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‘‘(d) REPORT.—The Secretary shall submit to the Con-
gress an annual report on the program carried out under 
this section.’’. 
(2) Section 770(a) of the Public Health Service 
Act (42 U.S.C. 295e(a)) is amended to read as fol-
lows: 
‘‘(a) IN GENERAL.—For the purpose of carrying out 
this subpart, there is authorized to be appropriated 
$43,000,000 for fiscal year 2011, and such sums as may 
be necessary for each of the fiscal years 2012 through 
2015.’’. 
(n)(1) Subsection (i) of section 331 of the Public 
Health Service Act (42 U.S.C. 254d) of the Public Health 
Service Act is amended— 
(A) in paragraph (1), by striking ‘‘In carrying 
out subpart III’’ and all that follows through the pe-
riod and inserting ‘‘In carrying out subpart III, the 
Secretary may, in accordance with this subsection, 
issue waivers to individuals who have entered into a 
contract for obligated service under the Scholarship 
Program or the Loan Repayment Program under 
which the individuals are authorized to satisfy the re-
quirement of obligated service through providing clin-
ical practice that is half time.’’; 
(B) in paragraph (2)—
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(i) in subparagraphs (A)(ii) and (B), by 
striking ‘‘less than full time’’ each place it ap-
pears and inserting ‘‘half time’’; 
(ii) in subparagraphs (C) and (F), by strik-
ing ‘‘less than full-time service’’ each place it ap-
pears and inserting ‘‘half-time service’’; and 
(iii) by amending subparagraphs (D) and 
(E) to read as follows: 
‘‘(D) the entity and the Corps member agree in 
writing that the Corps member will perform half-time 
clinical practice; 
‘‘(E) the Corps member agrees in writing to ful-
fill all of the service obligations under section 338C 
through half-time clinical practice and either— 
‘‘(i) double the period of obligated service 
that would otherwise be required; or 
‘‘(ii) in the case of contracts entered into 
under section 338B, accept a minimum service 
obligation of 2 years with an award amount 
equal to 50 percent of the amount that would 
otherwise be payable for full-time service; and’’; 
and 
(C) in paragraph (3), by striking ‘‘In evaluating 
a demonstration project described in paragraph (1)’’
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and inserting ‘‘In evaluating waivers issued under 
paragraph (1)’’. 
(2) Subsection (j) of section 331 of the Public Health 
Service Act (42 U.S.C. 254d) is amended by adding at the 
end the following: 
‘‘(5) The terms ‘full time’ and ‘full-time’ mean a 
minimum of 40 hours per week in a clinical practice, 
for a minimum of 45 weeks per year. 
‘‘(6) The terms ‘half time’ and ‘half-time’ mean 
a minimum of 20 hours per week (not to exceed 39 
hours per week) in a clinical practice, for a min-
imum of 45 weeks per year.’’. 
(3) Section 337(b)(1) of the Public Health Service Act 
(42 U.S.C. 254j(b)(1)) is amended by striking ‘‘Members 
may not be reappointed to the Council.’’. 
(4) Section 338B(g)(2)(A) of the Public Health Service 
Act (42 U.S.C. 254l–1(g)(2)(A)) is amended by striking 
‘‘$35,000’’ and inserting ‘‘$50,000, plus, beginning with fis-
cal year 2012, an amount determined by the Secretary on 
an annual basis to reflect inflation,’’. 
(5) Subsection (a) of section 338C of the Public Health 
Service Act (42 U.S.C. 254m), as amended by section 5508, 
is amended— 
(A) by striking the second sentence and inserting 
the following: ‘‘The Secretary may treat teaching as
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clinical practice for up to 20 percent of such period 
of obligated service.’’; and 
(B) by adding at the end the following: ‘‘Not-
withstanding the preceding sentence, with respect to a 
member of the Corps participating in the teaching 
health centers graduate medical education program 
under section 340H, for the purpose of calculating 
time spent in full-time clinical practice under this 
section, up to 50 percent of time spent teaching by 
such member may be counted toward his or her serv-
ice obligation.’’. 
SEC. 10502. INFRASTRUCTURE TO EXPAND ACCESS TO 
CARE. 
(a) APPROPRIATION.—There are authorized to be ap-
propriated, and there are appropriated to the Department 
of Health and Human Services, $100,000,000 for fiscal year 
2010, to remain available for obligation until September 
30, 2011, to be used for debt service on, or direct construc-
tion or renovation of, a health care facility that provides 
research, inpatient tertiary care, or outpatient clinical serv-
ices. Such facility shall be affiliated with an academic 
health center at a public research university in the United 
States that contains a State’s sole public academic medical 
and dental school.
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(b) REQUIREMENT.—Amount appropriated under sub-
section (a) may only be made available by the Secretary 
of Health and Human Services upon the receipt of an ap-
plication from the Governor of a State that certifies that— 
(1) the new health care facility is critical for the 
provision of greater access to health care within the 
State; 
(2) such facility is essential for the continued fi-
nancial viability of the State’s sole public medical 
and dental school and its academic health center; 
(3) the request for Federal support represents not 
more than 40 percent of the total cost of the proposed 
new facility; and 
(4) the State has established a dedicated funding 
mechanism to provide all remaining funds necessary 
to complete the construction or renovation of the pro-
posed facility. 
SEC. 10503. COMMUNITY HEALTH CENTERS AND THE NA-
TIONAL HEALTH SERVICE CORPS FUND. 
(a) PURPOSE.—It is the purpose of this section to es-
tablish a Community Health Center Fund (referred to in 
this section as the ‘‘CHC Fund’’), to be administered 
through the Office of the Secretary of the Department of 
Health and Human Services to provide for expanded and 
sustained national investment in community health centers
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under section 330 of the Public Health Service Act and the 
National Health Service Corps. 
(b) FUNDING.—There is authorized to be appropriated, 
and there is appropriated, out of any monies in the Treas-
ury not otherwise appropriated, to the CHC Fund— 
(1) to be transferred to the Secretary of Health 
and Human Services to provide enhanced funding for 
the community health center program under section 
330 of the Public Health Service Act— 
(A) $700,000,000 for fiscal year 2011; 
(B) $800,000,000 for fiscal year 2012; 
(C) $1,000,000,000 for fiscal year 2013; 
(D) $1,600,000,000 for fiscal year 2014; 
and 
(E) $2,900,000,000 for fiscal year 2015; 
and 
(2) to be transferred to the Secretary of Health 
and Human Services to provide enhanced funding for 
the National Health Service Corps— 
(A) $290,000,000 for fiscal year 2011; 
(B) $295,000,000 for fiscal year 2012; 
(C) $300,000,000 for fiscal year 2013; 
(D) $305,000,000 for fiscal year 2014; and 
(E) $310,000,000 for fiscal year 2015.
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(c) CONSTRUCTION.—There is authorized to be appro-
priated, and there is appropriated, out of any monies in 
the Treasury not otherwise appropriated, $1,500,000,000 to 
be available for fiscal years 2011 through 2015 to be used 
by the Secretary of Health and Human Services for the con-
struction and renovation of community health centers. 
(d) USE OF FUND.—The Secretary of Health and 
Human Services shall transfer amounts in the CHC Fund 
to accounts within the Department of Health and Human 
Services to increase funding, over the fiscal year 2008 level, 
for community health centers and the National Health 
Service Corps. 
(e) AVAILABILITY.—Amounts appropriated under sub-
sections (b) and (c) shall remain available until expended. 
SEC. 10504. DEMONSTRATION PROJECT TO PROVIDE AC-
CESS TO AFFORDABLE CARE. 
(a) IN GENERAL.—Not later than 6 months after the 
date of enactment of this Act, the Secretary of Health and 
Human Services (referred to in this section as the ‘‘Sec-
retary’’), acting through the Health Resources and Services 
Administration, shall establish a 3 year demonstration 
project in up to 10 States to provide access to comprehensive 
health care services to the uninsured at reduced fees. The 
Secretary shall evaluate the feasibility of expanding the 
project to additional States.
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(b) ELIGIBILITY.—To be eligible to participate in the 
demonstration project, an entity shall be a State-based, 
nonprofit, public-private partnership that provides access 
to comprehensive health care services to the uninsured at 
reduced fees. Each State in which a participant selected by 
the Secretary is located shall receive not more than 
$2,000,000 to establish and carry out the project for the 3- 
year demonstration period. 
(c) AUTHORIZATION.—There is authorized to be appro-
priated such sums as may be necessary to carry out this 
section. 
Subtitle F—Provisions Relating to 
Title VI 
SEC. 10601. REVISIONS TO LIMITATION ON MEDICARE EX-
CEPTION TO THE PROHIBITION ON CERTAIN 
PHYSICIAN REFERRALS FOR HOSPITALS. 
(a) IN GENERAL.—Section 1877(i) of the Social Secu-
rity Act, as added by section 6001(a), is amended— 
(1) in paragraph (1)(A)(i), by striking ‘‘Feb-
ruary 1, 2010’’ and inserting ‘‘August 1, 2010’’; and 
(2) in paragraph (3)(A)— 
(A) in clause (iii), by striking ‘‘August 1, 
2011’’ and inserting ‘‘February 1, 2012’’; and 
(B) in clause (iv), by striking ‘‘July 1, 
2011’’ and inserting ‘‘January 1, 2012’’.
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(b) CONFORMING AMENDMENT.—Section 6001(b)(2) of 
this Act is amended by striking ‘‘November 1, 2011’’ and 
inserting ‘‘May 1, 2012’’. 
SEC. 10602. CLARIFICATIONS TO PATIENT-CENTERED OUT-
COMES RESEARCH. 
Section 1181 of the Social Security Act (as added by 
section 6301) is amended— 
(1) in subsection (d)(2)(B)— 
(A) in clause (ii)(IV)— 
(i) by inserting ‘‘, as described in sub-
paragraph (A)(ii),’’ after ‘‘original re-
search’’; and 
(ii) by inserting ‘‘, as long as the re-
searcher enters into a data use agreement 
with the Institute for use of the data from 
the original research, as appropriate’’ after 
‘‘publication’’; and 
(B) by amending clause (iv) to read as fol-
lows: 
‘‘(iv) 
SUBSEQUENT
USE
OF
THE 
DATA.—The Institute shall not allow the 
subsequent use of data from original re-
search in work-for-hire contracts with indi-
viduals, entities, or instrumentalities that 
have a financial interest in the results, un-
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less approved under a data use agreement 
with the Institute.’’; 
(2) in subsection (d)(8)(A)(iv), by striking ‘‘not 
be construed as mandates for’’ and inserting ‘‘do not 
include’’; and 
(3) in subsection (f)(1)(C), by amending clause 
(ii) to read as follows: 
‘‘(ii) 7 members representing physi-
cians and providers, including 4 members 
representing physicians (at least 1 of whom 
is a surgeon), 1 nurse, 1 State-licensed inte-
grative health care practitioner, and 1 rep-
resentative of a hospital.’’. 
SEC. 10603. STRIKING PROVISIONS RELATING TO INDI-
VIDUAL PROVIDER APPLICATION FEES. 
(a) IN GENERAL.—Section 1866(j)(2)(C) of the Social 
Security Act, as added by section 6401(a), is amended— 
(1) by striking clause (i); 
(2) by redesignating clauses (ii) through (iv), re-
spectively, as clauses (i) through (iii); and 
(3) in clause (i), as redesignated by paragraph 
(2), by striking ‘‘clause (iii)’’ and inserting ‘‘clause 
(ii)’’. 
(b) TECHNICAL CORRECTION.—Section 6401(a)(2) of 
this Act is amended to read as follows:
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‘‘(2) by redesignating paragraph (2) as para-
graph (8); and’’. 
SEC. 10604. TECHNICAL CORRECTION TO SECTION 6405. 
Paragraphs (1) and (2) of section 6405(b) are amend-
ed to read as follows: 
‘‘(1) PART A.—Section 1814(a)(2) of the Social 
Security Act (42 U.S.C. 1395(a)(2)) is amended in 
the matter preceding subparagraph (A) by inserting 
‘, or, in the case of services described in subparagraph 
(C), a physician enrolled under section 1866(j),’ after 
‘in collaboration with a physician,’. 
‘‘(2) PART B.—Section 1835(a)(2) of the Social 
Security Act (42 U.S.C. 1395n(a)(2)) is amended in 
the matter preceding subparagraph (A) by inserting 
‘, or, in the case of services described in subparagraph 
(A), a physician enrolled under section 1866(j),’ after 
‘a physician’.’’. 
SEC. 10605. CERTAIN OTHER PROVIDERS PERMITTED TO 
CONDUCT FACE TO FACE ENCOUNTER FOR 
HOME HEALTH SERVICES. 
(a) PART A.—Section 1814(a)(2)(C) of the Social Se-
curity Act (42 U.S.C. 1395f(a)(2)(C)), as amended by sec-
tion 6407(a)(1), is amended by inserting ‘‘, or a nurse prac-
titioner or clinical nurse specialist (as those terms are de-
fined in section 1861(aa)(5)) who is working in collabora-
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tion with the physician in accordance with State law, or 
a certified nurse-midwife (as defined in section 1861(gg)) 
as authorized by State law, or a physician assistant (as 
defined in section 1861(aa)(5)) under the supervision of the 
physician,’’ after ‘‘himself or herself’’. 
(b) PART B.—Section 1835(a)(2)(A)(iv) of the Social 
Security Act, as added by section 6407(a)(2), is amended 
by inserting ‘‘, or a nurse practitioner or clinical nurse spe-
cialist (as those terms are defined in section 1861(aa)(5)) 
who is working in collaboration with the physician in ac-
cordance with State law, or a certified nurse-midwife (as 
defined in section 1861(gg)) as authorized by State law, or 
a physician assistant (as defined in section 1861(aa)(5)) 
under the supervision of the physician,’’ after ‘‘must docu-
ment that the physician’’. 
SEC. 10606. HEALTH CARE FRAUD ENFORCEMENT. 
(a) FRAUD SENTENCING GUIDELINES.— 
(1) DEFINITION.—In this subsection, the term 
‘‘Federal health care offense’’ has the meaning given 
that term in section 24 of title 18, United States 
Code, as amended by this Act. 
(2) REVIEW
AND
AMENDMENTS.—Pursuant to 
the authority under section 994 of title 28, United 
States Code, and in accordance with this subsection, 
the United States Sentencing Commission shall—
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(A) review the Federal Sentencing Guide-
lines and policy statements applicable to persons 
convicted of Federal health care offenses; 
(B) amend the Federal Sentencing Guide-
lines and policy statements applicable to persons 
convicted of Federal health care offenses involv-
ing Government health care programs to provide 
that the aggregate dollar amount of fraudulent 
bills submitted to the Government health care 
program shall constitute prima facie evidence of 
the amount of the intended loss by the defendant; 
and 
(C) amend the Federal Sentencing Guide-
lines to provide— 
(i) a 2-level increase in the offense level 
for any defendant convicted of a Federal 
health care offense relating to a Government 
health care program which involves a loss of 
not less than $1,000,000 and less than 
$7,000,000; 
(ii) a 3-level increase in the offense 
level for any defendant convicted of a Fed-
eral health care offense relating to a Gov-
ernment health care program which involves
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a loss of not less than $7,000,000 and less 
than $20,000,000; 
(iii) a 4-level increase in the offense 
level for any defendant convicted of a Fed-
eral health care offense relating to a Gov-
ernment health care program which involves 
a loss of not less than $20,000,000; and 
(iv) if appropriate, otherwise amend 
the Federal Sentencing Guidelines and pol-
icy statements applicable to persons con-
victed of Federal health care offenses involv-
ing Government health care programs. 
(3) REQUIREMENTS.—In carrying this sub-
section, the United States Sentencing Commission 
shall— 
(A) ensure that the Federal Sentencing 
Guidelines and policy statements— 
(i) reflect the serious harms associated 
with health care fraud and the need for ag-
gressive and appropriate law enforcement 
action to prevent such fraud; and 
(ii) provide increased penalties for per-
sons convicted of health care fraud offenses 
in appropriate circumstances;
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(B) consult with individuals or groups rep-
resenting health care fraud victims, law enforce-
ment officials, the health care industry, and the 
Federal judiciary as part of the review described 
in paragraph (2); 
(C) ensure reasonable consistency with other 
relevant directives and with other guidelines 
under the Federal Sentencing Guidelines; 
(D) account for any aggravating or miti-
gating circumstances that might justify excep-
tions, including circumstances for which the Fed-
eral Sentencing Guidelines, as in effect on the 
date of enactment of this Act, provide sentencing 
enhancements; 
(E) make any necessary conforming changes 
to the Federal Sentencing Guidelines; and 
(F) ensure that the Federal Sentencing 
Guidelines adequately meet the purposes of sen-
tencing. 
(b) INTENT
REQUIREMENT
FOR
HEALTH
CARE 
FRAUD.—Section 1347 of title 18, United States Code, is 
amended— 
(1) by inserting ‘‘(a)’’ before ‘‘Whoever know-
ingly’’; and 
(2) by adding at the end the following:
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‘‘(b) With respect to violations of this section, a person 
need not have actual knowledge of this section or specific 
intent to commit a violation of this section.’’. 
(c) HEALTH CARE FRAUD OFFENSE.—Section 24(a) 
of title 18, United States Code, is amended— 
(1) in paragraph (1), by striking the semicolon 
and inserting ‘‘or section 1128B of the Social Secu-
rity Act (42 U.S.C. 1320a–7b); or’’; and 
(2) in paragraph (2)— 
(A) by inserting ‘‘1349,’’ after ‘‘1343,’’; and 
(B) by inserting ‘‘section 301 of the Federal 
Food, Drug, and Cosmetic Act (21 U.S.C. 331), 
or section 501 of the Employee Retirement In-
come Security Act of 1974 (29 U.S.C. 1131),’’ 
after ‘‘title,’’. 
(d) SUBPOENA AUTHORITY RELATING
TO HEALTH 
CARE.— 
(1) SUBPOENAS UNDER THE HEALTH INSURANCE 
PORTABILITY
AND
ACCOUNTABILITY
ACT
OF
1996.— 
Section 1510(b) of title 18, United States Code, is 
amended— 
(A) in paragraph (1), by striking ‘‘to the 
grand jury’’; and 
(B) in paragraph (2)—
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(i) in subparagraph (A), by striking 
‘‘grand jury subpoena’’ and inserting ‘‘sub-
poena for records’’; and 
(ii) in the matter following subpara-
graph (B), by striking ‘‘to the grand jury’’. 
(2) SUBPOENAS UNDER THE CIVIL RIGHTS OF IN-
STITUTIONALIZED PERSONS ACT.—The Civil Rights of 
Institutionalized Persons Act (42 U.S.C. 1997 et seq.) 
is amended by inserting after section 3 the following: 
‘‘SEC. 3A. SUBPOENA AUTHORITY. 
‘‘(a) AUTHORITY.—The Attorney General, or at the 
direction of the Attorney General, any officer or employee 
of the Department of Justice may require by subpoena 
access to any institution that is the subject of an investiga-
tion under this Act and to any document, record, material, 
file, report, memorandum, policy, procedure, investigation, 
video or audio recording, or quality assurance report relat-
ing to any institution that is the subject of an investiga-
tion under this Act to determine whether there are condi-
tions which deprive persons residing in or confined to the 
institution of any rights, privileges, or immunities secured 
or protected by the Constitution or laws of the United 
States. 
‘‘(b) ISSUANCE
AND
ENFORCEMENT
OF
SUB-
POENAS.—
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‘‘(1) ISSUANCE.—Subpoenas issued under this 
section— 
‘‘(A) shall bear the signature of the Attor-
ney General or any officer or employee of the 
Department of Justice as designated by the At-
torney General; and 
‘‘(B) shall be served by any person or class 
of persons designated by the Attorney General 
or a designated officer or employee for that 
purpose. 
‘‘(2) ENFORCEMENT.—In the case of contu-
macy or failure to obey a subpoena issued under this 
section, the United States district court for the judi-
cial district in which the institution is located may 
issue an order requiring compliance. Any failure to 
obey the order of the court may be punished by the 
court as a contempt that court. 
‘‘(c) PROTECTION OF SUBPOENAED RECORDS AND IN-
FORMATION.—Any document, record, material, file, report, 
memorandum, policy, procedure, investigation, video or 
audio recording, or quality assurance report or other infor-
mation obtained under a subpoena issued under this sec-
tion— 
‘‘(1) may not be used for any purpose other than 
to protect the rights, privileges, or immunities secured
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or protected by the Constitution or laws of the United 
States of persons who reside, have resided, or will re-
side in an institution; 
‘‘(2) may not be transmitted by or within the 
Department of Justice for any purpose other than to 
protect the rights, privileges, or immunities secured or 
protected by the Constitution or laws of the United 
States of persons who reside, have resided, or will re-
side in an institution; and 
‘‘(3) shall be redacted, obscured, or otherwise al-
tered if used in any publicly available manner so as 
to prevent the disclosure of any personally identifiable 
information.’’. 
SEC. 10607. STATE DEMONSTRATION PROGRAMS TO EVALU-
ATE ALTERNATIVES TO CURRENT MEDICAL 
TORT LITIGATION. 
Part P of title III of the Public Health Service Act 
(42 U.S.C. 280g et seq.), as amended by this Act, is further 
amended by adding at the end the following: 
‘‘SEC. 399V–4. STATE DEMONSTRATION PROGRAMS TO 
EVALUATE ALTERNATIVES TO CURRENT MED-
ICAL TORT LITIGATION. 
‘‘(a) IN GENERAL.—The Secretary is authorized to 
award demonstration grants to States for the development, 
implementation, and evaluation of alternatives to current
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tort litigation for resolving disputes over injuries allegedly 
caused by health care providers or health care organiza-
tions. In awarding such grants, the Secretary shall ensure 
the diversity of the alternatives so funded. 
‘‘(b) DURATION.—The Secretary may award grants 
under subsection (a) for a period not to exceed 5 years. 
‘‘(c) CONDITIONS FOR DEMONSTRATION GRANTS.— 
‘‘(1) REQUIREMENTS.—Each State desiring a 
grant under subsection (a) shall develop an alter-
native to current tort litigation that— 
‘‘(A) allows for the resolution of disputes 
over injuries allegedly caused by health care pro-
viders or health care organizations; and 
‘‘(B) promotes a reduction of health care er-
rors by encouraging the collection and analysis 
of patient safety data related to disputes resolved 
under subparagraph (A) by organizations that 
engage in efforts to improve patient safety and 
the quality of health care. 
‘‘(2) ALTERNATIVE TO CURRENT TORT LITIGA-
TION.—Each State desiring a grant under subsection 
(a) shall demonstrate how the proposed alternative de-
scribed in paragraph (1)(A)—
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‘‘(A) makes the medical liability system 
more reliable by increasing the availability of 
prompt and fair resolution of disputes; 
‘‘(B) encourages the efficient resolution of 
disputes; 
‘‘(C) encourages the disclosure of health care 
errors; 
‘‘(D) enhances patient safety by detecting, 
analyzing, and helping to reduce medical errors 
and adverse events; 
‘‘(E) improves access to liability insurance; 
‘‘(F) fully informs patients about the dif-
ferences in the alternative and current tort liti-
gation; 
‘‘(G) provides patients the ability to opt out 
of or voluntarily withdraw from participating in 
the alternative at any time and to pursue other 
options, including litigation, outside the alter-
native; 
‘‘(H) would not conflict with State law at 
the time of the application in a way that would 
prohibit the adoption of an alternative to current 
tort litigation; and 
‘‘(I) would not limit or curtail a patient’s 
existing legal rights, ability to file a claim in or
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access a State’s legal system, or otherwise abro-
gate a patient’s ability to file a medical mal-
practice claim. 
‘‘(3) SOURCES OF COMPENSATION.—Each State 
desiring a grant under subsection (a) shall identify 
the sources from and methods by which compensation 
would be paid for claims resolved under the proposed 
alternative to current tort litigation, which may in-
clude public or private funding sources, or a com-
bination of such sources. Funding methods shall to the 
extent practicable provide financial incentives for ac-
tivities that improve patient safety. 
‘‘(4) SCOPE.— 
‘‘(A) IN GENERAL.—Each State desiring a 
grant under subsection (a) shall establish a scope 
of jurisdiction (such as Statewide, designated ge-
ographic region, a designated area of health care 
practice, or a designated group of health care 
providers or health care organizations) for the 
proposed alternative to current tort litigation 
that is sufficient to evaluate the effects of the al-
ternative. No scope of jurisdiction shall be estab-
lished under this paragraph that is based on a 
health care payer or patient population.
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‘‘(B) NOTIFICATION OF PATIENTS.—A State 
shall demonstrate how patients would be notified 
that they are receiving health care services that 
fall within such scope, and the process by which 
they may opt out of or voluntarily withdraw 
from participating in the alternative. The deci-
sion of the patient whether to participate or con-
tinue participating in the alternative process 
shall be made at any time and shall not be lim-
ited in any way. 
‘‘(5) PREFERENCE
IN
AWARDING
DEMONSTRA-
TION GRANTS.—In awarding grants under subsection 
(a), the Secretary shall give preference to States— 
‘‘(A) that have developed the proposed alter-
native through substantive consultation with rel-
evant stakeholders, including patient advocates, 
health care providers and health care organiza-
tions, attorneys with expertise in representing 
patients and health care providers, medical mal-
practice insurers, and patient safety experts; 
‘‘(B) that make proposals that are likely to 
enhance patient safety by detecting, analyzing, 
and helping to reduce medical errors and adverse 
events; and
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‘‘(C) that make proposals that are likely to 
improve access to liability insurance. 
‘‘(d) APPLICATION.— 
‘‘(1) IN GENERAL.—Each State desiring a grant 
under subsection (a) shall submit to the Secretary an 
application, at such time, in such manner, and con-
taining such information as the Secretary may re-
quire. 
‘‘(2) REVIEW PANEL.— 
‘‘(A) IN GENERAL.—In reviewing applica-
tions under paragraph (1), the Secretary shall 
consult with a review panel composed of relevant 
experts appointed by the Comptroller General. 
‘‘(B) COMPOSITION.— 
‘‘(i) NOMINATIONS.—The Comptroller 
General shall solicit nominations from the 
public for individuals to serve on the review 
panel. 
‘‘(ii) APPOINTMENT.—The Comptroller 
General shall appoint, at least 9 but not 
more than 13, highly qualified and knowl-
edgeable individuals to serve on the review 
panel and shall ensure that the following 
entities receive fair representation on such 
panel:
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‘‘(I) Patient advocates. 
‘‘(II) Health care providers and 
health care organizations. 
‘‘(III) Attorneys with expertise in 
representing patients and health care 
providers. 
‘‘(IV) Medical malpractice insur-
ers. 
‘‘(V) State officials. 
‘‘(VI) Patient safety experts. 
‘‘(C) CHAIRPERSON.—The Comptroller Gen-
eral, or an individual within the Government 
Accountability Office designated by the Comp-
troller General, shall be the chairperson of the re-
view panel. 
‘‘(D) AVAILABILITY OF INFORMATION.—The 
Comptroller General shall make available to the 
review panel such information, personnel, and 
administrative services and assistance as the re-
view panel may reasonably require to carry out 
its duties. 
‘‘(E) INFORMATION FROM AGENCIES.—The 
review panel may request directly from any de-
partment or agency of the United States any in-
formation that such panel considers necessary to
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carry out its duties. To the extent consistent with 
applicable laws and regulations, the head of such 
department or agency shall furnish the requested 
information to the review panel. 
‘‘(e) REPORTS.— 
‘‘(1) BY STATE.—Each State receiving a grant 
under subsection (a) shall submit to the Secretary an 
annual report evaluating the effectiveness of activities 
funded with grants awarded under such subsection. 
Such report shall, at a minimum, include the impact 
of the activities funded on patient safety and on the 
availability and price of medical liability insurance. 
‘‘(2) BY SECRETARY.—The Secretary shall sub-
mit to Congress an annual compendium of the reports 
submitted under paragraph (1) and an analysis of 
the activities funded under subsection (a) that exam-
ines any differences that result from such activities in 
terms of the quality of care, number and nature of 
medical errors, medical resources used, length of time 
for dispute resolution, and the availability and price 
of liability insurance. 
‘‘(f) TECHNICAL ASSISTANCE.— 
‘‘(1) IN GENERAL.—The Secretary shall provide 
technical assistance to the States applying for or 
awarded grants under subsection (a).
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‘‘(2) 
REQUIREMENTS.—Technical 
assistance 
under paragraph (1) shall include— 
‘‘(A) guidance on non-economic damages, 
including the consideration of individual facts 
and circumstances in determining appropriate 
payment, guidance on identifying avoidable in-
juries, and guidance on disclosure to patients of 
health care errors and adverse events; and 
‘‘(B) the development, in consultation with 
States, of common definitions, formats, and data 
collection infrastructure for States receiving 
grants under this section to use in reporting to 
facilitate aggregation and analysis of data both 
within and between States. 
‘‘(3) USE OF COMMON DEFINITIONS, FORMATS, 
AND
DATA
COLLECTION
INFRASTRUCTURE.—States 
not receiving grants under this section may also use 
the common definitions, formats, and data collection 
infrastructure developed under paragraph (2)(B). 
‘‘(g) EVALUATION.— 
‘‘(1) IN GENERAL.—The Secretary, in consulta-
tion with the review panel established under sub-
section (d)(2), shall enter into a contract with an ap-
propriate research organization to conduct an overall 
evaluation of the effectiveness of grants awarded
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under subsection (a) and to annually prepare and 
submit a report to Congress. Such an evaluation shall 
begin not later than 18 months following the date of 
implementation of the first program funded by a 
grant under subsection (a). 
‘‘(2) CONTENTS.—The evaluation under para-
graph (1) shall include— 
‘‘(A) an analysis of the effects of the grants 
awarded under subsection (a) with regard to the 
measures described in paragraph (3); 
‘‘(B) for each State, an analysis of the ex-
tent to which the alternative developed under 
subsection (c)(1) is effective in meeting the ele-
ments described in subsection (c)(2); 
‘‘(C) a comparison among the States receiv-
ing grants under subsection (a) of the effective-
ness of the various alternatives developed by such 
States under subsection (c)(1); 
‘‘(D) a comparison, considering the meas-
ures described in paragraph (3), of States receiv-
ing grants approved under subsection (a) and 
similar States not receiving such grants; and 
‘‘(E) a comparison, with regard to the 
measures described in paragraph (3), of—
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‘‘(i) States receiving grants under sub-
section (a); 
‘‘(ii) States that enacted, prior to the 
date of enactment of the Patient Protection 
and Affordable Care Act, any cap on non- 
economic damages; and 
‘‘(iii) States that have enacted, prior to 
the date of enactment of the Patient Protec-
tion and Affordable Care Act, a requirement 
that the complainant obtain an opinion re-
garding the merit of the claim, although the 
substance of such opinion may have no 
bearing on whether the complainant may 
proceed with a case. 
‘‘(3) MEASURES.—The evaluations under para-
graph (2) shall analyze and make comparisons on the 
basis of— 
‘‘(A) the nature and number of disputes 
over injuries allegedly caused by health care pro-
viders or health care organizations; 
‘‘(B) the nature and number of claims in 
which tort litigation was pursued despite the ex-
istence of an alternative under subsection (a);
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‘‘(C) the disposition of disputes and claims, 
including the length of time and estimated costs 
to all parties; 
‘‘(D) the medical liability environment; 
‘‘(E) health care quality; 
‘‘(F) patient safety in terms of detecting, 
analyzing, and helping to reduce medical errors 
and adverse events; 
‘‘(G) patient and health care provider and 
organization satisfaction with the alternative 
under subsection (a) and with the medical liabil-
ity environment; and 
‘‘(H) impact on utilization of medical serv-
ices, appropriately adjusted for risk. 
‘‘(4) FUNDING.—The Secretary shall reserve 5 
percent of the amount appropriated in each fiscal 
year under subsection (k) to carry out this subsection. 
‘‘(h) MEDPAC AND MACPAC REPORTS.— 
‘‘(1) MEDPAC.—The Medicare Payment Advi-
sory Commission shall conduct an independent review 
of the alternatives to current tort litigation that are 
implemented under grants under subsection (a) to de-
termine the impact of such alternatives on the Medi-
care program under title XVIII of the Social Security 
Act, and its beneficiaries.
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‘‘(2) MACPAC.—The Medicaid and CHIP Pay-
ment and Access Commission shall conduct an inde-
pendent review of the alternatives to current tort liti-
gation that are implemented under grants under sub-
section (a) to determine the impact of such alter-
natives on the Medicaid or CHIP programs under ti-
tles XIX and XXI of the Social Security Act, and 
their beneficiaries. 
‘‘(3) REPORTS.—Not later than December 31, 
2016, the Medicare Payment Advisory Commission 
and the Medicaid and CHIP Payment and Access 
Commission shall each submit to Congress a report 
that includes the findings and recommendations of 
each respective Commission based on independent re-
views conducted under paragraphs (1) and (2), in-
cluding an analysis of the impact of the alternatives 
reviewed on the efficiency and effectiveness of the re-
spective programs. 
‘‘(i) OPTION TO PROVIDE
FOR INITIAL PLANNING 
GRANTS.—Of the funds appropriated pursuant to sub-
section (k), the Secretary may use a portion not to exceed 
$500,000 per State to provide planning grants to such 
States for the development of demonstration project applica-
tions meeting the criteria described in subsection (c). In se-
lecting States to receive such planning grants, the Secretary
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shall give preference to those States in which State law at 
the time of the application would not prohibit the adoption 
of an alternative to current tort litigation. 
‘‘(j) DEFINITIONS.—In this section: 
‘‘(1) HEALTH CARE SERVICES.—The term ‘health 
care services’ means any services provided by a health 
care provider, or by any individual working under 
the supervision of a health care provider, that relate 
to— 
‘‘(A) the diagnosis, prevention, or treatment 
of any human disease or impairment; or 
‘‘(B) the assessment of the health of human 
beings. 
‘‘(2) HEALTH CARE ORGANIZATION.—The term 
‘health care organization’ means any individual or 
entity which is obligated to provide, pay for, or ad-
minister health benefits under any health plan. 
‘‘(3) 
HEALTH
CARE
PROVIDER.—The 
term 
‘health care provider’ means any individual or enti-
ty— 
‘‘(A) licensed, registered, or certified under 
Federal or State laws or regulations to provide 
health care services; or
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‘‘(B) required to be so licensed, registered, 
or certified but that is exempted by other statute 
or regulation. 
‘‘(k) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated to carry out this section, 
$50,000,000 for the 5-fiscal year period beginning with fis-
cal year 2011. 
‘‘(l) CURRENT STATE EFFORTS TO ESTABLISH AL-
TERNATIVE TO TORT LITIGATION.—Nothing in this section 
shall be construed to limit any prior, current, or future ef-
forts of any State to establish any alternative to tort litiga-
tion. 
‘‘(m) RULE OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed as limiting states’ authority over 
or responsibility for their state justice systems.’’. 
SEC. 10608. EXTENSION OF MEDICAL MALPRACTICE COV-
ERAGE TO FREE CLINICS. 
(a) IN GENERAL.—Section 224(o)(1) of the Public 
Health Service Act (42 U.S.C. 233(o)(1)) is amended by 
inserting after ‘‘to an individual’’ the following: ‘‘, or an 
officer, governing board member, employee, or contractor of 
a free clinic shall in providing services for the free clinic,’’. 
(b) EFFECTIVE DATE.—The amendment made by this 
section shall take effect on the date of enactment of this Act
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and apply to any act or omission which occurs on or after 
that date. 
SEC. 10609. LABELING CHANGES. 
Section 505(j) of the Federal Food, Drug, and Cos-
metic Act (21 U.S.C. 355(j)) is amended by adding at the 
end the following: 
‘‘(10)(A) If the proposed labeling of a drug that is the 
subject of an application under this subsection differs from 
the listed drug due to a labeling revision described under 
clause (i), the drug that is the subject of such application 
shall, notwithstanding any other provision of this Act, be 
eligible for approval and shall not be considered misbranded 
under section 502 if— 
‘‘(i) the application is otherwise eligible for ap-
proval under this subsection but for expiration of pat-
ent, an exclusivity period, or of a delay in approval 
described in paragraph (5)(B)(iii), and a revision to 
the labeling of the listed drug has been approved by 
the Secretary within 60 days of such expiration; 
‘‘(ii) the labeling revision described under clause 
(i) does not include a change to the ‘Warnings’ sec-
tion of the labeling; 
‘‘(iii) the sponsor of the application under this 
subsection agrees to submit revised labeling of the 
drug that is the subject of such application not later
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than 60 days after the notification of any changes to 
such labeling required by the Secretary; and 
‘‘(iv) such application otherwise meets the appli-
cable requirements for approval under this subsection. 
‘‘(B) If, after a labeling revision described in subpara-
graph (A)(i), the Secretary determines that the continued 
presence in interstate commerce of the labeling of the listed 
drug (as in effect before the revision described in subpara-
graph (A)(i)) adversely impacts the safe use of the drug, 
no application under this subsection shall be eligible for ap-
proval with such labeling.’’. 
Subtitle G—Provisions Relating to 
Title VIII 
SEC. 10801. PROVISIONS RELATING TO TITLE VIII. 
(a) Title XXXII of the Public Health Service Act, as 
added by section 8002(a)(1), is amended— 
(1) in section 3203— 
(A) in subsection (a)(1), by striking sub-
paragraph (E); 
(B) in subsection (b)(1)(C)(i), by striking 
‘‘for enrollment’’ and inserting ‘‘for reenroll-
ment’’; and 
(C) in subsection (c)(1), by striking ‘‘, as 
part of their automatic enrollment in the 
CLASS program,’’; and
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(2) in section 3204— 
(A) in subsection (c)(2), by striking sub-
paragraph (A) and inserting the following: 
‘‘(A) receives wages or income on which 
there is imposed a tax under section 3101(a) or 
3201(a) of the Internal Revenue Code of 1986; 
or’’; 
(B) in subsection (d), by striking ‘‘subpara-
graph (B) or (C) of subsection (c)(1)’’ and in-
serting ‘‘subparagraph (A) or (B) of subsection 
(c)(2)’’; 
(C) in subsection (e)(2)(A), by striking 
‘‘subparagraph (A)’’ and inserting ‘‘paragraph 
(1)’’; and 
(D) in subsection (g)(1), by striking ‘‘has 
elected to waive enrollment’’ and inserting ‘‘has 
not enrolled’’. 
(b) Section 8002 of this Act is amended in the heading 
for subsection (d), by striking ‘‘INFORMATION ON SUPPLE-
MENTAL COVERAGE’’ and inserting ‘‘CLASS PROGRAM IN-
FORMATION’’. 
(c) Section 6021(d)(2)(A)(iv) of the Deficit Reduction 
Act of 2005, as added by section 8002(d) of this Act, is 
amended by striking ‘‘and coverage available’’ and all that 
follows through ‘‘that program,’’.
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Subtitle H—Provisions Relating to 
Title IX 
SEC. 10901. MODIFICATIONS TO EXCISE TAX ON HIGH COST 
EMPLOYER-SPONSORED HEALTH COVERAGE. 
(a) LONGSHORE WORKERS TREATED AS EMPLOYEES 
ENGAGED IN HIGH-RISK PROFESSIONS.—Paragraph (3) of 
section 4980I(f) of the Internal Revenue Code of 1986, as 
added by section 9001 of this Act, is amended by inserting 
‘‘individuals whose primary work is longshore work (as de-
fined in section 258(b) of the Immigration and Nationality 
Act (8 U.S.C. 1288(b)), determined without regard to para-
graph (2) thereof),’’ before ‘‘and individuals engaged in the 
construction, mining’’. 
(b) EXEMPTION FROM HIGH-COST INSURANCE TAX IN-
CLUDES CERTAIN ADDITIONAL EXCEPTED BENEFITS.— 
Clause (i) of section 4980I(d)(1)(B) of the Internal Revenue 
Code of 1986, as added by section 9001 of this Act, is 
amended by striking ‘‘section 9832(c)(1)(A)’’ and inserting 
‘‘section 9832(c)(1) (other than subparagraph (G) thereof)’’. 
(c) EFFECTIVE DATE.—The amendments made by this 
section shall apply to taxable years beginning after Decem-
ber 31, 2012.
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SEC. 10902. INFLATION ADJUSTMENT OF LIMITATION ON 
HEALTH 
FLEXIBLE 
SPENDING 
ARRANGE-
MENTS UNDER CAFETERIA PLANS. 
(a) IN GENERAL.—Subsection (i) of section 125 of the 
Internal Revenue Code of 1986, as added by section 9005 
of this Act, is amended to read as follows: 
‘‘(i) LIMITATION ON HEALTH FLEXIBLE SPENDING 
ARRANGEMENTS.— 
‘‘(1) IN GENERAL.—For purposes of this section, 
if a benefit is provided under a cafeteria plan through 
employer contributions to a health flexible spending 
arrangement, such benefit shall not be treated as a 
qualified benefit unless the cafeteria plan provides 
that an employee may not elect for any taxable year 
to have salary reduction contributions in excess of 
$2,500 made to such arrangement. 
‘‘(2) ADJUSTMENT FOR INFLATION.—In the case 
of any taxable year beginning after December 31, 
2011, the dollar amount in paragraph (1) shall be in-
creased by an amount equal to— 
‘‘(A) such amount, multiplied by 
‘‘(B) the cost-of-living adjustment deter-
mined under section 1(f)(3) for the calendar year 
in which such taxable year begins by sub-
stituting ‘calendar year 2010’ for ‘calendar year 
1992’ in subparagraph (B) thereof.
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If any increase determined under this paragraph is 
not a multiple of $50, such increase shall be rounded 
to the next lowest multiple of $50.’’. 
(b) EFFECTIVE DATE.—The amendment made by this 
section shall apply to taxable years beginning after Decem-
ber 31, 2010. 
SEC. 10903. MODIFICATION OF LIMITATION ON CHARGES BY 
CHARITABLE HOSPITALS. 
(a) IN
GENERAL.—Subparagraph (A) of section 
501(r)(5) of the Internal Revenue Code of 1986, as added 
by section 9007 of this Act, is amended by striking ‘‘the 
lowest amounts charged’’ and inserting ‘‘the amounts gen-
erally billed’’. 
(b) EFFECTIVE DATE.—The amendment made by this 
section shall apply to taxable years beginning after the date 
of the enactment of this Act. 
SEC. 10904. MODIFICATION OF ANNUAL FEE ON MEDICAL 
DEVICE MANUFACTURERS AND IMPORTERS. 
(a) IN GENERAL.—Section 9009 of this Act is amend-
ed— 
(1) by striking ‘‘2009’’ in subsection (a)(1) and 
inserting ‘‘2010’’, 
(2) by inserting ‘‘($3,000,000,000 after 2017)’’ 
after ‘‘$2,000,000,000’’, and
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(3) by striking ‘‘2008’’ in subsection (i) and in-
serting ‘‘2009’’. 
(b) EFFECTIVE DATE.—The amendments made by this 
section shall take effect as if included in the enactment of 
section 9009. 
SEC. 10905. MODIFICATION OF ANNUAL FEE ON HEALTH IN-
SURANCE PROVIDERS. 
(a) DETERMINATION OF FEE AMOUNT.—Subsection 
(b) of section 9010 of this Act is amended to read as follows: 
‘‘(b) DETERMINATION OF FEE AMOUNT.— 
‘‘(1) IN GENERAL.—With respect to each covered 
entity, the fee under this section for any calendar 
year shall be equal to an amount that bears the same 
ratio to the applicable amount as— 
‘‘(A) the covered entity’s net premiums 
written with respect to health insurance for any 
United States health risk that are taken into ac-
count during the preceding calendar year, bears 
to 
‘‘(B) the aggregate net premiums written 
with respect to such health insurance of all cov-
ered entities that are taken into account during 
such preceding calendar year. 
‘‘(2) AMOUNTS TAKEN INTO ACCOUNT.—For pur-
poses of paragraph (1), the net premiums written
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with respect to health insurance for any United 
States health risk that are taken into account during 
any calendar year with respect to any covered entity 
shall be determined in accordance with the following 
table: 
‘‘With respect to a covered entity’s net premiums writ-
ten during the calendar year that are: 
The percentage of net 
premiums written that 
are taken into account 
is: 
Not more than $25,000,000 ........................................
0 percent 
More than $25,000,000 but not more than 
$50,000,000.
50 percent 
More than $50,000,000 ...............................................
100 percent. 
‘‘(3) SECRETARIAL DETERMINATION.—The Sec-
retary shall calculate the amount of each covered enti-
ty’s fee for any calendar year under paragraph (1). 
In calculating such amount, the Secretary shall deter-
mine such covered entity’s net premiums written with 
respect to any United States health risk on the basis 
of reports submitted by the covered entity under sub-
section (g) and through the use of any other source of 
information available to the Secretary.’’. 
(b) APPLICABLE AMOUNT.—Subsection (e) of section 
9010 of this Act is amended to read as follows: 
‘‘(e) APPLICABLE AMOUNT.—For purposes of sub-
section (b)(1), the applicable amount shall be determined 
in accordance with the following table: 
‘‘Calendar year 
Applicable 
amount 
2011 .............................................................................
$2,000,000,000
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2012 .............................................................................
$4,000,000,000 
2013 .............................................................................
$7,000,000,000 
2014, 2015 and 2016 ..................................................
$9,000,000,000 
2017 and thereafter ....................................................
$10,000,000,000.’’. 
(c) EXEMPTION FROM ANNUAL FEE ON HEALTH IN-
SURANCE
FOR CERTAIN NONPROFIT ENTITIES.—Section 
9010(c)(2) of this Act is amended by striking ‘‘or’’ at the 
end of subparagraph (A), by striking the period at the end 
of subparagraph (B) and inserting a comma, and by add-
ing at the end the following new subparagraphs: 
‘‘(C) any entity— 
‘‘(i)(I) which is incorporated as, is a 
wholly owned subsidiary of, or is a wholly 
owned affiliate of, a nonprofit corporation 
under a State law, or 
‘‘(II) which is described in section 
501(c)(4) of the Internal Revenue Code of 
1986 and the activities of which consist of 
providing commercial-type insurance (with-
in the meaning of section 501(m) of such 
Code), 
‘‘(ii) the premium rate increases of 
which are regulated by a State authority, 
‘‘(iii) which, as of the date of the en-
actment of this section, acts as the insurer 
of last resort in the State and is subject to 
State guarantee issue requirements, and
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‘‘(1) IN GENERAL.—The tax imposed by this sec-
tion shall be paid by the individual on whom the 
service is performed. 
‘‘(2) COLLECTION.—Every person receiving a 
payment for services on which a tax is imposed under 
subsection (a) shall collect the amount of the tax from 
the individual on whom the service is performed and 
remit such tax quarterly to the Secretary at such time 
and in such manner as provided by the Secretary. 
‘‘(3) SECONDARY LIABILITY.—Where any tax im-
posed by subsection (a) is not paid at the time pay-
ments for indoor tanning services are made, then to 
the extent that such tax is not collected, such tax shall 
be paid by the person who performs the service.’’. 
(c) CLERICAL AMENDMENT.—The table of chapter for 
subtitle D of the Internal Revenue Code of 1986, as amended 
by this Act, is amended by inserting after the item relating 
to chapter 48 the following new item: 
‘‘CHAPTER 49—COSMETIC SERVICES’’. 
(d) EFFECTIVE DATE.—The amendments made by this 
section shall apply to services performed on or after July 
1, 2010.