of the Agency for Healthcare 
Research and Quality (or any other relevant office 
designated by Agency for Healthcare Research and 
Quality) to carry out the activities described in section 
937 of the Public Health Service Act; and 
‘‘(ii) 20 percent to the Secretary to carry out the 
activities described in such section 937. 
‘‘(e) NET REVENUES.—For purposes of this section, the term 
‘net revenues’ means the amount estimated by the Secretary of 
the Treasury based on the excess of— 
‘‘(1) the fees received in the Treasury under subchapter 
B of chapter 34, over 
‘‘(2) the decrease in the tax imposed by chapter 1 resulting 
from the fees imposed by such subchapter. 
‘‘(f) TERMINATION.—No amounts shall be available for expendi-
ture from the PCORTF after September 30, 2019, and any amounts 
in such Trust Fund after such date shall be transferred to the 
general fund of the Treasury.’’. 
(B) CLERICAL AMENDMENT.—The table of sections for 
subchapter A of chapter 98 of such Code is amended by 
adding at the end the following new item: 
‘‘Sec. 9511. Patient-centered outcomes research trust fund.’’. 
(2) FINANCING FOR FUND FROM FEES ON INSURED AND SELF- 
INSURED HEALTH PLANS.— 
(A) GENERAL RULE.—Chapter 34 of the Internal Rev-
enue Code of 1986 is amended by adding at the end the 
following new subchapter: 
‘‘Subchapter B—Insured and Self-Insured Health Plans 
‘‘Sec. 4375. Health insurance. 
‘‘Sec. 4376. Self-insured health plans. 
‘‘Sec. 4377. Definitions and special rules. 
‘‘SEC. 4375. HEALTH INSURANCE. 
‘‘(a) IMPOSITION OF FEE.—There is hereby imposed on each 
specified health insurance policy for each policy year ending after
H. R. 3590—626 
September 30, 2012, a fee equal to the product of $2 ($1 in the 
case of policy years ending during fiscal year 2013) multiplied 
by the average number of lives covered under the policy. 
‘‘(b) LIABILITY FOR FEE.—The fee imposed by subsection (a) 
shall be paid by the issuer of the policy. 
‘‘(c) SPECIFIED HEALTH INSURANCE POLICY.—For purposes of 
this section: 
‘‘(1) IN GENERAL.—Except as otherwise provided in this 
section, the term ‘specified health insurance policy’ means any 
accident or health insurance policy (including a policy under 
a group health plan) issued with respect to individuals residing 
in the United States. 
‘‘(2) EXEMPTION FOR CERTAIN POLICIES.—The term ‘specified 
health insurance policy’ does not include any insurance if 
substantially all of its coverage is of excepted benefits described 
in section 9832(c). 
‘‘(3) TREATMENT OF PREPAID HEALTH COVERAGE ARRANGE-
MENTS.— 
‘‘(A) IN
GENERAL.—In the case of any arrangement 
described in subparagraph (B), such arrangement shall 
be treated as a specified health insurance policy, and the 
person referred to in such subparagraph shall be treated 
as the issuer. 
‘‘(B) DESCRIPTION
OF
ARRANGEMENTS.—An arrange-
ment is described in this subparagraph if under such 
arrangement fixed payments or premiums are received as 
consideration for any person’s agreement to provide or 
arrange for the provision of accident or health coverage 
to residents of the United States, regardless of how such 
coverage is provided or arranged to be provided. 
‘‘(d) 
ADJUSTMENTS
FOR
INCREASES
IN
HEALTH
CARE 
SPENDING.—In the case of any policy year ending in any fiscal 
year beginning after September 30, 2014, the dollar amount in 
effect under subsection (a) for such policy year shall be equal 
to the sum of such dollar amount for policy years ending in the 
previous fiscal year (determined after the application of this sub-
section), plus an amount equal to the product of— 
‘‘(1) such dollar amount for policy years ending in the 
previous fiscal year, multiplied by 
‘‘(2) the percentage increase in the projected per capita 
amount of National Health Expenditures, as most recently pub-
lished by the Secretary before the beginning of the fiscal year. 
‘‘(e) TERMINATION.—This section shall not apply to policy years 
ending after September 30, 2019. 
‘‘SEC. 4376. SELF-INSURED HEALTH PLANS. 
‘‘(a) IMPOSITION OF FEE.—In the case of any applicable self- 
insured health plan for each plan year ending after September 
30, 2012, there is hereby imposed a fee equal to $2 ($1 in the 
case of plan years ending during fiscal year 2013) multiplied by 
the average number of lives covered under the plan. 
‘‘(b) LIABILITY FOR FEE.— 
‘‘(1) IN GENERAL.—The fee imposed by subsection (a) shall 
be paid by the plan sponsor. 
‘‘(2) PLAN SPONSOR.—For purposes of paragraph (1) the 
term ‘plan sponsor’ means—
H. R. 3590—627 
‘‘(A) the employer in the case of a plan established 
or maintained by a single employer, 
‘‘(B) the employee organization in the case of a plan 
established or maintained by an employee organization, 
‘‘(C) in the case of— 
‘‘(i) a plan established or maintained by 2 or more 
employers or jointly by 1 or more employers and 1 
or more employee organizations, 
‘‘(ii) a multiple employer welfare arrangement, or 
‘‘(iii) a voluntary employees’ beneficiary association 
described in section 501(c)(9), the association, com-
mittee, joint board of trustees, or other similar group 
of representatives of the parties who establish or main-
tain the plan, or 
‘‘(D) the cooperative or association described in sub-
section (c)(2)(F) in the case of a plan established or main-
tained by such a cooperative or association. 
‘‘(c) APPLICABLE SELF-INSURED HEALTH PLAN.—For purposes 
of this section, the term ‘applicable self-insured health plan’ means 
any plan for providing accident or health coverage if— 
‘‘(1) any portion of such coverage is provided other than 
through an insurance policy, and 
‘‘(2) such plan is established or maintained— 
‘‘(A) by 1 or more employers for the benefit of their 
employees or former employees, 
‘‘(B) by 1 or more employee organizations for the benefit 
of their members or former members, 
‘‘(C) jointly by 1 or more employers and 1 or more 
employee organizations for the benefit of employees or 
former employees, 
‘‘(D) by a voluntary employees’ beneficiary association 
described in section 501(c)(9), 
‘‘(E) by any organization described in section 501(c)(6), 
or 
‘‘(F) in the case of a plan not described in the preceding 
subparagraphs, by a multiple employer welfare arrange-
ment (as defined in section 3(40) of Employee Retirement 
Income Security Act of 1974), a rural electric cooperative 
(as defined in section 3(40)(B)(iv) of such Act), or a rural 
telephone cooperative association (as defined in section 
3(40)(B)(v) of such Act). 
‘‘(d) 
ADJUSTMENTS
FOR
INCREASES
IN
HEALTH
CARE 
SPENDING.—In the case of any plan year ending in any fiscal 
year beginning after September 30, 2014, the dollar amount in 
effect under subsection (a) for such plan year shall be equal to 
the sum of such dollar amount for plan years ending in the previous 
fiscal year (determined after the application of this subsection), 
plus an amount equal to the product of— 
‘‘(1) such dollar amount for plan years ending in the pre-
vious fiscal year, multiplied by 
‘‘(2) the percentage increase in the projected per capita 
amount of National Health Expenditures, as most recently pub-
lished by the Secretary before the beginning of the fiscal year. 
‘‘(e) TERMINATION.—This section shall not apply to plan years 
ending after September 30, 2019.
H. R. 3590—629 
‘‘CHAPTER 34—TAXES ON CERTAIN INSURANCE 
POLICIES 
‘‘SUBCHAPTER A. POLICIES ISSUED BY FOREIGN INSURERS 
‘‘SUBCHAPTER B. INSURED AND SELF-INSURED HEALTH PLANS 
‘‘Subchapter A—Policies Issued By Foreign Insurers’’. 
(ii) The table of chapters for subtitle D of such 
Code is amended by striking the item relating to 
chapter 34 and inserting the following new item: 
‘‘CHAPTER 34—TAXES ON CERTAIN INSURANCE POLICIES’’. 
(f) TAX-EXEMPT STATUS OF THE PATIENT-CENTERED OUTCOMES 
RESEARCH INSTITUTE.—Subsection 501(l) of the Internal Revenue 
Code of 1986 is amended by adding at the end the following new 
paragraph: 
‘‘(4) The Patient-Centered Outcomes Research Institute 
established under section 1181(b) of the Social Security Act.’’. 
SEC. 6302. FEDERAL COORDINATING COUNCIL FOR COMPARATIVE 
EFFECTIVENESS RESEARCH. 
Notwithstanding any other provision of law, the Federal Coordi-
nating Council for Comparative Effectiveness Research established 
under section 804 of Division A of the American Recovery and 
Reinvestment Act of 2009 (42 U.S.C. 299b–8), including the require-
ment under subsection (e)(2) of such section, shall terminate on 
the date of enactment of this Act. 
Subtitle E—Medicare, Medicaid, and CHIP 
Program Integrity Provisions 
SEC. 6401. PROVIDER SCREENING AND OTHER ENROLLMENT REQUIRE-
MENTS UNDER MEDICARE, MEDICAID, AND CHIP. 
(a) MEDICARE.—Section 1866(j) of the Social Security Act (42 
U.S.C. 1395cc(j)) is amended— 
(1) in paragraph (1)(A), by adding at the end the following: 
‘‘Such process shall include screening of providers and suppliers 
in accordance with paragraph (2), a provisional period of 
enhanced oversight in accordance with paragraph (3), disclosure 
requirements in accordance with paragraph (4), the imposition 
of temporary enrollment moratoria in accordance with para-
graph (5), and the establishment of compliance programs in 
accordance with paragraph (6).’’; 
(2) by redesignating paragraph (2) as paragraph (7); and 
(3) by inserting after paragraph (1) the following: 
‘‘(2) PROVIDER SCREENING.— 
‘‘(A) PROCEDURES.—Not later than 180 days after the 
date of enactment of this paragraph, the Secretary, in 
consultation with the Inspector General of the Department 
of Health and Human Services, shall establish procedures 
under which screening is conducted with respect to pro-
viders of medical or other items or services and suppliers 
under the program under this title, the Medicaid program 
under title XIX, and the CHIP program under title XXI.
H. R. 3590—630 
‘‘(B) LEVEL OF SCREENING.—The Secretary shall deter-
mine the level of screening conducted under this paragraph 
according to the risk of fraud, waste, and abuse, as deter-
mined by the Secretary, with respect to the category of 
provider of medical or other items or services or supplier. 
Such screening— 
‘‘(i) shall include a licensure check, which may 
include such checks across States; and 
‘‘(ii) may, as the Secretary determines appropriate 
based on the risk of fraud, waste, and abuse described 
in the preceding sentence, include— 
‘‘(I) a criminal background check; 
‘‘(II) fingerprinting; 
‘‘(III) unscheduled and unannounced site 
visits, including preenrollment site visits; 
‘‘(IV) database checks (including such checks 
across States); and 
‘‘(V) such other screening as the Secretary 
determines appropriate. 
‘‘(C) APPLICATION FEES.— 
‘‘(i) INDIVIDUAL PROVIDERS.—Except as provided in 
clause (iii), the Secretary shall impose a fee on each 
individual provider of medical or other items or services 
or supplier (such as a physician, physician assistant, 
nurse practitioner, or clinical nurse specialist) with 
respect to which screening is conducted under this 
paragraph in an amount equal to— 
‘‘(I) for 2010, $200; and 
‘‘(II) for 2011 and each subsequent year, the 
amount determined under this clause for the pre-
ceding year, adjusted by the percentage change 
in the consumer price index for all urban con-
sumers (all items; United States city average) for 
the 12-month period ending with June of the pre-
vious year. 
‘‘(ii) INSTITUTIONAL
PROVIDERS.—Except as pro-
vided in clause (iii), the Secretary shall impose a fee 
on each institutional provider of medical or other items 
or services or supplier (such as a hospital or skilled 
nursing facility) with respect to which screening is 
conducted under this paragraph in an amount equal 
to— 
‘‘(I) for 2010, $500; and 
‘‘(II) for 2011 and each subsequent year, the 
amount determined under this clause for the pre-
ceding year, adjusted by the percentage change 
in the consumer price index for all urban con-
sumers (all items; United States city average) for 
the 12-month period ending with June of the pre-
vious year. 
‘‘(iii) HARDSHIP EXCEPTION; WAIVER FOR CERTAIN 
MEDICAID PROVIDERS.—The Secretary may, on a case- 
by-case basis, exempt a provider of medical or other 
items or services or supplier from the imposition of 
an application fee under this subparagraph if the Sec-
retary determines that the imposition of the application 
fee would result in a hardship. The Secretary may
H. R. 3590—631 
waive the application fee under this subparagraph for 
providers enrolled in a State Medicaid program for 
whom the State demonstrates that imposition of the 
fee would impede beneficiary access to care. 
‘‘(iv) USE OF FUNDS.—Amounts collected as a result 
of the imposition of a fee under this subparagraph 
shall be used by the Secretary for program integrity 
efforts, including to cover the costs of conducting 
screening under this paragraph and to carry out this 
subsection and section 1128J. 
‘‘(D) APPLICATION AND ENFORCEMENT.— 
‘‘(i) NEW PROVIDERS OF SERVICES AND SUPPLIERS.— 
The screening under this paragraph shall apply, in 
the case of a provider of medical or other items or 
services or supplier who is not enrolled in the program 
under this title, title XIX , or title XXI as of the 
date of enactment of this paragraph, on or after the 
date that is 1 year after such date of enactment. 
‘‘(ii) CURRENT PROVIDERS OF SERVICES AND SUP-
PLIERS.—The screening under this paragraph shall 
apply, in the case of a provider of medical or other 
items or services or supplier who is enrolled in the 
program under this title, title XIX, or title XXI as 
of such date of enactment, on or after the date that 
is 2 years after such date of enactment. 
‘‘(iii) REVALIDATION
OF
ENROLLMENT.—Effective 
beginning on the date that is 180 days after such 
date of enactment, the screening under this paragraph 
shall apply with respect to the revalidation of enroll-
ment of a provider of medical or other items or services 
or supplier in the program under this title, title XIX, 
or title XXI. 
‘‘(iv) LIMITATION ON ENROLLMENT AND REVALIDA-
TION OF ENROLLMENT.—In no case may a provider of 
medical or other items or services or supplier who 
has not been screened under this paragraph be initially 
enrolled or reenrolled in the program under this title, 
title XIX, or title XXI on or after the date that is 
3 years after such date of enactment. 
‘‘(E) EXPEDITED
RULEMAKING.—The Secretary may 
promulgate an interim final rule to carry out this para-
graph. 
‘‘(3) PROVISIONAL PERIOD OF ENHANCED OVERSIGHT FOR NEW 
PROVIDERS OF SERVICES AND SUPPLIERS.— 
‘‘(A) IN GENERAL.—The Secretary shall establish proce-
dures to provide for a provisional period of not less than 
30 days and not more than 1 year during which new 
providers of medical or other items or services and sup-
pliers, as the Secretary determines appropriate, including 
categories of providers or suppliers, would be subject to 
enhanced oversight, such as prepayment review and pay-
ment caps, under the program under this title, the Medicaid 
program under title XIX. and the CHIP program under 
title XXI. 
‘‘(B) IMPLEMENTATION.—The Secretary may establish 
by program instruction or otherwise the procedures under 
this paragraph.
H. R. 3590—632 
‘‘(4) INCREASED DISCLOSURE REQUIREMENTS.— 
‘‘(A) DISCLOSURE.—A provider of medical or other items 
or services or supplier who submits an application for 
enrollment or revalidation of enrollment in the program 
under this title, title XIX, or title XXI on or after the 
date that is 1 year after the date of enactment of this 
paragraph shall disclose (in a form and manner and at 
such time as determined by the Secretary) any current 
or previous affiliation (directly or indirectly) with a provider 
of medical or other items or services or supplier that has 
uncollected debt, has been or is subject to a payment 
suspension under a Federal health care program (as defined 
in section 1128B(f)), has been excluded from participation 
under the program under this title, the Medicaid program 
under title XIX, or the CHIP program under title XXI, 
or has had its billing privileges denied or revoked. 
‘‘(B) AUTHORITY
TO
DENY
ENROLLMENT.—If the Sec-
retary determines that such previous affiliation poses an 
undue risk of fraud, waste, or abuse, the Secretary may 
deny such application. Such a denial shall be subject to 
appeal in accordance with paragraph (7). 
‘‘(5) AUTHORITY
TO
ADJUST
PAYMENTS
OF
PROVIDERS
OF 
SERVICES AND SUPPLIERS WITH THE SAME TAX IDENTIFICATION 
NUMBER FOR PAST-DUE OBLIGATIONS.— 
‘‘(A) IN GENERAL.—Notwithstanding any other provi-
sion of this title, in the case of an applicable provider 
of services or supplier, the Secretary may make any nec-
essary adjustments to payments to the applicable provider 
of services or supplier under the program under this title 
in order to satisfy any past-due obligations described in 
subparagraph (B)(ii) of an obligated provider of services 
or supplier. 
‘‘(B) DEFINITIONS.—In this paragraph: 
‘‘(i) IN
GENERAL.—The term ‘applicable provider 
of services or supplier’ means a provider of services 
or supplier that has the same taxpayer identification 
number assigned under section 6109 of the Internal 
Revenue Code of 1986 as is assigned to the obligated 
provider of services or supplier under such section, 
regardless of whether the applicable provider of serv-
ices or supplier is assigned a different billing number 
or national provider identification number under the 
program under this title than is assigned to the obli-
gated provider of services or supplier. 
‘‘(ii) OBLIGATED
PROVIDER
OF
SERVICES
OR
SUP-
PLIER.—The term ‘obligated provider of services or sup-
plier’ means a provider of services or supplier that 
owes a past-due obligation under the program under 
this title (as determined by the Secretary). 
‘‘(6) TEMPORARY MORATORIUM ON ENROLLMENT OF NEW PRO-
VIDERS.— 
‘‘(A) IN GENERAL.—The Secretary may impose a tem-
porary moratorium on the enrollment of new providers 
of services and suppliers, including categories of providers 
of services and suppliers, in the program under this title, 
under the Medicaid program under title XIX, or under
H. R. 3590—633 
the CHIP program under title XXI if the Secretary deter-
mines such moratorium is necessary to prevent or combat 
fraud, waste, or abuse under either such program. 
‘‘(B) LIMITATION ON REVIEW.—There shall be no judicial 
review under section 1869, section 1878, or otherwise, of 
a temporary moratorium imposed under subparagraph (A). 
‘‘(7) COMPLIANCE PROGRAMS.— 
‘‘(A) IN GENERAL.—On or after the date of implementa-
tion determined by the Secretary under subparagraph (C), 
a provider of medical or other items or services or supplier 
within a particular industry sector or category shall, as 
a condition of enrollment in the program under this title, 
title XIX, or title XXI, establish a compliance program 
that contains the core elements established under subpara-
graph (B) with respect to that provider or supplier and 
industry or category. 
‘‘(B) ESTABLISHMENT
OF
CORE
ELEMENTS.—The Sec-
retary, in consultation with the Inspector General of the 
Department of Health and Human Services, shall establish 
core elements for a compliance program under subpara-
graph (A) for providers or suppliers within a particular 
industry or category. 
‘‘(C) TIMELINE FOR IMPLEMENTATION.—The Secretary 
shall determine the timeline for the establishment of the 
core elements under subparagraph (B) and the date of 
the implementation of subparagraph (A) for providers or 
suppliers within a particular industry or category. The 
Secretary shall, in determining such date of implementa-
tion, consider the extent to which the adoption of compli-
ance programs by a provider of medical or other items 
or services or supplier is widespread in a particular 
industry sector or with respect to a particular provider 
or supplier category.’’. 
(b) MEDICAID.— 
(1) STATE PLAN AMENDMENT.—Section 1902(a) of the Social 
Security Act (42 U.S.C. 1396a(a)), as amended by section 
4302(b), is amended— 
(A) in subsection (a)— 
(i) by striking ‘‘and’’ at the end of paragraph (75); 
(ii) by striking the period at the end of paragraph 
(76) and inserting a semicolon; and 
(iii) by inserting after paragraph (76) the following: 
‘‘(77) provide that the State shall comply with provider 
and supplier screening, oversight, and reporting requirements 
in accordance with subsection (ii);’’; and 
(B) by adding at the end the following: 
‘‘(ii) PROVIDER
AND SUPPLIER SCREENING, OVERSIGHT, AND 
REPORTING REQUIREMENTS.—For purposes of subsection (a)(77), the 
requirements of this subsection are the following: 
‘‘(1) SCREENING.—The State complies with the process for 
screening providers and suppliers under this title, as estab-
lished by the Secretary under section 1886(j)(2). 
‘‘(2) PROVISIONAL PERIOD OF ENHANCED OVERSIGHT FOR NEW 
PROVIDERS
AND
SUPPLIERS.—The State complies with proce-
dures to provide for a provisional period of enhanced oversight 
for new providers and suppliers under this title, as established 
by the Secretary under section 1886(j)(3).
H. R. 3590—634 
‘‘(3) DISCLOSURE REQUIREMENTS.—The State requires pro-
viders and suppliers under the State plan or under a waiver 
of the plan to comply with the disclosure requirements estab-
lished by the Secretary under section 1886(j)(4). 
‘‘(4) TEMPORARY MORATORIUM ON ENROLLMENT OF NEW PRO-
VIDERS OR SUPPLIERS.— 
‘‘(A) TEMPORARY MORATORIUM IMPOSED BY THE SEC-
RETARY.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), the State 
complies with any temporary moratorium on the enroll-
ment of new providers or suppliers imposed by the 
Secretary under section 1886(j)(6). 
‘‘(ii) EXCEPTION.—A State shall not be required 
to comply with a temporary moratorium described in 
clause (i) if the State determines that the imposition 
of such temporary moratorium would adversely impact 
beneficiaries’ access to medical assistance. 
‘‘(B) MORATORIUM ON ENROLLMENT OF PROVIDERS AND 
SUPPLIERS.—At the option of the State, the State imposes, 
for purposes of entering into participation agreements with 
providers or suppliers under the State plan or under a 
waiver of the plan, periods of enrollment moratoria, or 
numerical caps or other limits, for providers or suppliers 
identified by the Secretary as being at high-risk for fraud, 
waste, or abuse as necessary to combat fraud, waste, or 
abuse, but only if the State determines that the imposition 
of any such period, cap, or other limits would not adversely 
impact beneficiaries’ access to medical assistance. 
‘‘(5) COMPLIANCE PROGRAMS.—The State requires providers 
and suppliers under the State plan or under a waiver of the 
plan to establish, in accordance with the requirements of section 
1866(j)(7), a compliance program that contains the core ele-
ments established under subparagraph (B) of that section 
1866(j)(7) for providers or suppliers within a particular industry 
or category. 
‘‘(6) REPORTING OF ADVERSE PROVIDER ACTIONS.—The State 
complies with the national system for reporting criminal and 
civil convictions, sanctions, negative licensure actions, and other 
adverse provider actions to the Secretary, through the Adminis-
trator of the Centers for Medicare & Medicaid Services, in 
accordance with regulations of the Secretary. 
‘‘(7) ENROLLMENT AND NPI OF ORDERING OR REFERRING PRO-
VIDERS.—The State requires— 
‘‘(A) all ordering or referring physicians or other profes-
sionals to be enrolled under the State plan or under a 
waiver of the plan as a participating provider; and 
‘‘(B) the national provider identifier of any ordering 
or referring physician or other professional to be specified 
on any claim for payment that is based on an order or 
referral of the physician or other professional. 
‘‘(8) OTHER STATE OVERSIGHT.—Nothing in this subsection 
shall be interpreted to preclude or limit the ability of a State 
to engage in provider and supplier screening or enhanced pro-
vider and supplier oversight activities beyond those required 
by the Secretary.’’. 
(2) DISCLOSURE OF MEDICARE TERMINATED PROVIDERS AND 
SUPPLIERS TO STATES.—The Administrator of the Centers for
H. R. 3590—635 
Medicare & Medicaid Services shall establish a process for 
making available to the each State agency with responsibility 
for administering a State Medicaid plan (or a waiver of such 
plan) under title XIX of the Social Security Act or a child 
health plan under title XXI the name, national provider identi-
fier, and other identifying information for any provider of med-
ical or other items or services or supplier under the Medicare 
program under title XVIII or under the CHIP program under 
title XXI that is terminated from participation under that pro-
gram within 30 days of the termination (and, with respect 
to all such providers or suppliers who are terminated from 
the Medicare program on the date of enactment of this Act, 
within 90 days of such date). 
(3) CONFORMING AMENDMENT.—Section 1902(a)(23) of the 
Social Security Act (42 U.S.C. 1396a), is amended by inserting 
before the semicolon at the end the following: ‘‘or by a provider 
or supplier to which a moratorium under subsection (ii)(4) 
is applied during the period of such moratorium’’. 
(c) CHIP.—Section 2107(e)(1) of the Social Security Act (42 
U.S.C. 1397gg(e)(1)), as amended by section 2101(d), is amended— 
(1) by redesignating subparagraphs (D) through (M) as 
subparagraphs (E) through (N), respectively; and 
(2) by inserting after subparagraph (C), the following: 
‘‘(D) Subsections (a)(77) and (ii) of section 1902 
(relating to provider and supplier screening, oversight, and 
reporting requirements).’’. 
SEC. 6402. ENHANCED MEDICARE AND MEDICAID PROGRAM INTEG-
RITY PROVISIONS. 
(a) IN GENERAL.—Part A of title XI of the Social Security 
Act (42 U.S.C. 1301 et seq.), as amended by sections 6002, 6004, 
and 6102, is amended by inserting after section 1128I the following 
new section: 
‘‘SEC. 1128J. MEDICARE AND MEDICAID PROGRAM INTEGRITY PROVI-
SIONS. 
‘‘(a) DATA MATCHING.— 
‘‘(1) INTEGRATED DATA REPOSITORY.— 
‘‘(A) INCLUSION OF CERTAIN DATA.— 
‘‘(i) IN GENERAL.—The Integrated Data Repository 
of the Centers for Medicare & Medicaid Services shall 
include, at a minimum, claims and payment data from 
the following: 
‘‘(I) The programs under titles XVIII and XIX 
(including parts A, B, C, and D of title XVIII). 
‘‘(II) The program under title XXI. 
‘‘(III) Health-related programs administered 
by the Secretary of Veterans Affairs. 
‘‘(IV) Health-related programs administered by 
the Secretary of Defense. 
‘‘(V) The program of old-age, survivors, and 
disability insurance benefits established under 
title II. 
‘‘(VI) The Indian Health Service and the Con-
tract Health Service program. 
‘‘(ii) PRIORITY FOR INCLUSION OF CERTAIN DATA.— 
Inclusion of the data described in subclause (I) of such 
clause in the Integrated Data Repository shall be a
H. R. 3590—636 
priority. Data described in subclauses (II) through (VI) 
of such clause shall be included in the Integrated Data 
Repository as appropriate. 
‘‘(B) DATA SHARING AND MATCHING.— 
‘‘(i) IN GENERAL.—The Secretary shall enter into 
agreements with the individuals described in clause 
(ii) under which such individuals share and match 
data in the system of records of the respective agencies 
of such individuals with data in the system of records 
of the Department of Health and Human Services for 
the purpose of identifying potential fraud, waste, and 
abuse under the programs under titles XVIII and XIX. 
‘‘(ii) 
INDIVIDUALS
DESCRIBED.—The 
following 
individuals are described in this clause: 
‘‘(I) The Commissioner of Social Security. 
‘‘(II) The Secretary of Veterans Affairs. 
‘‘(III) The Secretary of Defense. 
‘‘(IV) The Director of the Indian Health 
Service. 
‘‘(iii) DEFINITION OF SYSTEM OF RECORDS.—For pur-
poses of this paragraph, the term ‘system of records’ 
has the meaning given such term in section 552a(a)(5) 
of title 5, United States Code. 
‘‘(2) ACCESS TO CLAIMS AND PAYMENT DATABASES.—For pur-
poses of conducting law enforcement and oversight activities 
and to the extent consistent with applicable information, pri-
vacy, security, and disclosure laws, including the regulations 
promulgated under the Health Insurance Portability and 
Accountability Act of 1996 and section 552a of title 5, United 
States Code, and subject to any information systems security 
requirements under such laws or otherwise required by the 
Secretary, the Inspector General of the Department of Health 
and Human Services and the Attorney General shall have 
access to claims and payment data of the Department of Health 
and Human Services and its contractors related to titles XVIII, 
XIX, and XXI. 
‘‘(b) OIG AUTHORITY TO OBTAIN INFORMATION.— 
‘‘(1) IN GENERAL.—Notwithstanding and in addition to any 
other provision of law, the Inspector General of the Department 
of Health and Human Services may, for purposes of protecting 
the integrity of the programs under titles XVIII and XIX, 
obtain information from any individual (including a beneficiary 
provided all applicable privacy protections are followed) or 
entity that— 
‘‘(A) is a provider of medical or other items or services, 
supplier, grant recipient, contractor, or subcontractor; or 
‘‘(B) directly or indirectly provides, orders, manufac-
tures, distributes, arranges for, prescribes, supplies, or 
receives medical or other items or services payable by 
any Federal health care program (as defined in section 
1128B(f)) regardless of how the item or service is paid 
for, or to whom such payment is made. 
‘‘(2) INCLUSION
OF
CERTAIN
INFORMATION.—Information 
which the Inspector General may obtain under paragraph (1) 
includes any supporting documentation necessary to validate 
claims for payment or payments under title XVIII or XIX,
H. R. 3590—637 
including a prescribing physician’s medical records for an indi-
vidual who is prescribed an item or service which is covered 
under part B of title XVIII, a covered part D drug (as defined 
in section 1860D–2(e)) for which payment is made under an 
MA–PD plan under part C of such title, or a prescription 
drug plan under part D of such title, and any records necessary 
for evaluation of the economy, efficiency, and effectiveness of 
the programs under titles XVIII and XIX. 
‘‘(c) ADMINISTRATIVE REMEDY FOR KNOWING PARTICIPATION BY 
BENEFICIARY IN HEALTH CARE FRAUD SCHEME.— 
‘‘(1) IN GENERAL.—In addition to any other applicable rem-
edies, if an applicable individual has knowingly participated 
in a Federal health care fraud offense or a conspiracy to commit 
a Federal health care fraud offense, the Secretary shall impose 
an appropriate administrative penalty commensurate with the 
offense or conspiracy. 
‘‘(2) APPLICABLE INDIVIDUAL.—For purposes of paragraph 
(1), the term ‘applicable individual’ means an individual— 
‘‘(A) entitled to, or enrolled for, benefits under part 
A of title XVIII or enrolled under part B of such title; 
‘‘(B) eligible for medical assistance under a State plan 
under title XIX or under a waiver of such plan; or 
‘‘(C) eligible for child health assistance under a child 
health plan under title XXI. 
‘‘(d) REPORTING AND RETURNING OF OVERPAYMENTS.— 
‘‘(1) IN GENERAL.—If a person has received an overpayment, 
the person shall— 
‘‘(A) report and return the overpayment to the Sec-
retary, the State, an intermediary, a carrier, or a con-
tractor, as appropriate, at the correct address; and 
‘‘(B) notify the Secretary, State, intermediary, carrier, 
or contractor to whom the overpayment was returned in 
writing of the reason for the overpayment. 
‘‘(2) DEADLINE FOR REPORTING AND RETURNING OVERPAY-
MENTS.—An overpayment must be reported and returned under 
paragraph (1) by the later of— 
‘‘(A) the date which is 60 days after the date on which 
the overpayment was identified; or 
‘‘(B) the date any corresponding cost report is due, 
if applicable. 
‘‘(3) ENFORCEMENT.—Any overpayment retained by a per-
son after the deadline for reporting and returning the overpay-
ment under paragraph (2) is an obligation (as defined in section 
3729(b)(3) of title 31, United States Code) for purposes of section 
3729 of such title. 
‘‘(4) DEFINITIONS.—In this subsection: 
‘‘(A) KNOWING AND KNOWINGLY.—The terms ‘knowing’ 
and ‘knowingly’ have the meaning given those terms in 
section 3729(b) of title 31, United States Code. 
‘‘(B) OVERPAYMENT.—The term ‘‘overpayment’’ means 
any funds that a person receives or retains under title 
XVIII or XIX to which the person, after applicable reconcili-
ation, is not entitled under such title. 
‘‘(C) PERSON.— 
‘‘(i) IN GENERAL.—The term ‘person’ means a pro-
vider of services, supplier, medicaid managed care 
organization (as defined in section 1903(m)(1)(A)),