Patient Protection and Affordable Care Act
PL 111-148 (H.R.3590), enacted 03/23/2010

124 STAT. 119 
PUBLIC LAW 111–148—MAR. 23, 2010 
Public Law 111–148 
111th Congress 
An Act 
Entitled The Patient Protection and Affordable Care Act. 
Be it enacted by the Senate and House of Representatives of 
the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the ‘‘Patient Protec-
tion and Affordable Care Act’’. 
(b) TABLE OF CONTENTS.—The table of contents of this Act 
is as follows: 
Sec. 1. Short title; table of contents. 
TITLE I—QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS 
Subtitle A—Immediate Improvements in Health Care Coverage for All Americans 
Sec. 1001. Amendments to the Public Health Service Act. 
‘‘PART A—INDIVIDUAL AND GROUP MARKET REFORMS 
‘‘SUBPART II—IMPROVING COVERAGE 
‘‘Sec. 2711. No lifetime or annual limits. 
‘‘Sec. 2712. Prohibition on rescissions. 
‘‘Sec. 2713. Coverage of preventive health services. 
‘‘Sec. 2714. Extension of dependent coverage. 
‘‘Sec. 2715. Development and utilization of uniform explanation of coverage 
documents and standardized definitions. 
‘‘Sec. 2716. Prohibition of discrimination based on salary. 
‘‘Sec. 2717. Ensuring the quality of care. 
‘‘Sec. 2718. Bringing down the cost of health care coverage. 
‘‘Sec. 2719. Appeals process. 
Sec. 1002. Health insurance consumer information. 
Sec. 1003. Ensuring that consumers get value for their dollars. 
Sec. 1004. Effective dates. 
Subtitle B—Immediate Actions to Preserve and Expand Coverage 
Sec. 1101. Immediate access to insurance for uninsured individuals with a pre-
existing condition. 
Sec. 1102. Reinsurance for early retirees. 
Sec. 1103. Immediate information that allows consumers to identify affordable cov-
erage options. 
Sec. 1104. Administrative simplification. 
Sec. 1105. Effective date. 
Subtitle C—Quality Health Insurance Coverage for All Americans 
PART I—HEALTH INSURANCE MARKET REFORMS 
Sec. 1201. Amendment to the Public Health Service Act. 
‘‘SUBPART I—GENERAL REFORM 
‘‘Sec. 2704. Prohibition of preexisting condition exclusions or other discrimina-
tion based on health status. 
‘‘Sec. 2701. Fair health insurance premiums. 
‘‘Sec. 2702. Guaranteed availability of coverage. 
42 USC 18001 
note. 
Patient 
Protection and 
Affordable Care 
Act. 
Mar. 23, 2010 
[H.R. 3590] 
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124 STAT. 120 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘Sec. 2703. Guaranteed renewability of coverage. 
‘‘Sec. 2705. Prohibiting discrimination against individual participants and 
beneficiaries based on health status. 
‘‘Sec. 2706. Non-discrimination in health care. 
‘‘Sec. 2707. Comprehensive health insurance coverage. 
‘‘Sec. 2708. Prohibition on excessive waiting periods. 
PART II—OTHER PROVISIONS 
Sec. 1251. Preservation of right to maintain existing coverage. 
Sec. 1252. Rating reforms must apply uniformly to all health insurance issuers and 
group health plans. 
Sec. 1253. Effective dates. 
Subtitle D—Available Coverage Choices for All Americans 
PART I—ESTABLISHMENT OF QUALIFIED HEALTH PLANS 
Sec. 1301. Qualified health plan defined. 
Sec. 1302. Essential health benefits requirements. 
Sec. 1303. Special rules. 
Sec. 1304. Related definitions. 
PART II—CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH 
BENEFIT EXCHANGES 
Sec. 1311. Affordable choices of health benefit plans. 
Sec. 1312. Consumer choice. 
Sec. 1313. Financial integrity. 
PART III—STATE FLEXIBILITY RELATING TO EXCHANGES 
Sec. 1321. State flexibility in operation and enforcement of Exchanges and related 
requirements. 
Sec. 1322. Federal program to assist establishment and operation of nonprofit, 
member-run health insurance issuers. 
Sec. 1323. Community health insurance option. 
Sec. 1324. Level playing field. 
PART IV—STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS 
Sec. 1331. State flexibility to establish basic health programs for low-income indi-
viduals not eligible for Medicaid. 
Sec. 1332. Waiver for State innovation. 
Sec. 1333. Provisions relating to offering of plans in more than one State. 
PART V—REINSURANCE AND RISK ADJUSTMENT 
Sec. 1341. Transitional reinsurance program for individual and small group mar-
kets in each State. 
Sec. 1342. Establishment of risk corridors for plans in individual and small group 
markets. 
Sec. 1343. Risk adjustment. 
Subtitle E—Affordable Coverage Choices for All Americans 
PART I—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS 
SUBPART A—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS 
Sec. 1401. Refundable tax credit providing premium assistance for coverage under 
a qualified health plan. 
Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health plans. 
SUBPART B—ELIGIBILITY DETERMINATIONS 
Sec. 1411. Procedures for determining eligibility for Exchange participation, pre-
mium tax credits and reduced cost-sharing, and individual responsibility 
exemptions. 
Sec. 1412. Advance determination and payment of premium tax credits and cost- 
sharing reductions. 
Sec. 1413. Streamlining of procedures for enrollment through an exchange and 
State Medicaid, CHIP, and health subsidy programs. 
Sec. 1414. Disclosures to carry out eligibility requirements for certain programs. 
Sec. 1415. Premium tax credit and cost-sharing reduction payments disregarded for 
Federal and Federally-assisted programs. 
PART II—SMALL BUSINESS TAX CREDIT 
Sec. 1421. Credit for employee health insurance expenses of small businesses. 
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124 STAT. 121 
PUBLIC LAW 111–148—MAR. 23, 2010 
Subtitle F—Shared Responsibility for Health Care 
PART I—INDIVIDUAL RESPONSIBILITY 
Sec. 1501. Requirement to maintain minimum essential coverage. 
Sec. 1502. Reporting of health insurance coverage. 
PART II—EMPLOYER RESPONSIBILITIES 
Sec. 1511. Automatic enrollment for employees of large employers. 
Sec. 1512. Employer requirement to inform employees of coverage options. 
Sec. 1513. Shared responsibility for employers. 
Sec. 1514. Reporting of employer health insurance coverage. 
Sec. 1515. Offering of Exchange-participating qualified health plans through cafe-
teria plans. 
Subtitle G—Miscellaneous Provisions 
Sec. 1551. Definitions. 
Sec. 1552. Transparency in government. 
Sec. 1553. Prohibition against discrimination on assisted suicide. 
Sec. 1554. Access to therapies. 
Sec. 1555. Freedom not to participate in Federal health insurance programs. 
Sec. 1556. Equity for certain eligible survivors. 
Sec. 1557. Nondiscrimination. 
Sec. 1558. Protections for employees. 
Sec. 1559. Oversight. 
Sec. 1560. Rules of construction. 
Sec. 1561. Health information technology enrollment standards and protocols. 
Sec. 1562. Conforming amendments. 
Sec. 1563. Sense of the Senate promoting fiscal responsibility. 
TITLE II—ROLE OF PUBLIC PROGRAMS 
Subtitle A—Improved Access to Medicaid 
Sec. 2001. Medicaid coverage for the lowest income populations. 
Sec. 2002. Income eligibility for nonelderly determined using modified gross in-
come. 
Sec. 2003. Requirement to offer premium assistance for employer-sponsored insur-
ance. 
Sec. 2004. Medicaid coverage for former foster care children. 
Sec. 2005. Payments to territories. 
Sec. 2006. Special adjustment to FMAP determination for certain States recovering 
from a major disaster. 
Sec. 2007. Medicaid Improvement Fund rescission. 
Subtitle B—Enhanced Support for the Children’s Health Insurance Program 
Sec. 2101. Additional federal financial participation for CHIP. 
Sec. 2102. Technical corrections. 
Subtitle C—Medicaid and CHIP Enrollment Simplification 
Sec. 2201. Enrollment Simplification and coordination with State Health Insurance 
Exchanges. 
Sec. 2202. Permitting hospitals to make presumptive eligibility determinations for 
all Medicaid eligible populations. 
Subtitle D—Improvements to Medicaid Services 
Sec. 2301. Coverage for freestanding birth center services. 
Sec. 2302. Concurrent care for children. 
Sec. 2303. State eligibility option for family planning services. 
Sec. 2304. Clarification of definition of medical assistance. 
Subtitle E—New Options for States to Provide Long-Term Services and Supports 
Sec. 2401. Community First Choice Option. 
Sec. 2402. Removal of barriers to providing home and community-based services. 
Sec. 2403. Money Follows the Person Rebalancing Demonstration. 
Sec. 2404. Protection for recipients of home and community-based services against 
spousal impoverishment. 
Sec. 2405. Funding to expand State Aging and Disability Resource Centers. 
Sec. 2406. Sense of the Senate regarding long-term care. 
Subtitle F—Medicaid Prescription Drug Coverage 
Sec. 2501. Prescription drug rebates. 
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124 STAT. 122 
PUBLIC LAW 111–148—MAR. 23, 2010 
Sec. 2502. Elimination of exclusion of coverage of certain drugs. 
Sec. 2503. Providing adequate pharmacy reimbursement. 
Subtitle G—Medicaid Disproportionate Share Hospital (DSH) Payments 
Sec. 2551. Disproportionate share hospital payments. 
Subtitle H—Improved Coordination for Dual Eligible Beneficiaries 
Sec. 2601. 5-year period for demonstration projects. 
Sec. 2602. Providing Federal coverage and payment coordination for dual eligible 
beneficiaries. 
Subtitle I—Improving the Quality of Medicaid for Patients and Providers 
Sec. 2701. Adult health quality measures. 
Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions. 
Sec. 2703. State option to provide health homes for enrollees with chronic condi-
tions. 
Sec. 2704. Demonstration project to evaluate integrated care around a hospitaliza-
tion. 
Sec. 2705. Medicaid Global Payment System Demonstration Project. 
Sec. 2706. Pediatric Accountable Care Organization Demonstration Project. 
Sec. 2707. Medicaid emergency psychiatric demonstration project. 
Subtitle J—Improvements to the Medicaid and CHIP Payment and Access 
Commission (MACPAC) 
Sec. 2801. MACPAC assessment of policies affecting all Medicaid beneficiaries. 
Subtitle K—Protections for American Indians and Alaska Natives 
Sec. 2901. Special rules relating to Indians. 
Sec. 2902. Elimination of sunset for reimbursement for all medicare part B services 
furnished by certain indian hospitals and clinics. 
Subtitle L—Maternal and Child Health Services 
Sec. 2951. Maternal, infant, and early childhood home visiting programs. 
Sec. 2952. Support, education, and research for postpartum depression. 
Sec. 2953. Personal responsibility education. 
Sec. 2954. Restoration of funding for abstinence education. 
Sec. 2955. Inclusion of information about the importance of having a health care 
power of attorney in transition planning for children aging out of foster 
care and independent living programs. 
TITLE III—IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE 
Subtitle A—Transforming the Health Care Delivery System 
PART I—LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE PROGRAM 
Sec. 3001. Hospital Value-Based purchasing program. 
Sec. 3002. Improvements to the physician quality reporting system. 
Sec. 3003. Improvements to the physician feedback program. 
Sec. 3004. Quality reporting for long-term care hospitals, inpatient rehabilitation 
hospitals, and hospice programs. 
Sec. 3005. Quality reporting for PPS-exempt cancer hospitals. 
Sec. 3006. Plans for a Value-Based purchasing program for skilled nursing facilities 
and home health agencies. 
Sec. 3007. Value-based payment modifier under the physician fee schedule. 
Sec. 3008. Payment adjustment for conditions acquired in hospitals. 
PART II—NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY 
Sec. 3011. National strategy. 
Sec. 3012. Interagency Working Group on Health Care Quality. 
Sec. 3013. Quality measure development. 
Sec. 3014. Quality measurement. 
Sec. 3015. Data collection; public reporting. 
PART III—ENCOURAGING DEVELOPMENT OF NEW PATIENT CARE MODELS 
Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation within 
CMS. 
Sec. 3022. Medicare shared savings program. 
Sec. 3023. National pilot program on payment bundling. 
Sec. 3024. Independence at home demonstration program. 
Sec. 3025. Hospital readmissions reduction program. 
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124 STAT. 123 
PUBLIC LAW 111–148—MAR. 23, 2010 
Sec. 3026. Community-Based Care Transitions Program. 
Sec. 3027. Extension of gainsharing demonstration. 
Subtitle B—Improving Medicare for Patients and Providers 
PART I—ENSURING BENEFICIARY ACCESS TO PHYSICIAN CARE AND OTHER SERVICES 
Sec. 3101. Increase in the physician payment update. 
Sec. 3102. Extension of the work geographic index floor and revisions to the prac-
tice expense geographic adjustment under the Medicare physician fee 
schedule. 
Sec. 3103. Extension of exceptions process for Medicare therapy caps. 
Sec. 3104. Extension of payment for technical component of certain physician pa-
thology services. 
Sec. 3105. Extension of ambulance add-ons. 
Sec. 3106. Extension of certain payment rules for long-term care hospital services 
and of moratorium on the establishment of certain hospitals and facili-
ties. 
Sec. 3107. Extension of physician fee schedule mental health add-on. 
Sec. 3108. Permitting physician assistants to order post-Hospital extended care 
services. 
Sec. 3109. Exemption of certain pharmacies from accreditation requirements. 
Sec. 3110. Part B special enrollment period for disabled TRICARE beneficiaries. 
Sec. 3111. Payment for bone density tests. 
Sec. 3112. Revision to the Medicare Improvement Fund. 
Sec. 3113. Treatment of certain complex diagnostic laboratory tests. 
Sec. 3114. Improved access for certified nurse-midwife services. 
PART II—RURAL PROTECTIONS 
Sec. 3121. Extension of outpatient hold harmless provision. 
Sec. 3122. Extension of Medicare reasonable costs payments for certain clinical di-
agnostic laboratory tests furnished to hospital patients in certain rural 
areas. 
Sec. 3123. Extension of the Rural Community Hospital Demonstration Program. 
Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program. 
Sec. 3125. Temporary improvements to the Medicare inpatient hospital payment 
adjustment for low-volume hospitals. 
Sec. 3126. Improvements to the demonstration project on community health inte-
gration models in certain rural counties. 
Sec. 3127. MedPAC study on adequacy of Medicare payments for health care pro-
viders serving in rural areas. 
Sec. 3128. Technical correction related to critical access hospital services. 
Sec. 3129. Extension of and revisions to Medicare rural hospital flexibility program. 
PART III—IMPROVING PAYMENT ACCURACY 
Sec. 3131. Payment adjustments for home health care. 
Sec. 3132. Hospice reform. 
Sec. 3133. Improvement to medicare disproportionate share hospital (DSH) pay-
ments. 
Sec. 3134. Misvalued codes under the physician fee schedule. 
Sec. 3135. Modification of equipment utilization factor for advanced imaging serv-
ices. 
Sec. 3136. Revision of payment for power-driven wheelchairs. 
Sec. 3137. Hospital wage index improvement. 
Sec. 3138. Treatment of certain cancer hospitals. 
Sec. 3139. Payment for biosimilar biological products. 
Sec. 3140. Medicare hospice concurrent care demonstration program. 
Sec. 3141. Application of budget neutrality on a national basis in the calculation of 
the Medicare hospital wage index floor. 
Sec. 3142. HHS study on urban Medicare-dependent hospitals. 
Sec. 3143. Protecting home health benefits. 
Subtitle C—Provisions Relating to Part C 
Sec. 3201. Medicare Advantage payment. 
Sec. 3202. Benefit protection and simplification. 
Sec. 3203. Application of coding intensity adjustment during MA payment transi-
tion. 
Sec. 3204. Simplification of annual beneficiary election periods. 
Sec. 3205. Extension for specialized MA plans for special needs individuals. 
Sec. 3206. Extension of reasonable cost contracts. 
Sec. 3207. Technical correction to MA private fee-for-service plans. 
Sec. 3208. Making senior housing facility demonstration permanent. 
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124 STAT. 124 
PUBLIC LAW 111–148—MAR. 23, 2010 
Sec. 3209. Authority to deny plan bids. 
Sec. 3210. Development of new standards for certain Medigap plans. 
Subtitle D—Medicare Part D Improvements for Prescription Drug Plans and MA– 
PD Plans 
Sec. 3301. Medicare coverage gap discount program. 
Sec. 3302. Improvement in determination of Medicare part D low-income bench-
mark premium. 
Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals under pre-
scription drug plans and MA–PD plans. 
Sec. 3304. Special rule for widows and widowers regarding eligibility for low-in-
come assistance. 
Sec. 3305. Improved information for subsidy eligible individuals reassigned to pre-
scription drug plans and MA–PD plans. 
Sec. 3306. Funding outreach and assistance for low-income programs. 
Sec. 3307. Improving formulary requirements for prescription drug plans and MA– 
PD plans with respect to certain categories or classes of drugs. 
Sec. 3308. Reducing part D premium subsidy for high-income beneficiaries. 
Sec. 3309. Elimination of cost sharing for certain dual eligible individuals. 
Sec. 3310. Reducing wasteful dispensing of outpatient prescription drugs in long- 
term care facilities under prescription drug plans and MA–PD plans. 
Sec. 3311. Improved Medicare prescription drug plan and MA–PD plan complaint 
system. 
Sec. 3312. Uniform exceptions and appeals process for prescription drug plans and 
MA–PD plans. 
Sec. 3313. Office of the Inspector General studies and reports. 
Sec. 3314. Including costs incurred by AIDS drug assistance programs and Indian 
Health Service in providing prescription drugs toward the annual out- 
of-pocket threshold under part D. 
Sec. 3315. Immediate reduction in coverage gap in 2010. 
Subtitle E—Ensuring Medicare Sustainability 
Sec. 3401. Revision of certain market basket updates and incorporation of produc-
tivity improvements into market basket updates that do not already in-
corporate such improvements. 
Sec. 3402. Temporary adjustment to the calculation of part B premiums. 
Sec. 3403. Independent Medicare Advisory Board. 
Subtitle F—Health Care Quality Improvements 
Sec. 3501. Health care delivery system research; Quality improvement technical as-
sistance. 
Sec. 3502. Establishing community health teams to support the patient-centered 
medical home. 
Sec. 3503. Medication management services in treatment of chronic disease. 
Sec. 3504. Design and implementation of regionalized systems for emergency care. 
Sec. 3505. Trauma care centers and service availability. 
Sec. 3506. Program to facilitate shared decisionmaking. 
Sec. 3507. Presentation of prescription drug benefit and risk information. 
Sec. 3508. Demonstration program to integrate quality improvement and patient 
safety training into clinical education of health professionals. 
Sec. 3509. Improving women’s health. 
Sec. 3510. Patient navigator program. 
Sec. 3511. Authorization of appropriations. 
Subtitle G—Protecting and Improving Guaranteed Medicare Benefits 
Sec. 3601. Protecting and improving guaranteed Medicare benefits. 
Sec. 3602. No cuts in guaranteed benefits. 
TITLE IV—PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC 
HEALTH 
Subtitle A—Modernizing Disease Prevention and Public Health Systems 
Sec. 4001. National Prevention, Health Promotion and Public Health Council. 
Sec. 4002. Prevention and Public Health Fund. 
Sec. 4003. Clinical and community preventive services. 
Sec. 4004. Education and outreach campaign regarding preventive benefits. 
Subtitle B—Increasing Access to Clinical Preventive Services 
Sec. 4101. School-based health centers. 
Sec. 4102. Oral healthcare prevention activities. 
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124 STAT. 125 
PUBLIC LAW 111–148—MAR. 23, 2010 
Sec. 4103. Medicare coverage of annual wellness visit providing a personalized pre-
vention plan. 
Sec. 4104. Removal of barriers to preventive services in Medicare. 
Sec. 4105. Evidence-based coverage of preventive services in Medicare. 
Sec. 4106. Improving access to preventive services for eligible adults in Medicaid. 
Sec. 4107. Coverage of comprehensive tobacco cessation services for pregnant 
women in Medicaid. 
Sec. 4108. Incentives for prevention of chronic diseases in medicaid. 
Subtitle C—Creating Healthier Communities 
Sec. 4201. Community transformation grants. 
Sec. 4202. Healthy aging, living well; evaluation of community-based prevention 
and wellness programs for Medicare beneficiaries. 
Sec. 4203. Removing barriers and improving access to wellness for individuals with 
disabilities. 
Sec. 4204. Immunizations. 
Sec. 4205. Nutrition labeling of standard menu items at chain restaurants. 
Sec. 4206. Demonstration project concerning individualized wellness plan. 
Sec. 4207. Reasonable break time for nursing mothers. 
Subtitle D—Support for Prevention and Public Health Innovation 
Sec. 4301. Research on optimizing the delivery of public health services. 
Sec. 4302. Understanding health disparities: data collection and analysis. 
Sec. 4303. CDC and employer-based wellness programs. 
Sec. 4304. Epidemiology-Laboratory Capacity Grants. 
Sec. 4305. Advancing research and treatment for pain care management. 
Sec. 4306. Funding for Childhood Obesity Demonstration Project. 
Subtitle E—Miscellaneous Provisions 
Sec. 4401. Sense of the Senate concerning CBO scoring. 
Sec. 4402. Effectiveness of Federal health and wellness initiatives. 
TITLE V—HEALTH CARE WORKFORCE 
Subtitle A—Purpose and Definitions 
Sec. 5001. Purpose. 
Sec. 5002. Definitions. 
Subtitle B—Innovations in the Health Care Workforce 
Sec. 5101. National health care workforce commission. 
Sec. 5102. State health care workforce development grants. 
Sec. 5103. Health care workforce assessment. 
Subtitle C—Increasing the Supply of the Health Care Workforce 
Sec. 5201. Federally supported student loan funds. 
Sec. 5202. Nursing student loan program. 
Sec. 5203. Health care workforce loan repayment programs. 
Sec. 5204. Public health workforce recruitment and retention programs. 
Sec. 5205. Allied health workforce recruitment and retention programs. 
Sec. 5206. Grants for State and local programs. 
Sec. 5207. Funding for National Health Service Corps. 
Sec. 5208. Nurse-managed health clinics. 
Sec. 5209. Elimination of cap on commissioned corps. 
Sec. 5210. Establishing a Ready Reserve Corps. 
Subtitle D—Enhancing Health Care Workforce Education and Training 
Sec. 5301. Training in family medicine, general internal medicine, general pediat-
rics, and physician assistantship. 
Sec. 5302. Training opportunities for direct care workers. 
Sec. 5303. Training in general, pediatric, and public health dentistry. 
Sec. 5304. Alternative dental health care providers demonstration project. 
Sec. 5305. Geriatric education and training; career awards; comprehensive geriatric 
education. 
Sec. 5306. Mental and behavioral health education and training grants. 
Sec. 5307. Cultural competency, prevention, and public health and individuals with 
disabilities training. 
Sec. 5308. Advanced nursing education grants. 
Sec. 5309. Nurse education, practice, and retention grants. 
Sec. 5310. Loan repayment and scholarship program. 
Sec. 5311. Nurse faculty loan program. 
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124 STAT. 126 
PUBLIC LAW 111–148—MAR. 23, 2010 
Sec. 5312. Authorization of appropriations for parts B through D of title VIII. 
Sec. 5313. Grants to promote the community health workforce. 
Sec. 5314. Fellowship training in public health. 
Sec. 5315. United States Public Health Sciences Track. 
Subtitle E—Supporting the Existing Health Care Workforce 
Sec. 5401. Centers of excellence. 
Sec. 5402. Health care professionals training for diversity. 
Sec. 5403. Interdisciplinary, community-based linkages. 
Sec. 5404. Workforce diversity grants. 
Sec. 5405. Primary care extension program. 
Subtitle F—Strengthening Primary Care and Other Workforce Improvements 
Sec. 5501. Expanding access to primary care services and general surgery services. 
Sec. 5502. Medicare Federally qualified health center improvements. 
Sec. 5503. Distribution of additional residency positions. 
Sec. 5504. Counting resident time in nonprovider settings. 
Sec. 5505. Rules for counting resident time for didactic and scholarly activities and 
other activities. 
Sec. 5506. Preservation of resident cap positions from closed hospitals. 
Sec. 5507. Demonstration projects To address health professions workforce needs; 
extension of family-to-family health information centers. 
Sec. 5508. Increasing teaching capacity. 
Sec. 5509. Graduate nurse education demonstration. 
Subtitle G—Improving Access to Health Care Services 
Sec. 5601. Spending for Federally Qualified Health Centers (FQHCs). 
Sec. 5602. Negotiated rulemaking for development of methodology and criteria for 
designating medically underserved populations and health professions 
shortage areas. 
Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services for Chil-
dren Program. 
Sec. 5604. Co-locating primary and specialty care in community-based mental 
health settings. 
Sec. 5605. Key National indicators. 
Subtitle H—General Provisions 
Sec. 5701. Reports. 
TITLE VI—TRANSPARENCY AND PROGRAM INTEGRITY 
Subtitle A—Physician Ownership and Other Transparency 
Sec. 6001. Limitation on Medicare exception to the prohibition on certain physician 
referrals for hospitals. 
Sec. 6002. Transparency reports and reporting of physician ownership or invest-
ment interests. 
Sec. 6003. Disclosure requirements for in-office ancillary services exception to the 
prohibition on physician self-referral for certain imaging services. 
Sec. 6004. Prescription drug sample transparency. 
Sec. 6005. Pharmacy benefit managers transparency requirements. 
Subtitle B—Nursing Home Transparency and Improvement 
PART I—IMPROVING TRANSPARENCY OF INFORMATION 
Sec. 6101. Required disclosure of ownership and additional disclosable parties in-
formation. 
Sec. 6102. Accountability requirements for skilled nursing facilities and nursing fa-
cilities. 
Sec. 6103. Nursing home compare Medicare website. 
Sec. 6104. Reporting of expenditures. 
Sec. 6105. Standardized complaint form. 
Sec. 6106. Ensuring staffing accountability. 
Sec. 6107. GAO study and report on Five-Star Quality Rating System. 
PART II—TARGETING ENFORCEMENT 
Sec. 6111. Civil money penalties. 
Sec. 6112. National independent monitor demonstration project. 
Sec. 6113. Notification of facility closure. 
Sec. 6114. National demonstration projects on culture change and use of informa-
tion technology in nursing homes. 
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124 STAT. 127 
PUBLIC LAW 111–148—MAR. 23, 2010 
PART III—IMPROVING STAFF TRAINING 
Sec. 6121. Dementia and abuse prevention training. 
Subtitle C—Nationwide Program for National and State Background Checks on 
Direct Patient Access Employees of Long-term Care Facilities and Providers 
Sec. 6201. Nationwide program for National and State background checks on direct 
patient access employees of long-term care facilities and providers. 
Subtitle D—Patient-Centered Outcomes Research 
Sec. 6301. Patient-Centered Outcomes Research. 
Sec. 6302. Federal coordinating council for comparative effectiveness research. 
Subtitle E—Medicare, Medicaid, and CHIP Program Integrity Provisions 
Sec. 6401. Provider screening and other enrollment requirements under Medicare, 
Medicaid, and CHIP. 
Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions. 
Sec. 6403. Elimination of duplication between the Healthcare Integrity and Protec-
tion Data Bank and the National Practitioner Data Bank. 
Sec. 6404. Maximum period for submission of Medicare claims reduced to not more 
than 12 months. 
Sec. 6405. Physicians who order items or services required to be Medicare enrolled 
physicians or eligible professionals. 
Sec. 6406. Requirement for physicians to provide documentation on referrals to pro-
grams at high risk of waste and abuse. 
Sec. 6407. Face to face encounter with patient required before physicians may cer-
tify eligibility for home health services or durable medical equipment 
under Medicare. 
Sec. 6408. Enhanced penalties. 
Sec. 6409. Medicare self-referral disclosure protocol. 
Sec. 6410. Adjustments to the Medicare durable medical equipment, prosthetics, 
orthotics, and supplies competitive acquisition program. 
Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program. 
Subtitle F—Additional Medicaid Program Integrity Provisions 
Sec. 6501. Termination of provider participation under Medicaid if terminated 
under Medicare or other State plan. 
Sec. 6502. Medicaid exclusion from participation relating to certain ownership, con-
trol, and management affiliations. 
Sec. 6503. Billing agents, clearinghouses, or other alternate payees required to reg-
ister under Medicaid. 
Sec. 6504. Requirement to report expanded set of data elements under MMIS to de-
tect fraud and abuse. 
Sec. 6505. Prohibition on payments to institutions or entities located outside of the 
United States. 
Sec. 6506. Overpayments. 
Sec. 6507. Mandatory State use of national correct coding initiative. 
Sec. 6508. General effective date. 
Subtitle G—Additional Program Integrity Provisions 
Sec. 6601. Prohibition on false statements and representations. 
Sec. 6602. Clarifying definition. 
Sec. 6603. Development of model uniform report form. 
Sec. 6604. Applicability of State law to combat fraud and abuse. 
Sec. 6605. Enabling the Department of Labor to issue administrative summary 
cease and desist orders and summary seizures orders against plans that 
are in financially hazardous condition. 
Sec. 6606. MEWA plan registration with Department of Labor. 
Sec. 6607. Permitting evidentiary privilege and confidential communications. 
Subtitle H—Elder Justice Act 
Sec. 6701. Short title of subtitle. 
Sec. 6702. Definitions. 
Sec. 6703. Elder Justice. 
Subtitle I—Sense of the Senate Regarding Medical Malpractice 
Sec. 6801. Sense of the Senate regarding medical malpractice. 
TITLE VII—IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES 
Subtitle A—Biologics Price Competition and Innovation 
Sec. 7001. Short title. 
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124 STAT. 128 
PUBLIC LAW 111–148—MAR. 23, 2010 
Sec. 7002. Approval pathway for biosimilar biological products. 
Sec. 7003. Savings. 
Subtitle B—More Affordable Medicines for Children and Underserved Communities 
Sec. 7101. Expanded participation in 340B program. 
Sec. 7102. Improvements to 340B program integrity. 
Sec. 7103. GAO study to make recommendations on improving the 340B program. 
TITLE VIII—CLASS ACT 
Sec. 8001. Short title of title. 
Sec. 8002. Establishment of national voluntary insurance program for purchasing 
community living assistance services and support. 
TITLE IX—REVENUE PROVISIONS 
Subtitle A—Revenue Offset Provisions 
Sec. 9001. Excise tax on high cost employer-sponsored health coverage. 
Sec. 9002. Inclusion of cost of employer-sponsored health coverage on W–2. 
Sec. 9003. Distributions for medicine qualified only if for prescribed drug or insulin. 
Sec. 9004. Increase in additional tax on distributions from HSAs and Archer MSAs 
not used for qualified medical expenses. 
Sec. 9005. Limitation on health flexible spending arrangements under cafeteria 
plans. 
Sec. 9006. Expansion of information reporting requirements. 
Sec. 9007. Additional requirements for charitable hospitals. 
Sec. 9008. Imposition of annual fee on branded prescription pharmaceutical manu-
facturers and importers. 
Sec. 9009. Imposition of annual fee on medical device manufacturers and import-
ers. 
Sec. 9010. Imposition of annual fee on health insurance providers. 
Sec. 9011. Study and report of effect on veterans health care. 
Sec. 9012. Elimination of deduction for expenses allocable to Medicare Part D sub-
sidy. 
Sec. 9013. Modification of itemized deduction for medical expenses. 
Sec. 9014. Limitation on excessive remuneration paid by certain health insurance 
providers. 
Sec. 9015. Additional hospital insurance tax on high-income taxpayers. 
Sec. 9016. Modification of section 833 treatment of certain health organizations. 
Sec. 9017. Excise tax on elective cosmetic medical procedures. 
Subtitle B—Other Provisions 
Sec. 9021. Exclusion of health benefits provided by Indian tribal governments. 
Sec. 9022. Establishment of simple cafeteria plans for small businesses. 
Sec. 9023. Qualifying therapeutic discovery project credit. 
TITLE X—STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR 
ALL AMERICANS 
Subtitle A—Provisions Relating to Title I 
Sec. 10101. Amendments to subtitle A. 
Sec. 10102. Amendments to subtitle B. 
Sec. 10103. Amendments to subtitle C. 
Sec. 10104. Amendments to subtitle D. 
Sec. 10105. Amendments to subtitle E. 
Sec. 10106. Amendments to subtitle F. 
Sec. 10107. Amendments to subtitle G. 
Sec. 10108. Free choice vouchers. 
Sec. 10109. Development of standards for financial and administrative trans-
actions. 
Subtitle B—Provisions Relating to Title II 
PART I—MEDICAID AND CHIP 
Sec. 10201. Amendments to the Social Security Act and title II of this Act. 
Sec. 10202. Incentives for States to offer home and community-based services as a 
long-term care alternative to nursing homes. 
Sec. 10203. Extension of funding for CHIP through fiscal year 2015 and other 
CHIP-related provisions. 
PART II—SUPPORT FOR PREGNANT AND PARENTING TEENS AND WOMEN 
Sec. 10211. Definitions. 
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124 STAT. 129 
PUBLIC LAW 111–148—MAR. 23, 2010 
Sec. 10212. Establishment of pregnancy assistance fund. 
Sec. 10213. Permissible uses of Fund. 
Sec. 10214. Appropriations. 
PART III—INDIAN HEALTH CARE IMPROVEMENT 
Sec. 10221. Indian health care improvement. 
Subtitle C—Provisions Relating to Title III 
Sec. 10301. Plans for a Value-Based purchasing program for ambulatory surgical 
centers. 
Sec. 10302. Revision to national strategy for quality improvement in health care. 
Sec. 10303. Development of outcome measures. 
Sec. 10304. Selection of efficiency measures. 
Sec. 10305. Data collection; public reporting. 
Sec. 10306. Improvements under the Center for Medicare and Medicaid Innovation. 
Sec. 10307. Improvements to the Medicare shared savings program. 
Sec. 10308. Revisions to national pilot program on payment bundling. 
Sec. 10309. Revisions to hospital readmissions reduction program. 
Sec. 10310. Repeal of physician payment update. 
Sec. 10311. Revisions to extension of ambulance add-ons. 
Sec. 10312. Certain payment rules for long-term care hospital services and morato-
rium on the establishment of certain hospitals and facilities. 
Sec. 10313. Revisions to the extension for the rural community hospital demonstra-
tion program. 
Sec. 10314. Adjustment to low-volume hospital provision. 
Sec. 10315. Revisions to home health care provisions. 
Sec. 10316. Medicare DSH. 
Sec. 10317. Revisions to extension of section 508 hospital provisions. 
Sec. 10318. Revisions to transitional extra benefits under Medicare Advantage. 
Sec. 10319. Revisions to market basket adjustments. 
Sec. 10320. Expansion of the scope of, and additional improvements to, the Inde-
pendent Medicare Advisory Board. 
Sec. 10321. Revision to community health teams. 
Sec. 10322. Quality reporting for psychiatric hospitals. 
Sec. 10323. Medicare coverage for individuals exposed to environmental health haz-
ards. 
Sec. 10324. Protections for frontier States. 
Sec. 10325. Revision to skilled nursing facility prospective payment system. 
Sec. 10326. Pilot testing pay-for-performance programs for certain Medicare pro-
viders. 
Sec. 10327. Improvements to the physician quality reporting system. 
Sec. 10328. Improvement in part D medication therapy management (MTM) pro-
grams. 
Sec. 10329. Developing methodology to assess health plan value. 
Sec. 10330. Modernizing computer and data systems of the Centers for Medicare & 
Medicaid services to support improvements in care delivery. 
Sec. 10331. Public reporting of performance information. 
Sec. 10332. Availability of medicare data for performance measurement. 
Sec. 10333. Community-based collaborative care networks. 
Sec. 10334. Minority health. 
Sec. 10335. Technical correction to the hospital value-based purchasing program. 
Sec. 10336. GAO study and report on Medicare beneficiary access to high-quality 
dialysis services. 
Subtitle D—Provisions Relating to Title IV 
Sec. 10401. Amendments to subtitle A. 
Sec. 10402. Amendments to subtitle B. 
Sec. 10403. Amendments to subtitle C. 
Sec. 10404. Amendments to subtitle D. 
Sec. 10405. Amendments to subtitle E. 
Sec. 10406. Amendment relating to waiving coinsurance for preventive services. 
Sec. 10407. Better diabetes care. 
Sec. 10408. Grants for small businesses to provide comprehensive workplace 
wellness programs. 
Sec. 10409. Cures Acceleration Network. 
Sec. 10410. Centers of Excellence for Depression. 
Sec. 10411. Programs relating to congenital heart disease. 
Sec. 10412. Automated Defibrillation in Adam’s Memory Act. 
Sec. 10413. Young women’s breast health awareness and support of young women 
diagnosed with breast cancer. 
Subtitle E—Provisions Relating to Title V 
Sec. 10501. Amendments to the Public Health Service Act, the Social Security Act, 
and title V of this Act. 
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124 STAT. 130 
PUBLIC LAW 111–148—MAR. 23, 2010 
Sec. 10502. Infrastructure to Expand Access to Care. 
Sec. 10503. Community Health Centers and the National Health Service Corps 
Fund. 
Sec. 10504. Demonstration project to provide access to affordable care. 
Subtitle F—Provisions Relating to Title VI 
Sec. 10601. Revisions to limitation on medicare exception to the prohibition on cer-
tain physician referrals for hospitals. 
Sec. 10602. Clarifications to patient-centered outcomes research. 
Sec. 10603. Striking provisions relating to individual provider application fees. 
Sec. 10604. Technical correction to section 6405. 
Sec. 10605. Certain other providers permitted to conduct face to face encounter for 
home health services. 
Sec. 10606. Health care fraud enforcement. 
Sec. 10607. State demonstration programs to evaluate alternatives to current med-
ical tort litigation. 
Sec. 10608. Extension of medical malpractice coverage to free clinics. 
Sec. 10609. Labeling changes. 
Subtitle G—Provisions Relating to Title VIII 
Sec. 10801. Provisions relating to title VIII. 
Subtitle H—Provisions Relating to Title IX 
Sec. 10901. Modifications to excise tax on high cost employer-sponsored health cov-
erage. 
Sec. 10902. Inflation adjustment of limitation on health flexible spending arrange-
ments under cafeteria plans. 
Sec. 10903. Modification of limitation on charges by charitable hospitals. 
Sec. 10904. Modification of annual fee on medical device manufacturers and im-
porters. 
Sec. 10905. Modification of annual fee on health insurance providers. 
Sec. 10906. Modifications to additional hospital insurance tax on high-income tax-
payers. 
Sec. 10907. Excise tax on indoor tanning services in lieu of elective cosmetic med-
ical procedures. 
Sec. 10908. Exclusion for assistance provided to participants in State student loan 
repayment programs for certain health professionals. 
Sec. 10909. Expansion of adoption credit and adoption assistance programs. 
TITLE I—QUALITY, AFFORDABLE 
HEALTH CARE FOR ALL AMERICANS 
Subtitle A—Immediate Improvements in 
Health Care Coverage for All Americans 
SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT. 
Part A of title XXVII of the Public Health Service Act (42 
U.S.C. 300gg et seq.) is amended— 
(1) by striking the part heading and inserting the following: 
‘‘PART A—INDIVIDUAL AND GROUP MARKET 
REFORMS’’; 
(2) by redesignating sections 2704 through 2707 as sections 
2725 through 2728, respectively; 
(3) by redesignating sections 2711 through 2713 as sections 
2731 through 2733, respectively; 
(4) by redesignating sections 2721 through 2723 as sections 
2735 through 2737, respectively; and 
(5) by inserting after section 2702, the following: 
42 USC 
300gg–21— 
300gg–23. 
42 USC 
300gg–11— 
300gg–13, 
300gg–9. 
42 USC 
300gg–4— 
300gg–7, 
300gg–25— 
300gg–28. 
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124 STAT. 131 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘Subpart II—Improving Coverage 
‘‘SEC. 2711. NO LIFETIME OR ANNUAL LIMITS. 
‘‘(a) IN GENERAL.—A group health plan and a health insurance 
issuer offering group or individual health insurance coverage may 
not establish— 
‘‘(1) lifetime limits on the dollar value of benefits for any 
participant or beneficiary; or 
‘‘(2) unreasonable annual limits (within the meaning of 
section 223 of the Internal Revenue Code of 1986) on the 
dollar value of benefits for any participant or beneficiary. 
‘‘(b) PER BENEFICIARY LIMITS.—Subsection (a) shall not be con-
strued to prevent a group health plan or health insurance coverage 
that is not required to provide essential health benefits under 
section 1302(b) of the Patient Protection and Affordable Care Act 
from placing annual or lifetime per beneficiary limits on specific 
covered benefits to the extent that such limits are otherwise per-
mitted under Federal or State law. 
‘‘SEC. 2712. PROHIBITION ON RESCISSIONS. 
‘‘A group health plan and a health insurance issuer offering 
group or individual health insurance coverage shall not rescind 
such plan or coverage with respect to an enrollee once the enrollee 
is covered under such plan or coverage involved, except that this 
section shall not apply to a covered individual who has performed 
an act or practice that constitutes fraud or makes an intentional 
misrepresentation of material fact as prohibited by the terms of 
the plan or coverage. Such plan or coverage may not be cancelled 
except with prior notice to the enrollee, and only as permitted 
under section 2702(c) or 2742(b). 
‘‘SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES. 
‘‘(a) IN GENERAL.—A group health plan and a health insurance 
issuer offering group or individual health insurance coverage shall, 
at a minimum provide coverage for and shall not impose any 
cost sharing requirements for— 
‘‘(1) evidence-based items or services that have in effect 
a rating of ‘A’ or ‘B’ in the current recommendations of the 
United States Preventive Services Task Force; 
‘‘(2) immunizations that have in effect a recommendation 
from the Advisory Committee on Immunization Practices of 
the Centers for Disease Control and Prevention with respect 
to the individual involved; and 
‘‘(3) with respect to infants, children, and adolescents, evi-
dence-informed preventive care and screenings provided for 
in the comprehensive guidelines supported by the Health 
Resources and Services Administration. 
‘‘(4) with respect to women, such additional preventive 
care and screenings not described in paragraph (1) as provided 
for in comprehensive guidelines supported by the Health 
Resources and Services Administration for purposes of this 
paragraph. 
‘‘(5) for the purposes of this Act, and for the purposes 
of any other provision of law, the current recommendations 
of the United States Preventive Service Task Force regarding 
breast cancer screening, mammography, and prevention shall 
42 USC 
300gg–13. 
42 USC 
300gg–12. 
42 USC 
300gg–11. 
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124 STAT. 132 
PUBLIC LAW 111–148—MAR. 23, 2010 
be considered the most current other than those issued in 
or around November 2009. 
Nothing in this subsection shall be construed to prohibit a plan 
or issuer from providing coverage for services in addition to those 
recommended by United States Preventive Services Task Force 
or to deny coverage for services that are not recommended by 
such Task Force. 
‘‘(b) INTERVAL.— 
‘‘(1) IN GENERAL.—The Secretary shall establish a minimum 
interval between the date on which a recommendation described 
in subsection (a)(1) or (a)(2) or a guideline under subsection 
(a)(3) is issued and the plan year with respect to which the 
requirement described in subsection (a) is effective with respect 
to the service described in such recommendation or guideline. 
‘‘(2) MINIMUM.—The interval described in paragraph (1) 
shall not be less than 1 year. 
‘‘(c) VALUE-BASED INSURANCE DESIGN.—The Secretary may 
develop guidelines to permit a group health plan and a health 
insurance issuer offering group or individual health insurance cov-
erage to utilize value-based insurance designs. 
‘‘SEC. 2714. EXTENSION OF DEPENDENT COVERAGE. 
‘‘(a) IN GENERAL.—A group health plan and a health insurance 
issuer offering group or individual health insurance coverage that 
provides dependent coverage of children shall continue to make 
such coverage available for an adult child (who is not married) 
until the child turns 26 years of age. Nothing in this section shall 
require a health plan or a health insurance issuer described in 
the preceding sentence to make coverage available for a child of 
a child receiving dependent coverage. 
‘‘(b) REGULATIONS.—The Secretary shall promulgate regulations 
to define the dependents to which coverage shall be made available 
under subsection (a). 
‘‘(c) RULE
OF CONSTRUCTION.—Nothing in this section shall 
be construed to modify the definition of ‘dependent’ as used in 
the Internal Revenue Code of 1986 with respect to the tax treatment 
of the cost of coverage. 
‘‘SEC. 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM EXPLA-
NATION OF COVERAGE DOCUMENTS AND STANDARDIZED 
DEFINITIONS. 
‘‘(a) IN GENERAL.—Not later than 12 months after the date 
of enactment of the Patient Protection and Affordable Care Act, 
the Secretary shall develop standards for use by a group health 
plan and a health insurance issuer offering group or individual 
health insurance coverage, in compiling and providing to enrollees 
a summary of benefits and coverage explanation that accurately 
describes the benefits and coverage under the applicable plan or 
coverage. In developing such standards, the Secretary shall consult 
with the National Association of Insurance Commissioners (referred 
to in this section as the ‘NAIC’), a working group composed of 
representatives of health insurance-related consumer advocacy 
organizations, health insurance issuers, health care professionals, 
patient advocates including those representing individuals with lim-
ited English proficiency, and other qualified individuals. 
‘‘(b) REQUIREMENTS.—The standards for the summary of bene-
fits and coverage developed under subsection (a) shall provide for 
the following: 
Deadline. 
42 USC 
300gg–15. 
42 USC 
300gg–14. 
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124 STAT. 133 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) APPEARANCE.—The standards shall ensure that the 
summary of benefits and coverage is presented in a uniform 
format that does not exceed 4 pages in length and does not 
include print smaller than 12-point font. 
‘‘(2) LANGUAGE.—The standards shall ensure that the sum-
mary is presented in a culturally and linguistically appropriate 
manner and utilizes terminology understandable by the average 
plan enrollee. 
‘‘(3) CONTENTS.—The standards shall ensure that the sum-
mary of benefits and coverage includes— 
‘‘(A) uniform definitions of standard insurance terms 
and medical terms (consistent with subsection (g)) so that 
consumers may compare health insurance coverage and 
understand the terms of coverage (or exception to such 
coverage); 
‘‘(B) a description of the coverage, including cost 
sharing for— 
‘‘(i) each of the categories of the essential health 
benefits described in subparagraphs (A) through (J) 
of section 1302(b)(1) of the Patient Protection and 
Affordable Care Act; and 
‘‘(ii) other benefits, as identified by the Secretary; 
‘‘(C) the exceptions, reductions, and limitations on cov-
erage; 
‘‘(D) the cost-sharing provisions, including deductible, 
coinsurance, and co-payment obligations; 
‘‘(E) the renewability and continuation of coverage 
provisions; 
‘‘(F) a coverage facts label that includes examples to 
illustrate common benefits scenarios, including pregnancy 
and serious or chronic medical conditions and related cost 
sharing, such scenarios to be based on recognized clinical 
practice guidelines; 
‘‘(G) a statement of whether the plan or coverage— 
‘‘(i) provides minimum essential coverage (as 
defined under section 5000A(f) of the Internal Revenue 
Code 1986); and 
‘‘(ii) ensures that the plan or coverage share of 
the total allowed costs of benefits provided under the 
plan or coverage is not less than 60 percent of such 
costs; 
‘‘(H) a statement that the outline is a summary of 
the policy or certificate and that the coverage document 
itself should be consulted to determine the governing 
contractual provisions; and 
‘‘(I) a contact number for the consumer to call with 
additional questions and an Internet web address where 
a copy of the actual individual coverage policy or group 
certificate of coverage can be reviewed and obtained. 
‘‘(c) PERIODIC REVIEW
AND UPDATING.—The Secretary shall 
periodically review and update, as appropriate, the standards devel-
oped under this section. 
‘‘(d) REQUIREMENT TO PROVIDE.— 
‘‘(1) IN GENERAL.—Not later than 24 months after the date 
of enactment of the Patient Protection and Affordable Care 
Act, each entity described in paragraph (3) shall provide, prior 
Deadline. 
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124 STAT. 134 
PUBLIC LAW 111–148—MAR. 23, 2010 
to any enrollment restriction, a summary of benefits and cov-
erage explanation pursuant
to the standards developed by 
the Secretary under subsection (a) to— 
‘‘(A) an applicant at the time of application; 
‘‘(B) an enrollee prior to the time of enrollment or 
reenrollment, as applicable; and 
‘‘(C) a policyholder or certificate holder at the time 
of issuance of the policy or delivery of the certificate. 
‘‘(2) COMPLIANCE.—An entity described in paragraph (3) 
is deemed to be in compliance with this section if the summary 
of benefits and coverage described in subsection (a) is provided 
in paper or electronic form. 
‘‘(3) ENTITIES
IN
GENERAL.—An entity described in this 
paragraph is— 
‘‘(A) a health insurance issuer (including a group health 
plan that is not a self-insured plan) offering health insur-
ance coverage within the United States; or 
‘‘(B) in the case of a self-insured group health plan, 
the plan sponsor or designated administrator of the plan 
(as such terms are defined in section 3(16) of the Employee 
Retirement Income Security Act of 1974). 
‘‘(4) NOTICE OF MODIFICATIONS.—If a group health plan 
or health insurance issuer makes any material modification 
in any of the terms of the plan or coverage involved (as defined 
for purposes of section 102 of the Employee Retirement Income 
Security Act of 1974) that is not reflected in the most recently 
provided summary of benefits and coverage, the plan or issuer 
shall provide notice of such modification to enrollees not later 
than 60 days prior to the date on which such modification 
will become effective. 
‘‘(e) PREEMPTION.—The standards developed under subsection 
(a) shall preempt any related State standards that require a sum-
mary of benefits and coverage that provides less information to 
consumers than that required to be provided under this section, 
as determined by the Secretary. 
‘‘(f) FAILURE TO PROVIDE.—An entity described in subsection 
(d)(3) that willfully fails to provide the information required under 
this section shall be subject to a fine of not more than $1,000 
for each such failure. Such failure with respect to each enrollee 
shall constitute a separate offense for purposes of this subsection. 
‘‘(g) DEVELOPMENT OF STANDARD DEFINITIONS.— 
‘‘(1) IN GENERAL.—The Secretary shall, by regulation, pro-
vide for the development of standards for the definitions of 
terms used in health insurance coverage, including the insur-
ance-related terms described in paragraph (2) and the medical 
terms described in paragraph (3). 
‘‘(2) INSURANCE-RELATED
TERMS.—The insurance-related 
terms described in this paragraph are premium, deductible, 
co-insurance, co-payment, out-of-pocket limit, preferred pro-
vider, non-preferred provider, out-of-network co-payments, UCR 
(usual, customary and reasonable) fees, excluded services, griev-
ance and appeals, and such other terms as the Secretary deter-
mines are important to define so that consumers may compare 
health insurance coverage and understand the terms of their 
coverage. 
Regulations. 
Fine. 
Deadline. 
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124 STAT. 135 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(3) MEDICAL TERMS.—The medical terms described in this 
paragraph are hospitalization, hospital outpatient care, emer-
gency room care, physician services, prescription drug coverage, 
durable medical equipment, home health care, skilled nursing 
care, rehabilitation services, hospice services, emergency med-
ical transportation, and such other terms as the Secretary 
determines are important to define so that consumers may 
compare the medical benefits offered by health insurance and 
understand the extent of those medical benefits (or exceptions 
to those benefits). 
‘‘SEC. 2716. PROHIBITION OF DISCRIMINATION BASED ON SALARY. 
‘‘(a) IN GENERAL.—The plan sponsor of a group health plan 
(other than a self-insured plan) may not establish rules relating 
to the health insurance coverage eligibility (including continued 
eligibility) of any full-time employee under the terms of the plan 
that are based on the total hourly or annual salary of the employee 
or otherwise establish eligibility rules that have the effect of 
discriminating in favor of higher wage employees. 
‘‘(b) LIMITATION.—Subsection (a) shall not be construed to pro-
hibit a plan sponsor from establishing contribution requirements 
for enrollment in the plan or coverage that provide for the payment 
by employees with lower hourly or annual compensation of a lower 
dollar or percentage contribution than the payment required of 
similarly situated employees with a higher hourly or annual com-
pensation. 
‘‘SEC. 2717. ENSURING THE QUALITY OF CARE. 
‘‘(a) QUALITY REPORTING.— 
‘‘(1) IN GENERAL.—Not later than 2 years after the date 
of enactment of the Patient Protection and Affordable Care 
Act, the Secretary, in consultation with experts in health care 
quality and stakeholders, shall develop reporting requirements 
for use by a group health plan, and a health insurance issuer 
offering group or individual health insurance coverage, with 
respect to plan or coverage benefits and health care provider 
reimbursement structures that— 
‘‘(A) improve health outcomes through the implementa-
tion of activities such as quality reporting, effective case 
management, care coordination, chronic disease manage-
ment, and medication and care compliance initiatives, 
including through the use of the medical homes model 
as defined for purposes of section 3602 of the Patient 
Protection and Affordable Care Act, for treatment or serv-
ices under the plan or coverage; 
‘‘(B) implement activities to prevent hospital readmis-
sions through a comprehensive program for hospital dis-
charge that includes patient-centered education and coun-
seling, comprehensive discharge planning, and post dis-
charge reinforcement by an appropriate health care profes-
sional; 
‘‘(C) implement activities to improve patient safety and 
reduce medical errors through the appropriate use of best 
clinical practices, evidence based medicine, and health 
information technology under the plan or coverage; and 
‘‘(D) implement wellness and health promotion activi-
ties. 
‘‘(2) REPORTING REQUIREMENTS.— 
42 USC 
300gg–17. 
42 USC 
300gg–16. 
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124 STAT. 136 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) IN GENERAL.—A group health plan and a health 
insurance issuer offering group or individual health insur-
ance coverage shall annually submit to the Secretary, and 
to enrollees under the plan or coverage, a report on whether 
the benefits under the plan or coverage satisfy the elements 
described in subparagraphs (A) through (D) of paragraph 
(1). 
‘‘(B) TIMING
OF
REPORTS.—A report under subpara-
graph (A) shall be made available to an enrollee under 
the plan or coverage during each open enrollment period. 
‘‘(C) AVAILABILITY OF REPORTS.—The Secretary shall 
make reports submitted under subparagraph (A) available 
to the public through an Internet website. 
‘‘(D) PENALTIES.—In developing the reporting require-
ments under paragraph (1), the Secretary may develop 
and impose appropriate penalties for non-compliance with 
such requirements. 
‘‘(E) EXCEPTIONS.—In developing the reporting require-
ments under paragraph (1), the Secretary may provide 
for exceptions to such requirements for group health plans 
and health insurance issuers that substantially meet the 
goals of this section. 
‘‘(b) WELLNESS AND PREVENTION PROGRAMS.—For purposes of 
subsection (a)(1)(D), wellness and health promotion activities may 
include personalized wellness and prevention services, which are 
coordinated, maintained or delivered by a health care provider, 
a wellness and prevention plan manager, or a health, wellness 
or prevention services organization that conducts health risk assess-
ments or offers ongoing face-to-face, telephonic or web-based inter-
vention efforts for each of the program’s participants, and which 
may include the following wellness and prevention efforts: 
‘‘(1) Smoking cessation. 
‘‘(2) Weight management. 
‘‘(3) Stress management. 
‘‘(4) Physical fitness. 
‘‘(5) Nutrition. 
‘‘(6) Heart disease prevention. 
‘‘(7) Healthy lifestyle support. 
‘‘(8) Diabetes prevention. 
‘‘(c) REGULATIONS.—Not later than 2 years after the date of 
enactment of the Patient Protection and Affordable Care Act, the 
Secretary shall promulgate regulations that provide criteria for 
determining whether a reimbursement structure is described in 
subsection (a). 
‘‘(d) STUDY AND REPORT.—Not later than 180 days after the 
date on which regulations are promulgated under subsection (c), 
the Government Accountability Office shall review such regulations 
and conduct a study and submit to the Committee on Health, 
Education, Labor, and Pensions of the Senate and the Committee 
on Energy and Commerce of the House of Representatives a report 
regarding the impact the activities under this section have had 
on the quality and cost of health care. 
‘‘SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE COVERAGE. 
‘‘(a) CLEAR ACCOUNTING FOR COSTS.—A health insurance issuer 
offering group or individual health insurance coverage shall, with 
Reports. 
42 USC 
300gg–18. 
Deadline. 
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124 STAT. 137 
PUBLIC LAW 111–148—MAR. 23, 2010 
respect to each plan year, submit to the Secretary a report con-
cerning the percentage of total premium revenue that such coverage 
expends— 
‘‘(1) on reimbursement for clinical services provided to 
enrollees under such coverage; 
‘‘(2) for activities that improve health care quality; and 
‘‘(3) on all other non-claims costs, including an explanation 
of the nature of such costs, and excluding State taxes and 
licensing or regulatory fees. 
The Secretary shall make reports received under this section avail-
able to the public on the Internet website of the Department of 
Health and Human Services. 
‘‘(b) ENSURING THAT CONSUMERS RECEIVE VALUE FOR THEIR 
PREMIUM PAYMENTS.— 
‘‘(1) REQUIREMENT TO PROVIDE VALUE FOR PREMIUM PAY-
MENTS.—A health insurance issuer offering group or individual 
health insurance coverage shall, with respect to each plan 
year, provide an annual rebate to each enrollee under such 
coverage, on a pro rata basis, in an amount that is equal 
to the amount by which premium revenue expended by the 
issuer on activities described in subsection (a)(3) exceeds— 
‘‘(A) with respect to a health insurance issuer offering 
coverage in the group market, 20 percent, or such lower 
percentage as a State may by regulation determine; or 
‘‘(B) with respect to a health insurance issuer offering 
coverage in the individual market, 25 percent, or such 
lower percentage as a State may by regulation determine, 
except that such percentage shall be adjusted to the extent 
the Secretary determines that the application of such 
percentage with a State may destabilize the existing indi-
vidual market in such State. 
‘‘(2) CONSIDERATION IN SETTING PERCENTAGES.—In deter-
mining the percentages under paragraph (1), a State shall 
seek to ensure adequate participation by health insurance 
issuers, competition in the health insurance market in the 
State, and value for consumers so that premiums are used 
for clinical services and quality improvements. 
‘‘(3) TERMINATION.—The provisions of this subsection shall 
have no force or effect after December 31, 2013. 
‘‘(c) STANDARD HOSPITAL CHARGES.—Each hospital operating 
within the United States shall for each year establish (and update) 
and make public (in accordance with guidelines developed by the 
Secretary) a list of the hospital’s standard charges for items and 
services provided by the hospital, including for diagnosis-related 
groups established under section 1886(d)(4) of the Social Security 
Act. 
‘‘(d) DEFINITIONS.—The Secretary, in consultation with the 
National Association of Insurance Commissions, shall establish uni-
form definitions for the activities reported under subsection (a). 
‘‘SEC. 2719. APPEALS PROCESS. 
‘‘A group health plan and a health insurance issuer offering 
group or individual health insurance coverage shall implement an 
effective appeals process for appeals of coverage determinations 
and claims, under which the plan or issuer shall, at a minimum— 
‘‘(1) have in effect an internal claims appeal process; 
42 USC 
300gg–19. 
Public 
information. 
Web posting. 
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124 STAT. 138 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) provide notice to enrollees, in a culturally and linguis-
tically appropriate manner, of available internal and external 
appeals processes, and the availability of any applicable office 
of health insurance consumer assistance or ombudsman estab-
lished under section 2793 to assist such enrollees with the 
appeals processes; 
‘‘(3) allow an enrollee to review their file, to present evi-
dence and testimony as part of the appeals process, and to 
receive continued coverage pending the outcome of the appeals 
process; and 
‘‘(4) provide an external review process for such plans and 
issuers that, at a minimum, includes the consumer protections 
set forth in the Uniform External Review Model Act promul-
gated by the National Association of Insurance Commissioners 
and is binding on such plans.’’. 
SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION. 
Part C of title XXVII of the Public Health Service Act (42 
U.S.C. 300gg–91 et seq.) is amended by adding at the end the 
following: 
‘‘SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION. 
‘‘(a) IN GENERAL.—The Secretary shall award grants to States 
to enable such States (or the Exchanges operating in such States) 
to establish, expand, or provide support for— 
‘‘(1) offices of health insurance consumer assistance; or 
‘‘(2) health insurance ombudsman programs. 
‘‘(b) ELIGIBILITY.— 
‘‘(1) IN GENERAL.—To be eligible to receive a grant, a State 
shall designate an independent office of health insurance con-
sumer assistance, or an ombudsman, that, directly or in 
coordination with State health insurance regulators and con-
sumer assistance organizations, receives and responds to 
inquiries and complaints concerning health insurance coverage 
with respect to Federal health insurance requirements and 
under State law. 
‘‘(2) CRITERIA.—A State that receives a grant under this 
section shall comply with criteria established by the Secretary 
for carrying out activities under such grant. 
‘‘(c) DUTIES.—The office of health insurance consumer assist-
ance or health insurance ombudsman shall— 
‘‘(1) assist with the filing of complaints and appeals, 
including filing appeals with the internal appeal or grievance 
process of the group health plan or health insurance issuer 
involved and providing information about the external appeal 
process; 
‘‘(2) collect, track, and quantify problems and inquiries 
encountered by consumers; 
‘‘(3) educate consumers on their rights and responsibilities 
with respect to group health plans and health insurance cov-
erage; 
‘‘(4) assist consumers with enrollment in a group health 
plan or health insurance coverage by providing information, 
referral, and assistance; and 
‘‘(5) resolve problems with obtaining premium tax credits 
under section 36B of the Internal Revenue Code of 1986. 
Grants. 
42 USC 
300gg–93. 
Notification. 
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124 STAT. 139 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(d) DATA COLLECTION.—As a condition of receiving a grant 
under subsection (a), an office of health insurance consumer assist-
ance or ombudsman program shall be required to collect and report 
data to the Secretary on the types of problems and inquiries encoun-
tered by consumers. The Secretary shall utilize such data to identify 
areas where more enforcement action is necessary and shall share 
such information with State insurance regulators, the Secretary 
of Labor, and the Secretary of the Treasury for use in the enforce-
ment activities of such agencies. 
‘‘(e) FUNDING.— 
‘‘(1) INITIAL
FUNDING.—There is hereby appropriated to 
the Secretary, out of any funds in the Treasury not otherwise 
appropriated, $30,000,000 for the first fiscal year for which 
this section applies to carry out this section. Such amount 
shall remain available without fiscal year limitation. 
‘‘(2) AUTHORIZATION
FOR
SUBSEQUENT
YEARS.—There is 
authorized to be appropriated to the Secretary for each fiscal 
year following the fiscal year described in paragraph (1), such 
sums as may be necessary to carry out this section.’’. 
SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOL-
LARS. 
Part C of title XXVII of the Public Health Service Act (42 
U.S.C. 300gg–91 et seq.), as amended by section 1002, is further 
amended by adding at the end the following: 
‘‘SEC. 2794. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOL-
LARS. 
‘‘(a) INITIAL PREMIUM REVIEW PROCESS.— 
‘‘(1) IN
GENERAL.—The Secretary, in conjunction with 
States, shall establish a process for the annual review, begin-
ning with the 2010 plan year and subject to subsection (b)(2)(A), 
of unreasonable increases in premiums for health insurance 
coverage. 
‘‘(2) JUSTIFICATION AND DISCLOSURE.—The process estab-
lished under paragraph (1) shall require health insurance 
issuers to submit to the Secretary and the relevant State a 
justification for an unreasonable premium increase prior to 
the implementation of the increase. Such issuers shall promi-
nently post such information on their Internet websites. The 
Secretary shall ensure the public disclosure of information on 
such increases and justifications for all health insurance 
issuers. 
‘‘(b) CONTINUING PREMIUM REVIEW PROCESS.— 
‘‘(1) INFORMING
SECRETARY
OF
PREMIUM
INCREASE
PAT-
TERNS.—As a condition of receiving a grant under subsection 
(c)(1), a State, through its Commissioner of Insurance, shall— 
‘‘(A) provide the Secretary with information about 
trends in premium increases in health insurance coverage 
in premium rating areas in the State; and 
‘‘(B) make recommendations, as appropriate, to the 
State Exchange about whether particular health insurance 
issuers should be excluded from participation in the 
Exchange based on a pattern or practice of excessive or 
unjustified premium increases. 
‘‘(2) MONITORING BY SECRETARY OF PREMIUM INCREASES.— 
‘‘(A) IN GENERAL.—Beginning with plan years begin-
ning in 2014, the Secretary, in conjunction with the States 
Effective date. 
Web posting. 
Effective date. 
42 USC 
300gg–94. 
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124 STAT. 140 
PUBLIC LAW 111–148—MAR. 23, 2010 
and consistent with the provisions of subsection (a)(2), shall 
monitor premium increases of health insurance coverage 
offered through an Exchange and outside of an Exchange. 
‘‘(B) CONSIDERATION IN OPENING EXCHANGE.—In deter-
mining under section 1312(f)(2)(B) of the Patient Protection 
and Affordable Care Act whether to offer qualified health 
plans in the large group market through an Exchange, 
the State shall take into account any excess of premium 
growth outside of the Exchange as compared to the rate 
of such growth inside the Exchange. 
‘‘(c) GRANTS IN SUPPORT OF PROCESS.— 
‘‘(1) PREMIUM REVIEW GRANTS DURING 2010 THROUGH 2014.— 
The Secretary shall carry out a program to award grants to 
States during the 5-year period beginning with fiscal year 2010 
to assist such States in carrying out subsection (a), including— 
‘‘(A) in reviewing and, if appropriate under State law, 
approving premium increases for health insurance cov-
erage; and 
‘‘(B) in providing information and recommendations 
to the Secretary under subsection (b)(1). 
‘‘(2) FUNDING.— 
‘‘(A) IN GENERAL.—Out of all funds in the Treasury 
not otherwise appropriated, there are appropriated to the 
Secretary $250,000,000, to be available for expenditure for 
grants under paragraph (1) and subparagraph (B). 
‘‘(B) FURTHER
AVAILABILITY
FOR
INSURANCE
REFORM 
AND CONSUMER PROTECTION.—If the amounts appropriated 
under subparagraph (A) are not fully obligated under 
grants under paragraph (1) by the end of fiscal year 2014, 
any remaining funds shall remain available to the Sec-
retary for grants to States for planning and implementing 
the insurance reforms and consumer protections under part 
A. 
‘‘(C) ALLOCATION.—The Secretary shall establish a for-
mula for determining the amount of any grant to a State 
under this subsection. Under such formula— 
‘‘(i) the Secretary shall consider the number of 
plans of health insurance coverage offered in each State 
and the population of the State; and 
‘‘(ii) no State qualifying for a grant under para-
graph (1) shall receive less than $1,000,000, or more 
than $5,000,000 for a grant year.’’. 
SEC. 1004. EFFECTIVE DATES. 
(a) IN GENERAL.—Except as provided for in subsection (b), 
this subtitle (and the amendments made by this subtitle) shall 
become effective for plan years beginning on or after the date 
that is 6 months after the date of enactment of this Act, except 
that the amendments made by sections 1002 and 1003 shall become 
effective for fiscal years beginning with fiscal year 2010. 
(b) SPECIAL RULE.—The amendments made by sections 1002 
and 1003 shall take effect on the date of enactment of this Act. 
42 USC 
300gg–11 note. 
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124 STAT. 141 
PUBLIC LAW 111–148—MAR. 23, 2010 
Subtitle B—Immediate Actions to Preserve 
and Expand Coverage 
SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNINSURED 
INDIVIDUALS WITH A PREEXISTING CONDITION. 
(a) IN GENERAL.—Not later than 90 days after the date of 
enactment of this Act, the Secretary shall establish a temporary 
high risk health insurance pool program to provide health insurance 
coverage for eligible individuals during the period beginning on 
the date on which such program is established and ending on 
January 1, 2014. 
(b) ADMINISTRATION.— 
(1) IN GENERAL.—The Secretary may carry out the program 
under this section directly or through contracts to eligible enti-
ties. 
(2) ELIGIBLE ENTITIES.—To be eligible for a contract under 
paragraph (1), an entity shall— 
(A) be a State or nonprofit private entity; 
(B) submit to the Secretary an application at such 
time, in such manner, and containing such information 
as the Secretary may require; and 
(C) agree to utilize contract funding to establish and 
administer a qualified high risk pool for eligible individuals. 
(3) MAINTENANCE OF EFFORT.—To be eligible to enter into 
a contract with the Secretary under this subsection, a State 
shall agree not to reduce the annual amount the State expended 
for the operation of one or more State high risk pools during 
the year preceding the year in which such contract is entered 
into. 
(c) QUALIFIED HIGH RISK POOL.— 
(1) IN GENERAL.—Amounts made available under this sec-
tion shall be used to establish a qualified high risk pool that 
meets the requirements of paragraph (2). 
(2) REQUIREMENTS.—A qualified high risk pool meets the 
requirements of this paragraph if such pool— 
(A) provides to all eligible individuals health insurance 
coverage that does not impose any preexisting condition 
exclusion with respect to such coverage; 
(B) provides health insurance coverage— 
(i) in which the issuer’s share of the total allowed 
costs of benefits provided under such coverage is not 
less than 65 percent of such costs; and 
(ii) that has an out of pocket limit not greater 
than the applicable amount described in section 
223(c)(2) of the Internal Revenue Code of 1986 for 
the year involved, except that the Secretary may 
modify such limit if necessary to ensure the pool meets 
the actuarial value limit under clause (i); 
(C) ensures that with respect to the premium rate 
charged for health insurance coverage offered to eligible 
individuals through the high risk pool, such rate shall— 
(i) except as provided in clause (ii), vary only as 
provided for under section 2701 of the Public Health 
Service Act (as amended by this Act and notwith-
standing the date on which such amendments take 
effect); 
Deadline. 
Time period. 
42 USC 18001. 
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124 STAT. 142 
PUBLIC LAW 111–148—MAR. 23, 2010 
(ii) vary on the basis of age by a factor of not 
greater than 4 to 1; and 
(iii) be established at a standard rate for a 
standard population; and 
(D) meets any other requirements determined appro-
priate by the Secretary. 
(d) ELIGIBLE INDIVIDUAL.—An individual shall be deemed to 
be an eligible individual for purposes of this section if such indi-
vidual— 
(1) is a citizen or national of the United States or is 
lawfully present in the United States (as determined in accord-
ance with section 1411); 
(2) has not been covered under creditable coverage (as 
defined in section 2701(c)(1) of the Public Health Service Act 
as in effect on the date of enactment of this Act) during the 
6-month period prior to the date on which such individual 
is applying for coverage through the high risk pool; and 
(3) has a pre-existing condition, as determined in a manner 
consistent with guidance issued by the Secretary. 
(e) PROTECTION AGAINST DUMPING RISK BY INSURERS.— 
(1) IN GENERAL.—The Secretary shall establish criteria for 
determining whether health insurance issuers and employment- 
based health plans have discouraged an individual from 
remaining enrolled in prior coverage based on that individual’s 
health status. 
(2) SANCTIONS.—An issuer or employment-based health 
plan shall be responsible for reimbursing the program under 
this section for the medical expenses incurred by the program 
for an individual who, based on criteria established by the 
Secretary, the Secretary finds was encouraged by the issuer 
to disenroll from health benefits coverage prior to enrolling 
in coverage through the program. The criteria shall include 
at least the following circumstances: 
(A) In the case of prior coverage obtained through 
an employer, the provision by the employer, group health 
plan, or the issuer of money or other financial consideration 
for disenrolling from the coverage. 
(B) In the case of prior coverage obtained directly from 
an issuer or under an employment-based health plan— 
(i) the provision by the issuer or plan of money 
or other financial consideration for disenrolling from 
the coverage; or 
(ii) in the case of an individual whose premium 
for the prior coverage exceeded the premium required 
by the program (adjusted based on the age factors 
applied to the prior coverage)— 
(I) the prior coverage is a policy that is no 
longer being actively marketed (as defined by the 
Secretary) by the issuer; or 
(II) the prior coverage is a policy for which 
duration of coverage form issue or health status 
are factors that can be considered in determining 
premiums at renewal. 
(3) CONSTRUCTION.—Nothing in this subsection shall be 
construed as constituting exclusive remedies for violations of 
criteria established under paragraph (1) or as preventing States 
Criteria. 
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124 STAT. 143 
PUBLIC LAW 111–148—MAR. 23, 2010 
from applying or enforcing such paragraph or other provisions 
under law with respect to health insurance issuers. 
(f) OVERSIGHT.—The Secretary shall establish— 
(1) an appeals process to enable individuals to appeal a 
determination under this section; and 
(2) procedures to protect against waste, fraud, and abuse. 
(g) FUNDING; TERMINATION OF AUTHORITY.— 
(1) IN GENERAL.—There is appropriated to the Secretary, 
out of any moneys in the Treasury not otherwise appropriated, 
$5,000,000,000 to pay claims against (and the administrative 
costs of) the high risk pool under this section that are in 
excess of the amount of premiums collected from eligible 
individuals enrolled in the high risk pool. Such funds shall 
be available without fiscal year limitation. 
(2) INSUFFICIENT FUNDS.—If the Secretary estimates for 
any fiscal year that the aggregate amounts available for the 
payment of the expenses of the high risk pool will be less 
than the actual amount of such expenses, the Secretary shall 
make such adjustments as are necessary to eliminate such 
deficit. 
(3) TERMINATION OF AUTHORITY.— 
(A) IN GENERAL.—Except as provided in subparagraph 
(B), coverage of eligible individuals under a high risk pool 
in a State shall terminate on January 1, 2014. 
(B) TRANSITION
TO
EXCHANGE.—The Secretary shall 
develop procedures to provide for the transition of eligible 
individuals enrolled in health insurance coverage offered 
through a high risk pool established under this section 
into qualified health plans offered through an Exchange. 
Such procedures shall ensure that there is no lapse in 
coverage with respect to the individual and may extend 
coverage after the termination of the risk pool involved, 
if the Secretary determines necessary to avoid such a lapse. 
(4) LIMITATIONS.—The Secretary has the authority to stop 
taking applications for participation in the program under this 
section to comply with the funding limitation provided for in 
paragraph (1). 
(5) RELATION TO STATE LAWS.—The standards established 
under this section shall supersede any State law or regulation 
(other than State licensing laws or State laws relating to plan 
solvency) with respect to qualified high risk pools which are 
established in accordance with this section. 
SEC. 1102. REINSURANCE FOR EARLY RETIREES. 
(a) ADMINISTRATION.— 
(1) IN GENERAL.—Not later than 90 days after the date 
of enactment of this Act, the Secretary shall establish a tem-
porary reinsurance program to provide reimbursement to 
participating employment-based plans for a portion of the cost 
of providing health insurance coverage to early retirees (and 
to the eligible spouses, surviving spouses, and dependents of 
such retirees) during the period beginning on the date on which 
such program is established and ending on January 1, 2014. 
(2) REFERENCE.—In this section: 
(A) HEALTH
BENEFITS.—The term ‘‘health benefits’’ 
means medical, surgical, hospital, prescription drug, and 
such other benefits as shall be determined by the Secretary, 
Deadline. 
Time period. 
42 USC 18002. 
Procedures. 
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124 STAT. 144 
PUBLIC LAW 111–148—MAR. 23, 2010 
whether self-funded, or delivered through the purchase 
of insurance or otherwise. 
(B) EMPLOYMENT-BASED
PLAN.—The term ‘‘employ-
ment-based plan’’ means a group health benefits plan 
that— 
(i) is— 
(I) maintained by one or more current or 
former employers (including without limitation any 
State or local government or political subdivision 
thereof), 
employee 
organization, 
a 
voluntary 
employees’ beneficiary association, or a committee 
or board of individuals appointed to administer 
such plan; or 
(II) a multiemployer plan (as defined in section 
3(37) of the Employee Retirement Income Security 
Act of 1974); and 
(ii) provides health benefits to early retirees. 
(C) EARLY RETIREES.—The term ‘‘early retirees’’ means 
individuals who are age 55 and older but are not eligible 
for coverage under title XVIII of the Social Security Act, 
and who are not active employees of an employer 
maintaining, or currently contributing to, the employment- 
based plan or of any employer that has made substantial 
contributions to fund such plan. 
(b) PARTICIPATION.— 
(1) EMPLOYMENT-BASED PLAN ELIGIBILITY.—A participating 
employment-based plan is an employment-based plan that— 
(A) meets the requirements of paragraph (2) with 
respect to health benefits provided under the plan; and 
(B) submits to the Secretary an application for partici-
pation in the program, at such time, in such manner, 
and containing such information as the Secretary shall 
require. 
(2) EMPLOYMENT-BASED
HEALTH
BENEFITS.—An employ-
ment-based plan meets the requirements of this paragraph 
if the plan— 
(A) implements programs and procedures to generate 
cost-savings with respect to participants with chronic and 
high-cost conditions; 
(B) provides documentation of the actual cost of medical 
claims involved; and 
(C) is certified by the Secretary. 
(c) PAYMENTS.— 
(1) SUBMISSION OF CLAIMS.— 
(A) IN
GENERAL.—A participating employment-based 
plan shall submit claims for reimbursement to the Sec-
retary which shall contain documentation of the actual 
costs of the items and services for which each claim is 
being submitted. 
(B) BASIS
FOR
CLAIMS.—Claims submitted under 
subparagraph (A) shall be based on the actual amount 
expended by the participating employment-based plan 
involved within the plan year for the health benefits pro-
vided to an early retiree or the spouse, surviving spouse, 
or dependent of such retiree. In determining the amount 
of a claim for purposes of this subsection, the participating 
Certification. 
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124 STAT. 145 
PUBLIC LAW 111–148—MAR. 23, 2010 
employment-based plan shall take into account any nego-
tiated price concessions (such as discounts, direct or 
indirect subsidies, rebates, and direct or indirect remunera-
tions) obtained by such plan with respect to such health 
benefit. For purposes of determining the amount of any 
such claim, the costs paid by the early retiree or the 
retiree’s spouse, surviving spouse, or dependent in the form 
of deductibles, co-payments, or co-insurance shall be 
included in the amounts paid by the participating employ-
ment-based plan. 
(2) PROGRAM PAYMENTS.—If the Secretary determines that 
a participating employment-based plan has submitted a valid 
claim under paragraph (1), the Secretary shall reimburse such 
plan for 80 percent of that portion of the costs attributable 
to such claim that exceed $15,000, subject to the limits con-
tained in paragraph (3). 
(3) LIMIT.—To be eligible for reimbursement under the 
program, a claim submitted by a participating employment- 
based plan shall not be less than $15,000 nor greater than 
$90,000. Such amounts shall be adjusted each fiscal year based 
on the percentage increase in the Medical Care Component 
of the Consumer Price Index for all urban consumers (rounded 
to the nearest multiple of $1,000) for the year involved. 
(4) USE OF PAYMENTS.—Amounts paid to a participating 
employment-based plan under this subsection shall be used 
to lower costs for the plan. Such payments may be used to 
reduce premium costs for an entity described in subsection 
(a)(2)(B)(i) or to reduce premium contributions, co-payments, 
deductibles, co-insurance, or other out-of-pocket costs for plan 
participants. Such payments shall not be used as general reve-
nues for an entity described in subsection (a)(2)(B)(i). The Sec-
retary shall develop a mechanism to monitor the appropriate 
use of such payments by such entities. 
(5) 
PAYMENTS
NOT
TREATED
AS
INCOME.—Payments 
received under this subsection shall not be included in deter-
mining the gross income of an entity described in subsection 
(a)(2)(B)(i) that is maintaining or currently contributing to a 
participating employment-based plan. 
(6) APPEALS.—The Secretary shall establish— 
(A) an appeals process to permit participating employ-
ment-based plans to appeal a determination of the Sec-
retary with respect to claims submitted under this section; 
and 
(B) procedures to protect against fraud, waste, and 
abuse under the program. 
(d) AUDITS.—The Secretary shall conduct annual audits of 
claims data submitted by participating employment-based plans 
under this section to ensure that such plans are in compliance 
with the requirements of this section. 
(e) FUNDING.—There is appropriated to the Secretary, out of 
any 
moneys 
in 
the 
Treasury 
not 
otherwise 
appropriated, 
$5,000,000,000 to carry out the program under this section. Such 
funds shall be available without fiscal year limitation. 
(f) LIMITATION.—The Secretary has the authority to stop taking 
applications for participation in the program based on the avail-
ability of funding under subsection (e). 
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124 STAT. 146 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 1103. IMMEDIATE INFORMATION THAT ALLOWS CONSUMERS TO 
IDENTIFY AFFORDABLE COVERAGE OPTIONS. 
(a) INTERNET PORTAL TO AFFORDABLE COVERAGE OPTIONS.— 
(1) IMMEDIATE
ESTABLISHMENT.—Not later than July 1, 
2010, the Secretary, in consultation with the States, shall estab-
lish a mechanism, including an Internet website, through which 
a resident of any State may identify affordable health insurance 
coverage options in that State. 
(2) CONNECTING TO AFFORDABLE COVERAGE.—An Internet 
website established under paragraph (1) shall, to the extent 
practicable, provide ways for residents of any State to receive 
information on at least the following coverage options: 
(A) Health insurance coverage offered by health insur-
ance issuers, other than coverage that provides reimburse-
ment only for the treatment or mitigation of— 
(i) a single disease or condition; or 
(ii) an unreasonably limited set of diseases or 
conditions (as determined by the Secretary); 
(B) Medicaid coverage under title XIX of the Social 
Security Act. 
(C) Coverage under title XXI of the Social Security 
Act. 
(D) A State health benefits high risk pool, to the extent 
that such high risk pool is offered in such State; and 
(E) Coverage under a high risk pool under section 
1101. 
(b) ENHANCING COMPARATIVE PURCHASING OPTIONS.— 
(1) IN GENERAL.—Not later than 60 days after the date 
of enactment of this Act, the Secretary shall develop a standard-
ized format to be used for the presentation of information 
relating to the coverage options described in subsection (a)(2). 
Such format shall, at a minimum, require the inclusion of 
information on the percentage of total premium revenue 
expended on nonclinical costs (as reported under section 2718(a) 
of the Public Health Service Act), eligibility, availability, pre-
mium rates, and cost sharing with respect to such coverage 
options and be consistent with the standards adopted for the 
uniform explanation of coverage as provided for in section 2715 
of the Public Health Service Act. 
(2) USE OF FORMAT.—The Secretary shall utilize the format 
developed under paragraph (1) in compiling information con-
cerning coverage options on the Internet website established 
under subsection (a). 
(c) AUTHORITY TO CONTRACT.—The Secretary may carry out 
this section through contracts entered into with qualified entities. 
SEC. 1104. ADMINISTRATIVE SIMPLIFICATION. 
(a) PURPOSE OF ADMINISTRATIVE SIMPLIFICATION.—Section 261 
of the Health Insurance Portability and Accountability Act of 1996 
(42 U.S.C. 1320d note) is amended— 
(1) by inserting ‘‘uniform’’ before ‘‘standards’’; and 
(2) by inserting ‘‘and to reduce the clerical burden on 
patients, health care providers, and health plans’’ before the 
period at the end. 
(b) OPERATING
RULES
FOR
HEALTH
INFORMATION
TRANS-
ACTIONS.— 
Deadline. 
Standard format. 
Deadlines. 
42 USC 18003. 
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124 STAT. 147 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) DEFINITION OF OPERATING RULES.—Section 1171 of the 
Social Security Act (42 U.S.C. 1320d) is amended by adding 
at the end the following: 
‘‘(9) OPERATING RULES.—The term ‘operating rules’ means 
the necessary business rules and guidelines for the electronic 
exchange of information that are not defined by a standard 
or its implementation specifications as adopted for purposes 
of this part.’’. 
(2) TRANSACTION
STANDARDS; 
OPERATING
RULES
AND 
COMPLIANCE.—Section 1173 of the Social Security Act (42 U.S.C. 
1320d–2) is amended— 
(A) in subsection (a)(2), by adding at the end the fol-
lowing new subparagraph: 
‘‘(J) Electronic funds transfers.’’; 
(B) in subsection (a), by adding at the end the following 
new paragraph: 
‘‘(4) REQUIREMENTS
FOR
FINANCIAL
AND
ADMINISTRATIVE 
TRANSACTIONS.— 
‘‘(A) IN GENERAL.—The standards and associated oper-
ating rules adopted by the Secretary shall— 
‘‘(i) to the extent feasible and appropriate, enable 
determination of an individual’s eligibility and finan-
cial responsibility for specific services prior to or at 
the point of care; 
‘‘(ii) be comprehensive, requiring minimal aug-
mentation by paper or other communications; 
‘‘(iii) provide for timely acknowledgment, response, 
and status reporting that supports a transparent 
claims and denial management process (including adju-
dication and appeals); and 
‘‘(iv) describe all data elements (including reason 
and remark codes) in unambiguous terms, require that 
such data elements be required or conditioned upon 
set values in other fields, and prohibit additional condi-
tions (except where necessary to implement State or 
Federal law, or to protect against fraud and abuse). 
‘‘(B) REDUCTION
OF
CLERICAL
BURDEN.—In adopting 
standards and operating rules for the transactions referred 
to under paragraph (1), the Secretary shall seek to reduce 
the number and complexity of forms (including paper and 
electronic forms) and data entry required by patients and 
providers.’’; and 
(C) by adding at the end the following new subsections: 
‘‘(g) OPERATING RULES.— 
‘‘(1) IN GENERAL.—The Secretary shall adopt a single set 
of operating rules for each transaction referred to under sub-
section (a)(1) with the goal of creating as much uniformity 
in the implementation of the electronic standards as possible. 
Such operating rules shall be consensus-based and reflect the 
necessary business rules affecting health plans and health care 
providers and the manner in which they operate pursuant 
to standards issued under Health Insurance Portability and 
Accountability Act of 1996. 
‘‘(2) OPERATING RULES DEVELOPMENT.—In adopting oper-
ating rules under this subsection, the Secretary shall consider 
recommendations for operating rules developed by a qualified 
nonprofit entity that meets the following requirements: 
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124 STAT. 148 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) The entity focuses its mission on administrative 
simplification. 
‘‘(B) The entity demonstrates a multi-stakeholder and 
consensus-based process for development of operating rules, 
including representation by or participation from health 
plans, health care providers, vendors, relevant Federal 
agencies, and other standard development organizations. 
‘‘(C) The entity has a public set of guiding principles 
that ensure the operating rules and process are open and 
transparent, and supports nondiscrimination and conflict 
of interest policies that demonstrate a commitment to open, 
fair, and nondiscriminatory practices. 
‘‘(D) The entity builds on the transaction standards 
issued under Health Insurance Portability and Account-
ability Act of 1996. 
‘‘(E) The entity allows for public review and updates 
of the operating rules. 
‘‘(3) REVIEW AND RECOMMENDATIONS.—The National Com-
mittee on Vital and Health Statistics shall— 
‘‘(A) advise the Secretary as to whether a nonprofit 
entity meets the requirements under paragraph (2); 
‘‘(B) review the operating rules developed and rec-
ommended by such nonprofit entity; 
‘‘(C) determine whether such operating rules represent 
a consensus view of the health care stakeholders and are 
consistent with and do not conflict with other existing 
standards; 
‘‘(D) evaluate whether such operating rules are con-
sistent with electronic standards adopted for health 
information technology; and 
‘‘(E) submit to the Secretary a recommendation as to 
whether the Secretary should adopt such operating rules. 
‘‘(4) IMPLEMENTATION.— 
‘‘(A) IN GENERAL.—The Secretary shall adopt operating 
rules under this subsection, by regulation in accordance 
with subparagraph (C), following consideration of the oper-
ating rules developed by the non-profit entity described 
in paragraph (2) and the recommendation submitted by 
the National Committee on Vital and Health Statistics 
under paragraph (3)(E) and having ensured consultation 
with providers. 
‘‘(B) ADOPTION REQUIREMENTS; EFFECTIVE DATES.— 
‘‘(i) ELIGIBILITY FOR A HEALTH PLAN AND HEALTH 
CLAIM STATUS.—The set of operating rules for eligibility 
for a health plan and health claim status transactions 
shall be adopted not later than July 1, 2011, in a 
manner ensuring that such operating rules are effective 
not later than January 1, 2013, and may allow for 
the use of a machine readable identification card. 
‘‘(ii) ELECTRONIC FUNDS TRANSFERS AND HEALTH 
CARE PAYMENT AND REMITTANCE ADVICE.—The set of 
operating rules for electronic funds transfers and 
health care payment and remittance advice trans-
actions shall— 
‘‘(I) allow for automated reconciliation of the 
electronic payment with the remittance advice; and 
Deadlines. 
Regulations. 
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124 STAT. 149 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(II) be adopted not later than July 1, 2012, 
in a manner ensuring that such operating rules 
are effective not later than January 1, 2014. 
‘‘(iii) HEALTH CLAIMS OR EQUIVALENT ENCOUNTER 
INFORMATION, ENROLLMENT AND DISENROLLMENT IN A 
HEALTH
PLAN, 
HEALTH
PLAN
PREMIUM
PAYMENTS, 
REFERRAL CERTIFICATION AND AUTHORIZATION.—The set 
of operating rules for health claims or equivalent 
encounter information, enrollment and disenrollment 
in a health plan, health plan premium payments, and 
referral certification and authorization transactions 
shall be adopted not later than July 1, 2014, in a 
manner ensuring that such operating rules are effective 
not later than January 1, 2016. 
‘‘(C) EXPEDITED
RULEMAKING.—The Secretary shall 
promulgate an interim final rule applying any standard 
or operating rule recommended by the National Committee 
on Vital and Health Statistics pursuant to paragraph (3). 
The Secretary shall accept and consider public comments 
on any interim final rule published under this subpara-
graph for 60 days after the date of such publication. 
‘‘(h) COMPLIANCE.— 
‘‘(1) HEALTH PLAN CERTIFICATION.— 
‘‘(A) ELIGIBILITY FOR A HEALTH PLAN, HEALTH CLAIM 
STATUS, ELECTRONIC FUNDS TRANSFERS, HEALTH CARE PAY-
MENT AND REMITTANCE ADVICE.—Not later than December 
31, 2013, a health plan shall file a statement with the 
Secretary, in such form as the Secretary may require, 
certifying that the data and information systems for such 
plan are in compliance with any applicable standards (as 
described under paragraph (7) of section 1171) and associ-
ated operating rules (as described under paragraph (9) 
of such section) for electronic funds transfers, eligibility 
for a health plan, health claim status, and health care 
payment and remittance advice, respectively. 
‘‘(B) HEALTH
CLAIMS
OR
EQUIVALENT
ENCOUNTER 
INFORMATION, ENROLLMENT
AND
DISENROLLMENT
IN
A 
HEALTH PLAN, HEALTH PLAN PREMIUM PAYMENTS, HEALTH 
CLAIMS
ATTACHMENTS, 
REFERRAL
CERTIFICATION
AND 
AUTHORIZATION.—Not later than December 31, 2015, a 
health plan shall file a statement with the Secretary, in 
such form as the Secretary may require, certifying that 
the data and information systems for such plan are in 
compliance with any applicable standards and associated 
operating rules for health claims or equivalent encounter 
information, enrollment and disenrollment in a health plan, 
health plan premium payments, health claims attachments, 
and referral certification and authorization, respectively. 
A health plan shall provide the same level of documentation 
to certify compliance with such transactions as is required 
to certify compliance with the transactions specified in 
subparagraph (A). 
‘‘(2) DOCUMENTATION OF COMPLIANCE.—A health plan shall 
provide the Secretary, in such form as the Secretary may 
require, with adequate documentation of compliance with the 
standards and operating rules described under paragraph (1). 
A health plan shall not be considered to have provided adequate 
Certification. 
Deadlines. 
Public comments. 
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124 STAT. 150 
PUBLIC LAW 111–148—MAR. 23, 2010 
documentation and shall not be certified as being in compliance 
with such standards, unless the health plan— 
‘‘(A) demonstrates to the Secretary that the plan con-
ducts the electronic transactions specified in paragraph 
(1) in a manner that fully complies with the regulations 
of the Secretary; and 
‘‘(B) provides documentation showing that the plan 
has completed end-to-end testing for such transactions with 
their partners, such as hospitals and physicians. 
‘‘(3) SERVICE CONTRACTS.—A health plan shall be required 
to ensure that any entities that provide services pursuant to 
a contract with such health plan shall comply with any 
applicable certification and compliance requirements (and pro-
vide the Secretary with adequate documentation of such compli-
ance) under this subsection. 
‘‘(4) CERTIFICATION
BY
OUTSIDE
ENTITY.—The Secretary 
may designate independent, outside entities to certify that a 
health plan has complied with the requirements under this 
subsection, provided that the certification standards employed 
by such entities are in accordance with any standards or oper-
ating rules issued by the Secretary. 
‘‘(5) COMPLIANCE WITH REVISED STANDARDS AND OPERATING 
RULES.— 
‘‘(A) IN GENERAL.—A health plan (including entities 
described under paragraph (3)) shall file a statement with 
the Secretary, in such form as the Secretary may require, 
certifying that the data and information systems for such 
plan are in compliance with any applicable revised stand-
ards and associated operating rules under this subsection 
for any interim final rule promulgated by the Secretary 
under subsection (i) that— 
‘‘(i) amends any standard or operating rule 
described under paragraph (1) of this subsection; or 
‘‘(ii) establishes a standard (as described under 
subsection (a)(1)(B)) or associated operating rules (as 
described under subsection (i)(5)) for any other finan-
cial and administrative transactions. 
‘‘(B) DATE OF COMPLIANCE.—A health plan shall comply 
with such requirements not later than the effective date 
of the applicable standard or operating rule. 
‘‘(6) AUDITS OF HEALTH PLANS.—The Secretary shall conduct 
periodic audits to ensure that health plans (including entities 
described under paragraph (3)) are in compliance with any 
standards and operating rules that are described under para-
graph (1) or subsection (i)(5). 
‘‘(i) REVIEW AND AMENDMENT OF STANDARDS AND OPERATING 
RULES.— 
‘‘(1) ESTABLISHMENT.—Not later than January 1, 2014, the 
Secretary shall establish a review committee (as described 
under paragraph (4)). 
‘‘(2) EVALUATIONS AND REPORTS.— 
‘‘(A) HEARINGS.—Not later than April 1, 2014, and 
not less than biennially thereafter, the Secretary, acting 
through the review committee, shall conduct hearings to 
evaluate and review the adopted standards and operating 
rules established under this section. 
Deadlines. 
Certification. 
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124 STAT. 151 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) REPORT.—Not later than July 1, 2014, and not 
less than biennially thereafter, the review committee shall 
provide recommendations for updating and improving such 
standards and operating rules. The review committee shall 
recommend a single set of operating rules per transaction 
standard and maintain the goal of creating as much uni-
formity as possible in the implementation of the electronic 
standards. 
‘‘(3) INTERIM FINAL RULEMAKING.— 
‘‘(A) IN
GENERAL.—Any recommendations to amend 
adopted standards and operating rules that have been 
approved by the review committee and reported to the 
Secretary under paragraph (2)(B) shall be adopted by the 
Secretary through promulgation of an interim final rule 
not later than 90 days after receipt of the committee’s 
report. 
‘‘(B) PUBLIC COMMENT.— 
‘‘(i) PUBLIC COMMENT PERIOD.—The Secretary shall 
accept and consider public comments on any interim 
final rule published under this paragraph for 60 days 
after the date of such publication. 
‘‘(ii) EFFECTIVE DATE.—The effective date of any 
amendment to existing standards or operating rules 
that is adopted through an interim final rule published 
under this paragraph shall be 25 months following 
the close of such public comment period. 
‘‘(4) REVIEW COMMITTEE.— 
‘‘(A) DEFINITION.—For the purposes of this subsection, 
the term ‘review committee’ means a committee chartered 
by or within the Department of Health and Human services 
that has been designated by the Secretary to carry out 
this subsection, including— 
‘‘(i) the National Committee on Vital and Health 
Statistics; or 
‘‘(ii) any appropriate committee as determined by 
the Secretary. 
‘‘(B) COORDINATION OF HIT STANDARDS.—In developing 
recommendations under this subsection, the review com-
mittee shall ensure coordination, as appropriate, with the 
standards that support the certified electronic health record 
technology approved by the Office of the National Coordi-
nator for Health Information Technology. 
‘‘(5) OPERATING RULES FOR OTHER STANDARDS ADOPTED BY 
THE
SECRETARY.—The Secretary shall adopt a single set of 
operating rules (pursuant to the process described under sub-
section (g)) for any transaction for which a standard had been 
adopted pursuant to subsection (a)(1)(B). 
‘‘(j) PENALTIES.— 
‘‘(1) PENALTY FEE.— 
‘‘(A) IN GENERAL.—Not later than April 1, 2014, and 
annually thereafter, the Secretary shall assess a penalty 
fee (as determined under subparagraph (B)) against a 
health plan that has failed to meet the requirements under 
subsection (h) with respect to certification and documenta-
tion of compliance with— 
‘‘(i) the standards and associated operating rules 
described under paragraph (1) of such subsection; and 
Deadline. 
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124 STAT. 152 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(ii) a standard (as described under subsection 
(a)(1)(B)) and associated operating rules (as described 
under subsection (i)(5)) for any other financial and 
administrative transactions. 
‘‘(B) FEE AMOUNT.—Subject to subparagraphs (C), (D), 
and (E), the Secretary shall assess a penalty fee against 
a health plan in the amount of $1 per covered life until 
certification is complete. The penalty shall be assessed 
per person covered by the plan for which its data systems 
for major medical policies are not in compliance and shall 
be imposed against the health plan for each day that the 
plan is not in compliance with the requirements under 
subsection (h). 
‘‘(C) ADDITIONAL PENALTY FOR MISREPRESENTATION.— 
A health plan that knowingly provides inaccurate or incom-
plete information in a statement of certification or docu-
mentation of compliance under subsection (h) shall be sub-
ject to a penalty fee that is double the amount that would 
otherwise be imposed under this subsection. 
‘‘(D) ANNUAL FEE INCREASE.—The amount of the pen-
alty fee imposed under this subsection shall be increased 
on an annual basis by the annual percentage increase 
in total national health care expenditures, as determined 
by the Secretary. 
‘‘(E) PENALTY LIMIT.—A penalty fee assessed against 
a health plan under this subsection shall not exceed, on 
an annual basis— 
‘‘(i) an amount equal to $20 per covered life under 
such plan; or 
‘‘(ii) an amount equal to $40 per covered life under 
the plan if such plan has knowingly provided inac-
curate or incomplete information (as described under 
subparagraph (C)). 
‘‘(F) DETERMINATION
OF
COVERED
INDIVIDUALS.—The 
Secretary shall determine the number of covered lives 
under a health plan based upon the most recent statements 
and filings that have been submitted by such plan to the 
Securities and Exchange Commission. 
‘‘(2) NOTICE AND DISPUTE PROCEDURE.—The Secretary shall 
establish a procedure for assessment of penalty fees under 
this subsection that provides a health plan with reasonable 
notice and a dispute resolution procedure prior to provision 
of a notice of assessment by the Secretary of the Treasury 
(as described under paragraph (4)(B)). 
‘‘(3) PENALTY FEE REPORT.—Not later than May 1, 2014, 
and annually thereafter, the Secretary shall provide the Sec-
retary of the Treasury with a report identifying those health 
plans that have been assessed a penalty fee under this sub-
section. 
‘‘(4) COLLECTION OF PENALTY FEE.— 
‘‘(A) IN
GENERAL.—The Secretary of the Treasury, 
acting through the Financial Management Service, shall 
administer the collection of penalty fees from health plans 
that have been identified by the Secretary in the penalty 
fee report provided under paragraph (3). 
‘‘(B) NOTICE.—Not later than August 1, 2014, and 
annually thereafter, the Secretary of the Treasury shall 
Deadline. 
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124 STAT. 153 
PUBLIC LAW 111–148—MAR. 23, 2010 
provide notice to each health plan that has been assessed 
a penalty fee by the Secretary under this subsection. Such 
notice shall include the amount of the penalty fee assessed 
by the Secretary and the due date for payment of such 
fee to the Secretary of the Treasury (as described in 
subparagraph (C)). 
‘‘(C) PAYMENT DUE DATE.—Payment by a health plan 
for a penalty fee assessed under this subsection shall be 
made to the Secretary of the Treasury not later than 
November 1, 2014, and annually thereafter. 
‘‘(D) UNPAID PENALTY FEES.—Any amount of a penalty 
fee assessed against a health plan under this subsection 
for which payment has not been made by the due date 
provided under subparagraph (C) shall be— 
‘‘(i) increased by the interest accrued on such 
amount, as determined pursuant to the underpayment 
rate established under section 6621 of the Internal 
Revenue Code of 1986; and 
‘‘(ii) treated as a past-due, legally enforceable debt 
owed to a Federal agency for purposes of section 
6402(d) of the Internal Revenue Code of 1986. 
‘‘(E) ADMINISTRATIVE FEES.—Any fee charged or allo-
cated for collection activities conducted by the Financial 
Management Service will be passed on to a health plan 
on a pro-rata basis and added to any penalty fee collected 
from the plan.’’. 
(c) PROMULGATION OF RULES.— 
(1) UNIQUE HEALTH PLAN IDENTIFIER.—The Secretary shall 
promulgate a final rule to establish a unique health plan identi-
fier (as described in section 1173(b) of the Social Security 
Act (42 U.S.C. 1320d–2(b))) based on the input of the National 
Committee on Vital and Health Statistics. The Secretary may 
do so on an interim final basis and such rule shall be effective 
not later than October 1, 2012. 
(2) ELECTRONIC
FUNDS
TRANSFER.—The Secretary shall 
promulgate a final rule to establish a standard for electronic 
funds transfers (as described in section 1173(a)(2)(J) of the 
Social Security Act, as added by subsection (b)(2)(A)). The Sec-
retary may do so on an interim final basis and shall adopt 
such standard not later than January 1, 2012, in a manner 
ensuring that such standard is effective not later than January 
1, 2014. 
(3) HEALTH
CLAIMS
ATTACHMENTS.—The Secretary shall 
promulgate a final rule to establish a transaction standard 
and a single set of associated operating rules for health claims 
attachments (as described in section 1173(a)(2)(B) of the Social 
Security Act (42 U.S.C. 1320d–2(a)(2)(B))) that is consistent 
with the X12 Version 5010 transaction standards. The Secretary 
may do so on an interim final basis and shall adopt a trans-
action standard and a single set of associated operating rules 
not later than January 1, 2014, in a manner ensuring that 
such standard is effective not later than January 1, 2016. 
(d) EXPANSION OF ELECTRONIC TRANSACTIONS IN MEDICARE.— 
Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) 
is amended— 
(1) in paragraph (23), by striking the ‘‘or’’ at the end; 
Deadline. 
Effective date. 
Deadline. 
Effective date. 
Effective date. 
42 USC 
1320d–2 note. 
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124 STAT. 154 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) in paragraph (24), by striking the period and inserting 
‘‘; or’’; and 
(3) by inserting after paragraph (24) the following new 
paragraph: 
‘‘(25) not later than January 1, 2014, for which the payment 
is other than by electronic funds transfer (EFT) or an electronic 
remittance in a form as specified in ASC X12 835 Health 
Care Payment and Remittance Advice or subsequent standard.’’. 
SEC. 1105. EFFECTIVE DATE. 
This subtitle shall take effect on the date of enactment of 
this Act. 
Subtitle C—Quality Health Insurance 
Coverage for All Americans 
PART I—HEALTH INSURANCE MARKET 
REFORMS 
SEC. 1201. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT. 
Part A of title XXVII of the Public Health Service Act (42 
U.S.C. 300gg et seq.), as amended by section 1001, is further 
amended— 
(1) by striking the heading for subpart 1 and inserting 
the following: 
‘‘Subpart I—General Reform’’; 
(2)(A) in section 2701 (42 U.S.C. 300gg), by striking the 
section heading and subsection (a) and inserting the following: 
‘‘SEC. 2704. PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS 
OR OTHER DISCRIMINATION BASED ON HEALTH STATUS. 
‘‘(a) IN GENERAL.—A group health plan and a health insurance 
issuer offering group or individual health insurance coverage may 
not impose any preexisting condition exclusion with respect to such 
plan or coverage.’’; and 
(B) by transferring such section (as amended by subpara-
graph (A)) so as to appear after the section 2703 added by 
paragraph (4); 
(3)(A) in section 2702 (42 U.S.C. 300gg–1)— 
(i) by striking the section heading and all that follows 
through subsection (a); 
(ii) in subsection (b)— 
(I) by striking ‘‘health insurance issuer offering 
health insurance coverage in connection with a group 
health plan’’ each place that such appears and inserting 
‘‘health insurance issuer offering group or individual 
health insurance coverage’’; and 
(II) in paragraph (2)(A)— 
(aa) 
by 
inserting 
‘‘or 
individual’’ 
after 
‘‘employer’’; and 
(bb) by inserting ‘‘or individual health cov-
erage, as the case may be’’ before the semicolon; 
and 
(iii) in subsection (e)— 
42 USC 
300gg–1, 
300gg–4. 
42 USC 
300gg–3. 
42 USC 
1320d note. 
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124 STAT. 155 
PUBLIC LAW 111–148—MAR. 23, 2010 
(I) by striking ‘‘(a)(1)(F)’’ and inserting ‘‘(a)(6)’’; 
(II) by striking ‘‘2701’’ and inserting ‘‘2704’’; and 
(III) by striking ‘‘2721(a)’’ and inserting ‘‘2735(a)’’; 
and 
(B) by transferring such section (as amended by 
subparagraph (A)) to appear after section 2705(a) as added 
by paragraph (4); and 
(4) by inserting after the subpart heading (as added by 
paragraph (1)) the following: 
‘‘SEC. 2701. FAIR HEALTH INSURANCE PREMIUMS. 
‘‘(a) PROHIBITING DISCRIMINATORY PREMIUM RATES.— 
‘‘(1) IN
GENERAL.—With respect to the premium rate 
charged by a health insurance issuer for health insurance cov-
erage offered in the individual or small group market— 
‘‘(A) such rate shall vary with respect to the particular 
plan or coverage involved only by— 
‘‘(i) whether such plan or coverage covers an indi-
vidual or family; 
‘‘(ii) rating area, as established in accordance with 
paragraph (2); 
‘‘(iii) age, except that such rate shall not vary 
by more than 3 to 1 for adults (consistent with section 
2707(c)); and 
‘‘(iv) tobacco use, except that such rate shall not 
vary by more than 1.5 to 1; and 
‘‘(B) such rate shall not vary with respect to the par-
ticular plan or coverage involved by any other factor not 
described in subparagraph (A). 
‘‘(2) RATING AREA.— 
‘‘(A) IN GENERAL.—Each State shall establish 1 or more 
rating areas within that State for purposes of applying 
the requirements of this title. 
‘‘(B) SECRETARIAL REVIEW.—The Secretary shall review 
the rating areas established by each State under subpara-
graph (A) to ensure the adequacy of such areas for purposes 
of carrying out the requirements of this title. If the Sec-
retary determines a State’s rating areas are not adequate, 
or that a State does not establish such areas, the Secretary 
may establish rating areas for that State. 
‘‘(3) PERMISSIBLE AGE BANDS.—The Secretary, in consulta-
tion with the National Association of Insurance Commissioners, 
shall define the permissible age bands for rating purposes 
under paragraph (1)(A)(iii). 
‘‘(4) APPLICATION OF VARIATIONS BASED ON AGE OR TOBACCO 
USE.—With respect to family coverage under a group health 
plan or health insurance coverage, the rating variations per-
mitted under clauses (iii) and (iv) of paragraph (1)(A) shall 
be applied based on the portion of the premium that is attrib-
utable to each family member covered under the plan or cov-
erage. 
‘‘(5) SPECIAL RULE FOR LARGE GROUP MARKET.—If a State 
permits health insurance issuers that offer coverage in the 
large group market in the State to offer such coverage through 
the State Exchange (as provided for under section 1312(f)(2)(B) 
Definition. 
42 USC 300gg. 
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124 STAT. 156 
PUBLIC LAW 111–148—MAR. 23, 2010 
of the Patient Protection and Affordable Care Act), the provi-
sions of this subsection shall apply to all coverage offered 
in such market in the State. 
‘‘SEC. 2702. GUARANTEED AVAILABILITY OF COVERAGE. 
‘‘(a) GUARANTEED ISSUANCE OF COVERAGE IN THE INDIVIDUAL 
AND GROUP MARKET.—Subject to subsections (b) through (e), each 
health insurance issuer that offers health insurance coverage in 
the individual or group market in a State must accept every 
employer and individual in the State that applies for such coverage. 
‘‘(b) ENROLLMENT.— 
‘‘(1) RESTRICTION.—A health insurance issuer described in 
subsection (a) may restrict enrollment in coverage described 
in such subsection to open or special enrollment periods. 
‘‘(2) ESTABLISHMENT.—A health insurance issuer described 
in subsection (a) shall, in accordance with the regulations 
promulgated under paragraph (3), establish special enrollment 
periods for qualifying events (under section 603 of the Employee 
Retirement Income Security Act of 1974). 
‘‘(3) REGULATIONS.—The Secretary shall promulgate regula-
tions with respect to enrollment periods under paragraphs (1) 
and (2). 
‘‘SEC. 2703. GUARANTEED RENEWABILITY OF COVERAGE. 
‘‘(a) IN GENERAL.—Except as provided in this section, if a health 
insurance issuer offers health insurance coverage in the individual 
or group market, the issuer must renew or continue in force such 
coverage at the option of the plan sponsor or the individual, as 
applicable. 
‘‘SEC. 2705. PROHIBITING DISCRIMINATION AGAINST INDIVIDUAL 
PARTICIPANTS AND BENEFICIARIES BASED ON HEALTH 
STATUS. 
‘‘(a) IN GENERAL.—A group health plan and a health insurance 
issuer offering group or individual health insurance coverage may 
not establish rules for eligibility (including continued eligibility) 
of any individual to enroll under the terms of the plan or coverage 
based on any of the following health status-related factors in rela-
tion to the individual or a dependent of the individual: 
‘‘(1) Health status. 
‘‘(2) Medical condition (including both physical and mental 
illnesses). 
‘‘(3) Claims experience. 
‘‘(4) Receipt of health care. 
‘‘(5) Medical history. 
‘‘(6) Genetic information. 
‘‘(7) Evidence of insurability (including conditions arising 
out of acts of domestic violence). 
‘‘(8) Disability. 
‘‘(9) Any other health status-related factor determined 
appropriate by the Secretary. 
‘‘(j) PROGRAMS OF HEALTH PROMOTION OR DISEASE PREVEN-
TION.— 
‘‘(1) GENERAL PROVISIONS.— 
‘‘(A) GENERAL
RULE.—For purposes of subsection 
(b)(2)(B), a program of health promotion or disease preven-
tion (referred to in this subsection as a ‘wellness program’) 
shall be a program offered by an employer that is designed 
42 USC 
300gg–4. 
42 USC 
300gg–2. 
42 USC 
300gg–1. 
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124 STAT. 157 
PUBLIC LAW 111–148—MAR. 23, 2010 
to promote health or prevent disease that meets the 
applicable requirements of this subsection. 
‘‘(B) NO
CONDITIONS
BASED
ON
HEALTH
STATUS 
FACTOR.—If none of the conditions for obtaining a premium 
discount or rebate or other reward for participation in 
a wellness program is based on an individual satisfying 
a standard that is related to a health status factor, such 
wellness program shall not violate this section if participa-
tion in the program is made available to all similarly 
situated individuals and the requirements of paragraph 
(2) are complied with. 
‘‘(C) CONDITIONS BASED ON HEALTH STATUS FACTOR.— 
If any of the conditions for obtaining a premium discount 
or rebate or other reward for participation in a wellness 
program is based on an individual satisfying a standard 
that is related to a health status factor, such wellness 
program shall not violate this section if the requirements 
of paragraph (3) are complied with. 
‘‘(2) WELLNESS
PROGRAMS
NOT
SUBJECT
TO
REQUIRE-
MENTS.—If none of the conditions for obtaining a premium 
discount or rebate or other reward under a wellness program 
as described in paragraph (1)(B) are based on an individual 
satisfying a standard that is related to a health status factor 
(or if such a wellness program does not provide such a reward), 
the wellness program shall not violate this section if participa-
tion in the program is made available to all similarly situated 
individuals. The following programs shall not have to comply 
with the requirements of paragraph (3) if participation in the 
program is made available to all similarly situated individuals: 
‘‘(A) A program that reimburses all or part of the 
cost for memberships in a fitness center. 
‘‘(B) A diagnostic testing program that provides a 
reward for participation and does not base any part of 
the reward on outcomes. 
‘‘(C) A program that encourages preventive care related 
to a health condition through the waiver of the copayment 
or deductible requirement under group health plan for 
the costs of certain items or services related to a health 
condition (such as prenatal care or well-baby visits). 
‘‘(D) A program that reimburses individuals for the 
costs of smoking cessation programs without regard to 
whether the individual quits smoking. 
‘‘(E) A program that provides a reward to individuals 
for attending a periodic health education seminar. 
‘‘(3) WELLNESS
PROGRAMS
SUBJECT
TO
REQUIREMENTS.— 
If any of the conditions for obtaining a premium discount, 
rebate, or reward under a wellness program as described in 
paragraph (1)(C) is based on an individual satisfying a standard 
that is related to a health status factor, the wellness program 
shall not violate this section if the following requirements are 
complied with: 
‘‘(A) The reward for the wellness program, together 
with the reward for other wellness programs with respect 
to the plan that requires satisfaction of a standard related 
to a health status factor, shall not exceed 30 percent of 
the cost of employee-only coverage under the plan. If, in 
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124 STAT. 158 
PUBLIC LAW 111–148—MAR. 23, 2010 
addition to employees or individuals, any class of depend-
ents (such as spouses or spouses and dependent children) 
may participate fully in the wellness program, such reward 
shall not exceed 30 percent of the cost of the coverage 
in which an employee or individual and any dependents 
are enrolled. For purposes of this paragraph, the cost of 
coverage shall be determined based on the total amount 
of employer and employee contributions for the benefit 
package under which the employee is (or the employee 
and any dependents are) receiving coverage. A reward may 
be in the form of a discount or rebate of a premium or 
contribution, a waiver of all or part of a cost-sharing mecha-
nism (such as deductibles, copayments, or coinsurance), 
the absence of a surcharge, or the value of a benefit that 
would otherwise not be provided under the plan. The Secre-
taries of Labor, Health and Human Services, and the 
Treasury may increase the reward available under this 
subparagraph to up to 50 percent of the cost of coverage 
if the Secretaries determine that such an increase is appro-
priate. 
‘‘(B) The wellness program shall be reasonably 
designed to promote health or prevent disease. A program 
complies with the preceding sentence if the program has 
a reasonable chance of improving the health of, or pre-
venting disease in, participating individuals and it is not 
overly burdensome, is not a subterfuge for discriminating 
based on a health status factor, and is not highly suspect 
in the method chosen to promote health or prevent disease. 
‘‘(C) The plan shall give individuals eligible for the 
program the opportunity to qualify for the reward under 
the program at least once each year. 
‘‘(D) The full reward under the wellness program shall 
be made available to all similarly situated individuals. 
For such purpose, among other things: 
‘‘(i) The reward is not available to all similarly 
situated individuals for a period unless the wellness 
program allows— 
‘‘(I) for a reasonable alternative standard (or 
waiver of the otherwise applicable standard) for 
obtaining the reward for any individual for whom, 
for that period, it is unreasonably difficult due 
to a medical condition to satisfy the otherwise 
applicable standard; and 
‘‘(II) for a reasonable alternative standard (or 
waiver of the otherwise applicable standard) for 
obtaining the reward for any individual for whom, 
for that period, it is medically inadvisable to 
attempt 
to 
satisfy 
the 
otherwise 
applicable 
standard. 
‘‘(ii) If reasonable under the circumstances, the 
plan or issuer may seek verification, such as a state-
ment from an individual’s physician, that a health 
status factor makes it unreasonably difficult or medi-
cally inadvisable for the individual to satisfy or attempt 
to satisfy the otherwise applicable standard. 
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124 STAT. 159 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(E) The plan or issuer involved shall disclose in all 
plan materials describing the terms of the wellness pro-
gram the availability of a reasonable alternative standard 
(or the possibility of waiver of the otherwise applicable 
standard) required under subparagraph (D). If plan mate-
rials disclose that such a program is available, without 
describing its terms, the disclosure under this subpara-
graph shall not be required. 
‘‘(k) EXISTING PROGRAMS.—Nothing in this section shall prohibit 
a program of health promotion or disease prevention that was 
established prior to the date of enactment of this section and 
applied with all applicable regulations, and that is operating on 
such date, from continuing to be carried out for as long as such 
regulations remain in effect. 
‘‘(l) WELLNESS PROGRAM DEMONSTRATION PROJECT.— 
‘‘(1) IN GENERAL.—Not later than July 1, 2014, the Sec-
retary, in consultation with the Secretary of the Treasury and 
the Secretary of Labor, shall establish a 10-State demonstration 
project under which participating States shall apply the provi-
sions of subsection (j) to programs of health promotion offered 
by a health insurance issuer that offers health insurance cov-
erage in the individual market in such State. 
‘‘(2) EXPANSION OF DEMONSTRATION PROJECT.—If the Sec-
retary, in consultation with the Secretary of the Treasury and 
the Secretary of Labor, determines that the demonstration 
project described in paragraph (1) is effective, such Secretaries 
may, beginning on July 1, 2017 expand such demonstration 
project to include additional participating States. 
‘‘(3) REQUIREMENTS.— 
‘‘(A) MAINTENANCE OF COVERAGE.—The Secretary, in 
consultation with the Secretary of the Treasury and the 
Secretary of Labor, shall not approve the participation 
of a State in the demonstration project under this section 
unless the Secretaries determine that the State’s project 
is designed in a manner that— 
‘‘(i) will not result in any decrease in coverage; 
and 
‘‘(ii) will not increase the cost to the Federal 
Government in providing credits under section 36B 
of the Internal Revenue Code of 1986 or cost-sharing 
assistance under section 1402 of the Patient Protection 
and Affordable Care Act. 
‘‘(B) OTHER REQUIREMENTS.—States that participate in 
the demonstration project under this subsection— 
‘‘(i) may permit premium discounts or rebates or 
the modification of otherwise applicable copayments 
or deductibles for adherence to, or participation in, 
a reasonably designed program of health promotion 
and disease prevention; 
‘‘(ii) shall ensure that requirements of consumer 
protection are met in programs of health promotion 
in the individual market; 
‘‘(iii) shall require verification from health insur-
ance issuers that offer health insurance coverage in 
the individual market of such State that premium 
discounts— 
Expansion date. 
Deadline. 
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124 STAT. 160 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(I) do not create undue burdens for individ-
uals insured in the individual market; 
‘‘(II) do not lead to cost shifting; and 
‘‘(III) are not a subterfuge for discrimination; 
‘‘(iv) shall ensure that consumer data is protected 
in accordance with the requirements of section 264(c) 
of the Health Insurance Portability and Accountability 
Act of 1996 (42 U.S.C. 1320d–2 note); and 
‘‘(v) shall ensure and demonstrate to the satisfac-
tion of the Secretary that the discounts or other 
rewards provided under the project reflect the expected 
level of participation in the wellness program involved 
and the anticipated effect the program will have on 
utilization or medical claim costs. 
‘‘(m) REPORT.— 
‘‘(1) IN GENERAL.—Not later than 3 years after the date 
of enactment of the Patient Protection and Affordable Care 
Act, the Secretary, in consultation with the Secretary of the 
Treasury and the Secretary of Labor, shall submit a report 
to the appropriate committees of Congress concerning— 
‘‘(A) the effectiveness of wellness programs (as defined 
in subsection (j)) in promoting health and preventing dis-
ease; 
‘‘(B) the impact of such wellness programs on the access 
to care and affordability of coverage for participants and 
non-participants of such programs; 
‘‘(C) the impact of premium-based and cost-sharing 
incentives on participant behavior and the role of such 
programs in changing behavior; and 
‘‘(D) the effectiveness of different types of rewards. 
‘‘(2) DATA COLLECTION.—In preparing the report described 
in paragraph (1), the Secretaries shall gather relevant informa-
tion from employers who provide employees with access to 
wellness programs, including State and Federal agencies. 
‘‘(n) REGULATIONS.—Nothing in this section shall be construed 
as prohibiting the Secretaries of Labor, Health and Human Services, 
or the Treasury from promulgating regulations in connection with 
this section. 
‘‘SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE. 
‘‘(a) PROVIDERS.—A group health plan and a health insurance 
issuer offering group or individual health insurance coverage shall 
not discriminate with respect to participation under the plan or 
coverage against any health care provider who is acting within 
the scope of that provider’s license or certification under applicable 
State law. This section shall not require that a group health plan 
or health insurance issuer contract with any health care provider 
willing to abide by the terms and conditions for participation estab-
lished by the plan or issuer. Nothing in this section shall be con-
strued as preventing a group health plan, a health insurance issuer, 
or the Secretary from establishing varying reimbursement rates 
based on quality or performance measures. 
‘‘(b) INDIVIDUALS.—The provisions of section 1558 of the Patient 
Protection and Affordable Care Act (relating to non-discrimination) 
shall apply with respect to a group health plan or health insurance 
issuer offering group or individual health insurance coverage. 
Applicability. 
42 USC 
300gg–5. 
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124 STAT. 161 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 2707. COMPREHENSIVE HEALTH INSURANCE COVERAGE. 
‘‘(a) COVERAGE FOR ESSENTIAL HEALTH BENEFITS PACKAGE.— 
A health insurance issuer that offers health insurance coverage 
in the individual or small group market shall ensure that such 
coverage includes the essential health benefits package required 
under section 1302(a) of the Patient Protection and Affordable Care 
Act. 
‘‘(b) COST-SHARING UNDER GROUP HEALTH PLANS.—A group 
health plan shall ensure that any annual cost-sharing imposed 
under the plan does not exceed the limitations provided for under 
paragraphs (1) and (2) of section 1302(c). 
‘‘(c) CHILD-ONLY PLANS.—If a health insurance issuer offers 
health insurance coverage in any level of coverage specified under 
section 1302(d) of the Patient Protection and Affordable Care Act, 
the issuer shall also offer such coverage in that level as a plan 
in which the only enrollees are individuals who, as of the beginning 
of a plan year, have not attained the age of 21. 
‘‘(d) DENTAL ONLY.—This section shall not apply to a plan 
described in section 1302(d)(2)(B)(ii)(I). 
‘‘SEC. 2708. PROHIBITION ON EXCESSIVE WAITING PERIODS. 
‘‘A group health plan and a health insurance issuer offering 
group or individual health insurance coverage shall not apply any 
waiting period (as defined in section 2704(b)(4)) that exceeds 90 
days.’’. 
PART II—OTHER PROVISIONS 
SEC. 1251. PRESERVATION OF RIGHT TO MAINTAIN EXISTING COV-
ERAGE. 
(a) NO CHANGES TO EXISTING COVERAGE.— 
(1) IN GENERAL.—Nothing in this Act (or an amendment 
made by this Act) shall be construed to require that an indi-
vidual terminate coverage under a group health plan or health 
insurance coverage in which such individual was enrolled on 
the date of enactment of this Act. 
(2) CONTINUATION OF COVERAGE.—With respect to a group 
health plan or health insurance coverage in which an individual 
was enrolled on the date of enactment of this Act, this subtitle 
and subtitle A (and the amendments made by such subtitles) 
shall not apply to such plan or coverage, regardless of whether 
the individual renews such coverage after such date of enact-
ment. 
(b) ALLOWANCE FOR FAMILY MEMBERS TO JOIN CURRENT COV-
ERAGE.—With respect to a group health plan or health insurance 
coverage in which an individual was enrolled on the date of enact-
ment of this Act and which is renewed after such date, family 
members of such individual shall be permitted to enroll in such 
plan or coverage if such enrollment is permitted under the terms 
of the plan in effect as of such date of enactment. 
(c) ALLOWANCE FOR NEW EMPLOYEES TO JOIN CURRENT PLAN.— 
A group health plan that provides coverage on the date of enactment 
of this Act may provide for the enrolling of new employees (and 
their families) in such plan, and this subtitle and subtitle A (and 
the amendments made by such subtitles) shall not apply with 
respect to such plan and such new employees (and their families). 
42 USC 18011. 
42 USC 
300gg–7. 
42 USC 
300gg–6. 
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124 STAT. 162 
PUBLIC LAW 111–148—MAR. 23, 2010 
(d) EFFECT ON COLLECTIVE BARGAINING AGREEMENTS.—In the 
case of health insurance coverage maintained pursuant to one or 
more collective bargaining agreements between employee represent-
atives and one or more employers that was ratified before the 
date of enactment of this Act, the provisions of this subtitle and 
subtitle A (and the amendments made by such subtitles) shall 
not apply until the date on which the last of the collective bar-
gaining agreements relating to the coverage terminates. Any cov-
erage amendment made pursuant to a collective bargaining agree-
ment relating to the coverage which amends the coverage solely 
to conform to any requirement added by this subtitle or subtitle 
A (or amendments) shall not be treated as a termination of such 
collective bargaining agreement. 
(e) DEFINITION.—In this title, the term ‘‘grandfathered health 
plan’’ means any group health plan or health insurance coverage 
to which this section applies. 
SEC. 1252. RATING REFORMS MUST APPLY UNIFORMLY TO ALL 
HEALTH INSURANCE ISSUERS AND GROUP HEALTH 
PLANS. 
Any standard or requirement adopted by a State pursuant 
to this title, or any amendment made by this title, shall be applied 
uniformly to all health plans in each insurance market to which 
the standard and requirements apply. The preceding sentence shall 
also apply to a State standard or requirement relating to the 
standard or requirement required by this title (or any such amend-
ment) that is not the same as the standard or requirement but 
that is not preempted under section 1321(d). 
SEC. 1253. EFFECTIVE DATES. 
This subtitle (and the amendments made by this subtitle) shall 
become effective for plan years beginning on or after January 1, 
2014. 
Subtitle D—Available Coverage Choices for 
All Americans 
PART I—ESTABLISHMENT OF QUALIFIED 
HEALTH PLANS 
SEC. 1301. QUALIFIED HEALTH PLAN DEFINED. 
(a) QUALIFIED HEALTH PLAN.—In this title: 
(1) IN GENERAL.—The term ‘‘qualified health plan’’ means 
a health plan that— 
(A) has in effect a certification (which may include 
a seal or other indication of approval) that such plan meets 
the criteria for certification described in section 1311(c) 
issued or recognized by each Exchange through which such 
plan is offered; 
(B) provides the essential health benefits package 
described in section 1302(a); and 
(C) is offered by a health insurance issuer that— 
(i) is licensed and in good standing to offer health 
insurance coverage in each State in which such issuer 
offers health insurance coverage under this title; 
42 USC 18021. 
42 USC 
300gg note. 
42 USC 18012. 
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124 STAT. 163 
PUBLIC LAW 111–148—MAR. 23, 2010 
(ii) agrees to offer at least one qualified health 
plan in the silver level and at least one plan in the 
gold level in each such Exchange; 
(iii) agrees to charge the same premium rate for 
each qualified health plan of the issuer without regard 
to whether the plan is offered through an Exchange 
or whether the plan is offered directly from the issuer 
or through an agent; and 
(iv) complies with the regulations developed by 
the Secretary under section 1311(d) and such other 
requirements as an applicable Exchange may establish. 
(2) INCLUSION OF CO-OP PLANS AND COMMUNITY HEALTH 
INSURANCE OPTION.—Any reference in this title to a qualified 
health plan shall be deemed to include a qualified health plan 
offered through the CO-OP program under section 1322 or 
a community health insurance option under section 1323, unless 
specifically provided for otherwise. 
(b) TERMS RELATING TO HEALTH PLANS.—In this title: 
(1) HEALTH PLAN.— 
(A) IN GENERAL.—The term ‘‘health plan’’ means health 
insurance coverage and a group health plan. 
(B) EXCEPTION FOR SELF-INSURED PLANS AND MEWAS.— 
Except to the extent specifically provided by this title, 
the term ‘‘health plan’’ shall not include a group health 
plan or multiple employer welfare arrangement to the 
extent the plan or arrangement is not subject to State 
insurance regulation under section 514 of the Employee 
Retirement Income Security Act of 1974. 
(2) HEALTH INSURANCE COVERAGE AND ISSUER.—The terms 
‘‘health insurance coverage’’ and ‘‘health insurance issuer’’ have 
the meanings given such terms by section 2791(b) of the Public 
Health Service Act. 
(3) GROUP HEALTH PLAN.—The term ‘‘group health plan’’ 
has the meaning given such term by section 2791(a) of the 
Public Health Service Act. 
SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS. 
(a) ESSENTIAL HEALTH BENEFITS PACKAGE.—In this title, the 
term ‘‘essential health benefits package’’ means, with respect to 
any health plan, coverage that— 
(1) provides for the essential health benefits defined by 
the Secretary under subsection (b); 
(2) limits cost-sharing for such coverage in accordance with 
subsection (c); and 
(3) subject to subsection (e), provides either the bronze, 
silver, gold, or platinum level of coverage described in sub-
section (d). 
(b) ESSENTIAL HEALTH BENEFITS.— 
(1) IN GENERAL.—Subject to paragraph (2), the Secretary 
shall define the essential health benefits, except that such 
benefits shall include at least the following general categories 
and the items and services covered within the categories: 
(A) Ambulatory patient services. 
(B) Emergency services. 
(C) Hospitalization. 
(D) Maternity and newborn care. 
42 USC 18022. 
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124 STAT. 164 
PUBLIC LAW 111–148—MAR. 23, 2010 
(E) Mental health and substance use disorder services, 
including behavioral health treatment. 
(F) Prescription drugs. 
(G) Rehabilitative and habilitative services and devices. 
(H) Laboratory services. 
(I) Preventive and wellness services and chronic dis-
ease management. 
(J) Pediatric services, including oral and vision care. 
(2) LIMITATION.— 
(A) IN GENERAL.—The Secretary shall ensure that the 
scope of the essential health benefits under paragraph (1) 
is equal to the scope of benefits provided under a typical 
employer plan, as determined by the Secretary. To inform 
this determination, the Secretary of Labor shall conduct 
a survey of employer-sponsored coverage to determine the 
benefits typically covered by employers, including multiem-
ployer plans, and provide a report on such survey to the 
Secretary. 
(B) CERTIFICATION.—In defining the essential health 
benefits described in paragraph (1), and in revising the 
benefits under paragraph (4)(H), the Secretary shall submit 
a report to the appropriate committees of Congress con-
taining a certification from the Chief Actuary of the Centers 
for Medicare & Medicaid Services that such essential health 
benefits meet the limitation described in paragraph (2). 
(3) NOTICE AND HEARING.—In defining the essential health 
benefits described in paragraph (1), and in revising the benefits 
under paragraph (4)(H), the Secretary shall provide notice and 
an opportunity for public comment. 
(4) REQUIRED ELEMENTS FOR CONSIDERATION.—In defining 
the essential health benefits under paragraph (1), the Secretary 
shall— 
(A) ensure that such essential health benefits reflect 
an appropriate balance among the categories described in 
such subsection, so that benefits are not unduly weighted 
toward any category; 
(B) not make coverage decisions, determine reimburse-
ment rates, establish incentive programs, or design benefits 
in ways that discriminate against individuals because of 
their age, disability, or expected length of life; 
(C) take into account the health care needs of diverse 
segments of the population, including women, children, 
persons with disabilities, and other groups; 
(D) ensure that health benefits established as essential 
not be subject to denial to individuals against their wishes 
on the basis of the individuals’ age or expected length 
of life or of the individuals’ present or predicted disability, 
degree of medical dependency, or quality of life; 
(E) provide that a qualified health plan shall not be 
treated as providing coverage for the essential health bene-
fits described in paragraph (1) unless the plan provides 
that— 
(i) coverage for emergency department services will 
be provided without imposing any requirement under 
the plan for prior authorization of services or any 
limitation on coverage where the provider of services 
does not have a contractual relationship with the plan 
Reports. 
Survey. 
Reports. 
Determination. 
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124 STAT. 165 
PUBLIC LAW 111–148—MAR. 23, 2010 
for the providing of services that is more restrictive 
than the requirements or limitations that apply to 
emergency department services received from providers 
who do have such a contractual relationship with the 
plan; and 
(ii) if such services are provided out-of-network, 
the 
cost-sharing 
requirement 
(expressed 
as 
a 
copayment amount or coinsurance rate) is the same 
requirement that would apply if such services were 
provided in-network; 
(F) provide that if a plan described in section 
1311(b)(2)(B)(ii) (relating to stand-alone dental benefits 
plans) is offered through an Exchange, another health plan 
offered through such Exchange shall not fail to be treated 
as a qualified health plan solely because the plan does 
not offer coverage of benefits offered through the stand- 
alone plan that are otherwise required under paragraph 
(1)(J); and 
(G) periodically review the essential health benefits 
under paragraph (1), and provide a report to Congress 
and the public that contains— 
(i) an assessment of whether enrollees are facing 
any difficulty accessing needed services for reasons 
of coverage or cost; 
(ii) an assessment of whether the essential health 
benefits needs to be modified or updated to account 
for changes in medical evidence or scientific advance-
ment; 
(iii) information on how the essential health bene-
fits will be modified to address any such gaps in access 
or changes in the evidence base; 
(iv) an assessment of the potential of additional 
or expanded benefits to increase costs and the inter-
actions between the addition or expansion of benefits 
and reductions in existing benefits to meet actuarial 
limitations described in paragraph (2); and 
(H) periodically update the essential health benefits 
under paragraph (1) to address any gaps in access to cov-
erage or changes in the evidence base the Secretary identi-
fies in the review conducted under subparagraph (G). 
(5) RULE OF CONSTRUCTION.—Nothing in this title shall 
be construed to prohibit a health plan from providing benefits 
in excess of the essential health benefits described in this 
subsection. 
(c) REQUIREMENTS RELATING TO COST-SHARING.— 
(1) ANNUAL LIMITATION ON COST-SHARING.— 
(A) 2014.—The cost-sharing incurred under a health 
plan with respect to self-only coverage or coverage other 
than self-only coverage for a plan year beginning in 2014 
shall not exceed the dollar amounts in effect under section 
223(c)(2)(A)(ii) of the Internal Revenue Code of 1986 for 
self-only and family coverage, respectively, for taxable years 
beginning in 2014. 
(B) 2015 AND LATER.—In the case of any plan year 
beginning in a calendar year after 2014, the limitation 
under this paragraph shall— 
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124 STAT. 166 
PUBLIC LAW 111–148—MAR. 23, 2010 
(i) in the case of self-only coverage, be equal to 
the dollar amount under subparagraph (A) for self- 
only coverage for plan years beginning in 2014, 
increased by an amount equal to the product of that 
amount and the premium adjustment percentage under 
paragraph (4) for the calendar year; and 
(ii) in the case of other coverage, twice the amount 
in effect under clause (i). 
If the amount of any increase under clause (i) is not a 
multiple of $50, such increase shall be rounded to the 
next lowest multiple of $50. 
(2) ANNUAL LIMITATION ON DEDUCTIBLES FOR EMPLOYER- 
SPONSORED PLANS.— 
(A) IN GENERAL.—In the case of a health plan offered 
in the small group market, the deductible under the plan 
shall not exceed— 
(i) $2,000 in the case of a plan covering a single 
individual; and 
(ii) $4,000 in the case of any other plan. 
The amounts under clauses (i) and (ii) may be increased 
by the maximum amount of reimbursement which is 
reasonably available to a participant under a flexible 
spending arrangement described in section 106(c)(2) of the 
Internal Revenue Code of 1986 (determined without regard 
to any salary reduction arrangement). 
(B) INDEXING OF LIMITS.—In the case of any plan year 
beginning in a calendar year after 2014— 
(i) the dollar amount under subparagraph (A)(i) 
shall be increased by an amount equal to the product 
of that amount and the premium adjustment percent-
age under paragraph (4) for the calendar year; and 
(ii) the dollar amount under subparagraph (A)(ii) 
shall be increased to an amount equal to twice the 
amount in effect under subparagraph (A)(i) for plan 
years beginning in the calendar year, determined after 
application of clause (i). 
If the amount of any increase under clause (i) is not a 
multiple of $50, such increase shall be rounded to the 
next lowest multiple of $50. 
(C) ACTUARIAL VALUE.—The limitation under this para-
graph shall be applied in such a manner so as to not 
affect the actuarial value of any health plan, including 
a plan in the bronze level. 
(D) COORDINATION WITH PREVENTIVE LIMITS.—Nothing 
in this paragraph shall be construed to allow a plan to 
have a deductible under the plan apply to benefits described 
in section 2713 of the Public Health Service Act. 
(3) COST-SHARING.—In this title— 
(A) IN GENERAL.—The term ‘‘cost-sharing’’ includes— 
(i) deductibles, coinsurance, copayments, or similar 
charges; and 
(ii) any other expenditure required of an insured 
individual which is a qualified medical expense (within 
the meaning of section 223(d)(2) of the Internal Rev-
enue Code of 1986) with respect to essential health 
benefits covered under the plan. 
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124 STAT. 167 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) EXCEPTIONS.—Such term does not include pre-
miums, balance billing amounts for non-network providers, 
or spending for non-covered services. 
(4) PREMIUM ADJUSTMENT PERCENTAGE.—For purposes of 
paragraphs (1)(B)(i) and (2)(B)(i), the premium adjustment 
percentage for any calendar year is the percentage (if any) 
by which the average per capita premium for health insurance 
coverage in the United States for the preceding calendar year 
(as estimated by the Secretary no later than October 1 of 
such preceding calendar year) exceeds such average per capita 
premium for 2013 (as determined by the Secretary). 
(d) LEVELS OF COVERAGE.— 
(1) LEVELS OF COVERAGE DEFINED.—The levels of coverage 
described in this subsection are as follows: 
(A) BRONZE LEVEL.—A plan in the bronze level shall 
provide a level of coverage that is designed to provide 
benefits that are actuarially equivalent to 60 percent of 
the full actuarial value of the benefits provided under 
the plan. 
(B) SILVER LEVEL.—A plan in the silver level shall 
provide a level of coverage that is designed to provide 
benefits that are actuarially equivalent to 70 percent of 
the full actuarial value of the benefits provided under 
the plan. 
(C) GOLD LEVEL.—A plan in the gold level shall provide 
a level of coverage that is designed to provide benefits 
that are actuarially equivalent to 80 percent of the full 
actuarial value of the benefits provided under the plan. 
(D) PLATINUM LEVEL.—A plan in the platinum level 
shall provide a level of coverage that is designed to provide 
benefits that are actuarially equivalent to 90 percent of 
the full actuarial value of the benefits provided under 
the plan. 
(2) ACTUARIAL VALUE.— 
(A) IN GENERAL.—Under regulations issued by the Sec-
retary, the level of coverage of a plan shall be determined 
on the basis that the essential health benefits described 
in subsection (b) shall be provided to a standard population 
(and without regard to the population the plan may actually 
provide benefits to). 
(B) EMPLOYER
CONTRIBUTIONS.—The Secretary may 
issue regulations under which employer contributions to 
a health savings account (within the meaning of section 
223 of the Internal Revenue Code of 1986) may be taken 
into account in determining the level of coverage for a 
plan of the employer. 
(C) APPLICATION.—In determining under this title, the 
Public Health Service Act, or the Internal Revenue Code 
of 1986 the percentage of the total allowed costs of benefits 
provided under a group health plan or health insurance 
coverage that are provided by such plan or coverage, the 
rules contained in the regulations under this paragraph 
shall apply. 
(3) ALLOWABLE
VARIANCE.—The Secretary shall develop 
guidelines to provide for a de minimis variation in the actuarial 
valuations used in determining the level of coverage of a plan 
to account for differences in actuarial estimates. 
Guidelines. 
Determination. 
Deadline. 
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124 STAT. 168 
PUBLIC LAW 111–148—MAR. 23, 2010 
(4) PLAN
REFERENCE.—In this title, any reference to a 
bronze, silver, gold, or platinum plan shall be treated as a 
reference to a qualified health plan providing a bronze, silver, 
gold, or platinum level of coverage, as the case may be. 
(e) CATASTROPHIC PLAN.— 
(1) IN GENERAL.—A health plan not providing a bronze, 
silver, gold, or platinum level of coverage shall be treated 
as meeting the requirements of subsection (d) with respect 
to any plan year if— 
(A) the only individuals who are eligible to enroll in 
the plan are individuals described in paragraph (2); and 
(B) the plan provides— 
(i) except as provided in clause (ii), the essential 
health benefits determined under subsection (b), except 
that the plan provides no benefits for any plan year 
until the individual has incurred cost-sharing expenses 
in an amount equal to the annual limitation in effect 
under subsection (c)(1) for the plan year (except as 
provided for in section 2713); and 
(ii) coverage for at least three primary care visits. 
(2) INDIVIDUALS ELIGIBLE FOR ENROLLMENT.—An individual 
is described in this paragraph for any plan year if the indi-
vidual— 
(A) has not attained the age of 30 before the beginning 
of the plan year; or 
(B) has a certification in effect for any plan year under 
this title that the individual is exempt from the require-
ment under section 5000A of the Internal Revenue Code 
of 1986 by reason of— 
(i) section 5000A(e)(1) of such Code (relating to 
individuals without affordable coverage); or 
(ii) section 5000A(e)(5) of such Code (relating to 
individuals with hardships). 
(3) RESTRICTION TO INDIVIDUAL MARKET.—If a health insur-
ance issuer offers a health plan described in this subsection, 
the issuer may only offer the plan in the individual market. 
(f) CHILD-ONLY PLANS.—If a qualified health plan is offered 
through the Exchange in any level of coverage specified under 
subsection (d), the issuer shall also offer that plan through the 
Exchange in that level as a plan in which the only enrollees are 
individuals who, as of the beginning of a plan year, have not 
attained the age of 21, and such plan shall be treated as a qualified 
health plan. 
SEC. 1303. SPECIAL RULES. 
(a) SPECIAL RULES RELATING TO COVERAGE OF ABORTION SERV-
ICES.— 
(1) VOLUNTARY CHOICE OF COVERAGE OF ABORTION SERV-
ICES.— 
(A) IN GENERAL.—Notwithstanding any other provision 
of this title (or any amendment made by this title), and 
subject to subparagraphs (C) and (D)— 
(i) nothing in this title (or any amendment made 
by this title), shall be construed to require a qualified 
health plan to provide coverage of services described 
in subparagraph (B)(i) or (B)(ii) as part of its essential 
health benefits for any plan year; and 
42 USC 18023. 
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124 STAT. 169 
PUBLIC LAW 111–148—MAR. 23, 2010 
(ii) the issuer of a qualified health plan shall deter-
mine whether or not the plan provides coverage of 
services described in subparagraph (B)(i) or (B)(ii) as 
part of such benefits for the plan year. 
(B) ABORTION SERVICES.— 
(i) ABORTIONS
FOR
WHICH
PUBLIC
FUNDING
IS 
PROHIBITED.—The services described in this clause are 
abortions for which the expenditure of Federal funds 
appropriated for the Department of Health and Human 
Services is not permitted, based on the law as in effect 
as of the date that is 6 months before the beginning 
of the plan year involved. 
(ii) ABORTIONS
FOR
WHICH
PUBLIC
FUNDING
IS 
ALLOWED.—The services described in this clause are 
abortions for which the expenditure of Federal funds 
appropriated for the Department of Health and Human 
Services is permitted, based on the law as in effect 
as of the date that is 6 months before the beginning 
of the plan year involved. 
(C) PROHIBITION
ON
FEDERAL
FUNDS
FOR
ABORTION 
SERVICES IN COMMUNITY HEALTH INSURANCE OPTION.— 
(i) DETERMINATION BY SECRETARY.—The Secretary 
may not determine, in accordance with subparagraph 
(A)(ii), that the community health insurance option 
established under section 1323 shall provide coverage 
of services described in subparagraph (B)(i) as part 
of benefits for the plan year unless the Secretary— 
(I) assures compliance with the requirements 
of paragraph (2); 
(II) assures, in accordance with applicable 
provisions 
of 
generally 
accepted 
accounting 
requirements, circulars on funds management of 
the Office of Management and Budget, and guid-
ance on accounting of the Government Account-
ability Office, that no Federal funds are used for 
such coverage; and 
(III) notwithstanding section 1323(e)(1)(C) or 
any other provision of this title, takes all necessary 
steps to assure that the United States does not 
bear the insurance risk for a community health 
insurance option’s coverage of services described 
in subparagraph (B)(i). 
(ii) STATE REQUIREMENT.—If a State requires, in 
addition to the essential health benefits required under 
section 1323(b)(3) (A), coverage of services described 
in subparagraph (B)(i) for enrollees of a community 
health insurance option offered in such State, the State 
shall assure that no funds flowing through or from 
the community health insurance option, and no other 
Federal funds, pay or defray the cost of providing cov-
erage of services described in subparagraph (B)(i). The 
United States shall not bear the insurance risk for 
a State’s required coverage of services described in 
subparagraph (B)(i). 
(iii) EXCEPTIONS.—Nothing in this subparagraph 
shall apply to coverage of services described in subpara-
graph (B)(ii) by the community health insurance 
Determination. 
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124 STAT. 170 
PUBLIC LAW 111–148—MAR. 23, 2010 
option. Services described in subparagraph (B)(ii) shall 
be covered to the same extent as such services are 
covered under title XIX of the Social Security Act. 
(D) ASSURED
AVAILABILITY
OF
VARIED
COVERAGE 
THROUGH EXCHANGES.— 
(i) IN GENERAL.—The Secretary shall assure that 
with respect to qualified health plans offered in any 
Exchange established pursuant to this title— 
(I) there is at least one such plan that provides 
coverage of services described in clauses (i) and 
(ii) of subparagraph (B); and 
(II) there is at least one such plan that does 
not provide coverage of services described in 
subparagraph (B)(i). 
(ii) SPECIAL RULES.—For purposes of clause (i)— 
(I) a plan shall be treated as described in 
clause (i)(II) if the plan does not provide coverage 
of services described in either subparagraph (B)(i) 
or (B)(ii); and 
(II) if a State has one Exchange covering more 
than 1 insurance market, the Secretary shall meet 
the requirements of clause (i) separately with 
respect to each such market. 
(2) PROHIBITION ON THE USE OF FEDERAL FUNDS.— 
(A) IN GENERAL.—If a qualified health plan provides 
coverage of services described in paragraph (1)(B)(i), the 
issuer of the plan shall not use any amount attributable 
to any of the following for purposes of paying for such 
services: 
(i) The credit under section 36B of the Internal 
Revenue Code of 1986 (and the amount (if any) of 
the advance payment of the credit under section 1412 
of the Patient Protection and Affordable Care Act). 
(ii) Any cost-sharing reduction under section 1402 
of thePatient Protection and Affordable Care Act (and 
the amount (if any) of the advance payment of the 
reduction under section 1412 of the Patient Protection 
and Affordable Care Act). 
(B) SEGREGATION OF FUNDS.—In the case of a plan 
to which subparagraph (A) applies, the issuer of the plan 
shall, out of amounts not described in subparagraph (A), 
segregate an amount equal to the actuarial amounts deter-
mined under subparagraph (C) for all enrollees from the 
amounts described in subparagraph (A). 
(C) ACTUARIAL
VALUE
OF
OPTIONAL
SERVICE
COV-
ERAGE.— 
(i) IN GENERAL.—The Secretary shall estimate the 
basic per enrollee, per month cost, determined on an 
average actuarial basis, for including coverage under 
a qualified health plan of the services described in 
paragraph (1)(B)(i). 
(ii) CONSIDERATIONS.—In making such estimate, 
the Secretary— 
(I) may take into account the impact on overall 
costs of the inclusion of such coverage, but may 
not take into account any cost reduction estimated 
Cost estimate. 
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124 STAT. 171 
PUBLIC LAW 111–148—MAR. 23, 2010 
to result from such services, including prenatal 
care, delivery, or postnatal care; 
(II) shall estimate such costs as if such cov-
erage were included for the entire population cov-
ered; and 
(III) may not estimate such a cost at less 
than $1 per enrollee, per month. 
(3) PROVIDER
CONSCIENCE
PROTECTIONS.—No individual 
health care provider or health care facility may be discriminated 
against because of a willingness or an unwillingness, if doing 
so is contrary to the religious or moral beliefs of the provider 
or facility, to provide, pay for, provide coverage of, or refer 
for abortions. 
(b) APPLICATION
OF STATE
AND FEDERAL LAWS REGARDING 
ABORTION.— 
(1) NO PREEMPTION OF STATE LAWS REGARDING ABORTION.— 
Nothing in this Act shall be construed to preempt or otherwise 
have any effect on State laws regarding the prohibition of 
(or requirement 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 con-
strued 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 and obligations of 
employees and employers under title VII of the Civil Rights 
Act of 1964. 
(c) 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 Social Security Act (popularly 
known as ‘‘EMTALA’’). 
SEC. 1304. RELATED DEFINITIONS. 
(a) DEFINITIONS RELATING TO MARKETS.—In this title: 
(1) GROUP MARKET.—The term ‘‘group market’’ means the 
health insurance market under which individuals obtain health 
insurance coverage (directly or through any arrangement) on 
behalf of themselves (and their dependents) through a group 
health plan maintained by an employer. 
(2) INDIVIDUAL
MARKET.—The term ‘‘individual market’’ 
means the market for health insurance coverage offered to 
individuals other than in connection with a group health plan. 
(3) LARGE AND SMALL GROUP MARKETS.—The terms ‘‘large 
group market’’ and ‘‘small group market’’ mean the health 
insurance market under which individuals obtain health insur-
ance coverage (directly or through any arrangement) on behalf 
of themselves (and their dependents) through a group health 
plan maintained by a large employer (as defined in subsection 
42 USC 18024. 
Abortions. 
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124 STAT. 172 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b)(1)) or by a small employer (as defined in subsection (b)(2)), 
respectively. 
(b) EMPLOYERS.—In this title: 
(1) LARGE EMPLOYER.—The term ‘‘large employer’’ means, 
in connection with a group health plan with respect to a cal-
endar year and a plan year, an employer who employed an 
average of at least 101 employees on business days during 
the preceding calendar year and who employs at least 1 
employee on the first day of the plan year. 
(2) SMALL EMPLOYER.—The term ‘‘small employer’’ means, 
in connection with a group health plan with respect to a cal-
endar year and a plan year, an employer who employed an 
average of at least 1 but not more than 100 employees on 
business days during the preceding calendar year and who 
employs at least 1 employee on the first day of the plan year. 
(3) STATE
OPTION
TO
TREAT
50
EMPLOYEES
AS
SMALL.— 
In the case of plan years beginning before January 1, 2016, 
a State may elect to apply this subsection by substituting 
‘‘51 employees’’ for ‘‘101 employees’’ in paragraph (1) and by 
substituting ‘‘50 employees’’ for ‘‘100 employees’’ in paragraph 
(2). 
(4) RULES FOR DETERMINING EMPLOYER SIZE.—For purposes 
of this subsection— 
(A) 
APPLICATION
OF
AGGREGATION
RULE
FOR 
EMPLOYERS.—All persons treated as a single employer 
under subsection (b), (c), (m), or (o) of section 414 of the 
Internal Revenue Code of 1986 shall be treated as 1 
employer. 
(B) EMPLOYERS
NOT
IN
EXISTENCE
IN
PRECEDING 
YEAR.—In the case of an employer which was not in exist-
ence throughout the preceding calendar year, the deter-
mination of whether such employer is a small or large 
employer shall be based on the average number of 
employees that it is reasonably expected such employer 
will employ on business days in the current calendar year. 
(C) PREDECESSORS.—Any reference in this subsection 
to an employer shall include a reference to any predecessor 
of such employer. 
(D) CONTINUATION
OF
PARTICIPATION
FOR
GROWING 
SMALL EMPLOYERS.—If— 
(i) a qualified employer that is a small employer 
makes enrollment in qualified health plans offered in 
the small group market available to its employees 
through an Exchange; and 
(ii) the employer ceases to be a small employer 
by reason of an increase in the number of employees 
of such employer; 
the employer shall continue to be treated as a small 
employer for purposes of this subtitle for the period begin-
ning with the increase and ending with the first day on 
which the employer does not make such enrollment avail-
able to its employees. 
(c) SECRETARY.—In this title, the term ‘‘Secretary’’ means the 
Secretary of Health and Human Services. 
(d) STATE.—In this title, the term ‘‘State’’ means each of the 
50 States and the District of Columbia. 
Time period. 
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124 STAT. 173 
PUBLIC LAW 111–148—MAR. 23, 2010 
PART II—CONSUMER CHOICES AND INSUR-
ANCE 
COMPETITION 
THROUGH 
HEALTH 
BENEFIT EXCHANGES 
SEC. 1311. AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS. 
(a) ASSISTANCE TO STATES TO ESTABLISH AMERICAN HEALTH 
BENEFIT EXCHANGES.— 
(1) PLANNING AND ESTABLISHMENT GRANTS.—There shall 
be appropriated to the Secretary, out of any moneys in the 
Treasury not otherwise appropriated, an amount necessary to 
enable the Secretary to make awards, not later than 1 year 
after the date of enactment of this Act, to States in the amount 
specified in paragraph (2) for the uses described in paragraph 
(3). 
(2) AMOUNT SPECIFIED.—For each fiscal year, the Secretary 
shall determine the total amount that the Secretary will make 
available to each State for grants under this subsection. 
(3) USE OF FUNDS.—A State shall use amounts awarded 
under this subsection for activities (including planning activi-
ties) related to establishing an American Health Benefit 
Exchange, as described in subsection (b). 
(4) RENEWABILITY OF GRANT.— 
(A) IN GENERAL.—Subject to subsection (d)(4), the Sec-
retary may renew a grant awarded under paragraph (1) 
if the State recipient of such grant— 
(i) is making progress, as determined by the Sec-
retary, toward— 
(I) establishing an Exchange; and 
(II) implementing the reforms described in 
subtitles A and C (and the amendments made 
by such subtitles); and 
(ii) is meeting such other benchmarks as the Sec-
retary may establish. 
(B) LIMITATION.—No grant shall be awarded under 
this subsection after January 1, 2015. 
(5) TECHNICAL
ASSISTANCE
TO
FACILITATE
PARTICIPATION 
IN
SHOP
EXCHANGES.—The Secretary shall provide technical 
assistance to States to facilitate the participation of qualified 
small businesses in such States in SHOP Exchanges. 
(b) AMERICAN HEALTH BENEFIT EXCHANGES.— 
(1) IN GENERAL.—Each State shall, not later than January 
1, 2014, establish an American Health Benefit Exchange 
(referred to in this title as an ‘‘Exchange’’) for the State that— 
(A) facilitates the purchase of qualified health plans; 
(B) provides for the establishment of a Small Business 
Health Options Program (in this title referred to as a 
‘‘SHOP Exchange’’) that is designed to assist qualified 
employers in the State who are small employers in facili-
tating the enrollment of their employees in qualified health 
plans offered in the small group market in the State; 
and 
(C) meets the requirements of subsection (d). 
(2) MERGER OF INDIVIDUAL AND SHOP EXCHANGES.—A State 
may elect to provide only one Exchange in the State for pro-
viding both Exchange and SHOP Exchange services to both 
qualified individuals and qualified small employers, but only 
Establishment. 
Deadline. 
Deadline. 
Determination. 
Deadline. 
42 USC 18031. 
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124 STAT. 174 
PUBLIC LAW 111–148—MAR. 23, 2010 
if the Exchange has adequate resources to assist such individ-
uals and employers. 
(c) RESPONSIBILITIES OF THE SECRETARY.— 
(1) IN GENERAL.—The Secretary shall, by regulation, estab-
lish criteria for the certification of health plans as qualified 
health plans. Such criteria shall require that, to be certified, 
a plan shall, at a minimum— 
(A) meet marketing requirements, and not employ mar-
keting practices or benefit designs that have the effect 
of discouraging the enrollment in such plan by individuals 
with significant health needs; 
(B) ensure a sufficient choice of providers (in a manner 
consistent with applicable network adequacy provisions 
under section 2702(c) of the Public Health Service Act), 
and provide information to enrollees and prospective 
enrollees on the availability of in-network and out-of-net-
work providers; 
(C) include within health insurance plan networks 
those essential community providers, where available, that 
serve predominately low-income, medically-underserved 
individuals, such as health care providers defined in section 
340B(a)(4) of the Public Health Service Act and providers 
described in section 1927(c)(1)(D)(i)(IV) of the Social Secu-
rity Act as set forth by section 221 of Public Law 111– 
8, except that nothing in this subparagraph shall be con-
strued to require any health plan to provide coverage for 
any specific medical procedure; 
(D)(i) be accredited with respect to local performance 
on clinical quality measures such as the Healthcare 
Effectiveness Data and Information Set, patient experience 
ratings on a standardized Consumer Assessment of 
Healthcare Providers and Systems survey, as well as con-
sumer access, utilization management, quality assurance, 
provider credentialing, complaints and appeals, network 
adequacy and access, and patient information programs 
by any entity recognized by the Secretary for the accredita-
tion of health insurance issuers or plans (so long as any 
such entity has transparent and rigorous methodological 
and scoring criteria); or 
(ii) receive such accreditation within a period estab-
lished by an Exchange for such accreditation that is 
applicable to all qualified health plans; 
(E) 
implement 
a 
quality 
improvement 
strategy 
described in subsection (g)(1); 
(F) utilize a uniform enrollment form that qualified 
individuals and qualified employers may use (either elec-
tronically or on paper) in enrolling in qualified health plans 
offered through such Exchange, and that takes into account 
criteria that the National Association of Insurance Commis-
sioners develops and submits to the Secretary; 
(G) utilize the standard format established for pre-
senting health benefits plan options; and 
(H) provide information to enrollees and prospective 
enrollees, and to each Exchange in which the plan is 
offered, on any quality measures for health plan perform-
ance endorsed under section 399JJ of the Public Health 
Service Act, as applicable. 
Regulations. 
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124 STAT. 175 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) RULE OF CONSTRUCTION.—Nothing in paragraph (1)(C) 
shall be construed to require a qualified health plan to contract 
with a provider described in such paragraph if such provider 
refuses to accept the generally applicable payment rates of 
such plan. 
(3) RATING SYSTEM.—The Secretary shall develop a rating 
system that would rate qualified health plans offered through 
an Exchange in each benefits level on the basis of the relative 
quality and price. The Exchange shall include the quality rating 
in the information provided to individuals and employers 
through the Internet portal established under paragraph (4). 
(4) ENROLLEE SATISFACTION SYSTEM.—The Secretary shall 
develop an enrollee satisfaction survey system that would 
evaluate the level of enrollee satisfaction with qualified health 
plans offered through an Exchange, for each such qualified 
health plan that had more than 500 enrollees in the previous 
year. The Exchange shall include enrollee satisfaction informa-
tion in the information provided to individuals and employers 
through the Internet portal established under paragraph (5) 
in a manner that allows individuals to easily compare enrollee 
satisfaction levels between comparable plans. 
(5) INTERNET PORTALS.—The Secretary shall— 
(A) continue to operate, maintain, and update the 
Internet portal developed under section 1103(a) and to 
assist States in developing and maintaining their own such 
portal; and 
(B) make available for use by Exchanges a model tem-
plate for an Internet portal that may be used to direct 
qualified individuals and qualified employers to qualified 
health plans, to assist such individuals and employers in 
determining whether they are eligible to participate in 
an Exchange or eligible for a premium tax credit or cost- 
sharing reduction, and to present standardized information 
(including quality ratings) regarding qualified health plans 
offered through an Exchange to assist consumers in making 
easy health insurance choices. 
Such template shall include, with respect to each qualified 
health plan offered through the Exchange in each rating area, 
access to the uniform outline of coverage the plan is required 
to provide under section 2716 of the Public Health Service 
Act and to a copy of the plan’s written policy. 
(6) ENROLLMENT PERIODS.—The Secretary shall require an 
Exchange to provide for— 
(A) an initial open enrollment, as determined by the 
Secretary (such determination to be made not later than 
July 1, 2012); 
(B) annual open enrollment periods, as determined 
by the Secretary for calendar years after the initial enroll-
ment period; 
(C) special enrollment periods specified in section 9801 
of the Internal Revenue Code of 1986 and other special 
enrollment periods under circumstances similar to such 
periods under part D of title XVIII of the Social Security 
Act; and 
(D) special monthly enrollment periods for Indians (as 
defined in section 4 of the Indian Health Care Improvement 
Act). 
Native 
Americans. 
Determination. 
Determination. 
Contracts. 
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124 STAT. 176 
PUBLIC LAW 111–148—MAR. 23, 2010 
(d) REQUIREMENTS.— 
(1) IN GENERAL.—An Exchange shall be a governmental 
agency or nonprofit entity that is established by a State. 
(2) OFFERING OF COVERAGE.— 
(A) IN GENERAL.—An Exchange shall make available 
qualified health plans to qualified individuals and qualified 
employers. 
(B) LIMITATION.— 
(i) IN
GENERAL.—An Exchange may not make 
available any health plan that is not a qualified health 
plan. 
(ii) OFFERING OF STAND-ALONE DENTAL BENEFITS.— 
Each Exchange within a State shall allow an issuer 
of a plan that only provides limited scope dental bene-
fits meeting the requirements of section 9832(c)(2)(A) 
of the Internal Revenue Code of 1986 to offer the 
plan through the Exchange (either separately or in 
conjunction with a qualified health plan) if the plan 
provides pediatric dental benefits meeting the require-
ments of section 1302(b)(1)(J)). 
(3) RULES RELATING TO ADDITIONAL REQUIRED BENEFITS.— 
(A) IN GENERAL.—Except as provided in subparagraph 
(B), an Exchange may make available a qualified health 
plan notwithstanding any provision of law that may require 
benefits other than the essential health benefits specified 
under section 1302(b). 
(B) STATES MAY REQUIRE ADDITIONAL BENEFITS.— 
(i) IN GENERAL.—Subject to the requirements of 
clause (ii), a State may require that a qualified health 
plan offered in such State offer benefits in addition 
to the essential health benefits specified under section 
1302(b). 
(ii) STATE MUST ASSUME COST.—A State shall make 
payments to or on behalf of an individual eligible for 
the premium tax credit under section 36B of the 
Internal Revenue Code of 1986 and any cost-sharing 
reduction under section 1402 to defray the cost to 
the individual of any additional benefits described in 
clause (i) which are not eligible for such credit or 
reduction under section 36B(b)(3)(D) of such Code and 
section 1402(c)(4). 
(4) FUNCTIONS.—An Exchange shall, at a minimum— 
(A) implement procedures for the certification, recertifi-
cation, and decertification, consistent with guidelines devel-
oped by the Secretary under subsection (c), of health plans 
as qualified health plans; 
(B) provide for the operation of a toll-free telephone 
hotline to respond to requests for assistance; 
(C) maintain an Internet website through which 
enrollees and prospective enrollees of qualified health plans 
may obtain standardized comparative information on such 
plans; 
(D) assign a rating to each qualified health plan offered 
through such Exchange in accordance with the criteria 
developed by the Secretary under subsection (c)(3); 
(E) utilize a standardized format for presenting health 
benefits plan options in the Exchange, including the use 
Web site. 
Hotline. 
Procedures. 
Payments. 
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124 STAT. 177 
PUBLIC LAW 111–148—MAR. 23, 2010 
of the uniform outline of coverage established under section 
2715 of the Public Health Service Act; 
(F) in accordance with section 1413, inform individuals 
of eligibility requirements for the medicaid program under 
title XIX of the Social Security Act, the CHIP program 
under title XXI of such Act, or any applicable State or 
local public program and if through screening of the 
application by the Exchange, the Exchange determines that 
such individuals are eligible for any such program, enroll 
such individuals in such program; 
(G) establish and make available by electronic means 
a calculator to determine the actual cost of coverage after 
the application of any premium tax credit under section 
36B of the Internal Revenue Code of 1986 and any cost- 
sharing reduction under section 1402; 
(H) subject to section 1411, grant a certification 
attesting that, for purposes of the individual responsibility 
penalty under section 5000A of the Internal Revenue Code 
of 1986, an individual is exempt from the individual 
requirement or from the penalty imposed by such section 
because— 
(i) there is no affordable qualified health plan 
available through the Exchange, or the individual’s 
employer, covering the individual; or 
(ii) the individual meets the requirements for any 
other such exemption from the individual responsibility 
requirement or penalty; 
(I) transfer to the Secretary of the Treasury— 
(i) a list of the individuals who are issued a certifi-
cation under subparagraph (H), including the name 
and taxpayer identification number of each individual; 
(ii) the name and taxpayer identification number 
of each individual who was an employee of an employer 
but who was determined to be eligible for the premium 
tax credit under section 36B of the Internal Revenue 
Code of 1986 because— 
(I) the employer did not provide minimum 
essential coverage; or 
(II) the employer provided such minimum 
essential coverage but it was determined under 
section 36B(c)(2)(C) of such Code to either be 
unaffordable to the employee or not provide the 
required minimum actuarial value; and 
(iii) the name and taxpayer identification number 
of each individual who notifies the Exchange under 
section 1411(b)(4) that they have changed employers 
and of each individual who ceases coverage under a 
qualified health plan during a plan year (and the effec-
tive date of such cessation); 
(J) provide to each employer the name of each employee 
of the employer described in subparagraph (I)(ii) who ceases 
coverage under a qualified health plan during a plan year 
(and the effective date of such cessation); and 
(K) establish the Navigator program described in sub-
section (i). 
(5) FUNDING LIMITATIONS.— 
Lists. 
Certification. 
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124 STAT. 178 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) NO FEDERAL FUNDS FOR CONTINUED OPERATIONS.— 
In establishing an Exchange under this section, the State 
shall ensure that such Exchange is self-sustaining begin-
ning on January 1, 2015, including allowing the Exchange 
to charge assessments or user fees to participating health 
insurance issuers, or to otherwise generate funding, to 
support its operations. 
(B) PROHIBITING WASTEFUL USE OF FUNDS.—In carrying 
out activities under this subsection, an Exchange shall 
not utilize any funds intended for the administrative and 
operational expenses of the Exchange for staff retreats, 
promotional giveaways, excessive executive compensation, 
or promotion of Federal or State legislative and regulatory 
modifications. 
(6) CONSULTATION.—An Exchange shall consult with stake-
holders relevant to carrying out the activities under this section, 
including— 
(A) health care consumers who are enrollees in quali-
fied health plans; 
(B) individuals and entities with experience in facili-
tating enrollment in qualified health plans; 
(C) representatives of small businesses and self- 
employed individuals; 
(D) State Medicaid offices; and 
(E) advocates for enrolling hard to reach populations. 
(7) PUBLICATION
OF
COSTS.—An Exchange shall publish 
the average costs of licensing, regulatory fees, and any other 
payments required by the Exchange, and the administrative 
costs of such Exchange, on an Internet website to educate 
consumers on such costs. Such information shall also include 
monies lost to waste, fraud, and abuse. 
(e) CERTIFICATION.— 
(1) IN GENERAL.—An Exchange may certify a health plan 
as a qualified health plan if— 
(A) such health plan meets the requirements for certifi-
cation as promulgated by the Secretary under subsection 
(c)(1); and 
(B) the Exchange determines that making available 
such health plan through such Exchange is in the interests 
of qualified individuals and qualified employers in the State 
or States in which such Exchange operates, except that 
the Exchange may not exclude a health plan— 
(i) on the basis that such plan is a fee-for-service 
plan; 
(ii) through the imposition of premium price con-
trols; or 
(iii) on the basis that the plan provides treatments 
necessary to prevent patients’ deaths in circumstances 
the Exchange determines are inappropriate or too 
costly. 
(2) PREMIUM CONSIDERATIONS.—The Exchange shall require 
health plans seeking certification as qualified health plans to 
submit a justification for any premium increase prior to 
implementation of the increase. Such plans shall prominently 
post such information on their websites. The Exchange may 
take this information, and the information and the rec-
ommendations provided to the Exchange by the State under 
Web site. 
Determination. 
Web site. 
Effective date. 
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124 STAT. 179 
PUBLIC LAW 111–148—MAR. 23, 2010 
section 2794(b)(1) of the Public Health Service Act (relating 
to patterns or practices of excessive or unjustified premium 
increases), into consideration when determining whether to 
make such health plan available through the Exchange. The 
Exchange shall take into account any excess of premium growth 
outside the Exchange as compared to the rate of such growth 
inside the Exchange, including information reported by the 
States. 
(f) FLEXIBILITY.— 
(1) REGIONAL
OR
OTHER
INTERSTATE
EXCHANGES.—An 
Exchange may operate in more than one State if— 
(A) each State in which such Exchange operates per-
mits such operation; and 
(B) the Secretary approves such regional or interstate 
Exchange. 
(2) SUBSIDIARY EXCHANGES.—A State may establish one 
or more subsidiary Exchanges if— 
(A) each such Exchange serves a geographically distinct 
area; and 
(B) the area served by each such Exchange is at least 
as large as a rating area described in section 2701(a) of 
the Public Health Service Act. 
(3) AUTHORITY TO CONTRACT.— 
(A) IN GENERAL.—A State may elect to authorize an 
Exchange established by the State under this section to 
enter into an agreement with an eligible entity to carry 
out 1 or more responsibilities of the Exchange. 
(B) ELIGIBLE
ENTITY.—In this paragraph, the term 
‘‘eligible entity’’ means— 
(i) a person— 
(I) incorporated under, and subject to the laws 
of, 1 or more States; 
(II) that has demonstrated experience on a 
State or regional basis in the individual and small 
group health insurance markets and in benefits 
coverage; and 
(III) that is not a health insurance issuer or 
that is treated under subsection (a) or (b) of section 
52 of the Internal Revenue Code of 1986 as a 
member of the same controlled group of corpora-
tions (or under common control with) as a health 
insurance issuer; or 
(ii) the State medicaid agency under title XIX of 
the Social Security Act. 
(g) REWARDING
QUALITY
THROUGH
MARKET-BASED
INCEN-
TIVES.— 
(1) STRATEGY
DESCRIBED.—A strategy described in this 
paragraph is a payment structure that provides increased 
reimbursement or other incentives for— 
(A) 
improving 
health 
outcomes 
through 
the 
implementation of activities that shall include quality 
reporting, effective case management, care coordination, 
chronic disease management, medication and care compli-
ance initiatives, including through the use of the medical 
home model, for treatment or services under the plan or 
coverage; 
Definition. 
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124 STAT. 180 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) the implementation of activities to prevent hospital 
readmissions through a comprehensive program for hos-
pital discharge that includes patient-centered education 
and counseling, comprehensive discharge planning, and 
post discharge reinforcement by an appropriate health care 
professional; 
(C) the implementation of activities to improve patient 
safety and reduce medical errors through the appropriate 
use of best clinical practices, evidence based medicine, and 
health information technology under the plan or coverage; 
and 
(D) the implementation of wellness and health pro-
motion activities. 
(2) GUIDELINES.—The Secretary, in consultation with 
experts in health care quality and stakeholders, shall develop 
guidelines concerning the matters described in paragraph (1). 
(3) REQUIREMENTS.—The guidelines developed under para-
graph (2) shall require the periodic reporting to the applicable 
Exchange of the activities that a qualified health plan has 
conducted to implement a strategy described in paragraph (1). 
(h) QUALITY IMPROVEMENT.— 
(1) ENHANCING PATIENT SAFETY.—Beginning on January 
1, 2015, a qualified health plan may contract with— 
(A) a hospital with greater than 50 beds only if such 
hospital— 
(i) utilizes a patient safety evaluation system as 
described in part C of title IX of the Public Health 
Service Act; and 
(ii) implements a mechanism to ensure that each 
patient receives a comprehensive program for hospital 
discharge that includes patient-centered education and 
counseling, comprehensive discharge planning, and 
post discharge reinforcement by an appropriate health 
care professional; or 
(B) a health care provider only if such provider imple-
ments such mechanisms to improve health care quality 
as the Secretary may by regulation require. 
(2) EXCEPTIONS.—The Secretary may establish reasonable 
exceptions to the requirements described in paragraph (1). 
(3) ADJUSTMENT.—The Secretary may by regulation adjust 
the number of beds described in paragraph (1)(A). 
(i) NAVIGATORS.— 
(1) IN GENERAL.—An Exchange shall establish a program 
under which it awards grants to entities described in paragraph 
(2) to carry out the duties described in paragraph (3). 
(2) ELIGIBILITY.— 
(A) IN
GENERAL.—To be eligible to receive a grant 
under paragraph (1), an entity shall demonstrate to the 
Exchange involved that the entity has existing relation-
ships, or could readily establish relationships, with 
employers and employees, consumers (including uninsured 
and underinsured consumers), or self-employed individuals 
likely to be qualified to enroll in a qualified health plan. 
(B) TYPES.—Entities described in subparagraph (A) 
may include trade, industry, and professional associations, 
commercial fishing industry organizations, ranching and 
farming organizations, community and consumer-focused 
Grants. 
Effective date. 
Reports. 
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124 STAT. 181 
PUBLIC LAW 111–148—MAR. 23, 2010 
nonprofit groups, chambers of commerce, unions, small 
business development centers, other licensed insurance 
agents and brokers, and other entities that— 
(i) are capable of carrying out the duties described 
in paragraph (3); 
(ii) meet the standards described in paragraph 
(4); and 
(iii) provide information consistent with the stand-
ards developed under paragraph (5). 
(3) DUTIES.—An entity that serves as a navigator under 
a grant under this subsection shall— 
(A) conduct public education activities to raise aware-
ness of the availability of qualified health plans; 
(B) distribute fair and impartial information con-
cerning enrollment in qualified health plans, and the avail-
ability of premium tax credits under section 36B of the 
Internal Revenue Code of 1986 and cost-sharing reductions 
under section 1402; 
(C) facilitate enrollment in qualified health plans; 
(D) provide referrals to any applicable office of health 
insurance 
consumer 
assistance 
or 
health 
insurance 
ombudsman established under section 2793 of the Public 
Health Service Act, or any other appropriate State agency 
or agencies, for any enrollee with a grievance, complaint, 
or question regarding their health plan, coverage, or a 
determination under such plan or coverage; and 
(E) provide information in a manner that is culturally 
and linguistically appropriate to the needs of the population 
being served by the Exchange or Exchanges. 
(4) STANDARDS.— 
(A) IN GENERAL.—The Secretary shall establish stand-
ards for navigators under this subsection, including provi-
sions to ensure that any private or public entity that is 
selected as a navigator is qualified, and licensed if appro-
priate, to engage in the navigator activities described in 
this subsection and to avoid conflicts of interest. Under 
such standards, a navigator shall not— 
(i) be a health insurance issuer; or 
(ii) receive any consideration directly or indirectly 
from any health insurance issuer in connection with 
the 
enrollment 
of 
any 
qualified 
individuals 
or 
employees of a qualified employer in a qualified health 
plan. 
(5) FAIR AND IMPARTIAL INFORMATION AND SERVICES.—The 
Secretary, in collaboration with States, shall develop standards 
to ensure that information made available by navigators is 
fair, accurate, and impartial. 
(6) FUNDING.—Grants under this subsection shall be made 
from the operational funds of the Exchange and not Federal 
funds received by the State to establish the Exchange. 
(j) APPLICABILITY OF MENTAL HEALTH PARITY.—Section 2726 
of the Public Health Service Act shall apply to qualified health 
plans in the same manner and to the same extent as such section 
applies to health insurance issuers and group health plans. 
(k) CONFLICT.—An Exchange may not establish rules that con-
flict with or prevent the application of regulations promulgated 
by the Secretary under this subtitle. 
Standards. 
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124 STAT. 182 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 1312. CONSUMER CHOICE. 
(a) CHOICE.— 
(1) QUALIFIED
INDIVIDUALS.—A qualified individual may 
enroll in any qualified health plan available to such individual. 
(2) QUALIFIED EMPLOYERS.— 
(A) EMPLOYER
MAY
SPECIFY
LEVEL.—A qualified 
employer may provide support for coverage of employees 
under a qualified health plan by selecting any level of 
coverage under section 1302(d) to be made available to 
employees through an Exchange. 
(B) EMPLOYEE MAY CHOOSE PLANS WITHIN A LEVEL.— 
Each employee of a qualified employer that elects a level 
of coverage under subparagraph (A) may choose to enroll 
in a qualified health plan that offers coverage at that 
level. 
(b) PAYMENT
OF PREMIUMS
BY QUALIFIED INDIVIDUALS.—A 
qualified individual enrolled in any qualified health plan may pay 
any applicable premium owed by such individual to the health 
insurance issuer issuing such qualified health plan. 
(c) SINGLE RISK POOL.— 
(1) INDIVIDUAL MARKET.—A health insurance issuer shall 
consider all enrollees in all health plans (other than grand-
fathered health plans) offered by such issuer in the individual 
market, including those enrollees who do not enroll in such 
plans through the Exchange, to be members of a single risk 
pool. 
(2) SMALL GROUP MARKET.—A health insurance issuer shall 
consider all enrollees in all health plans (other than grand-
fathered health plans) offered by such issuer in the small 
group market, including those enrollees who do not enroll in 
such plans through the Exchange, to be members of a single 
risk pool. 
(3) MERGER OF MARKETS.—A State may require the indi-
vidual and small group insurance markets within a State to 
be merged if the State determines appropriate. 
(4) STATE
LAW.—A State law requiring grandfathered 
health plans to be included in a pool described in paragraph 
(1) or (2) shall not apply. 
(d) EMPOWERING CONSUMER CHOICE.— 
(1) 
CONTINUED
OPERATION
OF
MARKET
OUTSIDE 
EXCHANGES.—Nothing in this title shall be construed to pro-
hibit— 
(A) a health insurance issuer from offering outside 
of an Exchange a health plan to a qualified individual 
or qualified employer; and 
(B) a qualified individual from enrolling in, or a quali-
fied employer from selecting for its employees, a health 
plan offered outside of an Exchange. 
(2) CONTINUED
OPERATION
OF
STATE
BENEFIT
REQUIRE-
MENTS.—Nothing in this title shall be construed to terminate, 
abridge, or limit the operation of any requirement under State 
law with respect to any policy or plan that is offered outside 
of an Exchange to offer benefits. 
(3) VOLUNTARY NATURE OF AN EXCHANGE.— 
(A) CHOICE TO ENROLL OR NOT TO ENROLL.—Nothing 
in this title shall be construed to restrict the choice of 
42 USC 18032. 
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124 STAT. 183 
PUBLIC LAW 111–148—MAR. 23, 2010 
a qualified individual to enroll or not to enroll in a qualified 
health plan or to participate in an Exchange. 
(B) PROHIBITION AGAINST COMPELLED ENROLLMENT.— 
Nothing in this title shall be construed to compel an indi-
vidual to enroll in a qualified health plan or to participate 
in an Exchange. 
(C) INDIVIDUALS ALLOWED TO ENROLL IN ANY PLAN.— 
A qualified individual may enroll in any qualified health 
plan, except that in the case of a catastrophic plan 
described in section 1302(e), a qualified individual may 
enroll in the plan only if the individual is eligible to enroll 
in the plan under section 1302(e)(2). 
(D) MEMBERS OF CONGRESS IN THE EXCHANGE.— 
(i) REQUIREMENT.—Notwithstanding any other 
provision of law, after the effective date of this subtitle, 
the only health plans that the Federal Government 
may make available to Members of Congress and 
congressional staff with respect to their service as a 
Member of Congress or congressional staff shall be 
health plans that are— 
(I) created under this Act (or an amendment 
made by this Act); or 
(II) offered through an Exchange established 
under this Act (or an amendment made by this 
Act). 
(ii) DEFINITIONS.—In this section: 
(I) MEMBER OF CONGRESS.—The term ‘‘Member 
of Congress’’ means any member of the House 
of Representatives or the Senate. 
(II) 
CONGRESSIONAL
STAFF.—The 
term 
‘‘congressional staff’’ means all full-time and part- 
time employees employed by the official office of 
a Member of Congress, whether in Washington, 
DC or outside of Washington, DC. 
(4) NO PENALTY FOR TRANSFERRING TO MINIMUM ESSENTIAL 
COVERAGE OUTSIDE EXCHANGE.—An Exchange, or a qualified 
health plan offered through an Exchange, shall not impose 
any penalty or other fee on an individual who cancels enroll-
ment in a plan because the individual becomes eligible for 
minimum essential coverage (as defined in section 5000A(f) 
of the Internal Revenue Code of 1986 without regard to para-
graph (1)(C) or (D) thereof) or such coverage becomes affordable 
(within the meaning of section 36B(c)(2)(C) of such Code). 
(e) ENROLLMENT THROUGH AGENTS
OR BROKERS.—The Sec-
retary shall establish procedures under which a State may allow 
agents or brokers— 
(1) to enroll individuals in any qualified health plans in 
the individual or small group market as soon as the plan 
is offered through an Exchange in the State; and 
(2) to assist individuals in applying for premium tax credits 
and cost-sharing reductions for plans sold through an Exchange. 
Such procedures may include the establishment of rate schedules 
for broker commissions paid by health benefits plans offered through 
an exchange. 
(f) QUALIFIED INDIVIDUALS AND EMPLOYERS; ACCESS LIMITED 
TO CITIZENS AND LAWFUL RESIDENTS.— 
(1) QUALIFIED INDIVIDUALS.—In this title: 
Procedures. 
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124 STAT. 184 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) IN
GENERAL.—The term ‘‘qualified individual’’ 
means, with respect to an Exchange, an individual who— 
(i) is seeking to enroll in a qualified health plan 
in the individual market offered through the Exchange; 
and 
(ii) resides in the State that established the 
Exchange (except with respect to territorial agreements 
under section 1312(f)). 
(B) INCARCERATED INDIVIDUALS EXCLUDED.—An indi-
vidual shall not be treated as a qualified individual if, 
at the time of enrollment, the individual is incarcerated, 
other than incarceration pending the disposition of charges. 
(2) QUALIFIED EMPLOYER.—In this title: 
(A) IN GENERAL.—The term ‘‘qualified employer’’ means 
a small employer that elects to make all full-time employees 
of such employer eligible for 1 or more qualified health 
plans offered in the small group market through an 
Exchange that offers qualified health plans. 
(B) EXTENSION TO LARGE GROUPS.— 
(i) IN GENERAL.—Beginning in 2017, each State 
may allow issuers of health insurance coverage in the 
large group market in the State to offer qualified health 
plans in such market through an Exchange. Nothing 
in this subparagraph shall be construed as requiring 
the issuer to offer such plans through an Exchange. 
(ii) LARGE EMPLOYERS ELIGIBLE.—If a State under 
clause (i) allows issuers to offer qualified health plans 
in the large group market through an Exchange, the 
term ‘‘qualified employer’’ shall include a large 
employer that elects to make all full-time employees 
of such employer eligible for 1 or more qualified health 
plans offered in the large group market through the 
Exchange. 
(3) ACCESS
LIMITED
TO
LAWFUL
RESIDENTS.—If an indi-
vidual is not, or is not reasonably expected to be for the entire 
period for which enrollment is sought, a citizen or national 
of the United States or an alien lawfully present in the United 
States, the individual shall not be treated as a qualified indi-
vidual and may not be covered under a qualified health plan 
in the individual market that is offered through an Exchange. 
SEC. 1313. FINANCIAL INTEGRITY. 
(a) ACCOUNTING FOR EXPENDITURES.— 
(1) IN
GENERAL.—An Exchange shall keep an accurate 
accounting of all activities, receipts, and expenditures and shall 
annually submit to the Secretary a report concerning such 
accountings. 
(2) INVESTIGATIONS.—The Secretary, in coordination with 
the Inspector General of the Department of Health and Human 
Services, may investigate the affairs of an Exchange, may 
examine the properties and records of an Exchange, and may 
require periodic reports in relation to activities undertaken 
by an Exchange. An Exchange shall fully cooperate in any 
investigation conducted under this paragraph. 
(3) AUDITS.—An Exchange shall be subject to annual audits 
by the Secretary. 
Deadline. 
Deadline. 
Reports. 
42 USC 18033. 
Effective date. 
Definition. 
Definition. 
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124 STAT. 185 
PUBLIC LAW 111–148—MAR. 23, 2010 
(4) PATTERN OF ABUSE.—If the Secretary determines that 
an Exchange or a State has engaged in serious misconduct 
with respect to compliance with the requirements of, or carrying 
out of activities required under, this title, the Secretary may 
rescind from payments otherwise due to such State involved 
under this or any other Act administered by the Secretary 
an amount not to exceed 1 percent of such payments per year 
until corrective actions are taken by the State that are deter-
mined to be adequate by the Secretary. 
(5) PROTECTIONS AGAINST FRAUD AND ABUSE.—With respect 
to activities carried out under this title, the Secretary shall 
provide for the efficient and non-discriminatory administration 
of Exchange activities and implement any measure or procedure 
that— 
(A) the Secretary determines is appropriate to reduce 
fraud and abuse in the administration of this title; and 
(B) the Secretary has authority to implement under 
this title or any other Act. 
(6) APPLICATION OF THE FALSE CLAIMS ACT.— 
(A) IN GENERAL.—Payments made by, through, or in 
connection with an Exchange are subject to the False 
Claims Act (31 U.S.C. 3729 et seq.) if those payments 
include any Federal funds. Compliance with the require-
ments of this Act concerning eligibility for a health insur-
ance issuer to participate in the Exchange shall be a mate-
rial condition of an issuer’s entitlement to receive pay-
ments, including payments of premium tax credits and 
cost-sharing reductions, through the Exchange. 
(B) DAMAGES.—Notwithstanding paragraph (1) of sec-
tion 3729(a) of title 31, United States Code, and subject 
to paragraph (2) of such section, the civil penalty assessed 
under the False Claims Act on any person found liable 
under such Act as described in subparagraph (A) shall 
be increased by not less than 3 times and not more than 
6 times the amount of damages which the Government 
sustains because of the act of that person. 
(b) GAO OVERSIGHT.—Not later than 5 years after the first 
date on which Exchanges are required to be operational under 
this title, the Comptroller General shall conduct an ongoing study 
of Exchange activities and the enrollees in qualified health plans 
offered through Exchanges. Such study shall review— 
(1) the operations and administration of Exchanges, 
including surveys and reports of qualified health plans offered 
through Exchanges and on the experience of such plans 
(including data on enrollees in Exchanges and individuals pur-
chasing health insurance coverage outside of Exchanges), the 
expenses of Exchanges, claims statistics relating to qualified 
health plans, complaints data relating to such plans, and the 
manner in which Exchanges meet their goals; 
(2) any significant observations regarding the utilization 
and adoption of Exchanges; 
(3) where appropriate, recommendations for improvements 
in the operations or policies of Exchanges; and 
(4) how many physicians, by area and specialty, are not 
taking or accepting new patients enrolled in Federal Govern-
ment health care programs, and the adequacy of provider net-
works of Federal Government health care programs. 
Deadline. 
Study. 
Penalty. 
Determination. 
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124 STAT. 186 
PUBLIC LAW 111–148—MAR. 23, 2010 
PART III—STATE FLEXIBILITY RELATING TO 
EXCHANGES 
SEC. 1321. STATE FLEXIBILITY IN OPERATION AND ENFORCEMENT OF 
EXCHANGES AND RELATED REQUIREMENTS. 
(a) ESTABLISHMENT OF STANDARDS.— 
(1) IN GENERAL.—The Secretary shall, as soon as prac-
ticable after the date of enactment of this Act, issue regulations 
setting standards for meeting the requirements under this title, 
and the amendments made by this title, with respect to— 
(A) the establishment and operation of Exchanges 
(including SHOP Exchanges); 
(B) the offering of qualified health plans through such 
Exchanges; 
(C) the establishment of the reinsurance and risk 
adjustment programs under part V; and 
(D) such other requirements as the Secretary deter-
mines appropriate. 
The preceding sentence shall not apply to standards for require-
ments under subtitles A and C (and the amendments made 
by such subtitles) for which the Secretary issues regulations 
under the Public Health Service Act. 
(2) CONSULTATION.—In issuing the regulations under para-
graph (1), the Secretary shall consult with the National Associa-
tion of Insurance Commissioners and its members and with 
health insurance issuers, consumer organizations, and such 
other individuals as the Secretary selects in a manner designed 
to ensure balanced representation among interested parties. 
(b) STATE ACTION.—Each State that elects, at such time and 
in such manner as the Secretary may prescribe, to apply the require-
ments described in subsection (a) shall, not later than January 
1, 2014, adopt and have in effect— 
(1) the Federal standards established under subsection (a); 
or 
(2) a State law or regulation that the Secretary determines 
implements the standards within the State. 
(c) FAILURE TO ESTABLISH EXCHANGE OR IMPLEMENT REQUIRE-
MENTS.— 
(1) IN GENERAL.—If— 
(A) a State is not an electing State under subsection 
(b); or 
(B) the Secretary determines, on or before January 
1, 2013, that an electing State— 
(i) will not have any required Exchange operational 
by January 1, 2014; or 
(ii) has not taken the actions the Secretary deter-
mines necessary to implement— 
(I) the other requirements set forth in the 
standards under subsection (a); or 
(II) the requirements set forth in subtitles A 
and C and the amendments made by such sub-
titles; 
the Secretary shall (directly or through agreement with a not- 
for-profit entity) establish and operate such Exchange within 
the State and the Secretary shall take such actions as are 
necessary to implement such other requirements. 
Determination. 
Deadline. 
Deadline. 
Regulations. 
42 USC 18041. 
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124 STAT. 187 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) ENFORCEMENT AUTHORITY.—The provisions of section 
2736(b) of the Public Health Services Act shall apply to the 
enforcement under paragraph (1) of requirements of subsection 
(a)(1) (without regard to any limitation on the application of 
those provisions to group health plans). 
(d) NO INTERFERENCE WITH STATE REGULATORY AUTHORITY.— 
Nothing in this title shall be construed to preempt any State law 
that does not prevent the application of the provisions of this 
title. 
(e) PRESUMPTION FOR CERTAIN STATE-OPERATED EXCHANGES.— 
(1) IN
GENERAL.—In the case of a State operating an 
Exchange before January 1, 2010, and which has insured a 
percentage of its population not less than the percentage of 
the population projected to be covered nationally after the 
implementation of this Act, that seeks to operate an Exchange 
under this section, the Secretary shall presume that such 
Exchange meets the standards under this section unless the 
Secretary determines, after completion of the process estab-
lished under paragraph (2), that the Exchange does not comply 
with such standards. 
(2) PROCESS.—The Secretary shall establish a process to 
work with a State described in paragraph (1) to provide assist-
ance necessary to assist the State’s Exchange in coming into 
compliance with the standards for approval under this section. 
SEC. 1322. FEDERAL PROGRAM TO ASSIST ESTABLISHMENT AND OPER-
ATION OF NONPROFIT, MEMBER-RUN HEALTH INSUR-
ANCE ISSUERS. 
(a) ESTABLISHMENT OF PROGRAM.— 
(1) IN GENERAL.—The Secretary shall establish a program 
to carry out the purposes of this section to be known as the 
Consumer Operated and Oriented Plan (CO–OP) program. 
(2) PURPOSE.—It is the purpose of the CO–OP program 
to foster the creation of qualified nonprofit health insurance 
issuers to offer qualified health plans in the individual and 
small group markets in the States in which the issuers are 
licensed to offer such plans. 
(b) LOANS AND GRANTS UNDER THE CO–OP PROGRAM.— 
(1) IN GENERAL.—The Secretary shall provide through the 
CO–OP program for the awarding to persons applying to become 
qualified nonprofit health insurance issuers of— 
(A) loans to provide assistance to such person in 
meeting its start-up costs; and 
(B) grants to provide assistance to such person in 
meeting any solvency requirements of States in which the 
person seeks to be licensed to issue qualified health plans. 
(2) REQUIREMENTS FOR AWARDING LOANS AND GRANTS.— 
(A) IN GENERAL.—In awarding loans and grants under 
the CO–OP program, the Secretary shall— 
(i) take into account the recommendations of the 
advisory board established under paragraph (3); 
(ii) give priority to applicants that will offer quali-
fied health plans on a Statewide basis, will utilize 
integrated care models, and have significant private 
support; and 
(iii) ensure that there is sufficient funding to estab-
lish at least 1 qualified nonprofit health insurance 
42 USC 18042. 
Determination. 
Applicability. 
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124 STAT. 188 
PUBLIC LAW 111–148—MAR. 23, 2010 
issuer in each State, except that nothing in this clause 
shall prohibit the Secretary from funding the establish-
ment of multiple qualified nonprofit health insurance 
issuers in any State if the funding is sufficient to 
do so. 
(B) STATES WITHOUT ISSUERS IN PROGRAM.—If no health 
insurance issuer applies to be a qualified nonprofit health 
insurance issuer within a State, the Secretary may use 
amounts appropriated under this section for the awarding 
of grants to encourage the establishment of a qualified 
nonprofit health insurance issuer within the State or the 
expansion of a qualified nonprofit health insurance issuer 
from another State to the State. 
(C) AGREEMENT.— 
(i) IN GENERAL.—The Secretary shall require any 
person receiving a loan or grant under the CO–OP 
program to enter into an agreement with the Secretary 
which requires such person to meet (and to continue 
to meet)— 
(I) any requirement under this section for such 
person to be treated as a qualified nonprofit health 
insurance issuer; and 
(II) any requirements contained in the agree-
ment for such person to receive such loan or grant. 
(ii) RESTRICTIONS ON USE OF FEDERAL FUNDS.— 
The agreement shall include a requirement that no 
portion of the funds made available by any loan or 
grant under this section may be used— 
(I) for carrying on propaganda, or otherwise 
attempting, to influence legislation; or 
(II) for marketing. 
Nothing in this clause shall be construed to allow 
a person to take any action prohibited by section 
501(c)(29) of the Internal Revenue Code of 1986. 
(iii) FAILURE TO MEET REQUIREMENTS.—If the Sec-
retary determines that a person has failed to meet 
any requirement described in clause (i) or (ii) and 
has failed to correct such failure within a reasonable 
period of time of when the person first knows (or 
reasonably should have known) of such failure, such 
person shall repay to the Secretary an amount equal 
to the sum of— 
(I) 110 percent of the aggregate amount of 
loans and grants received under this section; plus 
(II) interest on the aggregate amount of loans 
and grants received under this section for the 
period the loans or grants were outstanding. 
The Secretary shall notify the Secretary of the 
Treasury of any determination under this section of 
a failure that results in the termination of an issuer’s 
tax-exempt status under section 501(c)(29) of such 
Code. 
(D) TIME FOR AWARDING LOANS AND GRANTS.—The Sec-
retary shall not later than July 1, 2013, award the loans 
and grants under the CO–OP program and begin the dis-
tribution of amounts awarded under such loans and grants. 
(3) ADVISORY BOARD.— 
Establishment. 
Deadline. 
Notification. 
Determination. 
Payments. 
Lobbying. 
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124 STAT. 189 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) IN GENERAL.—The advisory board under this para-
graph shall consist of 15 members appointed by the Comp-
troller General of the United States from among individuals 
with qualifications described in section 1805(c)(2) of the 
Social Security Act. 
(B) RULES RELATING TO APPOINTMENTS.— 
(i) STANDARDS.—Any individual appointed under 
subparagraph (A) shall meet ethics and conflict of 
interest 
standards 
protecting 
against 
insurance 
industry involvement and interference. 
(ii) 
ORIGINAL
APPOINTMENTS.—The 
original 
appointment of board members under subparagraph 
(A)(ii) shall be made no later than 3 months after 
the date of enactment of this Act. 
(C) VACANCY.—Any vacancy on the advisory board 
shall be filled in the same manner as the original appoint-
ment. 
(D) PAY AND REIMBURSEMENT.— 
(i) NO COMPENSATION FOR MEMBERS OF ADVISORY 
BOARD.—Except as provided in clause (ii), a member 
of the advisory board may not receive pay, allowances, 
or benefits by reason of their service on the board. 
(ii) TRAVEL EXPENSES.—Each member shall receive 
travel expenses, including per diem in lieu of subsist-
ence under subchapter I of chapter 57 of title 5, United 
States Code. 
(E) APPLICATION OF FACA.—The Federal Advisory Com-
mittee Act (5 U.S.C. App.) shall apply to the advisory 
board, except that section 14 of such Act shall not apply. 
(F) TERMINATION.—The advisory board shall terminate 
on the earlier of the date that it completes its duties 
under this section or December 31, 2015. 
(c) QUALIFIED NONPROFIT HEALTH INSURANCE ISSUER.—For 
purposes of this section— 
(1) IN
GENERAL.—The term ‘‘qualified nonprofit health 
insurance issuer’’ means a health insurance issuer that is an 
organization— 
(A) that is organized under State law as a nonprofit, 
member corporation; 
(B) substantially all of the activities of which consist 
of the issuance of qualified health plans in the individual 
and small group markets in each State in which it is 
licensed to issue such plans; and 
(C) that meets the other requirements of this sub-
section. 
(2) CERTAIN ORGANIZATIONS PROHIBITED.—An organization 
shall not be treated as a qualified nonprofit health insurance 
issuer if— 
(A) the organization or a related entity (or any prede-
cessor of either) was a health insurance issuer on July 
16, 2009; or 
(B) the organization is sponsored by a State or local 
government, any political subdivision thereof, or any 
instrumentality of such government or political subdivision. 
(3) GOVERNANCE
REQUIREMENTS.—An organization shall 
not be treated as a qualified nonprofit health insurance issuer 
unless— 
Definition. 
Deadline. 
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124 STAT. 190 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) the governance of the organization is subject to 
a majority vote of its members; 
(B) its governing documents incorporate ethics and 
conflict of interest standards protecting against insurance 
industry involvement and interference; and 
(C) as provided in regulations promulgated by the Sec-
retary, the organization is required to operate with a strong 
consumer focus, including timeliness, responsiveness, and 
accountability to members. 
(4) PROFITS INURE TO BENEFIT OF MEMBERS.—An organiza-
tion shall not be treated as a qualified nonprofit health insur-
ance issuer unless any profits made by the organization are 
required to be used to lower premiums, to improve benefits, 
or for other programs intended to improve the quality of health 
care delivered to its members. 
(5) 
COMPLIANCE
WITH
STATE
INSURANCE
LAWS.—An 
organization shall not be treated as a qualified nonprofit health 
insurance issuer unless the organization meets all the require-
ments that other issuers of qualified health plans are required 
to meet in any State where the issuer offers a qualified health 
plan, including solvency and licensure requirements, rules on 
payments to providers, and compliance with network adequacy 
rules, rate and form filing rules, any applicable State premium 
assessments and any other State law described in section 
1324(b). 
(6) COORDINATION WITH STATE INSURANCE REFORMS.—An 
organization shall not be treated as a qualified nonprofit health 
insurance issuer unless the organization does not offer a health 
plan in a State until that State has in effect (or the Secretary 
has implemented for the State) the market reforms required 
by part A of title XXVII of the Public Health Service Act 
(as amended by subtitles A and C of this Act). 
(d) ESTABLISHMENT OF PRIVATE PURCHASING COUNCIL.— 
(1) IN
GENERAL.—Qualified nonprofit health insurance 
issuers participating in the CO–OP program under this section 
may establish a private purchasing council to enter into collec-
tive purchasing arrangements for items and services that 
increase administrative and other cost efficiencies, including 
claims administration, administrative services, health informa-
tion technology, and actuarial services. 
(2) COUNCIL MAY NOT SET PAYMENT RATES.—The private 
purchasing council established under paragraph (1) shall not 
set payment rates for health care facilities or providers partici-
pating in health insurance coverage provided by qualified non-
profit health insurance issuers. 
(3) CONTINUED APPLICATION OF ANTITRUST LAWS.— 
(A) IN GENERAL.—Nothing in this section shall be con-
strued to limit the application of the antitrust laws to 
any private purchasing council (whether or not established 
under this subsection) or to any qualified nonprofit health 
insurance issuer participating in such a council. 
(B) ANTITRUST LAWS.—For purposes of this subpara-
graph, the term ‘‘antitrust laws’’ has the meaning given 
the term in subsection (a) of the first section of the Clayton 
Act (15 U.S.C. 12(a)). Such term also includes section 5 
of the Federal Trade Commission Act (15 U.S.C. 45) to 
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124 STAT. 191 
PUBLIC LAW 111–148—MAR. 23, 2010 
the extent that such section 5 applies to unfair methods 
of competition. 
(e) LIMITATION ON PARTICIPATION.—No representative of any 
Federal, State, or local government (or of any political subdivision 
or instrumentality thereof), and no representative of a person 
described in subsection (c)(2)(A), may serve on the board of directors 
of a qualified nonprofit health insurance issuer or with a private 
purchasing council established under subsection (d). 
(f) LIMITATIONS ON SECRETARY.— 
(1) IN GENERAL.—The Secretary shall not— 
(A) participate in any negotiations between 1 or more 
qualified nonprofit health insurance issuers (or a private 
purchasing council established under subsection (d)) and 
any health care facilities or providers, including any drug 
manufacturer, pharmacy, or hospital; and 
(B) establish or maintain a price structure for 
reimbursement of any health benefits covered by such 
issuers. 
(2) COMPETITION.—Nothing in this section shall be con-
strued as authorizing the Secretary to interfere with the 
competitive nature of providing health benefits through quali-
fied nonprofit health insurance issuers. 
(g) APPROPRIATIONS.—There are hereby appropriated, out of 
any 
funds 
in 
the 
Treasury 
not 
otherwise 
appropriated, 
$6,000,000,000 to carry out this section. 
(h) TAX EXEMPTION FOR QUALIFIED NONPROFIT HEALTH INSUR-
ANCE ISSUER.— 
(1) IN GENERAL.—Section 501(c) of the Internal Revenue 
Code of 1986 (relating to list of exempt organizations) is 
amended by adding at the end the following: 
‘‘(29) CO–OP HEALTH INSURANCE ISSUERS.— 
‘‘(A) IN GENERAL.—A qualified nonprofit health insur-
ance issuer (within the meaning of section 1322 of the 
Patient Protection and Affordable Care Act) which has 
received a loan or grant under the CO–OP program under 
such section, but only with respect to periods for which 
the issuer is in compliance with the requirements of such 
section and any agreement with respect to the loan or 
grant. 
‘‘(B) CONDITIONS FOR EXEMPTION.—Subparagraph (A) 
shall apply to an organization only if— 
‘‘(i) the organization has given notice to the Sec-
retary, in such manner as the Secretary may by regula-
tions prescribe, that it is applying for recognition of 
its status under this paragraph, 
‘‘(ii) except as provided in section 1322(c)(4) of 
the Patient Protection and Affordable Care Act, no 
part of the net earnings of which inures to the benefit 
of any private shareholder or individual, 
‘‘(iii) no substantial part of the activities of which 
is carrying on propaganda, or otherwise attempting, 
to influence legislation, and 
‘‘(iv) the organization does not participate in, or 
intervene in (including the publishing or distributing 
of statements), any political campaign on behalf of 
(or in opposition to) any candidate for public office.’’. 
Lobbying. 
Notice. 
Applicability. 
26 USC 501. 
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124 STAT. 192 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) ADDITIONAL REPORTING REQUIREMENT.—Section 6033 of 
such Code (relating to returns by exempt organizations) is 
amended by redesignating subsection (m) as subsection (n) 
and by inserting after subsection (l) the following: 
‘‘(m) ADDITIONAL
INFORMATION
REQUIRED
FROM
CO–OP 
INSURERS.—An organization described in section 501(c)(29) shall 
include on the return required under subsection (a) the following 
information: 
‘‘(1) The amount of the reserves required by each State 
in which the organization is licensed to issue qualified health 
plans. 
‘‘(2) The amount of reserves on hand.’’. 
(3) APPLICATION
OF
TAX
ON
EXCESS
BENEFIT
TRANS-
ACTIONS.—Section 4958(e)(1) of such Code (defining applicable 
tax-exempt organization) is amended by striking ‘‘paragraph 
(3) or (4)’’ and inserting ‘‘paragraph (3), (4), or (29)’’. 
(i) GAO STUDY AND REPORT.— 
(1) STUDY.—The Comptroller General of the General 
Accountability Office shall conduct an ongoing study on com-
petition and market concentration in the health insurance 
market in the United States after the implementation of the 
reforms in such market under the provisions of, and the amend-
ments made by, this Act. Such study shall include an analysis 
of new issuers of health insurance in such market. 
(2) REPORT.—The Comptroller General shall, not later than 
December 31 of each even-numbered year (beginning with 
2014), report to the appropriate committees of the Congress 
the results of the study conducted under paragraph (1), 
including any recommendations for administrative or legislative 
changes the Comptroller General determines necessary or 
appropriate to increase competition in the health insurance 
market. 
SEC. 1323. COMMUNITY HEALTH INSURANCE OPTION. 
(a) VOLUNTARY NATURE.— 
(1) NO
REQUIREMENT
FOR
HEALTH
CARE
PROVIDERS
TO 
PARTICIPATE.—Nothing in this section shall be construed to 
require a health care provider to participate in a community 
health insurance option, or to impose any penalty for non- 
participation. 
(2) NO REQUIREMENT FOR INDIVIDUALS TO JOIN.—Nothing 
in this section shall be construed to require an individual 
to participate in a community health insurance option, or to 
impose any penalty for non-participation. 
(3) STATE OPT OUT.— 
(A) IN
GENERAL.—A State may elect to prohibit 
Exchanges in such State from offering a community health 
insurance option if such State enacts a law to provide 
for such prohibition. 
(B) TERMINATION OF OPT OUT.—A State may repeal 
a law described in subparagraph (A) and provide for the 
offering of such an option through the Exchange. 
(b) 
ESTABLISHMENT
OF
COMMUNITY
HEALTH
INSURANCE 
OPTION.— 
(1) ESTABLISHMENT.—The Secretary shall establish a 
community health insurance option to offer, through the 
Exchanges established under this title (other than Exchanges 
42 USC 18043. 
Effective date. 
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124 STAT. 193 
PUBLIC LAW 111–148—MAR. 23, 2010 
in States that elect to opt out as provided for in subsection 
(a)(3)), health care coverage that provides value, choice, com-
petition, and stability of affordable, high quality coverage 
throughout the United States. 
(2) COMMUNITY HEALTH INSURANCE OPTION.—In this sec-
tion, the term ‘‘community health insurance option’’ means 
health insurance coverage that— 
(A) except as specifically provided for in this section, 
complies with the requirements for being a qualified health 
plan; 
(B) provides high value for the premium charged; 
(C) reduces administrative costs and promotes adminis-
trative simplification for beneficiaries; 
(D) promotes high quality clinical care; 
(E) provides high quality customer service to bene-
ficiaries; 
(F) offers a sufficient choice of providers; and 
(G) complies with State laws (if any), except as other-
wise provided for in this title, relating to the laws described 
in section 1324(b). 
(3) ESSENTIAL HEALTH BENEFITS.— 
(A) GENERAL RULE.—Except as provided in subpara-
graph (B), a community health insurance option offered 
under this section shall provide coverage only for the essen-
tial health benefits described in section 1302(b). 
(B) STATES MAY OFFER ADDITIONAL BENEFITS.—Nothing 
in this section shall preclude a State from requiring that 
benefits in addition to the essential health benefits required 
under subparagraph (A) be provided to enrollees of a 
community health insurance option offered in such State. 
(C) CREDITS.— 
(i) IN
GENERAL.—An individual enrolled in a 
community health insurance option under this section 
shall be eligible for credits under section 36B of the 
Internal Revenue Code of 1986 in the same manner 
as an individual who is enrolled in a qualified health 
plan. 
(ii) NO ADDITIONAL FEDERAL COST.—A requirement 
by a State under subparagraph (B) that benefits in 
addition to the essential health benefits required under 
subparagraph (A) be provided to enrollees of a commu-
nity health insurance option shall not affect the 
amount of a premium tax credit provided under section 
36B of the Internal Revenue Code of 1986 with respect 
to such plan. 
(D) STATE MUST ASSUME COST.—A State shall make 
payments to or on behalf of an eligible individual to defray 
the cost of any additional benefits described in subpara-
graph (B). 
(E) ENSURING ACCESS TO ALL SERVICES.—Nothing in 
this Act shall prohibit an individual enrolled in a commu-
nity health insurance option from paying out-of-pocket the 
full cost of any item or service not included as an essential 
health benefit or otherwise covered as a benefit by a health 
plan. Nothing in subparagraph (B) shall prohibit any type 
of medical provider from accepting an out-of-pocket pay-
ment from an individual enrolled in a community health 
Payments. 
Definition. 
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124 STAT. 194 
PUBLIC LAW 111–148—MAR. 23, 2010 
insurance option for a service otherwise not included as 
an essential health benefit. 
(F) PROTECTING
ACCESS
TO
END
OF
LIFE
CARE.—A 
community health insurance option offered under this sec-
tion shall be prohibited from limiting access to end of 
life care. 
(4) COST SHARING.—A community health insurance option 
shall offer coverage at each of the levels of coverage described 
in section 1302(d). 
(5) PREMIUMS.— 
(A) PREMIUMS SUFFICIENT TO COVER COSTS.—The Sec-
retary shall establish geographically adjusted premium 
rates in an amount sufficient to cover expected costs 
(including claims and administrative costs) using methods 
in general use by qualified health plans. 
(B) APPLICABLE RULES.—The provisions of title XXVII 
of the Public Health Service Act relating to premiums 
shall apply to community health insurance options under 
this section, including modified community rating provi-
sions under section 2701 of such Act. 
(C) COLLECTION OF DATA.—The Secretary shall collect 
data as necessary to set premium rates under subpara-
graph (A). 
(D) NATIONAL
POOLING.—Notwithstanding any other 
provision of law, the Secretary may treat all enrollees 
in community health insurance options as members of a 
single pool. 
(E) CONTINGENCY MARGIN.—In establishing premium 
rates under subparagraph (A), the Secretary shall include 
an appropriate amount for a contingency margin. 
(6) REIMBURSEMENT RATES.— 
(A) NEGOTIATED RATES.—The Secretary shall negotiate 
rates for the reimbursement of health care providers for 
benefits covered under a community health insurance 
option. 
(B) LIMITATION.—The rates described in subparagraph 
(A) shall not be higher, in aggregate, than the average 
reimbursement rates paid by health insurance issuers 
offering qualified health plans through the Exchange. 
(C) INNOVATION.—Subject to the limits contained in 
subparagraph (A), a State Advisory Council established 
or designated under subsection (d) may develop or encour-
age the use of innovative payment policies that promote 
quality, efficiency and savings to consumers. 
(7) SOLVENCY AND CONSUMER PROTECTION.— 
(A) SOLVENCY.—The Secretary shall establish a Fed-
eral solvency standard to be applied with respect to a 
community health insurance option. A community health 
insurance option shall also be subject to the solvency 
standard of each State in which such community health 
insurance option is offered. 
(B) MINIMUM REQUIRED.—In establishing the standard 
described under subparagraph (A), the Secretary shall 
require a reserve fund that shall be equal to at least 
the dollar value of the incurred but not reported claims 
of a community health insurance option. 
Standard. 
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124 STAT. 195 
PUBLIC LAW 111–148—MAR. 23, 2010 
(C) CONSUMER PROTECTIONS.—The consumer protection 
laws of a State shall apply to a community health insurance 
option. 
(8) REQUIREMENTS
ESTABLISHED
IN
PARTNERSHIP
WITH 
INSURANCE COMMISSIONERS.— 
(A) IN GENERAL.—The Secretary, in collaboration with 
the National Association of Insurance Commissioners (in 
this paragraph referred to as the ‘‘NAIC’’), may promulgate 
regulations to establish additional requirements for a 
community health insurance option. 
(B) APPLICABILITY.—Any requirement promulgated 
under subparagraph (A) shall be applicable to such option 
beginning 90 days after the date on which the regulation 
involved becomes final. 
(c) START-UP FUND.— 
(1) ESTABLISHMENT OF FUND.— 
(A) IN GENERAL.—There is established in the Treasury 
of the United States a trust fund to be known as the 
‘‘Health Benefit Plan Start-Up Fund’’ (referred to in this 
section as the ‘‘Start-Up Fund’’), that shall consist of such 
amounts as may be appropriated or credited to the Start- 
Up Fund as provided for in this subsection to provide 
loans for the initial operations of a community health insur-
ance option. Such amounts shall remain available until 
expended. 
(B) FUNDING.—There is hereby appropriated to the 
Start-Up Fund, out of any moneys in the Treasury not 
otherwise appropriated an amount requested by the Sec-
retary of Health and Human Services as necessary to— 
(i) pay the start-up costs associated with the initial 
operations of a community health insurance option; 
and 
(ii) pay the costs of making payments on claims 
submitted during the period that is not more than 
90 days from the date on which such option is offered. 
(2) USE
OF
START-UP
FUND.—The Secretary shall use 
amounts contained in the Start-Up Fund to make payments 
(subject to the repayment requirements in paragraph (4)) for 
the purposes described in paragraph (1)(B). 
(3) PASS THROUGH OF REBATES.—The Secretary may estab-
lish procedures for reducing the amount of payments to a 
contracting administrator to take into account any rebates or 
price concessions. 
(4) REPAYMENT.— 
(A) IN
GENERAL.—A community health insurance 
option shall be required to repay the Secretary of the 
Treasury (on such terms as the Secretary may require) 
for any payments made under paragraph (1)(B) by the 
date that is not later than 9 years after the date on which 
the payment is made. The Secretary may require the pay-
ment of interest with respect to such repayments at rates 
that do not exceed the market interest rate (as determined 
by the Secretary). 
(B) SANCTIONS IN CASE OF FOR-PROFIT CONVERSION.— 
In any case in which the Secretary enters into a contract 
with a qualified entity for the offering of a community 
health insurance option and such entity is determined to 
Deadline. 
Effective date. 
Applicability. 
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124 STAT. 196 
PUBLIC LAW 111–148—MAR. 23, 2010 
be a for-profit entity by the Secretary, such entity shall 
be— 
(i) immediately liable to the Secretary for any pay-
ments received by such entity from the Start-Up Fund; 
and 
(ii) permanently ineligible to offer a qualified 
health plan. 
(d) STATE ADVISORY COUNCIL.— 
(1) ESTABLISHMENT.—A State (other than a State that 
elects to opt out as provided for in subsection (a)(3)) shall 
establish or designate a public or non-profit private entity 
to serve as the State Advisory Council to provide recommenda-
tions to the Secretary on the operations and policies of a 
community health insurance option in the State. Such Council 
shall provide recommendations on at least the following: 
(A) policies and procedures to integrate quality 
improvement and cost containment mechanisms into the 
health care delivery system; 
(B) mechanisms to facilitate public awareness of the 
availability of a community health insurance option; and 
(C) alternative payment structures under a community 
health insurance option for health care providers that 
encourage quality improvement and cost control. 
(2) MEMBERS.—The members of the State Advisory Council 
shall be representatives of the public and shall include health 
care consumers and providers. 
(3) APPLICABILITY OF RECOMMENDATIONS.—The Secretary 
may apply the recommendations of a State Advisory Council 
to a community health insurance option in that State, in any 
other State, or in all States. 
(e) AUTHORITY TO CONTRACT; TERMS OF CONTRACT.— 
(1) AUTHORITY.— 
(A) IN GENERAL.—The Secretary may enter into a con-
tract or contracts with one or more qualified entities for 
the 
purpose 
of 
performing 
administrative 
functions 
(including functions described in subsection (a)(4) of section 
1874A of the Social Security Act) with respect to a commu-
nity health insurance option in the same manner as the 
Secretary may enter into contracts under subsection (a)(1) 
of such section. The Secretary shall have the same 
authority with respect to a community health insurance 
option under this section as the Secretary has under sub-
sections (a)(1) and (b) of section 1874A of the Social Security 
Act with respect to title XVIII of such Act. 
(B) REQUIREMENTS APPLY.—If the Secretary enters into 
a contract with a qualified entity to offer a community 
health insurance option, under such contract such entity— 
(i) shall meet the criteria established under para-
graph (2); and 
(ii) shall receive an administrative fee under para-
graph (7). 
(C) LIMITATION.—Contracts under this subsection shall 
not involve the transfer of insurance risk to the contracting 
administrator. 
(D) REFERENCE.—An entity with which the Secretary 
has entered into a contract under this paragraph shall 
be referred to as a ‘‘contracting administrator’’. 
Fee. 
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124 STAT. 197 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) QUALIFIED ENTITY.—To be qualified to be selected by 
the Secretary to offer a community health insurance option, 
an entity shall— 
(A) meet the criteria established under section 
1874A(a)(2) of the Social Security Act; 
(B) be a nonprofit entity for purposes of offering such 
option; 
(C) meet the solvency standards applicable under sub-
section (b)(7); 
(D) be eligible to offer health insurance or health bene-
fits coverage; 
(E) meet quality standards specified by the Secretary; 
(F) have in place effective procedures to control fraud, 
abuse, and waste; and 
(G) meet such other requirements as the Secretary 
may impose. 
Procedures described under subparagraph (F) shall include the 
implementation of procedures to use beneficiary identifiers to 
identify individuals entitled to benefits so that such an individ-
ual’s social security account number is not used, and shall 
also include procedures for the use of technology (including 
front-end, prepayment intelligent data-matching technology 
similar to that used by hedge funds, investment funds, and 
banks) to provide real-time data analysis of claims for payment 
under this title to identify and investigate unusual billing or 
order practices under this title that could indicate fraud or 
abuse. 
(3) TERM.—A contract provided for under paragraph (1) 
shall be for a term of at least 5 years but not more than 
10 years, as determined by the Secretary. At the end of each 
such term, the Secretary shall conduct a competitive bidding 
process for the purposes of renewing existing contracts or 
selecting new qualified entities with which to enter into con-
tracts under such paragraph. 
(4) LIMITATION.—A contract may not be renewed under 
this subsection unless the Secretary determines that the con-
tracting administrator has met performance requirements 
established by the Secretary in the areas described in para-
graph (7)(B). 
(5) AUDITS.—The Inspector General shall conduct periodic 
audits with respect to contracting administrators under this 
subsection to ensure that the administrator involved is in 
compliance with this section. 
(6) REVOCATION.—A contract awarded under this subsection 
shall be revoked by the Secretary, upon the recommendation 
of the Inspector General, only after notice to the contracting 
administrator involved and an opportunity for a hearing. The 
Secretary may revoke such contract if the Secretary determines 
that such administrator has engaged in fraud, deception, waste, 
abuse of power, negligence, mismanagement of taxpayer dollars, 
or gross mismanagement. An entity that has had a contract 
revoked under this paragraph shall not be qualified to enter 
into a subsequent contract under this subsection. 
(7) FEE FOR ADMINISTRATION.— 
(A) IN
GENERAL.—The Secretary shall pay the con-
tracting administrator a fee for the management, adminis-
tration, and delivery of the benefits under this section. 
Notification. 
Determination. 
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124 STAT. 198 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) REQUIREMENT
FOR
HIGH
QUALITY
ADMINISTRA-
TION.—The Secretary may increase the fee described in 
subparagraph (A) by not more than 10 percent, or reduce 
the fee described in subparagraph (A) by not more than 
50 percent, based on the extent to which the contracting 
administrator, in the determination of the Secretary, meets 
performance requirements established by the Secretary, 
in at least the following areas: 
(i) Maintaining low premium costs and low cost 
sharing requirements, provided that such requirements 
are consistent with section 1302. 
(ii) Reducing administrative costs and promoting 
administrative simplification for beneficiaries. 
(iii) Promoting high quality clinical care. 
(iv) Providing high quality customer service to 
beneficiaries. 
(C) NON-RENEWAL.—The Secretary may not renew a 
contract to offer a community health insurance option 
under this section with any contracting entity that has 
been assessed more than one reduction under subparagraph 
(B) during the contract period. 
(8) LIMITATION.—Notwithstanding the terms of a contract 
under this subsection, the Secretary shall negotiate the 
reimbursement rates for purposes of subsection (b)(6). 
(f) REPORT BY HHS AND INSOLVENCY WARNINGS.— 
(1) IN GENERAL.—On an annual basis, the Secretary shall 
conduct a study on the solvency of a community health insur-
ance option and submit to Congress a report describing the 
results of such study. 
(2) RESULT.—If, in any year, the result of the study under 
paragraph (1) is that a community health insurance option 
is insolvent, such result shall be treated as a community health 
insurance option solvency warning. 
(3) SUBMISSION OF PLAN AND PROCEDURE.— 
(A) IN GENERAL.—If there is a community health insur-
ance option solvency warning under paragraph (2) made 
in a year, the President shall submit to Congress, within 
the 15-day period beginning on the date of the budget 
submission to Congress under section 1105(a) of title 31, 
United States Code, for the succeeding year, proposed legis-
lation to respond to such warning. 
(B) PROCEDURE.—In the case of a legislative proposal 
submitted by the President pursuant to subparagraph (A), 
such proposal shall be considered by Congress using the 
same procedures described under sections 803 and 804 
of the Medicare Prescription Drug, Improvement, and Mod-
ernization Act of 2003 that shall be used for a medicare 
funding warning. 
(g) MARKETING PARITY.—In a facility controlled by the Federal 
Government, or by a State, where marketing or promotional mate-
rials related to a community health insurance option are made 
available to the public, making available marketing or promotional 
materials relating to private health insurance plans shall not be 
prohibited. Such materials include informational pamphlets, guide-
books, enrollment forms, or other materials determined reasonable 
for display. 
President. 
Deadline. 
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124 STAT. 199 
PUBLIC LAW 111–148—MAR. 23, 2010 
(h) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 
to be appropriated such sums as may be necessary to carry out 
this section. 
SEC. 1324. LEVEL PLAYING FIELD. 
(a) IN GENERAL.—Notwithstanding any other provision of law, 
any health insurance coverage offered by a private health insurance 
issuer shall not be subject to any Federal or State law described 
in subsection (b) if a qualified health plan offered under the Con-
sumer Operated and Oriented Plan program under section 1322, 
a community health insurance option under section 1323, or a 
nationwide qualified health plan under section 1333(b), is not sub-
ject to such law. 
(b) LAWS DESCRIBED.—The Federal and State laws described 
in this subsection are those Federal and State laws relating to— 
(1) guaranteed renewal; 
(2) rating; 
(3) preexisting conditions; 
(4) non-discrimination; 
(5) quality improvement and reporting; 
(6) fraud and abuse; 
(7) solvency and financial requirements; 
(8) market conduct; 
(9) prompt payment; 
(10) appeals and grievances; 
(11) privacy and confidentiality; 
(12) licensure; and 
(13) benefit plan material or information. 
PART IV—STATE FLEXIBILITY TO ESTABLISH 
ALTERNATIVE PROGRAMS 
SEC. 1331. STATE FLEXIBILITY TO ESTABLISH BASIC HEALTH PRO-
GRAMS FOR LOW-INCOME INDIVIDUALS NOT ELIGIBLE 
FOR MEDICAID. 
(a) ESTABLISHMENT OF PROGRAM.— 
(1) IN
GENERAL.—The Secretary shall establish a basic 
health program meeting the requirements of this section under 
which a State may enter into contracts to offer 1 or more 
standard health plans providing at least the essential health 
benefits described in section 1302(b) to eligible individuals in 
lieu of offering such individuals coverage through an Exchange. 
(2) CERTIFICATIONS AS TO BENEFIT COVERAGE AND COSTS.— 
Such program shall provide that a State may not establish 
a basic health program under this section unless the State 
establishes to the satisfaction of the Secretary, and the Sec-
retary certifies, that— 
(A) in the case of an eligible individual enrolled in 
a standard health plan offered through the program, the 
State provides— 
(i) that the amount of the monthly premium an 
eligible individual is required to pay for coverage under 
the standard health plan for the individual and the 
individual’s dependents does not exceed the amount 
of the monthly premium that the eligible individual 
would have been required to pay (in the rating area 
in which the individual resides) if the individual had 
42 USC 18051. 
42 USC 18044. 
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124 STAT. 200 
PUBLIC LAW 111–148—MAR. 23, 2010 
enrolled in the applicable second lowest cost silver 
plan (as defined in section 36B(b)(3)(B) of the Internal 
Revenue Code of 1986) offered to the individual 
through an Exchange; and 
(ii) that the cost-sharing an eligible individual is 
required to pay under the standard health plan does 
not exceed— 
(I) the cost-sharing required under a platinum 
plan in the case of an eligible individual with 
household income not in excess of 150 percent 
of the poverty line for the size of the family 
involved; and 
(II) the cost-sharing required under a gold plan 
in the case of an eligible individual not described 
in subclause (I); and 
(B) the benefits provided under the standard health 
plans offered through the program cover at least the essen-
tial health benefits described in section 1302(b). 
For purposes of subparagraph (A)(i), the amount of the monthly 
premium an individual is required to pay under either the 
standard health plan or the applicable second lowest cost silver 
plan shall be determined after reduction for any premium tax 
credits and cost-sharing reductions allowable with respect to 
either plan. 
(b) STANDARD
HEALTH
PLAN.—In this section, the term 
‘‘standard heath plan’’ means a health benefits plan that the State 
contracts with under this section— 
(1) under which the only individuals eligible to enroll are 
eligible individuals; 
(2) that provides at least the essential health benefits 
described in section 1302(b); and 
(3) in the case of a plan that provides health insurance 
coverage offered by a health insurance issuer, that has a med-
ical loss ratio of at least 85 percent. 
(c) CONTRACTING PROCESS.— 
(1) IN GENERAL.—A State basic health program shall estab-
lish a competitive process for entering into contracts with 
standard health plans under subsection (a), including negotia-
tion of premiums and cost-sharing and negotiation of benefits 
in addition to the essential health benefits described in section 
1302(b). 
(2) SPECIFIC ITEMS TO BE CONSIDERED.—A State shall, as 
part of its competitive process under paragraph (1), include 
at least the following: 
(A) INNOVATION.—Negotiation with offerors of a 
standard health plan for the inclusion of innovative fea-
tures in the plan, including— 
(i) care coordination and care management for 
enrollees, especially for those with chronic health 
conditions; 
(ii) incentives for use of preventive services; and 
(iii) the establishment of relationships between 
providers and patients that maximize patient involve-
ment in health care decision-making, including pro-
viding incentives for appropriate utilization under the 
plan. 
Definition. 
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124 STAT. 201 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) HEALTH AND RESOURCE DIFFERENCES.—Consider-
ation of, and the making of suitable allowances for, dif-
ferences in health care needs of enrollees and differences 
in local availability of, and access to, health care providers. 
Nothing in this subparagraph shall be construed as 
allowing discrimination on the basis of pre-existing condi-
tions or other health status-related factors. 
(C) MANAGED CARE.—Contracting with managed care 
systems, or with systems that offer as many of the 
attributes of managed care as are feasible in the local 
health care market. 
(D) PERFORMANCE
MEASURES.—Establishing specific 
performance measures and standards for issuers of 
standard health plans that focus on quality of care and 
improved health outcomes, requiring such plans to report 
to the State with respect to the measures and standards, 
and making the performance and quality information avail-
able to enrollees in a useful form. 
(3) ENHANCED AVAILABILITY.— 
(A) MULTIPLE PLANS.—A State shall, to the maximum 
extent feasible, seek to make multiple standard health 
plans available to eligible individuals within a State to 
ensure individuals have a choice of such plans. 
(B) REGIONAL
COMPACTS.—A State may negotiate a 
regional compact with other States to include coverage 
of eligible individuals in all such States in agreements 
with issuers of standard health plans. 
(4) COORDINATION WITH OTHER STATE PROGRAMS.—A State 
shall seek to coordinate the administration of, and provision 
of benefits under, its program under this section with the 
State medicaid program under title XIX of the Social Security 
Act, the State child health plan under title XXI of such Act, 
and other State-administered health programs to maximize 
the efficiency of such programs and to improve the continuity 
of care. 
(d) TRANSFER OF FUNDS TO STATES.— 
(1) IN GENERAL.—If the Secretary determines that a State 
electing the application of this section meets the requirements 
of the program established under subsection (a), the Secretary 
shall transfer to the State for each fiscal year for which 1 
or more standard health plans are operating within the State 
the amount determined under paragraph (3). 
(2) USE OF FUNDS.—A State shall establish a trust for 
the deposit of the amounts received under paragraph (1) and 
amounts in the trust fund shall only be used to reduce the 
premiums and cost-sharing of, or to provide additional benefits 
for, eligible individuals enrolled in standard health plans within 
the State. Amounts in the trust fund, and expenditures of 
such amounts, shall not be included in determining the amount 
of any non-Federal funds for purposes of meeting any matching 
or expenditure requirement of any federally-funded program. 
(3) AMOUNT OF PAYMENT.— 
(A) SECRETARIAL DETERMINATION.— 
(i) IN GENERAL.—The amount determined under 
this paragraph for any fiscal year is the amount the 
Secretary determines is equal to 85 percent of the 
premium tax credits under section 36B of the Internal 
Determination. 
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124 STAT. 202 
PUBLIC LAW 111–148—MAR. 23, 2010 
Revenue Code of 1986, and the cost-sharing reductions 
under section 1402, that would have been provided 
for the fiscal year to eligible individuals enrolled in 
standard health plans in the State if such eligible 
individuals were allowed to enroll in qualified health 
plans through an Exchange established under this sub-
title. 
(ii) SPECIFIC REQUIREMENTS.—The Secretary shall 
make the determination under clause (i) on a per 
enrollee basis and shall take into account all relevant 
factors necessary to determine the value of the pre-
mium tax credits and cost-sharing reductions that 
would have been provided to eligible individuals 
described in clause (i), including the age and income 
of the enrollee, whether the enrollment is for self- 
only or family coverage, geographic differences in aver-
age spending for health care across rating areas, the 
health status of the enrollee for purposes of deter-
mining risk adjustment payments and reinsurance pay-
ments that would have been made if the enrollee had 
enrolled in a qualified health plan through an 
Exchange, and whether any reconciliation of the credit 
or cost-sharing reductions would have occurred if the 
enrollee had been so enrolled. This determination shall 
take into consideration the experience of other States 
with respect to participation in an Exchange and such 
credits and reductions provided to residents of the 
other States, with a special focus on enrollees with 
income below 200 percent of poverty. 
(iii) CERTIFICATION.—The Chief Actuary of the 
Centers for Medicare & Medicaid Services, in consulta-
tion with the Office of Tax Analysis of the Department 
of the Treasury, shall certify whether the methodology 
used to make determinations under this subparagraph, 
and such determinations, meet the requirements of 
clause (ii). Such certifications shall be based on suffi-
cient data from the State and from comparable States 
about their experience with programs created by this 
Act. 
(B) CORRECTIONS.—The Secretary shall adjust the pay-
ment for any fiscal year to reflect any error in the deter-
minations under subparagraph (A) for any preceding fiscal 
year. 
(4) APPLICATION OF SPECIAL RULES.—The provisions of sec-
tion 1303 shall apply to a State basic health program, and 
to standard health plans offered through such program, in 
the same manner as such rules apply to qualified health plans. 
(e) ELIGIBLE INDIVIDUAL.— 
(1) IN GENERAL.—In this section, the term ‘‘eligible indi-
vidual’’ means, with respect to any State, an individual— 
(A) who a resident of the State who is not eligible 
to enroll in the State’s medicaid program under title XIX 
of the Social Security Act for benefits that at a minimum 
consist of the essential health benefits described in section 
1302(b); 
Definition. 
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124 STAT. 203 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) whose household income exceeds 133 percent but 
does not exceed 200 percent of the poverty line for the 
size of the family involved; 
(C) who is not eligible for minimum essential coverage 
(as defined in section 5000A(f) of the Internal Revenue 
Code of 1986) or is eligible for an employer-sponsored plan 
that is not affordable coverage (as determined under section 
5000A(e)(2) of such Code); and 
(D) who has not attained age 65 as of the beginning 
of the plan year. 
Such term shall not include any individual who is not a quali-
fied individual under section 1312 who is eligible to be covered 
by a qualified health plan offered through an Exchange. 
(2) ELIGIBLE
INDIVIDUALS
MAY
NOT
USE
EXCHANGE.—An 
eligible individual shall not be treated as a qualified individual 
under section 1312 eligible for enrollment in a qualified health 
plan offered through an Exchange established under section 
1311. 
(f) SECRETARIAL OVERSIGHT.—The Secretary shall each year 
conduct a review of each State program to ensure compliance with 
the requirements of this section, including ensuring that the State 
program meets— 
(1) eligibility verification requirements for participation in 
the program; 
(2) the requirements for use of Federal funds received 
by the program; and 
(3) the quality and performance standards under this sec-
tion. 
(g) STANDARD HEALTH PLAN OFFERORS.—A State may provide 
that persons eligible to offer standard health plans under a basic 
health program established under this section may include a 
licensed health maintenance organization, a licensed health insur-
ance insurer, or a network of health care providers established 
to offer services under the program. 
(h) DEFINITIONS.—Any term used in this section which is also 
used in section 36B of the Internal Revenue Code of 1986 shall 
have the meaning given such term by such section. 
SEC. 1332. WAIVER FOR STATE INNOVATION. 
(a) APPLICATION.— 
(1) IN GENERAL.—A State may apply to the Secretary for 
the waiver of all or any requirements described in paragraph 
(2) with respect to health insurance coverage within that State 
for plan years beginning on or after January 1, 2017. Such 
application shall— 
(A) be filed at such time and in such manner as the 
Secretary may require; 
(B) contain such information as the Secretary may 
require, including— 
(i) a comprehensive description of the State legisla-
tion and program to implement a plan meeting the 
requirements for a waiver under this section; and 
(ii) a 10-year budget plan for such plan that is 
budget neutral for the Federal Government; and 
(C) provide an assurance that the State has enacted 
the law described in subsection (b)(2). 
Effective date. 
42 USC 18052. 
Review. 
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124 STAT. 204 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) REQUIREMENTS.—The requirements described in this 
paragraph with respect to health insurance coverage within 
the State for plan years beginning on or after January 1, 
2014, are as follows: 
(A) Part I of subtitle D. 
(B) Part II of subtitle D. 
(C) Section 1402. 
(D) Sections 36B, 4980H, and 5000A of the Internal 
Revenue Code of 1986. 
(3) PASS THROUGH OF FUNDING.—With respect to a State 
waiver under paragraph (1), under which, due to the structure 
of the State plan, individuals and small employers in the State 
would not qualify for the premium tax credits, cost-sharing 
reductions, or small business credits under sections 36B of 
the Internal Revenue Code of 1986 or under part I of subtitle 
E for which they would otherwise be eligible, the Secretary 
shall provide for an alternative means by which the aggregate 
amount of such credits or reductions that would have been 
paid on behalf of participants in the Exchanges established 
under this title had the State not received such waiver, shall 
be paid to the State for purposes of implementing the State 
plan under the waiver. Such amount shall be determined 
annually by the Secretary, taking into consideration the experi-
ence of other States with respect to participation in an 
Exchange and credits and reductions provided under such provi-
sions to residents of the other States. 
(4) WAIVER CONSIDERATION AND TRANSPARENCY.— 
(A) IN GENERAL.—An application for a waiver under 
this section shall be considered by the Secretary in accord-
ance with the regulations described in subparagraph (B). 
(B) REGULATIONS.—Not later than 180 days after the 
date of enactment of this Act, the Secretary shall promul-
gate regulations relating to waivers under this section that 
provide— 
(i) a process for public notice and comment at 
the State level, including public hearings, sufficient 
to ensure a meaningful level of public input; 
(ii) a process for the submission of an application 
that ensures the disclosure of— 
(I) the provisions of law that the State involved 
seeks to waive; and 
(II) the specific plans of the State to ensure 
that the waiver will be in compliance with sub-
section (b); 
(iii) a process for providing public notice and com-
ment after the application is received by the Secretary, 
that is sufficient to ensure a meaningful level of public 
input and that does not impose requirements that are 
in addition to, or duplicative of, requirements imposed 
under the Administrative Procedures Act, or require-
ments that are unreasonable or unnecessarily burden-
some with respect to State compliance; 
(iv) a process for the submission to the Secretary 
of periodic reports by the State concerning the 
implementation of the program under the waiver; and 
(v) a process for the periodic evaluation by the 
Secretary of the program under the waiver. 
Deadline. 
Effective date. 
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124 STAT. 205 
PUBLIC LAW 111–148—MAR. 23, 2010 
(C) REPORT.—The Secretary shall annually report to 
Congress concerning actions taken by the Secretary with 
respect to applications for waivers under this section. 
(5) COORDINATED WAIVER PROCESS.—The Secretary shall 
develop a process for coordinating and consolidating the State 
waiver processes applicable under the provisions of this section, 
and the existing waiver processes applicable under titles XVIII, 
XIX, and XXI of the Social Security Act, and any other Federal 
law relating to the provision of health care items or services. 
Such process shall permit a State to submit a single application 
for a waiver under any or all of such provisions. 
(6) DEFINITION.—In this section, the term ‘‘Secretary’’ 
means— 
(A) the Secretary of Health and Human Services with 
respect to waivers relating to the provisions described in 
subparagraph (A) through (C) of paragraph (2); and 
(B) the Secretary of the Treasury with respect to 
waivers relating to the provisions described in paragraph 
(2)(D). 
(b) GRANTING OF WAIVERS.— 
(1) IN GENERAL.—The Secretary may grant a request for 
a waiver under subsection (a)(1) only if the Secretary deter-
mines that the State plan— 
(A) will provide coverage that is at least as comprehen-
sive as the coverage defined in section 1302(b) and offered 
through Exchanges established under this title as certified 
by Office of the Actuary of the Centers for Medicare & 
Medicaid Services based on sufficient data from the State 
and from comparable States about their experience with 
programs created by this Act and the provisions of this 
Act that would be waived; 
(B) will provide coverage and cost sharing protections 
against excessive out-of-pocket spending that are at least 
as affordable as the provisions of this title would provide; 
(C) will provide coverage to at least a comparable 
number of its residents as the provisions of this title would 
provide; and 
(D) will not increase the Federal deficit. 
(2) REQUIREMENT TO ENACT A LAW.— 
(A) IN GENERAL.—A law described in this paragraph 
is a State law that provides for State actions under a 
waiver under this section, including the implementation 
of the State plan under subsection (a)(1)(B). 
(B) TERMINATION OF OPT OUT.—A State may repeal 
a law described in subparagraph (A) and terminate the 
authority provided under the waiver with respect to the 
State. 
(c) SCOPE OF WAIVER.— 
(1) IN GENERAL.—The Secretary shall determine the scope 
of a waiver of a requirement described in subsection (a)(2) 
granted to a State under subsection (a)(1). 
(2) LIMITATION.—The Secretary may not waive under this 
section any Federal law or requirement that is not within 
the authority of the Secretary. 
(d) DETERMINATIONS BY SECRETARY.— 
(1) TIME FOR DETERMINATION.—The Secretary shall make 
a determination under subsection (a)(1) not later than 180 
Deadline. 
Determination. 
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124 STAT. 206 
PUBLIC LAW 111–148—MAR. 23, 2010 
days after the receipt of an application from a State under 
such subsection. 
(2) EFFECT OF DETERMINATION.— 
(A) GRANTING
OF
WAIVERS.—If the Secretary deter-
mines to grant a waiver under subsection (a)(1), the Sec-
retary shall notify the State involved of such determination 
and the terms and effectiveness of such waiver. 
(B) DENIAL OF WAIVER.—If the Secretary determines 
a waiver should not be granted under subsection (a)(1), 
the Secretary shall notify the State involved, and the appro-
priate committees of Congress of such determination and 
the reasons therefore. 
(e) TERM OF WAIVER.—No waiver under this section may extend 
over a period of longer than 5 years unless the State requests 
continuation of such waiver, and such request shall be deemed 
granted unless the Secretary, within 90 days after the date of 
its submission to the Secretary, either denies such request in 
writing or informs the State in writing with respect to any addi-
tional information which is needed in order to make a final deter-
mination with respect to the request. 
SEC. 1333. PROVISIONS RELATING TO OFFERING OF PLANS IN MORE 
THAN ONE STATE. 
(a) HEALTH CARE CHOICE COMPACTS.— 
(1) IN GENERAL.—Not later than July 1, 2013, the Secretary 
shall, in consultation with the National Association of Insurance 
Commissioners, issue regulations for the creation of health 
care choice compacts under which 2 or more States may enter 
into an agreement under which— 
(A) 1 or more qualified health plans could be offered 
in the individual markets in all such States but, except 
as provided in subparagraph (B), only be subject to the 
laws and regulations of the State in which the plan was 
written or issued; 
(B) the issuer of any qualified health plan to which 
the compact applies— 
(i) would continue to be subject to market conduct, 
unfair trade practices, network adequacy, and con-
sumer protection standards (including standards 
relating to rating), including addressing disputes as 
to the performance of the contract, of the State in 
which the purchaser resides; 
(ii) would be required to be licensed in each State 
in which it offers the plan under the compact or to 
submit to the jurisdiction of each such State with 
regard to the standards described in clause (i) 
(including allowing access to records as if the insurer 
were licensed in the State); and 
(iii) must clearly notify consumers that the policy 
may not be subject to all the laws and regulations 
of the State in which the purchaser resides. 
(2) STATE
AUTHORITY.—A State may not enter into an 
agreement under this subsection unless the State enacts a 
law after the date of the enactment of this title that specifically 
authorizes the State to enter into such agreements. 
(3) APPROVAL OF COMPACTS.—The Secretary may approve 
interstate health care choice compacts under paragraph (1) 
Notification. 
Deadline. 
Regulations. 
42 USC 18053. 
Deadline. 
Notification. 
Notification. 
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124 STAT. 207 
PUBLIC LAW 111–148—MAR. 23, 2010 
only if the Secretary determines that such health care choice 
compact— 
(A) will provide coverage that is at least as comprehen-
sive as the coverage defined in section 1302(b) and offered 
through Exchanges established under this title; 
(B) will provide coverage and cost sharing protections 
against excessive out-of-pocket spending that are at least 
as affordable as the provisions of this title would provide; 
(C) will provide coverage to at least a comparable 
number of its residents as the provisions of this title would 
provide; 
(D) will not increase the Federal deficit; and 
(E) will not weaken enforcement of laws and regula-
tions described in paragraph (1)(B)(i) in any State that 
is included in such compact. 
(4) EFFECTIVE
DATE.—A health care choice compact 
described in paragraph (1) shall not take effect before January 
1, 2016. 
(b) AUTHORITY FOR NATIONWIDE PLANS.— 
(1) IN GENERAL.—Except as provided in paragraph (2), if 
an issuer (including a group of health insurance issuers affili-
ated either by common ownership and control or by the common 
use of a nationally licensed service mark) of a qualified health 
plan in the individual or small group market meets the require-
ments of this subsection (in this subsection a ‘‘nationwide quali-
fied health plan’’)— 
(A) the issuer of the plan may offer the nationwide 
qualified health plan in the individual or small group 
market in more than 1 State; and 
(B) with respect to State laws mandating benefit cov-
erage by a health plan, only the State laws of the State 
in which such plan is written or issued shall apply to 
the nationwide qualified health plan. 
(2) STATE
OPT-OUT.—A State may, by specific reference 
in a law enacted after the date of enactment of this title, 
provide that this subsection shall not apply to that State. 
Such opt-out shall be effective until such time as the State 
by law revokes it. 
(3) PLAN
REQUIREMENTS.—An issuer meets the require-
ments of this subsection with respect to a nationwide qualified 
health plan if, in the determination of the Secretary— 
(A) the plan offers a benefits package that is uniform 
in each State in which the plan is offered and meets the 
requirements set forth in paragraphs (4) through (6); 
(B) the issuer is licensed in each State in which it 
offers the plan and is subject to all requirements of State 
law not inconsistent with this section, including but not 
limited to, the standards and requirements that a State 
imposes that do not prevent the application of a require-
ment of part A of title XXVII of the Public Health Service 
Act or a requirement of this title; 
(C) the issuer meets all requirements of this title with 
respect to a qualified health plan, including the require-
ment to offer the silver and gold levels of the plan in 
each Exchange in the State for the market in which the 
plan is offered; 
Applicability. 
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124 STAT. 208 
PUBLIC LAW 111–148—MAR. 23, 2010 
(D) the issuer determines the premiums for the plan 
in any State on the basis of the rating rules in effect 
in that State for the rating areas in which it is offered; 
(E) the issuer offers the nationwide qualified health 
plan in at least 60 percent of the participating States 
in the first year in which the plan is offered, 65 percent 
of such States in the second year, 70 percent of such 
States in the third year, 75 percent of such States in 
the fourth year, and 80 percent of such States in the 
fifth and subsequent years; 
(F) the issuer shall offer the plan in participating 
States across the country, in all geographic regions, and 
in all States that have adopted adjusted community rating 
before the date of enactment of this Act; and 
(G) the issuer clearly notifies consumers that the policy 
may not contain some benefits otherwise mandated for 
plans in the State in which the purchaser resides and 
provides a detailed statement of the benefits offered and 
the benefit differences in that State, in accordance with 
rules promulgated by the Secretary. 
(4) FORM
REVIEW
FOR
NATIONWIDE
PLANS.—Notwith-
standing any contrary provision of State law, at least 3 months 
before any nationwide qualified health plan is offered, the 
issuer shall file all nationwide qualified health plan forms 
with the regulator in each participating State in which the 
plan will be offered. An issuer may appeal the disapproval 
of a nationwide qualified health plan form to the Secretary. 
(5) APPLICABLE RULES.—The Secretary shall, in consulta-
tion with the National Association of Insurance Commissioners, 
issue rules for the offering of nationwide qualified health plans 
under this subsection. Nationwide qualified health plans may 
be offered only after such rules have taken effect. 
(6) COVERAGE.—The Secretary shall provide that the health 
benefits coverage provided to an individual through a nation-
wide qualified health plan under this subsection shall include 
at least the essential benefits package described in section 
1302. 
(7) STATE LAW MANDATING BENEFIT COVERAGE BY A HEALTH 
BENEFITS PLAN.—For the purposes of this subsection, a State 
law mandating benefit coverage by a health plan is a law 
that mandates health insurance coverage or the offer of health 
insurance coverage for specific health services or specific dis-
eases. A law that mandates health insurance coverage or 
reimbursement for services provided by certain classes of pro-
viders of health care services, or a law that mandates that 
certain classes of individuals must be covered as a group or 
as dependents, is not a State law mandating benefit coverage 
by a health benefits plan. 
PART V—REINSURANCE AND RISK 
ADJUSTMENT 
SEC. 1341. TRANSITIONAL REINSURANCE PROGRAM FOR INDIVIDUAL 
AND SMALL GROUP MARKETS IN EACH STATE. 
(a) IN GENERAL.—Each State shall, not later than January 
1, 2014— 
Deadline. 
42 USC 18061. 
Deadline. 
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124 STAT. 209 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) include in the Federal standards or State law or regula-
tion the State adopts and has in effect under section 1321(b) 
the provisions described in subsection (b); and 
(2) establish (or enter into a contract with) 1 or more 
applicable reinsurance entities to carry out the reinsurance 
program under this section. 
(b) MODEL REGULATION.— 
(1) IN
GENERAL.—In establishing the Federal standards 
under section 1321(a), the Secretary, in consultation with the 
National Association of Insurance Commissioners (the ‘‘NAIC’’), 
shall include provisions that enable States to establish and 
maintain a program under which— 
(A) health insurance issuers, and third party adminis-
trators on behalf of group health plans, are required to 
make payments to an applicable reinsurance entity for 
any plan year beginning in the 3-year period beginning 
January 1, 2014 (as specified in paragraph (3); and 
(B) the applicable reinsurance entity collects payments 
under subparagraph (A) and uses amounts so collected 
to make reinsurance payments to health insurance issuers 
described in subparagraph (A) that cover high risk individ-
uals in the individual market (excluding grandfathered 
health plans) for any plan year beginning in such 3-year 
period. 
(2) HIGH-RISK INDIVIDUAL; PAYMENT AMOUNTS.—The Sec-
retary shall include the following in the provisions under para-
graph (1): 
(A) DETERMINATION OF HIGH-RISK INDIVIDUALS.—The 
method by which individuals will be identified as high 
risk individuals for purposes of the reinsurance program 
established under this section. Such method shall provide 
for identification of individuals as high-risk individuals 
on the basis of— 
(i) a list of at least 50 but not more than 100 
medical conditions that are identified as high-risk 
conditions and that may be based on the identification 
of diagnostic and procedure codes that are indicative 
of individuals with pre-existing, high-risk conditions; 
or 
(ii) any other comparable objective method of 
identification recommended by the American Academy 
of Actuaries. 
(B) PAYMENT AMOUNT.—The formula for determining 
the amount of payments that will be paid to health insur-
ance issuers described in paragraph (1)(A) that insure high- 
risk individuals. Such formula shall provide for the equi-
table allocation of available funds through reconciliation 
and may be designed— 
(i) to provide a schedule of payments that specifies 
the amount that will be paid for each of the conditions 
identified under subparagraph (A); or 
(ii) to use any other comparable method for deter-
mining payment amounts that is recommended by the 
American Academy of Actuaries and that encourages 
the use of care coordination and care management 
programs for high risk conditions. 
(3) DETERMINATION OF REQUIRED CONTRIBUTIONS.— 
Effective date. 
Time period. 
Contracts. 
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124 STAT. 210 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) IN GENERAL.—The Secretary shall include in the 
provisions under paragraph (1) the method for determining 
the amount each health insurance issuer and group health 
plan described in paragraph (1)(A) contributing to the 
reinsurance program under this section is required to con-
tribute under such paragraph for each plan year beginning 
in the 36-month period beginning January 1, 2014. The 
contribution amount for any plan year may be based on 
the percentage of revenue of each issuer and the total 
costs of providing benefits to enrollees in self-insured plans 
or on a specified amount per enrollee and may be required 
to be paid in advance or periodically throughout the plan 
year. 
(B) SPECIFIC REQUIREMENTS.—The method under this 
paragraph shall be designed so that— 
(i) the contribution amount for each issuer propor-
tionally reflects each issuer’s fully insured commercial 
book of business for all major medical products and 
the total value of all fees charged by the issuer and 
the costs of coverage administered by the issuer as 
a third party administrator; 
(ii) the contribution amount can include an addi-
tional amount to fund the administrative expenses of 
the applicable reinsurance entity; 
(iii) the aggregate contribution amounts for all 
States shall, based on the best estimates of the NAIC 
and without regard to amounts described in clause 
(ii), equal $10,000,000,000 for plan years beginning 
in 2014, $6,000,000,000 for plan years beginning 2015, 
and $4,000,000,000 for plan years beginning in 2016; 
and 
(iv) in addition to the aggregate contribution 
amounts under clause (iii), each issuer’s contribution 
amount for any calendar year under clause (iii) reflects 
its proportionate share of an additional $2,000,000,000 
for 2014, an additional $2,000,000,000 for 2015, and 
an additional $1,000,000,000 for 2016. 
Nothing in this subparagraph shall be construed to pre-
clude a State from collecting additional amounts from 
issuers on a voluntary basis. 
(4) EXPENDITURE OF FUNDS.—The provisions under para-
graph (1) shall provide that— 
(A) the contribution amounts collected for any calendar 
year may be allocated and used in any of the three calendar 
years for which amounts are collected based on the reinsur-
ance needs of a particular period or to reflect experience 
in a prior period; and 
(B) amounts remaining unexpended as of December, 
2016, may be used to make payments under any reinsur-
ance program of a State in the individual market in effect 
in the 2-year period beginning on January 1, 2017. 
Notwithstanding the preceding sentence, any contribution 
amounts described in paragraph (3)(B)(iv) shall be deposited 
into the general fund of the Treasury of the United States 
and may not be used for the program established under this 
section. 
Time period. 
Effective date. 
Effective date. 
Time period. 
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124 STAT. 211 
PUBLIC LAW 111–148—MAR. 23, 2010 
(c) APPLICABLE REINSURANCE ENTITY.—For purposes of this 
section— 
(1) IN GENERAL.—The term ‘‘applicable reinsurance entity’’ 
means a not-for-profit organization— 
(A) the purpose of which is to help stabilize premiums 
for coverage in the individual and small group markets 
in a State during the first 3 years of operation of an 
Exchange for such markets within the State when the 
risk of adverse selection related to new rating rules and 
market changes is greatest; and 
(B) the duties of which shall be to carry out the reinsur-
ance program under this section by coordinating the 
funding and operation of the risk-spreading mechanisms 
designed to implement the reinsurance program. 
(2) STATE DISCRETION.—A State may have more than 1 
applicable reinsurance entity to carry out the reinsurance pro-
gram under this section within the State and 2 or more States 
may enter into agreements to provide for an applicable reinsur-
ance entity to carry out such program in all such States. 
(3) ENTITIES ARE TAX-EXEMPT.—An applicable reinsurance 
entity established under this section shall be exempt from 
taxation under chapter 1 of the Internal Revenue Code of 
1986. The preceding sentence shall not apply to the tax imposed 
by section 511 such Code (relating to tax on unrelated business 
taxable income of an exempt organization). 
(d) COORDINATION WITH STATE HIGH-RISK POOLS.—The State 
shall eliminate or modify any State high-risk pool to the extent 
necessary to carry out the reinsurance program established under 
this section. The State may coordinate the State high-risk pool 
with such program to the extent not inconsistent with the provisions 
of this section. 
SEC. 1342. ESTABLISHMENT OF RISK CORRIDORS FOR PLANS IN INDI-
VIDUAL AND SMALL GROUP MARKETS. 
(a) IN GENERAL.—The Secretary shall establish and administer 
a program of risk corridors for calendar years 2014, 2015, and 
2016 under which a qualified health plan offered in the individual 
or small group market shall participate in a payment adjustment 
system based on the ratio of the allowable costs of the plan to 
the plan’s aggregate premiums. Such program shall be based on 
the program for regional participating provider organizations under 
part D of title XVIII of the Social Security Act. 
(b) PAYMENT METHODOLOGY.— 
(1) PAYMENTS OUT.—The Secretary shall provide under the 
program established under subsection (a) that if— 
(A) a participating plan’s allowable costs for any plan 
year are more than 103 percent but not more than 108 
percent of the target amount, the Secretary shall pay to 
the plan an amount equal to 50 percent of the target 
amount in excess of 103 percent of the target amount; 
and 
(B) a participating plan’s allowable costs for any plan 
year are more than 108 percent of the target amount, 
the Secretary shall pay to the plan an amount equal to 
the sum of 2.5 percent of the target amount plus 80 percent 
of allowable costs in excess of 108 percent of the target 
amount. 
42 USC 18062. 
Definition. 
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124 STAT. 212 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) PAYMENTS IN.—The Secretary shall provide under the 
program established under subsection (a) that if— 
(A) a participating plan’s allowable costs for any plan 
year are less than 97 percent but not less than 92 percent 
of the target amount, the plan shall pay to the Secretary 
an amount equal to 50 percent of the excess of 97 percent 
of the target amount over the allowable costs; and 
(B) a participating plan’s allowable costs for any plan 
year are less than 92 percent of the target amount, the 
plan shall pay to the Secretary an amount equal to the 
sum of 2.5 percent of the target amount plus 80 percent 
of the excess of 92 percent of the target amount over 
the allowable costs. 
(c) DEFINITIONS.—In this section: 
(1) ALLOWABLE COSTS.— 
(A) IN GENERAL.—The amount of allowable costs of 
a plan for any year is an amount equal to the total costs 
(other than administrative costs) of the plan in providing 
benefits covered by the plan. 
(B) REDUCTION FOR RISK ADJUSTMENT AND REINSUR-
ANCE
PAYMENTS.—Allowable costs shall reduced by any 
risk adjustment and reinsurance payments received under 
section 1341 and 1343. 
(2) TARGET
AMOUNT.—The target amount of a plan for 
any year is an amount equal to the total premiums (including 
any premium subsidies under any governmental program), 
reduced by the administrative costs of the plan. 
SEC. 1343. RISK ADJUSTMENT. 
(a) IN GENERAL.— 
(1) LOW ACTUARIAL RISK PLANS.—Using the criteria and 
methods developed under subsection (b), each State shall assess 
a charge on health plans and health insurance issuers (with 
respect to health insurance coverage) described in subsection 
(c) if the actuarial risk of the enrollees of such plans or coverage 
for a year is less than the average actuarial risk of all enrollees 
in all plans or coverage in such State for such year that are 
not self-insured group health plans (which are subject to the 
provisions of the Employee Retirement Income Security Act 
of 1974). 
(2) HIGH ACTUARIAL RISK PLANS.—Using the criteria and 
methods developed under subsection (b), each State shall pro-
vide a payment to health plans and health insurance issuers 
(with respect to health insurance coverage) described in sub-
section (c) if the actuarial risk of the enrollees of such plans 
or coverage for a year is greater than the average actuarial 
risk of all enrollees in all plans and coverage in such State 
for such year that are not self-insured group health plans 
(which are subject to the provisions of the Employee Retirement 
Income Security Act of 1974). 
(b) CRITERIA AND METHODS.—The Secretary, in consultation 
with States, shall establish criteria and methods to be used in 
carrying out the risk adjustment activities under this section. The 
Secretary may utilize criteria and methods similar to the criteria 
and methods utilized under part C or D of title XVIII of the 
Social Security Act. Such criteria and methods shall be included 
42 USC 18063. 
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124 STAT. 213 
PUBLIC LAW 111–148—MAR. 23, 2010 
in the standards and requirements the Secretary prescribes under 
section 1321. 
(c) SCOPE.—A health plan or a health insurance issuer is 
described in this subsection if such health plan or health insurance 
issuer provides coverage in the individual or small group market 
within the State. This subsection shall not apply to a grandfathered 
health plan or the issuer of a grandfathered health plan with 
respect to that plan. 
Subtitle E—Affordable Coverage Choices 
for All Americans 
PART I—PREMIUM TAX CREDITS AND COST- 
SHARING REDUCTIONS 
Subpart A—Premium Tax Credits and Cost- 
sharing Reductions 
SEC. 1401. REFUNDABLE TAX CREDIT PROVIDING PREMIUM ASSIST-
ANCE FOR COVERAGE UNDER A QUALIFIED HEALTH 
PLAN. 
(a) IN GENERAL.—Subpart C of part IV of subchapter A of 
chapter 1 of the Internal Revenue Code of 1986 (relating to refund-
able credits) is amended by inserting after section 36A the following 
new section: 
‘‘SEC. 36B. REFUNDABLE CREDIT FOR COVERAGE UNDER A QUALIFIED 
HEALTH PLAN. 
‘‘(a) IN GENERAL.—In the case of an applicable taxpayer, there 
shall be allowed as a credit against the tax imposed by this subtitle 
for any taxable year an amount equal to the premium assistance 
credit amount of the taxpayer for the taxable year. 
‘‘(b) PREMIUM ASSISTANCE CREDIT AMOUNT.—For purposes of 
this section— 
‘‘(1) IN
GENERAL.—The term ‘premium assistance credit 
amount’ means, with respect to any taxable year, the sum 
of the premium assistance amounts determined under para-
graph (2) with respect to all coverage months of the taxpayer 
occurring during the taxable year. 
‘‘(2) PREMIUM ASSISTANCE AMOUNT.—The premium assist-
ance amount determined under this subsection with respect 
to any coverage month is the amount equal to the lesser of— 
‘‘(A) the monthly premiums for such month for 1 or 
more qualified health plans offered in the individual market 
within a State which cover the taxpayer, the taxpayer’s 
spouse, or any dependent (as defined in section 152) of 
the taxpayer and which were enrolled in through an 
Exchange established by the State under 1311 of the 
Patient Protection and Affordable Care Act, or 
‘‘(B) the excess (if any) of— 
‘‘(i) the adjusted monthly premium for such month 
for the applicable second lowest cost silver plan with 
respect to the taxpayer, over 
Definition. 
26 USC 36. 
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124 STAT. 214 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(ii) an amount equal to 1/12 of the product of 
the applicable percentage and the taxpayer’s household 
income for the taxable year. 
‘‘(3) OTHER TERMS AND RULES RELATING TO PREMIUM ASSIST-
ANCE AMOUNTS.—For purposes of paragraph (2)— 
‘‘(A) APPLICABLE PERCENTAGE.— 
‘‘(i) IN
GENERAL.—Except as provided in clause 
(ii), the applicable percentage with respect to any tax-
payer for any taxable year is equal to 2.8 percent, 
increased by the number of percentage points (not 
greater than 7) which bears the same ratio to 7 percent-
age points as— 
‘‘(I) the taxpayer’s household income for the 
taxable year in excess of 100 percent of the poverty 
line for a family of the size involved, bears to 
‘‘(II) an amount equal to 200 percent of the 
poverty line for a family of the size involved. 
‘‘(ii) SPECIAL RULE FOR TAXPAYERS UNDER 133 PER-
CENT
OF
POVERTY
LINE.—If a taxpayer’s household 
income for the taxable year is in excess of 100 percent, 
but not more than 133 percent, of the poverty line 
for a family of the size involved, the taxpayer’s 
applicable percentage shall be 2 percent. 
‘‘(iii) INDEXING.—In the case of taxable years begin-
ning in any calendar year after 2014, the Secretary 
shall adjust the initial and final applicable percentages 
under clause (i), and the 2 percent under clause (ii), 
for the calendar year to reflect the excess of the rate 
of premium growth between the preceding calendar 
year and 2013 over the rate of income growth for 
such period. 
‘‘(B) APPLICABLE SECOND LOWEST COST SILVER PLAN.— 
The applicable second lowest cost silver plan with respect 
to any applicable taxpayer is the second lowest cost silver 
plan of the individual market in the rating area in which 
the taxpayer resides which— 
‘‘(i) is offered through the same Exchange through 
which the qualified health plans taken into account 
under paragraph (2)(A) were offered, and 
‘‘(ii) provides— 
‘‘(I) self-only coverage in the case of an 
applicable taxpayer— 
‘‘(aa) whose tax for the taxable year is 
determined under section 1(c) (relating to 
unmarried individuals other than surviving 
spouses and heads of households) and who 
is not allowed a deduction under section 151 
for the taxable year with respect to a 
dependent, or 
‘‘(bb) who is not described in item (aa) 
but who purchases only self-only coverage, and 
‘‘(II) family coverage in the case of any other 
applicable taxpayer. 
If a taxpayer files a joint return and no credit is allowed 
under this section with respect to 1 of the spouses by 
reason of subsection (e), the taxpayer shall be treated as 
described in clause (ii)(I) unless a deduction is allowed 
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124 STAT. 215 
PUBLIC LAW 111–148—MAR. 23, 2010 
under section 151 for the taxable year with respect to 
a dependent other than either spouse and subsection (e) 
does not apply to the dependent. 
‘‘(C) ADJUSTED
MONTHLY
PREMIUM.—The adjusted 
monthly premium for an applicable second lowest cost 
silver plan is the monthly premium which would have 
been charged (for the rating area with respect to which 
the premiums under paragraph (2)(A) were determined) 
for the plan if each individual covered under a qualified 
health plan taken into account under paragraph (2)(A) 
were covered by such silver plan and the premium was 
adjusted only for the age of each such individual in the 
manner allowed under section 2701 of the Public Health 
Service Act. In the case of a State participating in the 
wellness discount demonstration project under section 
2705(d) of the Public Health Service Act, the adjusted 
monthly premium shall be determined without regard to 
any premium discount or rebate under such project. 
‘‘(D) ADDITIONAL BENEFITS.—If— 
‘‘(i) a qualified health plan under section 1302(b)(5) 
of the Patient Protection and Affordable Care Act offers 
benefits in addition to the essential health benefits 
required to be provided by the plan, or 
‘‘(ii) a State requires a qualified health plan under 
section 1311(d)(3)(B) of such Act to cover benefits in 
addition to the essential health benefits required to 
be provided by the plan, 
the portion of the premium for the plan properly allocable 
(under rules prescribed by the Secretary of Health and 
Human Services) to such additional benefits shall not be 
taken into account in determining either the monthly pre-
mium or the adjusted monthly premium under paragraph 
(2). 
‘‘(E) SPECIAL RULE FOR PEDIATRIC DENTAL COVERAGE.— 
For purposes of determining the amount of any monthly 
premium, if an individual enrolls in both a qualified health 
plan and a plan described in section 1311(d)(2)(B)(ii)(I) 
of the Patient Protection and Affordable Care Act for any 
plan year, the portion of the premium for the plan described 
in such section that (under regulations prescribed by the 
Secretary) is properly allocable to pediatric dental benefits 
which are included in the essential health benefits required 
to be provided by a qualified health plan under section 
1302(b)(1)(J) of such Act shall be treated as a premium 
payable for a qualified health plan. 
‘‘(c) DEFINITION
AND RULES RELATING
TO APPLICABLE TAX-
PAYERS, COVERAGE MONTHS, AND QUALIFIED HEALTH PLAN.—For 
purposes of this section— 
‘‘(1) APPLICABLE TAXPAYER.— 
‘‘(A) IN
GENERAL.—The term ‘applicable taxpayer’ 
means, with respect to any taxable year, a taxpayer whose 
household income for the taxable year exceeds 100 percent 
but does not exceed 400 percent of an amount equal to 
the poverty line for a family of the size involved. 
‘‘(B) SPECIAL RULE FOR CERTAIN INDIVIDUALS LAWFULLY 
PRESENT IN THE UNITED STATES.—If— 
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124 STAT. 216 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) a taxpayer has a household income which is 
not greater than 100 percent of an amount equal to 
the poverty line for a family of the size involved, and 
‘‘(ii) the taxpayer is an alien lawfully present in 
the United States, but is not eligible for the medicaid 
program under title XIX of the Social Security Act 
by reason of such alien status, 
the taxpayer shall, for purposes of the credit under this 
section, be treated as an applicable taxpayer with a house-
hold income which is equal to 100 percent of the poverty 
line for a family of the size involved. 
‘‘(C) MARRIED
COUPLES
MUST
FILE
JOINT
RETURN.— 
If the taxpayer is married (within the meaning of section 
7703) at the close of the taxable year, the taxpayer shall 
be treated as an applicable taxpayer only if the taxpayer 
and the taxpayer’s spouse file a joint return for the taxable 
year. 
‘‘(D) DENIAL
OF
CREDIT
TO
DEPENDENTS.—No credit 
shall be allowed under this section to any individual with 
respect to whom a deduction under section 151 is allowable 
to another taxpayer for a taxable year beginning in the 
calendar year in which such individual’s taxable year 
begins. 
‘‘(2) COVERAGE MONTH.—For purposes of this subsection— 
‘‘(A) IN GENERAL.—The term ‘coverage month’ means, 
with respect to an applicable taxpayer, any month if— 
‘‘(i) as of the first day of such month the taxpayer, 
the taxpayer’s spouse, or any dependent of the taxpayer 
is covered by a qualified health plan described in sub-
section (b)(2)(A) that was enrolled in through an 
Exchange established by the State under section 1311 
of the Patient Protection and Affordable Care Act, and 
‘‘(ii) the premium for coverage under such plan 
for such month is paid by the taxpayer (or through 
advance payment of the credit under subsection (a) 
under section 1412 of the Patient Protection and 
Affordable Care Act). 
‘‘(B) EXCEPTION FOR MINIMUM ESSENTIAL COVERAGE.— 
‘‘(i) IN GENERAL.—The term ‘coverage month’ shall 
not include any month with respect to an individual 
if for such month the individual is eligible for minimum 
essential coverage other than eligibility for coverage 
described in section 5000A(f)(1)(C) (relating to coverage 
in the individual market). 
‘‘(ii) MINIMUM
ESSENTIAL
COVERAGE.—The term 
‘minimum essential coverage’ has the meaning given 
such term by section 5000A(f). 
‘‘(C) SPECIAL RULE FOR EMPLOYER-SPONSORED MINIMUM 
ESSENTIAL COVERAGE.—For purposes of subparagraph (B)— 
‘‘(i) COVERAGE MUST BE AFFORDABLE.—Except as 
provided in clause (iii), an employee shall not be 
treated as eligible for minimum essential coverage if 
such coverage— 
‘‘(I) consists of an eligible employer-sponsored 
plan (as defined in section 5000A(f)(2)), and 
‘‘(II) the employee’s required contribution 
(within the meaning of section 5000A(e)(1)(B)) with 
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124 STAT. 217 
PUBLIC LAW 111–148—MAR. 23, 2010 
respect to the plan exceeds 9.8 percent of the 
applicable taxpayer’s household income. 
This clause shall also apply to an individual who is 
eligible to enroll in the plan by reason of a relationship 
the individual bears to the employee. 
‘‘(ii) COVERAGE MUST PROVIDE MINIMUM VALUE.— 
Except as provided in clause (iii), an employee shall 
not be treated as eligible for minimum essential cov-
erage if such coverage consists of an eligible employer- 
sponsored plan (as defined in section 5000A(f)(2)) and 
the plan’s share of the total allowed costs of benefits 
provided under the plan is less than 60 percent of 
such costs. 
‘‘(iii) EMPLOYEE OR FAMILY MUST NOT BE COVERED 
UNDER EMPLOYER PLAN.—Clauses (i) and (ii) shall not 
apply if the employee (or any individual described in 
the last sentence of clause (i)) is covered under the 
eligible employer-sponsored plan or the grandfathered 
health plan. 
‘‘(iv) INDEXING.—In the case of plan years begin-
ning in any calendar year after 2014, the Secretary 
shall adjust the 9.8 percent under clause (i)(II) in the 
same manner as the percentages are adjusted under 
subsection (b)(3)(A)(ii). 
‘‘(3) DEFINITIONS AND OTHER RULES.— 
‘‘(A) QUALIFIED
HEALTH
PLAN.—The term ‘qualified 
health plan’ has the meaning given such term by section 
1301(a) of the Patient Protection and Affordable Care Act, 
except that such term shall not include a qualified health 
plan which is a catastrophic plan described in section 
1302(e) of such Act. 
‘‘(B) GRANDFATHERED HEALTH PLAN.—The term ‘grand-
fathered health plan’ has the meaning given such term 
by section 1251 of the Patient Protection and Affordable 
Care Act. 
‘‘(d) TERMS RELATING TO INCOME AND FAMILIES.—For purposes 
of this section— 
‘‘(1) FAMILY SIZE.—The family size involved with respect 
to any taxpayer shall be equal to the number of individuals 
for whom the taxpayer is allowed a deduction under section 
151 (relating to allowance of deduction for personal exemptions) 
for the taxable year. 
‘‘(2) HOUSEHOLD INCOME.— 
‘‘(A) 
HOUSEHOLD
INCOME.—The 
term 
‘household 
income’ means, with respect to any taxpayer, an amount 
equal to the sum of— 
‘‘(i) the modified gross income of the taxpayer, 
plus 
‘‘(ii) the aggregate modified gross incomes of all 
other individuals who— 
‘‘(I) were taken into account in determining 
the taxpayer’s family size under paragraph (1), 
and 
‘‘(II) were required to file a return of tax 
imposed by section 1 for the taxable year. 
‘‘(B) MODIFIED
GROSS
INCOME.—The term ‘modified 
gross income’ means gross income— 
Applicability. 
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124 STAT. 218 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) decreased by the amount of any deduction 
allowable under paragraph (1), (3), (4), or (10) of section 
62(a), 
‘‘(ii) increased by the amount of interest received 
or accrued during the taxable year which is exempt 
from tax imposed by this chapter, and 
‘‘(iii) determined without regard to sections 911, 
931, and 933. 
‘‘(3) POVERTY LINE.— 
‘‘(A) IN
GENERAL.—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)). 
‘‘(B) POVERTY LINE USED.—In the case of any qualified 
health plan offered through an Exchange for coverage 
during a taxable year beginning in a calendar year, the 
poverty line used shall be the most recently published 
poverty line as of the 1st day of the regular enrollment 
period for coverage during such calendar year. 
‘‘(e) RULES FOR INDIVIDUALS NOT LAWFULLY PRESENT.— 
‘‘(1) IN GENERAL.—If 1 or more individuals for whom a 
taxpayer is allowed a deduction under section 151 (relating 
to allowance of deduction for personal exemptions) for the tax-
able year (including the taxpayer or his spouse) are individuals 
who are not lawfully present— 
‘‘(A) the aggregate amount of premiums otherwise 
taken into account under clauses (i) and (ii) of subsection 
(b)(2)(A) shall be reduced by the portion (if any) of such 
premiums which is attributable to such individuals, and 
‘‘(B) for purposes of applying this section, the deter-
mination as to what percentage a taxpayer’s household 
income bears to the poverty level for a family of the size 
involved shall be made under one of the following methods: 
‘‘(i) A method under which— 
‘‘(I) the taxpayer’s family size is determined 
by not taking such individuals into account, and 
‘‘(II) the taxpayer’s household income is equal 
to the product of the taxpayer’s household income 
(determined without regard to this subsection) and 
a fraction— 
‘‘(aa) the numerator of which is the pov-
erty line for the taxpayer’s family size deter-
mined after application of subclause (I), and 
‘‘(bb) the denominator of which is the pov-
erty line for the taxpayer’s family size deter-
mined without regard to subclause (I). 
‘‘(ii) A comparable method reaching the same result 
as the method under clause (i). 
‘‘(2) LAWFULLY PRESENT.—For purposes of this section, an 
individual shall be treated as lawfully present only if the indi-
vidual is, and is reasonably expected to be for the entire period 
of enrollment for which the credit under this section is being 
claimed, a citizen or national of the United States or an alien 
lawfully present in the United States. 
‘‘(3) SECRETARIAL AUTHORITY.—The Secretary of Health and 
Human Services, in consultation with the Secretary, shall pre-
scribe rules setting forth the methods by which calculations 
of family size and household income are made for purposes 
Regulations. 
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124 STAT. 219 
PUBLIC LAW 111–148—MAR. 23, 2010 
of this subsection. Such rules shall be designed to ensure that 
the least burden is placed on individuals enrolling in qualified 
health plans through an Exchange and taxpayers eligible for 
the credit allowable under this section. 
‘‘(f) RECONCILIATION OF CREDIT AND ADVANCE CREDIT.— 
‘‘(1) IN GENERAL.—The amount of the credit allowed under 
this section for any taxable year shall be reduced (but not 
below zero) by the amount of any advance payment of such 
credit under section 1412 of the Patient Protection and Afford-
able Care Act. 
‘‘(2) EXCESS ADVANCE PAYMENTS.— 
‘‘(A) IN GENERAL.—If the advance payments to a tax-
payer under section 1412 of the Patient Protection and 
Affordable Care Act for a taxable year exceed the credit 
allowed by this section (determined without regard to para-
graph (1)), the tax imposed by this chapter for the taxable 
year shall be increased by the amount of such excess. 
‘‘(B) LIMITATION
ON
INCREASE
WHERE
INCOME
LESS 
THAN 400 PERCENT OF POVERTY LINE.— 
‘‘(i) IN GENERAL.—In the case of an applicable tax-
payer whose household income is less than 400 percent 
of the poverty line for the size of the family involved 
for the taxable year, the amount of the increase under 
subparagraph (A) shall in no event exceed $400 ($250 
in the case of a taxpayer whose tax is determined 
under section 1(c) for the taxable year). 
‘‘(ii) INDEXING
OF
AMOUNT.—In the case of any 
calendar year beginning after 2014, each of the dollar 
amounts under clause (i) shall be increased by an 
amount equal to— 
‘‘(I) such dollar amount, multiplied by 
‘‘(II) the cost-of-living adjustment determined 
under section 1(f)(3) for the calendar year, deter-
mined by substituting ‘calendar year 2013’ for ‘cal-
endar year 1992’ in subparagraph (B) thereof. 
If the amount of any increase under clause (i) is not 
a multiple of $50, such increase shall be rounded to 
the next lowest multiple of $50. 
‘‘(g) REGULATIONS.—The Secretary shall prescribe such regula-
tions as may be necessary to carry out the provisions of this section, 
including regulations which provide for— 
‘‘(1) the coordination of the credit allowed under this section 
with the program for advance payment of the credit under 
section 1412 of the Patient Protection and Affordable Care 
Act, and 
‘‘(2) the application of subsection (f) where the filing status 
of the taxpayer for a taxable year is different from such status 
used for determining the advance payment of the credit.’’. 
(b) DISALLOWANCE
OF
DEDUCTION.—Section 280C of the 
Internal Revenue Code of 1986 is amended by adding at the end 
the following new subsection: 
‘‘(g) CREDIT FOR HEALTH INSURANCE PREMIUMS.—No deduction 
shall be allowed for the portion of the premiums paid by the 
taxpayer for coverage of 1 or more individuals under a qualified 
health plan which is equal to the amount of the credit determined 
for the taxable year under section 36B(a) with respect to such 
premiums.’’. 
26 USC 280C. 
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124 STAT. 220 
PUBLIC LAW 111–148—MAR. 23, 2010 
(c) STUDY ON AFFORDABLE COVERAGE.— 
(1) STUDY AND REPORT.— 
(A) IN
GENERAL.—Not later than 5 years after the 
date of the enactment of this Act, the Comptroller General 
shall conduct a study on the affordability of health insur-
ance coverage, including— 
(i) the impact of the tax credit for qualified health 
insurance coverage of individuals under section 36B 
of the Internal Revenue Code of 1986 and the tax 
credit for employee health insurance expenses of small 
employers under section 45R of such Code on 
maintaining and expanding the health insurance cov-
erage of individuals; 
(ii) the availability of affordable health benefits 
plans, including a study of whether the percentage 
of household income used for purposes of section 
36B(c)(2)(C) of the Internal Revenue Code of 1986 (as 
added by this section) is the appropriate level for deter-
mining whether employer-provided coverage is afford-
able for an employee and whether such level may 
be lowered without significantly increasing the costs 
to the Federal Government and reducing employer- 
provided coverage; and 
(iii) the ability of individuals to maintain essential 
health benefits coverage (as defined in section 5000A(f) 
of the Internal Revenue Code of 1986). 
(B) REPORT.—The Comptroller General shall submit 
to the appropriate committees of Congress a report on 
the study conducted under subparagraph (A), together with 
legislative recommendations relating to the matters studied 
under such subparagraph. 
(2) APPROPRIATE COMMITTEES OF CONGRESS.—In this sub-
section, the term ‘‘appropriate committees of Congress’’ means 
the Committee on Ways and Means, the Committee on Edu-
cation and Labor, and the Committee on Energy and Commerce 
of the House of Representatives and the Committee on Finance 
and the Committee on Health, Education, Labor and Pensions 
of the Senate. 
(d) CONFORMING AMENDMENTS.— 
(1) Paragraph (2) of section 1324(b) of title 31, United 
States Code, is amended by inserting ‘‘36B,’’ after ‘‘36A,’’. 
(2) The table of sections for subpart C of part IV of sub-
chapter A of chapter 1 of the Internal Revenue Code of 1986 
is amended by inserting after the item relating to section 36A 
the following new item: 
‘‘Sec. 36B. Refundable credit for coverage under a qualified health plan.’’. 
(e) EFFECTIVE DATE.—The amendments made by this section 
shall apply to taxable years ending after December 31, 2013. 
SEC. 1402. REDUCED COST-SHARING FOR INDIVIDUALS ENROLLING 
IN QUALIFIED HEALTH PLANS. 
(a) IN GENERAL.—In the case of an eligible insured enrolled 
in a qualified health plan— 
(1) the Secretary shall notify the issuer of the plan of 
such eligibility; and 
(2) the issuer shall reduce the cost-sharing under the plan 
at the level and in the manner specified in subsection (c). 
Notification. 
42 USC 18071. 
26 USC 36B note. 
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124 STAT. 221 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b) ELIGIBLE INSURED.—In this section, the term ‘‘eligible 
insured’’ means an individual— 
(1) who enrolls in a qualified health plan in the silver 
level of coverage in the individual market offered through an 
Exchange; and 
(2) whose household income exceeds 100 percent but does 
not exceed 400 percent of the poverty line for a family of 
the size involved. 
In the case of an individual described in section 36B(c)(1)(B) of 
the Internal Revenue Code of 1986, the individual shall be treated 
as having household income equal to 100 percent for purposes 
of applying this section. 
(c) DETERMINATION OF REDUCTION IN COST-SHARING.— 
(1) REDUCTION IN OUT-OF-POCKET LIMIT.— 
(A) IN GENERAL.—The reduction in cost-sharing under 
this subsection shall first be achieved by reducing the 
applicable out-of pocket limit under section 1302(c)(1) in 
the case of— 
(i) an eligible insured whose household income is 
more than 100 percent but not more than 200 percent 
of the poverty line for a family of the size involved, 
by two-thirds; 
(ii) an eligible insured whose household income 
is more than 200 percent but not more than 300 per-
cent of the poverty line for a family of the size involved, 
by one-half; and 
(iii) an eligible insured whose household income 
is more than 300 percent but not more than 400 per-
cent of the poverty line for a family of the size involved, 
by one-third. 
(B) COORDINATION
WITH
ACTUARIAL
VALUE
LIMITS.— 
(i) IN GENERAL.—The Secretary shall ensure the 
reduction under this paragraph shall not result in an 
increase in the plan’s share of the total allowed costs 
of benefits provided under the plan above— 
(I) 90 percent in the case of an eligible insured 
described in paragraph (2)(A); 
(II) 80 percent in the case of an eligible insured 
described in paragraph (2)(B); and 
(III) 70 percent in the case of an eligible 
insured described in clause (ii) or (iii) of subpara-
graph (A). 
(ii) ADJUSTMENT.—The Secretary shall adjust the 
out-of pocket limits under paragraph (1) if necessary 
to ensure that such limits do not cause the respective 
actuarial values to exceed the levels specified in clause 
(i). 
(2) ADDITIONAL REDUCTION FOR LOWER INCOME INSUREDS.— 
The Secretary shall establish procedures under which the issuer 
of a qualified health plan to which this section applies shall 
further reduce cost-sharing under the plan in a manner suffi-
cient to— 
(A) in the case of an eligible insured whose household 
income is not less than 100 percent but not more than 
150 percent of the poverty line for a family of the size 
involved, increase the plan’s share of the total allowed 
Procedures. 
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124 STAT. 222 
PUBLIC LAW 111–148—MAR. 23, 2010 
costs of benefits provided under the plan to 90 percent 
of such costs; and 
(B) in the case of an eligible insured whose household 
income is more than 150 percent but not more than 200 
percent of the poverty line for a family of the size involved, 
increase the plan’s share of the total allowed costs of bene-
fits provided under the plan to 80 percent of such costs. 
(3) METHODS FOR REDUCING COST-SHARING.— 
(A) IN GENERAL.—An issuer of a qualified health plan 
making reductions under this subsection shall notify the 
Secretary of such reductions and the Secretary shall make 
periodic and timely payments to the issuer equal to the 
value of the reductions. 
(B) CAPITATED PAYMENTS.—The Secretary may estab-
lish a capitated payment system to carry out the payment 
of cost-sharing reductions under this section. Any such 
system shall take into account the value of the reductions 
and make appropriate risk adjustments to such payments. 
(4) ADDITIONAL BENEFITS.—If a qualified health plan under 
section 1302(b)(5) offers benefits in addition to the essential 
health benefits required to be provided by the plan, or a State 
requires a qualified health plan under section 1311(d)(3)(B) 
to cover benefits in addition to the essential health benefits 
required to be provided by the plan, the reductions in cost- 
sharing under this section shall not apply to such additional 
benefits. 
(5) SPECIAL
RULE
FOR
PEDIATRIC
DENTAL
PLANS.—If an 
individual enrolls in both a qualified health plan and a plan 
described in section 1311(d)(2)(B)(ii)(I) for any plan year, sub-
section (a) shall not apply to that portion of any reduction 
in cost-sharing under subsection (c) that (under regulations 
prescribed by the Secretary) is properly allocable to pediatric 
dental benefits which are included in the essential health bene-
fits required to be provided by a qualified health plan under 
section 1302(b)(1)(J). 
(d) SPECIAL RULES FOR INDIANS.— 
(1) INDIANS UNDER 300 PERCENT OF POVERTY.—If an indi-
vidual enrolled in any qualified health plan in the individual 
market through an Exchange is an Indian (as defined in section 
4(d) of the Indian Self-Determination and Education Assistance 
Act (25 U.S.C. 450b(d))) whose household income is not more 
than 300 percent of the poverty line for a family of the size 
involved, then, for purposes of this section— 
(A) such individual shall be treated as an eligible 
insured; and 
(B) the issuer of the plan shall eliminate any cost- 
sharing under the plan. 
(2) ITEMS OR SERVICES FURNISHED THROUGH INDIAN HEALTH 
PROVIDERS.—If an Indian (as so defined) enrolled in a qualified 
health plan is furnished an item or service directly by the 
Indian Health Service, an Indian Tribe, Tribal Organization, 
or Urban Indian Organization or through referral under con-
tract health services— 
(A) no cost-sharing under the plan shall be imposed 
under the plan for such item or service; and 
(B) the issuer of the plan shall not reduce the payment 
to any such entity for such item or service by the amount 
Notification. 
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124 STAT. 223 
PUBLIC LAW 111–148—MAR. 23, 2010 
of any cost-sharing that would be due from the Indian 
but for subparagraph (A). 
(3) PAYMENT.—The Secretary shall pay to the issuer of 
a qualified health plan the amount necessary to reflect the 
increase in actuarial value of the plan required by reason 
of this subsection. 
(e) RULES FOR INDIVIDUALS NOT LAWFULLY PRESENT.— 
(1) IN GENERAL.—If an individual who is an eligible insured 
is not lawfully present— 
(A) no cost-sharing reduction under this section shall 
apply with respect to the individual; and 
(B) for purposes of applying this section, the determina-
tion as to what percentage a taxpayer’s household income 
bears to the poverty level for a family of the size involved 
shall be made under one of the following methods: 
(i) A method under which— 
(I) the taxpayer’s family size is determined 
by not taking such individuals into account, and 
(II) the taxpayer’s household income is equal 
to the product of the taxpayer’s household income 
(determined without regard to this subsection) and 
a fraction— 
(aa) the numerator of which is the poverty 
line for the taxpayer’s family size determined 
after application of subclause (I), and 
(bb) the denominator of which is the pov-
erty line for the taxpayer’s family size deter-
mined without regard to subclause (I). 
(ii) A comparable method reaching the same result 
as the method under clause (i). 
(2) LAWFULLY PRESENT.—For purposes of this section, an 
individual shall be treated as lawfully present only if the indi-
vidual is, and is reasonably expected to be for the entire period 
of enrollment for which the cost-sharing reduction under this 
section is being claimed, a citizen or national of the United 
States or an alien lawfully present in the United States. 
(3) SECRETARIAL AUTHORITY.—The Secretary, in consulta-
tion with the Secretary of the Treasury, shall prescribe rules 
setting forth the methods by which calculations of family size 
and household income are made for purposes of this subsection. 
Such rules shall be designed to ensure that the least burden 
is placed on individuals enrolling in qualified health plans 
through an Exchange and taxpayers eligible for the credit allow-
able under this section. 
(f) DEFINITIONS AND SPECIAL RULES.—In this section: 
(1) IN
GENERAL.—Any term used in this section which 
is also used in section 36B of the Internal Revenue Code of 
1986 shall have the meaning given such term by such section. 
(2) LIMITATIONS ON REDUCTION.—No cost-sharing reduction 
shall be allowed under this section with respect to coverage 
for any month unless the month is a coverage month with 
respect to which a credit is allowed to the insured (or an 
applicable taxpayer on behalf of the insured) under section 
36B of such Code. 
(3) DATA USED FOR ELIGIBILITY.—Any determination under 
this section shall be made on the basis of the taxable year 
for which the advance determination is made under section 
Regulations. 
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124 STAT. 224 
PUBLIC LAW 111–148—MAR. 23, 2010 
1412 and not the taxable year for which the credit under 
section 36B of such Code is allowed. 
Subpart B—Eligibility Determinations 
SEC. 
1411. 
PROCEDURES 
FOR 
DETERMINING 
ELIGIBILITY 
FOR 
EXCHANGE PARTICIPATION, PREMIUM TAX CREDITS AND 
REDUCED COST-SHARING, AND INDIVIDUAL RESPONSI-
BILITY EXEMPTIONS. 
(a) ESTABLISHMENT OF PROGRAM.—The Secretary shall estab-
lish a program meeting the requirements of this section for deter-
mining— 
(1) whether an individual who is to be covered in the 
individual market by a qualified health plan offered through 
an Exchange, or who is claiming a premium tax credit or 
reduced cost-sharing, meets the requirements of sections 
1312(f)(3), 1402(e), and 1412(d) of this title and section 36B(e) 
of the Internal Revenue Code of 1986 that the individual be 
a citizen or national of the United States or an alien lawfully 
present in the United States; 
(2) in the case of an individual claiming a premium tax 
credit or reduced cost-sharing under section 36B of such Code 
or section 1402— 
(A) whether the individual meets the income and cov-
erage requirements of such sections; and 
(B) the amount of the tax credit or reduced cost- 
sharing; 
(3) whether an individual’s coverage under an employer- 
sponsored health benefits plan is treated as unaffordable under 
sections 36B(c)(2)(C) and 5000A(e)(2); and 
(4) whether to grant a certification under section 
1311(d)(4)(H) attesting that, for purposes of the individual 
responsibility requirement under section 5000A of the Internal 
Revenue Code of 1986, an individual is entitled to an exemption 
from either the individual responsibility requirement or the 
penalty imposed by such section. 
(b) INFORMATION REQUIRED TO BE PROVIDED BY APPLICANTS.— 
(1) IN GENERAL.—An applicant for enrollment in a qualified 
health plan offered through an Exchange in the individual 
market shall provide— 
(A) the name, address, and date of birth of each indi-
vidual who is to be covered by the plan (in this subsection 
referred to as an ‘‘enrollee’’); and 
(B) the information required by any of the following 
paragraphs that is applicable to an enrollee. 
(2) CITIZENSHIP OR IMMIGRATION STATUS.—The following 
information shall be provided with respect to every enrollee: 
(A) In the case of an enrollee whose eligibility is based 
on an attestation of citizenship of the enrollee, the enrollee’s 
social security number. 
(B) In the case of an individual whose eligibility is 
based on an attestation of the enrollee’s immigration status, 
the enrollee’s social security number (if applicable) and 
such identifying information with respect to the enrollee’s 
immigration status as the Secretary, after consultation 
with the Secretary of Homeland Security, determines 
appropriate. 
42 USC 18081. 
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124 STAT. 225 
PUBLIC LAW 111–148—MAR. 23, 2010 
(3) ELIGIBILITY AND AMOUNT OF TAX CREDIT OR REDUCED 
COST-SHARING.—In the case of an enrollee with respect to whom 
a premium tax credit or reduced cost-sharing under section 
36B of such Code or section 1402 is being claimed, the following 
information: 
(A) INFORMATION
REGARDING
INCOME
AND
FAMILY 
SIZE.—The information described in section 6103(l)(21) for 
the taxable year ending with or within the second calendar 
year preceding the calendar year in which the plan year 
begins. 
(B) CHANGES
IN
CIRCUMSTANCES.—The information 
described in section 1412(b)(2), including information with 
respect to individuals who were not required to file an 
income tax return for the taxable year described in 
subparagraph (A) or individuals who experienced changes 
in marital status or family size or significant reductions 
in income. 
(4) EMPLOYER-SPONSORED COVERAGE.—In the case of an 
enrollee with respect to whom eligibility for a premium tax 
credit under section 36B of such Code or cost-sharing reduction 
under section 1402 is being established on the basis that the 
enrollee’s (or related individual’s) employer is not treated under 
section 36B(c)(2)(C) of such Code as providing minimum essen-
tial coverage or affordable minimum essential coverage, the 
following information: 
(A) The name, address, and employer identification 
number (if available) of the employer. 
(B) Whether the enrollee or individual is a full-time 
employee and whether the employer provides such min-
imum essential coverage. 
(C) If the employer provides such minimum essential 
coverage, the lowest cost option for the enrollee’s or individ-
ual’s enrollment status and the enrollee’s or individual’s 
required contribution (within the meaning of section 
5000A(e)(1)(B) of such Code) under the employer-sponsored 
plan. 
(D) If an enrollee claims an employer’s minimum essen-
tial coverage is unaffordable, the information described 
in paragraph (3). 
If an enrollee changes employment or obtains additional 
employment while enrolled in a qualified health plan for which 
such credit or reduction is allowed, the enrollee shall notify 
the Exchange of such change or additional employment and 
provide the information described in this paragraph with 
respect to the new employer. 
(5) EXEMPTIONS FROM INDIVIDUAL RESPONSIBILITY REQUIRE-
MENTS.—In the case of an individual who is seeking an exemp-
tion certificate under section 1311(d)(4)(H) from any require-
ment or penalty imposed by section 5000A, the following 
information: 
(A) In the case of an individual seeking exemption 
based on the individual’s status as a member of an exempt 
religious sect or division, as a member of a health care 
sharing ministry, as an Indian, or as an individual eligible 
for a hardship exemption, such information as the Sec-
retary shall prescribe. 
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124 STAT. 226 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) In the case of an individual seeking exemption 
based on the lack of affordable coverage or the individual’s 
status as a taxpayer with household income less than 100 
percent of the poverty line, the information described in 
paragraphs (3) and (4), as applicable. 
(c) VERIFICATION OF INFORMATION CONTAINED IN RECORDS OF 
SPECIFIC FEDERAL OFFICIALS.— 
(1) 
INFORMATION
TRANSFERRED
TO
SECRETARY.—An 
Exchange shall submit the information provided by an applicant 
under subsection (b) to the Secretary for verification in accord-
ance with the requirements of this subsection and subsection 
(d). 
(2) CITIZENSHIP OR IMMIGRATION STATUS.— 
(A) COMMISSIONER
OF
SOCIAL
SECURITY.—The Sec-
retary shall submit to the Commissioner of Social Security 
the following information for a determination as to whether 
the information provided is consistent with the information 
in the records of the Commissioner: 
(i) The name, date of birth, and social security 
number of each individual for whom such information 
was provided under subsection (b)(2). 
(ii) The attestation of an individual that the indi-
vidual is a citizen. 
(B) SECRETARY OF HOMELAND SECURITY.— 
(i) IN GENERAL.—In the case of an individual— 
(I) who attests that the individual is an alien 
lawfully present in the United States; or 
(II) who attests that the individual is a citizen 
but with respect to whom the Commissioner of 
Social Security has notified the Secretary under 
subsection (e)(3) that the attestation is inconsistent 
with information in the records maintained by the 
Commissioner; 
the Secretary shall submit to the Secretary of Home-
land Security the information described in clause (ii) 
for a determination as to whether the information pro-
vided is consistent with the information in the records 
of the Secretary of Homeland Security. 
(ii) INFORMATION.—The information described in 
clause (ii) is the following: 
(I) The name, date of birth, and any identifying 
information with respect to the individual’s 
immigration status provided under subsection 
(b)(2). 
(II) The attestation that the individual is an 
alien lawfully present in the United States or in 
the case of an individual described in clause (i)(II), 
the attestation that the individual is a citizen. 
(3) ELIGIBILITY FOR TAX CREDIT AND COST-SHARING REDUC-
TION.—The Secretary shall submit the information described 
in subsection (b)(3)(A) provided under paragraph (3), (4), or 
(5) of subsection (b) to the Secretary of the Treasury for 
verification of household income and family size for purposes 
of eligibility. 
(4) METHODS.— 
(A) IN GENERAL.—The Secretary, in consultation with 
the Secretary of the Treasury, the Secretary of Homeland 
Electronic 
submission. 
Submission. 
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124 STAT. 227 
PUBLIC LAW 111–148—MAR. 23, 2010 
Security, and the Commissioner of Social Security, shall 
provide that verifications and determinations under this 
subsection shall be done— 
(i) through use of an on-line system or otherwise 
for the electronic submission of, and response to, the 
information submitted under this subsection with 
respect to an applicant; or 
(ii) by determining the consistency of the informa-
tion submitted with the information maintained in the 
records of the Secretary of the Treasury, the Secretary 
of Homeland Security, or the Commissioner of Social 
Security through such other method as is approved 
by the Secretary. 
(B) FLEXIBILITY.—The Secretary may modify the 
methods used under the program established by this section 
for the Exchange and verification of information if the 
Secretary determines such modifications would reduce the 
administrative costs and burdens on the applicant, 
including allowing an applicant to request the Secretary 
of the Treasury to provide the information described in 
paragraph (3) directly to the Exchange or to the Secretary. 
The Secretary shall not make any such modification unless 
the Secretary determines that any applicable requirements 
under this section and section 6103 of the Internal Revenue 
Code of 1986 with respect to the confidentiality, disclosure, 
maintenance, or use of information will be met. 
(d) VERIFICATION BY SECRETARY.—In the case of information 
provided under subsection (b) that is not required under subsection 
(c) to be submitted to another person for verification, the Secretary 
shall verify the accuracy of such information in such manner as 
the Secretary determines appropriate, including delegating respon-
sibility for verification to the Exchange. 
(e) ACTIONS RELATING TO VERIFICATION.— 
(1) IN GENERAL.—Each person to whom the Secretary pro-
vided information under subsection (c) shall report to the Sec-
retary under the method established under subsection (c)(4) 
the results of its verification and the Secretary shall notify 
the Exchange of such results. Each person to whom the Sec-
retary provided information under subsection (d) shall report 
to the Secretary in such manner as the Secretary determines 
appropriate. 
(2) VERIFICATION.— 
(A) ELIGIBILITY FOR ENROLLMENT AND PREMIUM TAX 
CREDITS
AND
COST-SHARING
REDUCTIONS.—If information 
provided by an applicant under paragraphs (1), (2), (3), 
and (4) of subsection (b) is verified under subsections (c) 
and (d)— 
(i) the individual’s eligibility to enroll through the 
Exchange and to apply for premium tax credits and 
cost-sharing reductions shall be satisfied; and 
(ii) the Secretary shall, if applicable, notify the 
Secretary of the Treasury under section 1412(c) of the 
amount of any advance payment to be made. 
(B) EXEMPTION FROM INDIVIDUAL RESPONSIBILITY.—If 
information provided by an applicant under subsection 
(b)(5) is verified under subsections (c) and (d), the Secretary 
Notification. 
Reports. 
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124 STAT. 228 
PUBLIC LAW 111–148—MAR. 23, 2010 
shall issue the certification of exemption described in sec-
tion 1311(d)(4)(H). 
(3) INCONSISTENCIES INVOLVING ATTESTATION OF CITIZEN-
SHIP OR LAWFUL PRESENCE.—If the information provided by 
any applicant under subsection (b)(2) is inconsistent with 
information in the records maintained by the Commissioner 
of Social Security or Secretary of Homeland Security, whichever 
is applicable, the applicant’s eligibility will be determined in 
the same manner as an individual’s eligibility under the med-
icaid program is determined under section 1902(ee) of the Social 
Security Act (as in effect on January 1, 2010). 
(4) INCONSISTENCIES INVOLVING OTHER INFORMATION.— 
(A) IN GENERAL.—If the information provided by an 
applicant under subsection (b) (other than subsection (b)(2)) 
is inconsistent with information in the records maintained 
by persons under subsection (c) or is not verified under 
subsection (d), the Secretary shall notify the Exchange 
and the Exchange shall take the following actions: 
(i) REASONABLE
EFFORT.—The Exchange shall 
make a reasonable effort to identify and address the 
causes of such inconsistency, including through typo-
graphical or other clerical errors, by contacting the 
applicant to confirm the accuracy of the information, 
and by taking such additional actions as the Secretary, 
through regulation or other guidance, may identify. 
(ii) NOTICE AND OPPORTUNITY TO CORRECT.—In the 
case the inconsistency or inability to verify is not 
resolved under subparagraph (A), the Exchange shall— 
(I) notify the applicant of such fact; 
(II) provide the applicant an opportunity to 
either present satisfactory documentary evidence 
or resolve the inconsistency with the person 
verifying the information under subsection (c) or 
(d) during the 90-day period beginning the date 
on which the notice required under subclause (I) 
is sent to the applicant. 
The Secretary may extend the 90-day period under 
subclause (II) for enrollments occurring during 2014. 
(B) SPECIFIC ACTIONS NOT INVOLVING CITIZENSHIP OR 
LAWFUL PRESENCE.— 
(i) IN GENERAL.—Except as provided in paragraph 
(3), the Exchange shall, during any period before the 
close of the period under subparagraph (A)(ii)(II), make 
any determination under paragraphs (2), (3), and (4) 
of subsection (a) on the basis of the information con-
tained on the application. 
(ii) ELIGIBILITY OR AMOUNT OF CREDIT OR REDUC-
TION.—If an inconsistency involving the eligibility for, 
or amount of, any premium tax credit or cost-sharing 
reduction is unresolved under this subsection as of 
the close of the period under subparagraph (A)(ii)(II), 
the Exchange shall notify the applicant of the amount 
(if any) of the credit or reduction that is determined 
on the basis of the records maintained by persons 
under subsection (c). 
(iii) EMPLOYER AFFORDABILITY.—If the Secretary 
notifies an Exchange that an enrollee is eligible for 
Time period. 
Notifications. 
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124 STAT. 229 
PUBLIC LAW 111–148—MAR. 23, 2010 
a premium tax credit under section 36B of such Code 
or cost-sharing reduction under section 1402 because 
the enrollee’s (or related individual’s) employer does 
not provide minimum essential coverage through an 
employer-sponsored plan or that the employer does 
provide that coverage but it is not affordable coverage, 
the Exchange shall notify the employer of such fact 
and that the employer may be liable for the payment 
assessed under section 4980H of such Code. 
(iv) EXEMPTION.—In any case where the inconsist-
ency involving, or inability to verify, information pro-
vided under subsection (b)(5) is not resolved as of the 
close of the period under subparagraph (A)(ii)(II), the 
Exchange shall notify an applicant that no certification 
of exemption from any requirement or payment under 
section 5000A of such Code will be issued. 
(C) APPEALS PROCESS.—The Exchange shall also notify 
each person receiving notice under this paragraph of the 
appeals processes established under subsection (f). 
(f) APPEALS AND REDETERMINATIONS.— 
(1) IN GENERAL.—The Secretary, in consultation with the 
Secretary of the Treasury, the Secretary of Homeland Security, 
and the Commissioner of Social Security, shall establish proce-
dures by which the Secretary or one of such other Federal 
officers— 
(A) hears and makes decisions with respect to appeals 
of any determination under subsection (e); and 
(B) redetermines eligibility on a periodic basis in appro-
priate circumstances. 
(2) EMPLOYER LIABILITY.— 
(A) IN GENERAL.—The Secretary shall establish a sepa-
rate appeals process for employers who are notified under 
subsection (e)(4)(C) that the employer may be liable for 
a tax imposed by section 4980H of the Internal Revenue 
Code of 1986 with respect to an employee because of a 
determination that the employer does not provide minimum 
essential coverage through an employer-sponsored plan or 
that the employer does provide that coverage but it is 
not affordable coverage with respect to an employee. Such 
process shall provide an employer the opportunity to— 
(i) present information to the Exchange for review 
of the determination either by the Exchange or the 
person making the determination, including evidence 
of the employer-sponsored plan and employer contribu-
tions to the plan; and 
(ii) have access to the data used to make the 
determination to the extent allowable by law. 
Such process shall be in addition to any rights of appeal 
the employer may have under subtitle F of such Code. 
(B) CONFIDENTIALITY.—Notwithstanding any provision 
of this title (or the amendments made by this title) or 
section 6103 of the Internal Revenue Code of 1986, an 
employer shall not be entitled to any taxpayer return 
information with respect to an employee for purposes of 
determining whether the employer is subject to the penalty 
under section 4980H of such Code with respect to the 
employee, except that— 
Procedures. 
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124 STAT. 230 
PUBLIC LAW 111–148—MAR. 23, 2010 
(i) the employer may be notified as to the name 
of an employee and whether or not the employee’s 
income is above or below the threshold by which the 
affordability of an employer’s health insurance cov-
erage is measured; and 
(ii) this subparagraph shall not apply to an 
employee who provides a waiver (at such time and 
in such manner as the Secretary may prescribe) 
authorizing an employer to have access to the 
employee’s taxpayer return information. 
(g) CONFIDENTIALITY OF APPLICANT INFORMATION.— 
(1) IN GENERAL.—An applicant for insurance coverage or 
for a premium tax credit or cost-sharing reduction shall be 
required to provide only the information strictly necessary to 
authenticate identity, determine eligibility, and determine the 
amount of the credit or reduction. 
(2) RECEIPT OF INFORMATION.—Any person who receives 
information provided by an applicant under subsection (b) 
(whether directly or by another person at the request of the 
applicant), or receives information from a Federal agency under 
subsection (c), (d), or (e), shall— 
(A) use the information only for the purposes of, and 
to the extent necessary in, ensuring the efficient operation 
of the Exchange, including verifying the eligibility of an 
individual to enroll through an Exchange or to claim a 
premium tax credit or cost-sharing reduction or the amount 
of the credit or reduction; and 
(B) not disclose the information to any other person 
except as provided in this section. 
(h) PENALTIES.— 
(1) FALSE OR FRAUDULENT INFORMATION.— 
(A) CIVIL PENALTY.— 
(i) IN GENERAL.—If— 
(I) any person fails to provides correct informa-
tion under subsection (b); and 
(II) such failure is attributable to negligence 
or disregard of any rules or regulations of the 
Secretary, 
such person shall be subject, in addition to any other 
penalties that may be prescribed by law, to a civil 
penalty of not more than $25,000 with respect to any 
failures involving an application for a plan year. For 
purposes of this subparagraph, the terms ‘‘negligence’’ 
and ‘‘disregard’’ shall have the same meanings as when 
used in section 6662 of the Internal Revenue Code 
of 1986. 
(ii) REASONABLE
CAUSE
EXCEPTION.—No penalty 
shall be imposed under clause (i) if the Secretary deter-
mines that there was a reasonable cause for the failure 
and that the person acted in good faith. 
(B) KNOWING AND WILLFUL VIOLATIONS.—Any person 
who knowingly and willfully provides false or fraudulent 
information under subsection (b) shall be subject, in addi-
tion to any other penalties that may be prescribed by 
law, to a civil penalty of not more than $250,000. 
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124 STAT. 231 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) IMPROPER USE OR DISCLOSURE OF INFORMATION.—Any 
person who knowingly and willfully uses or discloses informa-
tion in violation of subsection (g) shall be subject, in addition 
to any other penalties that may be prescribed by law, to a 
civil penalty of not more than $25,000. 
(3) LIMITATIONS ON LIENS AND LEVIES.—The Secretary (or, 
if applicable, the Attorney General of the United States) shall 
not— 
(A) file notice of lien with respect to any property 
of a person by reason of any failure to pay the penalty 
imposed by this subsection; or 
(B) levy on any such property with respect to such 
failure. 
(i) STUDY OF ADMINISTRATION OF EMPLOYER RESPONSIBILITY.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services shall, in consultation with the Secretary of the 
Treasury, conduct a study of the procedures that are necessary 
to ensure that in the administration of this title and section 
4980H of the Internal Revenue Code of 1986 (as added by 
section 1513) that the following rights are protected: 
(A) The rights of employees to preserve their right 
to confidentiality of their taxpayer return information and 
their right to enroll in a qualified health plan through 
an Exchange if an employer does not provide affordable 
coverage. 
(B) The rights of employers to adequate due process 
and access to information necessary to accurately deter-
mine any payment assessed on employers. 
(2) REPORT.—Not later than January 1, 2013, the Secretary 
of Health and Human Services shall report the results of the 
study conducted under paragraph (1), including any rec-
ommendations for legislative changes, to the Committees on 
Finance and Health, Education, Labor and Pensions of the 
Senate and the Committees of Education and Labor and Ways 
and Means of the House of Representatives. 
SEC. 1412. ADVANCE DETERMINATION AND PAYMENT OF PREMIUM 
TAX CREDITS AND COST-SHARING REDUCTIONS. 
(a) IN GENERAL.—The Secretary, in consultation with the Sec-
retary of the Treasury, shall establish a program under which— 
(1) upon request of an Exchange, advance determinations 
are made under section 1411 with respect to the income eligi-
bility of individuals enrolling in a qualified health plan in 
the individual market through the Exchange for the premium 
tax credit allowable under section 36B of the Internal Revenue 
Code of 1986 and the cost-sharing reductions under section 
1402; 
(2) the Secretary notifies— 
(A) the Exchange and the Secretary of the Treasury 
of the advance determinations; and 
(B) the Secretary of the Treasury of the name and 
employer identification number of each employer with 
respect to whom 1 or more employee of the employer were 
determined to be eligible for the premium tax credit under 
section 36B of the Internal Revenue Code of 1986 and 
the cost-sharing reductions under section 1402 because— 
Notification. 
42 USC 18082. 
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124 STAT. 232 
PUBLIC LAW 111–148—MAR. 23, 2010 
(i) the employer did not provide minimum essential 
coverage; or 
(ii) the employer provided such minimum essential 
coverage 
but 
it 
was 
determined 
under 
section 
36B(c)(2)(C) of such Code to either be unaffordable 
to the employee or not provide the required minimum 
actuarial value; and 
(3) the Secretary of the Treasury makes advance payments 
of such credit or reductions to the issuers of the qualified 
health plans in order to reduce the premiums payable by 
individuals eligible for such credit. 
(b) ADVANCE DETERMINATIONS.— 
(1) IN GENERAL.—The Secretary shall provide under the 
program established under subsection (a) that advance deter-
mination of eligibility with respect to any individual shall be 
made— 
(A) during the annual open enrollment period 
applicable to the individual (or such other enrollment 
period as may be specified by the Secretary); and 
(B) on the basis of the individual’s household income 
for the most recent taxable year for which the Secretary, 
after consultation with the Secretary of the Treasury, deter-
mines information is available. 
(2) CHANGES IN CIRCUMSTANCES.—The Secretary shall pro-
vide procedures for making advance determinations on the 
basis of information other than that described in paragraph 
(1)(B) in cases where information included with an application 
form demonstrates substantial changes in income, changes in 
family size or other household circumstances, change in filing 
status, the filing of an application for unemployment benefits, 
or other significant changes affecting eligibility, including— 
(A) allowing an individual claiming a decrease of 20 
percent or more in income, or filing an application for 
unemployment benefits, to have eligibility for the credit 
determined on the basis of household income for a later 
period or on the basis of the individual’s estimate of such 
income for the taxable year; and 
(B) the determination of household income in cases 
where the taxpayer was not required to file a return of 
tax imposed by this chapter for the second preceding tax-
able year. 
(c) PAYMENT
OF PREMIUM TAX CREDITS
AND COST-SHARING 
REDUCTIONS.— 
(1) IN GENERAL.—The Secretary shall notify the Secretary 
of the Treasury and the Exchange through which the individual 
is enrolling of the advance determination under section 1411. 
(2) PREMIUM TAX CREDIT.— 
(A) IN GENERAL.—The Secretary of the Treasury shall 
make the advance payment under this section of any pre-
mium tax credit allowed under section 36B of the Internal 
Revenue Code of 1986 to the issuer of a qualified health 
plan on a monthly basis (or such other periodic basis as 
the Secretary may provide). 
(B) ISSUER RESPONSIBILITIES.—An issuer of a qualified 
health plan receiving an advance payment with respect 
to an individual enrolled in the plan shall— 
Notifications. 
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124 STAT. 233 
PUBLIC LAW 111–148—MAR. 23, 2010 
(i) reduce the premium charged the insured for 
any period by the amount of the advance payment 
for the period; 
(ii) notify the Exchange and the Secretary of such 
reduction; 
(iii) include with each billing statement the 
amount by which the premium for the plan has been 
reduced by reason of the advance payment; and 
(iv) in the case of any nonpayment of premiums 
by the insured— 
(I) notify the Secretary of such nonpayment; 
and 
(II) allow a 3-month grace period for non-
payment of premiums before discontinuing cov-
erage. 
(3) COST-SHARING REDUCTIONS.—The Secretary shall also 
notify the Secretary of the Treasury and the Exchange under 
paragraph (1) if an advance payment of the cost-sharing reduc-
tions under section 1402 is to be made to the issuer of any 
qualified health plan with respect to any individual enrolled 
in the plan. The Secretary of the Treasury shall make such 
advance payment at such time and in such amount as the 
Secretary specifies in the notice. 
(d) NO FEDERAL PAYMENTS FOR INDIVIDUALS NOT LAWFULLY 
PRESENT.—Nothing in this subtitle or the amendments made by 
this subtitle allows Federal payments, credits, or cost-sharing reduc-
tions for individuals who are not lawfully present in the United 
States. 
(e) STATE FLEXIBILITY.—Nothing in this subtitle or the amend-
ments made by this subtitle shall be construed to prohibit a State 
from making payments to or on behalf of an individual for coverage 
under a qualified health plan offered through an Exchange that 
are in addition to any credits or cost-sharing reductions allowable 
to the individual under this subtitle and such amendments. 
SEC. 1413. STREAMLINING OF PROCEDURES FOR ENROLLMENT 
THROUGH AN EXCHANGE AND STATE MEDICAID, CHIP, 
AND HEALTH SUBSIDY PROGRAMS. 
(a) IN GENERAL.—The Secretary shall establish a system 
meeting the requirements of this section under which residents 
of each State may apply for enrollment in, receive a determination 
of eligibility for participation in, and continue participation in, 
applicable State health subsidy programs. Such system shall ensure 
that if an individual applying to an Exchange is found through 
screening to be eligible for medical assistance under the State 
medicaid plan under title XIX, or eligible for enrollment under 
a State children’s health insurance program (CHIP) under title 
XXI of such Act, the individual is enrolled for assistance under 
such plan or program. 
(b) REQUIREMENTS RELATING TO FORMS AND NOTICE.— 
(1) REQUIREMENTS RELATING TO FORMS.— 
(A) IN GENERAL.—The Secretary shall develop and pro-
vide to each State a single, streamlined form that— 
(i) may be used to apply for all applicable State 
health subsidy programs within the State; 
(ii) may be filed online, in person, by mail, or 
by telephone; 
42 USC 18083. 
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124 STAT. 234 
PUBLIC LAW 111–148—MAR. 23, 2010 
(iii) may be filed with an Exchange or with State 
officials operating one of the other applicable State 
health subsidy programs; and 
(iv) is structured to maximize an applicant’s ability 
to complete the form satisfactorily, taking into account 
the characteristics of individuals who qualify for 
applicable State health subsidy programs. 
(B) STATE AUTHORITY TO ESTABLISH FORM.—A State 
may develop and use its own single, streamlined form 
as an alternative to the form developed under subpara-
graph (A) if the alternative form is consistent with stand-
ards promulgated by the Secretary under this section. 
(C) SUPPLEMENTAL ELIGIBILITY FORMS.—The Secretary 
may allow a State to use a supplemental or alternative 
form in the case of individuals who apply for eligibility 
that is not determined on the basis of the household income 
(as defined in section 36B of the Internal Revenue Code 
of 1986). 
(2) NOTICE.—The Secretary shall provide that an applicant 
filing a form under paragraph (1) shall receive notice of eligi-
bility for an applicable State health subsidy program without 
any need to provide additional information or paperwork unless 
such information or paperwork is specifically required by law 
when information provided on the form is inconsistent with 
data used for the electronic verification under paragraph (3) 
or is otherwise insufficient to determine eligibility. 
(c) REQUIREMENTS RELATING TO ELIGIBILITY BASED ON DATA 
EXCHANGES.— 
(1) DEVELOPMENT
OF
SECURE
INTERFACES.—Each State 
shall develop for all applicable State health subsidy programs 
a secure, electronic interface allowing an exchange of data 
(including information contained in the application forms 
described in subsection (b)) that allows a determination of 
eligibility for all such programs based on a single application. 
Such interface shall be compatible with the method established 
for data verification under section 1411(c)(4). 
(2) DATA
MATCHING
PROGRAM.—Each applicable State 
health subsidy program shall participate in a data matching 
arrangement for determining eligibility for participation in the 
program under paragraph (3) that— 
(A) provides access to data described in paragraph 
(3); 
(B) applies only to individuals who— 
(i) receive assistance from an applicable State 
health subsidy program; or 
(ii) apply for such assistance— 
(I) by filing a form described in subsection 
(b); or 
(II) by requesting a determination of eligibility 
and authorizing disclosure of the information 
described in paragraph (3) to applicable State 
health coverage subsidy programs for purposes of 
determining and establishing eligibility; and 
(C) consistent with standards promulgated by the Sec-
retary, including the privacy and data security safeguards 
described in section 1942 of the Social Security Act or 
that are otherwise applicable to such programs. 
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124 STAT. 235 
PUBLIC LAW 111–148—MAR. 23, 2010 
(3) DETERMINATION OF ELIGIBILITY.— 
(A) IN GENERAL.—Each applicable State health subsidy 
program shall, to the maximum extent practicable— 
(i) establish, verify, and update eligibility for 
participation in the program using the data matching 
arrangement under paragraph (2); and 
(ii) determine such eligibility on the basis of reli-
able, third party data, including information described 
in sections 1137, 453(i), and 1942(a) of the Social Secu-
rity Act, obtained through such arrangement. 
(B) EXCEPTION.—This paragraph shall not apply in 
circumstances with respect to which the Secretary deter-
mines that the administrative and other costs of use of 
the data matching arrangement under paragraph (2) out-
weigh its expected gains in accuracy, efficiency, and pro-
gram participation. 
(4) SECRETARIAL STANDARDS.—The Secretary shall, after 
consultation with persons in possession of the data to be 
matched and representatives of applicable State health subsidy 
programs, promulgate standards governing the timing, con-
tents, and procedures for data matching described in this sub-
section. Such standards shall take into account administrative 
and other costs and the value of data matching to the establish-
ment, verification, and updating of eligibility for applicable 
State health subsidy programs. 
(d) ADMINISTRATIVE AUTHORITY.— 
(1) AGREEMENTS.—Subject to section 1411 and section 
6103(l)(21) of the Internal Revenue Code of 1986 and any 
other requirement providing safeguards of privacy and data 
integrity, the Secretary may establish model agreements, and 
enter into agreements, for the sharing of data under this sec-
tion. 
(2) AUTHORITY OF EXCHANGE TO CONTRACT OUT.—Nothing 
in this section shall be construed to— 
(A) prohibit contractual arrangements through which 
a State medicaid agency determines eligibility for all 
applicable State health subsidy programs, but only if such 
agency 
complies 
with 
the 
Secretary’s 
requirements 
ensuring reduced administrative costs, eligibility errors, 
and disruptions in coverage; or 
(B) change any requirement under title XIX that eligi-
bility for participation in a State’s medicaid program must 
be determined by a public agency. 
(e) APPLICABLE STATE HEALTH SUBSIDY PROGRAM.—In this sec-
tion, the term ‘‘applicable State health subsidy program’’ means— 
(1) the program under this title for the enrollment in 
qualified health plans offered through an Exchange, including 
the premium tax credits under section 36B of the Internal 
Revenue Code of 1986 and cost-sharing reductions under section 
1402; 
(2) a State medicaid program under title XIX of the Social 
Security Act; 
(3) a State children’s health insurance program (CHIP) 
under title XXI of such Act; and 
(4) a State program under section 1331 establishing quali-
fied basic health plans. 
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124 STAT. 236 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 1414. DISCLOSURES TO CARRY OUT ELIGIBILITY REQUIREMENTS 
FOR CERTAIN PROGRAMS. 
(a) DISCLOSURE OF TAXPAYER RETURN INFORMATION AND SOCIAL 
SECURITY NUMBERS.— 
(1) TAXPAYER RETURN INFORMATION.—Subsection (l) of sec-
tion 6103 of the Internal Revenue Code of 1986 is amended 
by adding at the end the following new paragraph: 
‘‘(21) DISCLOSURE OF RETURN INFORMATION TO CARRY OUT 
ELIGIBILITY REQUIREMENTS FOR CERTAIN PROGRAMS.— 
‘‘(A) IN GENERAL.—The Secretary, upon written request 
from the Secretary of Health and Human Services, shall 
disclose to officers, employees, and contractors of the 
Department of Health and Human Services return informa-
tion of any taxpayer whose income is relevant in deter-
mining any premium tax credit under section 36B or any 
cost-sharing reduction under section 1402 of the Patient 
Protection and Affordable Care Act or eligibility for partici-
pation in a State medicaid program under title XIX of 
the Social Security Act, a State’s children’s health insur-
ance program under title XXI of the Social Security Act, 
or a basic health program under section 1331 of Patient 
Protection and Affordable Care Act. Such return informa-
tion shall be limited to— 
‘‘(i) taxpayer identity information with respect to 
such taxpayer, 
‘‘(ii) the filing status of such taxpayer, 
‘‘(iii) the number of individuals for whom a deduc-
tion is allowed under section 151 with respect to the 
taxpayer (including the taxpayer and the taxpayer’s 
spouse), 
‘‘(iv) the modified gross income (as defined in sec-
tion 36B) of such taxpayer and each of the other 
individuals included under clause (iii) who are required 
to file a return of tax imposed by chapter 1 for the 
taxable year, 
‘‘(v) such other information as is prescribed by 
the Secretary by regulation as might indicate whether 
the taxpayer is eligible for such credit or reduction 
(and the amount thereof), and 
‘‘(vi) the taxable year with respect to which the 
preceding information relates or, if applicable, the fact 
that such information is not available. 
‘‘(B) INFORMATION
TO
EXCHANGE
AND
STATE
AGEN-
CIES.—The Secretary of Health and Human Services may 
disclose to an Exchange established under the Patient 
Protection and Affordable Care Act or its contractors, or 
to a State agency administering a State program described 
in subparagraph (A) or its contractors, any inconsistency 
between the information provided by the Exchange or State 
agency to the Secretary and the information provided to 
the Secretary under subparagraph (A). 
‘‘(C) RESTRICTION
ON
USE
OF
DISCLOSED
INFORMA-
TION.—Return information disclosed under subparagraph 
(A) or (B) may be used by officers, employees, and contrac-
tors of the Department of Health and Human Services, 
an Exchange, or a State agency only for the purposes 
of, and to the extent necessary in— 
26 USC 6103. 
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124 STAT. 237 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) establishing eligibility for participation in the 
Exchange, and verifying the appropriate amount of, 
any credit or reduction described in subparagraph (A), 
‘‘(ii) determining eligibility for participation in the 
State programs described in subparagraph (A).’’. 
(2) SOCIAL SECURITY NUMBERS.—Section 205(c)(2)(C) of the 
Social Security Act is amended by adding at the end the fol-
lowing new clause: 
‘‘(x) The Secretary of Health and Human Services, 
and the Exchanges established under section 1311 of 
the Patient Protection and Affordable Care Act, are 
authorized to collect and use the names and social 
security account numbers of individuals as required 
to administer the provisions of, and the amendments 
made by, the such Act.’’. 
(b) CONFIDENTIALITY AND DISCLOSURE.—Paragraph (3) of sec-
tion 6103(a) of such Code is amended by striking ‘‘or (20)’’ and 
inserting ‘‘(20), or (21)’’. 
(c) PROCEDURES
AND RECORDKEEPING RELATED
TO DISCLO-
SURES.—Paragraph (4) of section 6103(p) of such Code is amended— 
(1) by inserting ‘‘, or any entity described in subsection 
(l)(21),’’ after ‘‘or (20)’’ in the matter preceding subparagraph 
(A), 
(2) by inserting ‘‘or any entity described in subsection 
(l)(21),’’ after ‘‘or (o)(1)(A)’’ in subparagraph (F)(ii), and 
(3) by inserting ‘‘or any entity described in subsection 
(l)(21),’’ after ‘‘or (20)’’ both places it appears in the matter 
after subparagraph (F). 
(d) UNAUTHORIZED DISCLOSURE OR INSPECTION.—Paragraph (2) 
of section 7213(a) of such Code is amended by striking ‘‘or (20)’’ 
and inserting ‘‘(20), or (21)’’. 
SEC. 1415. PREMIUM TAX CREDIT AND COST-SHARING REDUCTION 
PAYMENTS DISREGARDED FOR FEDERAL AND FEDER-
ALLY-ASSISTED PROGRAMS. 
For purposes of determining the eligibility of any individual 
for benefits or assistance, or the amount or extent of benefits 
or assistance, under any Federal program or under any State or 
local program financed in whole or in part with Federal funds— 
(1) any credit or refund allowed or made to any individual 
by reason of section 36B of the Internal Revenue Code of 
1986 (as added by section 1401) shall not be taken into account 
as income and shall not be taken into account as resources 
for the month of receipt and the following 2 months; and 
(2) any cost-sharing reduction payment or advance payment 
of the credit allowed under such section 36B that is made 
under section 1402 or 1412 shall be treated as made to the 
qualified health plan in which an individual is enrolled and 
not to that individual. 
PART II—SMALL BUSINESS TAX CREDIT 
SEC. 1421. CREDIT FOR EMPLOYEE HEALTH INSURANCE EXPENSES 
OF SMALL BUSINESSES. 
(a) IN GENERAL.—Subpart D of part IV of subchapter A of 
chapter 1 of the Internal Revenue Code of 1986 (relating to business- 
42 USC 18084. 
26 USC 6103. 
42 USC 405. 
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124 STAT. 238 
PUBLIC LAW 111–148—MAR. 23, 2010 
related credits) is amended by inserting after section 45Q the fol-
lowing: 
‘‘SEC. 45R. EMPLOYEE HEALTH INSURANCE EXPENSES OF SMALL 
EMPLOYERS. 
‘‘(a) GENERAL RULE.—For purposes of section 38, in the case 
of an eligible small employer, the small employer health insurance 
credit determined under this section for any taxable year in the 
credit period is the amount determined under subsection (b). 
‘‘(b) HEALTH INSURANCE CREDIT AMOUNT.—Subject to sub-
section (c), the amount determined under this subsection with 
respect to any eligible small employer is equal to 50 percent (35 
percent in the case of a tax-exempt eligible small employer) of 
the lesser of— 
‘‘(1) the aggregate amount of nonelective contributions the 
employer made on behalf of its employees during the taxable 
year under the arrangement described in subsection (d)(4) for 
premiums for qualified health plans offered by the employer 
to its employees through an Exchange, or 
‘‘(2) the aggregate amount of nonelective contributions 
which the employer would have made during the taxable year 
under the arrangement if each employee taken into account 
under paragraph (1) had enrolled in a qualified health plan 
which had a premium equal to the average premium (as deter-
mined by the Secretary of Health and Human Services) for 
the small group market in the rating area in which the 
employee enrolls for coverage. 
‘‘(c) PHASEOUT
OF CREDIT AMOUNT BASED
ON NUMBER
OF 
EMPLOYEES AND AVERAGE WAGES.—The amount of the credit deter-
mined under subsection (b) without regard to this subsection shall 
be reduced (but not below zero) by the sum of the following amounts: 
‘‘(1) Such amount multiplied by a fraction the numerator 
of which is the total number of full-time equivalent employees 
of the employer in excess of 10 and the denominator of which 
is 15. 
‘‘(2) Such amount multiplied by a fraction the numerator 
of which is the average annual wages of the employer in excess 
of the dollar amount in effect under subsection (d)(3)(B) and 
the denominator of which is such dollar amount. 
‘‘(d) ELIGIBLE SMALL EMPLOYER.—For purposes of this section— 
‘‘(1) IN
GENERAL.—The term ‘eligible small employer’ 
means, with respect to any taxable year, an employer— 
‘‘(A) which has no more than 25 full-time equivalent 
employees for the taxable year, 
‘‘(B) the average annual wages of which do not exceed 
an amount equal to twice the dollar amount in effect under 
paragraph (3)(B) for the taxable year, and 
‘‘(C) which has in effect an arrangement described 
in paragraph (4). 
‘‘(2) FULL-TIME EQUIVALENT EMPLOYEES.— 
‘‘(A) IN
GENERAL.—The term ‘full-time equivalent 
employees’ means a number of employees equal to the 
number determined by dividing— 
‘‘(i) the total number of hours of service for which 
wages were paid by the employer to employees during 
the taxable year, by 
‘‘(ii) 2,080. 
26 USC 45R. 
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124 STAT. 239 
PUBLIC LAW 111–148—MAR. 23, 2010 
Such number shall be rounded to the next lowest whole 
number if not otherwise a whole number. 
‘‘(B) EXCESS
HOURS
NOT
COUNTED.—If an employee 
works in excess of 2,080 hours of service during any taxable 
year, such excess shall not be taken into account under 
subparagraph (A). 
‘‘(C) HOURS OF SERVICE.—The Secretary, in consulta-
tion with the Secretary of Labor, shall prescribe such regu-
lations, rules, and guidance as may be necessary to deter-
mine the hours of service of an employee, including rules 
for the application of this paragraph to employees who 
are not compensated on an hourly basis. 
‘‘(3) AVERAGE ANNUAL WAGES.— 
‘‘(A) IN GENERAL.—The average annual wages of an 
eligible small employer for any taxable year is the amount 
determined by dividing— 
‘‘(i) the aggregate amount of wages which were 
paid by the employer to employees during the taxable 
year, by 
‘‘(ii) the number of full-time equivalent employees 
of the employee determined under paragraph (2) for 
the taxable year. 
Such amount shall be rounded to the next lowest multiple 
of $1,000 if not otherwise such a multiple. 
‘‘(B) DOLLAR
AMOUNT.—For purposes of paragraph 
(1)(B)— 
‘‘(i) 2011, 2012, AND 2013.—The dollar amount in 
effect under this paragraph for taxable years beginning 
in 2011, 2012, or 2013 is $20,000. 
‘‘(ii) SUBSEQUENT YEARS.—In the case of a taxable 
year beginning in a calendar year after 2013, the dollar 
amount in effect under this paragraph shall be equal 
to $20,000, multiplied by the cost-of-living adjustment 
determined under section 1(f)(3) for the calendar year, 
determined by substituting ‘calendar year 2012’ for 
‘calendar year 1992’ in subparagraph (B) thereof. 
‘‘(4) CONTRIBUTION
ARRANGEMENT.—An arrangement is 
described in this paragraph if it requires an eligible small 
employer to make a nonelective contribution on behalf of each 
employee who enrolls in a qualified health plan offered to 
employees by the employer through an exchange in an amount 
equal to a uniform percentage (not less than 50 percent) of 
the premium cost of the qualified health plan. 
‘‘(5) SEASONAL WORKER HOURS AND WAGES NOT COUNTED.— 
For purposes of this subsection— 
‘‘(A) IN
GENERAL.—The number of hours of service 
worked by, and wages paid to, a seasonal worker of an 
employer shall not be taken into account in determining 
the full-time equivalent employees and average annual 
wages of the employer unless the worker works for the 
employer on more than 120 days during the taxable year. 
‘‘(B) DEFINITION OF SEASONAL WORKER.—The term ‘sea-
sonal worker’ means a worker who performs labor or serv-
ices on a seasonal basis as defined by the Secretary of 
Labor, including workers covered by section 500.20(s)(1) 
of title 29, Code of Federal Regulations and retail workers 
employed exclusively during holiday seasons. 
Regulations. 
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124 STAT. 240 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(e) OTHER RULES AND DEFINITIONS.—For purposes of this sec-
tion— 
‘‘(1) EMPLOYEE.— 
‘‘(A) 
CERTAIN
EMPLOYEES
EXCLUDED.—The 
term 
‘employee’ shall not include— 
‘‘(i) an employee within the meaning of section 
401(c)(1), 
‘‘(ii) any 2-percent shareholder (as defined in sec-
tion 1372(b)) of an eligible small business which is 
an S corporation, 
‘‘(iii) any 5-percent owner (as defined in section 
416(i)(1)(B)(i)) of an eligible small business, or 
‘‘(iv) any individual who bears any of the relation-
ships described in subparagraphs (A) through (G) of 
section 152(d)(2) to, or is a dependent described in 
section 152(d)(2)(H) of, an individual described in 
clause (i), (ii), or (iii). 
‘‘(B) LEASED EMPLOYEES.—The term ‘employee’ shall 
include a leased employee within the meaning of section 
414(n). 
‘‘(2) CREDIT PERIOD.—The term ‘credit period’ means, with 
respect to any eligible small employer, the 2-consecutive-taxable 
year period beginning with the 1st taxable year in which the 
employer (or any predecessor) offers 1 or more qualified health 
plans to its employees through an Exchange. 
‘‘(3) NONELECTIVE CONTRIBUTION.—The term ‘nonelective 
contribution’ means an employer contribution other than an 
employer contribution pursuant to a salary reduction arrange-
ment. 
‘‘(4) WAGES.—The term ‘wages’ has the meaning given such 
term by section 3121(a) (determined without regard to any 
dollar limitation contained in such section). 
‘‘(5) AGGREGATION AND OTHER RULES MADE APPLICABLE.— 
‘‘(A) AGGREGATION RULES.—All employers treated as 
a single employer under subsection (b), (c), (m), or (o) 
of section 414 shall be treated as a single employer for 
purposes of this section. 
‘‘(B) OTHER RULES.—Rules similar to the rules of sub-
sections (c), (d), and (e) of section 52 shall apply. 
‘‘(f) CREDIT MADE AVAILABLE TO TAX-EXEMPT ELIGIBLE SMALL 
EMPLOYERS.— 
‘‘(1) IN GENERAL.—In the case of a tax-exempt eligible small 
employer, there shall be treated as a credit allowable under 
subpart C (and not allowable under this subpart) the lesser 
of— 
‘‘(A) the amount of the credit determined under this 
section with respect to such employer, or 
‘‘(B) the amount of the payroll taxes of the employer 
during the calendar year in which the taxable year begins. 
‘‘(2) TAX-EXEMPT ELIGIBLE SMALL EMPLOYER.—For purposes 
of this section, the term ‘tax-exempt eligible small employer’ 
means an eligible small employer which is any organization 
described in section 501(c) which is exempt from taxation under 
section 501(a). 
‘‘(3) PAYROLL
TAXES.—For purposes of this subsection— 
‘‘(A) IN GENERAL.—The term ‘payroll taxes’ means— 
Applicability. 
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124 STAT. 241 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) amounts required to be withheld from the 
employees of the tax-exempt eligible small employer 
under section 3401(a), 
‘‘(ii) amounts required to be withheld from such 
employees under section 3101(b), and 
‘‘(iii) amounts of the taxes imposed on the tax- 
exempt eligible small employer under section 3111(b). 
‘‘(B) SPECIAL RULE.—A rule similar to the rule of sec-
tion 24(d)(2)(C) shall apply for purposes of subparagraph 
(A). 
‘‘(g) APPLICATION OF SECTION FOR CALENDAR YEARS 2011, 2012, 
AND 2013.—In the case of any taxable year beginning in 2011, 
2012, or 2013, the following modifications to this section shall 
apply in determining the amount of the credit under subsection 
(a): 
‘‘(1) NO
CREDIT
PERIOD
REQUIRED.—The credit shall be 
determined without regard to whether the taxable year is in 
a credit period and for purposes of applying this section to 
taxable years beginning after 2013, no credit period shall be 
treated as beginning with a taxable year beginning before 2014. 
‘‘(2) AMOUNT OF CREDIT.—The amount of the credit deter-
mined under subsection (b) shall be determined— 
‘‘(A) by substituting ‘35 percent (25 percent in the 
case of a tax-exempt eligible small employer)’ for ‘50 percent 
(35 percent in the case of a tax-exempt eligible small 
employer)’, 
‘‘(B) by reference to an eligible small employer’s non-
elective contributions for premiums paid for health insur-
ance coverage (within the meaning of section 9832(b)(1)) 
of an employee, and 
‘‘(C) by substituting for the average premium deter-
mined under subsection (b)(2) the amount the Secretary 
of Health and Human Services determines is the average 
premium for the small group market in the State in which 
the employer is offering health insurance coverage (or for 
such area within the State as is specified by the Secretary). 
‘‘(3) CONTRIBUTION ARRANGEMENT.—An arrangement shall 
not fail to meet the requirements of subsection (d)(4) solely 
because it provides for the offering of insurance outside of 
an Exchange. 
‘‘(h) INSURANCE DEFINITIONS.—Any term used in this section 
which is also used in the Public Health Service Act or subtitle 
A of title I of the Patient Protection and Affordable Care Act 
shall have the meaning given such term by such Act or subtitle. 
‘‘(i) REGULATIONS.—The Secretary shall prescribe such regula-
tions as may be necessary to carry out the provisions of this section, 
including regulations to prevent the avoidance of the 2-year limit 
on the credit period through the use of successor entities and 
the avoidance of the limitations under subsection (c) through the 
use of multiple entities.’’. 
(b) CREDIT TO BE PART OF GENERAL BUSINESS CREDIT.—Section 
38(b) of the Internal Revenue Code of 1986 (relating to current 
year business credit) is amended by striking ‘‘plus’’ at the end 
of paragraph (34), by striking the period at the end of paragraph 
(35) and inserting ‘‘, plus’’, and by inserting after paragraph (35) 
the following: 
26 USC 38. 
Determination. 
Applicability. 
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124 STAT. 242 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(36) the small employer health insurance credit deter-
mined under section 45R.’’. 
(c) CREDIT ALLOWED AGAINST ALTERNATIVE MINIMUM TAX.— 
Section 38(c)(4)(B) of the Internal Revenue Code of 1986 (defining 
specified credits) is amended by redesignating clauses (vi), (vii), 
and (viii) as clauses (vii), (viii), and (ix), respectively, and by 
inserting after clause (v) the following new clause: 
‘‘(vi) the credit determined under section 45R,’’. 
(d) DISALLOWANCE OF DEDUCTION FOR CERTAIN EXPENSES FOR 
WHICH CREDIT ALLOWED.— 
(1) IN GENERAL.—Section 280C of the Internal Revenue 
Code of 1986 (relating to disallowance of deduction for certain 
expenses for which credit allowed), as amended by section 
1401(b), is amended by adding at the end the following new 
subsection: 
‘‘(h) CREDIT FOR EMPLOYEE HEALTH INSURANCE EXPENSES OF 
SMALL EMPLOYERS.—No deduction shall be allowed for that portion 
of the premiums for qualified health plans (as defined in section 
1301(a) of the Patient Protection and Affordable Care Act), or 
for health insurance coverage in the case of taxable years beginning 
in 2011, 2012, or 2013, paid by an employer which is equal to 
the amount of the credit determined under section 45R(a) with 
respect to the premiums.’’. 
(2) DEDUCTION FOR EXPIRING CREDITS.—Section 196(c) of 
such Code is amended by striking ‘‘and’’ at the end of paragraph 
(12), by striking the period at the end of paragraph (13) and 
inserting ‘‘, and’’, and by adding at the end the following new 
paragraph: 
‘‘(14) the small employer health insurance credit deter-
mined under section 45R(a).’’. 
(e) CLERICAL AMENDMENT.—The table of sections for subpart 
D of part IV of subchapter A of chapter 1 of the Internal Revenue 
Code of 1986 is amended by adding at the end the following: 
‘‘Sec. 45R. Employee health insurance expenses of small employers.’’. 
(f) EFFECTIVE DATES.— 
(1) IN GENERAL.—The amendments made by this section 
shall apply to amounts paid or incurred in taxable years begin-
ning after December 31, 2010. 
(2) MINIMUM TAX.—The amendments made by subsection 
(c) shall apply to credits determined under section 45R of 
the Internal Revenue Code of 1986 in taxable years beginning 
after December 31, 2010, and to carrybacks of such credits. 
Subtitle F—Shared Responsibility for 
Health Care 
PART I—INDIVIDUAL RESPONSIBILITY 
SEC. 1501. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COV-
ERAGE. 
(a) FINDINGS.—Congress makes the following findings: 
(1) IN GENERAL.—The individual responsibility requirement 
provided for in this section (in this subsection referred to as 
the ‘‘requirement’’) is commercial and economic in nature, and 
substantially affects interstate commerce, as a result of the 
effects described in paragraph (2). 
42 USC 18091. 
Applicability. 
26 USC 38 note. 
26 USC 38. 
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124 STAT. 243 
PUBLIC LAW 111–148—MAR. 23, 2010 
(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 commer-
cial and economic in nature: economic and financial 
decisions about how and when health care is paid for, 
and when health insurance is purchased. 
(B) Health insurance and health care services are a 
significant part of the national economy. National health 
spending is projected to increase 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 projected 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 insur-
ance is sold by national or regional health insurance compa-
nies, health insurance is sold in interstate commerce and 
claims payments 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. According to the Congres-
sional Budget Office, the requirement will increase the 
number and share of Americans who are insured. 
(D) The requirement achieves near-universal coverage 
by building upon and strengthening the private employer- 
based health insurance system, which covers 176,000,000 
Americans nationwide. In Massachusetts, a similar require-
ment has strengthened private employer-based coverage: 
despite the economic downturn, the number of workers 
offered employer-based coverage has actually increased. 
(E) Half of all personal bankruptcies are caused in 
part by medical expenses. By significantly increasing health 
insurance coverage, the requirement, together with the 
other provisions of this Act, will improve financial security 
for families. 
(F) Under the Employee Retirement Income 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 
Government has a significant role in regulating health 
insurance which is in interstate commerce. 
(G) 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 pur-
chase health insurance until they needed care. By signifi-
cantly increasing health insurance coverage, the require-
ment, 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 insurance premiums. The requirement 
is essential to creating effective health insurance markets 
in which improved health insurance products that are 
guaranteed issue and do not exclude coverage of pre- 
existing conditions can be sold. 
(H) 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 
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124 STAT. 244 
PUBLIC LAW 111–148—MAR. 23, 2010 
markets. By significantly increasing health insurance cov-
erage 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 administra-
tive costs and lower health insurance premiums. The 
requirement is essential to creating effective health insur-
ance markets that do not require underwriting and elimi-
nate its associated administrative costs. 
(3) SUPREME COURT RULING.—In United States v. South- 
Eastern Underwriters Association (322 U.S. 533 (1944)), the 
Supreme Court of the United States ruled that insurance is 
interstate commerce subject to Federal regulation. 
(b) IN GENERAL.—Subtitle D of the Internal Revenue Code 
of 1986 is amended by adding at the end the following new chapter: 
‘‘CHAPTER 48—MAINTENANCE OF MINIMUM ESSENTIAL 
COVERAGE 
‘‘Sec. 5000A. Requirement to maintain minimum essential coverage. 
‘‘SEC. 5000A. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COV-
ERAGE. 
‘‘(a) REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COV-
ERAGE.—An applicable individual shall for each month beginning 
after 2013 ensure that the individual, and any dependent of the 
individual who is an applicable individual, is covered under min-
imum essential coverage for such month. 
‘‘(b) SHARED RESPONSIBILITY PAYMENT.— 
‘‘(1) IN GENERAL.—If an applicable individual fails to meet 
the requirement of subsection (a) for 1 or more months during 
any calendar year beginning after 2013, then, except as pro-
vided in subsection (d), there is hereby imposed a penalty 
with respect to the individual in the amount determined under 
subsection (c). 
‘‘(2) INCLUSION
WITH
RETURN.—Any penalty imposed by 
this section with respect to any month shall be included with 
a taxpayer’s return under chapter 1 for the taxable year which 
includes such month. 
‘‘(3) PAYMENT OF PENALTY.—If an individual with respect 
to whom a penalty is imposed by this section for any month— 
‘‘(A) is a dependent (as defined in section 152) of 
another taxpayer for the other taxpayer’s taxable year 
including such month, such other taxpayer shall be liable 
for such penalty, or 
‘‘(B) files a joint return for the taxable year including 
such month, such individual and the spouse of such indi-
vidual shall be jointly liable for such penalty. 
‘‘(c) AMOUNT OF PENALTY.— 
‘‘(1) IN GENERAL.—The penalty determined under this sub-
section for any month with respect to any individual is an 
amount equal to 1⁄12 of the applicable dollar amount for the 
calendar year. 
‘‘(2) DOLLAR
LIMITATION.—The amount of the penalty 
imposed by this section on any taxpayer for any taxable year 
with respect to all individuals for whom the taxpayer is liable 
under subsection (b)(3) shall not exceed an amount equal to 
300 percent the applicable dollar amount (determined without 
Penalty. 
26 USC 5000A. 
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124 STAT. 245 
PUBLIC LAW 111–148—MAR. 23, 2010 
regard to paragraph (3)(C)) for the calendar year with or within 
which the taxable year ends. 
‘‘(3) APPLICABLE DOLLAR AMOUNT.—For purposes of para-
graph (1)— 
‘‘(A) IN
GENERAL.—Except as provided in subpara-
graphs (B) and (C), the applicable dollar amount is $750. 
‘‘(B) PHASE IN.—The applicable dollar amount is $95 
for 2014 and $350 for 2015. 
‘‘(C) SPECIAL RULE FOR INDIVIDUALS UNDER AGE 18.— 
If an applicable individual has not attained the age of 
18 as of the beginning of a month, the applicable dollar 
amount with respect to such individual for the month shall 
be equal to one-half of the applicable dollar amount for 
the calendar year in which the month occurs. 
‘‘(D) INDEXING OF AMOUNT.—In the case of any calendar 
year beginning after 2016, the applicable dollar amount 
shall be equal to $750, increased by an amount equal 
to— 
‘‘(i) $750, multiplied by 
‘‘(ii) the cost-of-living adjustment determined 
under section 1(f)(3) for the calendar year, determined 
by substituting ‘calendar year 2015’ for ‘calendar year 
1992’ in subparagraph (B) thereof. 
If the amount of any increase under clause (i) is not a 
multiple of $50, such increase shall be rounded to the 
next lowest multiple of $50. 
‘‘(4) TERMS RELATING TO INCOME AND FAMILIES.—For pur-
poses of this section— 
‘‘(A) FAMILY
SIZE.—The family size involved with 
respect to any taxpayer shall be equal to the number of 
individuals for whom the taxpayer is allowed a deduction 
under section 151 (relating to allowance of deduction for 
personal exemptions) for the taxable year. 
‘‘(B) 
HOUSEHOLD
INCOME.—The 
term 
‘household 
income’ means, with respect to any taxpayer for any taxable 
year, an amount equal to the sum of— 
‘‘(i) the modified gross income of the taxpayer, 
plus 
‘‘(ii) the aggregate modified gross incomes of all 
other individuals who— 
‘‘(I) were taken into account in determining 
the taxpayer’s family size under paragraph (1), 
and 
‘‘(II) were required to file a return of tax 
imposed by section 1 for the taxable year. 
‘‘(C) MODIFIED
GROSS
INCOME.—The term ‘modified 
gross income’ means gross income— 
‘‘(i) decreased by the amount of any deduction 
allowable under paragraph (1), (3), (4), or (10) of section 
62(a), 
‘‘(ii) increased by the amount of interest received 
or accrued during the taxable year which is exempt 
from tax imposed by this chapter, and 
‘‘(iii) determined without regard to sections 911, 
931, and 933. 
‘‘(D) POVERTY LINE.— 
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124 STAT. 246 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) IN GENERAL.—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)). 
‘‘(ii) POVERTY LINE USED.—In the case of any tax-
able year ending with or within a calendar year, the 
poverty line used shall be the most recently published 
poverty line as of the 1st day of such calendar year. 
‘‘(d) APPLICABLE INDIVIDUAL.—For purposes of this section— 
‘‘(1) IN GENERAL.—The term ‘applicable individual’ means, 
with respect to any month, an individual other than an indi-
vidual described in paragraph (2), (3), or (4). 
‘‘(2) RELIGIOUS EXEMPTIONS.— 
‘‘(A) RELIGIOUS
CONSCIENCE
EXEMPTION.—Such term 
shall not include any individual 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 a member of 
a recognized religious sect or division thereof described 
in section 1402(g)(1) and an adherent of established tenets 
or teachings of such sect or division as described in such 
section. 
‘‘(B) HEALTH CARE SHARING MINISTRY.— 
‘‘(i) IN GENERAL.—Such term shall not include any 
individual for any month if such individual is a member 
of a health care sharing ministry for the month. 
‘‘(ii) HEALTH CARE SHARING MINISTRY.—The term 
‘health care sharing ministry’ means an organization— 
‘‘(I) which is described in section 501(c)(3) and 
is exempt from taxation under section 501(a), 
‘‘(II) members of which share a common set 
of ethical or religious beliefs and share medical 
expenses among members in accordance with those 
beliefs and without regard to the State in which 
a member resides or is employed, 
‘‘(III) members of which retain membership 
even after they develop a medical condition, 
‘‘(IV) which (or a predecessor of which) has 
been in existence at all times since December 31, 
1999, and medical expenses of its members have 
been shared continuously and without interruption 
since at least December 31, 1999, and 
‘‘(V) which conducts an annual audit which 
is performed by an independent certified public 
accounting firm in accordance with generally 
accepted accounting principles and which is made 
available to the public upon request. 
‘‘(3) INDIVIDUALS NOT LAWFULLY PRESENT.—Such term shall 
not include an individual for any month if for the month the 
individual is not a citizen or national of the United States 
or an alien lawfully present in the United States. 
‘‘(4) INCARCERATED
INDIVIDUALS.—Such term shall not 
include an individual for any month if for the month the indi-
vidual is incarcerated, other than incarceration pending the 
disposition of charges. 
‘‘(e) EXEMPTIONS.—No penalty shall be imposed under sub-
section (a) with respect to— 
‘‘(1) INDIVIDUALS WHO CANNOT AFFORD COVERAGE.— 
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124 STAT. 247 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) IN GENERAL.—Any applicable individual for any 
month if the applicable individual’s required contribution 
(determined on an annual basis) for coverage for the month 
exceeds 8 percent of such individual’s household income 
for the taxable year described in section 1412(b)(1)(B) of 
the Patient Protection and Affordable Care Act. For pur-
poses of applying this subparagraph, the taxpayer’s house-
hold income shall be increased by any exclusion from gross 
income for any portion of the required contribution made 
through a salary reduction arrangement. 
‘‘(B) REQUIRED CONTRIBUTION.—For purposes of this 
paragraph, the term ‘required contribution’ means— 
‘‘(i) in the case of an individual eligible to purchase 
minimum essential coverage consisting of coverage 
through an eligible-employer-sponsored plan, the por-
tion of the annual premium which would be paid by 
the individual (without regard to whether paid through 
salary reduction or otherwise) for self-only coverage, 
or 
‘‘(ii) in the case of an individual eligible only to 
purchase minimum essential coverage described in sub-
section (f)(1)(C), the annual premium for the lowest 
cost bronze plan available in the individual market 
through the Exchange in the State in the rating area 
in which the individual resides (without regard to 
whether the individual purchased a qualified health 
plan through the Exchange), reduced by the amount 
of the credit allowable under section 36B for the tax-
able year (determined as if the individual was covered 
by a qualified health plan offered through the 
Exchange for the entire taxable year). 
‘‘(C) SPECIAL
RULES
FOR
INDIVIDUALS
RELATED
TO 
EMPLOYEES.—For purposes of subparagraph (B)(i), if an 
applicable individual is eligible for minimum essential cov-
erage through an employer by reason of a relationship 
to an employee, the determination shall be made by ref-
erence to the affordability of the coverage to the employee. 
‘‘(D) INDEXING.—In the case of plan years beginning 
in any calendar year after 2014, subparagraph (A) shall 
be applied by substituting for ‘8 percent’ the percentage 
the Secretary of Health and Human Services determines 
reflects the excess of the rate of premium growth between 
the preceding calendar year and 2013 over the rate of 
income growth for such period. 
‘‘(2) TAXPAYERS WITH INCOME UNDER 100 PERCENT OF POV-
ERTY LINE.—Any applicable individual for any month during 
a calendar year if the individual’s household income for the 
taxable year described in section 1412(b)(1)(B) of the Patient 
Protection and Affordable Care Act is less than 100 percent 
of the poverty line for the size of the family involved (deter-
mined in the same manner as under subsection (b)(4)). 
‘‘(3) MEMBERS OF INDIAN TRIBES.—Any applicable individual 
for any month during which the individual is a member of 
an Indian tribe (as defined in section 45A(c)(6)). 
‘‘(4) MONTHS DURING SHORT COVERAGE GAPS.— 
‘‘(A) IN GENERAL.—Any month the last day of which 
occurred during a period in which the applicable individual 
Applicability. 
Determination. 
Definition. 
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124 STAT. 248 
PUBLIC LAW 111–148—MAR. 23, 2010 
was not covered by minimum essential coverage for a 
continuous period of less than 3 months. 
‘‘(B) SPECIAL
RULES.—For purposes of applying this 
paragraph— 
‘‘(i) the length of a continuous period shall be deter-
mined without regard to the calendar years in which 
months in such period occur, 
‘‘(ii) if a continuous period is greater than the 
period allowed under subparagraph (A), no exception 
shall be provided under this paragraph for any month 
in the period, and 
‘‘(iii) if there is more than 1 continuous period 
described in subparagraph (A) covering months in a 
calendar year, the exception provided by this para-
graph shall only apply to months in the first of such 
periods. 
The Secretary shall prescribe rules for the collection of 
the penalty imposed by this section in cases where contin-
uous periods include months in more than 1 taxable year. 
‘‘(5) HARDSHIPS.—Any applicable individual who for any 
month is determined by the Secretary of Health and Human 
Services under section 1311(d)(4)(H) to have suffered a hardship 
with respect to the capability to obtain coverage under a quali-
fied health plan. 
‘‘(f) MINIMUM ESSENTIAL COVERAGE.—For purposes of this sec-
tion— 
‘‘(1) IN GENERAL.—The term ‘minimum essential coverage’ 
means any of the following: 
‘‘(A) GOVERNMENT
SPONSORED
PROGRAMS.—Coverage 
under— 
‘‘(i) the Medicare program under part A of title 
XVIII of the Social Security Act, 
‘‘(ii) the Medicaid program under title XIX of the 
Social Security Act, 
‘‘(iii) the CHIP program under title XXI of the 
Social Security Act, 
‘‘(iv) the TRICARE for Life program, 
‘‘(v) the veteran’s health care program under 
chapter 17 of title 38, United States Code, or 
‘‘(vi) a health plan under section 2504(e) of title 
22, United States Code (relating to Peace Corps volun-
teers). 
‘‘(B) EMPLOYER-SPONSORED PLAN.—Coverage under an 
eligible employer-sponsored plan. 
‘‘(C) PLANS
IN
THE
INDIVIDUAL
MARKET.—Coverage 
under a health plan offered in the individual market within 
a State. 
‘‘(D) GRANDFATHERED HEALTH PLAN.—Coverage under 
a grandfathered health plan. 
‘‘(E) OTHER COVERAGE.—Such other health benefits cov-
erage, such as a State health benefits risk pool, as the 
Secretary of Health and Human Services, in coordination 
with the Secretary, recognizes for purposes of this sub-
section. 
‘‘(2) ELIGIBLE
EMPLOYER-SPONSORED
PLAN.—The term 
‘eligible employer-sponsored plan’ means, with respect to any 
Definition. 
Applicability. 
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124 STAT. 249 
PUBLIC LAW 111–148—MAR. 23, 2010 
employee, a group health plan or group health insurance cov-
erage offered by an employer to the employee which is— 
‘‘(A) a governmental plan (within the meaning of sec-
tion 2791(d)(8) of the Public Health Service Act), or 
‘‘(B) any other plan or coverage offered in the small 
or large group market within a State. 
Such term shall include a grandfathered health plan described 
in paragraph (1)(D) offered in a group market. 
‘‘(3) EXCEPTED BENEFITS NOT TREATED AS MINIMUM ESSEN-
TIAL COVERAGE.—The term ‘minimum essential coverage’ shall 
not include health insurance coverage which consists of cov-
erage of excepted benefits— 
‘‘(A) described in paragraph (1) of subsection (c) of 
section 2791 of the Public Health Service Act; or 
‘‘(B) described in paragraph (2), (3), or (4) of such 
subsection if the benefits are provided under a separate 
policy, certificate, or contract of insurance. 
‘‘(4) INDIVIDUALS RESIDING OUTSIDE UNITED STATES OR RESI-
DENTS
OF
TERRITORIES.—Any applicable individual shall be 
treated as having minimum essential coverage for any month— 
‘‘(A) if such month occurs during any period described 
in subparagraph (A) or (B) of section 911(d)(1) which is 
applicable to the individual, or 
‘‘(B) if such individual is a bona fide resident of any 
possession of the United States (as determined under sec-
tion 937(a)) for such month. 
‘‘(5) INSURANCE-RELATED TERMS.—Any term used in this 
section which is also used in title I of the Patient Protection 
and Affordable Care Act shall have the same meaning as when 
used in such title. 
‘‘(g) ADMINISTRATION AND PROCEDURE.— 
‘‘(1) IN GENERAL.—The penalty provided by this section 
shall be paid upon notice and demand by the Secretary, and 
except as provided in paragraph (2), shall be assessed and 
collected in the same manner as an assessable penalty under 
subchapter B of chapter 68. 
‘‘(2) SPECIAL RULES.—Notwithstanding any other provision 
of law— 
‘‘(A) WAIVER OF CRIMINAL PENALTIES.—In the case of 
any failure by a taxpayer to timely pay any penalty imposed 
by this section, such taxpayer shall not be subject to any 
criminal prosecution or penalty with respect to such failure. 
‘‘(B) LIMITATIONS ON LIENS AND LEVIES.—The Secretary 
shall not— 
‘‘(i) file notice of lien with respect to any property 
of a taxpayer by reason of any failure to pay the 
penalty imposed by this section, or 
‘‘(ii) levy on any such property with respect to 
such failure.’’. 
(c) CLERICAL AMENDMENT.—The table of chapters for subtitle 
D of the Internal Revenue Code of 1986 is amended by inserting 
after the item relating to chapter 47 the following new item: 
‘‘CHAPTER 48—MAINTENANCE OF MINIMUM ESSENTIAL COVERAGE.’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall apply to taxable years ending after December 31, 2013. 
26 USC 5000A 
note. 
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124 STAT. 250 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 1502. REPORTING OF HEALTH INSURANCE COVERAGE. 
(a) IN GENERAL.—Part III of subchapter A of chapter 61 of 
the Internal Revenue Code of 1986 is amended by inserting after 
subpart C the following new subpart: 
‘‘Subpart D—Information Regarding Health 
Insurance Coverage 
‘‘Sec. 6055. Reporting of health insurance coverage. 
‘‘SEC. 6055. REPORTING OF HEALTH INSURANCE COVERAGE. 
‘‘(a) IN GENERAL.—Every person who provides minimum essen-
tial coverage to an individual during a calendar year shall, at 
such time as the Secretary may prescribe, make a return described 
in subsection (b). 
‘‘(b) FORM AND MANNER OF RETURN.— 
‘‘(1) IN GENERAL.—A return is described in this subsection 
if such return— 
‘‘(A) is in such form as the Secretary may prescribe, 
and 
‘‘(B) contains— 
‘‘(i) the name, address and TIN of the primary 
insured and the name and TIN of each other individual 
obtaining coverage under the policy, 
‘‘(ii) the dates during which such individual was 
covered under minimum essential coverage during the 
calendar year, 
‘‘(iii) in the case of minimum essential coverage 
which consists of health insurance coverage, informa-
tion concerning— 
‘‘(I) whether or not the coverage is a qualified 
health plan offered through an Exchange estab-
lished under section 1311 of the Patient Protection 
and Affordable Care Act, and 
‘‘(II) in the case of a qualified health plan, 
the amount (if any) of any advance payment under 
section 1412 of the Patient Protection and Afford-
able Care Act of any cost-sharing reduction under 
section 1402 of such Act or of any premium tax 
credit under section 36B with respect to such cov-
erage, and 
‘‘(iv) such other information as the Secretary may 
require. 
‘‘(2) INFORMATION RELATING TO EMPLOYER-PROVIDED COV-
ERAGE.—If minimum essential coverage provided to an indi-
vidual under subsection (a) consists of health insurance cov-
erage of a health insurance issuer provided through a group 
health plan of an employer, a return described in this subsection 
shall include— 
‘‘(A) the name, address, and employer identification 
number of the employer maintaining the plan, 
‘‘(B) the portion of the premium (if any) required to 
be paid by the employer, and 
‘‘(C) if the health insurance coverage is a qualified 
health plan in the small group market offered through 
an Exchange, such other information as the Secretary may 
require for administration of the credit under section 45R 
26 USC 6055. 
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124 STAT. 251 
PUBLIC LAW 111–148—MAR. 23, 2010 
(relating to credit for employee health insurance expenses 
of small employers). 
‘‘(c) STATEMENTS TO BE FURNISHED
TO INDIVIDUALS WITH 
RESPECT TO WHOM INFORMATION IS REPORTED.— 
‘‘(1) IN GENERAL.—Every person required to make a return 
under subsection (a) shall furnish to each individual whose 
name is required to be set forth in such return a written 
statement showing— 
‘‘(A) the name and address of the person required 
to make such return and the phone number of the informa-
tion contact for such person, and 
‘‘(B) the information required to be shown on the return 
with respect to such individual. 
‘‘(2) TIME FOR FURNISHING STATEMENTS.—The written state-
ment required under paragraph (1) shall be furnished on or 
before January 31 of the year following the calendar year 
for which the return under subsection (a) was required to 
be made. 
‘‘(d) COVERAGE PROVIDED BY GOVERNMENTAL UNITS.—In the 
case of coverage provided by any governmental unit or any agency 
or instrumentality thereof, the officer or employee who enters into 
the agreement to provide such coverage (or the person appropriately 
designated for purposes of this section) shall make the returns 
and statements required by this section. 
‘‘(e) MINIMUM ESSENTIAL COVERAGE.—For purposes of this sec-
tion, the term ‘minimum essential coverage’ has the meaning given 
such term by section 5000A(f).’’. 
(b) ASSESSABLE PENALTIES.— 
(1) Subparagraph (B) of section 6724(d)(1) of the Internal 
Revenue Code of 1986 (relating to definitions) is amended by 
striking ‘‘or’’ at the end of clause (xxii), by striking ‘‘and’’ 
at the end of clause (xxiii) and inserting ‘‘or’’, and by inserting 
after clause (xxiii) the following new clause: 
‘‘(xxiv) section 6055 (relating to returns relating 
to information regarding health insurance coverage), 
and’’. 
(2) Paragraph (2) of section 6724(d) of such Code is 
amended by striking ‘‘or’’ at the end of subparagraph (EE), 
by striking the period at the end of subparagraph (FF) and 
inserting ‘‘, or’’ and by inserting after subparagraph (FF) the 
following new subparagraph: 
‘‘(GG) section 6055(c) (relating to statements relating 
to information regarding health insurance coverage).’’. 
(c) NOTIFICATION OF NONENROLLMENT.—Not later than June 
30 of each year, the Secretary of the Treasury, acting through 
the Internal Revenue Service and in consultation with the Secretary 
of Health and Human Services, shall send a notification to each 
individual who files an individual income tax return and who is 
not enrolled in minimum essential coverage (as defined in section 
5000A of the Internal Revenue Code of 1986). Such notification 
shall contain information on the services available through the 
Exchange operating in the State in which such individual resides. 
(d) CONFORMING AMENDMENT.—The table of subparts for part 
III of subchapter A of chapter 61 of such Code is amended by 
inserting after the item relating to subpart C the following new 
item: 
Deadline. 
42 USC 18092. 
26 USC 6724. 
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124 STAT. 252 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SUBPART D—INFORMATION REGARDING HEALTH INSURANCE COVERAGE’’. 
(e) EFFECTIVE DATE.—The amendments made by this section 
shall apply to calendar years beginning after 2013. 
PART II—EMPLOYER RESPONSIBILITIES 
SEC. 1511. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE 
EMPLOYERS. 
The Fair Labor Standards Act of 1938 is amended by inserting 
after section 18 (29 U.S.C. 218) the following: 
‘‘SEC. 18A. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE 
EMPLOYERS. 
‘‘In accordance with regulations promulgated by the Secretary, 
an employer to which this Act applies that has more than 200 
full-time employees and that offers employees enrollment in 1 or 
more health benefits plans shall automatically enroll new full- 
time employees in one of the plans offered (subject to any waiting 
period authorized by law) and to continue the enrollment of current 
employees in a health benefits plan offered through the employer. 
Any automatic enrollment program shall include adequate notice 
and the opportunity for an employee to opt out of any coverage 
the individual or employee were automatically enrolled in. Nothing 
in this section shall be construed to supersede any State law which 
establishes, implements, or continues in effect any standard or 
requirement relating to employers in connection with payroll except 
to the extent that such standard or requirement prevents an 
employer from instituting the automatic enrollment program under 
this section.’’. 
SEC. 1512. EMPLOYER REQUIREMENT TO INFORM EMPLOYEES OF COV-
ERAGE OPTIONS. 
The Fair Labor Standards Act of 1938 is amended by inserting 
after section 18A (as added by section 1513) the following: 
‘‘SEC. 18B. NOTICE TO EMPLOYEES. 
‘‘(a) IN GENERAL.—In accordance with regulations promulgated 
by the Secretary, an employer to which this Act applies, shall 
provide to each employee at the time of hiring (or with respect 
to current employees, not later than March 1, 2013), written 
notice— 
‘‘(1) informing the employee of the existence of an 
Exchange, including a description of the services provided by 
such Exchange, and the manner in which the employee may 
contact the Exchange to request assistance; 
‘‘(2) if the employer plan’s share of the total allowed costs 
of benefits provided under the plan is less than 60 percent 
of such costs, that the employee may be eligible for a premium 
tax credit under section 36B of the Internal Revenue Code 
of 1986 and a cost sharing reduction under section 1402 of 
the Patient Protection and Affordable Care Act if the employee 
purchases a qualified health plan through the Exchange; and 
‘‘(3) if the employee purchases a qualified health plan 
through the Exchange, the employee will lose the employer 
contribution (if any) to any health benefits plan offered by 
the employer and that all or a portion of such contribution 
may be excludable from income for Federal income tax pur-
poses. 
Deadline. 
29 USC 218B. 
29 USC 218A. 
26 USC 6055 
note. 
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124 STAT. 253 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(b) EFFECTIVE DATE.—Subsection (a) shall take effect with 
respect to employers in a State beginning on March 1, 2013.’’. 
SEC. 1513. SHARED RESPONSIBILITY FOR EMPLOYERS. 
(a) IN GENERAL.—Chapter 43 of the Internal Revenue Code 
of 1986 is amended by adding at the end the following: 
‘‘SEC. 4980H. SHARED RESPONSIBILITY FOR EMPLOYERS REGARDING 
HEALTH COVERAGE. 
‘‘(a) LARGE EMPLOYERS NOT OFFERING HEALTH COVERAGE.— 
If— 
‘‘(1) any applicable large employer fails to offer to its full- 
time employees (and their dependents) the opportunity to enroll 
in minimum essential coverage under an eligible employer- 
sponsored plan (as defined in section 5000A(f)(2)) for any 
month, and 
‘‘(2) at least one full-time employee of the applicable large 
employer has been certified to the employer under section 1411 
of the Patient Protection and Affordable Care Act as having 
enrolled for such month in a qualified health plan with respect 
to which an applicable premium tax credit or cost-sharing 
reduction is allowed or paid with respect to the employee, 
then there is hereby imposed on the employer an assessable pay-
ment equal to the product of the applicable payment amount and 
the number of individuals employed by the employer as full-time 
employees during such month. 
‘‘(b) LARGE EMPLOYERS WITH WAITING PERIODS EXCEEDING 30 
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-spon-
sored plan (as defined in section 5000A(f)(2)), there is hereby 
imposed on the employer an assessable payment, in the amount 
specified in paragraph (2), for each full-time employee of the 
employer to whom the extended waiting period applies. 
‘‘(2) AMOUNT.—For purposes of paragraph (1), the amount 
specified in this paragraph for a full-time employee is— 
‘‘(A) in the case of an extended waiting period which 
exceeds 30 days but does not exceed 60 days, $400, and 
‘‘(B) in the case of an extended waiting period which 
exceeds 60 days, $600. 
‘‘(3) 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 
30 days. 
‘‘(c) LARGE EMPLOYERS OFFERING COVERAGE WITH EMPLOYEES 
WHO QUALIFY FOR PREMIUM TAX CREDITS OR COST-SHARING REDUC-
TIONS.— 
‘‘(1) IN GENERAL.—If— 
‘‘(A) an applicable large employer offers to its full- 
time employees (and their dependents) the opportunity to 
enroll in minimum essential coverage under an eligible 
employer-sponsored plan (as defined in section 5000A(f)(2)) 
for any month, and 
‘‘(B) 1 or more full-time employees of the applicable 
large employer has been certified to the employer under 
section 1411 of the Patient Protection and Affordable Care 
Act as having enrolled for such month in a qualified health 
26 USC 4980H. 
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124 STAT. 254 
PUBLIC LAW 111–148—MAR. 23, 2010 
plan with respect to which an applicable premium tax 
credit or cost-sharing reduction is allowed or paid with 
respect to the employee, 
then there is hereby imposed on the employer an assessable 
payment equal to the product of the number of full-time 
employees of the applicable large employer described in 
subparagraph (B) for such month and 400 percent of the 
applicable payment amount. 
‘‘(2) OVERALL LIMITATION.—The aggregate amount of tax 
determined under paragraph (1) with respect to all employees 
of an applicable large employer for any month shall not exceed 
the product of the applicable payment amount and the number 
of individuals employed by the employer as full-time employees 
during such month. 
‘‘(d) DEFINITIONS AND SPECIAL RULES.—For purposes of this 
section— 
‘‘(1) APPLICABLE PAYMENT AMOUNT.—The term ‘applicable 
payment amount’ means, with respect to any month, 1⁄12 of 
$750. 
‘‘(2) APPLICABLE LARGE EMPLOYER.— 
‘‘(A) IN GENERAL.—The term ‘applicable large employer’ 
means, with respect to a calendar year, an employer who 
employed an average of at least 50 full-time employees 
on business days during the preceding calendar year. 
‘‘(B) EXEMPTION FOR CERTAIN EMPLOYERS.— 
‘‘(i) IN GENERAL.—An employer shall not be consid-
ered to employ more than 50 full-time employees if— 
‘‘(I) the employer’s workforce exceeds 50 full- 
time employees for 120 days or fewer during the 
calendar year, and 
‘‘(II) the employees in excess of 50 employed 
during such 120-day period were seasonal workers. 
‘‘(ii) DEFINITION OF SEASONAL WORKERS.—The term 
‘seasonal worker’ means a worker who performs labor 
or services on a seasonal basis as defined by the Sec-
retary of Labor, including workers covered by section 
500.20(s)(1) of title 29, Code of Federal Regulations 
and retail workers employed exclusively during holiday 
seasons. 
‘‘(C) RULES
FOR
DETERMINING
EMPLOYER
SIZE.—For 
purposes of this paragraph— 
‘‘(i) APPLICATION
OF
AGGREGATION
RULE
FOR 
EMPLOYERS.—All persons treated as a single employer 
under subsection (b), (c), (m), or (o) of section 414 
of the Internal Revenue Code of 1986 shall be treated 
as 1 employer. 
‘‘(ii) EMPLOYERS NOT IN EXISTENCE IN PRECEDING 
YEAR.—In the case of an employer which was not in 
existence throughout the preceding calendar year, the 
determination of whether such employer is an 
applicable large employer shall be based on the average 
number of employees that it is reasonably expected 
such employer will employ on business days in the 
current calendar year. 
‘‘(iii) PREDECESSORS.—Any reference in this sub-
section to an employer shall include a reference to 
any predecessor of such employer. 
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124 STAT. 255 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(3) APPLICABLE PREMIUM TAX CREDIT AND COST-SHARING 
REDUCTION.—The term ‘applicable premium tax credit and cost- 
sharing reduction’ means— 
‘‘(A) any premium tax credit allowed under section 
36B, 
‘‘(B) any cost-sharing reduction under section 1402 of 
the Patient Protection and Affordable Care Act, and 
‘‘(C) any advance payment of such credit or reduction 
under section 1412 of such Act. 
‘‘(4) FULL-TIME EMPLOYEE.— 
‘‘(A) IN GENERAL.—The term ‘full-time employee’ means 
an employee who is employed on average at least 30 hours 
of service per week. 
‘‘(B) HOURS OF SERVICE.—The Secretary, in consulta-
tion with the Secretary of Labor, shall prescribe such regu-
lations, rules, and guidance as may be necessary to deter-
mine the hours of service of an employee, including rules 
for the application of this paragraph to employees who 
are not compensated on an hourly basis. 
‘‘(5) INFLATION ADJUSTMENT.— 
‘‘(A) IN GENERAL.—In the case of any calendar year 
after 2014, each of the dollar amounts in subsection (b)(2) 
and (d)(1) shall be increased by an amount equal to the 
product of— 
‘‘(i) such dollar amount, and 
‘‘(ii) the premium adjustment percentage (as 
defined in section 1302(c)(4) of the Patient Protection 
and Affordable Care Act) for the calendar year. 
‘‘(B) ROUNDING.—If the amount of any increase under 
subparagraph (A) is not a multiple of $10, such increase 
shall be rounded to the next lowest multiple of $10. 
‘‘(6) OTHER DEFINITIONS.—Any term used in this section 
which is also used in the Patient Protection and Affordable 
Care Act shall have the same meaning as when used in such 
Act. 
‘‘(7) TAX NONDEDUCTIBLE.—For denial of deduction for the 
tax imposed by this section, see section 275(a)(6). 
‘‘(e) ADMINISTRATION AND PROCEDURE.— 
‘‘(1) IN
GENERAL.—Any assessable payment provided by 
this section shall be paid upon notice and demand by the 
Secretary, and shall be assessed and collected in the same 
manner as an assessable penalty under subchapter B of chapter 
68. 
‘‘(2) TIME FOR PAYMENT.—The Secretary may provide for 
the payment of any assessable payment provided by this section 
on an annual, monthly, or other periodic basis as the Secretary 
may prescribe. 
‘‘(3) COORDINATION
WITH
CREDITS, ETC..—The Secretary 
shall prescribe rules, regulations, or guidance for the repayment 
of any assessable payment (including interest) if such payment 
is based on the allowance or payment of an applicable premium 
tax credit or cost-sharing reduction with respect to an employee, 
such allowance or payment is subsequently disallowed, and 
the assessable payment would not have been required to be 
made but for such allowance or payment.’’. 
Regulations. 
Guidance. 
Regulations. 
Guidance. 
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124 STAT. 256 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b) CLERICAL AMENDMENT.—The table of sections for chapter 
43 of such Code is amended by adding at the end the following 
new item: 
‘‘Sec. 4980H. Shared responsibility for employers regarding health coverage.’’. 
(c) STUDY
AND REPORT
OF EFFECT
OF TAX
ON WORKERS’ 
WAGES.— 
(1) IN
GENERAL.—The Secretary of Labor shall conduct 
a study to determine whether employees’ wages are reduced 
by reason of the application of the assessable payments under 
section 4980H of the Internal Revenue Code of 1986 (as added 
by the amendments made by this section). The Secretary shall 
make such determination on the basis of the National Com-
pensation Survey published by the Bureau of Labor Statistics. 
(2) REPORT.—The Secretary shall report the results of the 
study under paragraph (1) to the Committee on Ways and 
Means of the House of Representatives and to the Committee 
on Finance of the Senate. 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall apply to months beginning after December 31, 2013. 
SEC. 1514. REPORTING OF EMPLOYER HEALTH INSURANCE COVERAGE. 
(a) IN GENERAL.—Subpart D of part III of subchapter A of 
chapter 61 of the Internal Revenue Code of 1986, as added by 
section 1502, is amended by inserting after section 6055 the fol-
lowing new section: 
‘‘SEC. 6056. LARGE EMPLOYERS REQUIRED TO REPORT ON HEALTH 
INSURANCE COVERAGE. 
‘‘(a) IN GENERAL.—Every applicable large employer required 
to meet the requirements of section 4980H with respect to its 
full-time employees during a calendar year shall, at such time 
as the Secretary may prescribe, make a return described in sub-
section (b). 
‘‘(b) FORM AND MANNER OF RETURN.—A return is described 
in this subsection if such return— 
‘‘(1) is in such form as the Secretary may prescribe, and 
‘‘(2) contains— 
‘‘(A) the name, date, and employer identification 
number of the employer, 
‘‘(B) a certification as to whether the employer offers 
to its full-time employees (and their dependents) the oppor-
tunity to enroll in minimum essential coverage under an 
eligible employer-sponsored plan (as defined in section 
5000A(f)(2)), 
‘‘(C) if the employer certifies that the employer did 
offer to its full-time employees (and their dependents) the 
opportunity to so enroll— 
‘‘(i) the length of any waiting period (as defined 
in section 2701(b)(4) of the Public Health Service Act) 
with respect to such coverage, 
‘‘(ii) the months during the calendar year for which 
coverage under the plan was available, 
‘‘(iii) the monthly premium for the lowest cost 
option in each of the enrollment categories under the 
plan, and 
‘‘(iv) the applicable large employer’s share of the 
total allowed costs of benefits provided under the plan, 
Certification. 
26 USC 6056. 
26 USC 4980H 
note. 
Determination. 
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124 STAT. 257 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(D) the number of full-time employees for each month 
during the calendar year, 
‘‘(E) the name, address, and TIN of each full-time 
employee during the calendar year and the months (if 
any) during which such employee (and any dependents) 
were covered under any such health benefits plans, and 
‘‘(F) such other information as the Secretary may 
require. 
‘‘(c) STATEMENTS TO BE FURNISHED
TO INDIVIDUALS WITH 
RESPECT TO WHOM INFORMATION IS REPORTED.— 
‘‘(1) IN GENERAL.—Every person required to make a return 
under subsection (a) shall furnish to each full-time employee 
whose name is required to be set forth in such return under 
subsection (b)(2)(E) a written statement showing— 
‘‘(A) the name and address of the person required 
to make such return and the phone number of the informa-
tion contact for such person, and 
‘‘(B) the information required to be shown on the return 
with respect to such individual. 
‘‘(2) TIME FOR FURNISHING STATEMENTS.—The written state-
ment required under paragraph (1) shall be furnished on or 
before January 31 of the year following the calendar year 
for which the return under subsection (a) was required to 
be made. 
‘‘(d) COORDINATION WITH OTHER REQUIREMENTS.—To the max-
imum extent feasible, the Secretary may provide that— 
‘‘(1) any return or statement required to be provided under 
this section may be provided as part of any return or statement 
required under section 6051 or 6055, and 
‘‘(2) in the case of an applicable large employer offering 
health insurance coverage of a health insurance issuer, the 
employer may enter into an agreement with the issuer to 
include information required under this section with the return 
and statement required to be provided by the issuer under 
section 6055. 
‘‘(e) COVERAGE PROVIDED BY GOVERNMENTAL UNITS.—In the 
case of any applicable large employer which is a governmental 
unit or any agency or instrumentality thereof, the person appro-
priately designated for purposes of this section shall make the 
returns and statements required by this section. 
‘‘(f) DEFINITIONS.—For purposes of this section, any term used 
in this section which is also used in section 4980H shall have 
the meaning given such term by section 4980H.’’. 
(b) ASSESSABLE PENALTIES.— 
(1) Subparagraph (B) of section 6724(d)(1) of the Internal 
Revenue Code of 1986 (relating to definitions), as amended 
by section 1502, is amended by striking ‘‘or’’ at the end of 
clause (xxiii), by striking ‘‘and’’ at the end of clause (xxiv) 
and inserting ‘‘or’’, and by inserting after clause (xxiv) the 
following new clause: 
‘‘(xxv) section 6056 (relating to returns relating 
to large employers required to report on health insur-
ance coverage), and’’. 
(2) Paragraph (2) of section 6724(d) of such Code, as so 
amended, is amended by striking ‘‘or’’ at the end of subpara-
graph (FF), by striking the period at the end of subparagraph 
26 USC 6724. 
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124 STAT. 258 
PUBLIC LAW 111–148—MAR. 23, 2010 
(GG) and inserting ‘‘, or’’ and by inserting after subparagraph 
(GG) the following new subparagraph: 
‘‘(HH) section 6056(c) (relating to statements relating 
to large employers required to report on health insurance 
coverage).’’. 
(c) CONFORMING AMENDMENT.—The table of sections for subpart 
D of part III of subchapter A of chapter 61 of such Code, as 
added by section 1502, is amended by adding at the end the fol-
lowing new item: 
‘‘Sec. 6056. Large employers required to report on health insurance coverage.’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall apply to periods beginning after December 31, 2013. 
SEC. 1515. OFFERING OF EXCHANGE-PARTICIPATING QUALIFIED 
HEALTH PLANS THROUGH CAFETERIA PLANS. 
(a) IN GENERAL.—Subsection (f) of section 125 of the Internal 
Revenue Code of 1986 is amended by adding at the end the following 
new paragraph: 
‘‘(3) CERTAIN EXCHANGE-PARTICIPATING QUALIFIED HEALTH 
PLANS NOT QUALIFIED.— 
‘‘(A) IN GENERAL.—The term ‘qualified benefit’ shall 
not include any qualified health plan (as defined in section 
1301(a) of the Patient Protection and Affordable Care Act) 
offered through an Exchange established under section 
1311 of such Act. 
‘‘(B) EXCEPTION FOR EXCHANGE-ELIGIBLE EMPLOYERS.— 
Subparagraph (A) shall not apply with respect to any 
employee if such employee’s employer is a qualified 
employer (as defined in section 1312(f)(2) of the Patient 
Protection and Affordable Care Act) offering the employee 
the opportunity to enroll through such an Exchange in 
a qualified health plan in a group market.’’. 
(b) CONFORMING AMENDMENTS.—Subsection (f) of section 125 
of such Code is amended— 
(1) by striking ‘‘For purposes of this section, the term’’ 
and inserting ‘‘For purposes of this section— 
‘‘(1) IN GENERAL.—The term’’, and 
(2) by striking ‘‘Such term shall not include’’ and inserting 
the following: 
‘‘(2) LONG-TERM
CARE
INSURANCE
NOT
QUALIFIED.—The 
term ‘qualified benefit’ shall not include’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to taxable years beginning after December 31, 2013. 
Subtitle G—Miscellaneous Provisions 
SEC. 1551. DEFINITIONS. 
Unless specifically provided for otherwise, the definitions con-
tained in section 2791 of the Public Health Service Act (42 U.S.C. 
300gg–91) shall apply with respect to this title. 
SEC. 1552. TRANSPARENCY IN GOVERNMENT. 
Not later than 30 days after the date of enactment of this 
Act, the Secretary of Health and Human Services shall publish 
on the Internet website of the Department of Health and Human 
Services, a list of all of the authorities provided to the Secretary 
under this Act (and the amendments made by this Act). 
Deadline. 
Web posting. 
42 USC 18112. 
Applicability. 
42 USC 18111. 
26 USC 125 note. 
26 USC 125. 
26 USC 6056 
note. 
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124 STAT. 259 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 1553. PROHIBITION AGAINST DISCRIMINATION ON ASSISTED SUI-
CIDE. 
(a) IN GENERAL.—The Federal Government, and any State or 
local government or health care provider that receives Federal 
financial assistance under this Act (or under an amendment made 
by this Act) or any health plan created under this Act (or under 
an amendment made by this Act), may not subject an individual 
or institutional health care entity to discrimination on the basis 
that the entity does not provide any health care item or service 
furnished for the purpose of causing, or for the purpose of assisting 
in causing, the death of any individual, such as by assisted suicide, 
euthanasia, or mercy killing. 
(b) DEFINITION.—In this section, the term ‘‘health care entity’’ 
includes an individual physician or other health care professional, 
a hospital, a provider-sponsored organization, a health maintenance 
organization, a health insurance plan, or any other kind of health 
care facility, organization, or plan. 
(c) CONSTRUCTION AND TREATMENT OF CERTAIN SERVICES.— 
Nothing in subsection (a) shall be construed to apply to, or to 
affect, any limitation relating to— 
(1) the withholding or withdrawing of medical treatment 
or medical care; 
(2) the withholding or withdrawing of nutrition or hydra-
tion; 
(3) abortion; or 
(4) the use of an item, good, benefit, or service furnished 
for the purpose of alleviating pain or discomfort, even if such 
use may increase the risk of death, so long as such item, 
good, benefit, or service is not also furnished for the purpose 
of causing, or the purpose of assisting in causing, death, for 
any reason. 
(d) ADMINISTRATION.—The Office for Civil Rights of the Depart-
ment of Health and Human Services is designated to receive com-
plaints of discrimination based on this section. 
SEC. 1554. ACCESS TO THERAPIES. 
Notwithstanding any other provision of this Act, the Secretary 
of Health and Human Services shall not promulgate any regulation 
that— 
(1) creates any unreasonable barriers to the ability of 
individuals to obtain appropriate medical care; 
(2) impedes timely access to health care services; 
(3) interferes with communications regarding a full range 
of treatment options between the patient and the provider; 
(4) restricts the ability of health care providers to provide 
full disclosure of all relevant information to patients making 
health care decisions; 
(5) violates the principles of informed consent and the 
ethical standards of health care professionals; or 
(6) limits the availability of health care treatment for the 
full duration of a patient’s medical needs. 
42 USC 18114. 
Abortion. 
42 USC 18113. 
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124 STAT. 260 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 1555. FREEDOM NOT TO PARTICIPATE IN FEDERAL HEALTH 
INSURANCE PROGRAMS. 
No individual, company, business, nonprofit entity, or health 
insurance issuer offering group or individual health insurance cov-
erage shall be required to participate in any Federal health insur-
ance program created under this Act (or any amendments made 
by this Act), or in any Federal health insurance program expanded 
by this Act (or any such amendments), and there shall be no 
penalty or fine imposed upon any such issuer for choosing not 
to participate in such programs. 
SEC. 1556. EQUITY FOR CERTAIN ELIGIBLE SURVIVORS. 
(a) REBUTTABLE PRESUMPTION.—Section 411(c)(4) of the Black 
Lung Benefits Act (30 U.S.C. 921(c)(4)) is amended by striking 
the last sentence. 
(b) CONTINUATION OF BENEFITS.—Section 422(l) of the Black 
Lung Benefits Act (30 U.S.C. 932(l)) is amended by striking ‘‘, 
except with respect to a claim filed under this part on or after 
the effective date of the Black Lung Benefits Amendments of 1981’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply with respect to claims filed under part B or part C 
of the Black Lung Benefits Act (30 U.S.C. 921 et seq., 931 et 
seq.) after January 1, 2005, that are pending on or after the date 
of enactment of this Act. 
SEC. 1557. NONDISCRIMINATION. 
(a) IN GENERAL.—Except as otherwise provided for in this title 
(or an amendment made by this title), an individual shall not, 
on the ground prohibited under title VI of the Civil Rights Act 
of 1964 (42 U.S.C. 2000d et seq.), title IX of the Education Amend-
ments of 1972 (20 U.S.C. 1681 et seq.), the Age Discrimination 
Act of 1975 (42 U.S.C. 6101 et seq.), or section 504 of the Rehabilita-
tion Act of 1973 (29 U.S.C. 794), be excluded from participation 
in, be denied the benefits of, or be subjected to discrimination 
under, any health program or activity, any part of which is receiving 
Federal financial assistance, including credits, subsidies, or con-
tracts of insurance, or under any program or activity that is 
administered by an Executive Agency or any entity established 
under this title (or amendments). The enforcement mechanisms 
provided for and available under such title VI, title IX, section 
504, or such Age Discrimination Act shall apply for purposes of 
violations of this subsection. 
(b) CONTINUED APPLICATION OF LAWS.—Nothing in this title 
(or an amendment made by this title) shall be construed to invali-
date or limit the rights, remedies, procedures, or legal standards 
available to individuals aggrieved under title VI of the Civil Rights 
Act of 1964 (42 U.S.C. 2000d et seq.), title VII of the Civil Rights 
Act of 1964 (42 U.S.C. 2000e et seq.), title IX of the Education 
Amendments of 1972 (20 U.S.C. 1681 et seq.), section 504 of the 
Rehabilitation Act of 1973 (29 U.S.C. 794), or the Age Discrimina-
tion Act of 1975 (42 U.S.C. 611 et seq.), or to supersede State 
laws that provide additional protections against discrimination on 
any basis described in subsection (a). 
(c) REGULATIONS.—The Secretary may promulgate regulations 
to implement this section. 
Applicability. 
42 USC 18116. 
Applicability. 
30 USC 921 note. 
42 USC 18115. 
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124 STAT. 261 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 1558. PROTECTIONS FOR EMPLOYEES. 
The Fair Labor Standards Act of 1938 is amended by inserting 
after section 18B (as added by section 1512) the following: 
‘‘SEC. 18C. PROTECTIONS FOR EMPLOYEES. 
‘‘(a) PROHIBITION.—No employer shall discharge or in any 
manner discriminate against any employee with respect to his 
or her compensation, terms, conditions, or other privileges of 
employment because the employee (or an individual acting at the 
request of the employee) has— 
‘‘(1) received a credit under section 36B of the Internal 
Revenue Code of 1986 or a subsidy under section 1402 of 
this Act; 
‘‘(2) provided, caused to be provided, or is about to provide 
or cause to be provided to the employer, the Federal Govern-
ment, or the attorney general of a State information relating 
to any violation of, or any act or omission the employee reason-
ably believes to be a violation of, any provision of this title 
(or an amendment made by this title); 
‘‘(3) testified or is about to testify in a proceeding concerning 
such violation; 
‘‘(4) assisted or participated, or is about to assist or partici-
pate, in such a proceeding; or 
‘‘(5) objected to, or refused to participate in, any activity, 
policy, practice, or assigned task that the employee (or other 
such person) reasonably believed to be in violation of any provi-
sion of this title (or amendment), or any order, rule, regulation, 
standard, or ban under this title (or amendment). 
‘‘(b) COMPLAINT PROCEDURE.— 
‘‘(1) IN GENERAL.—An employee who believes that he or 
she has been discharged or otherwise discriminated against 
by any employer in violation of this section may seek relief 
in accordance with the procedures, notifications, burdens of 
proof, remedies, and statutes of limitation set forth in section 
2087(b) of title 15, United States Code. 
‘‘(2) NO LIMITATION ON RIGHTS.—Nothing in this section 
shall be deemed to diminish the rights, privileges, or remedies 
of any employee under any Federal or State law or under 
any collective bargaining agreement. The rights and remedies 
in this section may not be waived by any agreement, policy, 
form, or condition of employment.’’. 
SEC. 1559. OVERSIGHT. 
The Inspector General of the Department of Health and Human 
Services shall have oversight authority with respect to the adminis-
tration and implementation of this title as it relates to such Depart-
ment. 
SEC. 1560. RULES OF CONSTRUCTION. 
(a) NO EFFECT
ON ANTITRUST LAWS.—Nothing in this title 
(or an amendment made by this title) shall be construed to modify, 
impair, or supersede the operation of any of the antitrust laws. 
For the purposes of this section, the term ‘‘antitrust laws’’ has 
the meaning given such term in subsection (a) of the first section 
of the Clayton Act, except that such term includes section 5 of 
the Federal Trade Commission Act to the extent that such section 
5 applies to unfair methods of competition. 
42 USC 18118. 
42 USC 18117. 
29 USC 218C. 
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124 STAT. 262 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b) RULE
OF CONSTRUCTION REGARDING HAWAII’S PREPAID 
HEALTH CARE ACT.—Nothing in this title (or an amendment made 
by this title) shall be construed to modify or limit the application 
of the exemption for Hawaii’s Prepaid Health Care Act (Haw. Rev. 
Stat. §§ 393–1 et seq.) as provided for under section 514(b)(5) 
of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 
1144(b)(5)). 
(c) STUDENT HEALTH INSURANCE PLANS.—Nothing in this title 
(or an amendment made by this title) shall be construed to prohibit 
an institution of higher education (as such term is defined for 
purposes of the Higher Education Act of 1965) from offering a 
student health insurance plan, to the extent that such requirement 
is otherwise permitted under applicable Federal, State or local 
law. 
(d) NO EFFECT ON EXISTING REQUIREMENTS.—Nothing in this 
title (or an amendment made by this title, unless specified by 
direct statutory reference) shall be construed to modify any existing 
Federal requirement concerning the State agency responsible for 
determining eligibility for programs identified in section 1413. 
SEC. 1561. HEALTH INFORMATION TECHNOLOGY ENROLLMENT STAND-
ARDS AND PROTOCOLS. 
Title XXX of the Public Health Service Act (42 U.S.C. 300jj 
et seq.) is amended by adding at the end the following: 
‘‘Subtitle C—Other Provisions 
‘‘SEC. 3021. HEALTH INFORMATION TECHNOLOGY ENROLLMENT 
STANDARDS AND PROTOCOLS. 
‘‘(a) IN GENERAL.— 
‘‘(1) STANDARDS AND PROTOCOLS.—Not later than 180 days 
after the date of enactment of this title, the Secretary, in 
consultation with the HIT Policy Committee and the HIT Stand-
ards Committee, shall develop interoperable and secure stand-
ards and protocols that facilitate enrollment of individuals in 
Federal and State health and human services programs, as 
determined by the Secretary. 
‘‘(2) METHODS.—The Secretary shall facilitate enrollment 
in such programs through methods determined appropriate by 
the Secretary, which shall include providing individuals and 
third parties authorized by such individuals and their designees 
notification of eligibility and verification of eligibility required 
under such programs. 
‘‘(b) CONTENT.—The standards and protocols for electronic 
enrollment in the Federal and State programs described in sub-
section (a) shall allow for the following: 
‘‘(1) Electronic matching against existing Federal and State 
data, including vital records, employment history, enrollment 
systems, tax records, and other data determined appropriate 
by the Secretary to serve as evidence of eligibility and in 
lieu of paper-based documentation. 
‘‘(2) Simplification and submission of electronic documenta-
tion, digitization of documents, and systems verification of eligi-
bility. 
‘‘(3) Reuse of stored eligibility information (including docu-
mentation) to assist with retention of eligible individuals. 
Deadline. 
Determination. 
42 USC 300jj–51. 
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124 STAT. 263 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(4) Capability for individuals to apply, recertify and man-
age their eligibility information online, including at home, at 
points of service, and other community-based locations. 
‘‘(5) Ability to expand the enrollment system to integrate 
new programs, rules, and functionalities, to operate at increased 
volume, and to apply streamlined verification and eligibility 
processes to other Federal and State programs, as appropriate. 
‘‘(6) Notification of eligibility, recertification, and other 
needed communication regarding eligibility, which may include 
communication via email and cellular phones. 
‘‘(7) Other functionalities necessary to provide eligibles with 
streamlined enrollment process. 
‘‘(c) APPROVAL
AND
NOTIFICATION.—With respect to any 
standard or protocol developed under subsection (a) that has been 
approved by the HIT Policy Committee and the HIT Standards 
Committee, the Secretary— 
‘‘(1) shall notify States of such standards or protocols; and 
‘‘(2) may require, as a condition of receiving Federal funds 
for the health information technology investments, that States 
or other entities incorporate such standards and protocols into 
such investments. 
‘‘(d) GRANTS FOR IMPLEMENTATION OF APPROPRIATE ENROLL-
MENT HIT.— 
‘‘(1) IN
GENERAL.—The Secretary shall award grant to 
eligible entities to develop new, and adapt existing, technology 
systems to implement the HIT enrollment standards and proto-
cols developed under subsection (a) (referred to in this sub-
section as ‘appropriate HIT technology’). 
‘‘(2) ELIGIBLE ENTITIES.—To be eligible for a grant under 
this subsection, an entity shall— 
‘‘(A) be a State, political subdivision of a State, or 
a local governmental entity; and 
‘‘(B) submit to the Secretary an application at such 
time, in such manner, and containing— 
‘‘(i) a plan to adopt and implement appropriate 
enrollment technology that includes— 
‘‘(I) proposed reduction in maintenance costs 
of technology systems; 
‘‘(II) elimination or updating of legacy systems; 
and 
‘‘(III) demonstrated collaboration with other 
entities that may receive a grant under this section 
that are located in the same State, political sub-
division, or locality; 
‘‘(ii) an assurance that the entity will share such 
appropriate enrollment technology in accordance with 
paragraph (4); and 
‘‘(iii) such other information as the Secretary may 
require. 
‘‘(3) SHARING.— 
‘‘(A) IN
GENERAL.—The Secretary shall ensure that 
appropriate enrollment HIT adopted under grants under 
this subsection is made available to other qualified State, 
qualified political subdivisions of a State, or other appro-
priate qualified entities (as described in subparagraph (B)) 
at no cost. 
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124 STAT. 264 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) QUALIFIED ENTITIES.—The Secretary shall deter-
mine what entities are qualified to receive enrollment HIT 
under subparagraph (A), taking into consideration the rec-
ommendations of the HIT Policy Committee and the HIT 
Standards Committee.’’. 
SEC. 1562. CONFORMING AMENDMENTS. 
(a) APPLICABILITY.—Section 2735 of the Public Health Service 
Act (42 U.S.C. 300gg–21), as so redesignated by section 1001(4), 
is amended— 
(1) by striking subsection (a); 
(2) in subsection (b)— 
(A) in paragraph (1), by striking ‘‘1 through 3’’ and 
inserting ‘‘1 and 2’’; and 
(B) in paragraph (2)— 
(i) in subparagraph (A), by striking ‘‘subparagraph 
(D)’’ and inserting ‘‘subparagraph (D) or (E)’’; 
(ii) by striking ‘‘1 through 3’’ and inserting ‘‘1 
and 2’’; and 
(iii) by adding at the end the following: 
‘‘(E) 
ELECTION
NOT
APPLICABLE.—The 
election 
described in subparagraph (A) shall not be available with 
respect to the provisions of subpart 1.’’; 
(3) in subsection (c), by striking ‘‘1 through 3 shall not 
apply to any group’’ and inserting ‘‘1 and 2 shall not apply 
to any individual coverage or any group’’; and 
(4) in subsection (d)— 
(A) in paragraph (1), by striking ‘‘1 through 3 shall 
not apply to any group’’ and inserting ‘‘1 and 2 shall not 
apply to any individual coverage or any group’’; 
(B) in paragraph (2)— 
(i) in the matter preceding subparagraph (A), by 
striking ‘‘1 through 3 shall not apply to any group’’ 
and inserting ‘‘1 and 2 shall not apply to any individual 
coverage or any group’’; and 
(ii) in subparagraph (C), by inserting ‘‘or, with 
respect to individual coverage, under any health insur-
ance coverage maintained by the same health insur-
ance issuer’’; and 
(C) in paragraph (3), by striking ‘‘any group’’ and 
inserting ‘‘any individual coverage or any group’’. 
(b) DEFINITIONS.—Section 2791(d) of the Public Health Service 
Act (42 U.S.C. 300gg–91(d)) is amended by adding at the end 
the following: 
‘‘(20) QUALIFIED HEALTH PLAN.—The term ‘qualified health 
plan’ has the meaning given such term in section 1301(a) of 
the Patient Protection and Affordable Care Act. 
‘‘(21) EXCHANGE.—The term ‘Exchange’ means an American 
Health Benefit Exchange established under section 1311 of 
the Patient Protection and Affordable Care Act.’’. 
(c) TECHNICAL AND CONFORMING AMENDMENTS.—Title XXVII 
of the Public Health Service Act (42 U.S.C. 300gg et seq.) is 
amended— 
(1) in section 2704 (42 U.S.C. 300gg), as so redesignated 
by section 1201(2)— 
(A) in subsection (c)— 
42 USC 300gg–3. 
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124 STAT. 265 
PUBLIC LAW 111–148—MAR. 23, 2010 
(i) in paragraph (2), by striking ‘‘group health plan’’ 
each place that such term appears and inserting ‘‘group 
or individual health plan’’; and 
(ii) in paragraph (3)— 
(I) by striking ‘‘group health insurance’’ each 
place that such term appears and inserting ‘‘group 
or individual health insurance’’; and 
(II) in subparagraph (D), by striking ‘‘small 
or large’’ and inserting ‘‘individual or group’’; 
(B) in subsection (d), by striking ‘‘group health insur-
ance’’ each place that such term appears and inserting 
‘‘group or individual health insurance’’; and 
(C) in subsection (e)(1)(A), by striking ‘‘group health 
insurance’’ and inserting ‘‘group or individual health insur-
ance’’; 
(2) by striking the second heading for subpart 2 of part 
A (relating to other requirements); 
(3) in section 2725 (42 U.S.C. 300gg–4), as so redesignated 
by section 1001(2)— 
(A) in subsection (a), by striking ‘‘health insurance 
issuer offering group health insurance coverage’’ and 
inserting ‘‘health insurance issuer offering group or indi-
vidual health insurance coverage’’; 
(B) in subsection (b)— 
(i) by striking ‘‘health insurance issuer offering 
group health insurance coverage in connection with 
a group health plan’’ in the matter preceding para-
graph (1) and inserting ‘‘health insurance issuer 
offering group or individual health insurance coverage’’; 
and 
(ii) in paragraph (1), by striking ‘‘plan’’ and 
inserting ‘‘plan or coverage’’; 
(C) in subsection (c)— 
(i) in paragraph (2), by striking ‘‘group health 
insurance coverage offered by a health insurance 
issuer’’ and inserting ‘‘health insurance issuer offering 
group or individual health insurance coverage’’; and 
(ii) in paragraph (3), by striking ‘‘issuer’’ and 
inserting ‘‘health insurance issuer’’; and 
(D) in subsection (e), by striking ‘‘health insurance 
issuer offering group health insurance coverage’’ and 
inserting ‘‘health insurance issuer offering group or indi-
vidual health insurance coverage’’; 
(4) in section 2726 (42 U.S.C. 300gg–5), as so redesignated 
by section 1001(2)— 
(A) in subsection (a), by striking ‘‘(or health insurance 
coverage offered in connection with such a plan)’’ each 
place that such term appears and inserting ‘‘or a health 
insurance issuer offering group or individual health insur-
ance coverage’’; 
(B) in subsection (b), by striking ‘‘(or health insurance 
coverage offered in connection with such a plan)’’ each 
place that such term appears and inserting ‘‘or a health 
insurance issuer offering group or individual health insur-
ance coverage’’; and 
(C) in subsection (c)— 
42 USC 
300gg–26. 
42 USC 
300gg–25. 
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124 STAT. 266 
PUBLIC LAW 111–148—MAR. 23, 2010 
(i) in paragraph (1), by striking ‘‘(and group health 
insurance coverage offered in connection with a group 
health plan)’’ and inserting ‘‘and a health insurance 
issuer offering group or individual health insurance 
coverage’’; 
(ii) in paragraph (2), by striking ‘‘(or health insur-
ance coverage offered in connection with such a plan)’’ 
each place that such term appears and inserting ‘‘or 
a health insurance issuer offering group or individual 
health insurance coverage’’; 
(5) in section 2727 (42 U.S.C. 300gg–6), as so redesignated 
by section 1001(2), by striking ‘‘health insurance issuers pro-
viding health insurance coverage in connection with group 
health plans’’ and inserting ‘‘and health insurance issuers 
offering group or individual health insurance coverage’’; 
(6) in section 2728 (42 U.S.C. 300gg–7), as so redesignated 
by section 1001(2)— 
(A) in subsection (a), by striking ‘‘health insurance 
coverage offered in connection with such plan’’ and 
inserting ‘‘individual health insurance coverage’’; 
(B) in subsection (b)— 
(i) in paragraph (1), by striking ‘‘or a health insur-
ance issuer that provides health insurance coverage 
in connection with a group health plan’’ and inserting 
‘‘or a health insurance issuer that offers group or indi-
vidual health insurance coverage’’; 
(ii) in paragraph (2), by striking ‘‘health insurance 
coverage offered in connection with the plan’’ and 
inserting ‘‘individual health insurance coverage’’; and 
(iii) in paragraph (3), by striking ‘‘health insurance 
coverage offered by an issuer in connection with such 
plan’’ and inserting ‘‘individual health insurance cov-
erage’’; 
(C) in subsection (c), by striking ‘‘health insurance 
issuer providing health insurance coverage in connection 
with a group health plan’’ and inserting ‘‘health insurance 
issuer that offers group or individual health insurance 
coverage’’; and 
(D) in subsection (e)(1), by striking ‘‘health insurance 
coverage offered in connection with such a plan’’ and 
inserting ‘‘individual health insurance coverage’’; 
(7) by striking the heading for subpart 3; 
(8) in section 2731 (42 U.S.C. 300gg–11), as so redesignated 
by section 1001(3)— 
(A) by striking the section heading and all that follows 
through subsection (b); 
(B) in subsection (c)— 
(i) in paragraph (1)— 
(I) in the matter preceding subparagraph (A), 
by striking ‘‘small group’’ and inserting ‘‘group and 
individual’’; and 
(II) in subparagraph (B)— 
(aa) in the matter preceding clause (i), 
by 
inserting 
‘‘and 
individuals’’ 
after 
‘‘employers’’; 
42 USC 300gg–1. 
42 USC 
300gg–28. 
42 USC 
300gg–27. 
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124 STAT. 267 
PUBLIC LAW 111–148—MAR. 23, 2010 
(bb) in clause (i), by inserting ‘‘or any 
additional 
individuals’’ 
after 
‘‘additional 
groups’’; and 
(cc) in clause (ii), by striking ‘‘without 
regard to the claims experience of those 
employers and their employees (and their 
dependents) or any health status-related factor 
relating to such’’ and inserting ‘‘and individ-
uals without regard to the claims experience 
of those individuals, employers and their 
employees (and their dependents) or any 
health status-related factor relating to such 
individuals’’; and 
(ii) in paragraph (2), by striking ‘‘small group’’ 
and inserting ‘‘group or individual’’; 
(C) in subsection (d)— 
(i) by striking ‘‘small group’’ each place that such 
appears and inserting ‘‘group or individual’’; and 
(ii) in paragraph (1)(B)— 
(I) by striking ‘‘all employers’’ and inserting 
‘‘all employers and individuals’’; 
(II) 
by 
striking 
‘‘those 
employers’’ 
and 
inserting ‘‘those individuals, employers’’; and 
(III) 
by 
striking 
‘‘such 
employees’’ 
and 
inserting ‘‘such individuals, employees’’; 
(D) by striking subsection (e); 
(E) by striking subsection (f); and 
(F) by transferring such section (as amended by this 
paragraph) to appear at the end of section 2702 (as added 
by section 1001(4)); 
(9) in section 2732 (42 U.S.C. 300gg–12), as so redesignated 
by section 1001(3)— 
(A) by striking the section heading and all that follows 
through subsection (a); 
(B) in subsection (b)— 
(i) in the matter preceding paragraph (1), by 
striking ‘‘group health plan in the small or large group 
market’’ and inserting ‘‘health insurance coverage 
offered in the group or individual market’’; 
(ii) in paragraph (1), by inserting ‘‘, or individual, 
as applicable,’’ after ‘‘plan sponsor’’; 
(iii) in paragraph (2), by inserting ‘‘, or individual, 
as applicable,’’ after ‘‘plan sponsor’’; and 
(iv) by striking paragraph (3) and inserting the 
following: 
‘‘(3) 
VIOLATION
OF
PARTICIPATION
OR
CONTRIBUTION 
RATES.—In the case of a group health plan, the plan sponsor 
has failed to comply with a material plan provision relating 
to employer contribution or group participation rules, pursuant 
to applicable State law.’’; 
(C) in subsection (c)— 
(i) in paragraph (1)— 
(I) in the matter preceding subparagraph (A), 
by striking ‘‘group health insurance coverage 
offered in the small or large group market’’ and 
inserting ‘‘group or individual health insurance 
coverage’’; 
42 USC 300gg–2. 
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124 STAT. 268 
PUBLIC LAW 111–148—MAR. 23, 2010 
(II) in subparagraph (A), by inserting ‘‘or indi-
vidual, as applicable,’’ after ‘‘plan sponsor’’; 
(III) in subparagraph (B)— 
(aa) by inserting ‘‘or individual, as 
applicable,’’ after ‘‘plan sponsor’’; and 
(bb) by inserting ‘‘or individual health 
insurance coverage’’; and 
(IV) in subparagraph (C), by inserting ‘‘or 
individuals, as applicable,’’ after ‘‘those sponsors’’; 
and 
(ii) in paragraph (2)(A)— 
(I) in the matter preceding clause (i), by 
striking ‘‘small group market or the large group 
market, or both markets,’’ and inserting ‘‘indi-
vidual or group market, or all markets,’’; and 
(II) in clause (i), by inserting ‘‘or individual, 
as applicable,’’ after ‘‘plan sponsor’’; and 
(D) by transferring such section (as amended by this 
paragraph) to appear at the end of section 2703 (as added 
by section 1001(4)); 
(10) in section 2733 (42 U.S.C. 300gg–13), as so redesig-
nated by section 1001(4)— 
(A) in subsection (a)— 
(i) in the matter preceding paragraph (1), by 
striking 
‘‘small 
employer’’ 
and 
inserting 
‘‘small 
employer or an individual’’; 
(ii) in paragraph (1), by inserting ‘‘, or individual, 
as applicable,’’ after ‘‘employer’’ each place that such 
appears; and 
(iii) in paragraph (2), by striking ‘‘small employer’’ 
and inserting ‘‘employer, or individual, as applicable,’’; 
(B) in subsection (b)— 
(i) in paragraph (1)— 
(I) in the matter preceding subparagraph (A), 
by 
striking 
‘‘small 
employer’’ 
and 
inserting 
‘‘employer, or individual, as applicable,’’; 
(II) in subparagraph (A), by adding ‘‘and’’ at 
the end; 
(III) by striking subparagraphs (B) and (C); 
and 
(IV) in subparagraph (D)— 
(aa) by inserting ‘‘, or individual, as 
applicable,’’ after ‘‘employer’’; and 
(bb) by redesignating such subparagraph 
as subparagraph (B); 
(ii) in paragraph (2)— 
(I) by striking ‘‘small employers’’ each place 
that such term appears and inserting ‘‘employers, 
or individuals, as applicable,’’; and 
(II) by striking ‘‘small employer’’ and inserting 
‘‘employer, or individual, as applicable,’’; and 
(C) by redesignating such section (as amended by this 
paragraph) as section 2709 and transferring such section 
to appear after section 2708 (as added by section 1001(5)); 
(11) by redesignating subpart 4 as subpart 2; 
(12) in section 2735 (42 U.S.C. 300gg–21), as so redesig-
nated by section 1001(4)— 
42 USC 300gg–9. 
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124 STAT. 269 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) by striking subsection (a); 
(B) by striking ‘‘subparts 1 through 3’’ each place that 
such appears and inserting ‘‘subpart 1’’; 
(C) by redesignating subsections (b) through (e) as 
subsections (a) through (d), respectively; and 
(D) by redesignating such section (as amended by this 
paragraph) as section 2722; 
(13) in section 2736 (42 U.S.C. 300gg–22), as so redesig-
nated by section 1001(4)— 
(A) in subsection (a)— 
(i) in paragraph (1), by striking ‘‘small or large 
group markets’’ and inserting ‘‘individual or group 
market’’; and 
(ii) in paragraph (2), by inserting ‘‘or individual 
health insurance coverage’’ after ‘‘group health plans’’; 
(B) in subsection (b)(1)(B), by inserting ‘‘individual 
health insurance coverage or’’ after ‘‘respect to’’; and 
(C) by redesignating such section (as amended by this 
paragraph) as section 2723; 
(14) in section 2737(a)(1) (42 U.S.C. 300gg–23), as so 
redesignated by section 1001(4)— 
(A) by inserting ‘‘individual or’’ before ‘‘group health 
insurance’’; and 
(B) by redesignating such section(as amended by this 
paragraph) as section 2724; 
(15) in section 2762 (42 U.S.C. 300gg–62)— 
(A) in the section heading by inserting ‘‘AND APPLICA-
TION’’ before the period; and 
(B) by adding at the end the following: 
‘‘(c) APPLICATION OF PART A PROVISIONS.— 
‘‘(1) IN GENERAL.—The provisions of part A shall apply 
to health insurance issuers providing health insurance coverage 
in the individual market in a State as provided for in such 
part. 
‘‘(2) CLARIFICATION.—To the extent that any provision of 
this part conflicts with a provision of part A with respect 
to health insurance issuers providing health insurance coverage 
in the individual market in a State, the provisions of such 
part A shall apply.’’; and 
(16) in section 2791(e) (42 U.S.C. 300gg–91(e))— 
(A) in paragraph (2), by striking ‘‘51’’ and inserting 
‘‘101’’; and 
(B) in paragraph (4)— 
(i) by striking ‘‘at least 2’’ each place that such 
appears and inserting ‘‘at least 1’’; and 
(ii) by striking ‘‘50’’ and inserting ‘‘100’’. 
(d) APPLICATION.—Notwithstanding any other provision of the 
Patient Protection and Affordable Care Act, nothing in such Act 
(or an amendment made by such Act) shall be construed to— 
(1) prohibit (or authorize the Secretary of Health and 
Human Services to promulgate regulations that prohibit) a 
group health plan or health insurance issuer from carrying 
out utilization management techniques that are commonly used 
as of the date of enactment of this Act; or 
(2) restrict the application of the amendments made by 
this subtitle. 
42 USC 18120. 
42 USC 
300gg–23. 
42 USC 
300gg–22. 
42 USC 
300gg–21. 
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124 STAT. 270 
PUBLIC LAW 111–148—MAR. 23, 2010 
(e) TECHNICAL AMENDMENT
TO
THE EMPLOYEE RETIREMENT 
INCOME SECURITY ACT OF 1974.—Subpart B of part 7 of subtitle 
A of title I of the Employee Retirement Income Security Act of 
1974 (29 U.S.C. 1181 et. seq.) is amended, by adding at the end 
the following: 
‘‘SEC. 715. ADDITIONAL MARKET REFORMS. 
‘‘(a) GENERAL RULE.—Except as provided in subsection (b)— 
‘‘(1) the provisions of part A of title XXVII of the Public 
Health Service Act (as amended by the Patient Protection and 
Affordable Care Act) shall apply to group health plans, and 
health insurance issuers providing health insurance coverage 
in connection with group health plans, as if included in this 
subpart; and 
‘‘(2) to the extent that any provision of this part conflicts 
with a provision of such part A with respect to group health 
plans, or health insurance issuers providing health insurance 
coverage in connection with group health plans, the provisions 
of such part A shall apply. 
‘‘(b) EXCEPTION.—Notwithstanding subsection (a), the provi-
sions of sections 2716 and 2718 of title XXVII of the Public Health 
Service Act (as amended by the Patient Protection and Affordable 
Care Act) shall not apply with respect to self-insured group health 
plans, and the provisions of this part shall continue to apply to 
such plans as if such sections of the Public Health Service Act 
(as so amended) had not been enacted.’’. 
(f) TECHNICAL AMENDMENT TO THE INTERNAL REVENUE CODE 
OF 1986.—Subchapter B of chapter 100 of the Internal Revenue 
Code of 1986 is amended by adding at the end the following: 
‘‘SEC. 9815. ADDITIONAL MARKET REFORMS. 
‘‘(a) GENERAL RULE.—Except as provided in subsection (b)— 
‘‘(1) the provisions of part A of title XXVII of the Public 
Health Service Act (as amended by the Patient Protection and 
Affordable Care Act) shall apply to group health plans, and 
health insurance issuers providing health insurance coverage 
in connection with group health plans, as if included in this 
subchapter; and 
‘‘(2) to the extent that any provision of this subchapter 
conflicts with a provision of such part A with respect to group 
health plans, or health insurance issuers providing health 
insurance coverage in connection with group health plans, the 
provisions of such part A shall apply. 
‘‘(b) EXCEPTION.—Notwithstanding subsection (a), the provi-
sions of sections 2716 and 2718 of title XXVII of the Public Health 
Service Act (as amended by the Patient Protection and Affordable 
Care Act) shall not apply with respect to self-insured group health 
plans, and the provisions of this subchapter shall continue to apply 
to such plans as if such sections of the Public Health Service 
Act (as so amended) had not been enacted.’’. 
SEC. 1563. SENSE OF THE SENATE PROMOTING FISCAL RESPONSI-
BILITY. 
(a) FINDINGS.—The Senate makes the following findings: 
(1) Based on Congressional Budget Office (CBO) estimates, 
this Act will reduce the Federal deficit between 2010 and 2019. 
(2) CBO projects this Act will continue to reduce budget 
deficits after 2019. 
Applicability. 
29 USC 9815. 
Applicability. 
29 USC 1185d. 
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124 STAT. 271 
PUBLIC LAW 111–148—MAR. 23, 2010 
(3) Based on CBO estimates, this Act will extend the sol-
vency of the Medicare HI Trust Fund. 
(4) This Act will increase the surplus in the Social Security 
Trust Fund, which should be reserved to strengthen the 
finances of Social Security. 
(5) The initial net savings generated by the Community 
Living Assistance Services and Supports (CLASS) program are 
necessary to ensure the long-term solvency of that program. 
(b) SENSE OF THE SENATE.—It is the sense of the Senate that— 
(1) the additional surplus in the Social Security Trust 
Fund generated by this Act should be reserved for Social Secu-
rity and not spent in this Act for other purposes; and 
(2) the net savings generated by the CLASS program should 
be reserved for the CLASS program and not spent in this 
Act for other purposes. 
TITLE II—ROLE OF PUBLIC PROGRAMS 
Subtitle A—Improved Access to Medicaid 
SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME POPU-
LATIONS. 
(a) COVERAGE FOR INDIVIDUALS WITH INCOME AT OR BELOW 
133 PERCENT OF THE POVERTY LINE.— 
(1) BEGINNING 2014.—Section 1902(a)(10)(A)(i) of the Social 
Security Act (42 U.S.C. 1396a) is amended— 
(A) by striking ‘‘or’’ at the end of subclause (VI); 
(B) by adding ‘‘or’’ at the end of subclause (VII); and 
(C) by inserting after subclause (VII) the following: 
‘‘(VIII) beginning January 1, 2014, who are 
under 65 years of age, not pregnant, not entitled 
to, or enrolled for, benefits under part A of title 
XVIII, or enrolled for benefits under part B of 
title XVIII, and are not described in a previous 
subclause of this clause, and whose income (as 
determined under subsection (e)(14)) does not 
exceed 133 percent of the poverty line (as defined 
in section 2110(c)(5)) applicable to a family of the 
size involved, subject to subsection (k);’’. 
(2) PROVISION
OF
AT
LEAST
MINIMUM
ESSENTIAL
COV-
ERAGE.— 
(A) IN GENERAL.—Section 1902 of such Act (42 U.S.C. 
1396a) is amended by inserting after subsection (j) the 
following: 
‘‘(k)(1) The medical assistance provided to an individual 
described in subclause (VIII) of subsection (a)(10)(A)(i) shall consist 
of benchmark coverage described in section 1937(b)(1) or benchmark 
equivalent coverage described in section 1937(b)(2). Such medical 
assistance shall be provided subject to the requirements of section 
1937, without regard to whether a State otherwise has elected 
the option to provide medical assistance through coverage under 
that section, unless an individual described in subclause (VIII) 
of subsection (a)(10)(A)(i) is also an individual for whom, under 
subparagraph (B) of section 1937(a)(2), the State may not require 
enrollment in benchmark coverage described in subsection (b)(1) 
Effective date. 
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124 STAT. 272 
PUBLIC LAW 111–148—MAR. 23, 2010 
of section 1937 or benchmark equivalent coverage described in 
subsection (b)(2) of that section.’’. 
(B) CONFORMING AMENDMENT.—Section 1903(i) of the 
Social Security Act, as amended by section 6402(c), is 
amended— 
(i) in paragraph (24), by striking ‘‘or’’ at the end; 
(ii) in paragraph (25), by striking the period and 
inserting ‘‘; or’’; and 
(iii) by adding at the end the following: 
‘‘(26) with respect to any amounts expended for medical 
assistance for individuals described in subclause (VIII) of sub-
section (a)(10)(A)(i) other than medical assistance provided 
through benchmark coverage described in section 1937(b)(1) 
or benchmark equivalent coverage described in section 
1937(b)(2).’’. 
(3) FEDERAL
FUNDING
FOR
COST
OF
COVERING
NEWLY 
ELIGIBLE INDIVIDUALS.—Section 1905 of the Social Security Act 
(42 U.S.C. 1396d), is amended— 
(A) in subsection (b), in the first sentence, by inserting 
‘‘subsection (y) and’’ before ‘‘section 1933(d)’’; and 
(B) by adding at the end the following new subsection: 
‘‘(y) INCREASED FMAP FOR MEDICAL ASSISTANCE FOR NEWLY 
ELIGIBLE MANDATORY INDIVIDUALS.— 
‘‘(1) AMOUNT OF INCREASE.— 
‘‘(A) 100 PERCENT FMAP.—During the period that begins 
on January 1, 2014, and ends on December 31, 2016, not-
withstanding subsection (b), the Federal medical assistance 
percentage determined for a State that is one of the 50 
States or the District of Columbia for each fiscal year 
occurring during that period with respect to amounts 
expended for medical assistance for newly eligible individ-
uals 
described 
in 
subclause 
(VIII) 
of 
section 
1902(a)(10)(A)(i) shall be equal to 100 percent. 
‘‘(B) 2017 AND 2018.— 
‘‘(i) IN GENERAL.—During the period that begins 
on January 1, 2017, and ends on December 31, 2018, 
notwithstanding subsection (b) and subject to subpara-
graph (D), the Federal medical assistance percentage 
determined for a State that is one of the 50 States 
or the District of Columbia for each fiscal year occur-
ring during that period with respect to amounts 
expended for medical assistance for newly eligible 
individuals described in subclause (VIII) of section 
1902(a)(10)(A)(i), shall be increased by the applicable 
percentage point increase specified in clause (ii) for 
the quarter and the State. 
‘‘(ii) APPLICABLE PERCENTAGE POINT INCREASE.— 
‘‘(I) IN GENERAL.—For purposes of clause (i), 
the applicable percentage point increase for a 
quarter is the following: 
Time periods. 
42 USC 13966. 
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124 STAT. 273 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘For any fiscal year quar-
ter occurring in the cal-
endar year: 
If the State is an expan-
sion State, the applicable 
percentage point increase 
is: 
If the State is not an ex-
pansion State, the appli-
cable percentage point in-
crease is: 
2017 
30.3 
34.3 
2018 
31.3 
33.3 
‘‘(II) EXPANSION STATE DEFINED.—For purposes 
of the table in subclause (I), a State is an expan-
sion State if, on the date of the enactment of 
the Patient Protection and Affordable Care Act, 
the State offers health benefits coverage statewide 
to parents and nonpregnant, childless adults whose 
income is at least 100 percent of the poverty line, 
that is not dependent on access to employer cov-
erage, employer contribution, or employment and 
is not limited to premium assistance, hospital-only 
benefits, a high deductible health plan, or alter-
native benefits under a demonstration program 
authorized under section 1938. A State that offers 
health benefits coverage to only parents or only 
nonpregnant childless adults described in the pre-
ceding sentence shall not be considered to be an 
expansion State. 
‘‘(C) 2019 AND SUCCEEDING YEARS.—Beginning January 
1, 2019, notwithstanding subsection (b) but subject to 
subparagraph (D), the Federal medical assistance percent-
age determined for a State that is one of the 50 States 
or the District of Columbia for each fiscal year quarter 
occurring during that period with respect to amounts 
expended for medical assistance for newly eligible individ-
uals 
described 
in 
subclause 
(VIII) 
of 
section 
1902(a)(10)(A)(i), shall be increased by 32.3 percentage 
points. 
‘‘(D) LIMITATION.—The Federal medical assistance 
percentage determined for a State under subparagraph 
(B) or (C) shall in no case be more than 95 percent. 
‘‘(2) DEFINITIONS.—In this subsection: 
‘‘(A) NEWLY
ELIGIBLE.—The term ‘newly eligible’ 
means, with respect to an individual described in subclause 
(VIII) of section 1902(a)(10)(A)(i), an individual who is not 
under 19 years of age (or such higher age as the State 
may have elected) and who, on the date of enactment 
of the Patient Protection and Affordable Care Act, is not 
eligible under the State plan or under a waiver of the 
plan for full benefits or for benchmark coverage described 
in subparagraph (A), (B), or (C) of section 1937(b)(1) or 
benchmark equivalent coverage described in section 
1937(b)(2) that has an aggregate actuarial value that is 
at least actuarially equivalent to benchmark coverage 
described in subparagraph (A), (B), or (C) of section 
1937(b)(1), or is eligible but not enrolled (or is on a waiting 
list) for such benefits or coverage through a waiver under 
the plan that has a capped or limited enrollment that 
is full. 
Effective date. 
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124 STAT. 274 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) FULL BENEFITS.—The term ‘full benefits’ means, 
with respect to an individual, medical assistance for all 
services covered under the State plan under this title that 
is not less in amount, duration, or scope, or is determined 
by the Secretary to be substantially equivalent, to the 
medical assistance available for an individual described 
in section 1902(a)(10)(A)(i).’’. 
(4) STATE
OPTIONS
TO
OFFER
COVERAGE
EARLIER
AND 
PRESUMPTIVE ELIGIBILITY; CHILDREN REQUIRED TO HAVE COV-
ERAGE FOR PARENTS TO BE ELIGIBLE.— 
(A) IN
GENERAL.—Subsection (k) of section 1902 of 
the Social Security Act (as added by paragraph (2)), is 
amended by inserting after paragraph (1) the following: 
‘‘(2) Beginning with the first day of any fiscal year quarter 
that begins on or after January 1, 2011, and before January 1, 
2014, a State may elect through a State plan amendment to provide 
medical assistance to individuals who would be described in sub-
clause (VIII) of subsection (a)(10)(A)(i) if that subclause were effec-
tive before January 1, 2014. A State may elect to phase-in the 
extension of eligibility for medical assistance to such individuals 
based on income, so long as the State does not extend such eligibility 
to individuals described in such subclause with higher income before 
making individuals described in such subclause with lower income 
eligible for medical assistance. 
‘‘(3) If an individual described in subclause (VIII) of subsection 
(a)(10)(A)(i) is the parent of a child who is under 19 years of 
age (or such higher age as the State may have elected) who is 
eligible for medical assistance under the State plan or under a 
waiver of such plan (under that subclause or under a State plan 
amendment under paragraph (2), the individual may not be enrolled 
under the State plan unless the individual’s child is enrolled under 
the State plan or under a waiver of the plan or is enrolled in 
other health insurance coverage. For purposes of the preceding 
sentence, the term ‘parent’ includes an individual treated as a 
caretaker relative for purposes of carrying out section 1931.’’. 
(B) PRESUMPTIVE
ELIGIBILITY.—Section 1920 of the 
Social Security Act (42 U.S.C. 1396r–1) is amended by 
adding at the end the following: 
‘‘(e) If the State has elected the option to provide a presumptive 
eligibility period under this section or section 1920A, the State 
may elect to provide a presumptive eligibility period (as defined 
in subsection (b)(1)) for individuals who are eligible for medical 
assistance under clause (i)(VIII) of subsection (a)(10)(A) or section 
1931 in the same manner as the State provides for such a period 
under this section or section 1920A, subject to such guidance as 
the Secretary shall establish.’’. 
(5) CONFORMING AMENDMENTS.— 
(A) Section 1902(a)(10) of such Act (42 U.S.C. 
1396a(a)(10)) is amended in the matter following subpara-
graph (G), by striking ‘‘and (XIV)’’ and inserting ‘‘(XIV)’’ 
and by inserting ‘‘and (XV) the medical assistance made 
available to an individual described in subparagraph 
(A)(i)(VIII) shall be limited to medical assistance described 
in subsection (k)(1)’’ before the semicolon. 
(B) Section 1902(l)(2)(C) of such Act (42 U.S.C. 
1396a(l)(2)(C)) is amended by striking ‘‘100’’ and inserting 
‘‘133’’. 
Guidelines. 
Effective date. 
Time period. 
42 USC 1396a. 
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124 STAT. 275 
PUBLIC LAW 111–148—MAR. 23, 2010 
(C) Section 1905(a) of such Act (42 U.S.C. 1396d(a)) 
is amended in the matter preceding paragraph (1)— 
(i) by striking ‘‘or’’ at the end of clause (xii); 
(ii) by inserting ‘‘or’’ at the end of clause (xiii); 
and 
(iii) by inserting after clause (xiii) the following: 
‘‘(xiv) 
individuals 
described 
in 
section 
1902(a)(10)(A)(i)(VIII),’’. 
(D) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)) 
is amended by inserting ‘‘1902(a)(10)(A)(i)(VIII),’’ after 
‘‘1902(a)(10)(A)(i)(VII),’’. 
(E) Section 1937(a)(1)(B) of such Act (42 U.S.C. 1396u– 
7(a)(1)(B)) is amended by inserting ‘‘subclause (VIII) of 
section 1902(a)(10)(A)(i) or under’’ after ‘‘eligible under’’. 
(b) MAINTENANCE OF MEDICAID INCOME ELIGIBILITY.—Section 
1902 of the Social Security Act (42 U.S.C. 1396a) is amended— 
(1) in subsection (a)— 
(A) by striking ‘‘and’’ at the end of paragraph (72); 
(B) by striking the period at the end of paragraph 
(73) and inserting ‘‘; and’’; and 
(C) by inserting after paragraph (73) the following 
new paragraph: 
‘‘(74) provide for maintenance of effort under the State 
plan or under any waiver of the plan in accordance with sub-
section (gg).’’; and 
(2) by adding at the end the following new subsection: 
‘‘(gg) MAINTENANCE OF EFFORT.— 
‘‘(1) GENERAL
REQUIREMENT
TO
MAINTAIN
ELIGIBILITY 
STANDARDS UNTIL STATE EXCHANGE IS FULLY OPERATIONAL.— 
Subject to the succeeding paragraphs of this subsection, during 
the period that begins on the date of enactment of the Patient 
Protection and Affordable Care Act and ends on the date on 
which the Secretary determines that an Exchange established 
by the State under section 1311 of the Patient Protection and 
Affordable Care Act is fully operational, as a condition for 
receiving any Federal payments under section 1903(a) for cal-
endar quarters occurring during such period, a State shall 
not have in effect eligibility standards, methodologies, or proce-
dures under the State plan under this title or under any waiver 
of such plan that is in effect during that period, that are 
more restrictive than the eligibility standards, methodologies, 
or procedures, respectively, under the plan or waiver that are 
in effect on the date of enactment of the Patient Protection 
and Affordable Care Act. 
‘‘(2) CONTINUATION OF ELIGIBILITY STANDARDS FOR CHIL-
DREN UNTIL OCTOBER 1, 2019.—The requirement under para-
graph (1) shall continue to apply to a State through September 
30, 2019, with respect to the eligibility standards, methodolo-
gies, and procedures under the State plan under this title 
or under any waiver of such plan that are applicable to deter-
mining the eligibility for medical assistance of any child who 
is under 19 years of age (or such higher age as the State 
may have elected). 
‘‘(3) NONAPPLICATION.—During the period that begins on 
January 1, 2011, and ends on December 31, 2013, the require-
ment under paragraph (1) shall not apply to a State with 
respect to nonpregnant, nondisabled adults who are eligible 
Time period. 
Deadline. 
Certification. 
Applicability. 
Time period. 
Determination. 
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124 STAT. 276 
PUBLIC LAW 111–148—MAR. 23, 2010 
for medical assistance under the State plan or under a waiver 
of the plan at the option of the State and whose income exceeds 
133 percent of the poverty line (as defined in section 2110(c)(5)) 
applicable to a family of the size involved if, on or after 
December 31, 2010, the State certifies to the Secretary that, 
with respect to the State fiscal year during which the certifi-
cation is made, the State has a budget deficit, or with respect 
to the succeeding State fiscal year, the State is projected to 
have a budget deficit. Upon submission of such a certification 
to the Secretary, the requirement under paragraph (1) shall 
not apply to the State with respect to any remaining portion 
of the period described in the preceding sentence. 
‘‘(4) DETERMINATION OF COMPLIANCE.— 
‘‘(A) STATES SHALL APPLY MODIFIED GROSS INCOME.— 
A State’s determination of income in accordance with sub-
section (e)(14) shall not be considered to be eligibility stand-
ards, methodologies, or procedures that are more restrictive 
than the standards, methodologies, or procedures in effect 
under the State plan or under a waiver of the plan on 
the date of enactment of the Patient Protection and Afford-
able Care Act for purposes of determining compliance with 
the requirements of paragraph (1), (2), or (3). 
‘‘(B) STATES
MAY
EXPAND
ELIGIBILITY
OR
MOVE 
WAIVERED POPULATIONS INTO COVERAGE UNDER THE STATE 
PLAN.—With respect to any period applicable under para-
graph (1), (2), or (3), a State that applies eligibility stand-
ards, methodologies, or procedures under the State plan 
under this title or under any waiver of the plan that 
are less restrictive than the eligibility standards, meth-
odologies, or procedures, applied under the State plan or 
under a waiver of the plan on the date of enactment of 
the Patient Protection and Affordable Care Act, or that 
makes individuals who, on such date of enactment, are 
eligible for medical assistance under a waiver of the State 
plan, after such date of enactment eligible for medical 
assistance through a State plan amendment with an income 
eligibility level that is not less than the income eligibility 
level that applied under the waiver, or as a result of 
the 
application 
of 
subclause 
(VIII) 
of 
section 
1902(a)(10)(A)(i), shall not be considered to have in effect 
eligibility standards, methodologies, or procedures that are 
more restrictive than the standards, methodologies, or 
procedures in effect under the State plan or under a waiver 
of the plan on the date of enactment of the Patient Protec-
tion and Affordable Care Act for purposes of determining 
compliance with the requirements of paragraph (1), (2), 
or (3).’’. 
(c) MEDICAID BENCHMARK BENEFITS MUST CONSIST OF AT LEAST 
MINIMUM ESSENTIAL COVERAGE.—Section 1937(b) of such Act (42 
U.S.C. 1396u–7(b)) is amended— 
(1) in paragraph (1), in the matter preceding subparagraph 
(A), by inserting ‘‘subject to paragraphs (5) and (6),’’ before 
‘‘each’’; 
(2) in paragraph (2)— 
(A) in the matter preceding subparagraph (A), by 
inserting ‘‘subject to paragraphs (5) and (6)’’ after ‘‘sub-
section (a)(1),’’; 
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124 STAT. 277 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) in subparagraph (A)— 
(i) by redesignating clauses (iv) and (v) as clauses 
(vi) and (vii), respectively; and 
(ii) by inserting after clause (iii), the following: 
‘‘(iv) Coverage of prescription drugs. 
‘‘(v) Mental health services.’’; and 
(C) in subparagraph (C)— 
(i) by striking clauses (i) and (ii); and 
(ii) by redesignating clauses (iii) and (iv) as clauses 
(i) and (ii), respectively; and 
(3) by adding at the end the following new paragraphs: 
‘‘(5) MINIMUM STANDARDS.—Effective January 1, 2014, any 
benchmark benefit package under paragraph (1) or benchmark 
equivalent coverage under paragraph (2) must provide at least 
essential health benefits as described in section 1302(b) of 
the Patient Protection and Affordable Care Act. 
‘‘(6) MENTAL HEALTH SERVICES PARITY.— 
‘‘(A) IN GENERAL.—In the case of any benchmark ben-
efit package under paragraph (1) or benchmark equivalent 
coverage under paragraph (2) that is offered by an entity 
that is not a medicaid managed care organization and 
that provides both medical and surgical benefits and mental 
health or substance use disorder benefits, the entity shall 
ensure that the financial requirements and treatment 
limitations applicable to such mental health or substance 
use disorder benefits comply with the requirements of sec-
tion 2705(a) of the Public Health Service Act in the same 
manner as such requirements apply to a group health 
plan. 
‘‘(B) DEEMED
COMPLIANCE.—Coverage provided with 
respect to an individual described in section 1905(a)(4)(B) 
and 
covered 
under 
the 
State 
plan 
under 
section 
1902(a)(10)(A) 
of 
the 
services 
described 
in 
section 
1905(a)(4)(B) (relating to early and periodic screening, diag-
nostic, and treatment services defined in section 1905(r)) 
and provided in accordance with section 1902(a)(43), shall 
be deemed to satisfy the requirements of subparagraph 
(A).’’. 
(d) ANNUAL REPORTS ON MEDICAID ENROLLMENT.— 
(1) STATE REPORTS.—Section 1902(a) of the Social Security 
Act (42 U.S.C. 1396a(a)), as amended by subsection (b), is 
amended— 
(A) by striking ‘‘and’’ at the end of paragraph (73); 
(B) by striking the period at the end of paragraph 
(74) and inserting ‘‘; and’’; and 
(C) by inserting after paragraph (74) the following 
new paragraph: 
‘‘(75) provide that, beginning January 2015, and annually 
thereafter, the State shall submit a report to the Secretary 
that contains— 
‘‘(A) the total number of enrolled and newly enrolled 
individuals in the State plan or under a waiver of the 
plan for the fiscal year ending on September 30 of the 
preceding calendar year, disaggregated by population, 
including children, parents, nonpregnant childless adults, 
disabled individuals, elderly individuals, and such other 
Effective date. 
Effective date. 
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124 STAT. 278 
PUBLIC LAW 111–148—MAR. 23, 2010 
categories or sub-categories of individuals eligible for med-
ical assistance under the State plan or under a waiver 
of the plan as the Secretary may require; 
‘‘(B) a description, which may be specified by popu-
lation, of the outreach and enrollment processes used by 
the State during such fiscal year; and 
‘‘(C) any other data reporting determined necessary 
by the Secretary to monitor enrollment and retention of 
individuals eligible for medical assistance under the State 
plan or under a waiver of the plan.’’. 
(2) REPORTS
TO
CONGRESS.—Beginning April 2015, and 
annually thereafter, the Secretary of Health and Human Serv-
ices shall submit a report to the appropriate committees of 
Congress on the total enrollment and new enrollment in Med-
icaid for the fiscal year ending on September 30 of the preceding 
calendar year on a national and State-by-State basis, and shall 
include in each such report such recommendations for adminis-
trative or legislative changes to improve enrollment in the 
Medicaid program as the Secretary determines appropriate. 
(e) STATE
OPTION
FOR
COVERAGE
FOR
INDIVIDUALS
WITH 
INCOME THAT EXCEEDS 133 PERCENT
OF
THE POVERTY LINE.— 
(1) COVERAGE AS OPTIONAL CATEGORICALLY NEEDY GROUP.— 
Section 1902 of the Social Security Act (42 U.S.C. 1396a) is 
amended— 
(A) in subsection (a)(10)(A)(ii)— 
(i) in subclause (XVIII), by striking ‘‘or’’ at the 
end; 
(ii) in subclause (XIX), by adding ‘‘or’’ at the end; 
and 
(iii) by adding at the end the following new sub-
clause: 
‘‘(XX) beginning January 1, 2014, who are 
under 65 years of age and are not described in 
or enrolled under a previous subclause of this 
clause, and whose income (as determined under 
subsection (e)(14)) exceeds 133 percent of the pov-
erty line (as defined in section 2110(c)(5)) 
applicable to a family of the size involved but 
does not exceed the highest income eligibility level 
established under the State plan or under a waiver 
of the plan, subject to subsection (hh);’’ and 
(B) by adding at the end the following new subsection: 
‘‘(hh)(1) A State may elect to phase-in the extension of eligibility 
for medical assistance to individuals described in subclause (XX) 
of subsection (a)(10)(A)(ii) based on the categorical group (including 
nonpregnant childless adults) or income, so long as the State does 
not extend such eligibility to individuals described in such subclause 
with higher income before making individuals described in such 
subclause with lower income eligible for medical assistance. 
‘‘(2) If an individual described in subclause (XX) of subsection 
(a)(10)(A)(ii) is the parent of a child who is under 19 years of 
age (or such higher age as the State may have elected) who is 
eligible for medical assistance under the State plan or under a 
waiver of such plan, the individual may not be enrolled under 
the State plan unless the individual’s child is enrolled under the 
State plan or under a waiver of the plan or is enrolled in other 
health insurance coverage. For purposes of the preceding sentence, 
Effective date. 
Effective date. 
42 USC 1396a 
note. 
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124 STAT. 279 
PUBLIC LAW 111–148—MAR. 23, 2010 
the term ‘parent’ includes an individual treated as a caretaker 
relative for purposes of carrying out section 1931.’’. 
(2) CONFORMING AMENDMENTS.— 
(A) Section 1905(a) of such Act (42 U.S.C. 1396d(a)), 
as amended by subsection (a)(5)(C), is amended in the 
matter preceding paragraph (1)— 
(i) by striking ‘‘or’’ at the end of clause (xiii); 
(ii) by inserting ‘‘or’’ at the end of clause (xiv); 
and 
(iii) by inserting after clause (xiv) the following: 
‘‘(xv) 
individuals 
described 
in 
section 
1902(a)(10)(A)(ii)(XX),’’. 
(B) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)) 
is amended by inserting ‘‘1902(a)(10)(A)(ii)(XX),’’ after 
‘‘1902(a)(10)(A)(ii)(XIX),’’. 
(C) Section 1920(e) of such Act (42 U.S.C. 1396r–1(e)), 
as added by subsection (a)(4)(B), is amended by inserting 
‘‘or clause (ii)(XX)’’ after ‘‘clause (i)(VIII)’’. 
SEC. 2002. INCOME ELIGIBILITY FOR NONELDERLY DETERMINED 
USING MODIFIED GROSS INCOME. 
(a) IN GENERAL.—Section 1902(e) of the Social Security Act 
(42 U.S.C. 1396a(e)) is amended by adding at the end the following: 
‘‘(14) 
INCOME
DETERMINED
USING
MODIFIED
GROSS 
INCOME.— 
‘‘(A) IN GENERAL.—Notwithstanding subsection (r) or 
any other provision of this title, except as provided in 
subparagraph (D), for purposes of determining income eligi-
bility for medical assistance under the State plan or under 
any waiver of such plan and for any other purpose 
applicable under the plan or waiver for which a determina-
tion of income is required, including with respect to the 
imposition of premiums and cost-sharing, a State shall 
use the modified gross income of an individual and, in 
the case of an individual in a family greater than 1, the 
household income of such family. A State shall establish 
income eligibility thresholds for populations to be eligible 
for medical assistance under the State plan or a waiver 
of the plan using modified gross income and household 
income that are not less than the effective income eligibility 
levels that applied under the State plan or waiver on 
the date of enactment of the Patient Protection and Afford-
able Care Act. For purposes of complying with the mainte-
nance of effort requirements under subsection (gg) during 
the transition to modified gross income and household 
income, a State shall, working with the Secretary, establish 
an equivalent income test that ensures individuals eligible 
for medical assistance under the State plan or under a 
waiver of the plan on the date of enactment of the Patient 
Protection and Affordable Care Act, do not lose coverage 
under the State plan or under a waiver of the plan. The 
Secretary may waive such provisions of this title and title 
XXI as are necessary to ensure that States establish income 
and eligibility determination systems that protect bene-
ficiaries. 
‘‘(B) NO
INCOME
OR
EXPENSE
DISREGARDS.—No type 
of expense, block, or other income disregard shall be applied 
Waiver authority. 
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124 STAT. 280 
PUBLIC LAW 111–148—MAR. 23, 2010 
by a State to determine income eligibility for medical assist-
ance under the State plan or under any waiver of such 
plan or for any other purpose applicable under the plan 
or waiver for which a determination of income is required. 
‘‘(C) NO ASSETS TEST.—A State shall not apply any 
assets or resources test for purposes of determining eligi-
bility for medical assistance under the State plan or under 
a waiver of the plan. 
‘‘(D) EXCEPTIONS.— 
‘‘(i) INDIVIDUALS ELIGIBLE BECAUSE OF OTHER AID 
OR
ASSISTANCE, 
ELDERLY
INDIVIDUALS, 
MEDICALLY 
NEEDY
INDIVIDUALS, AND
INDIVIDUALS
ELIGIBLE
FOR 
MEDICARE COST-SHARING.—Subparagraphs (A), (B), and 
(C) shall not apply to the determination of eligibility 
under the State plan or under a waiver for medical 
assistance for the following: 
‘‘(I) Individuals who are eligible for medical 
assistance under the State plan or under a waiver 
of the plan on a basis that does not require a 
determination of income by the State agency 
administering the State plan or waiver, including 
as a result of eligibility for, or receipt of, other 
Federal or State aid or assistance, individuals who 
are eligible on the basis of receiving (or being 
treated as if receiving) supplemental security 
income benefits under title XVI, and individuals 
who are eligible as a result of being or being 
deemed to be a child in foster care under the 
responsibility of the State. 
‘‘(II) Individuals who have attained age 65. 
‘‘(III) Individuals who qualify for medical 
assistance under the State plan or under any 
waiver of such plan on the basis of being blind 
or disabled (or being treated as being blind or 
disabled) without regard to whether the individual 
is eligible for supplemental security income bene-
fits under title XVI on the basis of being blind 
or disabled and including an individual who is 
eligible for medical assistance on the basis of sec-
tion 1902(e)(3). 
‘‘(IV) Individuals described in subsection 
(a)(10)(C). 
‘‘(V) Individuals described in any clause of sub-
section (a)(10)(E). 
‘‘(ii) EXPRESS LANE AGENCY FINDINGS.—In the case 
of a State that elects the Express Lane option under 
paragraph (13), notwithstanding subparagraphs (A), 
(B), and (C), the State may rely on a finding made 
by an Express Lane agency in accordance with that 
paragraph relating to the income of an individual for 
purposes of determining the individual’s eligibility for 
medical assistance under the State plan or under a 
waiver of the plan. 
‘‘(iii) MEDICARE
PRESCRIPTION
DRUG
SUBSIDIES 
DETERMINATIONS.—Subparagraphs (A), (B), and (C) 
shall not apply to any determinations of eligibility 
for premium and cost-sharing subsidies under and in 
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124 STAT. 281 
PUBLIC LAW 111–148—MAR. 23, 2010 
accordance with section 1860D–14 made by the State 
pursuant to section 1935(a)(2). 
‘‘(iv) LONG-TERM CARE.—Subparagraphs (A), (B), 
and (C) shall not apply to any determinations of eligi-
bility of individuals for purposes of medical assistance 
for nursing facility services, a level of care in any 
institution equivalent to that of nursing facility serv-
ices, home or community-based services furnished 
under a waiver or State plan amendment under section 
1915 or a waiver under section 1115, and services 
described in section 1917(c)(1)(C)(ii). 
‘‘(v) GRANDFATHER OF CURRENT ENROLLEES UNTIL 
DATE OF NEXT REGULAR REDETERMINATION.—An indi-
vidual who, on January 1, 2014, is enrolled in the 
State plan or under a waiver of the plan and who 
would be determined ineligible for medical assistance 
solely because of the application of the modified gross 
income or household income standard described in 
subparagraph (A), shall remain eligible for medical 
assistance under the State plan or waiver (and subject 
to the same premiums and cost-sharing as applied 
to the individual on that date) through March 31, 
2014, or the date on which the individual’s next regu-
larly scheduled redetermination of eligibility is to 
occur, whichever is later. 
‘‘(E) TRANSITION
PLANNING
AND
OVERSIGHT.—Each 
State shall submit to the Secretary for the Secretary’s 
approval the income eligibility thresholds proposed to be 
established using modified gross income and household 
income, the methodologies and procedures to be used to 
determine income eligibility using modified gross income 
and household income and, if applicable, a State plan 
amendment establishing an optional eligibility category 
under subsection (a)(10)(A)(ii)(XX). To the extent prac-
ticable, the State shall use the same methodologies and 
procedures for purposes of making such determinations 
as the State used on the date of enactment of the Patient 
Protection and Affordable Care Act. The Secretary shall 
ensure that the income eligibility thresholds proposed to 
be established using modified gross income and household 
income, including under the eligibility category established 
under subsection (a)(10)(A)(ii)(XX), and the methodologies 
and procedures proposed to be used to determine income 
eligibility, will not result in children who would have been 
eligible for medical assistance under the State plan or 
under a waiver of the plan on the date of enactment of 
the Patient Protection and Affordable Care Act no longer 
being eligible for such assistance. 
‘‘(F) LIMITATION ON SECRETARIAL AUTHORITY.—The Sec-
retary shall not waive compliance with the requirements 
of this paragraph except to the extent necessary to permit 
a State to coordinate eligibility requirements for dual 
eligible individuals (as defined in section 1915(h)(2)(B)) 
under the State plan or under a waiver of the plan and 
under title XVIII and individuals who require the level 
of care provided in a hospital, a nursing facility, or an 
intermediate care facility for the mentally retarded. 
Submission. 
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124 STAT. 282 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(G) DEFINITIONS
OF
MODIFIED
GROSS
INCOME
AND 
HOUSEHOLD INCOME.—In this paragraph, the terms ‘modi-
fied gross income’ and ‘household income’ have the 
meanings given such terms in section 36B(d)(2) of the 
Internal Revenue Code of 1986. 
‘‘(H) CONTINUED
APPLICATION
OF
MEDICAID
RULES 
REGARDING
POINT-IN-TIME
INCOME
AND
SOURCES
OF 
INCOME.—The requirement under this paragraph for States 
to use modified gross income and household income to 
determine income eligibility for medical assistance under 
the State plan or under any waiver of such plan and 
for any other purpose applicable under the plan or waiver 
for which a determination of income is required shall not 
be construed as affecting or limiting the application of— 
‘‘(i) the requirement under this title and under 
the State plan or a waiver of the plan to determine 
an individual’s income as of the point in time at which 
an application for medical assistance under the State 
plan or a waiver of the plan is processed; or 
‘‘(ii) any rules established under this title or under 
the State plan or a waiver of the plan regarding sources 
of countable income.’’. 
(b) CONFORMING AMENDMENT.—Section 1902(a)(17) of such Act 
(42 U.S.C. 1396a(a)(17)) is amended by inserting ‘‘(e)(14),’’ before 
‘‘(l)(3)’’. 
(c) EFFECTIVE DATE.—The amendments made by subsections 
(a) and (b) take effect on January 1, 2014. 
SEC. 2003. REQUIREMENT TO OFFER PREMIUM ASSISTANCE FOR 
EMPLOYER-SPONSORED INSURANCE. 
(a) IN GENERAL.—Section 1906A of such Act (42 U.S.C. 1396e– 
1) is amended— 
(1) in subsection (a)— 
(A) by striking ‘‘may elect to’’ and inserting ‘‘shall’’; 
(B) by striking ‘‘under age 19’’; and 
(C) by inserting ‘‘, in the case of an individual under 
age 19,’’ after ‘‘(and’’; 
(2) in subsection (c), in the first sentence, by striking ‘‘under 
age 19’’; and 
(3) in subsection (d)— 
(A) in paragraph (2)— 
(i) in the first sentence, by striking ‘‘under age 
19’’; and 
(ii) by striking the third sentence and inserting 
‘‘A State may not require, as a condition of an indi-
vidual (or the individual’s parent) being or remaining 
eligible for medical assistance under this title, that 
the individual (or the individual’s parent) apply for 
enrollment in qualified employer-sponsored coverage 
under this section.’’; and 
(B) in paragraph (3), by striking ‘‘the parent of an 
individual under age 19’’ and inserting ‘‘an individual (or 
the parent of an individual)’’; and 
(4) in subsection (e), by striking ‘‘under age 19’’ each place 
it appears. 
42 USC 1396a 
note. 
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124 STAT. 283 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b) CONFORMING AMENDMENT.—The heading for section 1906A 
of such Act (42 U.S.C. 1396e–1) is amended by striking ‘‘OPTION 
FOR CHILDREN’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
take effect on January 1, 2014. 
SEC. 2004. MEDICAID COVERAGE FOR FORMER FOSTER CARE CHIL-
DREN. 
(a) IN GENERAL.—Section 1902(a)(10)(A)(i) of the Social Security 
Act (42 U.S.C. 1396a), as amended by section 2001(a)(1), is 
amended— 
(1) by striking ‘‘or’’ at the end of subclause (VII); 
(2) by adding ‘‘or’’ at the end of subclause (VIII); and 
(3) by inserting after subclause (VIII) the following: 
‘‘(IX) who were in foster care under the respon-
sibility of a State for more than 6 months (whether 
or not consecutive) but are no longer in such care, 
who are not described in any of subclauses (I) 
through (VII) of this clause, and who are under 
25 years of age;’’. 
(b) OPTION TO PROVIDE PRESUMPTIVE ELIGIBILITY.—Section 
1920(e) of such Act (42 U.S.C. 1396r–1(e)), as added by section 
2001(a)(4)(B) and amended by section 2001(e)(2)(C), is amended 
by inserting ‘‘, clause (i)(IX),’’ after ‘‘clause (i)(VIII)’’. 
(c) CONFORMING AMENDMENTS.— 
(1) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)), 
as amended by section 2001(a)(5)(D), is amended by inserting 
‘‘1902(a)(10)(A)(i)(IX),’’ after ‘‘1902(a)(10)(A)(i)(VIII),’’. 
(2) Section 1937(a)(2)(B)(viii) of such Act (42 U.S.C. 1396u– 
7(a)(2)(B)(viii)) is amended by inserting ‘‘, or the individual 
qualifies for medical assistance on the basis of section 
1902(a)(10)(A)(i)(IX)’’ before the period. 
(d) EFFECTIVE DATE.—The amendments made by this section 
take effect on January 1, 2019. 
SEC. 2005. PAYMENTS TO TERRITORIES. 
(a) INCREASE IN LIMIT ON PAYMENTS.—Section 1108(g) of the 
Social Security Act (42 U.S.C. 1308(g)) is amended— 
(1) in paragraph (2), in the matter preceding subparagraph 
(A), by striking ‘‘paragraph (3)’’ and inserting ‘‘paragraphs (3) 
and (5)’’; 
(2) in paragraph (4), by striking ‘‘and (3)’’ and inserting 
‘‘(3), and (4)’’; and 
(3) by adding at the end the following paragraph: 
‘‘(5) FISCAL
YEAR
2011
AND
THEREAFTER.—The amounts 
otherwise determined under this subsection for Puerto Rico, 
the Virgin Islands, Guam, the Northern Mariana Islands, and 
American Samoa for the second, third, and fourth quarters 
of fiscal year 2011, and for each fiscal year after fiscal year 
2011 (after the application of subsection (f) and the preceding 
paragraphs of this subsection), shall be increased by 30 per-
cent.’’. 
(b) DISREGARD
OF
PAYMENTS
FOR
MANDATORY
EXPANDED 
ENROLLMENT.—Section 1108(g)(4) of such Act (42 U.S.C. 1308(g)(4)) 
is amended— 
(1) by striking ‘‘to fiscal years beginning’’ and inserting 
‘‘to— 
‘‘(A) fiscal years beginning’’; 
42 USC 1396a 
note. 
42 USC 1396e–1 
note. 
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124 STAT. 284 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) by striking the period at the end and inserting ‘‘; and’’; 
and 
(3) by adding at the end the following: 
‘‘(B) fiscal years beginning with fiscal year 2014, pay-
ments made to Puerto Rico, the Virgin Islands, Guam, 
the Northern Mariana Islands, or American Samoa with 
respect to amounts expended for medical assistance for 
newly eligible (as defined in section 1905(y)(2)) nonpreg-
nant childless adults who are eligible under subclause 
(VIII) of section 1902(a)(10)(A)(i) and whose income (as 
determined under section 1902(e)(14)) does not exceed (in 
the case of each such commonwealth and territory respec-
tively) the income eligibility level in effect for that popu-
lation under title XIX or under a waiver on the date of 
enactment of the Patient Protection and Affordable Care 
Act, shall not be taken into account in applying subsection 
(f) (as increased in accordance with paragraphs (1), (2), 
(3), and (5) of this subsection) to such commonwealth or 
territory for such fiscal year.’’. 
(c) INCREASED FMAP.— 
(1) IN GENERAL.—The first sentence of section 1905(b) of 
the Social Security Act (42 U.S.C. 1396d(b)) is amended by 
striking ‘‘shall be 50 per centum’’ and inserting ‘‘shall be 55 
percent’’. 
(2) EFFECTIVE DATE.—The amendment made by paragraph 
(1) takes effect on January 1, 2011. 
SEC. 2006. SPECIAL ADJUSTMENT TO FMAP DETERMINATION FOR CER-
TAIN STATES RECOVERING FROM A MAJOR DISASTER. 
Section 1905 of the Social Security Act (42 U.S.C. 1396d), 
as amended by sections 2001(a)(3) and 2001(b)(2), is amended— 
(1) in subsection (b), in the first sentence, by striking 
‘‘subsection (y)’’ and inserting ‘‘subsections (y) and (aa)’’; and 
(2) by adding at the end the following new subsection: 
‘‘(aa)(1) Notwithstanding subsection (b), beginning January 1, 
2011, the Federal medical assistance percentage for a fiscal year 
for a disaster-recovery FMAP adjustment State shall be equal to 
the following: 
‘‘(A) In the case of the first fiscal year (or part of a fiscal 
year) for which this subsection applies to the State, the Federal 
medical assistance percentage determined for the fiscal year 
without regard to this subsection and subsection (y), increased 
by 50 percent of the number of percentage points by which 
the Federal medical assistance percentage determined for the 
State for the fiscal year without regard to this subsection 
and subsection (y), is less than the Federal medical assistance 
percentage determined for the State for the preceding fiscal 
year after the application of only subsection (a) of section 5001 
of Public Law 111–5 (if applicable to the preceding fiscal year) 
and without regard to this subsection, subsection (y), and sub-
sections (b) and (c) of section 5001 of Public Law 111–5. 
‘‘(B) In the case of the second or any succeeding fiscal 
year for which this subsection applies to the State, the Federal 
medical assistance percentage determined for the preceding 
fiscal year under this subsection for the State, increased by 
25 percent of the number of percentage points by which the 
Federal medical assistance percentage determined for the State 
Effective date. 
42 USC 1396d 
note. 
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124 STAT. 285 
PUBLIC LAW 111–148—MAR. 23, 2010 
for the fiscal year without regard to this subsection and sub-
section (y), is less than the Federal medical assistance percent-
age determined for the State for the preceding fiscal year 
under this subsection. 
‘‘(2) In this subsection, the term ‘disaster-recovery FMAP 
adjustment State’ means a State that is one of the 50 States 
or the District of Columbia, for which, at any time during the 
preceding 7 fiscal years, the President has declared a major disaster 
under section 401 of the Robert T. Stafford Disaster Relief and 
Emergency Assistance Act and determined as a result of such 
disaster that every county or parish in the State warrant individual 
and public assistance or public assistance from the Federal Govern-
ment under such Act and for which— 
‘‘(A) in the case of the first fiscal year (or part of a fiscal 
year) for which this subsection applies to the State, the Federal 
medical assistance percentage determined for the State for 
the fiscal year without regard to this subsection and subsection 
(y), is less than the Federal medical assistance percentage 
determined for the State for the preceding fiscal year after 
the application of only subsection (a) of section 5001 of Public 
Law 111–5 (if applicable to the preceding fiscal year) and 
without regard to this subsection, subsection (y), and sub-
sections (b) and (c) of section 5001 of Public Law 111–5, by 
at least 3 percentage points; and 
‘‘(B) in the case of the second or any succeeding fiscal 
year for which this subsection applies to the State, the Federal 
medical assistance percentage determined for the State for 
the fiscal year without regard to this subsection and subsection 
(y), is less than the Federal medical assistance percentage 
determined for the State for the preceding fiscal year under 
this subsection by at least 3 percentage points. 
‘‘(3) The Federal medical assistance percentage determined for 
a disaster-recovery FMAP adjustment State under paragraph (1) 
shall apply for purposes of this title (other than with respect to 
disproportionate share hospital payments described in section 1923 
and payments under this title that are based on the enhanced 
FMAP described in 2105(b)) and shall not apply with respect to 
payments under title IV (other than under part E of title IV) 
or payments under title XXI.’’. 
SEC. 2007. MEDICAID IMPROVEMENT FUND RESCISSION. 
(a) RESCISSION.—Any amounts available to the Medicaid 
Improvement Fund established under section 1941 of the Social 
Security Act (42 U.S.C. 1396w–1) for any of fiscal years 2014 
through 2018 that are available for expenditure from the Fund 
and that are not so obligated as of the date of the enactment 
of this Act are rescinded. 
(b) CONFORMING AMENDMENTS.—Section 1941(b)(1) of the Social 
Security Act (42 U.S.C. 1396w–1(b)(1)) is amended— 
(1) in subparagraph (A), by striking ‘‘$100,000,000’’ and 
inserting ‘‘$0’’; and 
(2) in subparagraph (B), by striking ‘‘$150,000,000’’ and 
inserting ‘‘$0’’. 
Applicability. 
Definition. 
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124 STAT. 286 
PUBLIC LAW 111–148—MAR. 23, 2010 
Subtitle B—Enhanced Support for the 
Children’s Health Insurance Program 
SEC. 2101. ADDITIONAL FEDERAL FINANCIAL PARTICIPATION FOR 
CHIP. 
(a) IN GENERAL.—Section 2105(b) of the Social Security Act 
(42 U.S.C. 1397ee(b)) is amended by adding at the end the following: 
‘‘Notwithstanding the preceding sentence, during the period that 
begins on October 1, 2013, and ends on September 30, 2019, the 
enhanced FMAP determined for a State for a fiscal year (or for 
any portion of a fiscal year occurring during such period) shall 
be increased by 23 percentage points, but in no case shall exceed 
100 percent. The increase in the enhanced FMAP under the pre-
ceding sentence shall not apply with respect to determining the 
payment to a State under subsection (a)(1) for expenditures 
described in subparagraph (D)(iv), paragraphs (8), (9), (11) of sub-
section (c), or clause (4) of the first sentence of section 1905(b).’’. 
(b) MAINTENANCE OF EFFORT.— 
(1) IN GENERAL.—Section 2105(d) of the Social Security 
Act (42 U.S.C. 1397ee(d)) is amended by adding at the end 
the following: 
‘‘(3) CONTINUATION OF ELIGIBILITY STANDARDS FOR CHIL-
DREN UNTIL OCTOBER 1, 2019.— 
‘‘(A) IN GENERAL.—During the period that begins on 
the date of enactment of the Patient Protection and Afford-
able Care Act and ends on September 30, 2019, a State 
shall not have in effect eligibility standards, methodologies, 
or procedures under its State child health plan (including 
any waiver under such plan) for children (including chil-
dren provided medical assistance for which payment is 
made under section 2105(a)(1)(A)) that are more restrictive 
than the eligibility standards, methodologies, or procedures, 
respectively, under such plan (or waiver) as in effect on 
the date of enactment of that Act. The preceding sentence 
shall not be construed as preventing a State during such 
period from— 
‘‘(i) applying eligibility standards, methodologies, 
or procedures for children under the State child health 
plan or under any waiver of the plan that are less 
restrictive than the eligibility standards, methodolo-
gies, or procedures, respectively, for children under 
the plan or waiver that are in effect on the date of 
enactment of such Act; or 
‘‘(ii) imposing a limitation described in section 
2112(b)(7) for a fiscal year in order to limit expendi-
tures under the State child health plan to those for 
which Federal financial participation is available under 
this section for the fiscal year. 
‘‘(B) ASSURANCE
OF
EXCHANGE
COVERAGE
FOR
TAR-
GETED
LOW-INCOME
CHILDREN
UNABLE
TO
BE
PROVIDED 
CHILD HEALTH ASSISTANCE AS A RESULT OF FUNDING SHORT-
FALLS.—In the event that allotments provided under section 
2104 are insufficient to provide coverage to all children 
who are eligible to be targeted low-income children under 
the State child health plan under this title, a State shall 
Procedures. 
Time period. 
Time period. 
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124 STAT. 287 
PUBLIC LAW 111–148—MAR. 23, 2010 
establish procedures to ensure that such children are pro-
vided coverage through an Exchange established by the 
State under section 1311 of the Patient Protection and 
Affordable Care Act.’’. 
(2) CONFORMING
AMENDMENT
TO
TITLE
XXI
MEDICAID 
MAINTENANCE
OF
EFFORT.—Section 2105(d)(1) of the Social 
Security Act (42 U.S.C. 1397ee(d)(1)) is amended by adding 
before the period ‘‘, except as required under section 
1902(e)(14)’’. 
(c) 
NO
ENROLLMENT
BONUS
PAYMENTS
FOR
CHILDREN 
ENROLLED AFTER FISCAL YEAR 2013.—Section 2105(a)(3)(F)(iii) of 
the Social Security Act (42 U.S.C. 1397ee(a)(3)(F)(iii)) is amended 
by inserting ‘‘or any children enrolled on or after October 1, 2013’’ 
before the period. 
(d) INCOME ELIGIBILITY DETERMINED USING MODIFIED GROSS 
INCOME.— 
(1) STATE PLAN REQUIREMENT.—Section 2102(b)(1)(B) of the 
Social Security Act (42 U.S.C. 1397bb(b)(1)(B)) is amended— 
(A) in clause (iii), by striking ‘‘and’’ after the semicolon; 
(B) in clause (iv), by striking the period and inserting 
‘‘; and’’; and 
(C) by adding at the end the following: 
‘‘(v) shall, beginning January 1, 2014, use modified 
gross income and household income (as defined in sec-
tion 36B(d)(2) of the Internal Revenue Code of 1986) 
to determine eligibility for child health assistance 
under the State child health plan or under any waiver 
of such plan and for any other purpose applicable 
under the plan or waiver for which a determination 
of income is required, including with respect to the 
imposition of premiums and cost-sharing, consistent 
with section 1902(e)(14).’’. 
(2) CONFORMING
AMENDMENT.—Section 2107(e)(1) of the 
Social Security Act (42 U.S.C. 1397gg(e)(1)) is amended— 
(A) by redesignating subparagraphs (E) through (L) 
as subparagraphs (F) through (M), respectively; and 
(B) by inserting after subparagraph (D), the following: 
‘‘(E) Section 1902(e)(14) (relating to income determined 
using modified gross income and household income).’’. 
(e) APPLICATION OF STREAMLINED ENROLLMENT SYSTEM.—Sec-
tion 2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1)), 
as amended by subsection (d)(2), is amended by adding at the 
end the following: 
‘‘(N) Section 1943(b) (relating to coordination with 
State Exchanges and the State Medicaid agency).’’. 
(f) CHIP ELIGIBILITY FOR CHILDREN INELIGIBLE FOR MEDICAID 
AS A RESULT OF ELIMINATION OF DISREGARDS.—Notwithstanding 
any other provision of law, a State shall treat any child who 
is determined to be ineligible for medical assistance under the 
State Medicaid plan or under a waiver of the plan as a result 
of the elimination of the application of an income disregard based 
on expense or type of income, as required under section 1902(e)(14) 
of the Social Security Act (as added by this Act), as a targeted 
low-income child under section 2110(b) (unless the child is excluded 
under paragraph (2) of that section) and shall provide child health 
assistance to the child under the State child health plan (whether 
42 USC 1397jj 
note. 
Effective date. 
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124 STAT. 288 
PUBLIC LAW 111–148—MAR. 23, 2010 
implemented under title XIX or XXI, or both, of the Social Security 
Act). 
SEC. 2102. TECHNICAL CORRECTIONS. 
(a) CHIPRA.—Effective as if included in the enactment of the 
Children’s Health Insurance Program Reauthorization Act of 2009 
(Public Law 111–3) (in this section referred to as ‘‘CHIPRA’’): 
(1) Section 2104(m) of the Social Security Act, as added 
by section 102 of CHIPRA, is amended— 
(A) by redesignating paragraph (7) as paragraph (8); 
and 
(B) by inserting after paragraph (6), the following: 
‘‘(7) ADJUSTMENT
OF
FISCAL
YEAR
2010
ALLOTMENTS
TO 
ACCOUNT FOR CHANGES IN PROJECTED SPENDING FOR CERTAIN 
PREVIOUSLY APPROVED EXPANSION PROGRAMS.—For purposes of 
recalculating the fiscal year 2010 allotment, in the case of 
one of the 50 States or the District of Columbia that has 
an approved State plan amendment effective January 1, 2006, 
to provide child health assistance through the provision of 
benefits under the State plan under title XIX for children 
from birth through age 5 whose family income does not exceed 
200 percent of the poverty line, the Secretary shall increase 
the allotment by an amount that would be equal to the Federal 
share of expenditures that would have been claimed at the 
enhanced FMAP rate rather than the Federal medical assist-
ance percentage matching rate for such population.’’. 
(2) Section 605 of CHIPRA is amended by striking ‘‘legal 
residents’’ and insert ‘‘lawfully residing in the United States’’. 
(3) Subclauses (I) and (II) of paragraph (3)(C)(i) of section 
2105(a) of the Social Security Act (42 U.S.C. 1397ee(a)(3)(ii)), 
as added by section 104 of CHIPRA, are each amended by 
striking ‘‘, respectively’’. 
(4) Section 2105(a)(3)(E)(ii) of the Social Security Act (42 
U.S.C. 1397ee(a)(3)(E)(ii)), as added by section 104 of CHIPRA, 
is amended by striking subclause (IV). 
(5) Section 2105(c)(9)(B) of the Social Security Act (42 
U.S.C. 1397e(c)(9)(B)), as added by section 211(c)(1) of CHIPRA, 
is amended by striking ‘‘section 1903(a)(3)(F)’’ and inserting 
‘‘section 1903(a)(3)(G)’’. 
(6) Section 2109(b)(2)(B) of the Social Security Act (42 
U.S.C. 1397ii(b)(2)(B)), as added by section 602 of CHIPRA, 
is amended by striking ‘‘the child population growth factor 
under section 2104(m)(5)(B)’’ and inserting ‘‘a high-performing 
State under section 2111(b)(3)(B)’’. 
(7) Section 2110(c)(9)(B)(v) of the Social Security Act (42 
U.S.C. 1397jj(c)(9)(B)(v)), as added by section 505(b) of CHIPRA, 
is amended by striking ‘‘school or school system’’ and inserting 
‘‘local educational agency (as defined under section 9101 of 
the Elementary and Secondary Education Act of 1965’’. 
(8) Section 211(a)(1)(B) of CHIPRA is amended— 
(A) by striking ‘‘is amended’’ and all that follows 
through ‘‘adding’’ and inserting ‘‘is amended by adding’’; 
and 
(B) by redesignating the new subparagraph to be added 
by such section to section 1903(a)(3) of the Social Security 
Act as a new subparagraph (H). 
42 USC 1396b. 
42 USC 1397ee. 
42 USC 1396 
note. 
42 USC 1397dd. 
Effective date. 
42 USC 1396b 
note. 
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124 STAT. 289 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b) ARRA.—Effective as if included in the enactment of section 
5006(a) of division B of the American Recovery and Reinvestment 
Act of 2009 (Public Law 111–5), the second sentence of section 
1916A(a)(1) of the Social Security Act (42 U.S.C. 1396o–1(a)(1)) 
is amended by striking ‘‘or (i)’’ and inserting ‘‘, (i), or (j)’’. 
Subtitle C—Medicaid and CHIP 
Enrollment Simplification 
SEC. 2201. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH 
STATE HEALTH INSURANCE EXCHANGES. 
Title XIX of the Social Security Act (42 U.S.C. 1397aa et seq.) 
is amended by adding at the end the following: 
‘‘SEC. 1943. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH 
STATE HEALTH INSURANCE EXCHANGES. 
‘‘(a) CONDITION FOR PARTICIPATION IN MEDICAID.—As a condi-
tion of the State plan under this title and receipt of any Federal 
financial assistance under section 1903(a) for calendar quarters 
beginning after January 1, 2014, a State shall ensure that the 
requirements of subsection (b) is met. 
‘‘(b) ENROLLMENT SIMPLIFICATION
AND COORDINATION WITH 
STATE HEALTH INSURANCE EXCHANGES AND CHIP.— 
‘‘(1) IN GENERAL.—A State shall establish procedures for— 
‘‘(A) enabling individuals, through an Internet website 
that meets the requirements of paragraph (4), to apply 
for medical assistance under the State plan or under a 
waiver of the plan, to be enrolled in the State plan or 
waiver, to renew their enrollment in the plan or waiver, 
and to consent to enrollment or reenrollment in the State 
plan through electronic signature; 
‘‘(B) enrolling, without any further determination by 
the State and through such website, individuals who are 
identified by an Exchange established by the State under 
section 1311 of the Patient Protection and Affordable Care 
Act as being eligible for— 
‘‘(i) medical assistance under the State plan or 
under a waiver of the plan; or 
‘‘(ii) child health assistance under the State child 
health plan under title XXI; 
‘‘(C) ensuring that individuals who apply for but are 
determined to be ineligible for medical assistance under 
the State plan or a waiver or ineligible for child health 
assistance under the State child health plan under title 
XXI, are screened for eligibility for enrollment in qualified 
health plans offered through such an Exchange and, if 
applicable, premium assistance for the purchase of a quali-
fied health plan under section 36B of the Internal Revenue 
Code of 1986 (and, if applicable, advance payment of such 
assistance under section 1412 of the Patient Protection 
and Affordable Care Act), and, if eligible, enrolled in such 
a plan without having to submit an additional or separate 
application, and that such individuals receive information 
regarding reduced cost-sharing for eligible individuals 
under section 1402 of the Patient Protection and Affordable 
Web site. 
Procedures. 
Effective date. 
42 USC 1396w–3. 
42 USC 13960–1 
note. 
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124 STAT. 290 
PUBLIC LAW 111–148—MAR. 23, 2010 
Care Act, and any other assistance or subsidies available 
for coverage obtained through the Exchange; 
‘‘(D) ensuring that the State agency responsible for 
administering the State plan under this title (in this section 
referred to as the ‘State Medicaid agency’), the State agency 
responsible for administering the State child health plan 
under title XXI (in this section referred to as the ‘State 
CHIP agency’) and an Exchange established by the State 
under section 1311 of the Patient Protection and Affordable 
Care Act utilize a secure electronic interface sufficient to 
allow for a determination of an individual’s eligibility for 
such medical assistance, child health assistance, or pre-
mium assistance, and enrollment in the State plan under 
this title, title XXI, or a qualified health plan, as appro-
priate; 
‘‘(E) coordinating, for individuals who are enrolled in 
the State plan or under a waiver of the plan and who 
are also enrolled in a qualified health plan offered through 
such an Exchange, and for individuals who are enrolled 
in the State child health plan under title XXI and who 
are also enrolled in a qualified health plan, the provision 
of medical assistance or child health assistance to such 
individuals with the coverage provided under the qualified 
health plan in which they are enrolled, including services 
described in section 1905(a)(4)(B) (relating to early and 
periodic screening, diagnostic, and treatment services 
defined in section 1905(r)) and provided in accordance with 
the requirements of section 1902(a)(43); and 
‘‘(F) conducting outreach to and enrolling vulnerable 
and underserved populations eligible for medical assistance 
under this title XIX or for child health assistance under 
title XXI, including children, unaccompanied homeless 
youth, children and youth with special health care needs, 
pregnant women, racial and ethnic minorities, rural popu-
lations, victims of abuse or trauma, individuals with mental 
health or substance-related disorders, and individuals with 
HIV/AIDS. 
‘‘(2) 
AGREEMENTS
WITH
STATE
HEALTH
INSURANCE 
EXCHANGES.—The State Medicaid agency and the State CHIP 
agency may enter into an agreement with an Exchange estab-
lished by the State under section 1311 of the Patient Protection 
and Affordable Care Act under which the State Medicaid agency 
or State CHIP agency may determine whether a State resident 
is eligible for premium assistance for the purchase of a qualified 
health plan under section 36B of the Internal Revenue Code 
of 1986 (and, if applicable, advance payment of such assistance 
under section 1412 of the Patient Protection and Affordable 
Care Act), so long as the agreement meets such conditions 
and requirements as the Secretary of the Treasury may pre-
scribe to reduce administrative costs and the likelihood of eligi-
bility errors and disruptions in coverage. 
‘‘(3) STREAMLINED ENROLLMENT SYSTEM.—The State Med-
icaid agency and State CHIP agency shall participate in and 
comply with the requirements for the system established under 
section 1413 of the Patient Protection and Affordable Care 
Act (relating to streamlined procedures for enrollment through 
an Exchange, Medicaid, and CHIP). 
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124 STAT. 291 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(4) ENROLLMENT
WEBSITE
REQUIREMENTS.—The proce-
dures established by State under paragraph (1) shall include 
establishing and having in operation, not later than January 
1, 2014, an Internet website that is linked to any website 
of an Exchange established by the State under section 1311 
of the Patient Protection and Affordable Care Act and to the 
State CHIP agency (if different from the State Medicaid agency) 
and allows an individual who is eligible for medical assistance 
under the State plan or under a waiver of the plan and who 
is eligible to receive premium credit assistance for the purchase 
of a qualified health plan under section 36B of the Internal 
Revenue Code of 1986 to compare the benefits, premiums, 
and cost-sharing applicable to the individual under the State 
plan or waiver with the benefits, premiums, and cost-sharing 
available to the individual under a qualified health plan offered 
through such an Exchange, including, in the case of a child, 
the coverage that would be provided for the child through 
the State plan or waiver with the coverage that would be 
provided to the child through enrollment in family coverage 
under that plan and as supplemental coverage by the State 
under the State plan or waiver. 
‘‘(5) CONTINUED
NEED
FOR
ASSESSMENT
FOR
HOME
AND 
COMMUNITY-BASED SERVICES.—Nothing in paragraph (1) shall 
limit or modify the requirement that the State assess an indi-
vidual for purposes of providing home and community-based 
services under the State plan or under any waiver of such 
plan for individuals described in subsection (a)(10)(A)(ii)(VI).’’. 
SEC. 2202. PERMITTING HOSPITALS TO MAKE PRESUMPTIVE ELIGI-
BILITY DETERMINATIONS FOR ALL MEDICAID ELIGIBLE 
POPULATIONS. 
(a) IN GENERAL.—Section 1902(a)(47) of the Social Security 
Act (42 U.S.C. 1396a(a)(47)) is amended— 
(1) by striking ‘‘at the option of the State, provide’’ and 
inserting ‘‘provide— 
‘‘(A) at the option of the State,’’; 
(2) by inserting ‘‘and’’ after the semicolon; and 
(3) by adding at the end the following: 
‘‘(B) that any hospital that is a participating provider 
under the State plan may elect to be a qualified entity 
for purposes of determining, on the basis of preliminary 
information, whether any individual is eligible for medical 
assistance under the State plan or under a waiver of the 
plan for purposes of providing the individual with medical 
assistance during a presumptive eligibility period, in the 
same manner, and subject to the same requirements, as 
apply to the State options with respect to populations 
described in section 1920, 1920A, or 1920B (but without 
regard to whether the State has elected to provide for 
a presumptive eligibility period under any such sections), 
subject to such guidance as the Secretary shall establish;’’. 
(b) CONFORMING AMENDMENT.—Section 1903(u)(1)(D)(v) of such 
Act (42 U.S.C. 1396b(u)(1)(D)v)) is amended— 
(1) by striking ‘‘or for’’ and inserting ‘‘for’’; and 
(2) by inserting before the period at the end the following: 
‘‘, or for medical assistance provided to an individual during 
a presumptive eligibility period resulting from a determination 
Guidelines. 
Deadline. 
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124 STAT. 292 
PUBLIC LAW 111–148—MAR. 23, 2010 
of presumptive eligibility made by a hospital that elects under 
section 1902(a)(47)(B) to be a qualified entity for such purpose’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
take effect on January 1, 2014, and apply to services furnished 
on or after that date. 
Subtitle D—Improvements to Medicaid 
Services 
SEC. 2301. COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES. 
(a) IN GENERAL.—Section 1905 of the Social Security Act (42 
U.S.C. 1396d), is amended— 
(1) in subsection (a)— 
(A) in paragraph (27), by striking ‘‘and’’ at the end; 
(B) by redesignating paragraph (28) as paragraph (29); 
and 
(C) by inserting after paragraph (27) the following 
new paragraph: 
‘‘(28) freestanding birth center services (as defined in sub-
section (l)(3)(A)) and other ambulatory services that are offered 
by a freestanding birth center (as defined in subsection (l)(3)(B)) 
and that are otherwise included in the plan; and’’; and 
(2) in subsection (l), by adding at the end the following 
new paragraph: 
‘‘(3)(A) The term ‘freestanding birth center services’ means serv-
ices furnished to an individual at a freestanding birth center (as 
defined in subparagraph (B)) at such center. 
‘‘(B) The term ‘freestanding birth center’ means a health 
facility— 
‘‘(i) that is not a hospital; 
‘‘(ii) where childbirth is planned to occur away from the 
pregnant woman’s residence; 
‘‘(iii) that is licensed or otherwise approved by the State 
to provide prenatal labor and delivery or postpartum care and 
other ambulatory services that are included in the plan; and 
‘‘(iv) that complies with such other requirements relating 
to the health and safety of individuals furnished services by 
the facility as the State shall establish. 
‘‘(C) A State shall provide separate payments to providers 
administering prenatal labor and delivery or postpartum care in 
a freestanding birth center (as defined in subparagraph (B)), such 
as nurse midwives and other providers of services such as birth 
attendants recognized under State law, as determined appropriate 
by the Secretary. For purposes of the preceding sentence, the term 
‘birth attendant’ means an individual who is recognized or reg-
istered by the State involved to provide health care at childbirth 
and who provides such care within the scope of practice under 
which the individual is legally authorized to perform such care 
under State law (or the State regulatory mechanism provided by 
State law), regardless of whether the individual is under the super-
vision of, or associated with, a physician or other health care 
provider. Nothing in this subparagraph shall be construed as 
changing State law requirements applicable to a birth attendant.’’. 
(b) CONFORMING AMENDMENT.—Section 1902(a)(10)(A) of the 
Social Security Act (42 U.S.C. 1396a(a)(10)(A)), is amended in the 
Payments. 
Definitions. 
Applicability. 
42 USC 1396a 
note. 
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124 STAT. 293 
PUBLIC LAW 111–148—MAR. 23, 2010 
matter preceding clause (i) by striking ‘‘and (21)’’ and inserting 
‘‘, (21), and (28)’’. 
(c) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided in paragraph (2), the 
amendments made by this section shall take effect on the 
date of the enactment of this Act and shall apply to services 
furnished on or after such date. 
(2) EXCEPTION IF STATE LEGISLATION REQUIRED.—In the 
case of a State plan for medical assistance under title XIX 
of the Social Security Act which the Secretary of Health and 
Human Services determines requires State legislation (other 
than legislation appropriating funds) in order for the plan to 
meet the additional requirement imposed by the amendments 
made by this section, the State plan shall not be regarded 
as failing to comply with the requirements of such title solely 
on the basis of its failure to meet this additional requirement 
before the first day of the first calendar quarter beginning 
after the close of the first regular session of the State legislature 
that begins after the date of the enactment of this Act. For 
purposes of the previous sentence, in the case of a State that 
has a 2-year legislative session, each year of such session 
shall be deemed to be a separate regular session of the State 
legislature. 
SEC. 2302. CONCURRENT CARE FOR CHILDREN. 
(a) IN GENERAL.—Section 1905(o)(1) of the Social Security Act 
(42 U.S.C. 1396d(o)(1)) is amended— 
(1) in subparagraph (A), by striking ‘‘subparagraph (B)’’ 
and inserting ‘‘subparagraphs (B) and (C)’’; and 
(2) by adding at the end the following new subparagraph: 
‘‘(C) A voluntary election to have payment made for hospice 
care for a child (as defined by the State) shall not constitute 
a waiver of any rights of the child to be provided with, or to 
have payment made under this title for, services that are related 
to the treatment of the child’s condition for which a diagnosis 
of terminal illness has been made.’’. 
(b) APPLICATION TO CHIP.—Section 2110(a)(23) of the Social 
Security Act (42 U.S.C. 1397jj(a)(23)) is amended by inserting 
‘‘(concurrent, in the case of an individual who is a child, with 
care related to the treatment of the child’s condition with respect 
to which a diagnosis of terminal illness has been made’’ after 
‘‘hospice care’’. 
SEC. 2303. STATE ELIGIBILITY OPTION FOR FAMILY PLANNING SERV-
ICES. 
(a) COVERAGE AS OPTIONAL CATEGORICALLY NEEDY GROUP.— 
(1) IN GENERAL.—Section 1902(a)(10)(A)(ii) of the Social 
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by 
section 2001(e), is amended— 
(A) in subclause (XIX), by striking ‘‘or’’ at the end; 
(B) in subclause (XX), by adding ‘‘or’’ at the end; and 
(C) by adding at the end the following new subclause: 
‘‘(XXI) who are described in subsection (ii) 
(relating to individuals who meet certain income 
standards);’’. 
(2) GROUP DESCRIBED.—Section 1902 of such Act (42 U.S.C. 
1396a), as amended by section 2001(d), is amended by adding 
at the end the following new subsection: 
Determination. 
Applicability. 
42 USC 1396a 
note. 
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124 STAT. 294 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(ii)(1) Individuals described in this subsection are individuals— 
‘‘(A) whose income does not exceed an income eligibility 
level established by the State that does not exceed the 
highest income eligibility level established under the State 
plan under this title (or under its State child health plan 
under title XXI) for pregnant women; and 
‘‘(B) who are not pregnant. 
‘‘(2) At the option of a State, individuals described in this 
subsection may include individuals who, had individuals 
applied on or before January 1, 2007, would have been made 
eligible pursuant to the standards and processes imposed by 
that State for benefits described in clause (XV) of the matter 
following subparagraph (G) of section subsection (a)(10) pursu-
ant to a waiver granted under section 1115. 
‘‘(3) At the option of a State, for purposes of subsection 
(a)(17)(B), in determining eligibility for services under this sub-
section, the State may consider only the income of the applicant 
or recipient.’’. 
(3) LIMITATION ON BENEFITS.—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)— 
(A) by striking ‘‘and (XV)’’ and inserting ‘‘(XV)’’; and 
(B) by inserting ‘‘, and (XVI) the medical assistance 
made available to an individual described in subsection 
(ii) shall be limited to family planning services and supplies 
described in section 1905(a)(4)(C) including medical diag-
nosis and treatment services that are provided pursuant 
to a family planning service in a family planning setting’’ 
before the semicolon. 
(4) CONFORMING AMENDMENTS.— 
(A) Section 1905(a) of the Social Security Act (42 U.S.C. 
1396d(a)), as amended by section 2001(e)(2)(A), is amended 
in the matter preceding paragraph (1)— 
(i) in clause (xiv), by striking ‘‘or’’ at the end; 
(ii) in clause (xv), by adding ‘‘or’’ at the end; and 
(iii) by inserting after clause (xv) the following: 
‘‘(xvi) individuals described in section 1902(ii),’’. 
(B) 
Section 
1903(f)(4) 
of 
such 
Act 
(42 
U.S.C. 
1396b(f)(4)), as amended by section 2001(e)(2)(B), is 
amended 
by 
inserting 
‘‘1902(a)(10)(A)(ii)(XXI),’’ 
after 
‘‘1902(a)(10)(A)(ii)(XX),’’. 
(b) PRESUMPTIVE ELIGIBILITY.— 
(1) IN GENERAL.—Title XIX of the Social Security Act (42 
U.S.C. 1396 et seq.) is amended by inserting after section 
1920B the following: 
‘‘PRESUMPTIVE ELIGIBILITY FOR FAMILY PLANNING SERVICES 
‘‘SEC. 1920C. (a) STATE OPTION.—State plan approved under 
section 1902 may provide for making medical assistance available 
to an individual described in section 1902(ii) (relating to individuals 
who meet certain income eligibility standard) during a presumptive 
eligibility period. In the case of an individual described in section 
1902(ii), such medical assistance shall be limited to family planning 
services and supplies described in 1905(a)(4)(C) and, at the State’s 
option, medical diagnosis and treatment services that are provided 
42 USC 
1396r–1c. 
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124 STAT. 295 
PUBLIC LAW 111–148—MAR. 23, 2010 
in conjunction with a family planning service in a family planning 
setting. 
‘‘(b) DEFINITIONS.—For purposes of this section: 
‘‘(1) PRESUMPTIVE ELIGIBILITY PERIOD.—The term ‘presump-
tive eligibility period’ means, with respect to an individual 
described in subsection (a), the period that— 
‘‘(A) begins with the date on which a qualified entity 
determines, on the basis of preliminary information, that 
the individual is described in section 1902(ii); and 
‘‘(B) ends with (and includes) the earlier of— 
‘‘(i) the day on which a determination is made 
with respect to the eligibility of such individual for 
services under the State plan; or 
‘‘(ii) in the case of such an individual who does 
not file an application by the last day of the month 
following the month during which the entity makes 
the determination referred to in subparagraph (A), 
such last day. 
‘‘(2) QUALIFIED ENTITY.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 
term ‘qualified entity’ means any entity that— 
‘‘(i) is eligible for payments under a State plan 
approved under this title; and 
‘‘(ii) is determined by the State agency to be 
capable of making determinations of the type described 
in paragraph (1)(A). 
‘‘(B) RULE OF CONSTRUCTION.—Nothing in this para-
graph shall be construed as preventing a State from lim-
iting the classes of entities that may become qualified 
entities in order to prevent fraud and abuse. 
‘‘(c) ADMINISTRATION.— 
‘‘(1) IN GENERAL.—The State agency shall provide qualified 
entities with— 
‘‘(A) such forms as are necessary for an application 
to be made by an individual described in subsection (a) 
for medical assistance under the State plan; and 
‘‘(B) information on how to assist such individuals in 
completing and filing such forms. 
‘‘(2) NOTIFICATION REQUIREMENTS.—A qualified entity that 
determines under subsection (b)(1)(A) that an individual 
described in subsection (a) is presumptively eligible for medical 
assistance under a State plan shall— 
‘‘(A) notify the State agency of the determination within 
5 working days after the date on which determination 
is made; and 
‘‘(B) inform such individual at the time the determina-
tion is made that an application for medical assistance 
is required to be made by not later than the last day 
of the month following the month during which the deter-
mination is made. 
‘‘(3) APPLICATION FOR MEDICAL ASSISTANCE.—In the case 
of an individual described in subsection (a) who is determined 
by a qualified entity to be presumptively eligible for medical 
assistance under a State plan, the individual shall apply for 
medical assistance by not later than the last day of the month 
following the month during which the determination is made. 
Deadline. 
Deadline. 
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124 STAT. 296 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(d) PAYMENT.—Notwithstanding any other provision of law, 
medical assistance that— 
‘‘(1) is furnished to an individual described in subsection 
(a)— 
‘‘(A) during a presumptive eligibility period; and 
‘‘(B) by a entity that is eligible for payments under 
the State plan; and 
‘‘(2) is included in the care and services covered by the 
State plan, 
shall be treated as medical assistance provided by such plan for 
purposes of clause (4) of the first sentence of section 1905(b).’’. 
(2) CONFORMING AMENDMENTS.— 
(A) Section 1902(a)(47) of the Social Security Act (42 
U.S.C. 1396a(a)(47)), as amended by section 2202(a), is 
amended— 
(i) in subparagraph (A), by inserting before the 
semicolon at the end the following: ‘‘and provide for 
making medical assistance available to individuals 
described in subsection (a) of section 1920C during 
a presumptive eligibility period in accordance with 
such section’’; and 
(ii) in subparagraph (B), by striking ‘‘or 1920B’’ 
and inserting ‘‘1920B, or 1920C’’. 
(B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C. 
1396b(u)(1)(D)(v)), as amended by section 2202(b), is 
amended by inserting ‘‘or for medical assistance provided 
to an individual described in subsection (a) of section 1920C 
during a presumptive eligibility period under such section,’’ 
after ‘‘1920B during a presumptive eligibility period under 
such section,’’. 
(c) CLARIFICATION OF COVERAGE OF FAMILY PLANNING SERVICES 
AND SUPPLIES.—Section 1937(b) of the Social Security Act (42 U.S.C. 
1396u–7(b)), as amended by section 2001(c), is amended by adding 
at the end the following: 
‘‘(7) COVERAGE OF FAMILY PLANNING SERVICES AND SUP-
PLIES.—Notwithstanding the previous provisions of this section, 
a State may not provide for medical assistance through enroll-
ment of an individual with benchmark coverage or benchmark- 
equivalent coverage under this section unless such coverage 
includes for any individual described in section 1905(a)(4)(C), 
medical assistance for family planning services and supplies 
in accordance with such section.’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
take effect on the date of the enactment of this Act and shall 
apply to items and services furnished on or after such date. 
SEC. 2304. CLARIFICATION OF DEFINITION OF MEDICAL ASSISTANCE. 
Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) 
is amended by inserting ‘‘or the care and services themselves, 
or both’’ before ‘‘(if provided in or after’’. 
Applicability. 
42 USC 1396a 
note. 
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124 STAT. 297 
PUBLIC LAW 111–148—MAR. 23, 2010 
Subtitle E—New Options for States to 
Provide Long-Term Services and Supports 
SEC. 2401. COMMUNITY FIRST CHOICE OPTION. 
Section 1915 of the Social Security Act (42 U.S.C. 1396n) is 
amended by adding at the end the following: 
‘‘(k) STATE PLAN OPTION TO PROVIDE HOME AND COMMUNITY- 
BASED ATTENDANT SERVICES AND SUPPORTS.— 
‘‘(1) IN GENERAL.—Subject to the succeeding provisions of 
this subsection, beginning October 1, 2010, a State may provide 
through a State plan amendment for the provision of medical 
assistance for home and community-based attendant services 
and supports for individuals who are eligible for medical assist-
ance under the State plan whose income does not exceed 150 
percent of the poverty line (as defined in section 2110(c)(5)) 
or, if greater, the income level applicable for an individual 
who has been determined to require an institutional level of 
care to be eligible for nursing facility services under the State 
plan and with respect to whom there has been a determination 
that, but for the provision of such services, the individuals 
would require the level of care provided in a hospital, a nursing 
facility, an intermediate care facility for the mentally retarded, 
or an institution for mental diseases, the cost of which could 
be reimbursed under the State plan, but only if the individual 
chooses to receive such home and community-based attendant 
services and supports, and only if the State meets the following 
requirements: 
‘‘(A) AVAILABILITY.—The State shall make available 
home and community-based attendant services and sup-
ports to eligible individuals, as needed, to assist in accom-
plishing activities of daily living, instrumental activities 
of daily living, and health-related tasks through hands- 
on assistance, supervision, or cueing— 
‘‘(i) under a person-centered plan of services and 
supports that is based on an assessment of functional 
need and that is agreed to in writing by the individual 
or, as appropriate, the individual’s representative; 
‘‘(ii) in a home or community setting, which does 
not include a nursing facility, institution for mental 
diseases, or an intermediate care facility for the men-
tally retarded; 
‘‘(iii) under an agency-provider model or other 
model (as defined in paragraph (6)(C )); and 
‘‘(iv) the furnishing of which— 
‘‘(I) is selected, managed, and dismissed by 
the individual, or, as appropriate, with assistance 
from the individual’s representative; 
‘‘(II) is controlled, to the maximum extent pos-
sible, by the individual or where appropriate, the 
individual’s representative, regardless of who may 
act as the employer of record; and 
‘‘(III) provided by an individual who is quali-
fied to provide such services, including family 
members (as defined by the Secretary). 
‘‘(B) INCLUDED SERVICES AND SUPPORTS.—In addition 
to assistance in accomplishing activities of daily living, 
Contracts. 
Effective date. 
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124 STAT. 298 
PUBLIC LAW 111–148—MAR. 23, 2010 
instrumental activities of daily living, and health related 
tasks, the home and community-based attendant services 
and supports made available include— 
‘‘(i) the acquisition, maintenance, and enhance-
ment of skills necessary for the individual to accom-
plish activities of daily living, instrumental activities 
of daily living, and health related tasks; 
‘‘(ii) back-up systems or mechanisms (such as the 
use of beepers or other electronic devices) to ensure 
continuity of services and supports; and 
‘‘(iii) voluntary training on how to select, manage, 
and dismiss attendants. 
‘‘(C) EXCLUDED SERVICES AND SUPPORTS.—Subject to 
subparagraph (D), the home and community-based attend-
ant services and supports made available do not include— 
‘‘(i) room and board costs for the individual; 
‘‘(ii) special education and related services provided 
under the Individuals with Disabilities Education Act 
and vocational rehabilitation services provided under 
the Rehabilitation Act of 1973; 
‘‘(iii) assistive technology devices and assistive 
technology services other than those under (1)(B)(ii); 
‘‘(iv) medical supplies and equipment; or 
‘‘(v) home modifications. 
‘‘(D) PERMISSIBLE SERVICES AND SUPPORTS.—The home 
and community-based attendant services and supports may 
include— 
‘‘(i) expenditures for transition costs such as rent 
and utility deposits, first month’s rent and utilities, 
bedding, basic kitchen supplies, and other necessities 
required for an individual to make the transition from 
a nursing facility, institution for mental diseases, or 
intermediate care facility for the mentally retarded 
to a community-based home setting where the indi-
vidual resides; and 
‘‘(ii) expenditures relating to a need identified in 
an individual’s person-centered plan of services that 
increase independence or substitute for human assist-
ance, to the extent that expenditures would otherwise 
be made for the human assistance. 
‘‘(2) INCREASED
FEDERAL
FINANCIAL
PARTICIPATION.—For 
purposes of payments to a State under section 1903(a)(1), with 
respect to amounts expended by the State to provide medical 
assistance under the State plan for home and community- 
based attendant services and supports to eligible individuals 
in accordance with this subsection during a fiscal year quarter 
occurring during the period described in paragraph (1), the 
Federal medical assistance percentage applicable to the State 
(as determined under section 1905(b)) shall be increased by 
6 percentage points. 
‘‘(3) STATE
REQUIREMENTS.—In order for a State plan 
amendment to be approved under this subsection, the State 
shall— 
‘‘(A) develop and implement such amendment in 
collaboration with a Development and Implementation 
Council established by the State that includes a majority 
of members with disabilities, elderly individuals, and their 
Establishment. 
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124 STAT. 299 
PUBLIC LAW 111–148—MAR. 23, 2010 
representatives and consults and collaborates with such 
individuals; 
‘‘(B) provide consumer controlled home and community- 
based attendant services and supports to individuals on 
a statewide basis, in a manner that provides such services 
and supports in the most integrated setting appropriate 
to the individual’s needs, and without regard to the individ-
ual’s age, type or nature of disability, severity of disability, 
or the form of home and community-based attendant serv-
ices and supports that the individual requires in order 
to lead an independent life; 
‘‘(C) with respect to expenditures during the first full 
fiscal year in which the State plan amendment is imple-
mented, maintain or exceed the level of State expenditures 
for medical assistance that is provided under section 
1905(a), section 1915, section 1115, or otherwise to individ-
uals with disabilities or elderly individuals attributable 
to the preceding fiscal year; 
‘‘(D) establish and maintain a comprehensive, contin-
uous quality assurance system with respect to community- 
based attendant services and supports that— 
‘‘(i) includes standards for agency-based and other 
delivery models with respect to training, appeals for 
denials and reconsideration procedures of an individual 
plan, and other factors as determined by the Secretary; 
‘‘(ii) incorporates feedback from consumers and 
their representatives, disability organizations, pro-
viders, families of disabled or elderly individuals, mem-
bers of the community, and others and maximizes con-
sumer independence and consumer control; 
‘‘(iii) monitors the health and well-being of each 
individual who receives home and community-based 
attendant services and supports, including a process 
for the mandatory reporting, investigation, and resolu-
tion of allegations of neglect, abuse, or exploitation 
in connection with the provision of such services and 
supports; and 
‘‘(iv) provides information about the provisions of 
the quality assurance required under clauses (i) 
through (iii) to each individual receiving such services; 
and 
‘‘(E) collect and report information, as determined nec-
essary by the Secretary, for the purposes of approving 
the State plan amendment, providing Federal oversight, 
and conducting an evaluation under paragraph (5)(A), 
including data regarding how the State provides home 
and community-based attendant services and supports and 
other home and community-based services, the cost of such 
services and supports, and how the State provides individ-
uals with disabilities who otherwise qualify for institutional 
care under the State plan or under a waiver the choice 
to instead receive home and community-based services in 
lieu of institutional care. 
‘‘(4) COMPLIANCE
WITH
CERTAIN
LAWS.—A State shall 
ensure that, regardless of whether the State uses an agency- 
provider model or other models to provide home and commu-
nity-based attendant services and supports under a State plan 
Reports. 
Determination. 
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124 STAT. 300 
PUBLIC LAW 111–148—MAR. 23, 2010 
amendment under this subsection, such services and supports 
are provided in accordance with the requirements of the Fair 
Labor Standards Act of 1938 and applicable Federal and State 
laws regarding— 
‘‘(A) withholding and payment of Federal and State 
income and payroll taxes; 
‘‘(B) the provision of unemployment and workers com-
pensation insurance; 
‘‘(C) maintenance of general liability insurance; and 
‘‘(D) occupational health and safety. 
‘‘(5) EVALUATION, DATA COLLECTION, AND REPORT TO CON-
GRESS.— 
‘‘(A) EVALUATION.—The Secretary shall conduct an 
evaluation of the provision of home and community-based 
attendant services and supports under this subsection in 
order to determine the effectiveness of the provision of 
such services and supports in allowing the individuals 
receiving such services and supports to lead an independent 
life to the maximum extent possible; the impact on the 
physical and emotional health of the individuals who 
receive such services; and an comparative analysis of the 
costs of services provided under the State plan amendment 
under this subsection and those provided under institu-
tional care in a nursing facility, institution for mental 
diseases, or an intermediate care facility for the mentally 
retarded. 
‘‘(B) DATA COLLECTION.—The State shall provide the 
Secretary with the following information regarding the 
provision of home and community-based attendant services 
and supports under this subsection for each fiscal year 
for which such services and supports are provided: 
‘‘(i) The number of individuals who are estimated 
to receive home and community-based attendant serv-
ices and supports under this subsection during the 
fiscal year. 
‘‘(ii) The number of individuals that received such 
services and supports during the preceding fiscal year. 
‘‘(iii) The specific number of individuals served by 
type of disability, age, gender, education level, and 
employment status. 
‘‘(iv) Whether the specific individuals have been 
previously served under any other home and commu-
nity based services program under the State plan or 
under a waiver. 
‘‘(C) REPORTS.—Not later than— 
‘‘(i) December 31, 2013, the Secretary shall submit 
to Congress and make available to the public an 
interim report on the findings of the evaluation under 
subparagraph (A); and 
‘‘(ii) December 31, 2015, the Secretary shall submit 
to Congress and make available to the public a final 
report on the findings of the evaluation under subpara-
graph (A). 
‘‘(6) DEFINITIONS.—In this subsection: 
‘‘(A) ACTIVITIES OF DAILY LIVING.—The term ‘activities 
of daily living’ includes tasks such as eating, toileting, 
grooming, dressing, bathing, and transferring. 
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124 STAT. 301 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) CONSUMER
CONTROLLED.—The term ‘consumer 
controlled’ means a method of selecting and providing serv-
ices and supports that allow the individual, or where appro-
priate, the individual’s representative, maximum control 
of the home and community-based attendant services and 
supports, regardless of who acts as the employer of record. 
‘‘(C) DELIVERY MODELS.— 
‘‘(i) AGENCY-PROVIDER MODEL.—The term ‘agency- 
provider model’ means, with respect to the provision 
of home and community-based attendant services and 
supports for an individual, subject to paragraph (4), 
a method of providing consumer controlled services 
and supports under which entities contract for the 
provision of such services and supports. 
‘‘(ii) OTHER
MODELS.—The term ‘other models’ 
means, subject to paragraph (4), methods, other than 
an agency-provider model, for the provision of con-
sumer controlled services and supports. Such models 
may include the provision of vouchers, direct cash pay-
ments, or use of a fiscal agent to assist in obtaining 
services. 
‘‘(D) 
HEALTH-RELATED
TASKS.—The 
term 
‘health- 
related tasks’ means specific tasks related to the needs 
of an individual, which can be delegated or assigned by 
licensed health-care professionals under State law to be 
performed by an attendant. 
‘‘(E) INDIVIDUAL’S REPRESENTATIVE.—The term ‘individ-
ual’s representative’ means a parent, family member, 
guardian, advocate, or other authorized representative of 
an individual 
‘‘(F) INSTRUMENTAL ACTIVITIES OF DAILY LIVING.—The 
term ‘instrumental activities of daily living’ includes (but 
is not limited to) meal planning and preparation, managing 
finances, shopping for food, clothing, and other essential 
items, performing essential household chores, commu-
nicating by phone or other media, and traveling around 
and participating in the community.’’. 
SEC. 2402. REMOVAL OF BARRIERS TO PROVIDING HOME AND COMMU-
NITY-BASED SERVICES. 
(a) OVERSIGHT AND ASSESSMENT OF THE ADMINISTRATION OF 
HOME AND COMMUNITY-BASED SERVICES.—The Secretary of Health 
and Human Services shall promulgate regulations to ensure that 
all States develop service systems that are designed to— 
(1) allocate resources for services in a manner that is 
responsive to the changing needs and choices of beneficiaries 
receiving non-institutionally-based long-term services and sup-
ports (including such services and supports that are provided 
under programs other the State Medicaid program), and that 
provides strategies for beneficiaries receiving such services to 
maximize their independence, including through the use of 
client-employed providers; 
(2) provide the support and coordination needed for a bene-
ficiary in need of such services (and their family caregivers 
or representative, if applicable) to design an individualized, 
self-directed, community-supported life; and 
Regulations. 
42 USC 1396n 
note. 
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124 STAT. 302 
PUBLIC LAW 111–148—MAR. 23, 2010 
(3) improve coordination among, and the regulation of, 
all providers of such services under federally and State-funded 
programs in order to— 
(A) achieve a more consistent administration of policies 
and procedures across programs in relation to the provision 
of such services; and 
(B) oversee and monitor all service system functions 
to assure— 
(i) coordination of, and effectiveness of, eligibility 
determinations and individual assessments; 
(ii) development and service monitoring of a com-
plaint system, a management system, a system to 
qualify and monitor providers, and systems for role- 
setting and individual budget determinations; and 
(iii) an adequate number of qualified direct care 
workers to provide self-directed personal assistance 
services. 
(b) ADDITIONAL STATE OPTIONS.—Section 1915(i) of the Social 
Security Act (42 U.S.C. 1396n(i)) is amended by adding at the 
end the following new paragraphs: 
‘‘(6) STATE OPTION TO PROVIDE HOME AND COMMUNITY-BASED 
SERVICES
TO
INDIVIDUALS
ELIGIBLE
FOR
SERVICES
UNDER
A 
WAIVER.— 
‘‘(A) IN GENERAL.—A State that provides home and 
community-based services in accordance with this sub-
section to individuals who satisfy the needs-based criteria 
for the receipt of such services established under paragraph 
(1)(A) may, in addition to continuing to provide such serv-
ices to such individuals, elect to provide home and commu-
nity-based services in accordance with the requirements 
of this paragraph to individuals who are eligible for home 
and community-based services under a waiver approved 
for the State under subsection (c), (d), or (e) or under 
section 1115 to provide such services, but only for those 
individuals whose income does not exceed 300 percent of 
the supplemental security income benefit rate established 
by section 1611(b)(1). 
‘‘(B) APPLICATION OF SAME REQUIREMENTS FOR INDIVID-
UALS
SATISFYING
NEEDS-BASED
CRITERIA.—Subject 
to 
subparagraph (C), a State shall provide home and commu-
nity-based services to individuals under this paragraph 
in the same manner and subject to the same requirements 
as apply under the other paragraphs of this subsection 
to the provision of home and community-based services 
to individuals who satisfy the needs-based criteria estab-
lished under paragraph (1)(A). 
‘‘(C) AUTHORITY TO OFFER DIFFERENT TYPE, AMOUNT, 
DURATION, OR SCOPE OF HOME AND COMMUNITY-BASED SERV-
ICES.—A State may offer home and community-based serv-
ices to individuals under this paragraph that differ in 
type, amount, duration, or scope from the home and 
community-based services offered for individuals who sat-
isfy the needs-based criteria established under paragraph 
(1)(A), so long as such services are within the scope of 
services described in paragraph (4)(B) of subsection (c) 
for which the Secretary has the authority to approve a 
waiver and do not include room or board. 
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124 STAT. 303 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(7) STATE OPTION TO OFFER HOME AND COMMUNITY-BASED 
SERVICES TO SPECIFIC, TARGETED POPULATIONS.— 
‘‘(A) IN GENERAL.—A State may elect in a State plan 
amendment under this subsection to target the provision 
of home and community-based services under this sub-
section to specific populations and to differ the type, 
amount, duration, or scope of such services to such specific 
populations. 
‘‘(B) 5-YEAR TERM.— 
‘‘(i) IN GENERAL.—An election by a State under 
this paragraph shall be for a period of 5 years. 
‘‘(ii) PHASE-IN OF SERVICES AND ELIGIBILITY PER-
MITTED
DURING
INITIAL
5-YEAR
PERIOD.—A State 
making an election under this paragraph may, during 
the first 5-year period for which the election is made, 
phase-in the enrollment of eligible individuals, or the 
provision of services to such individuals, or both, so 
long as all eligible individuals in the State for such 
services are enrolled, and all such services are pro-
vided, before the end of the initial 5-year period. 
‘‘(C) RENEWAL.—An election by a State under this para-
graph may be renewed for additional 5-year terms if the 
Secretary determines, prior to beginning of each such 
renewal period, that the State has— 
‘‘(i) adhered to the requirements of this subsection 
and paragraph in providing services under such an 
election; and 
‘‘(ii) met the State’s objectives with respect to 
quality improvement and beneficiary outcomes.’’. 
(c) REMOVAL OF LIMITATION ON SCOPE OF SERVICES.—Para-
graph (1) of section 1915(i) of the Social Security Act (42 U.S.C. 
1396n(i)), as amended by subsection (a), is amended by striking 
‘‘or such other services requested by the State as the Secretary 
may approve’’. 
(d) OPTIONAL ELIGIBILITY CATEGORY TO PROVIDE FULL MED-
ICAID BENEFITS TO INDIVIDUALS RECEIVING HOME AND COMMUNITY- 
BASED SERVICES UNDER A STATE PLAN AMENDMENT.— 
(1) IN GENERAL.—Section 1902(a)(10)(A)(ii) of the Social 
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by 
section 2304(a)(1), is amended— 
(A) in subclause (XX), by striking ‘‘or’’ at the end; 
(B) in subclause (XXI), by adding ‘‘or’’ at the end; 
and 
(C) by inserting after subclause (XXI), the following 
new subclause: 
‘‘(XXII) who are eligible for home and commu-
nity-based services under needs-based criteria 
established under paragraph (1)(A) of section 
1915(i), or who are eligible for home and commu-
nity-based services under paragraph (6) of such 
section, and who will receive home and community- 
based services pursuant to a State plan amend-
ment under such subsection;’’. 
(2) CONFORMING AMENDMENTS.— 
(A) Section 1903(f)(4) of the Social Security Act (42 
U.S.C. 1396b(f)(4)), as amended by section 2304(a)(4)(B), 
is amended in the matter preceding subparagraph (A), 
Time period. 
Determination. 
Deadline. 
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124 STAT. 304 
PUBLIC LAW 111–148—MAR. 23, 2010 
by 
inserting 
‘‘1902(a)(10)(A)(ii)(XXII),’’ 
after 
‘‘1902(a)(10)(A)(ii)(XXI),’’. 
(B) Section 1905(a) of the Social Security Act (42 U.S.C. 
1396d(a)), as so amended, is amended in the matter pre-
ceding paragraph (1)— 
(i) in clause (xv), by striking ‘‘or’’ at the end; 
(ii) in clause (xvi), by adding ‘‘or’’ at the end; 
and 
(iii) by inserting after clause (xvi) the following 
new clause: 
‘‘(xvii) individuals who are eligible for home and commu-
nity-based services under needs-based criteria established 
under paragraph (1)(A) of section 1915(i), or who are eligible 
for home and community-based services under paragraph (6) 
of such section, and who will receive home and community- 
based services pursuant to a State plan amendment under 
such subsection,’’. 
(e) ELIMINATION OF OPTION TO LIMIT NUMBER OF ELIGIBLE 
INDIVIDUALS OR LENGTH OF PERIOD FOR GRANDFATHERED INDIVID-
UALS IF ELIGIBILITY CRITERIA IS MODIFIED.—Paragraph (1) of sec-
tion 1915(i) of such Act (42 U.S.C. 1396n(i)) is amended— 
(1) by striking subparagraph (C) and inserting the fol-
lowing: 
‘‘(C) PROJECTION OF NUMBER OF INDIVIDUALS TO BE 
PROVIDED
HOME
AND
COMMUNITY-BASED
SERVICES.—The 
State submits to the Secretary, in such form and manner, 
and upon such frequency as the Secretary shall specify, 
the projected number of individuals to be provided home 
and community-based services.’’; and 
(2) in subclause (II) of subparagraph (D)(ii), by striking 
‘‘to be eligible for such services for a period of at least 12 
months beginning on the date the individual first received 
medical assistance for such services’’ and inserting ‘‘to continue 
to be eligible for such services after the effective date of the 
modification and until such time as the individual no longer 
meets the standard for receipt of such services under such 
pre-modified criteria’’. 
(f) ELIMINATION OF OPTION TO WAIVE STATEWIDENESS; ADDI-
TION OF OPTION TO WAIVE COMPARABILITY.—Paragraph (3) of sec-
tion 1915(i) of such Act (42 U.S.C. 1396n(3)) is amended by striking 
‘‘1902(a)(1) (relating to statewideness)’’ and inserting ‘‘1902(a)(10)(B) 
(relating to comparability)’’. 
(g) EFFECTIVE DATE.—The amendments made by subsections 
(b) through (f) take effect on the first day of the first fiscal year 
quarter that begins after the date of enactment of this Act. 
SEC. 2403. MONEY FOLLOWS THE PERSON REBALANCING DEMONSTRA-
TION. 
(a) EXTENSION OF DEMONSTRATION.— 
(1) IN GENERAL.—Section 6071(h) of the Deficit Reduction 
Act of 2005 (42 U.S.C. 1396a note) is amended— 
(A) in paragraph (1)(E), by striking ‘‘fiscal year 2011’’ 
and inserting ‘‘each of fiscal years 2011 through 2016’’; 
and 
(B) in paragraph (2), by striking ‘‘2011’’ and inserting 
‘‘2016’’. 
42 USC 1396a 
note. 
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124 STAT. 305 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) EVALUATION.—Paragraphs (2) and (3) of section 6071(g) 
of such Act is amended are each amended by striking ‘‘2011’’ 
and inserting ‘‘2016’’. 
(b) REDUCTION OF INSTITUTIONAL RESIDENCY PERIOD.— 
(1) IN GENERAL.—Section 6071(b)(2) of the Deficit Reduction 
Act of 2005 (42 U.S.C. 1396a note) is amended— 
(A) in subparagraph (A)(i), by striking ‘‘, for a period 
of not less than 6 months or for such longer minimum 
period, not to exceed 2 years, as may be specified by the 
State’’ and inserting ‘‘for a period of not less than 90 
consecutive days’’; and 
(B) by adding at the end the following: 
‘‘Any days that an individual resides in an institution on the 
basis of having been admitted solely for purposes of receiving 
short-term rehabilitative services for a period for which pay-
ment for such services is limited under title XVIII shall not 
be taken into account for purposes of determining the 90- 
day period required under subparagraph (A)(i).’’. 
(2) EFFECTIVE DATE.—The amendments made by this sub-
section take effect 30 days after the date of enactment of 
this Act. 
SEC. 2404. PROTECTION FOR RECIPIENTS OF HOME AND COMMUNITY- 
BASED SERVICES AGAINST SPOUSAL IMPOVERISHMENT. 
During the 5-year period that begins on January 1, 2014, 
section 1924(h)(1)(A) of the Social Security Act (42 U.S.C. 1396r– 
5(h)(1)(A)) shall be applied as though ‘‘is eligible for medical assist-
ance for home and community-based services provided under sub-
section (c), (d), or (i) of section 1915, under a waiver approved 
under section 1115, or who is eligible for such medical assistance 
by reason of being determined eligible under section 1902(a)(10)(C) 
or by reason of section 1902(f) or otherwise on the basis of a 
reduction of income based on costs incurred for medical or other 
remedial care, or who is eligible for medical assistance for home 
and community-based attendant services and supports under section 
1915(k)’’ were substituted in such section for ‘‘(at the option of 
the State) is described in section 1902(a)(10)(A)(ii)(VI)’’. 
SEC. 2405. FUNDING TO EXPAND STATE AGING AND DISABILITY 
RESOURCE CENTERS. 
Out of any funds in the Treasury not otherwise appropriated, 
there is appropriated to the Secretary of Health and Human Serv-
ices, acting through the Assistant Secretary for Aging, $10,000,000 
for each of fiscal years 2010 through 2014, to carry out subsections 
(a)(20)(B)(iii) and (b)(8) of section 202 of the Older Americans Act 
of 1965 (42 U.S.C. 3012). 
SEC. 2406. SENSE OF THE SENATE REGARDING LONG-TERM CARE. 
(a) FINDINGS.—The Senate makes the following findings: 
(1) Nearly 2 decades have passed since Congress seriously 
considered long-term care reform. The United States Bipartisan 
Commission on Comprehensive Health Care, also know as the 
‘‘Pepper Commission’’, released its ‘‘Call for Action’’ blueprint 
for health reform in September 1990. In the 20 years since 
those recommendations were made, Congress has never acted 
on the report. 
(2) In 1999, under the United States Supreme Court’s 
decision in Olmstead v. L.C., 527 U.S. 581 (1999), individuals 
Time period. 
Applicability. 
42 USC 1396r–5 
note. 
42 USC 1396a 
note. 
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124 STAT. 306 
PUBLIC LAW 111–148—MAR. 23, 2010 
with disabilities have the right to choose to receive their long- 
term services and supports in the community, rather than 
in an institutional setting. 
(3) Despite the Pepper Commission and Olmstead decision, 
the long-term care provided to our Nation’s elderly and disabled 
has not improved. In fact, for many, it has gotten far worse. 
(4) In 2007, 69 percent of Medicaid long-term care spending 
for elderly individuals and adults with physical disabilities 
paid for institutional services. Only 6 states spent 50 percent 
or more of their Medicaid long-term care dollars on home and 
community-based services for elderly individuals and adults 
with physical disabilities while 1⁄2 of the States spent less 
than 25 percent. This disparity continues even though, on aver-
age, it is estimated that Medicaid dollars can support nearly 
3 elderly individuals and adults with physical disabilities in 
home and community-based services for every individual in 
a nursing home. Although every State has chosen to provide 
certain services under home and community-based waivers, 
these services are unevenly available within and across States, 
and reach a small percentage of eligible individuals. 
(b) SENSE OF THE SENATE.—It is the sense of the Senate that— 
(1) during the 111th session of Congress, Congress should 
address long-term services and supports in a comprehensive 
way that guarantees elderly and disabled individuals the care 
they need; and 
(2) long term services and supports should be made avail-
able in the community in addition to in institutions. 
Subtitle F—Medicaid Prescription Drug 
Coverage 
SEC. 2501. PRESCRIPTION DRUG REBATES. 
(a) INCREASE IN MINIMUM REBATE PERCENTAGE FOR SINGLE 
SOURCE DRUGS AND INNOVATOR MULTIPLE SOURCE DRUGS.— 
(1) IN GENERAL.—Section 1927(c)(1)(B) of the Social Secu-
rity Act (42 U.S.C. 1396r–8(c)(1)(B)) is amended— 
(A) in clause (i)— 
(i) in subclause (IV), by striking ‘‘and’’ at the end; 
(ii) in subclause (V)— 
(I) by inserting ‘‘and before January 1, 2010’’ 
after ‘‘December 31, 1995,’’; and 
(II) by striking the period at the end and 
inserting ‘‘; and’’; and 
(iii) by adding at the end the following new sub-
clause: 
‘‘(VI) except as provided in clause (iii), after 
December 31, 2009, 23.1 percent.’’; and 
(B) by adding at the end the following new clause: 
‘‘(iii) MINIMUM REBATE PERCENTAGE FOR CERTAIN 
DRUGS.— 
‘‘(I) IN GENERAL.—In the case of a single source 
drug or an innovator multiple source drug 
described in subclause (II), the minimum rebate 
percentage for rebate periods specified in clause 
(i)(VI) is 17.1 percent. 
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124 STAT. 307 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(II) DRUG DESCRIBED.—For purposes of sub-
clause (I), a single source drug or an innovator 
multiple source drug described in this subclause 
is any of the following drugs: 
‘‘(aa) A clotting factor for which a separate 
furnishing payment is made under section 
1842(o)(5) and which is included on a list of 
such factors specified and updated regularly 
by the Secretary. 
‘‘(bb) A drug approved by the Food and 
Drug Administration exclusively for pediatric 
indications.’’. 
(2) RECAPTURE OF TOTAL SAVINGS DUE TO INCREASE.—Sec-
tion 1927(b)(1) of such Act (42 U.S.C. 1396r–8(b)(1)) is amended 
by adding at the end the following new subparagraph: 
‘‘(C) SPECIAL RULE FOR INCREASED MINIMUM REBATE 
PERCENTAGE.— 
‘‘(i) IN
GENERAL.—In addition to the amounts 
applied as a reduction under subparagraph (B), for 
rebate periods beginning on or after January 1, 2010, 
during a fiscal year, the Secretary shall reduce pay-
ments to a State under section 1903(a) in the manner 
specified in clause (ii), in an amount equal to the 
product of— 
‘‘(I) 100 percent minus the Federal medical 
assistance percentage applicable to the rebate 
period for the State; and 
‘‘(II) the amounts received by the State under 
such subparagraph that are attributable (as esti-
mated by the Secretary based on utilization and 
other data) to the increase in the minimum rebate 
percentage effected by the amendments made by 
subsections (a)(1), (b), and (d) of section 2501 of 
the Patient Protection and Affordable Care Act, 
taking into account the additional drugs included 
under the amendments made by subsection (c) of 
section 2501 of such Act. 
The Secretary shall adjust such payment reduction 
for a calendar quarter to the extent the Secretary 
determines, based upon subsequent utilization and 
other data, that the reduction for such quarter was 
greater or less than the amount of payment reduction 
that should have been made. 
‘‘(ii) 
MANNER
OF
PAYMENT
REDUCTION.—The 
amount of the payment reduction under clause (i) for 
a State for a quarter shall be deemed an overpayment 
to the State under this title to be disallowed against 
the State’s regular quarterly draw for all Medicaid 
spending under section 1903(d)(2). Such a disallowance 
is not subject to a reconsideration under section 
1116(d).’’. 
(b) 
INCREASE
IN
REBATE
FOR
OTHER
DRUGS.—Section 
1927(c)(3)(B) of such Act (42 U.S.C. 1396r–8(c)(3)(B)) is amended— 
(1) in clause (i), by striking ‘‘and’’ at the end; 
(2) in clause (ii)— 
(A) by inserting ‘‘and before January 1, 2010,’’ after 
‘‘December 31, 1993,’’; and 
Determination. 
Time period. 
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124 STAT. 308 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) by striking the period and inserting ‘‘; and’’; and 
(3) by adding at the end the following new clause: 
‘‘(iii) after December 31, 2009, is 13 percent.’’. 
(c) 
EXTENSION
OF
PRESCRIPTION
DRUG
DISCOUNTS
TO 
ENROLLEES OF MEDICAID MANAGED CARE ORGANIZATIONS.— 
(1) IN
GENERAL.—Section 1903(m)(2)(A) of such Act (42 
U.S.C. 1396b(m)(2)(A)) is amended— 
(A) in clause (xi), by striking ‘‘and’’ at the end; 
(B) in clause (xii), by striking the period at the end 
and inserting ‘‘; and’’; and 
(C) by adding at the end the following: 
‘‘(xiii) such contract provides that (I) covered out-
patient drugs dispensed to individuals eligible for med-
ical assistance who are enrolled with the entity shall 
be subject to the same rebate required by the agree-
ment entered into under section 1927 as the State 
is subject to and that the State shall collect such 
rebates from manufacturers, (II) capitation rates paid 
to the entity shall be based on actual cost experience 
related to rebates and subject to the Federal regula-
tions requiring actuarially sound rates, and (III) the 
entity shall report to the State, on such timely and 
periodic basis as specified by the Secretary in order 
to include in the information submitted by the State 
to a manufacturer and the Secretary under section 
1927(b)(2)(A), information on the total number of units 
of each dosage form and strength and package size 
by National Drug Code of each covered outpatient drug 
dispensed to individuals eligible for medical assistance 
who are enrolled with the entity and for which the 
entity is responsible for coverage of such drug under 
this subsection (other than covered outpatient drugs 
that under subsection (j)(1) of section 1927 are not 
subject to the requirements of that section) and such 
other data as the Secretary determines necessary to 
carry out this subsection.’’. 
(2) CONFORMING AMENDMENTS.—Section 1927 (42 U.S.C. 
1396r–8) is amended— 
(A) in subsection (b)— 
(i) in paragraph (1)(A), in the first sentence, by 
inserting ‘‘, including such drugs dispensed to individ-
uals enrolled with a medicaid managed care organiza-
tion if the organization is responsible for coverage of 
such drugs’’ before the period; and 
(ii) in paragraph (2)(A), by inserting ‘‘including 
such information reported by each medicaid managed 
care organization,’’ after ‘‘for which payment was made 
under the plan during the period,’’; and 
(B) in subsection (j), by striking paragraph (1) and 
inserting the following: 
‘‘(1) Covered outpatient drugs are not subject to the require-
ments of this section if such drugs are— 
‘‘(A) dispensed by health maintenance organizations, 
including Medicaid managed care organizations that con-
tract under section 1903(m); and 
‘‘(B) subject to discounts under section 340B of the 
Public Health Service Act.’’. 
Contracts. 
Reports. 
Determination. 
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124 STAT. 309 
PUBLIC LAW 111–148—MAR. 23, 2010 
(d) ADDITIONAL REBATE FOR NEW FORMULATIONS OF EXISTING 
DRUGS.— 
(1) IN GENERAL.—Section 1927(c)(2) of the Social Security 
Act (42 U.S.C. 1396r–8(c)(2)) is amended by adding at the 
end the following new subparagraph: 
‘‘(C) TREATMENT OF NEW FORMULATIONS.— 
‘‘(i) IN
GENERAL.—Except as provided in clause 
(ii), in the case of a drug that is a new formulation, 
such as an extended-release formulation, of a single 
source drug or an innovator multiple source drug, the 
rebate obligation with respect to the drug under this 
section shall be the amount computed under this sec-
tion for the new formulation of the drug or, if greater, 
the product of— 
‘‘(I) the average manufacturer price for each 
dosage form and strength of the new formulation 
of the single source drug or innovator multiple 
source drug; 
‘‘(II) the highest additional rebate (calculated 
as a percentage of average manufacturer price) 
under this section for any strength of the original 
single source drug or innovator multiple source 
drug; and 
‘‘(III) the total number of units of each dosage 
form and strength of the new formulation paid 
for under the State plan in the rebate period (as 
reported by the State). 
‘‘(ii) NO APPLICATION TO NEW FORMULATIONS OF 
ORPHAN DRUGS.—Clause (i) shall not apply to a new 
formulation of a covered outpatient drug that is or 
has been designated under section 526 of the Federal 
Food, Drug, and Cosmetic Act (21 U.S.C. 360bb) for 
a rare disease or condition, without regard to whether 
the period of market exclusivity for the drug under 
section 527 of such Act has expired or the specific 
indication for use of the drug.’’. 
(2) EFFECTIVE DATE.—The amendment made by paragraph 
(1) shall apply to drugs that are paid for by a State after 
December 31, 2009. 
(e) MAXIMUM REBATE AMOUNT.—Section 1927(c)(2) of such Act 
(42 U.S.C. 1396r–8(c)(2)), as amended by subsection (d), is amended 
by adding at the end the following new subparagraph: 
‘‘(D) MAXIMUM REBATE AMOUNT.—In no case shall the 
sum of the amounts applied under paragraph (1)(A)(ii) 
and this paragraph with respect to each dosage form and 
strength of a single source drug or an innovator multiple 
source drug for a rebate period beginning after December 
31, 2009, exceed 100 percent of the average manufacturer 
price of the drug.’’. 
(f) CONFORMING AMENDMENTS.— 
(1) IN GENERAL.—Section 340B of the Public Health Service 
Act (42 U.S.C. 256b) is amended— 
(A) in subsection (a)(2)(B)(i), by striking ‘‘1927(c)(4)’’ 
and inserting ‘‘1927(c)(3)’’; and 
(B) by striking subsection (c); and 
(C) redesignating subsection (d) as subsection (c). 
42 USC 1396r–8 
note. 
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124 STAT. 310 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) EFFECTIVE DATE.—The amendments made by this sub-
section take effect on January 1, 2010. 
SEC. 2502. ELIMINATION OF EXCLUSION OF COVERAGE OF CERTAIN 
DRUGS. 
(a) IN GENERAL.—Section 1927(d) of the Social Security Act 
(42 U.S.C. 1397r–8(d)) is amended— 
(1) in paragraph (2)— 
(A) by striking subparagraphs (E), (I), and (J), respec-
tively; and 
(B) by redesignating subparagraphs (F), (G), (H), and 
(K) as subparagraphs (E), (F), (G), and (H), respectively; 
and 
(2) by adding at the end the following new paragraph: 
‘‘(7) NON-EXCLUDABLE
DRUGS.—The following drugs or 
classes of drugs, or their medical uses, shall not be excluded 
from coverage: 
‘‘(A) Agents when used to promote smoking cessation, 
including agents approved by the Food and Drug Adminis-
tration under the over-the-counter monograph process for 
purposes of promoting, and when used to promote, tobacco 
cessation. 
‘‘(B) Barbiturates. 
‘‘(C) Benzodiazepines.’’. 
(b) EFFECTIVE DATE.—The amendments made by this section 
shall apply to services furnished on or after January 1, 2014. 
SEC. 2503. PROVIDING ADEQUATE PHARMACY REIMBURSEMENT. 
(a) PHARMACY REIMBURSEMENT LIMITS.— 
(1) IN
GENERAL.—Section 1927(e) of the Social Security 
Act (42 U.S.C. 1396r–8(e)) is amended— 
(A) in paragraph (4), by striking ‘‘(or, effective January 
1, 2007, two or more)’’; and 
(B) by striking paragraph (5) and inserting the fol-
lowing: 
‘‘(5) USE OF AMP IN UPPER PAYMENT LIMITS.—The Secretary 
shall calculate the Federal upper reimbursement limit estab-
lished under paragraph (4) as no less than 175 percent of 
the weighted average (determined on the basis of utilization) 
of the most recently reported monthly average manufacturer 
prices for pharmaceutically and therapeutically equivalent mul-
tiple source drug products that are available for purchase by 
retail community pharmacies on a nationwide basis. The Sec-
retary shall implement a smoothing process for average manu-
facturer prices. Such process shall be similar to the smoothing 
process used in determining the average sales price of a drug 
or biological under section 1847A.’’. 
(2) DEFINITION OF AMP.—Section 1927(k)(1) of such Act 
(42 U.S.C. 1396r–8(k)(1)) is amended— 
(A) in subparagraph (A), by striking ‘‘by’’ and all that 
follows through the period and inserting ‘‘by— 
‘‘(i) wholesalers for drugs distributed to retail 
community pharmacies; and 
‘‘(ii) retail community pharmacies that purchase 
drugs directly from the manufacturer.’’; and 
(B) by striking subparagraph (B) and inserting the 
following: 
42 USC 1396r–8 
note. 
42 USC 256b 
note. 
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124 STAT. 311 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) EXCLUSION OF CUSTOMARY PROMPT PAY DISCOUNTS 
AND OTHER PAYMENTS.— 
‘‘(i) IN GENERAL.—The average manufacturer price 
for a covered outpatient drug shall exclude— 
‘‘(I) customary prompt pay discounts extended 
to wholesalers; 
‘‘(II) bona fide service fees paid by manufactur-
ers to wholesalers or retail community pharmacies, 
including (but not limited to) distribution service 
fees, inventory management fees, product stocking 
allowances, and fees associated with administra-
tive services agreements and patient care pro-
grams (such as medication compliance programs 
and patient education programs); 
‘‘(III) reimbursement by manufacturers for 
recalled, damaged, expired, or otherwise unsalable 
returned goods, including (but not limited to) 
reimbursement for the cost of the goods and any 
reimbursement of costs associated with return 
goods handling and processing, reverse logistics, 
and drug destruction; and 
‘‘(IV) payments received from, and rebates or 
discounts provided to, pharmacy benefit managers, 
managed care organizations, health maintenance 
organizations, insurers, hospitals, clinics, mail 
order pharmacies, long term care providers, manu-
facturers, or any other entity that does not conduct 
business as a wholesaler or a retail community 
pharmacy. 
‘‘(ii) INCLUSION
OF
OTHER
DISCOUNTS
AND
PAY-
MENTS.—Notwithstanding clause (i), any other dis-
counts, rebates, payments, or other financial trans-
actions that are received by, paid by, or passed through 
to, retail community pharmacies shall be included in 
the average manufacturer price for a covered out-
patient drug.’’; and 
(C) in subparagraph (C), by striking ‘‘the retail phar-
macy class of trade’’ and inserting ‘‘retail community phar-
macies’’. 
(3) DEFINITION
OF
MULTIPLE
SOURCE
DRUG.—Section 
1927(k)(7) of such Act (42 U.S.C. 1396r–8(k)(7)) is amended— 
(A) in subparagraph (A)(i)(III), by striking ‘‘the State’’ 
and inserting ‘‘the United States’’; and 
(B) in subparagraph (C)— 
(i) in clause (i), by inserting ‘‘and’’ after the semi-
colon; 
(ii) in clause (ii), by striking ‘‘; and’’ and inserting 
a period; and 
(iii) by striking clause (iii). 
(4) DEFINITIONS OF RETAIL COMMUNITY PHARMACY; WHOLE-
SALER.—Section 1927(k) of such Act (42 U.S.C. 1396r–8(k)) 
is amended by adding at the end the following new paragraphs: 
‘‘(10) RETAIL
COMMUNITY
PHARMACY.—The term ‘retail 
community pharmacy’ means an independent pharmacy, a 
chain pharmacy, a supermarket pharmacy, or a mass merchan-
diser pharmacy that is licensed as a pharmacy by the State 
and that dispenses medications to the general public at retail 
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124 STAT. 312 
PUBLIC LAW 111–148—MAR. 23, 2010 
prices. Such term does not include a pharmacy that dispenses 
prescription medications to patients primarily through the mail, 
nursing home pharmacies, long-term care facility pharmacies, 
hospital pharmacies, clinics, charitable or not-for-profit phar-
macies, government pharmacies, or pharmacy benefit man-
agers. 
‘‘(11) WHOLESALER.—The term ‘wholesaler’ means a drug 
wholesaler that is engaged in wholesale distribution of prescrip-
tion drugs to retail community pharmacies, including (but not 
limited to) manufacturers, repackers, distributors, own-label 
distributors, private-label distributors, jobbers, brokers, ware-
houses (including manufacturer’s and distributor’s warehouses, 
chain drug warehouses, and wholesale drug warehouses) inde-
pendent wholesale drug traders, and retail community phar-
macies that conduct wholesale distributions.’’. 
(b) DISCLOSURE OF PRICE INFORMATION TO THE PUBLIC.—Sec-
tion 1927(b)(3) of such Act (42 U.S.C. 1396r–8(b)(3)) is amended— 
(1) in subparagraph (A)— 
(A) in the first sentence, by inserting after clause (iii) 
the following: 
‘‘(iv) not later than 30 days after the last day 
of each month of a rebate period under the agreement, 
on the manufacturer’s total number of units that are 
used to calculate the monthly average manufacturer 
price for each covered outpatient drug;’’; and 
(B) in the second sentence, by inserting ‘‘(relating to 
the weighted average of the most recently reported monthly 
average manufacturer prices)’’ after ‘‘(D)(v)’’; and 
(2) in subparagraph (D)(v), by striking ‘‘average manufac-
turer prices’’ and inserting ‘‘the weighted average of the most 
recently reported monthly average manufacturer prices and 
the average retail survey price determined for each multiple 
source drug in accordance with subsection (f)’’. 
(c) CLARIFICATION
OF APPLICATION
OF SURVEY
OF RETAIL 
PRICES.—Section 1927(f)(1) of such Act (42 U.S.C. 1396r–8(b)(1)) 
is amended— 
(1) in subparagraph (A)(i), by inserting ‘‘with respect to 
a retail community pharmacy,’’ before ‘‘the determination’’; and 
(2) in subparagraph (C)(ii), by striking ‘‘retail pharmacies’’ 
and inserting ‘‘retail community pharmacies’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall take effect on the first day of the first calendar year quarter 
that begins at least 180 days after the date of enactment of this 
Act, without regard to whether or not final regulations to carry 
out such amendments have been promulgated by such date. 
Subtitle G—Medicaid Disproportionate 
Share Hospital (DSH) Payments 
SEC. 2551. DISPROPORTIONATE SHARE HOSPITAL PAYMENTS. 
(a) IN GENERAL.—Section 1923(f) of the Social Security Act 
(42 U.S.C. 1396r–4(f)) is amended— 
(1) in paragraph (1), by striking ‘‘and (3)’’ and inserting 
‘‘, (3), and (7)’’; 
(2) in paragraph (3)(A), by striking ‘‘paragraph (6)’’ and 
inserting ‘‘paragraphs (6) and (7)’’; 
42 USC 1396r–8 
note. 
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124 STAT. 313 
PUBLIC LAW 111–148—MAR. 23, 2010 
(3) by redesignating paragraph (7) as paragraph (8); and 
(4) by inserting after paragraph (6) the following new para-
graph: 
‘‘(7) REDUCTION OF STATE DSH ALLOTMENTS ONCE REDUC-
TION IN UNINSURED THRESHOLD REACHED.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (E), the 
DSH allotment for a State for fiscal years beginning with 
the fiscal year described in subparagraph (C) (with respect 
to the State), is equal to— 
‘‘(i) in the case of the first fiscal year described 
in subparagraph (C) with respect to a State, the DSH 
allotment that would be determined under this sub-
section for the State for the fiscal year without applica-
tion of this paragraph (but after the application of 
subparagraph (D)), reduced by the applicable percent-
age determined for the State for the fiscal year under 
subparagraph (B)(i); and 
‘‘(ii) in the case of any subsequent fiscal year with 
respect to the State, the DSH allotment determined 
under this paragraph for the State for the preceding 
fiscal year, reduced by the applicable percentage deter-
mined for the State for the fiscal year under subpara-
graph (B)(ii). 
‘‘(B) 
APPLICABLE
PERCENTAGE.—For 
purposes 
of 
subparagraph (A), the applicable percentage for a State 
for a fiscal year is the following: 
‘‘(i) UNINSURED
REDUCTION
THRESHOLD
FISCAL 
YEAR.—In the case of the first fiscal year described 
in subparagraph (C) with respect to the State— 
‘‘(I) if the State is a low DSH State described 
in paragraph (5)(B), the applicable percentage is 
equal to 25 percent; and 
‘‘(II) if the State is any other State, the 
applicable percentage is 50 percent. 
‘‘(ii) SUBSEQUENT
FISCAL
YEARS
IN
WHICH
THE 
PERCENTAGE OF UNINSURED DECREASES.—In the case 
of any fiscal year after the first fiscal year described 
in subparagraph (C) with respect to a State, if the 
Secretary determines on the basis of the most recent 
American Community Survey of the Bureau of the 
Census, that the percentage of uncovered individuals 
residing in the State is less than the percentage of 
such individuals determined for the State for the pre-
ceding fiscal year— 
‘‘(I) if the State is a low DSH State described 
in paragraph (5)(B), 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 25 percent; and 
‘‘(II) if the State is any other State, 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 50 percent. 
‘‘(C) 
FISCAL
YEAR
DESCRIBED.—For 
purposes 
of 
subparagraph (A), the fiscal year described in this subpara-
graph with respect to a State is the first fiscal year that 
Determination. 
Determination. 
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124 STAT. 314 
PUBLIC LAW 111–148—MAR. 23, 2010 
occurs after fiscal year 2012 for which the Secretary deter-
mines, on the basis of the most recent American Commu-
nity Survey of the Bureau of the Census, that the percent-
age of uncovered individuals residing in the State is at 
least 45 percent less than the percentage of such individ-
uals determined for the State for fiscal year 2009. 
‘‘(D) EXCLUSION OF PORTIONS DIVERTED FOR COVERAGE 
EXPANSIONS.—For purposes of applying the applicable 
percentage reduction under subparagraph (A) to the DSH 
allotment for a State for a fiscal year, the DSH allotment 
for a State that would be determined under this subsection 
for the State for the fiscal year without the application 
of this paragraph (and prior to any such reduction) shall 
not include any portion of the allotment for which the 
Secretary has approved the State’s diversion to the costs 
of providing medical assistance or other health benefits 
coverage under a waiver that is in effect on July 2009. 
‘‘(E) MINIMUM ALLOTMENT.—In no event shall the DSH 
allotment determined for a State in accordance with this 
paragraph for fiscal year 2013 or any succeeding fiscal 
year be less than the amount equal to 35 percent of the 
DSH allotment determined for the State for fiscal year 
2012 under this subsection (and after the application of 
this paragraph, if applicable), increased by the percentage 
change in the consumer price index for all urban consumers 
(all items, U.S. city average) for each previous fiscal year 
occurring before the fiscal year. 
‘‘(F) UNCOVERED INDIVIDUALS.—In this paragraph, the 
term ‘uncovered individuals’ means individuals with no 
health insurance coverage at any time during a year (as 
determined by the Secretary based on the most recent 
data available).’’. 
(b) EFFECTIVE DATE.—The amendments made by subsection 
(a) take effect on October 1, 2011. 
Subtitle H—Improved Coordination for 
Dual Eligible Beneficiaries 
SEC. 2601. 5-YEAR PERIOD FOR DEMONSTRATION PROJECTS. 
(a) IN GENERAL.—Section 1915(h) of the Social Security Act 
(42 U.S.C. 1396n(h)) is amended— 
(1) by inserting ‘‘(1)’’ after ‘‘(h)’’; 
(2) by inserting ‘‘, or a waiver described in paragraph 
(2)’’ after ‘‘(e)’’; and 
(3) by adding at the end the following new paragraph: 
‘‘(2)(A) Notwithstanding subsections (c)(3) and (d) (3), any 
waiver under subsection (b), (c), or (d), or a waiver under section 
1115, that provides medical assistance for dual eligible individuals 
(including any such waivers under which non dual eligible individ-
uals may be enrolled in addition to dual eligible individuals) may 
be conducted for a period of 5 years and, upon the request of 
the State, may be extended for additional 5-year periods unless 
the Secretary determines that for the previous waiver period the 
conditions for the waiver have not been met or it would no longer 
be cost-effective and efficient, or consistent with the purposes of 
this title, to extend the waiver. 
Determination. 
42 USC 1396r–4 
note. 
Definition. 
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124 STAT. 315 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) In this paragraph, the term ‘dual eligible individual’ means 
an individual who is entitled to, or enrolled for, benefits under 
part A of title XVIII, or enrolled for benefits under part B of 
title XVIII, and is eligible for medical assistance under the State 
plan under this title or under a waiver of such plan.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Section 1915 of such Act (42 U.S.C. 1396n) is amended— 
(A) in subsection (b), by adding at the end the following 
new sentence: ‘‘Subsection (h)(2) shall apply to a waiver 
under this subsection.’’; 
(B) in subsection (c)(3), in the second sentence, by 
inserting ‘‘(other than a waiver described in subsection 
(h)(2))’’ after ‘‘A waiver under this subsection’’; 
(C) in subsection (d)(3), in the second sentence, by 
inserting ‘‘(other than a waiver described in subsection 
(h)(2))’’ after ‘‘A waiver under this subsection’’. 
(2) Section 1115 of such Act (42 U.S.C. 1315) is amended— 
(A) in subsection (e)(2), by inserting ‘‘(5 years, in the 
case of a waiver described in section 1915(h)(2))’’ after 
‘‘3 years’’; and 
(B) in subsection (f)(6), by inserting ‘‘(5 years, in the 
case of a waiver described in section 1915(h)(2))’’ after 
‘‘3 years’’. 
SEC. 2602. PROVIDING FEDERAL COVERAGE AND PAYMENT COORDINA-
TION FOR DUAL ELIGIBLE BENEFICIARIES. 
(a) ESTABLISHMENT OF FEDERAL COORDINATED HEALTH CARE 
OFFICE.— 
(1) IN GENERAL.—Not later than March 1, 2010, the Sec-
retary of Health and Human Services (in this section referred 
to as the ‘‘Secretary’’) shall establish a Federal Coordinated 
Health Care Office. 
(2) ESTABLISHMENT
AND
REPORTING
TO
CMS
ADMINIS-
TRATOR.—The Federal Coordinated Health Care Office— 
(A) shall be established within the Centers for Medi-
care & Medicaid Services; and 
(B) have as the Office a Director who shall be appointed 
by, and be in direct line of authority to, the Administrator 
of the Centers for Medicare & Medicaid Services. 
(b) PURPOSE.—The purpose of the Federal Coordinated Health 
Care Office is to bring together officers and employees of the Medi-
care and Medicaid programs at the Centers for Medicare & Medicaid 
Services in order to— 
(1) more effectively integrate benefits under the Medicare 
program under title XVIII of the Social Security Act and the 
Medicaid program under title XIX of such Act; and 
(2) improve the coordination between the Federal Govern-
ment and States for individuals eligible for benefits under 
both such programs in order to ensure that such individuals 
get full access to the items and services to which they are 
entitled under titles XVIII and XIX of the Social Security 
Act. 
(c) GOALS.—The goals of the Federal Coordinated Health Care 
Office are as follows: 
(1) Providing dual eligible individuals full access to the 
benefits to which such individuals are entitled under the Medi-
care and Medicaid programs. 
Appointment. 
Deadline. 
42 USC 1315b. 
Definition. 
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124 STAT. 316 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) Simplifying the processes for dual eligible individuals 
to access the items and services they are entitled to under 
the Medicare and Medicaid programs. 
(3) Improving the quality of health care and long-term 
services for dual eligible individuals. 
(4) Increasing dual eligible individuals’ understanding of 
and satisfaction with coverage under the Medicare and Med-
icaid programs. 
(5) Eliminating regulatory conflicts between rules under 
the Medicare and Medicaid programs. 
(6) Improving care continuity and ensuring safe and effec-
tive care transitions for dual eligible individuals. 
(7) Eliminating cost-shifting between the Medicare and 
Medicaid program and among related health care providers. 
(8) Improving the quality of performance of providers of 
services and suppliers under the Medicare and Medicaid pro-
grams. 
(d) SPECIFIC RESPONSIBILITIES.—The specific responsibilities of 
the Federal Coordinated Health Care Office are as follows: 
(1) Providing States, specialized MA plans for special needs 
individuals (as defined in section 1859(b)(6) of the Social Secu-
rity Act (42 U.S.C. 1395w–28(b)(6))), physicians and other rel-
evant entities or individuals with the education and tools nec-
essary for developing programs that align benefits under the 
Medicare and Medicaid programs for dual eligible individuals. 
(2) Supporting State efforts to coordinate and align acute 
care and long-term care services for dual eligible individuals 
with other items and services furnished under the Medicare 
program. 
(3) Providing support for coordination of contracting and 
oversight by States and the Centers for Medicare & Medicaid 
Services with respect to the integration of the Medicare and 
Medicaid programs in a manner that is supportive of the goals 
described in paragraph (3). 
(4) To consult and coordinate with the Medicare Payment 
Advisory Commission established under section 1805 of the 
Social Security Act (42 U.S.C. 1395b–6) and the Medicaid and 
CHIP Payment and Access Commission established under sec-
tion 1900 of such Act (42 U.S.C. 1396) with respect to policies 
relating to the enrollment in, and provision of, benefits to 
dual eligible individuals under the Medicare program under 
title XVIII of the Social Security Act and the Medicaid program 
under title XIX of such Act. 
(5) To study the provision of drug coverage for new full- 
benefit dual eligible individuals (as defined in section 1935(c)(6) 
of the Social Security Act (42 U.S.C. 1396u–5(c)(6)), as well 
as to monitor and report annual total expenditures, health 
outcomes, and access to benefits for all dual eligible individuals. 
(e) REPORT.—The Secretary shall, as part of the budget trans-
mitted under section 1105(a) of title 31, United States Code, submit 
to Congress an annual report containing recommendations for legis-
lation that would improve care coordination and benefits for dual 
eligible individuals. 
(f) DUAL ELIGIBLE DEFINED.—In this section, the term ‘‘dual 
eligible individual’’ means an individual who is entitled to, or 
enrolled for, benefits under part A of title XVIII of the Social 
Security Act, or enrolled for benefits under part B of title XVIII 
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124 STAT. 317 
PUBLIC LAW 111–148—MAR. 23, 2010 
of such Act, and is eligible for medical assistance under a State 
plan under title XIX of such Act or under a waiver of such plan. 
Subtitle I—Improving the Quality of 
Medicaid for Patients and Providers 
SEC. 2701. ADULT HEALTH QUALITY MEASURES. 
Title XI of the Social Security Act (42 U.S.C. 1301 et seq.), 
as amended by section 401 of the Children’s Health Insurance 
Program Reauthorization Act of 2009 (Public Law 111–3), is 
amended by inserting after section 1139A the following new section: 
‘‘SEC. 1139B. ADULT HEALTH QUALITY MEASURES. 
‘‘(a) DEVELOPMENT OF CORE SET OF HEALTH CARE QUALITY 
MEASURES FOR ADULTS ELIGIBLE FOR BENEFITS UNDER MEDICAID.— 
The Secretary shall identify and publish a recommended core set 
of adult health quality measures for Medicaid eligible adults in 
the same manner as the Secretary identifies and publishes a core 
set of child health quality measures under section 1139A, including 
with respect to identifying and publishing existing adult health 
quality measures that are in use under public and privately spon-
sored health care coverage arrangements, or that are part of 
reporting systems that measure both the presence and duration 
of health insurance coverage over time, that may be applicable 
to Medicaid eligible adults. 
‘‘(b) DEADLINES.— 
‘‘(1) RECOMMENDED
MEASURES.—Not later than January 
1, 2011, the Secretary shall identify and publish for comment 
a recommended core set of adult health quality measures for 
Medicaid eligible adults. 
‘‘(2) DISSEMINATION.—Not later than January 1, 2012, the 
Secretary shall publish an initial core set of adult health quality 
measures that are applicable to Medicaid eligible adults. 
‘‘(3) STANDARDIZED REPORTING.—Not later than January 
1, 2013, the Secretary, in consultation with States, shall develop 
a standardized format for reporting information based on the 
initial core set of adult health quality measures and create 
procedures to encourage States to use such measures to volun-
tarily report information regarding the quality of health care 
for Medicaid eligible adults. 
‘‘(4) REPORTS TO CONGRESS.—Not later than January 1, 
2014, and every 3 years thereafter, the Secretary shall include 
in the report to Congress required under section 1139A(a)(6) 
information similar to the information required under that 
section with respect to the measures established under this 
section. 
‘‘(5) ESTABLISHMENT OF MEDICAID QUALITY MEASUREMENT 
PROGRAM.— 
‘‘(A) IN GENERAL.—Not later than 12 months after the 
release of the recommended core set of adult health quality 
measures under paragraph (1)), the Secretary shall estab-
lish a Medicaid Quality Measurement Program in the same 
manner as the Secretary establishes the pediatric quality 
measures program under section 1139A(b). The aggregate 
amount awarded by the Secretary for grants and contracts 
for the development, testing, and validation of emerging 
Publication. 
Publication. 
Publication. 
42 USC 
1320b–9b. 
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124 STAT. 318 
PUBLIC LAW 111–148—MAR. 23, 2010 
and innovative evidence-based measures under such pro-
gram shall equal the aggregate amount awarded by the 
Secretary for grants under section 1139A(b)(4)(A) 
‘‘(B) REVISING, STRENGTHENING, AND IMPROVING INITIAL 
CORE MEASURES.—Beginning not later than 24 months after 
the establishment of the Medicaid Quality Measurement 
Program, and annually thereafter, the Secretary shall pub-
lish recommended changes to the initial core set of adult 
health quality measures that shall reflect the results of 
the testing, validation, and consensus process for the 
development of adult health quality measures. 
‘‘(c) CONSTRUCTION.—Nothing in this section shall be construed 
as supporting the restriction of coverage, under title XIX or XXI 
or otherwise, to only those services that are evidence-based, or 
in anyway limiting available services. 
‘‘(d) ANNUAL
STATE
REPORTS
REGARDING
STATE-SPECIFIC 
QUALITY OF CARE MEASURES APPLIED UNDER MEDICAID.— 
‘‘(1) ANNUAL
STATE
REPORTS.—Each State with a State 
plan or waiver approved under title XIX shall annually report 
(separately or as part of the annual report required under 
section 1139A(c)), to the Secretary on the— 
‘‘(A) State-specific adult health quality measures 
applied by the State under the such plan, including meas-
ures described in subsection (a)(5); and 
‘‘(B) State-specific information on the quality of health 
care furnished to Medicaid eligible adults under such plan, 
including information collected through external quality 
reviews of managed care organizations under section 1932 
and benchmark plans under section 1937. 
‘‘(2) PUBLICATION.—Not later than September 30, 2014, 
and annually thereafter, the Secretary shall collect, analyze, 
and make publicly available the information reported by States 
under paragraph (1). 
‘‘(e) APPROPRIATION.—Out of any funds in the Treasury not 
otherwise appropriated, there is appropriated for each of fiscal 
years 2010 through 2014, $60,000,000 for the purpose of carrying 
out this section. Funds appropriated under this subsection shall 
remain available until expended.’’. 
SEC. 2702. PAYMENT ADJUSTMENT FOR HEALTH CARE-ACQUIRED 
CONDITIONS. 
(a) IN GENERAL.—The Secretary of Health and Human Services 
(in this subsection referred to as the ‘‘Secretary’’) shall identify 
current State practices that prohibit payment for health care- 
acquired conditions and shall incorporate the practices identified, 
or elements of such practices, which the Secretary determines 
appropriate for application to the Medicaid program in regulations. 
Such regulations shall be effective as of July 1, 2011, and shall 
prohibit payments to States under section 1903 of the Social Secu-
rity Act for any amounts expended for providing medical assistance 
for health care-acquired conditions specified in the regulations. 
The regulations shall ensure that the prohibition on payment for 
health care-acquired conditions shall not result in a loss of access 
to care or services for Medicaid beneficiaries. 
(b) HEALTH CARE-ACQUIRED CONDITION.—In this section. the 
term ‘‘health care-acquired condition’’ means a medical condition 
for which an individual was diagnosed that could be identified 
Definition. 
Determination. 
Regulations. 
Effective date. 
42 USC 1396b–1. 
Deadlines. 
Public 
information. 
Publication. 
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124 STAT. 319 
PUBLIC LAW 111–148—MAR. 23, 2010 
by a secondary diagnostic code described in section 1886(d)(4)(D)(iv) 
of the Social Security Act (42 U.S.C. 1395ww(d)(4)(D)(iv)). 
(c) MEDICARE PROVISIONS.—In carrying out this section, the 
Secretary shall apply to State plans (or waivers) under title XIX 
of the Social Security Act the regulations promulgated pursuant 
to section 1886(d)(4)(D) of such Act (42 U.S.C. 1395ww(d)(4)(D)) 
relating to the prohibition of payments based on the presence of 
a secondary diagnosis code specified by the Secretary in such regula-
tions, as appropriate for the Medicaid program. The Secretary may 
exclude certain conditions identified under title XVIII of the Social 
Security Act for non-payment under title XIX of such Act when 
the Secretary finds the inclusion of such conditions to be inappli-
cable to beneficiaries under title XIX. 
SEC. 
2703. 
STATE 
OPTION 
TO 
PROVIDE 
HEALTH 
HOMES 
FOR 
ENROLLEES WITH CHRONIC CONDITIONS. 
(a) STATE PLAN AMENDMENT.—Title XIX of the Social Security 
Act (42 U.S.C. 1396a et seq.), as amended by sections 2201 and 
2305, is amended by adding at the end the following new section: 
‘‘SEC. 1945. STATE OPTION TO PROVIDE COORDINATED CARE 
THROUGH A HEALTH HOME FOR INDIVIDUALS WITH CHRONIC CONDI-
TIONS.— 
‘‘(a) IN GENERAL.—Notwithstanding section 1902(a)(1) (relating 
to statewideness), section 1902(a)(10)(B) (relating to comparability), 
and any other provision of this title for which the Secretary deter-
mines it is necessary to waive in order to implement this section, 
beginning January 1, 2011, a State, at its option as a State plan 
amendment, may provide for medical assistance under this title 
to eligible individuals with chronic conditions who select a des-
ignated provider (as described under subsection (h)(5)), a team 
of health care professionals (as described under subsection (h)(6)) 
operating with such a provider, or a health team (as described 
under subsection (h)(7)) as the individual’s health home for purposes 
of providing the individual with health home services. 
‘‘(b) HEALTH HOME QUALIFICATION STANDARDS.—The Secretary 
shall establish standards for qualification as a designated provider 
for the purpose of being eligible to be a health home for purposes 
of this section. 
‘‘(c) PAYMENTS.— 
‘‘(1) IN GENERAL.—A State shall provide a designated pro-
vider, a team of health care professionals operating with such 
a provider, or a health team with payments for the provision 
of health home services to each eligible individual with chronic 
conditions that selects such provider, team of health care profes-
sionals, or health team as the individual’s health home. Pay-
ments made to a designated provider, a team of health care 
professionals operating with such a provider, or a health team 
for such services shall be treated as medical assistance for 
purposes of section 1903(a), except that, during the first 8 
fiscal year quarters that the State plan amendment is in effect, 
the Federal medical assistance percentage applicable to such 
payments shall be equal to 90 percent. 
‘‘(2) METHODOLOGY.— 
‘‘(A) IN GENERAL.—The State shall specify in the State 
plan amendment the methodology the State will use for 
determining payment for the provision of health home serv-
ices. Such methodology for determining payment— 
Determination. 
Effective date. 
42 USC 1396w–4. 
Applicability. 
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124 STAT. 320 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) may be tiered to reflect, with respect to each 
eligible individual with chronic conditions provided 
such services by a designated provider, a team of health 
care professionals operating with such a provider, or 
a health team, as well as the severity or number of 
each such individual’s chronic conditions or the specific 
capabilities of the provider, team of health care profes-
sionals, or health team; and 
‘‘(ii) shall be established consistent with section 
1902(a)(30)(A). 
‘‘(B) ALTERNATE MODELS OF PAYMENT.—The method-
ology for determining payment for provision of health home 
services under this section shall not be limited to a per- 
member per-month basis and may provide (as proposed 
by the State and subject to approval by the Secretary) 
for alternate models of payment. 
‘‘(3) PLANNING GRANTS.— 
‘‘(A) IN GENERAL.—Beginning January 1, 2011, the Sec-
retary may award planning grants to States for purposes 
of developing a State plan amendment under this section. 
A planning grant awarded to a State under this paragraph 
shall remain available until expended. 
‘‘(B) STATE CONTRIBUTION.—A State awarded a plan-
ning grant shall contribute an amount equal to the State 
percentage determined under section 1905(b) (without 
regard to section 5001 of Public Law 111–5) for each fiscal 
year for which the grant is awarded. 
‘‘(C) LIMITATION.—The total amount of payments made 
to 
States 
under 
this 
paragraph 
shall 
not 
exceed 
$25,000,000. 
‘‘(d) HOSPITAL REFERRALS.—A State shall include in the State 
plan amendment a requirement for hospitals that are participating 
providers under the State plan or a waiver of such plan to establish 
procedures for referring any eligible individuals with chronic condi-
tions who seek or need treatment in a hospital emergency depart-
ment to designated providers. 
‘‘(e) COORDINATION.—A State shall consult and coordinate, as 
appropriate, with the Substance Abuse and Mental Health Services 
Administration in addressing issues regarding the prevention and 
treatment of mental illness and substance abuse among eligible 
individuals with chronic conditions. 
‘‘(f) MONITORING.—A State shall include in the State plan 
amendment— 
‘‘(1) a methodology for tracking avoidable hospital readmis-
sions and calculating savings that result from improved chronic 
care coordination and management under this section; and 
‘‘(2) a proposal for use of health information technology 
in providing health home services under this section and 
improving service delivery and coordination across the care 
continuum (including the use of wireless patient technology 
to improve coordination and management of care and patient 
adherence to recommendations made by their provider). 
‘‘(g) REPORT
ON
QUALITY
MEASURES.—As a condition for 
receiving payment for health home services provided to an eligible 
individual with chronic conditions, a designated provider shall 
report to the State, in accordance with such requirements as the 
Secretary shall specify, on all applicable measures for determining 
Effective date. 
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124 STAT. 321 
PUBLIC LAW 111–148—MAR. 23, 2010 
the quality of such services. When appropriate and feasible, a 
designated provider shall use health information technology in pro-
viding the State with such information. 
‘‘(h) DEFINITIONS.—In this section: 
‘‘(1) ELIGIBLE INDIVIDUAL WITH CHRONIC CONDITIONS.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 
term ‘eligible individual with chronic conditions’ means 
an individual who— 
‘‘(i) is eligible for medical assistance under the 
State plan or under a waiver of such plan; and 
‘‘(ii) has at least— 
‘‘(I) 2 chronic conditions; 
‘‘(II) 1 chronic condition and is at risk of 
having a second chronic condition; or 
‘‘(III) 1 serious and persistent mental health 
condition. 
‘‘(B) RULE OF CONSTRUCTION.—Nothing in this para-
graph shall prevent the Secretary from establishing higher 
levels as to the number or severity of chronic or mental 
health conditions for purposes of determining eligibility 
for receipt of health home services under this section. 
‘‘(2) CHRONIC CONDITION.—The term ‘chronic condition’ has 
the meaning given that term by the Secretary and shall include, 
but is not limited to, the following: 
‘‘(A) A mental health condition. 
‘‘(B) Substance use disorder. 
‘‘(C) Asthma. 
‘‘(D) Diabetes. 
‘‘(E) Heart disease. 
‘‘(F) Being overweight, as evidenced by having a Body 
Mass Index (BMI) over 25. 
‘‘(3) HEALTH HOME.—The term ‘health home’ means a des-
ignated provider (including a provider that operates in coordina-
tion with a team of health care professionals) or a health 
team selected by an eligible individual with chronic conditions 
to provide health home services. 
‘‘(4) HEALTH HOME SERVICES.— 
‘‘(A) IN
GENERAL.—The term ‘health home services’ 
means comprehensive and timely high-quality services 
described in subparagraph (B) that are provided by a des-
ignated provider, a team of health care professionals oper-
ating with such a provider, or a health team. 
‘‘(B) SERVICES DESCRIBED.—The services described in 
this subparagraph are— 
‘‘(i) comprehensive care management; 
‘‘(ii) care coordination and health promotion; 
‘‘(iii) comprehensive transitional care, including 
appropriate follow-up, from inpatient to other settings; 
‘‘(iv) patient and family support (including author-
ized representatives); 
‘‘(v) referral to community and social support serv-
ices, if relevant; and 
‘‘(vi) use of health information technology to link 
services, as feasible and appropriate. 
‘‘(5) DESIGNATED PROVIDER.—The term ‘designated provider’ 
means a physician, clinical practice or clinical group practice, 
rural clinic, community health center, community mental health 
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124 STAT. 322 
PUBLIC LAW 111–148—MAR. 23, 2010 
center, home health agency, or any other entity or provider 
(including pediatricians, gynecologists, and obstetricians) that 
is determined by the State and approved by the Secretary 
to be qualified to be a health home for eligible individuals 
with chronic conditions on the basis of documentation 
evidencing that the physician, practice, or clinic— 
‘‘(A) has the systems and infrastructure in place to 
provide health home services; and 
‘‘(B) satisfies the qualification standards established 
by the Secretary under subsection (b). 
‘‘(6) TEAM
OF
HEALTH
CARE
PROFESSIONALS.—The term 
‘team of health care professionals’ means a team of health 
professionals (as described in the State plan amendment) that 
may— 
‘‘(A) include physicians and other professionals, such 
as a nurse care coordinator, nutritionist, social worker, 
behavioral health professional, or any professionals deemed 
appropriate by the State; and 
‘‘(B) be free standing, virtual, or based at a hospital, 
community health center, community mental health center, 
rural clinic, clinical practice or clinical group practice, aca-
demic health center, or any entity deemed appropriate 
by the State and approved by the Secretary. 
‘‘(7) HEALTH
TEAM.—The term ‘health team’ has the 
meaning given such term for purposes of section 3502 of the 
Patient Protection and Affordable Care Act.’’. 
(b) EVALUATION.— 
(1) INDEPENDENT EVALUATION.— 
(A) IN GENERAL.—The Secretary shall enter into a con-
tract with an independent entity or organization to conduct 
an evaluation and assessment of the States that have 
elected the option to provide coordinated care through a 
health home for Medicaid beneficiaries with chronic condi-
tions under section 1945 of the Social Security Act (as 
added by subsection (a)) for the purpose of determining 
the effect of such option on reducing hospital admissions, 
emergency room visits, and admissions to skilled nursing 
facilities. 
(B) EVALUATION REPORT.—Not later than January 1, 
2017, the Secretary shall report to Congress on the evalua-
tion and assessment conducted under subparagraph (A). 
(2) SURVEY AND INTERIM REPORT.— 
(A) IN GENERAL.—Not later than January 1, 2014, the 
Secretary of Health and Human Services shall survey 
States that have elected the option under section 1945 
of the Social Security Act (as added by subsection (a)) 
and report to Congress on the nature, extent, and use 
of such option, particularly as it pertains to— 
(i) hospital admission rates; 
(ii) chronic disease management; 
(iii) coordination of care for individuals with 
chronic conditions; 
(iv) assessment of program implementation; 
(v) processes and lessons learned (as described in 
subparagraph (B)); 
(vi) assessment of quality improvements and clin-
ical outcomes under such option; and 
42 USC 1396w–4 
note. 
Contracts. 
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124 STAT. 323 
PUBLIC LAW 111–148—MAR. 23, 2010 
(vii) estimates of cost savings. 
(B) IMPLEMENTATION
REPORTING.—A State that has 
elected the option under section 1945 of the Social Security 
Act (as added by subsection (a)) shall report to the Sec-
retary, as necessary, on processes that have been developed 
and lessons learned regarding provision of coordinated care 
through a health home for Medicaid beneficiaries with 
chronic conditions under such option. 
SEC. 2704. DEMONSTRATION PROJECT TO EVALUATE INTEGRATED 
CARE AROUND A HOSPITALIZATION. 
(a) AUTHORITY TO CONDUCT PROJECT.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’) shall 
establish a demonstration project under title XIX of the Social 
Security Act to evaluate the use of bundled payments for the 
provision of integrated care for a Medicaid beneficiary— 
(A) with respect to an episode of care that includes 
a hospitalization; and 
(B) for concurrent physicians services provided during 
a hospitalization. 
(2) DURATION.—The demonstration project shall begin on 
January 1, 2012, and shall end on December 31, 2016. 
(b) REQUIREMENTS.—The demonstration project shall be con-
ducted in accordance with the following: 
(1) The demonstration project shall be conducted in up 
to 8 States, determined by the Secretary based on consideration 
of the potential to lower costs under the Medicaid program 
while improving care for Medicaid beneficiaries. A State 
selected to participate in the demonstration project may target 
the demonstration project to particular categories of bene-
ficiaries, beneficiaries with particular diagnoses, or particular 
geographic regions of the State, but the Secretary shall insure 
that, as a whole, the demonstration project is, to the greatest 
extent possible, representative of the demographic and 
geographic composition of Medicaid beneficiaries nationally. 
(2) The demonstration project shall focus on conditions 
where there is evidence of an opportunity for providers of 
services and suppliers to improve the quality of care furnished 
to Medicaid beneficiaries while reducing total expenditures 
under the State Medicaid programs selected to participate, 
as determined by the Secretary. 
(3) A State selected to participate in the demonstration 
project shall specify the 1 or more episodes of care the State 
proposes to address in the project, the services to be included 
in the bundled payments, and the rationale for the selection 
of such episodes of care and services. The Secretary may modify 
the episodes of care as well as the services to be included 
in the bundled payments prior to or after approving the project. 
The Secretary may also vary such factors among the different 
States participating in the demonstration project. 
(4) The Secretary shall ensure that payments made under 
the demonstration project are adjusted for severity of illness 
and other characteristics of Medicaid beneficiaries within a 
category or having a diagnosis targeted as part of the dem-
onstration project. States shall ensure that Medicaid bene-
ficiaries are not liable for any additional cost sharing than 
Determination. 
42 USC 1396a 
note. 
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124 STAT. 324 
PUBLIC LAW 111–148—MAR. 23, 2010 
if their care had not been subject to payment under the dem-
onstration project. 
(5) Hospitals participating in the demonstration project 
shall have or establish robust discharge planning programs 
to ensure that Medicaid beneficiaries requiring post-acute care 
are appropriately placed in, or have ready access to, post- 
acute care settings. 
(6) The Secretary and each State selected to participate 
in the demonstration project shall ensure that the demonstra-
tion project does not result in the Medicaid beneficiaries whose 
care is subject to payment under the demonstration project 
being provided with less items and services for which medical 
assistance is provided under the State Medicaid program than 
the items and services for which medical assistance would 
have been provided to such beneficiaries under the State Med-
icaid program in the absence of the demonstration project. 
(c) WAIVER OF PROVISIONS.—Notwithstanding section 1115(a) 
of the Social Security Act (42 U.S.C. 1315(a)), the Secretary may 
waive such provisions of titles XIX, XVIII, and XI of that Act 
as may be necessary to accomplish the goals of the demonstration, 
ensure beneficiary access to acute and post-acute care, and maintain 
quality of care. 
(d) EVALUATION AND REPORT.— 
(1) DATA.—Each State selected to participate in the dem-
onstration project under this section shall provide to the Sec-
retary, in such form and manner as the Secretary shall specify, 
relevant data necessary to monitor outcomes, costs, and quality, 
and evaluate the rationales for selection of the episodes of 
care and services specified by States under subsection (b)(3). 
(2) REPORT.—Not later than 1 year after the conclusion 
of the demonstration project, the Secretary shall submit a report 
to Congress on the results of the demonstration project. 
SEC. 2705. MEDICAID GLOBAL PAYMENT SYSTEM DEMONSTRATION 
PROJECT. 
(a) IN GENERAL.—The Secretary of Health and Human Services 
(referred to in this section as the ‘‘Secretary’’) shall, in coordination 
with the Center for Medicare and Medicaid Innovation (as estab-
lished under section 1115A of the Social Security Act, as added 
by section 3021 of this Act), establish the Medicaid Global Payment 
System Demonstration Project under which a participating State 
shall adjust the payments made to an eligible safety net hospital 
system or network from a fee-for-service payment structure to a 
global capitated payment model. 
(b) DURATION
AND SCOPE.—The demonstration project con-
ducted under this section shall operate during a period of fiscal 
years 2010 through 2012. The Secretary shall select not more than 
5 States to participate in the demonstration project. 
(c) ELIGIBLE SAFETY NET HOSPITAL SYSTEM OR NETWORK.— 
For purposes of this section, the term ‘‘eligible safety net hospital 
system or network’’ means a large, safety net hospital system or 
network (as defined by the Secretary) that operates within a State 
selected by the Secretary under subsection (b). 
(d) EVALUATION.— 
(1) TESTING.—The Innovation Center shall test and 
evaluate the demonstration project conducted under this section 
Definition. 
Selection. 
42 USC 1315a 
note. 
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124 STAT. 325 
PUBLIC LAW 111–148—MAR. 23, 2010 
to examine any changes in health care quality outcomes and 
spending by the eligible safety net hospital systems or networks. 
(2) BUDGET NEUTRALITY.—During the testing period under 
paragraph (1), any budget neutrality requirements under sec-
tion 1115A(b)(3) of the Social Security Act (as so added) shall 
not be applicable. 
(3) MODIFICATION.—During the testing period under para-
graph (1), the Secretary may, in the Secretary’s discretion, 
modify or terminate the demonstration project conducted under 
this section. 
(e) REPORT.—Not later than 12 months after the date of comple-
tion of the demonstration project under this section, the Secretary 
shall submit to Congress a report containing the results of the 
evaluation and testing conducted under subsection (d), together 
with recommendations for such legislation and administrative 
action as the Secretary determines appropriate. 
(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated such sums as are necessary to carry out this 
section. 
SEC. 2706. PEDIATRIC ACCOUNTABLE CARE ORGANIZATION DEM-
ONSTRATION PROJECT. 
(a) AUTHORITY TO CONDUCT DEMONSTRATION.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services (referred to in this section as the ‘‘Secretary’’) shall 
establish the Pediatric Accountable Care Organization Dem-
onstration Project to authorize a participating State to allow 
pediatric medical providers that meet specified requirements 
to be recognized as an accountable care organization for pur-
poses of receiving incentive payments (as described under sub-
section (d)), in the same manner as an accountable care 
organization is recognized and provided with incentive pay-
ments under section 1899 of the Social Security Act (as added 
by section 3022). 
(2) DURATION.—The demonstration project shall begin on 
January 1, 2012, and shall end on December 31, 2016. 
(b) APPLICATION.—A State that desires to participate in the 
demonstration project under this section shall submit to the Sec-
retary an application at such time, in such manner, and containing 
such information as the Secretary may require. 
(c) REQUIREMENTS.— 
(1) PERFORMANCE GUIDELINES.—The Secretary, in consulta-
tion with the States and pediatric providers, shall establish 
guidelines to ensure that the quality of care delivered to individ-
uals by a provider recognized as an accountable care organiza-
tion under this section is not less than the quality of care 
that would have otherwise been provided to such individuals. 
(2) SAVINGS REQUIREMENT.—A participating State, in con-
sultation with the Secretary, shall establish an annual minimal 
level of savings in expenditures for items and services covered 
under the Medicaid program under title XIX of the Social 
Security Act and the CHIP program under title XXI of such 
Act that must be reached by an accountable care organization 
in order for such organization to receive an incentive payment 
under subsection (d). 
(3) MINIMUM PARTICIPATION PERIOD.—A provider desiring 
to be recognized as an accountable care organization under 
Contracts. 
42 USC 1396a 
note. 
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124 STAT. 326 
PUBLIC LAW 111–148—MAR. 23, 2010 
the demonstration project shall enter into an agreement with 
the State to participate in the project for not less than a 
3-year period. 
(d) INCENTIVE PAYMENT.—An accountable care organization 
that meets the performance guidelines established by the Secretary 
under subsection (c)(1) and achieves savings greater than the 
annual minimal savings level established by the State under sub-
section (c)(2) shall receive an incentive payment for such year 
equal to a portion (as determined appropriate by the Secretary) 
of the amount of such excess savings. The Secretary may establish 
an annual cap on incentive payments for an accountable care 
organization. 
(e) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated such sums as are necessary to carry out this 
section. 
SEC. 2707. MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION 
PROJECT. 
(a) AUTHORITY TO CONDUCT DEMONSTRATION PROJECT.—The 
Secretary of Health and Human Services (in this section referred 
to as the ‘‘Secretary’’) shall establish a demonstration project under 
which an eligible State (as described in subsection (c)) shall provide 
payment under the State Medicaid plan under title XIX of the 
Social Security Act to an institution for mental diseases that is 
not publicly owned or operated and that is subject to the require-
ments of section 1867 of the Social Security Act (42 U.S.C. 1395dd) 
for the provision of medical assistance available under such plan 
to individuals who— 
(1) have attained age 21, but have not attained age 65; 
(2) are eligible for medical assistance under such plan; 
and 
(3) require such medical assistance to stabilize an emer-
gency medical condition. 
(b) STABILIZATION REVIEW.—A State shall specify in its applica-
tion described in subsection (c)(1) establish a mechanism for how 
it will ensure that institutions participating in the demonstration 
will determine whether or not such individuals have been stabilized 
(as defined in subsection (h)(5)). This mechanism shall commence 
before the third day of the inpatient stay. States participating 
in the demonstration project may manage the provision of services 
for the stabilization of medical emergency conditions through utili-
zation review, authorization, or management practices, or the 
application of medical necessity and appropriateness criteria 
applicable to behavioral health. 
(c) ELIGIBLE STATE DEFINED.— 
(1) IN GENERAL.—An eligible State is a State that has 
made an application and has been selected pursuant to para-
graphs (2) and (3). 
(2) APPLICATION.—A State seeking to participate in the 
demonstration project under this section shall submit to the 
Secretary, at such time and in such format as the Secretary 
requires, an application that includes such information, provi-
sions, and assurances, as the Secretary may require. 
(3) SELECTION.—A State shall be determined eligible for 
the demonstration by the Secretary on a competitive basis 
among States with applications meeting the requirements of 
Commencement 
date. 
42 USC 1396a 
note. 
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124 STAT. 327 
PUBLIC LAW 111–148—MAR. 23, 2010 
paragraph (1). In selecting State applications for the demonstra-
tion project, the Secretary shall seek to achieve an appropriate 
national balance in the geographic distribution of such projects. 
(d) LENGTH OF DEMONSTRATION PROJECT.—The demonstration 
project established under this section shall be conducted for a 
period of 3 consecutive years. 
(e) LIMITATIONS ON FEDERAL FUNDING.— 
(1) APPROPRIATION.— 
(A) IN GENERAL.—Out of any funds in the Treasury 
not otherwise appropriated, there is appropriated to carry 
out this section, $75,000,000 for fiscal year 2011. 
(B) BUDGET AUTHORITY.—Subparagraph (A) constitutes 
budget authority in advance of appropriations Act and rep-
resents the obligation of the Federal Government to provide 
for the payment of the amounts appropriated under that 
subparagraph. 
(2) 5-YEAR AVAILABILITY.—Funds appropriated under para-
graph (1) shall remain available for obligation through 
December 31, 2015. 
(3) LIMITATION ON PAYMENTS.—In no case may— 
(A) the aggregate amount of payments made by the 
Secretary to eligible States under this section exceed 
$75,000,000; or 
(B) payments be provided by the Secretary under this 
section after December 31, 2015. 
(4) FUNDS ALLOCATED TO STATES.—Funds shall be allocated 
to eligible States on the basis of criteria, including a State’s 
application and the availability of funds, as determined by 
the Secretary. 
(5) PAYMENTS TO STATES.—The Secretary shall pay to each 
eligible State, from its allocation under paragraph (4), an 
amount each quarter equal to the Federal medical assistance 
percentage of expenditures in the quarter for medical assistance 
described in subsection (a). As a condition of receiving payment, 
a State shall collect and report information, as determined 
necessary by the Secretary, for the purposes of providing Fed-
eral oversight and conducting an evaluation under subsection 
(f)(1). 
(f) EVALUATION AND REPORT TO CONGRESS.— 
(1) EVALUATION.—The Secretary shall conduct an evalua-
tion of the demonstration project in order to determine the 
impact on the functioning of the health and mental health 
service system and on individuals enrolled in the Medicaid 
program and shall include the following: 
(A) An assessment of access to inpatient mental health 
services under the Medicaid program; average lengths of 
inpatient stays; and emergency room visits. 
(B) An assessment of discharge planning by partici-
pating hospitals. 
(C) An assessment of the impact of the demonstration 
project on the costs of the full range of mental health 
services (including inpatient, emergency and ambulatory 
care). 
(D) An analysis of the percentage of consumers with 
Medicaid coverage who are admitted to inpatient facilities 
as a result of the demonstration project as compared to 
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124 STAT. 328 
PUBLIC LAW 111–148—MAR. 23, 2010 
those admitted to these same facilities through other 
means. 
(E) A recommendation regarding whether the dem-
onstration project should be continued after December 31, 
2013, and expanded on a national basis. 
(2) REPORT.—Not later than December 31, 2013, the Sec-
retary shall submit to Congress and make available to the 
public a report on the findings of the evaluation under para-
graph (1). 
(g) WAIVER AUTHORITY.— 
(1) IN GENERAL.—The Secretary shall waive the limitation 
of subdivision (B) following paragraph (28) of section 1905(a) 
of the Social Security Act (42 U.S.C. 1396d(a)) (relating to 
limitations on payments for care or services for individuals 
under 65 years of age who are patients in an institution for 
mental diseases) for purposes of carrying out the demonstration 
project under this section. 
(2) LIMITED OTHER WAIVER AUTHORITY.—The Secretary may 
waive other requirements of titles XI and XIX of the Social 
Security Act (including the requirements of sections 1902(a)(1) 
(relating to statewideness) and 1902(1)(10)(B) (relating to com-
parability)) only to extent necessary to carry out the demonstra-
tion project under this section. 
(h) DEFINITIONS.—In this section: 
(1) EMERGENCY MEDICAL CONDITION.—The term ‘‘emergency 
medical condition’’ means, with respect to an individual, an 
individual who expresses suicidal or homicidal thoughts or ges-
tures, if determined dangerous to self or others. 
(2) FEDERAL MEDICAL ASSISTANCE PERCENTAGE.—The term 
‘‘Federal medical assistance percentage’’ has the meaning given 
that term with respect to a State under section 1905(b) of 
the Social Security Act (42 U.S.C. 1396d(b)). 
(3) INSTITUTION FOR MENTAL DISEASES.—The term ‘‘institu-
tion for mental diseases’’ has the meaning given to that term 
in section 1905(i) of the Social Security Act (42 U.S.C. 1396d(i)). 
(4) MEDICAL ASSISTANCE.—The term ‘‘medical assistance’’ 
has the meaning given that term in section 1905(a) of the 
Social Security Act (42 U.S.C. 1396d(a)). 
(5) STABILIZED.—The term ‘‘stabilized’’ means, with respect 
to an individual, that the emergency medical condition no longer 
exists with respect to the individual and the individual is 
no longer dangerous to self or others. 
(6) STATE.—The term ‘‘State’’ has the meaning given that 
term for purposes of title XIX of the Social Security Act (42 
U.S.C. 1396 et seq.). 
Subtitle J—Improvements to the Medicaid 
and CHIP Payment and Access Commis-
sion (MACPAC) 
SEC. 2801. MACPAC ASSESSMENT OF POLICIES AFFECTING ALL MED-
ICAID BENEFICIARIES. 
(a) IN GENERAL.—Section 1900 of the Social Security Act (42 
U.S.C. 1396) is amended— 
(1) in subsection (b)— 
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124 STAT. 329 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) in paragraph (1)— 
(i) in the paragraph heading, by inserting ‘‘FOR 
ALL STATES’’ before ‘‘AND ANNUAL’’; and 
(ii) in subparagraph (A), by striking ‘‘children’s’’; 
(iii) in subparagraph (B), by inserting ‘‘, the Sec-
retary, and States’’ after ‘‘Congress’’; 
(iv) in subparagraph (C), by striking ‘‘March 1’’ 
and inserting ‘‘March 15’’; and 
(v) in subparagraph (D), by striking ‘‘June 1’’ and 
inserting ‘‘June 15’’; 
(B) in paragraph (2)— 
(i) in subparagraph (A)— 
(I) in clause (i)— 
(aa) by inserting ‘‘the efficient provision 
of’’ after ‘‘expenditures for’’; and 
(bb) by striking ‘‘hospital, skilled nursing 
facility, physician, Federally-qualified health 
center, rural health center, and other fees’’ 
and inserting ‘‘payments to medical, dental, 
and health professionals, hospitals, residential 
and long-term care providers, providers of 
home and community based services, Feder-
ally-qualified health centers and rural health 
clinics, managed care entities, and providers 
of other covered items and services’’; and 
(II) in clause (iii), by inserting ‘‘(including how 
such factors and methodologies enable such bene-
ficiaries to obtain the services for which they are 
eligible, affect provider supply, and affect providers 
that serve a disproportionate share of low-income 
and other vulnerable populations)’’ after ‘‘bene-
ficiaries’’; 
(ii) by redesignating subparagraphs (B) and (C) 
as subparagraphs (F) and (H), respectively; 
(iii) by inserting after subparagraph (A), the fol-
lowing: 
‘‘(B) ELIGIBILITY POLICIES.—Medicaid and CHIP eligi-
bility policies, including a determination of the degree to 
which Federal and State policies provide health care cov-
erage to needy populations. 
‘‘(C) ENROLLMENT AND RETENTION PROCESSES.—Med-
icaid and CHIP enrollment and retention processes, 
including a determination of the degree to which Federal 
and State policies encourage the enrollment of individuals 
who are eligible for such programs and screen out individ-
uals who are ineligible, while minimizing the share of 
program expenses devoted to such processes. 
‘‘(D) COVERAGE POLICIES.—Medicaid and CHIP benefit 
and coverage policies, including a determination of the 
degree to which Federal and State policies provide access 
to the services enrollees require to improve and maintain 
their health and functional status. 
‘‘(E) QUALITY OF CARE.—Medicaid and CHIP policies 
as they relate to the quality of care provided under those 
programs, including a determination of the degree to which 
Federal and State policies achieve their stated goals and 
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124 STAT. 330 
PUBLIC LAW 111–148—MAR. 23, 2010 
interact with similar goals established by other purchasers 
of health care services.’’; 
(iv) by inserting after subparagraph (F) (as redesig-
nated by clause (ii) of this subparagraph), the following: 
‘‘(G) INTERACTIONS WITH MEDICARE AND MEDICAID.— 
Consistent with paragraph (11), the interaction of policies 
under Medicaid and the Medicare program under title 
XVIII, including with respect to how such interactions 
affect access to services, payments, and dual eligible 
individuals.’’ and 
(v) in subparagraph (H) (as so redesignated), by 
inserting ‘‘and preventive, acute, and long-term serv-
ices and supports’’ after ‘‘barriers’’; 
(C) by redesignating paragraphs (3) through (9) as 
paragraphs (4) through (10), respectively; 
(D) by inserting after paragraph (2), the following new 
paragraph: 
‘‘(3) RECOMMENDATIONS
AND
REPORTS
OF
STATE-SPECIFIC 
DATA.—MACPAC shall— 
‘‘(A) review national and State-specific Medicaid and 
CHIP data; and 
‘‘(B) submit reports and recommendations to Congress, 
the Secretary, and States based on such reviews.’’; 
(E) in paragraph (4), as redesignated by subparagraph 
(C), by striking ‘‘or any other problems’’ and all that follows 
through the period and inserting ‘‘, as well as other factors 
that adversely affect, or have the potential to adversely 
affect, access to care by, or the health care status of, 
Medicaid and CHIP beneficiaries. MACPAC shall include 
in the annual report required under paragraph (1)(D) a 
description of all such areas or problems identified with 
respect to the period addressed in the report.’’; 
(F) in paragraph (5), as so redesignated,— 
(i) in the paragraph heading, by inserting ‘‘AND 
REGULATIONS’’ after ‘‘REPORTS’’; and 
(ii) by striking ‘‘If’’ and inserting the following: 
‘‘(A) CERTAIN SECRETARIAL REPORTS.—If’’; and 
(iii) in the second sentence, by inserting ‘‘and the 
Secretary’’ after ‘‘appropriate committees of Congress’’; 
and 
(iv) by adding at the end the following: 
‘‘(B) REGULATIONS.—MACPAC shall review Medicaid 
and CHIP regulations and may comment through submis-
sion of a report to the appropriate committees of Congress 
and the Secretary, on any such regulations that affect 
access, quality, or efficiency of health care.’’; 
(G) in paragraph (10), as so redesignated, by inserting 
‘‘, and shall submit with any recommendations, a report 
on the Federal and State-specific budget consequences of 
the recommendations’’ before the period; and 
(H) by adding at the end the following: 
‘‘(11) CONSULTATION AND COORDINATION WITH MEDPAC.— 
‘‘(A) IN
GENERAL.—MACPAC shall consult with the 
Medicare Payment Advisory Commission (in this paragraph 
referred to as ‘MedPAC’) established under section 1805 
in carrying out its duties under this section, as appropriate 
and particularly with respect to the issues specified in 
Reports. 
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124 STAT. 331 
PUBLIC LAW 111–148—MAR. 23, 2010 
paragraph (2) as they relate to those Medicaid beneficiaries 
who are dually eligible for Medicaid and the Medicare 
program under title XVIII, adult Medicaid beneficiaries 
(who are not dually eligible for Medicare), and beneficiaries 
under Medicare. Responsibility for analysis of and rec-
ommendations to change Medicare policy regarding Medi-
care beneficiaries, including Medicare beneficiaries who are 
dually eligible for Medicare and Medicaid, shall rest with 
MedPAC. 
‘‘(B) INFORMATION SHARING.—MACPAC and MedPAC 
shall have access to deliberations and records of the other 
such entity, respectively, upon the request of the other 
such entity. 
‘‘(12) CONSULTATION WITH STATES.—MACPAC shall regu-
larly consult with States in carrying out its duties under this 
section, including with respect to developing processes for car-
rying out such duties, and shall ensure that input from States 
is taken into account and represented in MACPAC’s rec-
ommendations and reports. 
‘‘(13) COORDINATE AND CONSULT WITH THE FEDERAL COORDI-
NATED HEALTH CARE OFFICE.—MACPAC shall coordinate and 
consult with the Federal Coordinated Health Care Office estab-
lished under section 2081 of the Patient Protection and Afford-
able Care Act before making any recommendations regarding 
dual eligible individuals. 
‘‘(14) PROGRAMMATIC
OVERSIGHT
VESTED
IN
THE
SEC-
RETARY.—MACPAC’s authority to make recommendations in 
accordance with this section shall not affect, or be considered 
to duplicate, the Secretary’s authority to carry out Federal 
responsibilities with respect to Medicaid and CHIP.’’; 
(2) in subsection (c)(2)— 
(A) by striking subparagraphs (A) and (B) and inserting 
the following: 
‘‘(A) IN GENERAL.—The membership of MACPAC shall 
include individuals who have had direct experience as 
enrollees or parents or caregivers of enrollees in Medicaid 
or CHIP and individuals with national recognition for their 
expertise in Federal safety net health programs, health 
finance and economics, actuarial science, health plans and 
integrated delivery systems, reimbursement for health care, 
health information technology, and other providers of 
health services, public health, and other related fields, 
who provide a mix of different professions, broad geographic 
representation, and a balance between urban and rural 
representation. 
‘‘(B) INCLUSION.—The membership of MACPAC shall 
include (but not be limited to) physicians, dentists, and 
other health professionals, employers, third-party payers, 
and individuals with expertise in the delivery of health 
services. Such membership shall also include representa-
tives of children, pregnant women, the elderly, individuals 
with disabilities, caregivers, and dual eligible individuals, 
current or former representatives of State agencies respon-
sible for administering Medicaid, and current or former 
representatives of State agencies responsible for admin-
istering CHIP.’’. 
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124 STAT. 332 
PUBLIC LAW 111–148—MAR. 23, 2010 
(3) in subsection (d)(2), by inserting ‘‘and State’’ after ‘‘Fed-
eral’’; 
(4) in subsection (e)(1), in the first sentence, by inserting 
‘‘and, as a condition for receiving payments under sections 
1903(a) and 2105(a), from any State agency responsible for 
administering Medicaid or CHIP,’’ after ‘‘United States’’; and 
(5) in subsection (f)— 
(A) in the subsection heading, by striking ‘‘AUTHORIZA-
TION OF APPROPRIATIONS’’ and inserting ‘‘FUNDING’’; 
(B) in paragraph (1), by inserting ‘‘(other than for 
fiscal year 2010)’’ before ‘‘in the same manner’’; and 
(C) by adding at the end the following: 
‘‘(3) FUNDING FOR FISCAL YEAR 2010.— 
‘‘(A) IN GENERAL.—Out of any funds in the Treasury 
not otherwise appropriated, there is appropriated to 
MACPAC to carry out the provisions of this section for 
fiscal year 2010, $9,000,000. 
‘‘(B) TRANSFER
OF
FUNDS.—Notwithstanding section 
2104(a)(13), from the amounts appropriated in such section 
for fiscal year 2010, $2,000,000 is hereby transferred and 
made available in such fiscal year to MACPAC to carry 
out the provisions of this section. 
‘‘(4) AVAILABILITY.—Amounts made available under para-
graphs (2) and (3) to MACPAC to carry out the provisions 
of this section shall remain available until expended.’’. 
(b) CONFORMING MEDPAC AMENDMENTS.—Section 1805(b) of 
the Social Security Act (42 U.S.C. 1395b–6(b)), is amended— 
(1) in paragraph (1)(C), by striking ‘‘March 1 of each year 
(beginning with 1998)’’ and inserting ‘‘March 15’’; 
(2) in paragraph (1)(D), by inserting ‘‘, and (beginning 
with 2012) containing an examination of the topics described 
in paragraph (9), to the extent feasible’’ before the period; 
and 
(3) by adding at the end the following: 
‘‘(9) REVIEW
AND
ANNUAL
REPORT
ON
MEDICAID
AND 
COMMERCIAL TRENDS.—The Commission shall review and report 
on aggregate trends in spending, utilization, and financial 
performance under the Medicaid program under title XIX and 
the private market for health care services with respect to 
providers for which, on an aggregate national basis, a signifi-
cant portion of revenue or services is associated with the Med-
icaid program. Where appropriate, the Commission shall con-
duct such review in consultation with the Medicaid and CHIP 
Payment and Access Commission established under section 
1900 (in this section referred to as ‘MACPAC’). 
‘‘(10) COORDINATE AND CONSULT WITH THE FEDERAL COORDI-
NATED HEALTH CARE OFFICE.—The Commission shall coordinate 
and consult with the Federal Coordinated Health Care Office 
established under section 2081 of the Patient Protection and 
Affordable Care Act before making any recommendations 
regarding dual eligible individuals. 
‘‘(11) INTERACTION
OF
MEDICAID
AND
MEDICARE.—The 
Commission shall consult with MACPAC in carrying out its 
duties under this section, as appropriate. Responsibility for 
analysis of and recommendations to change Medicare policy 
regarding Medicare beneficiaries, including Medicare bene-
ficiaries who are dually eligible for Medicare and Medicaid, 
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124 STAT. 333 
PUBLIC LAW 111–148—MAR. 23, 2010 
shall rest with the Commission. Responsibility for analysis 
of and recommendations to change Medicaid policy regarding 
Medicaid beneficiaries, including Medicaid beneficiaries who 
are dually eligible for Medicare and Medicaid, shall rest with 
MACPAC.’’. 
Subtitle K—Protections for American 
Indians and Alaska Natives 
SEC. 2901. SPECIAL RULES RELATING TO INDIANS. 
(a) NO COST-SHARING FOR INDIANS WITH INCOME AT OR BELOW 
300 PERCENT OF POVERTY ENROLLED IN COVERAGE THROUGH A 
STATE EXCHANGE.—For provisions prohibiting cost sharing for 
Indians enrolled in any qualified health plan in the individual 
market through an Exchange, see section 1402(d) of the Patient 
Protection and Affordable Care Act. 
(b) PAYER OF LAST RESORT.—Health programs operated by the 
Indian Health Service, Indian tribes, tribal organizations, and 
Urban Indian organizations (as those terms are defined in section 
4 of the Indian Health Care Improvement Act (25 U.S.C. 1603)) 
shall be the payer of last resort for services provided by such 
Service, tribes, or organizations to individuals eligible for services 
through such programs, notwithstanding any Federal, State, or 
local law to the contrary. 
(c) FACILITATING ENROLLMENT OF INDIANS UNDER THE EXPRESS 
LANE OPTION.—Section 1902(e)(13)(F)(ii) of the Social Security Act 
(42 U.S.C. 1396a(e)(13)(F)(ii)) is amended— 
(1) in the clause heading, by inserting ‘‘AND INDIAN TRIBES 
AND TRIBAL ORGANIZATIONS’’ after ‘‘AGENCIES’’; and 
(2) by adding at the end the following: 
‘‘(IV) The Indian Health Service, an Indian 
Tribe, Tribal Organization, or Urban Indian 
Organization (as defined in section 1139(c)).’’. 
(d) TECHNICAL CORRECTIONS.—Section 1139(c) of the Social 
Security Act (42 U.S.C. 1320b–9(c)) is amended by striking ‘‘In 
this section’’ and inserting ‘‘For purposes of this section, title XIX, 
and title XXI’’. 
SEC. 2902. ELIMINATION OF SUNSET FOR REIMBURSEMENT FOR ALL 
MEDICARE PART B SERVICES FURNISHED BY CERTAIN 
INDIAN HOSPITALS AND CLINICS. 
(a) REIMBURSEMENT FOR ALL MEDICARE PART B SERVICES FUR-
NISHED
BY
CERTAIN
INDIAN
HOSPITALS
AND
CLINICS.—Section 
1880(e)(1)(A) of the Social Security Act (42 U.S.C. 1395qq(e)(1)(A)) 
is amended by striking ‘‘during the 5-year period beginning on’’ 
and inserting ‘‘on or after’’. 
(b) EFFECTIVE DATE.—The amendments made by this section 
shall apply to items or services furnished on or after January 
1, 2010. 
Applicability. 
42 USC 1395qq 
note. 
25 USC 1623. 
25 USC 1623. 
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124 STAT. 334 
PUBLIC LAW 111–148—MAR. 23, 2010 
Subtitle L—Maternal and Child Health 
Services 
SEC. 2951. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VIS-
ITING PROGRAMS. 
Title V of the Social Security Act (42 U.S.C. 701 et seq.) 
is amended by adding at the end the following new section: 
‘‘SEC. 511. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VIS-
ITING PROGRAMS. 
‘‘(a) PURPOSES.—The purposes of this section are— 
‘‘(1) to strengthen and improve the programs and activities 
carried out under this title; 
‘‘(2) to improve coordination of services for at risk commu-
nities; and 
‘‘(3) to identify and provide comprehensive services to 
improve outcomes for families who reside in at risk commu-
nities. 
‘‘(b) REQUIREMENT
FOR ALL STATES TO ASSESS STATEWIDE 
NEEDS AND IDENTIFY AT RISK COMMUNITIES.— 
‘‘(1) IN GENERAL.—Not later than 6 months after the date 
of enactment of this section, each State shall, as a condition 
of receiving payments from an allotment for the State under 
section 502 for fiscal year 2011, conduct a statewide needs 
assessment (which shall be separate from the statewide needs 
assessment required under section 505(a)) that identifies— 
‘‘(A) communities with concentrations of— 
‘‘(i) premature birth, low-birth weight infants, and 
infant mortality, including infant death due to neglect, 
or other indicators of at-risk prenatal, maternal, new-
born, or child health; 
‘‘(ii) poverty; 
‘‘(iii) crime; 
‘‘(iv) domestic violence; 
‘‘(v) high rates of high-school drop-outs; 
‘‘(vi) substance abuse; 
‘‘(vii) unemployment; or 
‘‘(viii) child maltreatment; 
‘‘(B) the quality and capacity of existing programs or 
initiatives for early childhood home visitation in the State 
including— 
‘‘(i) the number and types of individuals and fami-
lies who are receiving services under such programs 
or initiatives; 
‘‘(ii) the gaps in early childhood home visitation 
in the State; and 
‘‘(iii) the extent to which such programs or initia-
tives are meeting the needs of eligible families 
described in subsection (k)(2); and 
‘‘(C) the State’s capacity for providing substance abuse 
treatment and counseling services to individuals and fami-
lies in need of such treatment or services. 
‘‘(2) COORDINATION
WITH
OTHER
ASSESSMENTS.—In con-
ducting the statewide needs assessment required under para-
graph (1), the State shall coordinate with, and take into 
account, other appropriate needs assessments conducted by 
Deadline. 
42 USC 711. 
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124 STAT. 335 
PUBLIC LAW 111–148—MAR. 23, 2010 
the State, as determined by the Secretary, including the needs 
assessment required under section 505(a) (both the most 
recently completed assessment and any such assessment in 
progress), the communitywide strategic planning and needs 
assessments conducted in accordance with section 640(g)(1)(C) 
of the Head Start Act, and the inventory of current unmet 
needs and current community-based and prevention-focused 
programs and activities to prevent child abuse and neglect, 
and other family resource services operating in the State 
required under section 205(3) of the Child Abuse Prevention 
and Treatment Act. 
‘‘(3) SUBMISSION
TO
THE
SECRETARY.—Each State shall 
submit to the Secretary, in such form and manner as the 
Secretary shall require— 
‘‘(A) the results of the statewide needs assessment 
required under paragraph (1); and 
‘‘(B) a description of how the State intends to address 
needs identified by the assessment, particularly with 
respect to communities identified under paragraph (1)(A), 
which may include applying for a grant to conduct an 
early childhood home visitation program in accordance with 
the requirements of this section. 
‘‘(c) GRANTS
FOR EARLY CHILDHOOD HOME VISITATION PRO-
GRAMS.— 
‘‘(1) AUTHORITY TO MAKE GRANTS.—In addition to any other 
payments made under this title to a State, the Secretary shall 
make grants to eligible entities to enable the entities to deliver 
services under early childhood home visitation programs that 
satisfy the requirements of subsection (d) to eligible families 
in order to promote improvements in maternal and prenatal 
health, infant health, child health and development, parenting 
related to child development outcomes, school readiness, and 
the socioeconomic status of such families, and reductions in 
child abuse, neglect, and injuries. 
‘‘(2) AUTHORITY TO USE INITIAL GRANT FUNDS FOR PLANNING 
OR IMPLEMENTATION.—An eligible entity that receives a grant 
under paragraph (1) may use a portion of the funds made 
available to the entity during the first 6 months of the period 
for which the grant is made for planning or implementation 
activities to assist with the establishment of early childhood 
home visitation programs that satisfy the requirements of sub-
section (d). 
‘‘(3) GRANT DURATION.—The Secretary shall determine the 
period of years for which a grant is made to an eligible entity 
under paragraph (1). 
‘‘(4) TECHNICAL ASSISTANCE.—The Secretary shall provide 
an eligible entity that receives a grant under paragraph (1) 
with technical assistance in administering programs or activi-
ties conducted in whole or in part with grant funds. 
‘‘(d) REQUIREMENTS.—The requirements of this subsection for 
an early childhood home visitation program conducted with a grant 
made under this section are as follows: 
‘‘(1) QUANTIFIABLE, MEASURABLE IMPROVEMENT IN BENCH-
MARK AREAS.— 
‘‘(A) IN GENERAL.—The eligible entity establishes, sub-
ject to the approval of the Secretary, quantifiable, measur-
able 3- and 5-year benchmarks for demonstrating that the 
Determination. 
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124 STAT. 336 
PUBLIC LAW 111–148—MAR. 23, 2010 
program results in improvements for the eligible families 
participating in the program in each of the following areas: 
‘‘(i) Improved maternal and newborn health. 
‘‘(ii) Prevention of child injuries, child abuse, 
neglect, or maltreatment, and reduction of emergency 
department visits. 
‘‘(iii) Improvement in school readiness and achieve-
ment. 
‘‘(iv) Reduction in crime or domestic violence. 
‘‘(v) Improvements in family economic self-suffi-
ciency. 
‘‘(vi) Improvements in the coordination and refer-
rals for other community resources and supports. 
‘‘(B) DEMONSTRATION
OF
IMPROVEMENTS
AFTER
3 
YEARS.— 
‘‘(i) REPORT TO THE SECRETARY.—Not later than 
30 days after the end of the 3rd year in which the 
eligible entity conducts the program, the entity submits 
to the Secretary a report demonstrating improvement 
in at least 4 of the areas specified in subparagraph 
(A). 
‘‘(ii) CORRECTIVE ACTION PLAN.—If the report sub-
mitted by the eligible entity under clause (i) fails to 
demonstrate improvement in at least 4 of the areas 
specified in subparagraph (A), the entity shall develop 
and implement a plan to improve outcomes in each 
of the areas specified in subparagraph (A), subject 
to approval by the Secretary. The plan shall include 
provisions for the Secretary to monitor implementation 
of the plan and conduct continued oversight of the 
program, including through submission by the entity 
of regular reports to the Secretary. 
‘‘(iii) TECHNICAL ASSISTANCE.— 
‘‘(I) IN GENERAL.—The Secretary shall provide 
an eligible entity required to develop and imple-
ment an improvement plan under clause (ii) with 
technical assistance to develop and implement the 
plan. The Secretary may provide the technical 
assistance directly or through grants, contracts, 
or cooperative agreements. 
‘‘(II) ADVISORY
PANEL.—The Secretary shall 
establish an advisory panel for purposes of 
obtaining recommendations regarding the tech-
nical assistance provided to entities in accordance 
with subclause (I). 
‘‘(iv) NO
IMPROVEMENT
OR
FAILURE
TO
SUBMIT 
REPORT.—If the Secretary determines after a period 
of time specified by the Secretary that an eligible entity 
implementing an improvement plan under clause (ii) 
has failed to demonstrate any improvement in the 
areas specified in subparagraph (A), or if the Secretary 
determines that an eligible entity has failed to submit 
the report required under clause (i), the Secretary shall 
terminate the entity’s grant and may include any unex-
pended grant funds in grants made to nonprofit 
organizations under subsection (h)(2)(B). 
Determination. 
Termination. 
Establishment. 
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124 STAT. 337 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(C) FINAL REPORT.—Not later than December 31, 2015, 
the eligible entity shall submit a report to the Secretary 
demonstrating improvements (if any) in each of the areas 
specified in subparagraph (A). 
‘‘(2) IMPROVEMENTS
IN
OUTCOMES
FOR
INDIVIDUAL
FAMI-
LIES.— 
‘‘(A) IN
GENERAL.—The program is designed, with 
respect to an eligible family participating in the program, 
to result in the participant outcomes described in subpara-
graph (B) that the eligible entity identifies on the basis 
of an individualized assessment of the family, are relevant 
for that family. 
‘‘(B) PARTICIPANT
OUTCOMES.—The participant out-
comes described in this subparagraph are the following: 
‘‘(i) Improvements in prenatal, maternal, and new-
born health, including improved pregnancy outcomes 
‘‘(ii) Improvements in child health and develop-
ment, including the prevention of child injuries and 
maltreatment and improvements in cognitive, lan-
guage, social-emotional, and physical developmental 
indicators. 
‘‘(iii) Improvements in parenting skills. 
‘‘(iv) Improvements in school readiness and child 
academic achievement. 
‘‘(v) Reductions in crime or domestic violence. 
‘‘(vi) Improvements in family economic self-suffi-
ciency. 
‘‘(vii) Improvements in the coordination of referrals 
for, and the provision of, other community resources 
and supports for eligible families, consistent with State 
child welfare agency training. 
‘‘(3) CORE
COMPONENTS.—The program includes the fol-
lowing core components: 
‘‘(A) SERVICE DELIVERY MODEL OR MODELS.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), the pro-
gram is conducted using 1 or more of the service 
delivery models described in item (aa) or (bb) of sub-
clause (I) or in subclause (II) selected by the eligible 
entity: 
‘‘(I) The model conforms to a clear consistent 
home visitation model that has been in existence 
for at least 3 years and is research-based, grounded 
in relevant empirically-based knowledge, linked to 
program determined outcomes, associated with a 
national organization or institution of higher edu-
cation that has comprehensive home visitation pro-
gram standards that ensure high quality service 
delivery and continuous program quality improve-
ment, and has demonstrated significant, (and in 
the case of the service delivery model described 
in item (aa), sustained) positive outcomes, as 
described in the benchmark areas specified in 
paragraph (1)(A) and the participant outcomes 
described in paragraph (2)(B), when evaluated 
using well-designed and rigorous— 
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124 STAT. 338 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(aa) 
randomized 
controlled 
research 
designs, and the evaluation results have been 
published in a peer-reviewed journal; or 
‘‘(bb) quasi-experimental research designs. 
‘‘(II) The model conforms to a promising and 
new approach to achieving the benchmark areas 
specified in paragraph (1)(A) and the participant 
outcomes described in paragraph (2)(B), has been 
developed or identified by a national organization 
or institution of higher education, and will be 
evaluated through well-designed and rigorous 
process. 
‘‘(ii) MAJORITY
OF
GRANT
FUNDS
USED
FOR
EVI-
DENCE-BASED MODELS.—An eligible entity shall use not 
more than 25 percent of the amount of the grant paid 
to the entity for a fiscal year for purposes of conducting 
a program using the service delivery model described 
in clause (i)(II). 
‘‘(iii) CRITERIA FOR EVIDENCE OF EFFECTIVENESS 
OF MODELS.—The Secretary shall establish criteria for 
evidence of effectiveness of the service delivery models 
and shall ensure that the process for establishing the 
criteria is transparent and provides the opportunity 
for public comment. 
‘‘(B) ADDITIONAL REQUIREMENTS.— 
‘‘(i) The program adheres to a clear, consistent 
model that satisfies the requirements of being 
grounded in empirically-based knowledge related to 
home visiting and linked to the benchmark areas speci-
fied in paragraph (1)(A) and the participant outcomes 
described in paragraph (2)(B) related to the purposes 
of the program. 
‘‘(ii) The program employs well-trained and com-
petent staff, as demonstrated by education or training, 
such as nurses, social workers, educators, child 
development specialists, or other well-trained and com-
petent staff, and provides ongoing and specific training 
on the model being delivered. 
‘‘(iii) The program maintains high quality super-
vision to establish home visitor competencies. 
‘‘(iv) The program demonstrates strong organiza-
tional capacity to implement the activities involved. 
‘‘(v) The program establishes appropriate linkages 
and referral networks to other community resources 
and supports for eligible families. 
‘‘(vi) The program monitors the fidelity of program 
implementation to ensure that services are delivered 
pursuant to the specified model. 
‘‘(4) PRIORITY FOR SERVING HIGH-RISK POPULATIONS.—The 
eligible entity gives priority to providing services under the 
program to the following: 
‘‘(A) Eligible families who reside in communities in 
need of such services, as identified in the statewide needs 
assessment required under subsection (b)(1)(A). 
‘‘(B) Low-income eligible families. 
‘‘(C) Eligible families who are pregnant women who 
have not attained age 21. 
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124 STAT. 339 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(D) Eligible families that have a history of child abuse 
or neglect or have had interactions with child welfare serv-
ices. 
‘‘(E) Eligible families that have a history of substance 
abuse or need substance abuse treatment. 
‘‘(F) Eligible families that have users of tobacco prod-
ucts in the home. 
‘‘(G) Eligible families that are or have children with 
low student achievement. 
‘‘(H) Eligible families with children with developmental 
delays or disabilities. 
‘‘(I) Eligible families who, or that include individuals 
who, are serving or formerly served in the Armed Forces, 
including such families that have members of the Armed 
Forces who have had multiple deployments outside of the 
United States. 
‘‘(e) APPLICATION REQUIREMENTS.—An eligible entity desiring 
a grant under this section shall submit an application to the Sec-
retary for approval, in such manner as the Secretary may require, 
that includes the following: 
‘‘(1) A description of the populations to be served by the 
entity, including specific information regarding how the entity 
will serve high risk populations described in subsection (d)(4). 
‘‘(2) An assurance that the entity will give priority to 
serving low-income eligible families and eligible families who 
reside in at risk communities identified in the statewide needs 
assessment required under subsection (b)(1)(A). 
‘‘(3) The service delivery model or models described in 
subsection (d)(3)(A) that the entity will use under the program 
and the basis for the selection of the model or models. 
‘‘(4) A statement identifying how the selection of the popu-
lations to be served and the service delivery model or models 
that the entity will use under the program for such populations 
is consistent with the results of the statewide needs assessment 
conducted under subsection (b). 
‘‘(5) The quantifiable, measurable benchmarks established 
by the State to demonstrate that the program contributes to 
improvements in the areas specified in subsection (d)(1)(A). 
‘‘(6) An assurance that the entity will obtain and submit 
documentation or other appropriate evidence from the organiza-
tion or entity that developed the service delivery model or 
models used under the program to verify that the program 
is implemented and services are delivered according to the 
model specifications. 
‘‘(7) Assurances that the entity will establish procedures 
to ensure that— 
‘‘(A) the participation of each eligible family in the 
program is voluntary; and 
‘‘(B) services are provided to an eligible family in 
accordance with the individual assessment for that family. 
‘‘(8) Assurances that the entity will— 
‘‘(A) submit annual reports to the Secretary regarding 
the program and activities carried out under the program 
that include such information and data as the Secretary 
shall require; and 
‘‘(B) participate in, and cooperate with, data and 
information collection necessary for the evaluation required 
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124 STAT. 340 
PUBLIC LAW 111–148—MAR. 23, 2010 
under subsection (g)(2) and other research and evaluation 
activities carried out under subsection (h)(3). 
‘‘(9) A description of other State programs that include 
home visitation services, including, if applicable to the State, 
other programs carried out under this title with funds made 
available from allotments under section 502(c), programs 
funded under title IV, title II of the Child Abuse Prevention 
and Treatment Act (relating to community-based grants for 
the prevention of child abuse and neglect), and section 645A 
of the Head Start Act (relating to Early Head Start programs). 
‘‘(10) Other information as required by the Secretary. 
‘‘(f) MAINTENANCE OF EFFORT.—Funds provided to an eligible 
entity receiving a grant under this section shall supplement, and 
not supplant, funds from other sources for early childhood home 
visitation programs or initiatives. 
‘‘(g) EVALUATION.— 
‘‘(1) INDEPENDENT, EXPERT
ADVISORY
PANEL.—The Sec-
retary, in accordance with subsection (h)(1)(A), shall appoint 
an independent advisory panel consisting of experts in program 
evaluation and research, education, and early childhood 
development— 
‘‘(A) to review, and make recommendations on, the 
design and plan for the evaluation required under para-
graph (2) within 1 year after the date of enactment of 
this section; 
‘‘(B) to maintain and advise the Secretary regarding 
the progress of the evaluation; and 
‘‘(C) to comment, if the panel so desires, on the report 
submitted under paragraph (3). 
‘‘(2) AUTHORITY TO CONDUCT EVALUATION.—On the basis 
of the recommendations of the advisory panel under paragraph 
(1), the Secretary shall, by grant, contract, or interagency agree-
ment, conduct an evaluation of the statewide needs assessments 
submitted under subsection (b) and the grants made under 
subsections (c) and (h)(3)(B). The evaluation shall include— 
‘‘(A) an analysis, on a State-by-State basis, of the 
results of such assessments, including indicators of 
maternal and prenatal health and infant health and mor-
tality, and State actions in response to the assessments; 
and 
‘‘(B) an assessment of— 
‘‘(i) the effect of early childhood home visitation 
programs on child and parent outcomes, including with 
respect to each of the benchmark areas specified in 
subsection (d)(1)(A) and the participant outcomes 
described in subsection (d)(2)(B); 
‘‘(ii) the effectiveness of such programs on different 
populations, including the extent to which the ability 
of programs to improve participant outcomes varies 
across programs and populations; and 
‘‘(iii) the potential for the activities conducted 
under such programs, if scaled broadly, to improve 
health care practices, eliminate health disparities, and 
improve health care system quality, efficiencies, and 
reduce costs. 
Assessment. 
Grants. 
Contracts. 
Establishment. 
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124 STAT. 341 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(3) REPORT.—Not later than March 31, 2015, the Secretary 
shall submit a report to Congress on the results of the evalua-
tion conducted under paragraph (2) and shall make the report 
publicly available. 
‘‘(h) OTHER PROVISIONS.— 
‘‘(1) INTRA-AGENCY COLLABORATION.—The Secretary shall 
ensure that the Maternal and Child Health Bureau and the 
Administration for Children and Families collaborate with 
respect to carrying out this section, including with respect 
to— 
‘‘(A) reviewing and analyzing the statewide needs 
assessments required under subsection (b), the awarding 
and oversight of grants awarded under this section, the 
establishment of the advisory panels required under sub-
sections (d)(1)(B)(iii)(II) and (g)(1), and the evaluation and 
report required under subsection (g); and 
‘‘(B) consulting with other Federal agencies with 
responsibility for administering or evaluating programs 
that serve eligible families to coordinate and collaborate 
with respect to research related to such programs and 
families, including the Office of the Assistant Secretary 
for Planning and Evaluation of the Department of Health 
and Human Services, the Centers for Disease Control and 
Prevention, the National Institute of Child Health and 
Human Development of the National Institutes of Health, 
the Office of Juvenile Justice and Delinquency Prevention 
of the Department of Justice, and the Institute of Education 
Sciences of the Department of Education. 
‘‘(2) GRANTS TO ELIGIBLE ENTITIES THAT ARE NOT STATES.— 
‘‘(A) INDIAN TRIBES, TRIBAL ORGANIZATIONS, OR URBAN 
INDIAN
ORGANIZATIONS.—The 
Secretary 
shall 
specify 
requirements for eligible entities that are Indian Tribes 
(or a consortium of Indian Tribes), Tribal Organizations, 
or Urban Indian Organizations to apply for and conduct 
an early childhood home visitation program with a grant 
under this section. Such requirements shall, to the greatest 
extent practicable, be consistent with the requirements 
applicable to eligible entities that are States and shall 
require an Indian Tribe (or consortium), Tribal Organiza-
tion, or Urban Indian Organization to— 
‘‘(i) conduct a needs assessment similar to the 
assessment required for all States under subsection 
(b); and 
‘‘(ii) establish quantifiable, measurable 3- and 5- 
year benchmarks consistent with subsection (d)(1)(A). 
‘‘(B) NONPROFIT ORGANIZATIONS.—If, as of the begin-
ning of fiscal year 2012, a State has not applied or been 
approved for a grant under this section, the Secretary 
may use amounts appropriated under paragraph (1) of 
subsection (j) that are available for expenditure under para-
graph (3) of that subsection to make a grant to an eligible 
entity that is a nonprofit organization described in sub-
section (k)(1)(B) to conduct an early childhood home visita-
tion program in the State. The Secretary shall specify 
the requirements for such an organization to apply for 
and conduct the program which shall, to the greatest extent 
practicable, be consistent with the requirements applicable 
Requirements. 
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124 STAT. 342 
PUBLIC LAW 111–148—MAR. 23, 2010 
to eligible entities that are States and shall require the 
organization to— 
‘‘(i) carry out the program based on the needs 
assessment conducted by the State under subsection 
(b); and 
‘‘(ii) establish quantifiable, measurable 3- and 5- 
year benchmarks consistent with subsection (d)(1)(A). 
‘‘(3) RESEARCH AND OTHER EVALUATION ACTIVITIES.— 
‘‘(A) IN
GENERAL.—The Secretary shall carry out a 
continuous program of research and evaluation activities 
in order to increase knowledge about the implementation 
and effectiveness of home visiting programs, using random 
assignment designs to the maximum extent feasible. The 
Secretary may carry out such activities directly, or through 
grants, cooperative agreements, or contracts. 
‘‘(B) REQUIREMENTS.—The Secretary shall ensure 
that— 
‘‘(i) evaluation of a specific program or project is 
conducted by persons or individuals not directly 
involved in the operation of such program or project; 
and 
‘‘(ii) the conduct of research and evaluation activi-
ties 
includes 
consultation 
with 
independent 
researchers, State officials, and developers and pro-
viders of home visiting programs on topics including 
research design and administrative data matching. 
‘‘(4) REPORT
AND
RECOMMENDATION.—Not later than 
December 31, 2015, the Secretary shall submit a report to 
Congress regarding the programs conducted with grants under 
this section. The report required under this paragraph shall 
include— 
‘‘(A) information regarding the extent to which eligible 
entities receiving grants under this section demonstrated 
improvements in each of the areas specified in subsection 
(d)(1)(A); 
‘‘(B) information regarding any technical assistance 
provided under subsection (d)(1)(B)(iii)(I), including the 
type of any such assistance provided; and 
‘‘(C) recommendations for such legislative or adminis-
trative action as the Secretary determines appropriate. 
‘‘(i) APPLICATION OF OTHER PROVISIONS OF TITLE.— 
‘‘(1) IN GENERAL.—Except as provided in paragraph (2), 
the other provisions of this title shall not apply to a grant 
made under this section. 
‘‘(2) EXCEPTIONS.—The following provisions of this title 
shall apply to a grant made under this section to the same 
extent and in the same manner as such provisions apply to 
allotments made under section 502(c): 
‘‘(A) Section 504(b)(6) (relating to prohibition on pay-
ments to excluded individuals and entities). 
‘‘(B) Section 504(c) (relating to the use of funds for 
the purchase of technical assistance). 
‘‘(C) Section 504(d) (relating to a limitation on adminis-
trative expenditures). 
‘‘(D) Section 506 (relating to reports and audits), but 
only to the extent determined by the Secretary to be appro-
priate for grants made under this section. 
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124 STAT. 343 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(E) Section 507 (relating to penalties for false state-
ments). 
‘‘(F) Section 508 (relating to nondiscrimination). 
‘‘(G) Section 509(a) (relating to the administration of 
the grant program). 
‘‘(j) APPROPRIATIONS.— 
‘‘(1) IN GENERAL.—Out of any funds in the Treasury not 
otherwise appropriated, there are appropriated to the Secretary 
to carry out this section— 
‘‘(A) $100,000,000 for fiscal year 2010; 
‘‘(B) $250,000,000 for fiscal year 2011; 
‘‘(C) $350,000,000 for fiscal year 2012; 
‘‘(D) $400,000,000 for fiscal year 2013; and 
‘‘(E) $400,000,000 for fiscal year 2014. 
‘‘(2) RESERVATIONS.—Of the amount appropriated under 
this subsection for a fiscal year, the Secretary shall reserve— 
‘‘(A) 3 percent of such amount for purposes of making 
grants to eligible entities that are Indian Tribes (or a 
consortium of Indian Tribes), Tribal Organizations, or 
Urban Indian Organizations; and 
‘‘(B) 3 percent of such amount for purposes of carrying 
out subsections (d)(1)(B)(iii), (g), and (h)(3). 
‘‘(3) AVAILABILITY.—Funds made available to an eligible 
entity under this section for a fiscal year shall remain available 
for expenditure by the eligible entity through the end of the 
second succeeding fiscal year after award. Any funds that are 
not expended by the eligible entity during the period in which 
the funds are available under the preceding sentence may 
be used for grants to nonprofit organizations under subsection 
(h)(2)(B). 
‘‘(k) DEFINITIONS.—In this section: 
‘‘(1) ELIGIBLE ENTITY.— 
‘‘(A) IN GENERAL.—The term ‘eligible entity’ means a 
State, an Indian Tribe, Tribal Organization, or Urban 
Indian Organization, Puerto Rico, Guam, the Virgin 
Islands, the Northern Mariana Islands, and American 
Samoa. 
‘‘(B) NONPROFIT ORGANIZATIONS.—Only for purposes of 
awarding grants under subsection (h)(2)(B), such term shall 
include a nonprofit organization with an established record 
of providing early childhood home visitation programs or 
initiatives in a State or several States. 
‘‘(2) ELIGIBLE FAMILY.—The term ‘eligible family’ means— 
‘‘(A) a woman who is pregnant, and the father of the 
child if the father is available; or 
‘‘(B) a parent or primary caregiver of a child, including 
grandparents or other relatives of the child, and foster 
parents, who are serving as the child’s primary caregiver 
from birth to kindergarten entry, and including a noncusto-
dial parent who has an ongoing relationship with, and 
at times provides physical care for, the child. 
‘‘(3) INDIAN
TRIBE; 
TRIBAL
ORGANIZATION.—The terms 
‘Indian Tribe’ and ‘Tribal Organization’, and ‘Urban Indian 
Organization’ have the meanings given such terms in section 
4 of the Indian Health Care Improvement Act.’’. 
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124 STAT. 344 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 2952. SUPPORT, EDUCATION, AND RESEARCH FOR POSTPARTUM 
DEPRESSION. 
(a) RESEARCH ON POSTPARTUM CONDITIONS.— 
(1) EXPANSION AND INTENSIFICATION OF ACTIVITIES.—The 
Secretary of Health and Human Services (in this subsection 
and subsection (c) referred to as the ‘‘Secretary’’) is encouraged 
to continue activities on postpartum depression or postpartum 
psychosis (in this subsection and subsection (c) referred to 
as ‘‘postpartum conditions’’), including research to expand the 
understanding of the causes of, and treatments for, postpartum 
conditions. Activities under this paragraph shall include con-
ducting and supporting the following: 
(A) Basic research concerning the etiology and causes 
of the conditions. 
(B) Epidemiological studies to address the frequency 
and natural history of the conditions and the differences 
among racial and ethnic groups with respect to the condi-
tions. 
(C) The development of improved screening and diag-
nostic techniques. 
(D) Clinical research for the development and evalua-
tion of new treatments. 
(E) Information and education programs for health 
care professionals and the public, which may include a 
coordinated national campaign to increase the awareness 
and knowledge of postpartum conditions. Activities under 
such a national campaign may— 
(i) include public service announcements through 
television, radio, and other means; and 
(ii) focus on— 
(I) raising awareness about screening; 
(II) educating new mothers and their families 
about postpartum conditions to promote earlier 
diagnosis and treatment; and 
(III) ensuring that such education includes 
complete 
information 
concerning 
postpartum 
conditions, including its symptoms, methods of 
coping with the illness, and treatment resources. 
(2) SENSE OF CONGRESS REGARDING LONGITUDINAL STUDY 
OF RELATIVE MENTAL HEALTH CONSEQUENCES FOR WOMEN OF 
RESOLVING A PREGNANCY.— 
(A) SENSE OF CONGRESS.—It is the sense of Congress 
that the Director of the National Institute of Mental Health 
may conduct a nationally representative longitudinal study 
(during the period of fiscal years 2010 through 2019) of 
the relative mental health consequences for women of 
resolving a pregnancy (intended and unintended) in various 
ways, including carrying the pregnancy to term and par-
enting the child, carrying the pregnancy to term and 
placing the child for adoption, miscarriage, and having 
an abortion. This study may assess the incidence, timing, 
magnitude, and duration of the immediate and long-term 
mental health consequences (positive or negative) of these 
pregnancy outcomes. 
(B) REPORT.—Subject to the completion of the study 
under subsection (a), beginning not later than 5 years 
after the date of the enactment of this Act, and periodically 
42 USC 712 note. 
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124 STAT. 345 
PUBLIC LAW 111–148—MAR. 23, 2010 
thereafter for the duration of the study, such Director 
may prepare and submit to the Congress reports on the 
findings of the study. 
(b) GRANTS TO PROVIDE SERVICES
TO INDIVIDUALS WITH
A 
POSTPARTUM CONDITION AND THEIR FAMILIES.—Title V of the Social 
Security Act (42 U.S.C. 701 et seq.), as amended by section 2951, 
is amended by adding at the end the following new section: 
‘‘SEC. 512. SERVICES TO INDIVIDUALS WITH A POSTPARTUM CONDI-
TION AND THEIR FAMILIES. 
‘‘(a) IN GENERAL.—In addition to any other payments made 
under this title to a State, the Secretary may make grants to 
eligible entities for projects for the establishment, operation, and 
coordination of effective and cost-efficient systems for the delivery 
of essential services to individuals with or at risk for postpartum 
conditions and their families. 
‘‘(b) CERTAIN ACTIVITIES.—To the extent practicable and appro-
priate, the Secretary shall ensure that projects funded under sub-
section (a) provide education and services with respect to the diag-
nosis and management of postpartum conditions for individuals 
with or at risk for postpartum conditions and their families. The 
Secretary may allow such projects to include the following: 
‘‘(1) Delivering or enhancing outpatient and home-based 
health and support services, including case management and 
comprehensive treatment services. 
‘‘(2) Delivering or enhancing inpatient care management 
services that ensure the well-being of the mother and family 
and the future development of the infant. 
‘‘(3) Improving the quality, availability, and organization 
of health care and support services (including transportation 
services, attendant care, homemaker services, day or respite 
care, and providing counseling on financial assistance and 
insurance). 
‘‘(4) Providing education about postpartum conditions to 
promote earlier diagnosis and treatment. Such education may 
include— 
‘‘(A) providing complete information on postpartum 
conditions, symptoms, methods of coping with the illness, 
and treatment resources; and 
‘‘(B) in the case of a grantee that is a State, hospital, 
or birthing facility— 
‘‘(i) providing education to new mothers and 
fathers, and other family members as appropriate, con-
cerning postpartum conditions before new mothers 
leave the health facility; and 
‘‘(ii) ensuring that training programs regarding 
such education are carried out at the health facility. 
‘‘(c) INTEGRATION WITH OTHER PROGRAMS.—To the extent prac-
ticable and appropriate, the Secretary may integrate the grant 
program under this section with other grant programs carried out 
by the Secretary, including the program under section 330 of the 
Public Health Service Act. 
‘‘(d) REQUIREMENTS.—The Secretary shall establish require-
ments for grants made under this section that include a limit 
on the amount of grants funds that may be used for administration, 
accounting, reporting, or program oversight functions and a require-
ment for each eligible entity that receives a grant to submit, for 
42 USC 712. 
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124 STAT. 346 
PUBLIC LAW 111–148—MAR. 23, 2010 
each grant period, a report to the Secretary that describes how 
grant funds were used during such period. 
‘‘(e) TECHNICAL ASSISTANCE.—The Secretary may provide tech-
nical assistance to entities seeking a grant under this section in 
order to assist such entities in complying with the requirements 
of this section. 
‘‘(f) APPLICATION OF OTHER PROVISIONS OF TITLE.— 
‘‘(1) IN GENERAL.—Except as provided in paragraph (2), 
the other provisions of this title shall not apply to a grant 
made under this section. 
‘‘(2) EXCEPTIONS.—The following provisions of this title 
shall apply to a grant made under this section to the same 
extent and in the same manner as such provisions apply to 
allotments made under section 502(c): 
‘‘(A) Section 504(b)(6) (relating to prohibition on pay-
ments to excluded individuals and entities). 
‘‘(B) Section 504(c) (relating to the use of funds for 
the purchase of technical assistance). 
‘‘(C) Section 504(d) (relating to a limitation on adminis-
trative expenditures). 
‘‘(D) Section 506 (relating to reports and audits), but 
only to the extent determined by the Secretary to be appro-
priate for grants made under this section. 
‘‘(E) Section 507 (relating to penalties for false state-
ments). 
‘‘(F) Section 508 (relating to nondiscrimination). 
‘‘(G) Section 509(a) (relating to the administration of 
the grant program). 
‘‘(g) DEFINITIONS.—In this section: 
‘‘(1) The term ‘eligible entity’— 
‘‘(A) means a public or nonprofit private entity; and 
‘‘(B) includes a State or local government, public-pri-
vate partnership, recipient of a grant under section 330H 
of the Public Health Service Act (relating to the Healthy 
Start Initiative), public or nonprofit private hospital, 
community-based organization, hospice, ambulatory care 
facility, community health center, migrant health center, 
public housing primary care center, or homeless health 
center. 
‘‘(2) The term ‘postpartum condition’ means postpartum 
depression or postpartum psychosis.’’. 
(c) GENERAL PROVISIONS.— 
(1) AUTHORIZATION OF APPROPRIATIONS.—To carry out this 
section and the amendment made by subsection (b), there are 
authorized to be appropriated, in addition to such other sums 
as may be available for such purpose— 
(A) $3,000,000 for fiscal year 2010; and 
(B) such sums as may be necessary for fiscal years 
2011 and 2012. 
(2) REPORT BY THE SECRETARY.— 
(A) STUDY.—The Secretary shall conduct a study on 
the benefits of screening for postpartum conditions. 
(B) REPORT.—Not later than 2 years after the date 
of the enactment of this Act, the Secretary shall complete 
the study required by subparagraph (A) and submit a 
report to the Congress on the results of such study. 
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124 STAT. 347 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 2953. PERSONAL RESPONSIBILITY EDUCATION. 
Title V of the Social Security Act (42 U.S.C. 701 et seq.), 
as amended by sections 2951 and 2952(c), is amended by adding 
at the end the following: 
‘‘SEC. 513. PERSONAL RESPONSIBILITY EDUCATION. 
‘‘(a) ALLOTMENTS TO STATES.— 
‘‘(1) AMOUNT.— 
‘‘(A) IN GENERAL.—For the purpose described in sub-
section (b), subject to the succeeding provisions of this 
section, for each of fiscal years 2010 through 2014, the 
Secretary shall allot to each State an amount equal to 
the product of— 
‘‘(i) the amount appropriated under subsection (f) 
for the fiscal year and available for allotments to States 
after the application of subsection (c); and 
‘‘(ii) the State youth population percentage deter-
mined under paragraph (2). 
‘‘(B) MINIMUM ALLOTMENT.— 
‘‘(i) IN GENERAL.—Each State allotment under this 
paragraph for a fiscal year shall be at least $250,000. 
‘‘(ii) PRO RATA ADJUSTMENTS.—The Secretary shall 
adjust on a pro rata basis the amount of the State 
allotments determined under this paragraph for a fiscal 
year to the extent necessary to comply with clause 
(i). 
‘‘(C) APPLICATION REQUIRED TO ACCESS ALLOTMENTS.— 
‘‘(i) IN GENERAL.—A State shall not be paid from 
its allotment for a fiscal year unless the State submits 
an application to the Secretary for the fiscal year and 
the Secretary approves the application (or requires 
changes to the application that the State satisfies) 
and meets such additional requirements as the Sec-
retary may specify. 
‘‘(ii) REQUIREMENTS.—The State application shall 
contain an assurance that the State has complied with 
the requirements of this section in preparing and 
submitting the application and shall include the fol-
lowing as well as such additional information as the 
Secretary may require: 
‘‘(I) Based on data from the Centers for Dis-
ease Control and Prevention National Center for 
Health Statistics, the most recent pregnancy rates 
for the State for youth ages 10 to 14 and youth 
ages 15 to 19 for which data are available, the 
most recent birth rates for such youth populations 
in the State for which data are available, and 
trends in those rates for the most recently pre-
ceding 5-year period for which such data are avail-
able. 
‘‘(II) State-established goals for reducing the 
pregnancy rates and birth rates for such youth 
populations. 
‘‘(III) A description of the State’s plan for using 
the State allotments provided under this section 
to achieve such goals, especially among youth 
42 USC 713. 
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124 STAT. 348 
PUBLIC LAW 111–148—MAR. 23, 2010 
populations that are the most high-risk or vulner-
able for pregnancies or otherwise have special cir-
cumstances, including youth in foster care, home-
less youth, youth with HIV/AIDS, pregnant youth 
who are under 21 years of age, mothers who are 
under 21 years of age, and youth residing in areas 
with high birth rates for youth. 
‘‘(2) STATE YOUTH POPULATION PERCENTAGE.— 
‘‘(A) IN GENERAL.—For purposes of paragraph (1)(A)(ii), 
the State youth population percentage is, with respect to 
a State, the proportion (expressed as a percentage) of— 
‘‘(i) the number of individuals who have attained 
age 10 but not attained age 20 in the State; to 
‘‘(ii) the number of such individuals in all States. 
‘‘(B) DETERMINATION
OF
NUMBER
OF
YOUTH.—The 
number of individuals described in clauses (i) and (ii) of 
subparagraph (A) in a State shall be determined on the 
basis of the most recent Bureau of the Census data. 
‘‘(3) AVAILABILITY OF STATE ALLOTMENTS.—Subject to para-
graph (4)(A), amounts allotted to a State pursuant to this 
subsection for a fiscal year shall remain available for expendi-
ture by the State through the end of the second succeeding 
fiscal year. 
‘‘(4) AUTHORITY TO AWARD GRANTS FROM STATE ALLOTMENTS 
TO LOCAL ORGANIZATIONS AND ENTITIES IN NONPARTICIPATING 
STATES.— 
‘‘(A) GRANTS
FROM
UNEXPENDED
ALLOTMENTS.—If a 
State does not submit an application under this section 
for fiscal year 2010 or 2011, the State shall no longer 
be eligible to submit an application to receive funds from 
the amounts allotted for the State for each of fiscal years 
2010 through 2014 and such amounts shall be used by 
the Secretary to award grants under this paragraph for 
each of fiscal years 2012 through 2014. The Secretary also 
shall use any amounts from the allotments of States that 
submit applications under this section for a fiscal year 
that remain unexpended as of the end of the period in 
which the allotments are available for expenditure under 
paragraph (3) for awarding grants under this paragraph. 
‘‘(B) 3-YEAR GRANTS.— 
‘‘(i) IN
GENERAL.—The Secretary shall solicit 
applications to award 3-year grants in each of fiscal 
years 2012, 2013, and 2014 to local organizations and 
entities to conduct, consistent with subsection (b), pro-
grams and activities in States that do not submit an 
application for an allotment under this section for fiscal 
year 2010 or 2011. 
‘‘(ii) FAITH-BASED ORGANIZATIONS OR CONSORTIA.— 
The Secretary may solicit and award grants under 
this paragraph to faith-based organizations or con-
sortia. 
‘‘(C) EVALUATION.—An organization or entity awarded 
a grant under this paragraph shall agree to participate 
in a rigorous Federal evaluation. 
‘‘(5) MAINTENANCE OF EFFORT.—No payment shall be made 
to a State from the allotment determined for the State under 
this subsection or to a local organization or entity awarded 
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124 STAT. 349 
PUBLIC LAW 111–148—MAR. 23, 2010 
a grant under paragraph (4), if the expenditure of non-federal 
funds by the State, organization, or entity for activities, pro-
grams, or initiatives for which amounts from allotments and 
grants under this subsection may be expended is less than 
the amount expended by the State, organization, or entity 
for such programs or initiatives for fiscal year 2009. 
‘‘(6) DATA COLLECTION AND REPORTING.—A State or local 
organization or entity receiving funds under this section shall 
cooperate with such requirements relating to the collection 
of data and information and reporting on outcomes regarding 
the programs and activities carried out with such funds, as 
the Secretary shall specify. 
‘‘(b) PURPOSE.— 
‘‘(1) IN GENERAL.—The purpose of an allotment under sub-
section (a)(1) to a State is to enable the State (or, in the 
case of grants made under subsection (a)(4)(B), to enable a 
local organization or entity) to carry out personal responsibility 
education programs consistent with this subsection. 
‘‘(2) PERSONAL RESPONSIBILITY EDUCATION PROGRAMS.— 
‘‘(A) IN GENERAL.—In this section, the term ‘personal 
responsibility education program’ means a program that 
is designed to educate adolescents on— 
‘‘(i) both abstinence and contraception for the 
prevention of pregnancy and sexually transmitted 
infections, including HIV/AIDS, consistent with the 
requirements of subparagraph (B); and 
‘‘(ii) at least 3 of the adulthood preparation subjects 
described in subparagraph (C). 
‘‘(B) 
REQUIREMENTS.—The 
requirements 
of 
this 
subparagraph are the following: 
‘‘(i) The program replicates evidence-based effective 
programs or substantially incorporates elements of 
effective programs that have been proven on the basis 
of rigorous scientific research to change behavior, 
which means delaying sexual activity, increasing 
condom or contraceptive use for sexually active youth, 
or reducing pregnancy among youth. 
‘‘(ii) The program is medically-accurate and com-
plete. 
‘‘(iii) The program includes activities to educate 
youth who are sexually active regarding responsible 
sexual behavior with respect to both abstinence and 
the use of contraception. 
‘‘(iv) The program places substantial emphasis on 
both abstinence and contraception for the prevention 
of pregnancy among youth and sexually transmitted 
infections. 
‘‘(v) 
The 
program 
provides 
age-appropriate 
information and activities. 
‘‘(vi) The information and activities carried out 
under the program are provided in the cultural context 
that is most appropriate for individuals in the par-
ticular population group to which they are directed. 
‘‘(C) ADULTHOOD PREPARATION SUBJECTS.—The adult-
hood preparation subjects described in this subparagraph 
are the following: 
Definition. 
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124 STAT. 350 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) Healthy relationships, such as positive self- 
esteem and relationship dynamics, friendships, dating, 
romantic involvement, marriage, and family inter-
actions. 
‘‘(ii) Adolescent development, such as the develop-
ment of healthy attitudes and values about adolescent 
growth and development, body image, racial and ethnic 
diversity, and other related subjects. 
‘‘(iii) Financial literacy. 
‘‘(iv) Parent-child communication. 
‘‘(v) Educational and career success, such as devel-
oping skills for employment preparation, job seeking, 
independent living, financial self-sufficiency, and work-
place productivity. 
‘‘(vi) Healthy life skills, such as goal-setting, deci-
sion making, negotiation, communication and inter-
personal skills, and stress management. 
‘‘(c) RESERVATIONS OF FUNDS.— 
‘‘(1) GRANTS TO IMPLEMENT INNOVATIVE STRATEGIES.—From 
the amount appropriated under subsection (f) for the fiscal 
year, the Secretary shall reserve $10,000,000 of such amount 
for purposes of awarding grants to entities to implement innova-
tive youth pregnancy prevention strategies and target services 
to high-risk, vulnerable, and culturally under-represented youth 
populations, including youth in foster care, homeless youth, 
youth with HIV/AIDS, pregnant women who are under 21 
years of age and their partners, mothers who are under 21 
years of age and their partners, and youth residing in areas 
with high birth rates for youth. An entity awarded a grant 
under this paragraph shall agree to participate in a rigorous 
Federal evaluation of the activities carried out with grant funds. 
‘‘(2) OTHER RESERVATIONS.—From the amount appropriated 
under subsection (f) for the fiscal year that remains after the 
application of paragraph (1), the Secretary shall reserve the 
following amounts: 
‘‘(A) GRANTS FOR INDIAN TRIBES OR TRIBAL ORGANIZA-
TIONS.—The Secretary shall reserve 5 percent of such 
remainder for purposes of awarding grants to Indian tribes 
and tribal organizations in such manner, and subject to 
such requirements, as the Secretary, in consultation with 
Indian tribes and tribal organizations, determines appro-
priate. 
‘‘(B) SECRETARIAL RESPONSIBILITIES.— 
‘‘(i) RESERVATION OF FUNDS.—The Secretary shall 
reserve 10 percent of such remainder for expenditures 
by the Secretary for the activities described in clauses 
(ii) and (iii). 
‘‘(ii) PROGRAM SUPPORT.—The Secretary shall pro-
vide, directly or through a competitive grant process, 
research, training and technical assistance, including 
dissemination of research and information regarding 
effective and promising practices, providing consulta-
tion and resources on a broad array of teen pregnancy 
prevention strategies, including abstinence and contra-
ception, and developing resources and materials to sup-
port the activities of recipients of grants and other 
State, tribal, and community organizations working 
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124 STAT. 351 
PUBLIC LAW 111–148—MAR. 23, 2010 
to reduce teen pregnancy. In carrying out such func-
tions, the Secretary shall collaborate with a variety 
of entities that have expertise in the prevention of 
teen pregnancy, HIV and sexually transmitted infec-
tions, healthy relationships, financial literacy, and 
other topics addressed through the personal responsi-
bility education programs. 
‘‘(iii) EVALUATION.—The Secretary shall evaluate 
the programs and activities carried out with funds 
made available through allotments or grants under 
this section. 
‘‘(d) ADMINISTRATION.— 
‘‘(1) IN GENERAL.—The Secretary shall administer this sec-
tion through the Assistant Secretary for the Administration 
for Children and Families within the Department of Health 
and Human Services. 
‘‘(2) APPLICATION OF OTHER PROVISIONS OF TITLE.— 
‘‘(A) IN GENERAL.—Except as provided in subparagraph 
(B), the other provisions of this title shall not apply to 
allotments or grants made under this section. 
‘‘(B) EXCEPTIONS.—The following provisions of this title 
shall apply to allotments and grants made under this sec-
tion to the same extent and in the same manner as such 
provisions apply to allotments made under section 502(c): 
‘‘(i) Section 504(b)(6) (relating to prohibition on 
payments to excluded individuals and entities). 
‘‘(ii) Section 504(c) (relating to the use of funds 
for the purchase of technical assistance). 
‘‘(iii) Section 504(d) (relating to a limitation on 
administrative expenditures). 
‘‘(iv) Section 506 (relating to reports and audits), 
but only to the extent determined by the Secretary 
to be appropriate for grants made under this section. 
‘‘(v) Section 507 (relating to penalties for false 
statements). 
‘‘(vi) Section 508 (relating to nondiscrimination). 
‘‘(e) DEFINITIONS.—In this section: 
‘‘(1) AGE-APPROPRIATE.—The term ‘age-appropriate’, with 
respect to the information in pregnancy prevention, means 
topics, messages, and teaching methods suitable to particular 
ages or age groups of children and adolescents, based on devel-
oping cognitive, emotional, and behavioral capacity typical for 
the age or age group. 
‘‘(2) MEDICALLY
ACCURATE
AND
COMPLETE.—The term 
‘medically accurate and complete’ means verified or supported 
by the weight of research conducted in compliance with accepted 
scientific methods and— 
‘‘(A) published in peer-reviewed journals, where 
applicable; or 
‘‘(B) comprising information that leading professional 
organizations and agencies with relevant expertise in the 
field recognize as accurate, objective, and complete. 
‘‘(3) INDIAN
TRIBES; TRIBAL
ORGANIZATIONS.—The terms 
‘Indian tribe’ and ‘Tribal organization’ have the meanings given 
such terms in section 4 of the Indian Health Care Improvement 
Act (25 U.S.C. 1603)). 
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124 STAT. 352 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(4) YOUTH.—The term ‘youth’ means an individual who 
has attained age 10 but has not attained age 20. 
‘‘(f) APPROPRIATION.—For the purpose of carrying out this sec-
tion, there is appropriated, out of any money in the Treasury 
not otherwise appropriated, $75,000,000 for each of fiscal years 
2010 through 2014. Amounts appropriated under this subsection 
shall remain available until expended.’’. 
SEC. 2954. RESTORATION OF FUNDING FOR ABSTINENCE EDUCATION. 
Section 510 of the Social Security Act (42 U.S.C. 710) is 
amended— 
(1) in subsection (a), by striking ‘‘fiscal year 1998 and 
each subsequent fiscal year’’ and inserting ‘‘each of fiscal years 
2010 through 2014’’; and 
(2) in subsection (d)— 
(A) in the first sentence, by striking ‘‘1998 through 
2003’’ and inserting ‘‘2010 through 2014’’; and 
(B) in the second sentence, by inserting ‘‘(except that 
such appropriation shall be made on the date of enactment 
of the Patient Protection and Affordable Care Act in the 
case of fiscal year 2010)’’ before the period. 
SEC. 2955. INCLUSION OF INFORMATION ABOUT THE IMPORTANCE 
OF HAVING A HEALTH CARE POWER OF ATTORNEY IN 
TRANSITION PLANNING FOR CHILDREN AGING OUT OF 
FOSTER CARE AND INDEPENDENT LIVING PROGRAMS. 
(a) TRANSITION PLANNING.—Section 475(5)(H) of the Social 
Security Act (42 U.S.C. 675(5)(H)) is amended by inserting ‘‘includes 
information about the importance of designating another individual 
to make health care treatment decisions on behalf of the child 
if the child becomes unable to participate in such decisions and 
the child does not have, or does not want, a relative who would 
otherwise be authorized under State law to make such decisions, 
and provides the child with the option to execute a health care 
power of attorney, health care proxy, or other similar document 
recognized under State law,’’ after ‘‘employment services,’’. 
(b) INDEPENDENT LIVING EDUCATION.—Section 477(b)(3) of such 
Act (42 U.S.C. 677(b)(3)) is amended by adding at the end the 
following: 
‘‘(K) A certification by the chief executive officer of 
the State that the State will ensure that an adolescent 
participating in the program under this section are pro-
vided with education about the importance of designating 
another individual to make health care treatment decisions 
on behalf of the adolescent if the adolescent becomes unable 
to participate in such decisions and the adolescent does 
not have, or does not want, a relative who would otherwise 
be authorized under State law to make such decisions, 
whether a health care power of attorney, health care proxy, 
or other similar document is recognized under State law, 
and how to execute such a document if the adolescent 
wants to do so.’’. 
(c) HEALTH OVERSIGHT
AND COORDINATION PLAN.—Section 
422(b)(15)(A) of such Act (42 U.S.C. 622(b)(15)(A)) is amended— 
(1) in clause (v), by striking ‘‘and’’ at the end; and 
(2) by adding at the end the following: 
‘‘(vii) steps to ensure that the components of the 
transition plan development process required under 
Certification. 
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124 STAT. 353 
PUBLIC LAW 111–148—MAR. 23, 2010 
section 475(5)(H) that relate to the health care needs 
of children aging out of foster care, including the 
requirements to include options for health insurance, 
information about a health care power of attorney, 
health care proxy, or other similar document recog-
nized under State law, and to provide the child with 
the option to execute such a document, are met; and’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
take effect on October 1, 2010. 
TITLE III—IMPROVING THE QUALITY 
AND EFFICIENCY OF HEALTH CARE 
Subtitle A—Transforming the Health Care 
Delivery System 
PART I—LINKING PAYMENT TO QUALITY 
OUTCOMES UNDER THE MEDICARE PROGRAM 
SEC. 3001. HOSPITAL VALUE-BASED PURCHASING PROGRAM. 
(a) PROGRAM.— 
(1) IN GENERAL.—Section 1886 of the Social Security Act 
(42 U.S.C. 1395ww), as amended by section 4102(a) of the 
HITECH Act (Public Law 111–5), is amended by adding at 
the end the following new subsection: 
‘‘(o) HOSPITAL VALUE-BASED PURCHASING PROGRAM.— 
‘‘(1) ESTABLISHMENT.— 
‘‘(A) IN GENERAL.—Subject to the succeeding provisions 
of this subsection, the Secretary shall establish a hospital 
value-based purchasing program (in this subsection 
referred to as the ‘Program’) under which value-based 
incentive payments are made in a fiscal year to hospitals 
that meet the performance standards under paragraph (3) 
for the performance period for such fiscal year (as estab-
lished under paragraph (4)). 
‘‘(B) PROGRAM
TO
BEGIN
IN
FISCAL
YEAR
2013.—The 
Program shall apply to payments for discharges occurring 
on or after October 1, 2012. 
‘‘(C) APPLICABILITY OF PROGRAM TO HOSPITALS.— 
‘‘(i) IN GENERAL.—For purposes of this subsection, 
subject to clause (ii), the term ‘hospital’ means a sub-
section (d) hospital (as defined in subsection (d)(1)(B)). 
‘‘(ii) EXCLUSIONS.—The term ‘hospital’ shall not 
include, with respect to a fiscal year, a hospital— 
‘‘(I) that is subject to the payment reduction 
under subsection (b)(3)(B)(viii)(I) for such fiscal 
year; 
‘‘(II) for which, during the performance period 
for such fiscal year, the Secretary has cited defi-
ciencies that pose immediate jeopardy to the health 
or safety of patients; 
42 USC 622 note. 
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124 STAT. 354 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(III) for which there are not a minimum 
number (as determined by the Secretary) of meas-
ures that apply to the hospital for the performance 
period for such fiscal year; or 
‘‘(IV) for which there are not a minimum 
number (as determined by the Secretary) of cases 
for the measures that apply to the hospital for 
the performance period for such fiscal year. 
‘‘(iii) INDEPENDENT
ANALYSIS.—For purposes of 
determining the minimum numbers under subclauses 
(III) and (IV) of clause (ii), the Secretary shall have 
conducted an independent analysis of what numbers 
are appropriate. 
‘‘(iv) EXEMPTION.—In the case of a hospital that 
is paid under section 1814(b)(3), the Secretary may 
exempt such hospital from the application of this sub-
section if the State which is paid under such section 
submits an annual report to the Secretary describing 
how a similar program in the State for a participating 
hospital or hospitals achieves or surpasses the meas-
ured results in terms of patient health outcomes and 
cost savings established under this subsection. 
‘‘(2) MEASURES.— 
‘‘(A) IN GENERAL.—The Secretary shall select measures 
for purposes of the Program. Such measures shall be 
selected from the measures specified under subsection 
(b)(3)(B)(viii). 
‘‘(B) REQUIREMENTS.— 
‘‘(i) FOR FISCAL YEAR 2013.—For value-based incen-
tive payments made with respect to discharges occur-
ring during fiscal year 2013, the Secretary shall ensure 
the following: 
‘‘(I) CONDITIONS
OR
PROCEDURES.—Measures 
are selected under subparagraph (A) that cover 
at least the following 5 specific conditions or proce-
dures: 
‘‘(aa) Acute myocardial infarction (AMI). 
‘‘(bb) Heart failure. 
‘‘(cc) Pneumonia. 
‘‘(dd) Surgeries, as measured by the Sur-
gical Care Improvement Project (formerly 
referred to as ‘Surgical Infection Prevention’ 
for discharges occurring before July 2006). 
‘‘(ee) Healthcare-associated infections, as 
measured by the prevention metrics and tar-
gets established in the HHS Action Plan to 
Prevent Healthcare-Associated Infections (or 
any successor plan) of the Department of 
Health and Human Services. 
‘‘(II) 
HCAHPS.—Measures 
selected 
under 
subparagraph (A) shall be related to the Hospital 
Consumer Assessment of Healthcare Providers and 
Systems survey (HCAHPS). 
‘‘(ii) INCLUSION
OF
EFFICIENCY
MEASURES.—For 
value-based incentive payments made with respect to 
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124 STAT. 355 
PUBLIC LAW 111–148—MAR. 23, 2010 
discharges occurring during fiscal year 2014 or a subse-
quent fiscal year, the Secretary shall ensure that meas-
ures selected under subparagraph (A) include efficiency 
measures, including measures of ‘Medicare spending 
per beneficiary’. Such measures shall be adjusted for 
factors such as age, sex, race, severity of illness, and 
other factors that the Secretary determines appro-
priate. 
‘‘(C) LIMITATIONS.— 
‘‘(i) TIME REQUIREMENT FOR PRIOR REPORTING AND 
NOTICE.—The Secretary may not select a measure 
under subparagraph (A) for use under the Program 
with respect to a performance period for a fiscal year 
(as established under paragraph (4)) unless such 
measure 
has 
been 
specified 
under 
subsection 
(b)(3)(B)(viii) and included on the Hospital Compare 
Internet website for at least 1 year prior to the begin-
ning of such performance period. 
‘‘(ii) MEASURE NOT APPLICABLE UNLESS HOSPITAL 
FURNISHES SERVICES APPROPRIATE TO THE MEASURE.— 
A measure selected under subparagraph (A) shall not 
apply to a hospital if such hospital does not furnish 
services appropriate to such measure. 
‘‘(D) REPLACING
MEASURES.—Subclause (VI) of sub-
section (b)(3)(B)(viii) shall apply to measures selected under 
subparagraph (A) in the same manner as such subclause 
applies to measures selected under such subsection. 
‘‘(3) PERFORMANCE STANDARDS.— 
‘‘(A) ESTABLISHMENT.—The Secretary shall establish 
performance standards with respect to measures selected 
under paragraph (2) for a performance period for a fiscal 
year (as established under paragraph (4)). 
‘‘(B) ACHIEVEMENT AND IMPROVEMENT.—The perform-
ance standards established under subparagraph (A) shall 
include levels of achievement and improvement. 
‘‘(C) TIMING.—The Secretary shall establish and 
announce the performance standards under subparagraph 
(A) not later than 60 days prior to the beginning of the 
performance period for the fiscal year involved. 
‘‘(D) CONSIDERATIONS IN ESTABLISHING STANDARDS.— 
In establishing performance standards with respect to 
measures under this paragraph, the Secretary shall take 
into account appropriate factors, such as— 
‘‘(i) 
practical 
experience 
with 
the 
measures 
involved, including whether a significant proportion 
of hospitals failed to meet the performance standard 
during previous performance periods; 
‘‘(ii) historical performance standards; 
‘‘(iii) improvement rates; and 
‘‘(iv) the opportunity for continued improvement. 
‘‘(4) PERFORMANCE PERIOD.—For purposes of the Program, 
the Secretary shall establish the performance period for a fiscal 
year. Such performance period shall begin and end prior to 
the beginning of such fiscal year. 
‘‘(5) HOSPITAL PERFORMANCE SCORE.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 
Secretary shall develop a methodology for assessing the 
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124 STAT. 356 
PUBLIC LAW 111–148—MAR. 23, 2010 
total performance of each hospital based on performance 
standards with respect to the measures selected under 
paragraph (2) for a performance period (as established 
under paragraph (4)). Using such methodology, the Sec-
retary shall provide for an assessment (in this subsection 
referred to as the ‘hospital performance score’) for each 
hospital for each performance period. 
‘‘(B) APPLICATION.— 
‘‘(i) APPROPRIATE
DISTRIBUTION.—The Secretary 
shall ensure that the application of the methodology 
developed under subparagraph (A) results in an appro-
priate distribution of value-based incentive payments 
under paragraph (6) among hospitals achieving dif-
ferent levels of hospital performance scores, with hos-
pitals achieving the highest hospital performance 
scores receiving the largest value-based incentive pay-
ments. 
‘‘(ii) HIGHER OF ACHIEVEMENT OR IMPROVEMENT.— 
The methodology developed under subparagraph (A) 
shall provide that the hospital performance score is 
determined using the higher of its achievement or 
improvement score for each measure. 
‘‘(iii) WEIGHTS.—The methodology developed under 
subparagraph (A) shall provide for the assignment of 
weights for categories of measures as the Secretary 
determines appropriate. 
‘‘(iv) NO MINIMUM PERFORMANCE STANDARD.—The 
Secretary shall not set a minimum performance 
standard in determining the hospital performance score 
for any hospital. 
‘‘(v) REFLECTION OF MEASURES APPLICABLE TO THE 
HOSPITAL.—The hospital performance score for a hos-
pital shall reflect the measures that apply to the hos-
pital. 
‘‘(6) CALCULATION OF VALUE-BASED INCENTIVE PAYMENTS.— 
‘‘(A) IN GENERAL.—In the case of a hospital that the 
Secretary determines meets (or exceeds) the performance 
standards under paragraph (3) for the performance period 
for a fiscal year (as established under paragraph (4)), the 
Secretary shall increase the base operating DRG payment 
amount (as defined in paragraph (7)(D)), as determined 
after application of paragraph (7)(B)(i), for a hospital for 
each discharge occurring in such fiscal year by the value- 
based incentive payment amount. 
‘‘(B) VALUE-BASED INCENTIVE PAYMENT AMOUNT.—The 
value-based incentive payment amount for each discharge 
of a hospital in a fiscal year shall be equal to the product 
of— 
‘‘(i) the base operating DRG payment amount (as 
defined in paragraph (7)(D)) for the discharge for the 
hospital for such fiscal year; and 
‘‘(ii) the value-based incentive payment percentage 
specified under subparagraph (C) for the hospital for 
such fiscal year. 
‘‘(C) VALUE-BASED INCENTIVE PAYMENT PERCENTAGE.— 
Determination. 
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124 STAT. 357 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) IN GENERAL.—The Secretary shall specify a 
value-based incentive payment percentage for a hos-
pital for a fiscal year. 
‘‘(ii) REQUIREMENTS.—In specifying the value- 
based incentive payment percentage for each hospital 
for a fiscal year under clause (i), the Secretary shall 
ensure that— 
‘‘(I) such percentage is based on the hospital 
performance score of the hospital under paragraph 
(5); and 
‘‘(II) the total amount of value-based incentive 
payments under this paragraph to all hospitals 
in such fiscal year is equal to the total amount 
available for value-based incentive payments for 
such fiscal year under paragraph (7)(A), as esti-
mated by the Secretary. 
‘‘(7) FUNDING FOR VALUE-BASED INCENTIVE PAYMENTS.— 
‘‘(A) AMOUNT.—The total amount available for value- 
based incentive payments under paragraph (6) for all hos-
pitals for a fiscal year shall be equal to the total amount 
of reduced payments for all hospitals under subparagraph 
(B) for such fiscal year, as estimated by the Secretary. 
‘‘(B) ADJUSTMENT TO PAYMENTS.— 
‘‘(i) IN GENERAL.—The Secretary shall reduce the 
base operating DRG payment amount (as defined in 
subparagraph (D)) for a hospital for each discharge 
in a fiscal year (beginning with fiscal year 2013) by 
an amount equal to the applicable percent (as defined 
in subparagraph (C)) of the base operating DRG pay-
ment amount for the discharge for the hospital for 
such fiscal year. The Secretary shall make such reduc-
tions for all hospitals in the fiscal year involved, 
regardless of whether or not the hospital has been 
determined by the Secretary to have earned a value- 
based incentive payment under paragraph (6) for such 
fiscal year. 
‘‘(ii) NO EFFECT ON OTHER PAYMENTS.—Payments 
described in items (aa) and (bb) of subparagraph 
(D)(i)(II) for a hospital shall be determined as if this 
subsection had not been enacted. 
‘‘(C) APPLICABLE PERCENT DEFINED.—For purposes of 
subparagraph (B), the term ‘applicable percent’ means— 
‘‘(i) with respect to fiscal year 2013, 1.0 percent; 
‘‘(ii) with respect to fiscal year 2014, 1.25 percent; 
‘‘(iii) with respect to fiscal year 2015, 1.5 percent; 
‘‘(iv) with respect to fiscal year 2016, 1.75 percent; 
and 
‘‘(v) with respect to fiscal year 2017 and succeeding 
fiscal years, 2 percent. 
‘‘(D) 
BASE
OPERATING
DRG
PAYMENT
AMOUNT 
DEFINED.— 
‘‘(i) IN
GENERAL.—Except as provided in clause 
(ii), in this subsection, the term ‘base operating DRG 
payment amount’ means, with respect to a hospital 
for a fiscal year— 
‘‘(I) the payment amount that would otherwise 
be made under subsection (d) (determined without 
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124 STAT. 358 
PUBLIC LAW 111–148—MAR. 23, 2010 
regard to subsection (q)) for a discharge if this 
subsection did not apply; reduced by 
‘‘(II) any portion of such payment amount that 
is attributable to— 
‘‘(aa) payments under paragraphs (5)(A), 
(5)(B), (5)(F), and (12) of subsection (d); and 
‘‘(bb) such other payments under sub-
section (d) determined appropriate by the Sec-
retary. 
‘‘(ii) SPECIAL RULES FOR CERTAIN HOSPITALS.— 
‘‘(I) SOLE
COMMUNITY
HOSPITALS
AND
MEDI-
CARE-DEPENDENT, SMALL RURAL HOSPITALS.—In the 
case of a medicare-dependent, small rural hospital 
(with respect to discharges occurring during fiscal 
year 2012 and 2013) or a sole community hospital, 
in applying subparagraph (A)(i), the payment 
amount that would otherwise be made under sub-
section (d) shall be determined without regard to 
subparagraphs (I) and (L) of subsection (b)(3) and 
subparagraphs (D) and (G) of subsection (d)(5). 
‘‘(II) HOSPITALS PAID UNDER SECTION 1814.— 
In the case of a hospital that is paid under section 
1814(b)(3), the term ‘base operating DRG payment 
amount’ means the payment amount under such 
section. 
‘‘(8) ANNOUNCEMENT OF NET RESULT OF ADJUSTMENTS.— 
Under the Program, the Secretary shall, not later than 60 
days prior to the fiscal year involved, inform each hospital 
of the adjustments to payments to the hospital for discharges 
occurring in such fiscal year under paragraphs (6) and (7)(B)(i). 
‘‘(9) NO EFFECT IN SUBSEQUENT FISCAL YEARS.—The value- 
based incentive payment under paragraph (6) and the payment 
reduction under paragraph (7)(B)(i) shall each apply only with 
respect to the fiscal year involved, and the Secretary shall 
not take into account such value-based incentive payment or 
payment reduction in making payments to a hospital under 
this section in a subsequent fiscal year. 
‘‘(10) PUBLIC REPORTING.— 
‘‘(A) HOSPITAL SPECIFIC INFORMATION.— 
‘‘(i) IN
GENERAL.—The Secretary shall make 
information available to the public regarding the 
performance of individual hospitals under the Program, 
including— 
‘‘(I) the performance of the hospital with 
respect to each measure that applies to the hos-
pital; 
‘‘(II) the performance of the hospital with 
respect to each condition or procedure; and 
‘‘(III) the hospital performance score assessing 
the total performance of the hospital. 
‘‘(ii) OPPORTUNITY TO REVIEW AND SUBMIT CORREC-
TIONS.—The Secretary shall ensure that a hospital has 
the opportunity to review, and submit corrections for, 
the information to be made public with respect to 
the hospital under clause (i) prior to such information 
being made public. 
Deadline. 
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124 STAT. 359 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(iii) WEBSITE.—Such information shall be posted 
on the Hospital Compare Internet website in an easily 
understandable format. 
‘‘(B) AGGREGATE
INFORMATION.—The Secretary shall 
periodically post on the Hospital Compare Internet website 
aggregate information on the Program, including— 
‘‘(i) the number of hospitals receiving value-based 
incentive payments under paragraph (6) and the range 
and total amount of such value-based incentive pay-
ments; and 
‘‘(ii) the number of hospitals receiving less than 
the maximum value-based incentive payment available 
to the hospital for the fiscal year involved and the 
range and amount of such payments. 
‘‘(11) IMPLEMENTATION.— 
‘‘(A) APPEALS.—The Secretary shall establish a process 
by which hospitals may appeal the calculation of a hos-
pital’s performance assessment with respect to the perform-
ance standards established under paragraph (3)(A) and 
the hospital performance score under paragraph (5). The 
Secretary shall ensure that such process provides for reso-
lution of such appeals in a timely manner. 
‘‘(B) LIMITATION ON REVIEW.—Except as provided in 
subparagraph (A), there shall be no administrative or 
judicial review under section 1869, section 1878, or other-
wise of the following: 
‘‘(i) The methodology used to determine the amount 
of the value-based incentive payment under paragraph 
(6) and the determination of such amount. 
‘‘(ii) The determination of the amount of funding 
available for such value-based incentive payments 
under paragraph (7)(A) and the payment reduction 
under paragraph (7)(B)(i). 
‘‘(iii) The establishment of the performance stand-
ards under paragraph (3) and the performance period 
under paragraph (4). 
‘‘(iv) The measures specified under subsection 
(b)(3)(B)(viii) and the measures selected under para-
graph (2). 
‘‘(v) The methodology developed under paragraph 
(5) that is used to calculate hospital performance scores 
and the calculation of such scores. 
‘‘(vi) The validation methodology specified in sub-
section (b)(3)(B)(viii)(XI). 
‘‘(C) CONSULTATION WITH SMALL HOSPITALS.—The Sec-
retary shall consult with small rural and urban hospitals 
on the application of the Program to such hospitals. 
‘‘(12) PROMULGATION OF REGULATIONS.—The Secretary shall 
promulgate regulations to carry out the Program, including 
the selection of measures under paragraph (2), the methodology 
developed under paragraph (5) that is used to calculate hospital 
performance scores, and the methodology used to determine 
the amount of value-based incentive payments under paragraph 
(6).’’. 
(2) AMENDMENTS
FOR
REPORTING
OF
HOSPITAL
QUALITY 
INFORMATION.—Section 1886(b)(3)(B)(viii) of the Social Security 
Act (42 U.S.C. 1395ww(b)(3)(B)(viii)) is amended— 
Web posting. 
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124 STAT. 360 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) in subclause (II), by adding at the end the following 
sentence: ‘‘The Secretary may require hospitals to submit 
data on measures that are not used for the determination 
of value-based incentive payments under subsection (o).’’; 
(B) in subclause (V), by striking ‘‘beginning with fiscal 
year 2008’’ and inserting ‘‘for fiscal years 2008 through 
2012’’; 
(C) in subclause (VII), in the first sentence, by striking 
‘‘data submitted’’ and inserting ‘‘information regarding 
measures submitted’’; and 
(D) by adding at the end the following new subclauses: 
‘‘(VIII) Effective for payments beginning with fiscal year 2013, 
with respect to quality measures for outcomes of care, the Secretary 
shall provide for such risk adjustment as the Secretary determines 
to be appropriate to maintain incentives for hospitals to treat 
patients with severe illnesses or conditions. 
‘‘(IX)(aa) Subject to item (bb), effective for payments beginning 
with fiscal year 2013, each measure specified by the Secretary 
under this clause shall be endorsed by the entity with a contract 
under section 1890(a). 
‘‘(bb) 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 measures 
that have been endorsed or adopted by a consensus organization 
identified by the Secretary. 
‘‘(X) To the extent practicable, the Secretary shall, with input 
from consensus organizations and other stakeholders, take steps 
to ensure that the measures specified by the Secretary under this 
clause are coordinated and aligned with quality measures applicable 
to— 
‘‘(aa) physicians under section 1848(k); and 
‘‘(bb) other providers of services and suppliers under this 
title. 
‘‘(XI) The Secretary shall establish a process to validate meas-
ures specified under this clause as appropriate. Such process shall 
include the auditing of a number of randomly selected hospitals 
sufficient to ensure validity of the reporting program under this 
clause as a whole and shall provide a hospital with an opportunity 
to appeal the validation of measures reported by such hospital.’’. 
(3) WEBSITE IMPROVEMENTS.—Section 1886(b)(3)(B) of the 
Social Security Act (42 U.S.C. 1395ww(b)(3)(B)), as amended 
by section 4102(b) of the HITECH Act (Public Law 111–5), 
is amended by adding at the end the following new clause: 
‘‘(x)(I) The Secretary shall develop standard Internet website 
reports tailored to meet the needs of various stakeholders such 
as hospitals, patients, researchers, and policymakers. The Secretary 
shall seek input from such stakeholders in determining the type 
of information that is useful and the formats that best facilitate 
the use of the information. 
‘‘(II) The Secretary shall modify the Hospital Compare Internet 
website to make the use and navigation of that website readily 
available to individuals accessing it.’’. 
(4) GAO STUDY AND REPORT.— 
(A) STUDY.—The Comptroller General of the United 
States shall conduct a study on the performance of the 
Web posting. 
Reports. 
Validation 
process. 
Effective date. 
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124 STAT. 361 
PUBLIC LAW 111–148—MAR. 23, 2010 
hospital value-based purchasing program established under 
section 1886(o) of the Social Security Act, as added by 
paragraph (1). Such study shall include an analysis of 
the impact of such program on— 
(i) the quality of care furnished to Medicare bene-
ficiaries, including diverse Medicare beneficiary popu-
lations (such as diverse in terms of race, ethnicity, 
and socioeconomic status); 
(ii) expenditures under the Medicare program, 
including any reduced expenditures under Part A of 
title XVIII of such Act that are attributable to the 
improvement in the delivery of inpatient hospital serv-
ices by reason of such hospital value-based purchasing 
program; 
(iii) the quality performance among safety net hos-
pitals and any barriers such hospitals face in meeting 
the performance standards applicable under such hos-
pital value-based purchasing program; and 
(iv) the quality performance among small rural 
and small urban hospitals and any barriers such hos-
pitals face in meeting the performance standards 
applicable under such hospital value-based purchasing 
program. 
(B) REPORTS.— 
(i) INTERIM
REPORT.—Not later than October 1, 
2015, the Comptroller General of the United States 
shall submit to Congress an interim report containing 
the results of the study conducted under subparagraph 
(A), together with recommendations for such legislation 
and administrative action as the Comptroller General 
determines appropriate. 
(ii) FINAL REPORT.—Not later than July 1, 2017, 
the Comptroller General of the United States shall 
submit to Congress a report containing the results 
of the study conducted under subparagraph (A), 
together with recommendations for such legislation and 
administrative action as the Comptroller General 
determines appropriate. 
(5) HHS STUDY AND REPORT.— 
(A) STUDY.—The Secretary of Health and Human Serv-
ices shall conduct a study on the performance of the hos-
pital value-based purchasing program established under 
section 1886(o) of the Social Security Act, as added by 
paragraph (1). Such study shall include an analysis— 
(i) of ways to improve the hospital value-based 
purchasing program and ways to address any unin-
tended consequences that may occur as a result of 
such program; 
(ii) of whether the hospital value-based purchasing 
program resulted in lower spending under the Medi-
care program under title XVIII of such Act or other 
financial savings to hospitals; 
(iii) the appropriateness of the Medicare program 
sharing in any savings generated through the hospital 
value-based purchasing program; and 
(iv) any other area determined appropriate by the 
Secretary. 
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124 STAT. 362 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) REPORT.—Not later than January 1, 2016, the Sec-
retary of Health and Human Services shall submit to Con-
gress a report containing the results of the study conducted 
under subparagraph (A), together with recommendations 
for such legislation and administrative action as the Sec-
retary determines appropriate. 
(b) VALUE-BASED PURCHASING DEMONSTRATION PROGRAMS.— 
(1) VALUE-BASED
PURCHASING
DEMONSTRATION
PROGRAM 
FOR INPATIENT CRITICAL ACCESS HOSPITALS.— 
(A) ESTABLISHMENT.— 
(i) IN GENERAL.—Not later than 2 years after the 
date of enactment of this Act, the Secretary of Health 
and Human Services (in this subsection referred to 
as the ‘‘Secretary’’) shall establish a demonstration pro-
gram under which the Secretary establishes a value- 
based purchasing program under the Medicare pro-
gram under title XVIII of the Social Security Act for 
critical access hospitals (as defined in paragraph (1) 
of section 1861(mm) of such Act (42 U.S.C. 1395x(mm))) 
with respect to inpatient critical access hospital serv-
ices (as defined in paragraph (2) of such section) in 
order to test innovative methods of measuring and 
rewarding quality and efficient health care furnished 
by such hospitals. 
(ii) DURATION.—The demonstration program under 
this paragraph shall be conducted for a 3-year period. 
(iii) SITES.—The Secretary shall conduct the dem-
onstration program under this paragraph at an appro-
priate number (as determined by the Secretary) of 
critical access hospitals. The Secretary shall ensure 
that such hospitals are representative of the spectrum 
of such hospitals that participate in the Medicare pro-
gram. 
(B) WAIVER
AUTHORITY.—The Secretary may waive 
such requirements of titles XI and XVIII of the Social 
Security Act as may be necessary to carry out the dem-
onstration program under this paragraph. 
(C) BUDGET NEUTRALITY REQUIREMENT.—In conducting 
the demonstration program under this section, the Sec-
retary shall ensure that the aggregate payments made 
by the Secretary do not exceed the amount which the 
Secretary would have paid if the demonstration program 
under this section was not implemented. 
(D) REPORT.—Not later than 18 months after the 
completion of the demonstration program under this para-
graph, the Secretary shall submit to Congress a report 
on the demonstration program together with— 
(i) recommendations on the establishment of a 
permanent value-based purchasing program under the 
Medicare program for critical access hospitals with 
respect to inpatient critical access hospital services; 
and 
(ii) recommendations for such other legislation and 
administrative action as the Secretary determines 
appropriate. 
Deadline. 
42 USC 1395ww 
note. 
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124 STAT. 363 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) VALUE-BASED
PURCHASING
DEMONSTRATION
PROGRAM 
FOR HOSPITALS EXCLUDED FROM HOSPITAL VALUE-BASED PUR-
CHASING PROGRAM AS A RESULT OF INSUFFICIENT NUMBERS OF 
MEASURES AND CASES.— 
(A) ESTABLISHMENT.— 
(i) IN GENERAL.—Not later than 2 years after the 
date of enactment of this Act, the Secretary shall estab-
lish a demonstration program under which the Sec-
retary establishes a value-based purchasing program 
under the Medicare program under title XVIII of the 
Social Security Act for applicable hospitals (as defined 
in clause (ii)) with respect to inpatient hospital services 
(as defined in section 1861(b) of the Social Security 
Act (42 U.S.C. 1395x(b))) in order to test innovative 
methods of measuring and rewarding quality and effi-
cient health care furnished by such hospitals. 
(ii) APPLICABLE HOSPITAL DEFINED.—For purposes 
of this paragraph, the term ‘‘applicable hospital’’ means 
a hospital described in subclause (III) or (IV) of section 
1886(o)(1)(C)(ii) of the Social Security Act, as added 
by subsection (a)(1). 
(iii) 
DURATION.—The 
demonstration 
program 
under this paragraph shall be conducted for a 3-year 
period. 
(iv) SITES.—The Secretary shall conduct the dem-
onstration program under this paragraph at an appro-
priate number (as determined by the Secretary) of 
applicable hospitals. The Secretary shall ensure that 
such hospitals are representative of the spectrum of 
such hospitals that participate in the Medicare pro-
gram. 
(B) WAIVER
AUTHORITY.—The Secretary may waive 
such requirements of titles XI and XVIII of the Social 
Security Act as may be necessary to carry out the dem-
onstration program under this paragraph. 
(C) BUDGET NEUTRALITY REQUIREMENT.—In conducting 
the demonstration program under this section, the Sec-
retary shall ensure that the aggregate payments made 
by the Secretary do not exceed the amount which the 
Secretary would have paid if the demonstration program 
under this section was not implemented. 
(D) REPORT.—Not later than 18 months after the 
completion of the demonstration program under this para-
graph, the Secretary shall submit to Congress a report 
on the demonstration program together with— 
(i) recommendations on the establishment of a 
permanent value-based purchasing program under the 
Medicare program for applicable hospitals with respect 
to inpatient hospital services; and 
(ii) recommendations for such other legislation and 
administrative action as the Secretary determines 
appropriate. 
SEC. 3002. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING 
SYSTEM. 
(a) EXTENSION.—Section 1848(m) of the Social Security Act 
(42 U.S.C. 1395w–4(m)) is amended— 
Deadline. 
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124 STAT. 364 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) in paragraph (1)— 
(A) in subparagraph (A), in the matter preceding clause 
(i), by striking ‘‘2010’’ and inserting ‘‘2014’’; and 
(B) in subparagraph (B)— 
(i) in clause (i), by striking ‘‘and’’ at the end; 
(ii) in clause (ii), by striking the period at the 
end and inserting a semicolon; and 
(iii) by adding at the end the following new clauses: 
‘‘(iii) for 2011, 1.0 percent; and 
‘‘(iv) for 2012, 2013, and 2014, 0.5 percent.’’; 
(2) in paragraph (3)— 
(A) in subparagraph (A), in the matter preceding clause 
(i), by inserting ‘‘(or, for purposes of subsection (a)(8), for 
the quality reporting period for the year)’’ after ‘‘reporting 
period’’; and 
(B) in subparagraph (C)(i), by inserting ‘‘, or, for pur-
poses of subsection (a)(8), for a quality reporting period 
for the year’’ after ‘‘(a)(5), for a reporting period for a 
year’’; 
(3) in paragraph (5)(E)(iv), by striking ‘‘subsection (a)(5)(A)’’ 
and inserting ‘‘paragraphs (5)(A) and (8)(A) of subsection (a)’’; 
and 
(4) in paragraph (6)(C)— 
(A) in clause (i)(II), by striking ‘‘, 2009, 2010, and 
2011’’ and inserting ‘‘and subsequent years’’; and 
(B) in clause (iii)— 
(i) by inserting ‘‘(a)(8)’’ after ‘‘(a)(5)’’; and 
(ii) by striking ‘‘under subparagraph (D)(iii) of such 
subsection’’ 
and 
inserting 
‘‘under 
subsection 
(a)(5)(D)(iii) or the quality reporting period under sub-
section (a)(8)(D)(iii), respectively’’. 
(b) 
INCENTIVE
PAYMENT
ADJUSTMENT
FOR
QUALITY 
REPORTING.—Section 1848(a) of the Social Security Act (42 U.S.C. 
1395w–4(a)) is amended by adding at the end the following new 
paragraph: 
‘‘(8) INCENTIVES FOR QUALITY REPORTING.— 
‘‘(A) ADJUSTMENT.— 
‘‘(i) IN GENERAL.—With respect to covered profes-
sional services furnished by an eligible professional 
during 2015 or any subsequent year, if the eligible 
professional does not satisfactorily submit data on 
quality measures for covered professional services for 
the quality reporting period for the year (as determined 
under subsection (m)(3)(A)), the fee schedule amount 
for such services furnished by such professional during 
the year (including the fee schedule amount for pur-
poses of determining a payment based on such amount) 
shall be equal to the applicable percent of the fee 
schedule amount that would otherwise apply to such 
services under this subsection (determined after 
application of paragraphs (3), (5), and (7), but without 
regard to this paragraph). 
‘‘(ii) APPLICABLE PERCENT.—For purposes of clause 
(i), the term ‘applicable percent’ means— 
‘‘(I) for 2015, 98.5 percent; and 
‘‘(II) for 2016 and each subsequent year, 98 
percent. 
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124 STAT. 365 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) APPLICATION.— 
‘‘(i) PHYSICIAN REPORTING SYSTEM RULES.—Para-
graphs (5), (6), and (8) of subsection (k) shall apply 
for purposes of this paragraph in the same manner 
as they apply for purposes of such subsection. 
‘‘(ii) INCENTIVE
PAYMENT
VALIDATION
RULES.— 
Clauses (ii) and (iii) of subsection (m)(5)(D) shall apply 
for purposes of this paragraph in a similar manner 
as they apply for purposes of such subsection. 
‘‘(C) DEFINITIONS.—For purposes of this paragraph: 
‘‘(i) ELIGIBLE
PROFESSIONAL; COVERED
PROFES-
SIONAL SERVICES.—The terms ‘eligible professional’ and 
‘covered professional services’ have the meanings given 
such terms in subsection (k)(3). 
‘‘(ii) PHYSICIAN
REPORTING
SYSTEM.—The term 
‘physician reporting system’ means the system estab-
lished under subsection (k). 
‘‘(iii) QUALITY
REPORTING
PERIOD.—The term 
‘quality reporting period’ means, with respect to a year, 
a period specified by the Secretary.’’. 
(c) MAINTENANCE OF CERTIFICATION PROGRAMS.— 
(1) IN GENERAL.—Section 1848(k)(4) of the Social Security 
Act (42 U.S.C. 1395w–4(k)(4)) is amended by inserting ‘‘or 
through a Maintenance of Certification program operated by 
a specialty body of the American Board of Medical Specialties 
that meets the criteria for such a registry’’ after ‘‘Database)’’. 
(2) EFFECTIVE DATE.—The amendment made by paragraph 
(1) shall apply for years after 2010. 
(d) INTEGRATION OF PHYSICIAN QUALITY REPORTING AND EHR 
REPORTING.—Section 1848(m) of the Social Security Act (42 U.S.C. 
1395w–4(m)) is amended by adding at the end the following new 
paragraph: 
‘‘(7) INTEGRATION OF PHYSICIAN QUALITY REPORTING AND 
EHR REPORTING.—Not later than January 1, 2012, the Secretary 
shall develop a plan to integrate reporting on quality measures 
under this subsection with reporting requirements under sub-
section (o) relating to the meaningful use of electronic health 
records. Such integration shall consist of the following: 
‘‘(A) The selection of measures, the reporting of which 
would both demonstrate— 
‘‘(i) meaningful use of an electronic health record 
for purposes of subsection (o); and 
‘‘(ii) quality of care furnished to an individual. 
‘‘(B) Such other activities as specified by the Sec-
retary.’’. 
(e) FEEDBACK.—Section 1848(m)(5) of the Social Security Act 
(42 U.S.C. 1395w–4(m)(5)) is amended by adding at the end the 
following new subparagraph: 
‘‘(H) FEEDBACK.—The Secretary shall provide timely 
feedback to eligible professionals on the performance of 
the eligible professional with respect to satisfactorily 
submitting data on quality measures under this sub-
section.’’. 
(f) APPEALS.—Such section is further amended— 
(1) in subparagraph (E), by striking ‘‘There shall’’ and 
inserting ‘‘Except as provided in subparagraph (I), there shall’’; 
and 
Plans. 
42 USC 1395w–4 
note. 
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124 STAT. 366 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) by adding at the end the following new subparagraph: 
‘‘(I) INFORMAL APPEALS PROCESS.—The Secretary shall, 
by not later than January 1, 2011, establish and have 
in place an informal process for eligible professionals to 
seek a review of the determination that an eligible profes-
sional did not satisfactorily submit data on quality meas-
ures under this subsection.’’. 
SEC. 3003. IMPROVEMENTS TO THE PHYSICIAN FEEDBACK PROGRAM. 
(a) IN GENERAL.—Section 1848(n) of the Social Security Act 
(42 U.S.C. 1395w–4(n)) is amended— 
(1) in paragraph (1)— 
(A) in subparagraph (A)— 
(i) by striking ‘‘GENERAL.—The Secretary’’ and 
inserting ‘‘GENERAL.— 
‘‘(i) ESTABLISHMENT.—The Secretary’’; 
(ii) in clause (i), as added by clause (i), by striking 
‘‘the ‘Program’)’’ and all that follows through the period 
at the end of the second sentence and inserting ‘‘the 
‘Program’).’’; and 
(iii) by adding at the end the following new clauses: 
‘‘(ii) REPORTS ON RESOURCES.—The Secretary shall 
use claims data under this title (and may use other 
data) to provide confidential reports to physicians (and, 
as determined appropriate by the Secretary, to groups 
of physicians) that measure the resources involved in 
furnishing care to individuals under this title. 
‘‘(iii) INCLUSION
OF
CERTAIN
INFORMATION.—If 
determined appropriate by the Secretary, the Secretary 
may include information on the quality of care fur-
nished to individuals under this title by the physician 
(or group of physicians) in such reports.’’; and 
(B) in subparagraph (B), by striking ‘‘subparagraph 
(A)’’ and inserting ‘‘subparagraph (A)(ii)’’; 
(2) in paragraph (4)— 
(A) in the heading, by inserting ‘‘INITIAL’’ after ‘‘FOCUS’’; 
and 
(B) in the matter preceding subparagraph (A), by 
inserting ‘‘initial’’ after ‘‘focus the’’; 
(3) in paragraph (6), by adding at the end the following 
new sentence: ‘‘For adjustments for reports on utilization under 
paragraph (9), see subparagraph (D) of such paragraph.’’; and 
(4) by adding at the end the following new paragraphs: 
‘‘(9) REPORTS ON UTILIZATION.— 
‘‘(A) DEVELOPMENT OF EPISODE GROUPER.— 
‘‘(i) IN GENERAL.—The Secretary shall develop an 
episode grouper that combines separate but clinically 
related items and services into an episode of care for 
an individual, as appropriate. 
‘‘(ii) TIMELINE
FOR
DEVELOPMENT.—The episode 
grouper described in subparagraph (A) shall be devel-
oped by not later than January 1, 2012. 
‘‘(iii) PUBLIC
AVAILABILITY.—The Secretary shall 
make the details of the episode grouper described in 
subparagraph (A) available to the public. 
‘‘(iv) ENDORSEMENT.—The Secretary shall seek 
endorsement of the episode grouper described in 
Deadline. 
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124 STAT. 367 
PUBLIC LAW 111–148—MAR. 23, 2010 
subparagraph (A) by the entity with a contract under 
section 1890(a). 
‘‘(B) REPORTS
ON
UTILIZATION.—Effective beginning 
with 2012, the Secretary shall provide reports to physicians 
that compare, as determined appropriate by the Secretary, 
patterns of resource use of the individual physician to 
such patterns of other physicians. 
‘‘(C) ANALYSIS OF DATA.—The Secretary shall, for pur-
poses of preparing reports under this paragraph, establish 
methodologies as appropriate, such as to— 
‘‘(i) attribute episodes of care, in whole or in part, 
to physicians; 
‘‘(ii) identify appropriate physicians for purposes 
of comparison under subparagraph (B); and 
‘‘(iii) aggregate episodes of care attributed to a 
physician under clause (i) into a composite measure 
per individual. 
‘‘(D) DATA ADJUSTMENT.—In preparing reports under 
this paragraph, the Secretary shall make appropriate 
adjustments, including adjustments— 
‘‘(i) to account for differences in socioeconomic and 
demographic characteristics, ethnicity, and health 
status of individuals (such as to recognize that less 
healthy individuals may require more intensive inter-
ventions); and 
‘‘(ii) to eliminate the effect of geographic adjust-
ments in payment rates (as described in subsection 
(e)). 
‘‘(E) PUBLIC AVAILABILITY OF METHODOLOGY.—The Sec-
retary shall make available to the public— 
‘‘(i) the methodologies established under subpara-
graph (C); 
‘‘(ii) information regarding any adjustments made 
to data under subparagraph (D); and 
‘‘(iii) aggregate reports with respect to physicians. 
‘‘(F) DEFINITION OF PHYSICIAN.—In this paragraph: 
‘‘(i) IN
GENERAL.—The term ‘physician’ has the 
meaning given that term in section 1861(r)(1). 
‘‘(ii) TREATMENT OF GROUPS.—Such term includes, 
as the Secretary determines appropriate, a group of 
physicians. 
‘‘(G) LIMITATIONS
ON
REVIEW.—There shall be no 
administrative or judicial review under section 1869, sec-
tion 1878, or otherwise of the establishment of the method-
ology under subparagraph (C), including the determination 
of an episode of care under such methodology. 
‘‘(10) COORDINATION WITH OTHER VALUE-BASED PURCHASING 
REFORMS.—The Secretary shall coordinate the Program with 
the value-based payment modifier established under subsection 
(p) and, as the Secretary determines appropriate, other similar 
provisions of this title.’’. 
(b) CONFORMING AMENDMENT.—Section 1890(b) of the Social 
Security Act (42 U.S.C. 1395aaa(b)) is amended by adding at the 
end the following new paragraph: 
‘‘(6) REVIEW AND ENDORSEMENT OF EPISODE GROUPER UNDER 
THE PHYSICIAN FEEDBACK PROGRAM.—The entity shall provide 
for the review and, as appropriate, the endorsement of the 
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124 STAT. 368 
PUBLIC LAW 111–148—MAR. 23, 2010 
episode grouper developed by the Secretary under section 
1848(n)(9)(A). Such review shall be conducted on an expedited 
basis.’’. 
SEC. 3004. QUALITY REPORTING FOR LONG-TERM CARE HOSPITALS, 
INPATIENT REHABILITATION HOSPITALS, AND HOSPICE 
PROGRAMS. 
(a) LONG-TERM CARE HOSPITALS.—Section 1886(m) of the Social 
Security Act (42 U.S.C. 1395ww(m)), as amended by section 3401(c), 
is amended by adding at the end the following new paragraph: 
‘‘(5) 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 long-term care hospital 
that does not submit data to the Secretary in accord-
ance with subparagraph (C) with respect to such a 
rate year, any annual update to a standard Federal 
rate for discharges for the hospital during the rate 
year, and after application of paragraph (3), shall be 
reduced by 2 percentage points. 
‘‘(ii) SPECIAL
RULE.—The application of this 
subparagraph may result in such annual 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 payment 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 reduction 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 long-term care hospital 
shall submit to the Secretary data on quality measures 
specified under subparagraph (D). Such data shall be sub-
mitted in a form and manner, and at a time, specified 
by the Secretary for purposes of this subparagraph. 
‘‘(D) QUALITY MEASURES.— 
‘‘(i) IN
GENERAL.—Subject to clause (ii), any 
measure specified by the Secretary under this subpara-
graph 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 Sec-
retary 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 measures 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 subparagraph that will be applicable with 
respect to rate year 2014. 
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124 STAT. 369 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(E) PUBLIC AVAILABILITY OF DATA SUBMITTED.—The 
Secretary shall establish procedures for making data sub-
mitted under subparagraph (C) available to the public. 
Such procedures shall ensure that a long-term care hospital 
has the opportunity to review the data that is to be made 
public with respect to the hospital prior to such data being 
made public. The Secretary shall report quality measures 
that relate to services furnished in inpatient settings in 
long-term care hospitals on the Internet website of the 
Centers for Medicare & Medicaid Services.’’. 
(b) INPATIENT REHABILITATION HOSPITALS.—Section 1886(j) of 
the Social Security Act (42 U.S.C. 1395ww(j)) is amended— 
(1) by redesignating paragraph (7) as paragraph (8); and 
(2) by inserting after paragraph (6) the following new para-
graph: 
‘‘(7) QUALITY REPORTING.— 
‘‘(A) REDUCTION IN UPDATE FOR FAILURE TO REPORT.— 
‘‘(i) IN GENERAL.—For purposes of fiscal year 2014 
and each subsequent fiscal year, in the case of a 
rehabilitation facility that does not submit data to 
the Secretary in accordance with subparagraph (C) 
with respect to such a fiscal year, after determining 
the increase factor described in paragraph (3)(C), and 
after application of paragraph (3)(D), the Secretary 
shall reduce such increase factor for payments for dis-
charges occurring during such fiscal year by 2 percent-
age points. 
‘‘(ii) SPECIAL
RULE.—The application of this 
subparagraph may result in the increase factor 
described in paragraph (3)(C) being less than 0.0 for 
a fiscal year, and may result in payment rates under 
this subsection for a fiscal year being less than such 
payment rates for the preceding fiscal year. 
‘‘(B) NONCUMULATIVE
APPLICATION.—Any reduction 
under subparagraph (A) shall apply only with respect to 
the fiscal year involved and the Secretary shall not take 
into account such reduction in computing the payment 
amount under this subsection for a subsequent fiscal year. 
‘‘(C) SUBMISSION
OF
QUALITY
DATA.—For fiscal year 
2014 and each subsequent rate year, each rehabilitation 
facility shall submit to the Secretary data on quality meas-
ures specified under subparagraph (D). Such data shall 
be submitted in a form and manner, and at a time, specified 
by the Secretary for purposes of this subparagraph. 
‘‘(D) QUALITY MEASURES.— 
‘‘(i) IN
GENERAL.—Subject to clause (ii), any 
measure specified by the Secretary under this subpara-
graph 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 Sec-
retary 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 measures that have been endorsed or 
Web posting. 
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Procedures. 
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124 STAT. 370 
PUBLIC LAW 111–148—MAR. 23, 2010 
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 subparagraph that will be applicable with 
respect to fiscal year 2014. 
‘‘(E) PUBLIC AVAILABILITY OF DATA SUBMITTED.—The 
Secretary shall establish procedures for making data sub-
mitted under subparagraph (C) available to the public. 
Such procedures shall ensure that a rehabilitation facility 
has the opportunity to review the data that is to be made 
public with respect to the facility prior to such data being 
made public. The Secretary shall report quality measures 
that relate to services furnished in inpatient settings in 
rehabilitation facilities on the Internet website of the Cen-
ters for Medicare & Medicaid Services.’’. 
(c) HOSPICE PROGRAMS.—Section 1814(i) of the Social Security 
Act (42 U.S.C. 1395f(i)) is amended— 
(1) by redesignating paragraph (5) as paragraph (6); and 
(2) by inserting after paragraph (4) the following new para-
graph: 
‘‘(5) QUALITY REPORTING.— 
‘‘(A) REDUCTION IN UPDATE FOR FAILURE TO REPORT.— 
‘‘(i) IN GENERAL.—For purposes of fiscal year 2014 
and each subsequent fiscal year, in the case of a hospice 
program that does not submit data to the Secretary 
in accordance with subparagraph (C) with respect to 
such a fiscal year, after determining the market basket 
percentage increase under paragraph (1)(C)(ii)(VII) or 
paragraph (1)(C)(iii), as applicable, and after applica-
tion of paragraph (1)(C)(iv), with respect to the fiscal 
year, the Secretary shall reduce such market basket 
percentage increase by 2 percentage points. 
‘‘(ii) SPECIAL
RULE.—The application of this 
subparagraph may result in the market basket percent-
age increase under paragraph (1)(C)(ii)(VII) or para-
graph (1)(C)(iii), as applicable, being less than 0.0 for 
a fiscal year, and may result in payment rates under 
this subsection for a fiscal year being less than such 
payment rates for the preceding fiscal year. 
‘‘(B) NONCUMULATIVE
APPLICATION.—Any reduction 
under subparagraph (A) shall apply only with respect to 
the fiscal year involved and the Secretary shall not take 
into account such reduction in computing the payment 
amount under this subsection for a subsequent fiscal year. 
‘‘(C) SUBMISSION
OF
QUALITY
DATA.—For fiscal year 
2014 and each subsequent fiscal year, each hospice program 
shall submit to the Secretary data on quality measures 
specified under subparagraph (D). Such data shall be sub-
mitted in a form and manner, and at a time, specified 
by the Secretary for purposes of this subparagraph. 
‘‘(D) QUALITY MEASURES.— 
‘‘(i) IN
GENERAL.—Subject to clause (ii), any 
measure specified by the Secretary under this subpara-
graph must have been endorsed by the entity with 
a contract under section 1890(a). 
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Procedures. 
Publication. 
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124 STAT. 371 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(ii) EXCEPTION.—In the case of a specified area 
or medical topic determined appropriate by the Sec-
retary 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 measures 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 subparagraph that will be applicable with 
respect to fiscal year 2014. 
‘‘(E) PUBLIC AVAILABILITY OF DATA SUBMITTED.—The 
Secretary shall establish procedures for making data sub-
mitted under subparagraph (C) available to the public. 
Such procedures shall ensure that a hospice program has 
the opportunity to review the data that is to be made 
public with respect to the hospice program prior to such 
data being made public. The Secretary shall report quality 
measures that relate to hospice care provided by hospice 
programs on the Internet website of the Centers for Medi-
care & Medicaid Services.’’. 
SEC. 3005. QUALITY REPORTING FOR PPS-EXEMPT CANCER HOS-
PITALS. 
Section 1866 of the Social Security Act (42 U.S.C. 1395cc) 
is amended— 
(1) in subsection (a)(1)— 
(A) in subparagraph (U), by striking ‘‘and’’ at the end; 
(B) in subparagraph (V), by striking the period at 
the end and inserting ‘‘, and’’; and 
(C) by adding at the end the following new subpara-
graph: 
‘‘(W) in the case of a hospital described in section 
1886(d)(1)(B)(v), to report quality data to the Secretary 
in accordance with subsection (k).’’; and 
(2) by adding at the end the following new subsection: 
‘‘(k) QUALITY REPORTING BY CANCER HOSPITALS.— 
‘‘(1) IN GENERAL.—For purposes of fiscal year 2014 and 
each subsequent fiscal year, a hospital described in section 
1886(d)(1)(B)(v) shall submit data to the Secretary in accord-
ance with paragraph (2) with respect to such a fiscal year. 
‘‘(2) SUBMISSION OF QUALITY DATA.—For fiscal year 2014 
and each subsequent fiscal year, each hospital described in 
such section shall submit to the Secretary data on quality 
measures specified under paragraph (3). Such data shall be 
submitted in a form and manner, and at a time, specified 
by the Secretary for purposes of this subparagraph. 
‘‘(3) QUALITY MEASURES.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), any 
measure specified by the Secretary under this paragraph 
must have been endorsed by the entity with a contract 
under section 1890(a). 
‘‘(B) 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 
Web posting. 
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Procedures. 
Publication. 
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124 STAT. 372 
PUBLIC LAW 111–148—MAR. 23, 2010 
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. 
‘‘(C) TIME FRAME.—Not later than October 1, 2012, 
the Secretary shall publish the measures selected under 
this paragraph that will be applicable with respect to fiscal 
year 2014. 
‘‘(4) PUBLIC AVAILABILITY OF DATA SUBMITTED.—The Sec-
retary shall establish procedures for making data submitted 
under paragraph (4) available to the public. Such procedures 
shall ensure that a hospital described in section 1886(d)(1)(B)(v) 
has the opportunity to review the data that is to be made 
public with respect to the hospital prior to such data being 
made public. The Secretary shall report quality measures of 
process, structure, outcome, patients’ perspective on care, effi-
ciency, and costs of care that relate to services furnished in 
such hospitals on the Internet website of the Centers for Medi-
care & Medicaid Services.’’. 
SEC. 3006. PLANS FOR A VALUE-BASED PURCHASING PROGRAM FOR 
SKILLED NURSING FACILITIES AND HOME HEALTH 
AGENCIES. 
(a) SKILLED NURSING FACILITIES.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’) shall 
develop a plan to implement a value-based purchasing program 
for payments under the Medicare program under title XVIII 
of the Social Security Act for skilled nursing facilities (as 
defined in section 1819(a) of such Act (42 U.S.C. 1395i–3(a))). 
(2) DETAILS.—In developing the plan under paragraph (1), 
the Secretary shall consider the following issues: 
(A) The ongoing development, selection, and modifica-
tion process for measures (including under section 1890 
of the Social Security Act (42 U.S.C. 1395aaa) and section 
1890A such Act, as added by section 3014), to the extent 
feasible and practicable, of all dimensions of quality and 
efficiency in skilled nursing facilities. 
(i) IN GENERAL.—Subject to clause (ii), any measure 
specified by the Secretary under subparagraph (A)(iii) 
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 Sec-
retary 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 measures that have been endorsed or 
adopted by a consensus organization identified by the 
Secretary. 
(B) The reporting, collection, and validation 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, 
Web posting. 
Review. 
Procedures. 
Publication. 
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124 STAT. 373 
PUBLIC LAW 111–148—MAR. 23, 2010 
the size of such payments, and the sources of funding 
for the value-based bonus payments. 
(D) Methods for the public disclosure of information 
on the performance of skilled nursing facilities. 
(E) Any other issues determined appropriate by the 
Secretary. 
(3) CONSULTATION.—In developing the plan under para-
graph (1), the Secretary shall— 
(A) consult with relevant affected parties; and 
(B) consider experience with such demonstrations that 
the Secretary determines are relevant to the value-based 
purchasing program described in paragraph (1). 
(4) REPORT TO CONGRESS.—Not later than October 1, 2011, 
the Secretary shall submit to Congress a report containing 
the plan developed under paragraph (1). 
(b) HOME HEALTH AGENCIES.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’) shall 
develop a plan to implement a value-based purchasing program 
for payments under the Medicare program under title XVIII 
of the Social Security Act for home health agencies (as defined 
in section 1861(o) of such Act (42 U.S.C. 1395x(o))). 
(2) DETAILS.—In developing the plan under paragraph (1), 
the Secretary shall consider the following issues: 
(A) The ongoing development, selection, and modifica-
tion process for measures (including under section 1890 
of the Social Security Act (42 U.S.C. 1395aaa) and section 
1890A such Act, as added by section 3014), to the extent 
feasible and practicable, of all dimensions of quality and 
efficiency in home health agencies. 
(B) The reporting, collection, and validation 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 information 
on the performance of home health agencies. 
(E) Any other issues determined appropriate by the 
Secretary. 
(3) CONSULTATION.—In developing the plan under para-
graph (1), the Secretary shall— 
(A) consult with relevant affected parties; and 
(B) consider experience with such demonstrations that 
the Secretary determines are relevant to the value-based 
purchasing program described in paragraph (1). 
(4) REPORT TO CONGRESS.—Not later than October 1, 2011, 
the Secretary shall submit to Congress a report containing 
the plan developed under paragraph (1). 
SEC. 3007. VALUE-BASED PAYMENT MODIFIER UNDER THE PHYSICIAN 
FEE SCHEDULE. 
Section 1848 of the Social Security Act (42 U.S.C. 1395w– 
4) is amended— 
(1) in subsection (b)(1), by inserting ‘‘subject to subsection 
(p),’’ after ‘‘1998,’’; and 
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124 STAT. 374 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) by adding at the end the following new subsection: 
‘‘(p) ESTABLISHMENT
OF VALUE-BASED PAYMENT MODIFIER.— 
‘‘(1) IN GENERAL.—The Secretary shall establish a payment 
modifier that provides for differential payment to a physician 
or a group of physicians under the fee schedule established 
under subsection (b) based upon the quality of care furnished 
compared to cost (as determined under paragraphs (2) and 
(3), respectively) during a performance period. Such payment 
modifier shall be separate from the geographic adjustment fac-
tors established under subsection (e). 
‘‘(2) QUALITY.— 
‘‘(A) IN
GENERAL.—For purposes of paragraph (1), 
quality of care shall be evaluated, to the extent practicable, 
based on a composite of measures of the quality of care 
furnished (as established by the Secretary under subpara-
graph (B)). 
‘‘(B) MEASURES.— 
‘‘(i) The Secretary shall establish appropriate 
measures of the quality of care furnished by a physi-
cian or group of physicians to individuals enrolled 
under this part, such as measures that reflect health 
outcomes. Such measures shall be risk adjusted as 
determined appropriate by the Secretary. 
‘‘(ii) The Secretary shall seek endorsement of the 
measures established under this subparagraph by the 
entity with a contract under section 1890(a). 
‘‘(3) COSTS.—For purposes of paragraph (1), costs shall 
be evaluated, to the extent practicable, based on a composite 
of appropriate measures of costs established by the Secretary 
(such as the composite measure under the methodology estab-
lished under subsection (n)(9)(C)(iii)) that eliminate the effect 
of geographic adjustments in payment rates (as described in 
subsection (e)), and take into account risk factors (such as 
socioeconomic and demographic characteristics, ethnicity, and 
health status of individuals (such as to recognize that less 
healthy individuals may require more intensive interventions) 
and other factors determined appropriate by the Secretary. 
‘‘(4) IMPLEMENTATION.— 
‘‘(A) PUBLICATION OF MEASURES, DATES OF IMPLEMENTA-
TION, PERFORMANCE PERIOD.—Not later than January 1, 
2012, the Secretary shall publish the following: 
‘‘(i) The measures of quality of care and costs estab-
lished under paragraphs (2) and (3), respectively. 
‘‘(ii) The dates for implementation of the payment 
modifier (as determined under subparagraph (B)). 
‘‘(iii) The initial performance period (as specified 
under subparagraph (B)(ii)). 
‘‘(B) DEADLINES FOR IMPLEMENTATION.— 
‘‘(i) INITIAL IMPLEMENTATION.—Subject to the pre-
ceding provisions of this subparagraph, the Secretary 
shall begin implementing the payment modifier estab-
lished under this subsection through the rulemaking 
process during 2013 for the physician fee schedule 
established under subsection (b). 
‘‘(ii) INITIAL PERFORMANCE PERIOD.— 
‘‘(I) IN GENERAL.—The Secretary shall specify 
an initial performance period for application of 
Deadline. 
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124 STAT. 375 
PUBLIC LAW 111–148—MAR. 23, 2010 
the payment modifier established under this sub-
section with respect to 2015. 
‘‘(II) PROVISION OF INFORMATION DURING INI-
TIAL
PERFORMANCE
PERIOD.—During the initial 
performance period, the Secretary shall, to the 
extent practicable, provide information to physi-
cians and groups of physicians about the quality 
of care furnished by the physician or group of 
physicians to individuals enrolled under this part 
compared to cost (as determined under paragraphs 
(2) and (3), respectively) with respect to the 
performance period. 
‘‘(iii) APPLICATION.—The Secretary shall apply the 
payment modifier established under this subsection 
for items and services furnished— 
‘‘(I) beginning on January 1, 2015, with respect 
to specific physicians and groups of physicians the 
Secretary determines appropriate; and 
‘‘(II) beginning not later than January 1, 2017, 
with respect to all physicians and groups of physi-
cians. 
‘‘(C) BUDGET
NEUTRALITY.—The payment modifier 
established under this subsection shall be implemented 
in a budget neutral manner. 
‘‘(5) SYSTEMS-BASED CARE.—The Secretary shall, as appro-
priate, apply the payment modifier established under this sub-
section in a manner that promotes systems-based care. 
‘‘(6) CONSIDERATION OF SPECIAL CIRCUMSTANCES OF CERTAIN 
PROVIDERS.—In applying the payment modifier under this sub-
section, the Secretary shall, as appropriate, take into account 
the special circumstances of physicians or groups of physicians 
in rural areas and other underserved communities. 
‘‘(7) APPLICATION.—For purposes of the initial application 
of the payment modifier established under this subsection 
during the period beginning on January 1, 2015, and ending 
on December 31, 2016, the term ‘physician’ has the meaning 
given such term in section 1861(r). On or after January 1, 
2017, the Secretary may apply this subsection to eligible profes-
sionals (as defined in subsection (k)(3)(B)) as the Secretary 
determines appropriate. 
‘‘(8) DEFINITIONS.—For purposes of this subsection: 
‘‘(A) COSTS.—The term ‘costs’ means expenditures per 
individual as determined appropriate by the Secretary. In 
making the determination under the preceding sentence, 
the Secretary may take into account the amount of growth 
in expenditures per individual for a physician compared 
to the amount of such growth for other physicians. 
‘‘(B) PERFORMANCE
PERIOD.—The term ‘performance 
period’ means a period specified by the Secretary. 
‘‘(9) COORDINATION WITH OTHER VALUE-BASED PURCHASING 
REFORMS.—The Secretary shall coordinate the value-based pay-
ment modifier established under this subsection with the Physi-
cian Feedback Program under subsection (n) and, as the Sec-
retary determines appropriate, other similar provisions of this 
title. 
Determination. 
Effective date. 
Determination. 
Time period. 
Applicability. 
Deadline. 
Effective date. 
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124 STAT. 376 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(10) LIMITATIONS ON REVIEW.—There shall be no adminis-
trative or judicial review under section 1869, section 1878, 
or otherwise of— 
‘‘(A) the establishment of the value-based payment 
modifier under this subsection; 
‘‘(B) the evaluation of quality of care under paragraph 
(2), including the establishment of appropriate measures 
of the quality of care under paragraph (2)(B); 
‘‘(C) the evaluation of costs under paragraph (3), 
including the establishment of appropriate measures of 
costs under such paragraph; 
‘‘(D) the dates for implementation of the value-based 
payment modifier; 
‘‘(E) the specification of the initial performance period 
and any other performance period under paragraphs 
(4)(B)(ii) and (8)(B), respectively; 
‘‘(F) the application of the value-based payment modi-
fier under paragraph (7); and 
‘‘(G) the determination of costs under paragraph 
(8)(A).’’. 
SEC. 3008. PAYMENT ADJUSTMENT FOR CONDITIONS ACQUIRED IN 
HOSPITALS. 
(a) IN GENERAL.—Section 1886 of the Social Security Act (42 
U.S.C. 1395ww), as amended by section 3001, is amended by adding 
at the end the following new subsection: 
‘‘(p) ADJUSTMENT
TO
HOSPITAL
PAYMENTS
FOR
HOSPITAL 
ACQUIRED CONDITIONS.— 
‘‘(1) IN
GENERAL.—In order to provide an incentive for 
applicable hospitals to reduce hospital acquired conditions 
under this title, with respect to discharges from an applicable 
hospital occurring during fiscal year 2015 or a subsequent 
fiscal year, the amount of payment under this section or section 
1814(b)(3), as applicable, for such discharges during the fiscal 
year shall be equal to 99 percent of the amount of payment 
that would otherwise apply to such discharges under this sec-
tion or section 1814(b)(3) (determined after the application of 
subsections (o) and (q) and section 1814(l)(4) but without regard 
to this subsection). 
‘‘(2) APPLICABLE HOSPITALS.— 
‘‘(A) IN GENERAL.—For purposes of this subsection, the 
term ‘applicable hospital’ means a subsection (d) hospital 
that meets the criteria described in subparagraph (B). 
‘‘(B) CRITERIA DESCRIBED.— 
‘‘(i) IN GENERAL.—The criteria described in this 
subparagraph, with respect to a subsection (d) hospital, 
is that the subsection (d) hospital is in the top quartile 
of all subsection (d) hospitals, relative to the national 
average, of hospital acquired conditions during the 
applicable period, as determined by the Secretary. 
‘‘(ii) RISK ADJUSTMENT.—In carrying out clause (i), 
the Secretary shall establish and apply an appropriate 
risk adjustment methodology. 
‘‘(C) EXEMPTION.—In the case of a hospital that is 
paid under section 1814(b)(3), the Secretary may exempt 
such hospital from the application of this subsection if 
the State which is paid under such section submits an 
Deadline. 
Reports. 
Determination. 
Definition. 
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124 STAT. 377 
PUBLIC LAW 111–148—MAR. 23, 2010 
annual report to the Secretary describing how a similar 
program in the State for a participating hospital or hos-
pitals achieves or surpasses the measured results in terms 
of patient health outcomes and cost savings established 
under this subsection. 
‘‘(3) HOSPITAL ACQUIRED CONDITIONS.—For purposes of this 
subsection, the term ‘hospital acquired condition’ means a condi-
tion identified for purposes of subsection (d)(4)(D)(iv) and any 
other condition determined appropriate by the Secretary that 
an individual acquires during a stay in an applicable hospital, 
as determined by the Secretary. 
‘‘(4) APPLICABLE
PERIOD.—In this subsection, the term 
‘applicable period’ means, with respect to a fiscal year, a period 
specified by the Secretary. 
‘‘(5) REPORTING TO HOSPITALS.—Prior to fiscal year 2015 
and each subsequent fiscal year, the Secretary shall provide 
confidential reports to applicable hospitals with respect to hos-
pital acquired conditions of the applicable hospital during the 
applicable period. 
‘‘(6) REPORTING HOSPITAL SPECIFIC INFORMATION.— 
‘‘(A) IN GENERAL.—The Secretary shall make informa-
tion available to the public regarding hospital acquired 
conditions of each applicable hospital. 
‘‘(B) OPPORTUNITY
TO
REVIEW
AND
SUBMIT
CORREC-
TIONS.—The Secretary shall ensure that an applicable hos-
pital has the opportunity to review, and submit corrections 
for, the information to be made public with respect to 
the hospital under subparagraph (A) prior to such informa-
tion being made public. 
‘‘(C) WEBSITE.—Such information shall be posted on 
the Hospital Compare Internet website in an easily under-
standable format. 
‘‘(7) LIMITATIONS ON REVIEW.—There shall be no adminis-
trative or judicial review under section 1869, section 1878, 
or otherwise of the following: 
‘‘(A) The criteria described in paragraph (2)(A). 
‘‘(B) The specification of hospital acquired conditions 
under paragraph (3). 
‘‘(C) The specification of the applicable period under 
paragraph (4). 
‘‘(D) The provision of reports to applicable hospitals 
under paragraph (5) and the information made available 
to the public under paragraph (6).’’. 
(b) STUDY
AND
REPORT
ON
EXPANSION
OF
HEALTHCARE 
ACQUIRED CONDITIONS POLICY TO OTHER PROVIDERS.— 
(1) STUDY.—The Secretary of Health and Human Services 
shall conduct a study on expanding the healthcare acquired 
conditions policy under subsection (d)(4)(D) of section 1886 
of the Social Security Act (42 U.S.C. 1395ww) to payments 
made to other facilities under the Medicare program under 
title XVIII of the Social Security Act, including such payments 
made to inpatient rehabilitation facilities, long-term care hos-
pitals (as described in subsection(d)(1)(B)(iv) of such section), 
hospital outpatient departments, and other hospitals excluded 
from the inpatient prospective payment system under such 
section, skilled nursing facilities, ambulatory surgical centers, 
and health clinics. Such study shall include an analysis of 
Public 
information. 
Definition. 
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124 STAT. 378 
PUBLIC LAW 111–148—MAR. 23, 2010 
how such policies could impact quality of patient care, patient 
safety, and spending under the Medicare program. 
(2) REPORT.—Not later than January 1, 2012, the Secretary 
shall submit to Congress a report containing the results of 
the study conducted under paragraph (1), together with rec-
ommendations for such legislation and administrative action 
as the Secretary determines appropriate. 
PART II—NATIONAL STRATEGY TO IMPROVE 
HEALTH CARE QUALITY 
SEC. 3011. NATIONAL STRATEGY. 
Title III of the Public Health Service Act (42 U.S.C. 241 et 
seq.) is amended by adding at the end the following: 
‘‘PART S—HEALTH CARE QUALITY PROGRAMS 
‘‘Subpart I—National Strategy for Quality 
Improvement in Health Care 
‘‘SEC. 399HH. NATIONAL STRATEGY FOR QUALITY IMPROVEMENT IN 
HEALTH CARE. 
‘‘(a) ESTABLISHMENT OF NATIONAL STRATEGY AND PRIORITIES.— 
‘‘(1) NATIONAL STRATEGY.—The Secretary, through a trans-
parent collaborative process, shall establish a national strategy 
to improve the delivery of health care services, patient health 
outcomes, and population health. 
‘‘(2) IDENTIFICATION OF PRIORITIES.— 
‘‘(A) 
IN
GENERAL.—The 
Secretary 
shall 
identify 
national priorities for improvement in developing the 
strategy under paragraph (1). 
‘‘(B) REQUIREMENTS.—The Secretary shall ensure that 
priorities identified under subparagraph (A) will— 
‘‘(i) have the greatest potential for improving the 
health outcomes, efficiency, and patient-centeredness 
of health care for all populations, including children 
and vulnerable populations; 
‘‘(ii) identify areas in the delivery of health care 
services that have the potential for rapid improvement 
in the quality and efficiency of patient care; 
‘‘(iii) address gaps in quality, efficiency, compara-
tive effectiveness information, and health outcomes 
measures and data aggregation techniques; 
‘‘(iv) improve Federal payment policy to emphasize 
quality and efficiency; 
‘‘(v) enhance the use of health care data to improve 
quality, efficiency, transparency, and outcomes; 
‘‘(vi) address the health care provided to patients 
with high-cost chronic diseases; 
‘‘(vii) improve research and dissemination of strate-
gies and best practices to improve patient safety and 
reduce medical errors, preventable admissions and re-
admissions, and health care-associated infections; 
‘‘(viii) reduce health disparities across health dis-
parity populations (as defined in section 485E) and 
geographic areas; and 
42 USC 280j. 
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124 STAT. 379 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(ix) address other areas as determined appro-
priate by the Secretary. 
‘‘(C) CONSIDERATIONS.—In identifying priorities under 
subparagraph (A), the Secretary shall take into consider-
ation the recommendations submitted by the entity with 
a contract under section 1890(a) of the Social Security 
Act and other stakeholders. 
‘‘(D) COORDINATION WITH STATE AGENCIES.—The Sec-
retary shall collaborate, coordinate, and consult with State 
agencies responsible for administering the Medicaid pro-
gram under title XIX of the Social Security Act and the 
Children’s Health Insurance Program under title XXI of 
such Act with respect to developing and disseminating 
strategies, goals, models, and timetables that are consistent 
with the national priorities identified under subparagraph 
(A). 
‘‘(b) STRATEGIC PLAN.— 
‘‘(1) IN GENERAL.—The national strategy shall include a 
comprehensive strategic plan to achieve the priorities described 
in subsection (a). 
‘‘(2) REQUIREMENTS.—The strategic plan shall include 
provisions for addressing, at a minimum, the following: 
‘‘(A) Coordination among agencies within the Depart-
ment, which shall include steps to minimize duplication 
of efforts and utilization of common quality measures, 
where available. Such common quality measures shall be 
measures identified by the Secretary under section 1139A 
or 1139B of the Social Security Act or endorsed under 
section 1890 of such Act. 
‘‘(B) Agency-specific strategic plans to achieve national 
priorities. 
‘‘(C) Establishment of annual benchmarks for each rel-
evant agency to achieve national priorities. 
‘‘(D) A process for regular reporting by the agencies 
to the Secretary on the implementation of the strategic 
plan. 
‘‘(E) Strategies to align public and private payers with 
regard to quality and patient safety efforts. 
‘‘(F) Incorporating quality improvement and measure-
ment in the strategic plan for health information technology 
required by the American Recovery and Reinvestment Act 
of 2009 (Public Law 111–5). 
‘‘(c) PERIODIC UPDATE OF NATIONAL STRATEGY.—The Secretary 
shall update the national strategy not less than annually. Any 
such update shall include a review of short- and long-term goals. 
‘‘(d) SUBMISSION AND AVAILABILITY OF NATIONAL STRATEGY AND 
UPDATES.— 
‘‘(1) DEADLINE
FOR
INITIAL
SUBMISSION
OF
NATIONAL 
STRATEGY.—Not later than January 1, 2011, the Secretary shall 
submit to the relevant committees of Congress the national 
strategy described in subsection (a). 
‘‘(2) UPDATES.— 
‘‘(A) IN GENERAL.—The Secretary shall submit to the 
relevant committees of Congress an annual update to the 
strategy described in paragraph (1). 
‘‘(B) INFORMATION SUBMITTED.—Each update submitted 
under subparagraph (A) shall include— 
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124 STAT. 380 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) a review of the short- and long-term goals 
of the national strategy and any gaps in such strategy; 
‘‘(ii) an analysis of the progress, or lack of progress, 
in meeting such goals and any barriers to such 
progress; 
‘‘(iii) the information reported under section 1139A 
of the Social Security Act, consistent with the reporting 
requirements of such section; and 
‘‘(iv) in the case of an update required to be sub-
mitted on or after January 1, 2014, the information 
reported under section 1139B(b)(4) of the Social Secu-
rity Act, consistent with the reporting requirements 
of such section. 
‘‘(C) SATISFACTION
OF
OTHER
REPORTING
REQUIRE-
MENTS.—Compliance with the requirements of clauses (iii) 
and (iv) of subparagraph (B) shall satisfy the reporting 
requirements under sections 1139A(a)(6) and 1139B(b)(4), 
respectively, of the Social Security Act. 
‘‘(e) HEALTH CARE QUALITY INTERNET WEBSITE.—Not later than 
January 1, 2011, the Secretary shall create an Internet website 
to make public information regarding— 
‘‘(1) the national priorities for health care quality improve-
ment established under subsection (a)(2); 
‘‘(2) the agency-specific strategic plans for health care 
quality described in subsection (b)(2)(B); and 
‘‘(3) other information, as the Secretary determines to be 
appropriate.’’. 
SEC. 3012. INTERAGENCY WORKING GROUP ON HEALTH CARE 
QUALITY. 
(a) IN GENERAL.—The President shall convene a working group 
to be known as the Interagency Working Group on Health Care 
Quality (referred to in this section as the ‘‘Working Group’’). 
(b) GOALS.—The goals of the Working Group shall be to achieve 
the following: 
(1) Collaboration, cooperation, and consultation between 
Federal departments and agencies with respect to developing 
and disseminating strategies, goals, models, and timetables 
that are consistent with the national priorities identified under 
section 399HH(a)(2) of the Public Health Service Act (as added 
by section 3011). 
(2) Avoidance of inefficient duplication of quality improve-
ment efforts and resources, where practicable, and a stream-
lined process for quality reporting and compliance require-
ments. 
(3) Assess alignment of quality efforts in the public sector 
with private sector initiatives. 
(c) COMPOSITION.— 
(1) IN GENERAL.—The Working Group shall be composed 
of senior level representatives of— 
(A) the Department of Health and Human Services; 
(B) the Centers for Medicare & Medicaid Services; 
(C) the National Institutes of Health; 
(D) the Centers for Disease Control and Prevention; 
(E) the Food and Drug Administration; 
(F) the Health Resources and Services Administration; 
(G) the Agency for Healthcare Research and Quality; 
President. 
Establishment. 
42 USC 280j 
note. 
Deadline. 
Public 
information. 
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124 STAT. 381 
PUBLIC LAW 111–148—MAR. 23, 2010 
(H) the Office of the National Coordinator for Health 
Information Technology; 
(I) the Substance Abuse and Mental Health Services 
Administration; 
(J) the Administration for Children and Families; 
(K) the Department of Commerce; 
(L) the Office of Management and Budget; 
(M) the United States Coast Guard; 
(N) the Federal Bureau of Prisons; 
(O) the National Highway Traffic Safety Administra-
tion; 
(P) the Federal Trade Commission; 
(Q) the Social Security Administration; 
(R) the Department of Labor; 
(S) the United States Office of Personnel Management; 
(T) the Department of Defense; 
(U) the Department of Education; 
(V) the Department of Veterans Affairs; 
(W) the Veterans Health Administration; and 
(X) any other Federal agencies and departments with 
activities relating to improving health care quality and 
safety, as determined by the President. 
(2) CHAIR AND VICE-CHAIR.— 
(A) CHAIR.—The Working Group shall be chaired by 
the Secretary of Health and Human Services. 
(B) VICE CHAIR.—Members of the Working Group, other 
than the Secretary of Health and Human Services, shall 
serve as Vice Chair of the Group on a rotating basis, 
as determined by the Group. 
(d) REPORT TO CONGRESS.—Not later than December 31, 2010, 
and annually thereafter, the Working Group shall submit to the 
relevant Committees of Congress, and make public on an Internet 
website, a report describing the progress and recommendations 
of the Working Group in meeting the goals described in subsection 
(b). 
SEC. 3013. QUALITY MEASURE DEVELOPMENT. 
(a) PUBLIC HEALTH SERVICE ACT.—Title IX of the Public Health 
Service Act (42 U.S.C. 299 et seq.) is amended— 
(1) by redesignating part D as part E; 
(2) by redesignating sections 931 through 938 as sections 
941 through 948, respectively; 
(3) in section 948(1), as so redesignated, by striking ‘‘931’’ 
and inserting ‘‘941’’; and 
(4) by inserting after section 926 the following: 
‘‘PART D—HEALTH CARE QUALITY 
IMPROVEMENT 
‘‘Subpart I—Quality Measure Development 
‘‘SEC. 931. QUALITY MEASURE DEVELOPMENT. 
‘‘(a) QUALITY MEASURE.—In this subpart, the term ‘quality 
measure’ means a standard for measuring the performance and 
improvement of population health or of health plans, providers 
of services, and other clinicians in the delivery of health care 
services. 
Definition. 
42 USC 299b–31. 
42 USC 
299c—299c–7. 
Public 
information. 
Web posting. 
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124 STAT. 382 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(b) IDENTIFICATION OF QUALITY MEASURES.— 
‘‘(1) IDENTIFICATION.—The Secretary, in consultation with 
the Director of the Agency for Healthcare Research and Quality 
and the Administrator of the Centers for Medicare & Medicaid 
Services, shall identify, not less often than triennially, gaps 
where no quality measures exist and existing quality measures 
that need improvement, updating, or expansion, consistent with 
the national strategy under section 399HH, to the extent avail-
able, for use in Federal health programs. In identifying such 
gaps and existing quality measures that need improvement, 
the Secretary shall take into consideration— 
‘‘(A) the gaps identified by the entity with a contract 
under section 1890(a) of the Social Security Act and other 
stakeholders; 
‘‘(B) quality measures identified by the pediatric 
quality measures program under section 1139A of the 
Social Security Act; and 
‘‘(C) quality measures identified through the Medicaid 
Quality Measurement Program under section 1139B of the 
Social Security Act. 
‘‘(2) PUBLICATION.—The Secretary shall make available to 
the public on an Internet website a report on any gaps identified 
under paragraph (1) and the process used to make such identi-
fication. 
‘‘(c) GRANTS OR CONTRACTS FOR QUALITY MEASURE DEVELOP-
MENT.— 
‘‘(1) IN GENERAL.—The Secretary shall award grants, con-
tracts, or intergovernmental agreements to eligible entities for 
purposes of developing, improving, updating, or expanding 
quality measures identified under subsection (b). 
‘‘(2) PRIORITIZATION IN THE DEVELOPMENT OF QUALITY MEAS-
URES.—In awarding grants, contracts, or agreements under 
this subsection, the Secretary shall give priority to the develop-
ment of quality measures that allow the assessment of— 
‘‘(A) health outcomes and functional status of patients; 
‘‘(B) the management and coordination of health care 
across episodes of care and care transitions for patients 
across the continuum of providers, health care settings, 
and health plans; 
‘‘(C) the experience, quality, and use of information 
provided to and used by patients, caregivers, and author-
ized representatives to inform decisionmaking about treat-
ment options, including the use of shared decisionmaking 
tools and preference sensitive care (as defined in section 
936); 
‘‘(D) the meaningful use of health information tech-
nology; 
‘‘(E) the safety, effectiveness, patient-centeredness, 
appropriateness, and timeliness of care; 
‘‘(F) the efficiency of care; 
‘‘(G) the equity of health services and health disparities 
across health disparity populations (as defined in section 
485E) and geographic areas; 
‘‘(H) patient experience and satisfaction; 
‘‘(I) the use of innovative strategies and methodologies 
identified under section 933; and 
Public 
information. 
Web posting. 
Reports. 
Consultation. 
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124 STAT. 383 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(J) other areas determined appropriate by the Sec-
retary. 
‘‘(3) ELIGIBLE ENTITIES.—To be eligible for a grant or con-
tract under this subsection, an entity shall— 
‘‘(A) have demonstrated expertise and capacity in the 
development and evaluation of quality measures; 
‘‘(B) have adopted procedures to include in the quality 
measure development process— 
‘‘(i) the views of those providers or payers whose 
performance will be assessed by the measure; and 
‘‘(ii) the views of other parties who also will use 
the quality measures (such as patients, consumers, 
and health care purchasers); 
‘‘(C) collaborate with the entity with a contract under 
section 1890(a) of the Social Security Act and other stake-
holders, as practicable, and the Secretary so that quality 
measures developed by the eligible entity will meet the 
requirements to be considered for endorsement by the 
entity with a contract under such section 1890(a); 
‘‘(D) have transparent policies regarding governance 
and conflicts of interest; and 
‘‘(E) submit an application to the Secretary at such 
time and in such manner, as the Secretary may require. 
‘‘(4) USE OF FUNDS.—An entity that receives a grant, con-
tract, or agreement under this subsection shall use such award 
to develop quality measures that meet the following require-
ments: 
‘‘(A) Such measures support measures required to be 
reported under the Social Security Act, where applicable, 
and in support of gaps and existing quality measures that 
need improvement, as described in subsection (b)(1)(A). 
‘‘(B) Such measures support measures developed under 
section 1139A of the Social Security Act and the Medicaid 
Quality Measurement Program under section 1139B of such 
Act, where applicable. 
‘‘(C) To the extent practicable, data on such quality 
measures is able to be collected using health information 
technologies. 
‘‘(D) Each quality measure is free of charge to users 
of such measure. 
‘‘(E) Each quality measure is publicly available on an 
Internet website. 
‘‘(d) OTHER ACTIVITIES BY THE SECRETARY.—The Secretary may 
use amounts available under this section to update and test, where 
applicable, quality measures endorsed by the entity with a contract 
under section 1890(a) of the Social Security Act or adopted by 
the Secretary. 
‘‘(e) COORDINATION OF GRANTS.—The Secretary shall ensure 
that grants or contracts awarded under this section are coordinated 
with grants and contracts awarded under sections 1139A(5) and 
1139B(4)(A) of the Social Security Act.’’. 
(b) SOCIAL SECURITY ACT.—Section 1890A of the Social Security 
Act, as added by section 3014(b), is amended by adding at the 
end the following new subsection: 
‘‘(e) DEVELOPMENT OF QUALITY MEASURES.—The Administrator 
of the Center for Medicare & Medicaid Services shall through 
contracts develop quality measures (as determined appropriate by 
Requirements. 
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124 STAT. 384 
PUBLIC LAW 111–148—MAR. 23, 2010 
the Administrator) for use under this Act. In developing such meas-
ures, the Administrator shall consult with the Director of the 
Agency for Healthcare Research and Quality.’’. 
(c) FUNDING.—There are authorized to be appropriated to the 
Secretary of Health and Human Services to carry out this section, 
$75,000,000 for each of fiscal years 2010 through 2014. Of the 
amounts appropriated under the preceding sentence in a fiscal 
year, not less than 50 percent of such amounts shall be used 
pursuant to subsection (e) of section 1890A of the Social Security 
Act, as added by subsection (b), with respect to programs under 
such Act. Amounts appropriated under this subsection for a fiscal 
year shall remain available until expended. 
SEC. 3014. QUALITY MEASUREMENT. 
(a) NEW DUTIES FOR CONSENSUS-BASED ENTITY.— 
(1) MULTI-STAKEHOLDER GROUP INPUT.—Section 1890(b) of 
the Social Security Act (42 U.S.C. 1395aaa(b)), as amended 
by section 3003, is amended by adding at the end the following 
new paragraphs: 
‘‘(7) CONVENING MULTI-STAKEHOLDER GROUPS.— 
‘‘(A) IN
GENERAL.—The entity shall convene multi- 
stakeholder groups to provide input on— 
‘‘(i) the selection of quality measures described in 
subparagraph (B), from among— 
‘‘(I) such measures that have been endorsed 
by the entity; and 
‘‘(II) such measures that have not been consid-
ered for endorsement by such entity but are used 
or proposed to be used by the Secretary for the 
collection or reporting of quality measures; and 
‘‘(ii) national priorities (as identified under section 
399HH of the Public Health Service Act) for improve-
ment in population health and in the delivery of health 
care services for consideration under the national 
strategy established under section 399HH of the Public 
Health Service Act. 
‘‘(B) QUALITY MEASURES.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), the quality 
measures described in this subparagraph are quality 
measures— 
‘‘(I) for use pursuant to sections 1814(i)(5)(D), 
1833(i)(7), 1833(t)(17), 1848(k)(2)(C), 1866(k)(3), 
1881(h)(2)(A)(iii), 1886(b)(3)(B)(viii), 1886(j)(7)(D), 
1886(m)(5)(D), 1886(o)(2), and 1895(b)(3)(B)(v); 
‘‘(II) for use in reporting performance informa-
tion to the public; and 
‘‘(III) for use in health care programs other 
than for use under this Act. 
‘‘(ii) EXCLUSION.—Data sets (such as the outcome 
and assessment information set for home health serv-
ices and the minimum data set for skilled nursing 
facility services) that are used for purposes of classifica-
tion systems used in establishing payment rates under 
this title shall not be quality measures described in 
this subparagraph. 
‘‘(C) REQUIREMENT FOR TRANSPARENCY IN PROCESS.— 
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124 STAT. 385 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) IN GENERAL.—In convening multi-stakeholder 
groups under subparagraph (A) with respect to the 
selection of quality measures, the entity shall provide 
for an open and transparent process for the activities 
conducted pursuant to such convening. 
‘‘(ii) SELECTION OF ORGANIZATIONS PARTICIPATING 
IN
MULTI-STAKEHOLDER
GROUPS.—The 
process 
described in clause (i) shall ensure that the selection 
of representatives comprising such groups provides for 
public nominations for, and the opportunity for public 
comment on, such selection. 
‘‘(D) MULTI-STAKEHOLDER
GROUP
DEFINED.—In this 
paragraph, the term ‘multi-stakeholder group’ means, with 
respect to a quality measure, a voluntary collaborative 
of organizations representing a broad group of stakeholders 
interested in or affected by the use of such quality measure. 
‘‘(8) TRANSMISSION
OF
MULTI-STAKEHOLDER
INPUT.—Not 
later than February 1 of each year (beginning with 2012), 
the entity shall transmit to the Secretary the input of multi- 
stakeholder groups provided under paragraph (7).’’. 
(2) ANNUAL REPORT.—Section 1890(b)(5)(A) of the Social 
Security Act (42 U.S.C. 1395aaa(b)(5)(A)) is amended— 
(A) in clause (ii), by striking ‘‘and’’ at the end; 
(B) in clause (iii), by striking the period at the end 
and inserting a semicolon; and 
(C) by adding at the end the following new clauses: 
‘‘(iv) gaps in endorsed quality measures, which 
shall include measures that are within priority areas 
identified by the Secretary under the national strategy 
established under section 399HH of the Public Health 
Service Act, and where quality measures are unavail-
able or inadequate to identify or address such gaps; 
‘‘(v) areas in which evidence is insufficient to sup-
port endorsement of quality measures in priority areas 
identified by the Secretary under the national strategy 
established under section 399HH of the Public Health 
Service Act and where targeted research may address 
such gaps; and 
‘‘(vi) the matters described in clauses (i) and (ii) 
of paragraph (7)(A).’’. 
(b) MULTI-STAKEHOLDER GROUP INPUT INTO SELECTION
OF 
QUALITY MEASURES.—Title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.) is amended by inserting after section 1890 
the following: 
‘‘QUALITY MEASUREMENT 
‘‘SEC. 1890A. (a) MULTI-STAKEHOLDER
GROUP
INPUT
INTO 
SELECTION OF QUALITY MEASURES.—The Secretary shall establish 
a pre-rulemaking process under which the following steps occur 
with respect to the selection of quality measures described in section 
1890(b)(7)(B): 
‘‘(1) INPUT.—Pursuant to section 1890(b)(7), the entity with 
a contract under section 1890 shall convene multi-stakeholder 
groups to provide input to the Secretary on the selection of 
quality measures described in subparagraph (B) of such para-
graph. 
Regulations. 
Deadlines. 
42 USC 
1395aaa–1. 
Deadline. 
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124 STAT. 386 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) PUBLIC AVAILABILITY OF MEASURES CONSIDERED FOR 
SELECTION.—Not later than December 1 of each year (beginning 
with 2011), the Secretary shall make available to the public 
a list of quality measures described in section 1890(b)(7)(B) 
that the Secretary is considering under this title. 
‘‘(3) TRANSMISSION OF MULTI-STAKEHOLDER INPUT.—Pursu-
ant to section 1890(b)(8), not later than February 1 of each 
year (beginning with 2012), the entity shall transmit to the 
Secretary the input of multi-stakeholder groups described in 
paragraph (1). 
‘‘(4) CONSIDERATION OF MULTI-STAKEHOLDER INPUT.—The 
Secretary shall take into consideration the input from multi- 
stakeholder groups described in paragraph (1) in selecting 
quality measures described in section 1890(b)(7)(B) that have 
been endorsed by the entity with a contract under section 
1890 and measures that have not been endorsed by such entity. 
‘‘(5) RATIONALE FOR USE OF QUALITY MEASURES.—The Sec-
retary shall publish in the Federal Register the rationale for 
the use of any quality measure described in section 
1890(b)(7)(B) that has not been endorsed by the entity with 
a contract under section 1890. 
‘‘(6) ASSESSMENT
OF
IMPACT.—Not later than March 1, 
2012, and at least once every three years thereafter, the Sec-
retary shall— 
‘‘(A) conduct an assessment of the quality impact of 
the use of endorsed measures described in section 
1890(b)(7)(B); and 
‘‘(B) make such assessment available to the public. 
‘‘(b) PROCESS FOR DISSEMINATION OF MEASURES USED BY THE 
SECRETARY.— 
‘‘(1) IN GENERAL.—The Secretary shall establish a process 
for disseminating quality measures used by the Secretary. Such 
process shall include the following: 
‘‘(A) The incorporation of such measures, where 
applicable, in workforce programs, training curricula, and 
any other means of dissemination determined appropriate 
by the Secretary. 
‘‘(B) The dissemination of such quality measures 
through the national strategy developed under section 
399HH of the Public Health Service Act. 
‘‘(2) EXISTING
METHODS.—To the extent practicable, the 
Secretary shall utilize and expand existing dissemination 
methods in disseminating quality measures under the process 
established under paragraph (1). 
‘‘(c) REVIEW OF QUALITY MEASURES USED BY THE SECRETARY.— 
‘‘(1) IN GENERAL.—The Secretary shall— 
‘‘(A) periodically (but in no case less often than once 
every 3 years) review quality measures described in section 
1890(b)(7)(B); and 
‘‘(B) with respect to each such measure, determine 
whether to— 
‘‘(i) maintain the use of such measure; or 
‘‘(ii) phase out such measure. 
‘‘(2) CONSIDERATIONS.—In conducting the review under 
paragraph (1), the Secretary shall take steps to— 
‘‘(A) seek to avoid duplication of measures used; and 
Public 
information. 
Federal Register, 
publication. 
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124 STAT. 387 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) take into consideration current innovative meth-
odologies and strategies for quality improvement practices 
in the delivery of health care services that represent best 
practices for such quality improvement and measures 
endorsed by the entity with a contract under section 1890 
since the previous review by the Secretary. 
‘‘(d) RULE OF CONSTRUCTION.—Nothing in this section shall 
preclude a State from using the quality measures identified under 
sections 1139A and 1139B.’’. 
(c) FUNDING.—For purposes of carrying out the amendments 
made by this section, the Secretary shall provide 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 under section 1841 
of such Act (42 U.S.C. 1395t), in such proportion as the Secretary 
determines appropriate, of $20,000,000, to the Centers for Medicare 
& Medicaid Services Program Management Account for each of 
fiscal years 2010 through 2014. Amounts transferred under the 
preceding sentence shall remain available until expended. 
SEC. 3015. DATA COLLECTION; PUBLIC REPORTING. 
Title III of the Public Health Service Act (42 U.S.C. 241 et 
seq.), as amended by section 3011, is further amended by adding 
at the end the following: 
‘‘SEC. 399II. COLLECTION AND ANALYSIS OF DATA FOR QUALITY AND 
RESOURCE USE MEASURES. 
‘‘(a) IN GENERAL.—The Secretary shall collect and aggregate 
consistent data on quality and resource use measures from informa-
tion systems used to support health care delivery to implement 
the public reporting of performance information, as described in 
section 399JJ, and may award grants or contracts for this purpose. 
The Secretary shall ensure that such collection, aggregation, and 
analysis systems span an increasingly broad range of patient popu-
lations, providers, and geographic areas over time. 
‘‘(b) GRANTS OR CONTRACTS FOR DATA COLLECTION.— 
‘‘(1) IN GENERAL.—The Secretary may award grants or con-
tracts to eligible entities to support new, or improve existing, 
efforts to collect and aggregate quality and resource use meas-
ures described under subsection (c). 
‘‘(2) ELIGIBLE ENTITIES.—To be eligible for a grant or con-
tract under this subsection, an entity shall— 
‘‘(A) be— 
‘‘(i) a multi-stakeholder entity that coordinates the 
development of methods and implementation plans for 
the consistent reporting of summary quality and cost 
information; 
‘‘(ii) an entity capable of submitting such summary 
data for a particular population and providers, such 
as a disease registry, regional collaboration, health 
plan collaboration, or other population-wide source; or 
‘‘(iii) a Federal Indian Health Service program or 
a health program operated by an Indian tribe (as 
defined in section 4 of the Indian Health Care Improve-
ment Act); 
‘‘(B) promote the use of the systems that provide data 
to improve and coordinate patient care; 
42 USC 280j–1. 
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124 STAT. 388 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(C) support the provision of timely, consistent quality 
and resource use information to health care providers, and 
other groups and organizations as appropriate, with an 
opportunity for providers to correct inaccurate measures; 
and 
‘‘(D) agree to report, as determined by the Secretary, 
measures on quality and resource use to the public in 
accordance with the public reporting process established 
under section 399JJ. 
‘‘(c) CONSISTENT
DATA
AGGREGATION.—The Secretary may 
award grants or contracts under this section only to entities that 
enable summary data that can be integrated and compared across 
multiple sources. The Secretary shall provide standards for the 
protection of the security and privacy of patient data. 
‘‘(d) MATCHING FUNDS.—The Secretary may not award a grant 
or contract under this section to an entity unless the entity agrees 
that it will make available (directly or through contributions from 
other public or private entities) non-Federal contributions toward 
the activities to be carried out under the grant or contract in 
an amount equal to $1 for each $5 of Federal funds provided 
under the grant or contract. Such non-Federal matching funds 
may be provided directly or through donations from public or private 
entities and may be in cash or in-kind, fairly evaluated, including 
plant, equipment, or services. 
‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—To carry out this sec-
tion, there are authorized to be appropriated such sums as may 
be necessary for fiscal years 2010 through 2014. 
‘‘SEC. 399JJ. PUBLIC REPORTING OF PERFORMANCE INFORMATION. 
‘‘(a) DEVELOPMENT OF PERFORMANCE WEBSITES.—The Secretary 
shall make available to the public, through standardized Internet 
websites, performance information summarizing data on quality 
measures. Such information shall be tailored to respond to the 
differing needs of hospitals and other institutional health care pro-
viders, physicians and other clinicians, patients, consumers, 
researchers, policymakers, States, and other stakeholders, as the 
Secretary may specify. 
‘‘(b) INFORMATION ON CONDITIONS.—The performance informa-
tion made publicly available on an Internet website, as described 
in subsection (a), shall include information regarding clinical condi-
tions to the extent such information is available, and the informa-
tion shall, where appropriate, be provider-specific and sufficiently 
disaggregated and specific to meet the needs of patients with dif-
ferent clinical conditions. 
‘‘(c) CONSULTATION.— 
‘‘(1) IN GENERAL.—In carrying out this section, the Sec-
retary shall consult with the entity with a contract under 
section 1890(a) of the Social Security Act, and other entities, 
as appropriate, to determine the type of information that is 
useful to stakeholders and the format that best facilitates use 
of the reports and of performance reporting Internet websites. 
‘‘(2) CONSULTATION WITH STAKEHOLDERS.—The entity with 
a contract under section 1890(a) of the Social Security Act 
shall convene multi-stakeholder groups, as described in such 
section, to review the design and format of each Internet 
website made available under subsection (a) and shall transmit 
Web posting. 
42 USC 280j–2. 
Standards. 
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124 STAT. 389 
PUBLIC LAW 111–148—MAR. 23, 2010 
to the Secretary the views of such multi-stakeholder groups 
with respect to each such design and format. 
‘‘(d) COORDINATION.—Where appropriate, the Secretary shall 
coordinate the manner in which data are presented through Internet 
websites described in subsection (a) and for public reporting of 
other quality measures by the Secretary, including such quality 
measures under title XVIII of the Social Security Act. 
‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—To carry out this sec-
tion, there are authorized to be appropriated such sums as may 
be necessary for fiscal years 2010 through 2014.’’. 
PART III—ENCOURAGING DEVELOPMENT OF 
NEW PATIENT CARE MODELS 
SEC. 3021. ESTABLISHMENT OF CENTER FOR MEDICARE AND MED-
ICAID INNOVATION WITHIN CMS. 
(a) IN GENERAL.—Title XI of the Social Security Act is amended 
by inserting after section 1115 the following new section: 
‘‘CENTER FOR MEDICARE AND MEDICAID INNOVATION 
‘‘SEC. 1115A. (a) CENTER FOR MEDICARE AND MEDICAID INNOVA-
TION ESTABLISHED.— 
‘‘(1) IN GENERAL.—There is created within the Centers for 
Medicare & Medicaid Services a Center for Medicare and Med-
icaid Innovation (in this section referred to as the ‘CMI’) to 
carry out the duties described in this section. The purpose 
of the CMI is to test innovative payment and service delivery 
models to reduce program expenditures under the applicable 
titles while preserving or enhancing the quality of care fur-
nished to individuals under such titles. In selecting such 
models, the Secretary shall give preference to models that 
also improve the coordination, quality, and efficiency of health 
care services furnished to applicable individuals defined in 
paragraph (4)(A). 
‘‘(2) DEADLINE.—The Secretary shall ensure that the CMI 
is carrying out the duties described in this section by not 
later than January 1, 2011. 
‘‘(3) CONSULTATION.—In carrying out the duties under this 
section, the CMI shall consult representatives of relevant Fed-
eral agencies, and clinical and analytical experts with expertise 
in medicine and health care management. The CMI shall use 
open door forums or other mechanisms to seek input from 
interested parties. 
‘‘(4) DEFINITIONS.—In this section: 
‘‘(A) APPLICABLE
INDIVIDUAL.—The term ‘applicable 
individual’ means— 
‘‘(i) an individual who is entitled to, or enrolled 
for, benefits under part A of title XVIII or enrolled 
for benefits under part B of such title; 
‘‘(ii) an individual who is eligible for medical assist-
ance under title XIX, under a State plan or waiver; 
or 
‘‘(iii) an individual who meets the criteria of both 
clauses (i) and (ii). 
‘‘(B) APPLICABLE
TITLE.—The term ‘applicable title’ 
means title XVIII, title XIX, or both. 
42 USC 1315a. 
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124 STAT. 390 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(b) TESTING OF MODELS (PHASE I).— 
‘‘(1) IN GENERAL.—The CMI shall test payment and service 
delivery models in accordance with selection criteria under 
paragraph (2) to determine the effect of applying such models 
under the applicable title (as defined in subsection (a)(4)(B)) 
on program expenditures under such titles and the quality 
of care received by individuals receiving benefits under such 
title. 
‘‘(2) SELECTION OF MODELS TO BE TESTED.— 
‘‘(A) IN GENERAL.—The Secretary shall select models 
to be tested from models where the Secretary determines 
that there is evidence that the model addresses a defined 
population for which there are deficits in care leading 
to poor clinical outcomes or potentially avoidable expendi-
tures. The models selected under the preceding sentence 
may include the models described in subparagraph (B). 
‘‘(B) OPPORTUNITIES.—The models described in this 
subparagraph are the following models: 
‘‘(i) Promoting broad payment and practice reform 
in primary care, including patient-centered medical 
home models for high-need applicable individuals, med-
ical homes that address women’s unique health care 
needs, and models that transition primary care prac-
tices away from fee-for-service based reimbursement 
and toward comprehensive payment or salary-based 
payment. 
‘‘(ii) Contracting directly with groups of providers 
of services and suppliers to promote innovative care 
delivery models, such as through risk-based com-
prehensive payment or salary-based payment. 
‘‘(iii) Utilizing geriatric assessments and com-
prehensive care plans to coordinate the care (including 
through interdisciplinary teams) of applicable individ-
uals with multiple chronic conditions and at least one 
of the following: 
‘‘(I) An inability to perform 2 or more activities 
of daily living. 
‘‘(II) 
Cognitive 
impairment, 
including 
dementia. 
‘‘(iv) Promote care coordination between providers 
of services and suppliers that transition health care 
providers away from fee-for-service based reimburse-
ment and toward salary-based payment. 
‘‘(v) Supporting care coordination for chronically- 
ill applicable individuals at high risk of hospitalization 
through a health information technology-enabled pro-
vider network that includes care coordinators, a chronic 
disease registry, and home tele-health technology. 
‘‘(vi) Varying payment to physicians who order 
advanced diagnostic imaging services (as defined in 
section 1834(e)(1)(B)) according to the physician’s 
adherence to appropriateness criteria for the ordering 
of such services, as determined in consultation with 
physician specialty groups and other relevant stake-
holders. 
Determination. 
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124 STAT. 391 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(vii) Utilizing medication therapy management 
services, such as those described in section 935 of 
the Public Health Service Act. 
‘‘(viii) Establishing community-based health teams 
to support small-practice medical homes by assisting 
the primary care practitioner in chronic care manage-
ment, including patient self-management, activities. 
‘‘(ix) Assisting applicable individuals in making 
informed health care choices by paying providers of 
services and suppliers for using patient decision-sup-
port tools, including tools that meet the standards 
developed and identified under section 936(c)(2)(A) of 
the Public Health Service Act, that improve applicable 
individual and caregiver understanding of medical 
treatment options. 
‘‘(x) Allowing States to test and evaluate fully inte-
grating care for dual eligible individuals in the State, 
including the management and oversight of all funds 
under the applicable titles with respect to such individ-
uals. 
‘‘(xi) Allowing States to test and evaluate systems 
of all-payer payment reform for the medical care of 
residents of the State, including dual eligible individ-
uals. 
‘‘(xii) Aligning nationally recognized, evidence- 
based guidelines of cancer care with payment incen-
tives under title XVIII in the areas of treatment plan-
ning and follow-up care planning for applicable individ-
uals described in clause (i) or (iii) of subsection (a)(4)(A) 
with cancer, including the identification of gaps in 
applicable quality measures. 
‘‘(xiii) Improving post-acute care through con-
tinuing care hospitals that offer inpatient rehabilita-
tion, long-term care hospitals, and home health or 
skilled nursing care during an inpatient stay and the 
30 days immediately following discharge. 
‘‘(xiv) Funding home health providers who offer 
chronic care management services to applicable 
individuals in cooperation with interdisciplinary teams. 
‘‘(xv) Promoting improved quality and reduced cost 
by developing a collaborative of high-quality, low-cost 
health care institutions that is responsible for— 
‘‘(I) developing, documenting, and dissemi-
nating best practices and proven care methods; 
‘‘(II) implementing such best practices and 
proven care methods within such institutions to 
demonstrate further improvements in quality and 
efficiency; and 
‘‘(III) providing assistance to other health care 
institutions on how best to employ such best prac-
tices and proven care methods to improve health 
care quality and lower costs. 
‘‘(xvi) Facilitate inpatient care, including intensive 
care, of hospitalized applicable individuals at their local 
hospital through the use of electronic monitoring by 
specialists, including intensivists and critical care 
specialists, based at integrated health systems. 
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124 STAT. 392 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(xvii) Promoting greater efficiencies and timely 
access to outpatient services (such as outpatient phys-
ical therapy services) through models that do not 
require a physician or other health professional to 
refer the service or be involved in establishing the 
plan of care for the service, when such service is fur-
nished by a health professional who has the authority 
to furnish the service under existing State law. 
‘‘(xviii) Establishing comprehensive payments to 
Healthcare Innovation Zones, consisting of groups of 
providers that include a teaching hospital, physicians, 
and other clinical entities, that, through their struc-
ture, operations, and joint-activity deliver a full spec-
trum of integrated and comprehensive health care serv-
ices to applicable individuals while also incorporating 
innovative methods for the clinical training of future 
health care professionals. 
‘‘(C) ADDITIONAL
FACTORS
FOR
CONSIDERATION.—In 
selecting models for testing under subparagraph (A), the 
CMI may consider the following additional factors: 
‘‘(i) Whether the model includes a regular process 
for monitoring and updating patient care plans in a 
manner that is consistent with the needs and pref-
erences of applicable individuals. 
‘‘(ii) Whether the model places the applicable indi-
vidual, including family members and other informal 
caregivers of the applicable individual, at the center 
of the care team of the applicable individual. 
‘‘(iii) Whether the model provides for in-person 
contact with applicable individuals. 
‘‘(iv) Whether the model utilizes technology, such 
as electronic health records and patient-based remote 
monitoring systems, to coordinate care over time and 
across settings. 
‘‘(v) Whether the model provides for the mainte-
nance of a close relationship between care coordinators, 
primary 
care 
practitioners, 
specialist 
physicians, 
community-based organizations, and other providers 
of services and suppliers. 
‘‘(vi) Whether the model relies on a team-based 
approach to interventions, such as comprehensive care 
assessments, care planning, and self-management 
coaching. 
‘‘(vii) Whether, under the model, providers of serv-
ices and suppliers are able to share information with 
patients, caregivers, and other providers of services 
and suppliers on a real time basis. 
‘‘(3) BUDGET NEUTRALITY.— 
‘‘(A) INITIAL PERIOD.—The Secretary shall not require, 
as a condition for testing a model under paragraph (1), 
that the design of such model ensure that such model 
is budget neutral initially with respect to expenditures 
under the applicable title. 
‘‘(B) TERMINATION
OR
MODIFICATION.—The Secretary 
shall terminate or modify the design and implementation 
of a model unless the Secretary determines (and the Chief 
Actuary of the Centers for Medicare & Medicaid Services, 
Determination. 
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124 STAT. 393 
PUBLIC LAW 111–148—MAR. 23, 2010 
with respect to program spending under the applicable 
title, certifies), after testing has begun, that the model 
is expected to— 
‘‘(i) improve the quality of care (as determined 
by the Administrator of the Centers for Medicare & 
Medicaid Services) without increasing spending under 
the applicable title; 
‘‘(ii) reduce spending under the applicable title 
without reducing the quality of care; or 
‘‘(iii) improve the quality of care and reduce 
spending. 
Such termination may occur at any time after such testing 
has begun and before completion of the testing. 
‘‘(4) EVALUATION.— 
‘‘(A) IN
GENERAL.—The Secretary shall conduct an 
evaluation of each model tested under this subsection. Such 
evaluation shall include an analysis of— 
‘‘(i) the quality of care furnished under the model, 
including the measurement of patient-level outcomes 
and patient-centeredness criteria determined appro-
priate by the Secretary; and 
‘‘(ii) the changes in spending under the applicable 
titles by reason of the model. 
‘‘(B) INFORMATION.—The Secretary shall make the 
results of each evaluation under this paragraph available 
to the public in a timely fashion and may establish require-
ments for States and other entities participating in the 
testing of models under this section to collect and report 
information that the Secretary determines is necessary to 
monitor and evaluate such models. 
‘‘(c) EXPANSION OF MODELS (PHASE II).—Taking into account 
the evaluation under subsection (b)(4), the Secretary may, through 
rulemaking, expand (including implementation on a nationwide 
basis) the duration and the scope of a model that is being tested 
under subsection (b) or a demonstration project under section 
1866C, to the extent determined appropriate by the Secretary, 
if— 
‘‘(1) the Secretary determines that such expansion is 
expected to— 
‘‘(A) reduce spending under applicable title without 
reducing the quality of care; or 
‘‘(B) improve the quality of care and reduce spending; 
and 
‘‘(2) the Chief Actuary of the Centers for Medicare & Med-
icaid Services certifies that such expansion would reduce pro-
gram spending under applicable titles. 
‘‘(d) IMPLEMENTATION.— 
‘‘(1) WAIVER AUTHORITY.—The Secretary may waive such 
requirements of titles XI and XVIII and of sections 1902(a)(1), 
1902(a)(13), and 1903(m)(2)(A)(iii) as may be necessary solely 
for purposes of carrying out this section with respect to testing 
models described in subsection (b). 
‘‘(2) LIMITATIONS ON REVIEW.—There shall be no adminis-
trative or judicial review under section 1869, section 1878, 
or otherwise of— 
‘‘(A) the selection of models for testing or expansion 
under this section; 
Certification. 
Determination. 
Public 
information. 
Determination. 
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124 STAT. 394 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) the selection of organizations, sites, or participants 
to test those models selected; 
‘‘(C) the elements, parameters, scope, and duration of 
such models for testing or dissemination; 
‘‘(D) determinations regarding budget neutrality under 
subsection (b)(3); 
‘‘(E) the termination or modification of the design and 
implementation of a model under subsection (b)(3)(B); and 
‘‘(F) determinations about expansion of the duration 
and scope of a model under subsection (c), including the 
determination that a model is not expected to meet criteria 
described in paragraph (1) or (2) of such subsection. 
‘‘(3) ADMINISTRATION.—Chapter 35 of title 44, United States 
Code, shall not apply to the testing and evaluation of models 
or expansion of such models under this section. 
‘‘(e) APPLICATION TO CHIP.—The Center may carry out activi-
ties under this section with respect to title XXI in the same manner 
as provided under this section with respect to the program under 
the applicable titles. 
‘‘(f) FUNDING.— 
‘‘(1) IN GENERAL.—There are appropriated, from amounts 
in the Treasury not otherwise appropriated— 
‘‘(A) $5,000,000 for the design, implementation, and 
evaluation of models under subsection (b) for fiscal year 
2010; 
‘‘(B) $10,000,000,000 for the activities initiated under 
this section for the period of fiscal years 2011 through 
2019; and 
‘‘(C) the amount described in subparagraph (B) for 
the activities initiated under this section for each subse-
quent 10-year fiscal period (beginning with the 10-year 
fiscal period beginning with fiscal year 2020). 
Amounts appropriated under the preceding sentence shall 
remain available until expended. 
‘‘(2) USE OF CERTAIN FUNDS.—Out of amounts appropriated 
under subparagraphs (B) and (C) of paragraph (1), not less 
than $25,000,000 shall be made available each such fiscal year 
to design, implement, and evaluate models under subsection 
(b). 
‘‘(g) REPORT TO CONGRESS.—Beginning in 2012, and not less 
than once every other year thereafter, the Secretary shall submit 
to Congress a report on activities under this section. Each such 
report shall describe the models tested under subsection (b), 
including the number of individuals described in subsection 
(a)(4)(A)(i) and of individuals described in subsection (a)(4)(A)(ii) 
participating in such models and payments made under applicable 
titles for services on behalf of such individuals, any models chosen 
for expansion under subsection (c), and the results from evaluations 
under subsection (b)(4). In addition, each such report shall provide 
such recommendations as the Secretary determines are appropriate 
for legislative action to facilitate the development and expansion 
of successful payment models.’’. 
(b) MEDICAID CONFORMING AMENDMENT.—Section 1902(a) of 
the Social Security Act (42 U.S.C. 1396a(a)), as amended by section 
8002(b), is amended— 
(1) in paragraph (81), by striking ‘‘and’’ at the end; 
Determination. 
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124 STAT. 395 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) in paragraph (82), by striking the period at the end 
and inserting ‘‘; and’’; and 
(3) by inserting after paragraph (82) the following new 
paragraph: 
‘‘(83) provide for implementation of the payment models 
specified by the Secretary under section 1115A(c) for 
implementation on a nationwide basis unless the State dem-
onstrates to the satisfaction of the Secretary that implementa-
tion would not be administratively feasible or appropriate to 
the health care delivery system of the State.’’. 
(c) REVISIONS TO HEALTH CARE QUALITY DEMONSTRATION PRO-
GRAM.—Subsections (b) and (f) of section 1866C of the Social Secu-
rity Act (42 U.S.C. 1395cc–3) are amended by striking ‘‘5-year’’ 
each place it appears. 
SEC. 3022. MEDICARE SHARED SAVINGS PROGRAM. 
Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) 
is amended by adding at the end the following new section: 
‘‘SHARED SAVINGS PROGRAM 
‘‘SEC. 1899. (a) ESTABLISHMENT.— 
‘‘(1) IN GENERAL.—Not later than January 1, 2012, the 
Secretary shall establish a shared savings program (in this 
section referred to as the ‘program’) that promotes account-
ability for a patient population and coordinates items and serv-
ices under parts A and B, and encourages investment in infra-
structure and redesigned care processes for high quality and 
efficient service delivery. Under such program— 
‘‘(A) groups of providers of services and suppliers 
meeting criteria specified by the Secretary may work 
together to manage and coordinate care for Medicare fee- 
for-service beneficiaries through an accountable care 
organization (referred to in this section as an ‘ACO’); and 
‘‘(B) ACOs that meet quality performance standards 
established by the Secretary are eligible to receive pay-
ments for shared savings under subsection (d)(2). 
‘‘(b) ELIGIBLE ACOS.— 
‘‘(1) IN GENERAL.—Subject to the succeeding provisions of 
this subsection, as determined appropriate by the Secretary, 
the following groups of providers of services and suppliers which 
have established a mechanism for shared governance are 
eligible to participate as ACOs under the program under this 
section: 
‘‘(A) ACO professionals in group practice arrangements. 
‘‘(B) Networks of individual practices of ACO profes-
sionals. 
‘‘(C) Partnerships or joint venture arrangements 
between hospitals and ACO professionals. 
‘‘(D) Hospitals employing ACO professionals. 
‘‘(E) Such other groups of providers of services and 
suppliers as the Secretary determines appropriate. 
‘‘(2) REQUIREMENTS.—An ACO shall meet the following 
requirements: 
‘‘(A) The ACO shall be willing to become accountable 
for the quality, cost, and overall care of the Medicare 
fee-for-service beneficiaries assigned to it. 
Deadline. 
42 USC 1395jjj. 
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124 STAT. 396 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) The ACO shall enter into an agreement with the 
Secretary to participate in the program for not less than 
a 3-year period (referred to in this section as the ‘agreement 
period’). 
‘‘(C) The ACO shall have a formal legal structure that 
would allow the organization to receive and distribute pay-
ments for shared savings under subsection (d)(2) to partici-
pating providers of services and suppliers. 
‘‘(D) The ACO shall include primary care ACO profes-
sionals that are sufficient for the number of Medicare fee- 
for-service beneficiaries assigned to the ACO under sub-
section (c). At a minimum, the ACO shall have at least 
5,000 such beneficiaries assigned to it under subsection 
(c) in order to be eligible to participate in the ACO program. 
‘‘(E) The ACO shall provide the Secretary with such 
information regarding ACO professionals participating in 
the ACO as the Secretary determines necessary to support 
the assignment of Medicare fee-for-service beneficiaries to 
an ACO, the implementation of quality and other reporting 
requirements under paragraph (3), and the determination 
of payments for shared savings under subsection (d)(2). 
‘‘(F) The ACO shall have in place a leadership and 
management structure that includes clinical and adminis-
trative systems. 
‘‘(G) The ACO shall define processes to promote evi-
dence-based medicine and patient engagement, report on 
quality and cost measures, and coordinate care, such as 
through the use of telehealth, remote patient monitoring, 
and other such enabling technologies. 
‘‘(H) The ACO shall demonstrate to the Secretary that 
it meets patient-centeredness criteria specified by the Sec-
retary, such as the use of patient and caregiver assessments 
or the use of individualized care plans. 
‘‘(3) QUALITY AND OTHER REPORTING REQUIREMENTS.— 
‘‘(A) IN
GENERAL.—The Secretary shall determine 
appropriate measures to assess the quality of care fur-
nished by the ACO, such as measures of— 
‘‘(i) clinical processes and outcomes; 
‘‘(ii) patient and, where practicable, caregiver 
experience of care; and 
‘‘(iii) utilization (such as rates of hospital admis-
sions for ambulatory care sensitive conditions). 
‘‘(B) REPORTING REQUIREMENTS.—An ACO shall submit 
data in a form and manner specified by the Secretary 
on measures the Secretary determines necessary for the 
ACO to report in order to evaluate the quality of care 
furnished by the ACO. Such data may include care transi-
tions across health care settings, including hospital dis-
charge planning and post-hospital discharge follow-up by 
ACO professionals, as the Secretary determines appro-
priate. 
‘‘(C) QUALITY
PERFORMANCE
STANDARDS.—The Sec-
retary shall establish quality performance standards to 
assess the quality of care furnished by ACOs. The Secretary 
shall seek to improve the quality of care furnished by 
Determinations. 
Contracts. 
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124 STAT. 397 
PUBLIC LAW 111–148—MAR. 23, 2010 
ACOs over time by specifying higher standards, new meas-
ures, or both for purposes of assessing such quality of 
care. 
‘‘(D) OTHER REPORTING REQUIREMENTS.—The Secretary 
may, as the Secretary determines appropriate, incorporate 
reporting requirements and incentive payments related to 
the physician quality reporting initiative (PQRI) under sec-
tion 1848, including such requirements and such payments 
related to electronic prescribing, electronic health records, 
and other similar initiatives under section 1848, and may 
use alternative criteria than would otherwise apply under 
such section for determining whether to make such pay-
ments. The incentive payments described in the preceding 
sentence shall not be taken into consideration when calcu-
lating any payments otherwise made under subsection (d). 
‘‘(4) NO DUPLICATION IN PARTICIPATION IN SHARED SAVINGS 
PROGRAMS.—A provider of services or supplier that participates 
in any of the following shall not be eligible to participate 
in an ACO under this section: 
‘‘(A) A model tested or expanded under section 1115A 
that involves shared savings under this title, or any other 
program or demonstration project that involves such shared 
savings. 
‘‘(B) The independence at home medical practice pilot 
program under section 1866E. 
‘‘(c) ASSIGNMENT OF MEDICARE FEE-FOR-SERVICE BENEFICIARIES 
TO ACOS.—The Secretary shall determine an appropriate method 
to assign Medicare fee-for-service beneficiaries to an ACO based 
on their utilization of primary care services provided under this 
title by an ACO professional described in subsection (h)(1)(A). 
‘‘(d) PAYMENTS AND TREATMENT OF SAVINGS.— 
‘‘(1) PAYMENTS.— 
‘‘(A) IN GENERAL.—Under the program, subject to para-
graph (3), payments shall continue to be made to providers 
of services and suppliers participating in an ACO under 
the original Medicare fee-for-service program under parts 
A and B in the same manner as they would otherwise 
be made except that a participating ACO is eligible to 
receive payment for shared savings under paragraph (2) 
if— 
‘‘(i) the ACO meets quality performance standards 
established by the Secretary under subsection (b)(3); 
and 
‘‘(ii) the ACO meets the requirement under 
subparagraph (B)(i). 
‘‘(B) SAVINGS REQUIREMENT AND BENCHMARK.— 
‘‘(i) DETERMINING SAVINGS.—In each year of the 
agreement period, an ACO shall be eligible to receive 
payment for shared savings under paragraph (2) only 
if the estimated average per capita Medicare expendi-
tures under the ACO for Medicare fee-for-service bene-
ficiaries for parts A and B services, adjusted for bene-
ficiary characteristics, is at least the percent specified 
by the Secretary below the applicable benchmark under 
clause (ii). The Secretary shall determine the appro-
priate percent described in the preceding sentence to 
account for normal variation in expenditures under 
Determination. 
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124 STAT. 398 
PUBLIC LAW 111–148—MAR. 23, 2010 
this title, based upon the number of Medicare fee- 
for-service beneficiaries assigned to an ACO. 
‘‘(ii) ESTABLISH
AND
UPDATE
BENCHMARK.—The 
Secretary shall estimate a benchmark for each agree-
ment period for each ACO using the most recent avail-
able 3 years of per-beneficiary expenditures for parts 
A and B services for Medicare fee-for-service bene-
ficiaries assigned to the ACO. Such benchmark shall 
be adjusted for beneficiary characteristics and such 
other factors as the Secretary determines appropriate 
and updated by the projected absolute amount of 
growth in national per capita expenditures for parts 
A and B services under the original Medicare fee- 
for-service program, as estimated by the Secretary. 
Such benchmark shall be reset at the start of each 
agreement period. 
‘‘(2) PAYMENTS FOR SHARED SAVINGS.—Subject to perform-
ance with respect to the quality performance standards estab-
lished by the Secretary under subsection (b)(3), if an ACO 
meets the requirements under paragraph (1), a percent (as 
determined appropriate by the Secretary) of the difference 
between such estimated average per capita Medicare expendi-
tures in a year, adjusted for beneficiary characteristics, under 
the ACO and such benchmark for the ACO may be paid to 
the ACO as shared savings and the remainder of such difference 
shall be retained by the program under this title. The Secretary 
shall establish limits on the total amount of shared savings 
that may be paid to an ACO under this paragraph. 
‘‘(3) MONITORING AVOIDANCE OF AT-RISK PATIENTS.—If the 
Secretary determines that an ACO has taken steps to avoid 
patients at risk in order to reduce the likelihood of increasing 
costs to the ACO the Secretary may impose an appropriate 
sanction on the ACO, including termination from the program. 
‘‘(4) TERMINATION.—The Secretary may terminate an agree-
ment with an ACO if it does not meet the quality performance 
standards established by the Secretary under subsection (b)(3). 
‘‘(e) ADMINISTRATION.—Chapter 35 of title 44, United States 
Code, shall not apply to the program. 
‘‘(f) WAIVER
AUTHORITY.—The Secretary may waive such 
requirements of sections 1128A and 1128B and title XVIII of this 
Act as may be necessary to carry out the provisions of this section. 
‘‘(g) LIMITATIONS ON REVIEW.—There shall be no administrative 
or judicial review under section 1869, section 1878, or otherwise 
of— 
‘‘(1) the specification of criteria under subsection (a)(1)(B); 
‘‘(2) the assessment of the quality of care furnished by 
an ACO and the establishment of performance standards under 
subsection (b)(3); 
‘‘(3) the assignment of Medicare fee-for-service beneficiaries 
to an ACO under subsection (c); 
‘‘(4) the determination of whether an ACO is eligible for 
shared savings under subsection (d)(2) and the amount of such 
shared savings, including the determination of the estimated 
average per capita Medicare expenditures under the ACO for 
Medicare fee-for-service beneficiaries assigned to the ACO and 
the average benchmark for the ACO under subsection (d)(1)(B); 
Limitations. 
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124 STAT. 399 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(5) the percent of shared savings specified by the Secretary 
under subsection (d)(2) and any limit on the total amount 
of shared savings established by the Secretary under such 
subsection; and 
‘‘(6) the termination of an ACO under subsection (d)(4). 
‘‘(h) DEFINITIONS.—In this section: 
‘‘(1) ACO PROFESSIONAL.—The term ‘ACO professional’ 
means— 
‘‘(A) a physician (as defined in section 1861(r)(1)); and 
‘‘(B) 
a 
practitioner 
described 
in 
section 
1842(b)(18)(C)(i). 
‘‘(2) HOSPITAL.—The term ‘hospital’ means a subsection 
(d) hospital (as defined in section 1886(d)(1)(B)). 
‘‘(3) MEDICARE FEE-FOR-SERVICE BENEFICIARY.—The term 
‘Medicare fee-for-service beneficiary’ means an individual who 
is enrolled in the original Medicare fee-for-service program 
under parts A and B and is not enrolled in an MA plan 
under part C, an eligible organization under section 1876, or 
a PACE program under section 1894.’’. 
SEC. 3023. NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING. 
Title XVIII of the Social Security Act, as amended by section 
3021, is amended by inserting after section 1886C the following 
new section: 
‘‘NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING 
‘‘SEC. 1866D. (a) IMPLEMENTATION.— 
‘‘(1) IN
GENERAL.—The Secretary shall establish a pilot 
program for integrated care during an episode of care provided 
to an applicable beneficiary around a hospitalization in order 
to improve the coordination, quality, and efficiency of health 
care services under this title. 
‘‘(2) DEFINITIONS.—In this section: 
‘‘(A) APPLICABLE BENEFICIARY.—The term ‘applicable 
beneficiary’ means an individual who— 
‘‘(i) is entitled to, or enrolled for, benefits under 
part A and enrolled for benefits under part B of such 
title, but not enrolled under part C or a PACE program 
under section 1894; and 
‘‘(ii) is admitted to a hospital for an applicable 
condition. 
‘‘(B) APPLICABLE
CONDITION.—The term ‘applicable 
condition’ means 1 or more of 8 conditions selected by 
the Secretary. In selecting conditions under the preceding 
sentence, the Secretary shall take into consideration the 
following factors: 
‘‘(i) Whether the conditions selected include a mix 
of chronic and acute conditions. 
‘‘(ii) Whether the conditions selected include a mix 
of surgical and medical conditions. 
‘‘(iii) Whether a condition is one for which there 
is evidence of an opportunity for providers of services 
and suppliers to improve the quality of care furnished 
while reducing total expenditures under this title. 
‘‘(iv) Whether a condition has significant variation 
in— 
‘‘(I) the number of readmissions; and 
42 USC 
1395cc–4. 
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124 STAT. 400 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(II) the amount of expenditures for post-acute 
care spending under this title. 
‘‘(v) Whether a condition is high-volume and has 
high post-acute care expenditures under this title. 
‘‘(vi) Which conditions the Secretary determines 
are most amenable to bundling across the spectrum 
of care given practice patterns under this title. 
‘‘(C) APPLICABLE SERVICES.—The term ‘applicable serv-
ices’ means the following: 
‘‘(i) Acute care inpatient services. 
‘‘(ii) Physicians’ services delivered in and outside 
of an acute care hospital setting. 
‘‘(iii) Outpatient hospital services, including emer-
gency department services. 
‘‘(iv) Post-acute care services, including home 
health services, skilled nursing services, inpatient 
rehabilitation services, and inpatient hospital services 
furnished by a long-term care hospital. 
‘‘(v) Other services the Secretary determines appro-
priate. 
‘‘(D) EPISODE OF CARE.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), the term 
‘episode of care’ means, with respect to an applicable 
condition and an applicable beneficiary, the period that 
includes— 
‘‘(I) the 3 days prior to the admission of the 
applicable beneficiary to a hospital for the 
applicable condition; 
‘‘(II) the length of stay of the applicable bene-
ficiary in such hospital; and 
‘‘(III) the 30 days following the discharge of 
the applicable beneficiary from such hospital. 
‘‘(ii) ESTABLISHMENT
OF
PERIOD
BY
THE
SEC-
RETARY.—The Secretary, as appropriate, may establish 
a period (other than the period described in clause 
(i)) for an episode of care under the pilot program. 
‘‘(E) PHYSICIANS’ 
SERVICES.—The term ‘physicians’ 
services’ has the meaning given such term in section 
1861(q). 
‘‘(F) PILOT PROGRAM.—The term ‘pilot program’ means 
the pilot program under this section. 
‘‘(G) PROVIDER
OF
SERVICES.—The term ‘provider of 
services’ has the meaning given such term in section 
1861(u). 
‘‘(H) READMISSION.—The term ‘readmission’ has the 
meaning given such term in section 1886(q)(5)(E). 
‘‘(I) SUPPLIER.—The term ‘supplier’ has the meaning 
given such term in section 1861(d). 
‘‘(3) DEADLINE FOR IMPLEMENTATION.—The Secretary shall 
establish the pilot program not later than January 1, 2013. 
‘‘(b) DEVELOPMENTAL PHASE.— 
‘‘(1) 
DETERMINATION
OF
PATIENT
ASSESSMENT 
INSTRUMENT.—The Secretary shall determine which patient 
assessment instrument (such as the Continuity Assessment 
Record and Evaluation (CARE) tool) shall be used under the 
pilot program to evaluate the applicable condition of an 
applicable beneficiary for purposes of determining the most 
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124 STAT. 401 
PUBLIC LAW 111–148—MAR. 23, 2010 
clinically appropriate site for the provision of post-acute care 
to the applicable beneficiary. 
‘‘(2) DEVELOPMENT OF QUALITY MEASURES FOR AN EPISODE 
OF CARE AND FOR POST-ACUTE CARE.— 
‘‘(A) IN GENERAL.—The Secretary, in consultation with 
the Agency for Healthcare Research and Quality and the 
entity with a contract under section 1890(a) of the Social 
Security Act, shall develop quality measures for use in 
the pilot program— 
‘‘(i) for episodes of care; and 
‘‘(ii) for post-acute care. 
‘‘(B) SITE-NEUTRAL
POST-ACUTE
CARE
QUALITY
MEAS-
URES.—Any quality measures developed under subpara-
graph (A)(ii) shall be site-neutral. 
‘‘(C) COORDINATION WITH QUALITY MEASURE DEVELOP-
MENT
AND
ENDORSEMENT
PROCEDURES.—The Secretary 
shall ensure that the development of quality measures 
under subparagraph (A) is done in a manner that is con-
sistent with the measures developed and endorsed under 
section 1890 and 1890A that are applicable to all post- 
acute care settings. 
‘‘(c) DETAILS.— 
‘‘(1) DURATION.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 
pilot program shall be conducted for a period of 5 years. 
‘‘(B) EXTENSION.—The Secretary may extend the dura-
tion of the pilot program for providers of services and 
suppliers participating in the pilot program as of the day 
before the end of the 5-year period described in subpara-
graph (A), for a period determined appropriate by the Sec-
retary, if the Secretary determines that such extension 
will result in improving or not reducing the quality of 
patient care and reducing spending under this title. 
‘‘(2) PARTICIPATING
PROVIDERS
OF
SERVICES
AND
SUP-
PLIERS.— 
‘‘(A) IN GENERAL.—An entity comprised of providers 
of services and suppliers, including a hospital, a physician 
group, a skilled nursing facility, and a home health agency, 
who are otherwise participating under this title, may 
submit an application to the Secretary to provide applicable 
services to applicable individuals under this section. 
‘‘(B) REQUIREMENTS.—The Secretary shall develop 
requirements for entities to participate in the pilot program 
under this section. Such requirements shall ensure that 
applicable beneficiaries have an adequate choice of pro-
viders of services and suppliers under the pilot program. 
‘‘(3) PAYMENT METHODOLOGY.— 
‘‘(A) IN GENERAL.— 
‘‘(i) ESTABLISHMENT OF PAYMENT METHODS.—The 
Secretary shall develop payment methods for the pilot 
program for entities participating in the pilot program. 
Such payment methods may include bundled payments 
and bids from entities for episodes of care. The Sec-
retary shall make payments to the entity for services 
covered under this section. 
‘‘(ii) NO
ADDITIONAL
PROGRAM
EXPENDITURES.— 
Payments under this section for applicable items and 
Determination. 
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124 STAT. 402 
PUBLIC LAW 111–148—MAR. 23, 2010 
services under this title (including payment for services 
described in subparagraph (B)) for applicable bene-
ficiaries for a year shall be established in a manner 
that does not result in spending more for such entity 
for such beneficiaries than would otherwise be 
expended for such entity for such beneficiaries for such 
year if the pilot program were not implemented, as 
estimated by the Secretary. 
‘‘(B) INCLUSION
OF
CERTAIN
SERVICES.—A payment 
methodology tested under the pilot program shall include 
payment for the furnishing of applicable services and other 
appropriate services, such as care coordination, medication 
reconciliation, discharge planning, transitional care serv-
ices, and other patient-centered activities as determined 
appropriate by the Secretary. 
‘‘(C) BUNDLED PAYMENTS.— 
‘‘(i) IN GENERAL.—A bundled payment under the 
pilot program shall— 
‘‘(I) be comprehensive, covering the costs of 
applicable services and other appropriate services 
furnished to an individual during an episode of 
care (as determined by the Secretary); and 
‘‘(II) be made to the entity which is partici-
pating in the pilot program. 
‘‘(ii) REQUIREMENT FOR PROVISION OF APPLICABLE 
SERVICES
AND
OTHER
APPROPRIATE
SERVICES.— 
Applicable services and other appropriate services for 
which payment is made under this subparagraph shall 
be furnished or directed by the entity which is partici-
pating in the pilot program. 
‘‘(D) PAYMENT FOR POST-ACUTE CARE SERVICES AFTER 
THE EPISODE OF CARE.—The Secretary shall establish proce-
dures, in the case where an applicable beneficiary requires 
continued post-acute care services after the last day of 
the episode of care, under which payment for such services 
shall be made. 
‘‘(4) QUALITY MEASURES.— 
‘‘(A) IN
GENERAL.—The Secretary shall establish 
quality measures (including quality measures of process, 
outcome, and structure) related to care provided by entities 
participating in the pilot program. Quality measures estab-
lished under the preceding sentence shall include measures 
of the following: 
‘‘(i) Functional status improvement. 
‘‘(ii) Reducing rates of avoidable hospital readmis-
sions. 
‘‘(iii) Rates of discharge to the community. 
‘‘(iv) Rates of admission to an emergency room 
after a hospitalization. 
‘‘(v) Incidence of health care acquired infections. 
‘‘(vi) Efficiency measures. 
‘‘(vii) Measures of patient-centeredness of care. 
‘‘(viii) Measures of patient perception of care. 
‘‘(ix) Other measures, including measures of 
patient outcomes, determined appropriate by the Sec-
retary. 
‘‘(B) REPORTING ON QUALITY MEASURES.— 
Procedures. 
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124 STAT. 403 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) IN GENERAL.—A entity shall submit data to 
the Secretary on quality measures established under 
subparagraph (A) during each year of the pilot program 
(in a form and manner, subject to clause (iii), specified 
by the Secretary). 
‘‘(ii) SUBMISSION
OF
DATA
THROUGH
ELECTRONIC 
HEALTH RECORD.—To the extent practicable, the Sec-
retary shall specify that data on measures be submitted 
under clause (i) through the use of an qualified elec-
tronic health record (as defined in section 3000(13) 
of the Public Health Service Act (42 U.S.C. 300jj– 
11(13)) in a manner specified by the Secretary. 
‘‘(d) WAIVER.—The Secretary may waive such provisions of this 
title and title XI as may be necessary to carry out the pilot program. 
‘‘(e) INDEPENDENT EVALUATION AND REPORTS ON PILOT PRO-
GRAM.— 
‘‘(1) INDEPENDENT EVALUATION.—The Secretary shall con-
duct an independent evaluation of the pilot program, including 
the extent to which the pilot program has— 
‘‘(A) improved quality measures established under sub-
section (c)(4)(A); 
‘‘(B) improved health outcomes; 
‘‘(C) improved applicable beneficiary access to care; 
and 
‘‘(D) reduced spending under this title. 
‘‘(2) REPORTS.— 
‘‘(A) INTERIM REPORT.—Not later than 2 years after 
the implementation of the pilot program, the Secretary 
shall submit to Congress a report on the initial results 
of the independent evaluation conducted under paragraph 
(1). 
‘‘(B) FINAL REPORT.—Not later than 3 years after the 
implementation of the pilot program, the Secretary shall 
submit to Congress a report on the final results of the 
independent evaluation conducted under paragraph (1). 
‘‘(f) CONSULTATION.—The Secretary shall consult with rep-
resentatives of small rural hospitals, including critical access hos-
pitals (as defined in section 1861(mm)(1)), regarding their participa-
tion in the pilot program. Such consultation shall include consider-
ation of innovative methods of implementing bundled payments 
in hospitals described in the preceding sentence, taking into consid-
eration any difficulties in doing so as a result of the low volume 
of services provided by such hospitals. 
‘‘(g) IMPLEMENTATION PLAN.— 
‘‘(1) IN GENERAL.—Not later than January 1, 2016, the 
Secretary shall submit a plan for the implementation of an 
expansion of the pilot program if the Secretary determines 
that such expansion will result in improving or not reducing 
the quality of patient care and reducing spending under this 
title. 
‘‘(h) ADMINISTRATION.—Chapter 35 of title 44, United States 
Code, shall not apply to the selection, testing, and evaluation of 
models or the expansion of such models under this section.’’. 
Deadline. 
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124 STAT. 404 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 3024. INDEPENDENCE AT HOME DEMONSTRATION PROGRAM. 
Title XVIII of the Social Security Act is amended by inserting 
after section 1866D, as inserted by section 3023, the following 
new section: 
‘‘INDEPENDENCE AT HOME MEDICAL PRACTICE DEMONSTRATION 
PROGRAM 
‘‘SEC. 1866D. (a) ESTABLISHMENT.— 
‘‘(1) IN
GENERAL.—The Secretary shall conduct a dem-
onstration program (in this section referred to as the ‘dem-
onstration program’) to test a payment incentive and service 
delivery model that utilizes physician and nurse practitioner 
directed home-based primary care teams designed to reduce 
expenditures and improve health outcomes in the provision 
of items and services under this title to applicable beneficiaries 
(as defined in subsection (d)). 
‘‘(2) REQUIREMENT.—The demonstration program shall test 
whether a model described in paragraph (1), which is account-
able for providing comprehensive, coordinated, continuous, and 
accessible care to high-need populations at home and coordi-
nating health care across all treatment settings, results in— 
‘‘(A) reducing preventable hospitalizations; 
‘‘(B) preventing hospital readmissions; 
‘‘(C) reducing emergency room visits; 
‘‘(D) improving health outcomes commensurate with 
the beneficiaries’ stage of chronic illness; 
‘‘(E) improving the efficiency of care, such as by 
reducing duplicative diagnostic and laboratory tests; 
‘‘(F) reducing the cost of health care services covered 
under this title; and 
‘‘(G) achieving beneficiary and family caregiver satis-
faction. 
‘‘(b) INDEPENDENCE AT HOME MEDICAL PRACTICE.— 
‘‘(1) INDEPENDENCE AT HOME MEDICAL PRACTICE DEFINED.— 
In this section: 
‘‘(A) IN GENERAL.—The term ‘independence at home 
medical practice’ means a legal entity that— 
‘‘(i) is comprised of an individual physician or nurse 
practitioner or group of physicians and nurse practi-
tioners that provides care as part of a team that 
includes physicians, nurses, physician assistants, phar-
macists, and other health and social services staff as 
appropriate who have experience providing home-based 
primary care to applicable beneficiaries, make in-home 
visits, and are available 24 hours per day, 7 days 
per week to carry out plans of care that are tailored 
to the individual beneficiary’s chronic conditions and 
designed to achieve the results in subsection (a); 
‘‘(ii) is organized at least in part for the purpose 
of providing physicians’ services; 
‘‘(iii) has documented experience in providing 
home-based primary care services to high-cost chron-
ically ill beneficiaries, as determined appropriate by 
the Secretary; 
42 USC 
1395cc–5. 
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124 STAT. 405 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(iv) furnishes services to at least 200 applicable 
beneficiaries (as defined in subsection (d)) during each 
year of the demonstration program; 
‘‘(v) has entered into an agreement with the Sec-
retary; 
‘‘(vi) uses electronic health information systems, 
remote monitoring, and mobile diagnostic technology; 
and 
‘‘(vii) meets such other criteria as the Secretary 
determines to be appropriate to participate in the dem-
onstration program. 
The entity shall report on quality measures (in such form, 
manner, and frequency as specified by the Secretary, which 
may be for the group, for providers of services and sup-
pliers, or both) and report to the Secretary (in a form, 
manner, and frequency as specified by the Secretary) such 
data as the Secretary determines appropriate to monitor 
and evaluate the demonstration program. 
‘‘(B) PHYSICIAN.—The term ‘physician’ includes, except 
as the Secretary may otherwise provide, any individual 
who furnishes services for which payment may be made 
as physicians’ services and has the medical training or 
experience to fulfill the physician’s role described in 
subparagraph (A)(i). 
‘‘(2) PARTICIPATION OF NURSE PRACTITIONERS AND PHYSICIAN 
ASSISTANTS.—Nothing in this section shall be construed to pre-
vent a nurse practitioner or physician assistant from partici-
pating in, or leading, a home-based primary care team as 
part of an independence at home medical practice if— 
‘‘(A) all the requirements of this section are met; 
‘‘(B) the nurse practitioner or physician assistant, as 
the case may be, is acting consistent with State law; and 
‘‘(C) the nurse practitioner or physician assistant has 
the medical training or experience to fulfill the nurse 
practitioner or physician assistant role described in para-
graph (1)(A)(i). 
‘‘(3) INCLUSION
OF
PROVIDERS
AND
PRACTITIONERS.— 
Nothing in this subsection shall be construed as preventing 
an independence at home medical practice from including a 
provider of services or a participating practitioner described 
in section 1842(b)(18)(C) that is affiliated with the practice 
under an arrangement structured so that such provider of 
services or practitioner participates in the demonstration pro-
gram and shares in any savings under the demonstration pro-
gram. 
‘‘(4) QUALITY
AND
PERFORMANCE
STANDARDS.—The Sec-
retary shall develop quality performance standards for 
independence at home medical practices participating in the 
demonstration program. 
‘‘(c) PAYMENT METHODOLOGY.— 
‘‘(1) ESTABLISHMENT OF TARGET SPENDING LEVEL.—The Sec-
retary shall establish an estimated annual spending target, 
for the amount the Secretary estimates would have been spent 
in the absence of the demonstration, for items and services 
Reports. 
Determination. 
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124 STAT. 406 
PUBLIC LAW 111–148—MAR. 23, 2010 
covered under parts A and B furnished to applicable bene-
ficiaries for each qualifying independence at home medical prac-
tice under this section. Such spending targets shall be deter-
mined on a per capita basis. Such spending targets shall include 
a risk corridor that takes into account normal variation in 
expenditures for items and services covered under parts A 
and B furnished to such beneficiaries with the size of the 
corridor being related to the number of applicable beneficiaries 
furnished services by each independence at home medical prac-
tice. The spending targets may also be adjusted for other factors 
as the Secretary determines appropriate. 
‘‘(2) INCENTIVE
PAYMENTS.—Subject to performance on 
quality measures, a qualifying independence at home medical 
practice is eligible to receive an incentive payment under this 
section if actual expenditures for a year for the applicable 
beneficiaries it enrolls are less than the estimated spending 
target established under paragraph (1) for such year. An incen-
tive payment for such year shall be equal to a portion (as 
determined by the Secretary) of the amount by which actual 
expenditures (including incentive payments under this para-
graph) for applicable beneficiaries under parts A and B for 
such year are estimated to be less than 5 percent less than 
the estimated spending target for such year, as determined 
under paragraph (1). 
‘‘(d) APPLICABLE BENEFICIARIES.— 
‘‘(1) DEFINITION.—In this section, the term ‘applicable bene-
ficiary’ means, with respect to a qualifying independence at 
home medical practice, an individual who the practice has 
determined— 
‘‘(A) is entitled to benefits under part A and enrolled 
for benefits under part B; 
‘‘(B) is not enrolled in a Medicare Advantage plan 
under part C or a PACE program under section 1894; 
‘‘(C) has 2 or more chronic illnesses, such as congestive 
heart failure, diabetes, other dementias designated by the 
Secretary, chronic obstructive pulmonary disease, ischemic 
heart 
disease, 
stroke, 
Alzheimer’s 
Disease 
and 
neurodegenerative diseases, and other diseases and condi-
tions designated by the Secretary which result in high 
costs under this title; 
‘‘(D) within the past 12 months has had a nonelective 
hospital admission; 
‘‘(E) within the past 12 months has received acute 
or subacute rehabilitation services; 
‘‘(F) has 2 or more functional dependencies requiring 
the assistance of another person (such as bathing, dressing, 
toileting, walking, or feeding); and 
‘‘(G) meets such other criteria as the Secretary deter-
mines appropriate. 
‘‘(2) PATIENT
ELECTION
TO
PARTICIPATE.—The Secretary 
shall determine an appropriate method of ensuring that 
applicable beneficiaries have agreed to enroll in an independ-
ence at home medical practice under the demonstration pro-
gram. Enrollment in the demonstration program shall be vol-
untary. 
‘‘(3) BENEFICIARY ACCESS TO SERVICES.—Nothing in this 
section shall be construed as encouraging physicians or nurse 
Determination. 
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124 STAT. 407 
PUBLIC LAW 111–148—MAR. 23, 2010 
practitioners to limit applicable beneficiary access to services 
covered under this title and applicable beneficiaries shall not 
be required to relinquish access to any benefit under this title 
as a condition of receiving services from an independence at 
home medical practice. 
‘‘(e) IMPLEMENTATION.— 
‘‘(1) STARTING
DATE.—The demonstration program shall 
begin no later than January 1, 2012. An agreement with an 
independence at home medical practice under the demonstra-
tion program may cover not more than a 3-year period. 
‘‘(2) NO PHYSICIAN DUPLICATION IN DEMONSTRATION PARTICI-
PATION.—The Secretary shall not pay an independence at home 
medical practice under this section that participates in section 
1899. 
‘‘(3) NO
BENEFICIARY
DUPLICATION
IN
DEMONSTRATION 
PARTICIPATION.—The Secretary shall ensure that no applicable 
beneficiary enrolled in an independence at home medical prac-
tice under this section is participating in the programs under 
section 1899. 
‘‘(4) PREFERENCE.—In approving an independence at home 
medical practice, the Secretary shall give preference to practices 
that are— 
‘‘(A) located in high-cost areas of the country; 
‘‘(B) have experience in furnishing health care services 
to applicable beneficiaries in the home; and 
‘‘(C) use electronic medical records, health information 
technology, and individualized plans of care. 
‘‘(5) LIMITATION ON NUMBER OF PRACTICES.—In selecting 
qualified independence at home medical practices to participate 
under the demonstration program, the Secretary shall limit 
the number of such practices so that the number of applicable 
beneficiaries that may participate in the demonstration pro-
gram does not exceed 10,000. 
‘‘(6) WAIVER.—The Secretary may waive such provisions 
of this title and title XI as the Secretary determines necessary 
in order to implement the demonstration program. 
‘‘(7) ADMINISTRATION.—Chapter 35 of title 44, United States 
Code, shall not apply to this section. 
‘‘(f) EVALUATION AND MONITORING.— 
‘‘(1) IN
GENERAL.—The Secretary shall evaluate each 
independence at home medical practice under the demonstra-
tion program to assess whether the practice achieved the results 
described in subsection (a). 
‘‘(2) MONITORING
APPLICABLE
BENEFICIARIES.—The Sec-
retary may monitor data on expenditures and quality of services 
under this title after an applicable beneficiary discontinues 
receiving services under this title through a qualifying 
independence at home medical practice. 
‘‘(g) REPORTS TO CONGRESS.—The Secretary shall conduct an 
independent evaluation of the demonstration program and submit 
to Congress a final report, including best practices under the dem-
onstration program. Such report shall include an analysis of the 
demonstration program on coordination of care, expenditures under 
this title, applicable beneficiary access to services, and the quality 
of health care services provided to applicable beneficiaries. 
‘‘(h) FUNDING.—For purposes of administering and carrying 
out the demonstration program, other than for payments for items 
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124 STAT. 408 
PUBLIC LAW 111–148—MAR. 23, 2010 
and services furnished under this title and incentive payments 
under subsection (c), in addition to funds otherwise appropriated, 
there shall be transferred to the Secretary for the Center for Medi-
care & Medicaid Services Program Management Account from the 
Federal Hospital Insurance Trust Fund under section 1817 and 
the Federal Supplementary Medical Insurance Trust Fund under 
section 1841 (in proportions determined appropriate by the Sec-
retary) $5,000,000 for each of fiscal years 2010 through 2015. 
Amounts transferred under this subsection for a fiscal year shall 
be available until expended. 
‘‘(i) TERMINATION.— 
‘‘(1) MANDATORY TERMINATION.—The Secretary shall termi-
nate an agreement with an independence at home medical 
practice if— 
‘‘(A) the Secretary estimates or determines that such 
practice will not receive an incentive payment for the 
second of 2 consecutive years under the demonstration 
program; or 
‘‘(B) such practice fails to meet quality standards 
during any year of the demonstration program. 
‘‘(2) PERMISSIVE TERMINATION.—The Secretary may termi-
nate an agreement with an independence at home medical 
practice for such other reasons determined appropriate by the 
Secretary.’’. 
SEC. 3025. HOSPITAL READMISSIONS REDUCTION PROGRAM. 
(a) IN GENERAL.—Section 1886 of the Social Security Act (42 
U.S.C. 1395ww), as amended by sections 3001 and 3008, is amended 
by adding at the end the following new subsection: 
‘‘(q) HOSPITAL READMISSIONS REDUCTION PROGRAM.— 
‘‘(1) IN GENERAL.—With respect to payment for discharges 
from an applicable hospital (as defined in paragraph (5)(C)) 
occurring during a fiscal year beginning on or after October 
1, 2012, in order to account for excess readmissions in the 
hospital, the Secretary shall reduce the payments that would 
otherwise be made to such hospital under subsection (d) (or 
section 1814(b)(3), as the case may be) for such a discharge 
by an amount equal to the product of— 
‘‘(A) the base operating DRG payment amount (as 
defined in paragraph (2)) for the discharge; and 
‘‘(B) the adjustment factor (described in paragraph 
(3)(A)) for the hospital for the fiscal year. 
‘‘(2) BASE
OPERATING
DRG
PAYMENT
AMOUNT
DEFINED.— 
‘‘(A) IN GENERAL.—Except as provided in subparagraph 
(B), in this subsection, the term ‘base operating DRG pay-
ment amount’ means, with respect to a hospital for a fiscal 
year— 
‘‘(i) the payment amount that would otherwise be 
made under subsection (d) (determined without regard 
to subsection (o)) for a discharge if this subsection 
did not apply; reduced by 
‘‘(ii) any portion of such payment amount that 
is attributable to payments under paragraphs (5)(A), 
(5)(B), (5)(F), and (12) of subsection (d). 
‘‘(B) SPECIAL RULES FOR CERTAIN HOSPITALS.— 
‘‘(i) SOLE COMMUNITY HOSPITALS AND MEDICARE- 
DEPENDENT, SMALL RURAL HOSPITALS.—In the case of 
Definition. 
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124 STAT. 409 
PUBLIC LAW 111–148—MAR. 23, 2010 
a medicare-dependent, small rural hospital (with 
respect to discharges occurring during fiscal years 2012 
and 2013) or a sole community hospital, in applying 
subparagraph (A)(i), the payment amount that would 
otherwise be made under subsection (d) shall be deter-
mined without regard to subparagraphs (I) and (L) 
of subsection (b)(3) and subparagraphs (D) and (G) 
of subsection (d)(5). 
‘‘(ii) HOSPITALS PAID UNDER SECTION 1814.—In the 
case of a hospital that is paid under section 1814(b)(3), 
the Secretary may exempt such hospitals provided that 
States paid under such section submit an annual report 
to the Secretary describing how a similar program 
in the State for a participating hospital or hospitals 
achieves or surpasses the measured results in terms 
of patient health outcomes and cost savings established 
herein with respect to this section. 
‘‘(3) ADJUSTMENT FACTOR.— 
‘‘(A) IN GENERAL.—For purposes of paragraph (1), the 
adjustment factor under this paragraph for an applicable 
hospital for a fiscal year is equal to the greater of— 
‘‘(i) the ratio described in subparagraph (B) for 
the hospital for the applicable period (as defined in 
paragraph (5)(D)) for such fiscal year; or 
‘‘(ii) the floor adjustment factor specified in 
subparagraph (C). 
‘‘(B) RATIO.—The ratio described in this subparagraph 
for a hospital for an applicable period is equal to 1 minus 
the ratio of— 
‘‘(i) the aggregate payments for excess readmis-
sions (as defined in paragraph (4)(A)) with respect 
to an applicable hospital for the applicable period; and 
‘‘(ii) the aggregate payments for all discharges (as 
defined in paragraph (4)(B)) with respect to such 
applicable hospital for such applicable period. 
‘‘(C) FLOOR
ADJUSTMENT
FACTOR.—For purposes of 
subparagraph (A), the floor adjustment factor specified in 
this subparagraph for— 
‘‘(i) fiscal year 2013 is 0.99; 
‘‘(ii) fiscal year 2014 is 0.98; or 
‘‘(iii) fiscal year 2015 and subsequent fiscal years 
is 0.97. 
‘‘(4) AGGREGATE
PAYMENTS, EXCESS
READMISSION
RATIO 
DEFINED.—For purposes of this subsection: 
‘‘(A) AGGREGATE
PAYMENTS
FOR
EXCESS
READMIS-
SIONS.—The term ‘aggregate payments for excess readmis-
sions’ means, for a hospital for an applicable period, the 
sum, for applicable conditions (as defined in paragraph 
(5)(A)), of the product, for each applicable condition, of— 
‘‘(i) the base operating DRG payment amount for 
such hospital for such applicable period for such condi-
tion; 
‘‘(ii) the number of admissions for such condition 
for such hospital for such applicable period; and 
‘‘(iii) the excess readmissions ratio (as defined in 
subparagraph (C)) for such hospital for such applicable 
period minus 1. 
Reports. 
Deadline. 
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124 STAT. 410 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) AGGREGATE PAYMENTS FOR ALL DISCHARGES.—The 
term ‘aggregate payments for all discharges’ means, for 
a hospital for an applicable period, the sum of the base 
operating DRG payment amounts for all discharges for 
all conditions from such hospital for such applicable period. 
‘‘(C) EXCESS READMISSION RATIO.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), the term 
‘excess readmissions ratio’ means, with respect to an 
applicable condition for a hospital for an applicable 
period, the ratio (but not less than 1.0) of— 
‘‘(I) the risk adjusted readmissions based on 
actual readmissions, as determined consistent with 
a readmission measure methodology that has been 
endorsed under paragraph (5)(A)(ii)(I), for an 
applicable hospital for such condition with respect 
to such applicable period; to 
‘‘(II) the risk adjusted expected readmissions 
(as determined consistent with such a method-
ology) for such hospital for such condition with 
respect to such applicable period. 
‘‘(ii) EXCLUSION
OF
CERTAIN
READMISSIONS.—For 
purposes of clause (i), with respect to a hospital, excess 
readmissions shall not include readmissions for an 
applicable condition for which there are fewer than 
a minimum number (as determined by the Secretary) 
of discharges for such applicable condition for the 
applicable period and such hospital. 
‘‘(5) DEFINITIONS.—For purposes of this subsection: 
‘‘(A) APPLICABLE
CONDITION.—The term ‘applicable 
condition’ means, subject to subparagraph (B), a condition 
or procedure selected by the Secretary among conditions 
and procedures for which— 
‘‘(i) readmissions (as defined in subparagraph (E)) 
that represent conditions or procedures that are high 
volume or high expenditures under this title (or other 
criteria specified by the Secretary); and 
‘‘(ii) measures of such readmissions— 
‘‘(I) have been endorsed by the entity with 
a contract under section 1890(a); and 
‘‘(II) such endorsed measures have exclusions 
for readmissions that are unrelated to the prior 
discharge (such as a planned readmission or 
transfer to another applicable hospital). 
‘‘(B) EXPANSION
OF
APPLICABLE
CONDITIONS.—Begin-
ning with fiscal year 2015, the Secretary shall, to the 
extent practicable, expand the applicable conditions beyond 
the 3 conditions for which measures have been endorsed 
as described in subparagraph (A)(ii)(I) as of the date of 
the enactment of this subsection to the additional 4 condi-
tions that have been identified by the Medicare Payment 
Advisory Commission in its report to Congress in June 
2007 and to other conditions and procedures as determined 
appropriate by the Secretary. In expanding such applicable 
conditions, the Secretary shall seek the endorsement 
described in subparagraph (A)(ii)(I) but may apply such 
measures without such an endorsement in the case of a 
specified area or medical topic determined appropriate by 
Effective date. 
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124 STAT. 411 
PUBLIC LAW 111–148—MAR. 23, 2010 
the Secretary for which a feasible and practical measure 
has not been endorsed by the entity with a contract under 
section 1890(a) as long as due consideration is given to 
measures that have been endorsed or adopted by a con-
sensus organization identified by the Secretary. 
‘‘(C) APPLICABLE HOSPITAL.—The term ‘applicable hos-
pital’ means a subsection (d) hospital or a hospital that 
is paid under section 1814(b)(3), as the case may be. 
‘‘(D) APPLICABLE PERIOD.—The term ‘applicable period’ 
means, with respect to a fiscal year, such period as the 
Secretary shall specify. 
‘‘(E) READMISSION.—The term ‘readmission’ means, in 
the case of an individual who is discharged from an 
applicable hospital, the admission of the individual to the 
same or another applicable hospital within a time period 
specified by the Secretary from the date of such discharge. 
Insofar as the discharge relates to an applicable condition 
for which there is an endorsed measure described in 
subparagraph (A)(ii)(I), such time period (such as 30 days) 
shall be consistent with the time period specified for such 
measure. 
‘‘(6) REPORTING HOSPITAL SPECIFIC INFORMATION.— 
‘‘(A) IN GENERAL.—The Secretary shall make informa-
tion available to the public regarding readmission rates 
of each subsection (d) hospital under the program. 
‘‘(B) OPPORTUNITY
TO
REVIEW
AND
SUBMIT
CORREC-
TIONS.—The Secretary shall ensure that a subsection (d) 
hospital has the opportunity to review, and submit correc-
tions for, the information to be made public with respect 
to the hospital under subparagraph (A) prior to such 
information being made public. 
‘‘(C) WEBSITE.—Such information shall be posted on 
the Hospital Compare Internet website in an easily under-
standable format. 
‘‘(7) LIMITATIONS ON REVIEW.—There shall be no adminis-
trative or judicial review under section 1869, section 1878, 
or otherwise of the following: 
‘‘(A) The determination of base operating DRG payment 
amounts. 
‘‘(B) The methodology for determining the adjustment 
factor under paragraph (3), including excess readmissions 
ratio under paragraph (4)(C), aggregate payments for 
excess readmissions under paragraph (4)(A), and aggregate 
payments for all discharges under paragraph (4)(B), and 
applicable periods and applicable conditions under para-
graph (5). 
‘‘(C) The measures of readmissions as described in 
paragraph (5)(A)(ii). 
‘‘(8) READMISSION RATES FOR ALL PATIENTS.— 
‘‘(A) CALCULATION
OF
READMISSION.—The Secretary 
shall calculate readmission rates for all patients (as defined 
in subparagraph (D)) for a specified hospital (as defined 
in subparagraph (D)(ii)) for an applicable condition (as 
defined in paragraph (5)(B)) and other conditions deemed 
appropriate by the Secretary for an applicable period (as 
defined in paragraph (5)(D)) in the same manner as used 
to calculate such readmission rates for hospitals with 
Public 
information. 
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124 STAT. 412 
PUBLIC LAW 111–148—MAR. 23, 2010 
respect to this title and posted on the CMS Hospital Com-
pare website. 
‘‘(B) POSTING
OF
HOSPITAL
SPECIFIC
ALL
PATIENT 
READMISSION RATES.—The Secretary shall make informa-
tion on all patient readmission rates calculated under 
subparagraph (A) available on the CMS Hospital Compare 
website in a form and manner determined appropriate 
by the Secretary. The Secretary may also make other 
information determined appropriate by the Secretary avail-
able on such website. 
‘‘(C) HOSPITAL SUBMISSION OF ALL PATIENT DATA.— 
‘‘(i) Except as provided for in clause (ii), each speci-
fied hospital (as defined in subparagraph (D)(ii)) shall 
submit to the Secretary, in a form, manner and time 
specified by the Secretary, data and information deter-
mined necessary by the Secretary for the Secretary 
to calculate the all patient readmission rates described 
in subparagraph (A). 
‘‘(ii) Instead of a specified hospital submitting to 
the Secretary the data and information described in 
clause (i), such data and information may be submitted 
to the Secretary, on behalf of such a specified hospital, 
by a state or an entity determined appropriate by 
the Secretary. 
‘‘(D) DEFINITIONS.—For purposes of this paragraph: 
‘‘(i) The term ‘all patients’ means patients who 
are treated on an inpatient basis and discharged from 
a specified hospital (as defined in clause (ii)). 
‘‘(ii) The term ‘specified hospital’ means a sub-
section (d) hospital, hospitals described in clauses (i) 
through (v) of subsection (d)(1)(B) and, as determined 
feasible and appropriate by the Secretary, other hos-
pitals not otherwise described in this subparagraph.’’. 
(b) QUALITY IMPROVEMENT.—Part S of title III of the Public 
Health Service Act, as amended by section 3015, is further amended 
by adding at the end the following: 
‘‘SEC. 399KK. QUALITY IMPROVEMENT PROGRAM FOR HOSPITALS 
WITH A HIGH SEVERITY ADJUSTED READMISSION RATE. 
‘‘(a) ESTABLISHMENT.— 
‘‘(1) IN GENERAL.—Not later than 2 years after the date 
of enactment of this section, the Secretary shall make available 
a program for eligible hospitals to improve their readmission 
rates through the use of patient safety organizations (as defined 
in section 921(4)). 
‘‘(2) ELIGIBLE HOSPITAL DEFINED.—In this subsection, the 
term ‘eligible hospital’ means a hospital that the Secretary 
determines has a high rate of risk adjusted readmissions for 
the conditions described in section 1886(q)(8)(A) of the Social 
Security Act and has not taken appropriate steps to reduce 
such readmissions and improve patient safety as evidenced 
through historically high rates of readmissions, as determined 
by the Secretary. 
‘‘(3) RISK ADJUSTMENT.—The Secretary shall utilize appro-
priate risk adjustment measures to determine eligible hospitals. 
‘‘(b) REPORT TO THE SECRETARY.—As determined appropriate 
by the Secretary, eligible hospitals and patient safety organizations 
Determination. 
Deadline. 
42 USC 280j–3. 
Web posting. 
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124 STAT. 413 
PUBLIC LAW 111–148—MAR. 23, 2010 
working with those hospitals shall report to the Secretary on the 
processes employed by the hospital to improve readmission rates 
and the impact of such processes on readmission rates.’’. 
SEC. 3026. COMMUNITY-BASED CARE TRANSITIONS PROGRAM. 
(a) IN GENERAL.—The Secretary shall establish a Community- 
Based Care Transitions Program under which the Secretary pro-
vides funding to eligible entities that furnish improved care transi-
tion services to high-risk Medicare beneficiaries. 
(b) DEFINITIONS.—In this section: 
(1) ELIGIBLE ENTITY.—The term ‘‘eligible entity’’ means the 
following: 
(A) A subsection (d) hospital (as defined in section 
1886(d)(1)(B) of the Social Security Act (42 U.S.C. 
1395ww(d)(1)(B))) identified by the Secretary as having 
a high readmission rate, such as under section 1886(q) 
of the Social Security Act, as added by section 3025. 
(B) An appropriate community-based organization that 
provides care transition services under this section across 
a continuum of care through arrangements with subsection 
(d) hospitals (as so defined) to furnish the services described 
in subsection (c)(2)(B)(i) and whose governing body includes 
sufficient representation of multiple health care stake-
holders (including consumers). 
(2) HIGH-RISK
MEDICARE
BENEFICIARY.—The term ‘‘high- 
risk Medicare beneficiary’’ means a Medicare beneficiary who 
has attained a minimum hierarchical condition category score, 
as determined by the Secretary, based on a diagnosis of multiple 
chronic conditions or other risk factors associated with a hos-
pital readmission or substandard transition into post-hos-
pitalization care, which may include 1 or more of the following: 
(A) Cognitive impairment. 
(B) Depression. 
(C) A history of multiple readmissions. 
(D) Any other chronic disease or risk factor as deter-
mined by the Secretary. 
(3) MEDICARE
BENEFICIARY.—The term ‘‘Medicare bene-
ficiary’’ means an individual who is entitled to benefits under 
part A of title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.) and enrolled under part B of such title, but 
not enrolled under part C of such title. 
(4) PROGRAM.—The term ‘‘program’’ means the program 
conducted under this section. 
(5) 
READMISSION.—The 
term 
‘‘readmission’’ 
has 
the 
meaning given such term in section 1886(q)(5)(E) of the Social 
Security Act, as added by section 3025. 
(6) SECRETARY.—The term ‘‘Secretary’’ means the Secretary 
of Health and Human Services. 
(c) REQUIREMENTS.— 
(1) DURATION.— 
(A) IN GENERAL.—The program shall be conducted for 
a 5-year period, beginning January 1, 2011. 
(B) EXPANSION.—The Secretary may expand the dura-
tion and the scope of the program, to the extent determined 
appropriate by the Secretary, if the Secretary determines 
(and the Chief Actuary of the Centers for Medicare & 
Medicaid Services, with respect to spending under this 
Determination. 
Certification. 
42 USC 1395b–1 
note. 
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124 STAT. 414 
PUBLIC LAW 111–148—MAR. 23, 2010 
title, certifies) that such expansion would reduce spending 
under this title without reducing quality. 
(2) APPLICATION; PARTICIPATION.— 
(A) IN GENERAL.— 
(i) APPLICATION.—An eligible entity seeking to 
participate in the program shall submit an application 
to the Secretary at such time, in such manner, and 
containing such information as the Secretary may 
require. 
(ii) PARTNERSHIP.—If an eligible entity is a hos-
pital, such hospital shall enter into a partnership with 
a community-based organization to participate in the 
program. 
(B) INTERVENTION PROPOSAL.—Subject to subparagraph 
(C), an application submitted under subparagraph (A)(i) 
shall include a detailed proposal for at least 1 care transi-
tion intervention, which may include the following: 
(i) Initiating care transition services for a high- 
risk Medicare beneficiary not later than 24 hours prior 
to the discharge of the beneficiary from the eligible 
entity. 
(ii) Arranging timely post-discharge follow-up serv-
ices to the high-risk Medicare beneficiary to provide 
the beneficiary (and, as appropriate, the primary care-
giver of the beneficiary) with information regarding 
responding to symptoms that may indicate additional 
health problems or a deteriorating condition. 
(iii) Providing the high-risk Medicare beneficiary 
(and, as appropriate, the primary caregiver of the bene-
ficiary) with assistance to ensure productive and timely 
interactions between patients and post-acute and out-
patient providers. 
(iv) Assessing and actively engaging with a high- 
risk Medicare beneficiary (and, as appropriate, the pri-
mary caregiver of the beneficiary) through the provi-
sion of self-management support and relevant informa-
tion that is specific to the beneficiary’s condition. 
(v) Conducting comprehensive medication review 
and management (including, if appropriate, counseling 
and self-management support). 
(C) LIMITATION.—A care transition intervention pro-
posed under subparagraph (B) may not include payment 
for services required under the discharge planning process 
described in section 1861(ee) of the Social Security Act 
(42 U.S.C. 1395x(ee)). 
(3) SELECTION.—In selecting eligible entities to participate 
in the program, the Secretary shall give priority to eligible 
entities that— 
(A) participate in a program administered by the 
Administration on Aging to provide concurrent care transi-
tions interventions with multiple hospitals and practi-
tioners; or 
(B) provide services to medically underserved popu-
lations, small communities, and rural areas. 
(d) IMPLEMENTATION.—Notwithstanding any other provision of 
law, the Secretary may implement the provisions of this section 
by program instruction or otherwise. 
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124 STAT. 415 
PUBLIC LAW 111–148—MAR. 23, 2010 
(e) WAIVER
AUTHORITY.—The Secretary may waive such 
requirements of titles XI and XVIII of the Social Security Act 
as may be necessary to carry out the program. 
(f) FUNDING.—For purposes of carrying out this section, the 
Secretary of Health and Human Services shall provide 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 under sec-
tion 1841 of such Act (42 U.S.C. 1395t), in such proportion as 
the Secretary determines appropriate, of $500,000,000, to the Cen-
ters for Medicare & Medicaid Services Program Management 
Account for the period of fiscal years 2011 through 2015. Amounts 
transferred under the preceding sentence shall remain available 
until expended. 
SEC. 3027. EXTENSION OF GAINSHARING DEMONSTRATION. 
(a) IN GENERAL.—Subsection (d)(3) of section 5007 of the Deficit 
Reduction Act of 2005 (Public Law 109–171) is amended by inserting 
‘‘(or September 30, 2011, in the case of a demonstration project 
in operation as of October 1, 2008)’’ after ‘‘December 31, 2009’’. 
(b) FUNDING.— 
(1) IN
GENERAL.—Subsection (f)(1) of such section is 
amended by inserting ‘‘and for fiscal year 2010, $1,600,000,’’ 
after ‘‘$6,000,000,’’. 
(2) AVAILABILITY.—Subsection (f)(2) of such section is 
amended by striking ‘‘2010’’ and inserting ‘‘2014 or until 
expended’’. 
(c) REPORTS.— 
(1) QUALITY IMPROVEMENT AND SAVINGS.—Subsection (e)(3) 
of such section is amended by striking ‘‘December 1, 2008’’ 
and inserting ‘‘March 31, 2011’’. 
(2) FINAL
REPORT.—Subsection (e)(4) of such section is 
amended by striking ‘‘May 1, 2010’’ and inserting ‘‘March 31, 
2013’’. 
Subtitle B—Improving Medicare for 
Patients and Providers 
PART I—ENSURING BENEFICIARY ACCESS TO 
PHYSICIAN CARE AND OTHER SERVICES 
SEC. 3101. INCREASE IN THE PHYSICIAN PAYMENT UPDATE. 
Section 1848(d) of the Social Security Act (42 U.S.C. 1395w– 
4(d)) is amended by adding at the end the following new paragraph: 
‘‘(10) UPDATE FOR 2010.— 
‘‘(A) IN GENERAL.—Subject to paragraphs (7)(B), (8)(B), 
and (9)(B), in lieu of the update to the single conversion 
factor established in paragraph (1)(C) that would otherwise 
apply for 2010, the update to the single conversion factor 
shall be 0.5 percent. 
‘‘(B) NO
EFFECT
ON
COMPUTATION
OF
CONVERSION 
FACTOR FOR 2011 AND SUBSEQUENT YEARS.—The conversion 
factor under this subsection shall be computed under para-
graph (1)(A) for 2011 and subsequent years as if subpara-
graph (A) had never applied.’’. 
42 USC 1395ww 
note. 
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124 STAT. 416 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 3102. EXTENSION OF THE WORK GEOGRAPHIC INDEX FLOOR AND 
REVISIONS TO THE PRACTICE EXPENSE GEOGRAPHIC 
ADJUSTMENT UNDER THE MEDICARE PHYSICIAN FEE 
SCHEDULE. 
(a) EXTENSION OF WORK GPCI FLOOR.—Section 1848(e)(1)(E) 
of the Social Security Act (42 U.S.C. 1395w–4(e)(1)(E)) is amended 
by striking ‘‘before January 1, 2010’’ and inserting ‘‘before January 
1, 2011’’. 
(b) PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT FOR 2010 AND 
SUBSEQUENT YEARS.—Section 1848(e)(1) of the Social Security Act 
(42 U.S.C. 1395w4(e)(1)) is amended— 
(1) in subparagraph (A), by striking ‘‘and (G)’’ and inserting 
‘‘(G), and (H)’’; and 
(2) by adding at the end the following new subparagraph: 
‘‘(H) PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT FOR 
2010 AND SUBSEQUENT YEARS.— 
‘‘(i) FOR 2010.—Subject to clause (iii), for services 
furnished during 2010, the employee wage and rent 
portions of the practice expense geographic index 
described in subparagraph (A)(i) shall reflect 3⁄4 of 
the difference between the relative costs of employee 
wages and rents in each of the different fee schedule 
areas and the national average of such employee wages 
and rents. 
‘‘(ii) FOR 2011.—Subject to clause (iii), for services 
furnished during 2011, the employee wage and rent 
portions of the practice expense geographic index 
described in subparagraph (A)(i) shall reflect 1⁄2 of 
the difference between the relative costs of employee 
wages and rents in each of the different fee schedule 
areas and the national average of such employee wages 
and rents. 
‘‘(iii) HOLD HARMLESS.—The practice expense por-
tion of the geographic adjustment factor applied in 
a fee schedule area for services furnished in 2010 or 
2011 shall not, as a result of the application of clause 
(i) or (ii), be reduced below the practice expense portion 
of the geographic adjustment factor under subpara-
graph (A)(i) (as calculated prior to the application of 
such clause (i) or (ii), respectively) for such area for 
such year. 
‘‘(iv) ANALYSIS.—The Secretary shall analyze cur-
rent 
methods 
of 
establishing 
practice 
expense 
geographic adjustments under subparagraph (A)(i) and 
evaluate data that fairly and reliably establishes 
distinctions in the costs of operating a medical practice 
in the different fee schedule areas. Such analysis shall 
include an evaluation of the following: 
‘‘(I) The feasibility of using actual data or reli-
able survey data developed by medical organiza-
tions on the costs of operating a medical practice, 
including office rents and non-physician staff 
wages, in different fee schedule areas. 
‘‘(II) The office expense portion of the practice 
expense 
geographic 
adjustment 
described 
in 
subparagraph (A)(i), including the extent to which 
42 USC 1395w–4. 
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124 STAT. 417 
PUBLIC LAW 111–148—MAR. 23, 2010 
types of office expenses are determined in local 
markets instead of national markets. 
‘‘(III) The weights assigned to each of the cat-
egories within the practice expense geographic 
adjustment described in subparagraph (A)(i). 
‘‘(v) REVISION FOR 2012 AND SUBSEQUENT YEARS.— 
As a result of the analysis described in clause (iv), 
the Secretary shall, not later than January 1, 2012, 
make appropriate adjustments to the practice expense 
geographic adjustment described in subparagraph 
(A)(i) to ensure accurate geographic adjustments across 
fee schedule areas, including— 
‘‘(I) basing the office rents component and its 
weight on office expenses that vary among fee 
schedule areas; and 
‘‘(II) considering a representative range of 
professional 
and 
non-professional 
personnel 
employed in a medical office based on the use 
of the American Community Survey data or other 
reliable data for wage adjustments. 
Such adjustments shall be made without regard to 
adjustments made pursuant to clauses (i) and (ii) and 
shall be made in a budget neutral manner.’’. 
SEC. 3103. EXTENSION OF EXCEPTIONS PROCESS FOR MEDICARE 
THERAPY CAPS. 
Section 1833(g)(5) of the Social Security Act (42 U.S.C. 
1395l(g)(5)) is amended by striking ‘‘December 31, 2009’’ and 
inserting ‘‘December 31, 2010’’. 
SEC. 3104. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF 
CERTAIN PHYSICIAN PATHOLOGY SERVICES. 
Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits 
Improvement and Protection Act of 2000 (as enacted into law by 
section 1(a)(6) of Public Law 106–554), as amended by section 
732 of the Medicare Prescription Drug, Improvement, and Mod-
ernization Act of 2003 (42 U.S.C. 1395w–4 note), section 104 of 
division B of the Tax Relief and Health Care Act of 2006 (42 
U.S.C. 1395w–4 note), section 104 of the Medicare, Medicaid, and 
SCHIP Extension Act of 2007 (Public Law 110–173), and section 
136 of the Medicare Improvements for Patients and Providers Act 
of 2008 (Public Law 110–275), is amended by striking ‘‘and 2009’’ 
and inserting ‘‘2009, and 2010’’. 
SEC. 3105. 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)) is amended— 
(1) in the matter preceding clause (i)— 
(A) by striking ‘‘2007, and for’’ and inserting ‘‘2007, 
for’’; and 
(B) by striking ‘‘2010’’ and inserting ‘‘2010, and for 
such services furnished on or after April 1, 2010, and 
before January 1, 2011,’’; and 
(2) in each of clauses (i) and (ii), by inserting ‘‘, and on 
or after April 1, 2010, and before January 1, 2011’’ after 
‘‘January 1, 2010’’ each place it appears. 
(b) AIR
AMBULANCE.—Section 146(b)(1) of the Medicare 
Improvements for Patients and Providers Act of 2008 (Public Law 
42 USC 1395m 
note. 
Deadline. 
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124 STAT. 418 
PUBLIC LAW 111–148—MAR. 23, 2010 
110–275) is amended by striking ‘‘December 31, 2009’’ and inserting 
‘‘December 31, 2009, and during the period beginning on April 
1, 2010, and ending on January 1, 2011’’. 
(c) SUPER RURAL AMBULANCE.—Section 1834(l)(12)(A) of the 
Social Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended by 
striking ‘‘2010’’ and inserting ‘‘2010, and on or after April 1, 2010, 
and before January 1, 2011’’. 
SEC. 3106. EXTENSION OF CERTAIN PAYMENT RULES FOR LONG-TERM 
CARE HOSPITAL SERVICES AND OF MORATORIUM ON 
THE ESTABLISHMENT OF CERTAIN HOSPITALS AND 
FACILITIES. 
(a) EXTENSION OF 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 Amer-
ican Recovery and Reinvestment Act (Public Law 111–5), is further 
amended by striking ‘‘3-year period’’ each place it appears and 
inserting ‘‘4-year period’’. 
(b) EXTENSION OF MORATORIUM.—Section 114(d)(1) of such Act 
(42 U.S.C. 1395ww note), in the matter preceding subparagraph 
(A), is amended by striking ‘‘3-year period’’ and inserting ‘‘4-year 
period’’. 
SEC. 3107. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH 
ADD-ON. 
Section 138(a)(1) of the Medicare Improvements for Patients 
and Providers Act of 2008 (Public Law 110–275) is amended by 
striking ‘‘December 31, 2009’’ and inserting ‘‘December 31, 2010’’. 
SEC. 3108. PERMITTING PHYSICIAN ASSISTANTS TO ORDER POST-HOS-
PITAL EXTENDED CARE SERVICES. 
(a) ORDERING POST-HOSPITAL EXTENDED CARE SERVICES.— 
(1) IN GENERAL.—Section 1814(a)(2) of the Social Security 
Act (42 U.S.C. 1395f(a)(2)), in the matter preceding subpara-
graph (A), is amended by striking ‘‘or clinical nurse specialist’’ 
and inserting ‘‘, a clinical nurse specialist, or a physician assist-
ant (as those terms are defined in section 1861(aa)(5))’’ after 
‘‘nurse practitioner’’. 
(2) CONFORMING
AMENDMENT.—Section 1814(a) of the 
Social Security Act (42 U.S.C. 1395f(a)) is amended, in the 
second sentence, by striking ‘‘or clinical nurse specialist’’ and 
inserting ‘‘clinical nurse specialist, or physician assistant’’ after 
‘‘nurse practitioner,’’. 
(b) EFFECTIVE DATE.—The amendments made by this section 
shall apply to items and services furnished on or after January 
1, 2011. 
SEC. 3109. EXEMPTION OF CERTAIN PHARMACIES FROM ACCREDITA-
TION REQUIREMENTS. 
(a) IN GENERAL.—Section 1834(a)(20) of the Social Security 
Act (42 U.S.C. 1395m(a)(20)), as added by section 154(b)(1)(A) of 
the Medicare Improvements for Patients and Providers Act of 2008 
(Public Law 100–275), is amended— 
(1) in subparagraph (F)(i)— 
(A) by inserting ‘‘and subparagraph (G)’’ after ‘‘clause 
(ii)’’; and 
(B) by inserting ‘‘, except that the Secretary shall not 
require a pharmacy to have submitted to the Secretary 
42 USC 1395f 
note. 
42 USC 1395w–4 
note. 
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124 STAT. 419 
PUBLIC LAW 111–148—MAR. 23, 2010 
such evidence of accreditation prior to January 1, 2011’’ 
before the semicolon at the end; and 
(2) by adding at the end the following new subparagraph: 
‘‘(G) APPLICATION OF ACCREDITATION REQUIREMENT TO 
CERTAIN PHARMACIES.— 
‘‘(i) IN GENERAL.—With respect to items and serv-
ices furnished on or after January 1, 2011, in imple-
menting quality standards under this paragraph— 
‘‘(I) subject to subclause (II), in applying such 
standards and the accreditation requirement of 
subparagraph (F)(i) with respect to pharmacies 
described in clause (ii) furnishing such items and 
services, such standards and accreditation require-
ment shall not apply to such pharmacies; and 
‘‘(II) the Secretary may apply to such phar-
macies an alternative accreditation requirement 
established by the Secretary if the Secretary deter-
mines such alternative accreditation requirement 
is more appropriate for such pharmacies. 
‘‘(ii) 
PHARMACIES
DESCRIBED.—A 
pharmacy 
described in this clause is a pharmacy that meets 
each of the following criteria: 
‘‘(I) The total billings by the pharmacy for 
such items and services under this title are less 
than 5 percent of total pharmacy sales, as deter-
mined based on the average total pharmacy sales 
for the previous 3 calendar years, 3 fiscal years, 
or other yearly period specified by the Secretary. 
‘‘(II) The pharmacy has been enrolled under 
section 1866(j) as a supplier of durable medical 
equipment, prosthetics, orthotics, and supplies, has 
been issued (which may include the renewal of) 
a provider number for at least 5 years, and for 
which a final adverse action (as defined in section 
424.57(a) of title 42, Code of Federal Regulations) 
has not been imposed in the past 5 years. 
‘‘(III) The pharmacy submits to the Secretary 
an attestation, in a form and manner, and at a 
time, specified by the Secretary, that the pharmacy 
meets the criteria described in subclauses (I) and 
(II). Such attestation shall be subject to section 
1001 of title 18, United States Code. 
‘‘(IV) The pharmacy agrees to submit materials 
as requested by the Secretary, or during the course 
of an audit conducted on a random sample of phar-
macies selected annually, to verify that the phar-
macy meets the criteria described in subclauses 
(I) and (II). Materials submitted under the pre-
ceding sentence shall include a certification by an 
accountant on behalf of the pharmacy or the 
submission of tax returns filed by the pharmacy 
during the relevant periods, as requested by the 
Secretary.’’. 
(b) ADMINISTRATION.—Notwithstanding any other provision of 
law, the Secretary may implement the amendments made by sub-
section (a) by program instruction or otherwise. 
42 USC 1395m 
note. 
Criteria. 
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124 STAT. 420 
PUBLIC LAW 111–148—MAR. 23, 2010 
(c) RULE OF CONSTRUCTION.—Nothing in the provisions of or 
amendments made by this section shall be construed as affecting 
the application of an accreditation requirement for pharmacies to 
qualify for bidding in a competitive acquisition area under section 
1847 of the Social Security Act (42 U.S.C. 1395w–3). 
SEC. 3110. PART B SPECIAL ENROLLMENT PERIOD FOR DISABLED 
TRICARE BENEFICIARIES. 
(a) IN GENERAL.— 
(1) IN GENERAL.—Section 1837 of the Social Security Act 
(42 U.S.C. 1395p) is amended by adding at the end the following 
new subsection: 
‘‘(l)(1) In the case of any individual who is a covered beneficiary 
(as defined in section 1072(5) of title 10, United States Code) 
at the time the individual is entitled to part A under section 
226(b) or section 226A and who is eligible to enroll but who has 
elected not to enroll (or to be deemed enrolled) during the individ-
ual’s initial enrollment period, there shall be a special enrollment 
period described in paragraph (2). 
‘‘(2) The special enrollment period described in this paragraph, 
with respect to an individual, is the 12-month period beginning 
on the day after the last day of the initial enrollment period of 
the individual or, if later, the 12-month period beginning with 
the month the individual is notified of enrollment under this section. 
‘‘(3) In the case of an individual who enrolls during the special 
enrollment period provided under paragraph (1), the coverage period 
under this part shall begin on the first day of the month in which 
the individual enrolls, or, at the option of the individual, the first 
month after the end of the individual’s initial enrollment period. 
‘‘(4) An individual may only enroll during the special enrollment 
period provided under paragraph (1) one time during the individ-
ual’s lifetime. 
‘‘(5) The Secretary shall ensure that the materials relating 
to coverage under this part that are provided to an individual 
described in paragraph (1) prior to the individual’s initial enrollment 
period contain information concerning the impact of not enrolling 
under this part, including the impact on health care benefits under 
the TRICARE program under chapter 55 of title 10, United States 
Code. 
‘‘(6) The Secretary of Defense shall collaborate with the Sec-
retary of Health and Human Services and the Commissioner of 
Social Security to provide for the accurate identification of individ-
uals described in paragraph (1). The Secretary of Defense shall 
provide such individuals with notification with respect to this sub-
section. The Secretary of Defense shall collaborate with the Sec-
retary of Health and Human Services and the Commissioner of 
Social Security to ensure appropriate follow up pursuant to any 
notification provided under the preceding sentence.’’. 
(2) EFFECTIVE DATE.—The amendment made by paragraph 
(1) shall apply to elections made with respect to initial enroll-
ment periods that end after the date of the enactment of this 
Act. 
(b) WAIVER OF INCREASE OF PREMIUM.—Section 1839(b) of the 
Social Security Act (42 U.S.C. 1395r(b)) is amended by striking 
‘‘section 1837(i)(4)’’ and inserting ‘‘subsection (i)(4) or (l) of section 
1837’’. 
42 USC 1395p 
note. 
42 USC 1395m 
note. 
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124 STAT. 421 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 3111. PAYMENT FOR BONE DENSITY TESTS. 
(a) PAYMENT.— 
(1) IN GENERAL.—Section 1848 of the Social Security Act 
(42 U.S.C. 1395w–4) is amended— 
(A) in subsection (b)— 
(i) in paragraph (4)(B), by inserting ‘‘, and for 
2010 and 2011, dual-energy x-ray absorptiometry serv-
ices (as described in paragraph (6))’’ before the period 
at the end; and 
(ii) by adding at the end the following new para-
graph: 
‘‘(6) TREATMENT OF BONE MASS SCANS.—For dual-energy 
x-ray absorptiometry services (identified in 2006 by HCPCS 
codes 76075 and 76077 (and any succeeding codes)) furnished 
during 2010 and 2011, instead of the payment amount that 
would otherwise be determined under this section for such 
years, the payment amount shall be equal to 70 percent of 
the product of— 
‘‘(A) the relative value for the service (as determined 
in subsection (c)(2)) for 2006; 
‘‘(B) the conversion factor (established under subsection 
(d)) for 2006; and 
‘‘(C) the geographic adjustment factor (established 
under subsection (e)(2)) for the service for the fee schedule 
area for 2010 and 2011, respectively.’’; and 
(B) in subsection (c)(2)(B)(iv)— 
(i) in subclause (II), by striking ‘‘and’’ at the end; 
(ii) in subclause (III), by striking the period at 
the end and inserting ‘‘; and’’; and 
(iii) by adding at the end the following new sub-
clause: 
‘‘(IV) subsection (b)(6) shall not be taken into 
account in applying clause (ii)(II) for 2010 or 
2011.’’. 
(2) IMPLEMENTATION.—Notwithstanding any other provi-
sion of law, the Secretary may implement the amendments 
made by paragraph (1) by program instruction or otherwise. 
(b) STUDY AND REPORT BY THE INSTITUTE OF MEDICINE.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services is authorized to enter into an agreement with the 
Institute of Medicine of the National Academies to conduct 
a study on the ramifications of Medicare payment reductions 
for dual-energy x-ray absorptiometry (as described in section 
1848(b)(6) of the Social Security Act, as added by subsection 
(a)(1)) during 2007, 2008, and 2009 on beneficiary access to 
bone mass density tests. 
(2) REPORT.—An agreement entered into under paragraph 
(1) shall provide for the Institute of Medicine to submit to 
the Secretary and to Congress a report containing the results 
of the study conducted under such paragraph. 
SEC. 3112. REVISION TO THE MEDICARE IMPROVEMENT FUND. 
Section 1898(b)(1)(A) of the Social Security Act (42 U.S.C. 
1395iii) is amended by striking ‘‘$22,290,000,000’’ and inserting 
‘‘$0’’. 
42 USC 1395w–4 
note. 
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124 STAT. 422 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 3113. TREATMENT OF CERTAIN COMPLEX DIAGNOSTIC LABORA-
TORY TESTS. 
(a) DEMONSTRATION PROJECT.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’) shall 
conduct a demonstration project under part B title XVIII of 
the Social Security Act under which separate payments are 
made under such part for complex diagnostic laboratory tests 
provided to individuals under such part. Under the demonstra-
tion project, the Secretary shall establish appropriate payment 
rates for such tests. 
(2) COVERED
COMPLEX
DIAGNOSTIC
LABORATORY
TEST 
DEFINED.—In this section, the term ‘‘complex diagnostic labora-
tory test’’ means a diagnostic laboratory test— 
(A) that is an analysis of gene protein expression, 
topographic genotyping, or a cancer chemotherapy sensi-
tivity assay; 
(B) that is determined by the Secretary to be a labora-
tory test for which there is not an alternative test having 
equivalent performance characteristics; 
(C) which is billed using a Health Care Procedure 
Coding System (HCPCS) code other than a not otherwise 
classified code under such Coding System; 
(D) which is approved or cleared by the Food and 
Drug Administration or is covered under title XVIII of 
the Social Security Act; and 
(E) is described in section 1861(s)(3) of the Social Secu-
rity Act (42 U.S.C. 1395x(s)(3)). 
(3) SEPARATE PAYMENT DEFINED.—In this section, the term 
‘‘separate payment’’ means direct payment to a laboratory 
(including a hospital-based or independent laboratory) that per-
forms a complex diagnostic laboratory test with respect to a 
specimen collected from an individual during a period in which 
the individual is a patient of a hospital if the test is performed 
after such period of hospitalization and if separate payment 
would not otherwise be made under title XVIII of the Social 
Security 
Act 
by 
reason 
of 
sections 
1862(a)(14) 
and 
1866(a)(1)(H)(i) of the such Act (42 U.S.C. 1395y(a)(14); 42 
U.S.C. 1395cc(a)(1)(H)(i)). 
(b) DURATION.—Subject to subsection (c)(2), the Secretary shall 
conduct the demonstration project under this section for the 2- 
year period beginning on July 1, 2011. 
(c) PAYMENTS
AND LIMITATION.—Payments under the dem-
onstration project under this section shall— 
(1) be made from the Federal Supplemental Medical Insur-
ance Trust Fund under section 1841 of the Social Security 
Act (42 U.S.C. 1395t); and 
(2) may not exceed $100,000,000. 
(d) REPORT.—Not later than 2 years after the completion of 
the demonstration project under this section, the Secretary shall 
submit to Congress a report on the project. Such report shall 
include— 
(1) an assessment of the impact of the demonstration 
project on access to care, quality of care, health outcomes, 
and expenditures under title XVIII of the Social Security Act 
(including any savings under such title); and 
42 USC 1395l 
note. 
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124 STAT. 423 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) such recommendations as the Secretary determines 
appropriate. 
(e) IMPLEMENTATION FUNDING.—For purposes of administering 
this section (including preparing and submitting the report under 
subsection (d)), the Secretary shall provide for the transfer, from 
the Federal Supplemental Medical Insurance Trust Fund under 
section 1841 of the Social Security Act (42 U.S.C. 1395t), to the 
Centers for Medicare & Medicaid Services Program Management 
Account, of $5,000,000. Amounts transferred under the preceding 
sentence shall remain available until expended. 
SEC. 3114. IMPROVED ACCESS FOR CERTIFIED NURSE-MIDWIFE SERV-
ICES. 
Section 1833(a)(1)(K) of the Social Security Act (42 U.S.C. 
1395l(a)(1)(K)) is amended by inserting ‘‘(or 100 percent for services 
furnished on or after January 1, 2011)’’ after ‘‘1992, 65 percent’’. 
PART II—RURAL PROTECTIONS 
SEC. 3121. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION. 
(a) IN GENERAL.—Section 1833(t)(7)(D)(i) of the Social Security 
Act (42 U.S.C. 1395l(t)(7)(D)(i)) is amended— 
(1) in subclause (II)— 
(A) in the first sentence, by striking ‘‘2010’’and 
inserting ‘‘2011’’; and 
(B) in the second sentence, by striking ‘‘or 2009’’ and 
inserting ‘‘, 2009, or 2010’’; and 
(2) in subclause (III), by striking ‘‘January 1, 2010’’ and 
inserting ‘‘January 1, 2011’’. 
(b) PERMITTING
ALL
SOLE
COMMUNITY
HOSPITALS
TO
BE 
ELIGIBLE FOR HOLD HARMLESS.—Section 1833(t)(7)(D)(i)(III) of the 
Social Security Act (42 U.S.C. 1395l(t)(7)(D)(i)(III)) is amended by 
adding at the end the following new sentence: ‘‘In the case of 
covered OPD services furnished on or after January 1, 2010, and 
before January 1, 2011, the preceding sentence shall be applied 
without regard to the 100-bed limitation.’’. 
SEC. 3122. EXTENSION OF MEDICARE REASONABLE COSTS PAYMENTS 
FOR 
CERTAIN 
CLINICAL 
DIAGNOSTIC 
LABORATORY 
TESTS FURNISHED TO HOSPITAL PATIENTS IN CERTAIN 
RURAL AREAS. 
Section 416(b) of the Medicare Prescription Drug, Improvement, 
and Modernization Act of 2003 (42 U.S.C. 1395l–4), as amended 
by section 105 of division B of the Tax Relief and Health Care 
Act of 2006 (42 U.S.C. 1395l note) and section 107 of the Medicare, 
Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395l note), 
is amended by inserting ‘‘or during the 1-year period beginning 
on July 1, 2010’’ before the period at the end. 
SEC. 3123. EXTENSION OF THE RURAL COMMUNITY HOSPITAL DEM-
ONSTRATION PROGRAM. 
(a) ONE-YEAR
EXTENSION.—Section 410A of the Medicare 
Prescription Drug, Improvement, and Modernization Act of 2003 
(Public Law 108–173; 117 Stat. 2272) is amended by adding at 
the end the following new subsection: 
‘‘(g) ONE-YEAR EXTENSION OF DEMONSTRATION PROGRAM.— 
‘‘(1) IN GENERAL.—Subject to the succeeding provisions of 
this subsection, the Secretary shall conduct the demonstration 
42 USC 1395ww 
note. 
42 USC 1395l 
note. 
Time period. 
Applicability. 
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124 STAT. 424 
PUBLIC LAW 111–148—MAR. 23, 2010 
program under this section for an additional 1-year period 
(in this section referred to as the ‘1-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.—Notwith-
standing subsection (a)(2), during the 1-year extension period, 
the Secretary shall expand the number of States with low 
population densities determined by the Secretary under such 
subsection to 20. In determining which States to include in 
such expansion, 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 HOSPITALS PARTICI-
PATING
IN
THE
DEMONSTRATION
PROGRAM.—Notwithstanding 
subsection (a)(4), during the 1-year extension period, not more 
than 30 rural community hospitals may participate in the dem-
onstration program under this section. 
‘‘(4) NO AFFECT ON HOSPITALS IN DEMONSTRATION PROGRAM 
ON DATE OF ENACTMENT.—In the case of a rural community 
hospital that is participating in the demonstration program 
under this section as of the last day of the initial 5-year 
period, the Secretary shall provide for the continued participa-
tion of such rural community hospital in the demonstration 
program during the 1-year extension period unless the rural 
community hospital makes an election, in such form and 
manner as the Secretary may specify, to discontinue such 
participation.’’. 
(b) CONFORMING AMENDMENTS.—Subsection (a)(5) of section 
410A of the Medicare Prescription Drug, Improvement, and Mod-
ernization Act of 2003 (Public Law 108–173; 117 Stat. 2272) is 
amended by inserting ‘‘(in this section referred to as the ‘initial 
5-year period’) and, as provided in subsection (g), for the 1-year 
extension period’’ after ‘‘5-year period’’. 
(c) TECHNICAL AMENDMENTS.— 
(1) Subsection (b) of section 410A of the Medicare Prescrip-
tion Drug, Improvement, and Modernization Act of 2003 (Public 
Law 108–173; 117 Stat. 2272) is amended— 
(A) in paragraph (1)(B)(ii), by striking ‘‘2)’’ and 
inserting ‘‘2))’’; and 
(B) in paragraph (2), by inserting ‘‘cost’’ before 
‘‘reporting period’’ the first place such term appears in 
each of subparagraphs (A) and (B). 
(2) Subsection (f)(1) of section 410A of the Medicare 
Prescription Drug, Improvement, and Modernization Act of 
2003 (Public Law 108–173; 117 Stat. 2272) is amended— 
(A) in subparagraph (A)(ii), by striking ‘‘paragraph (2)’’ 
and inserting ‘‘subparagraph (B)’’; and 
(B) in subparagraph (B), by striking ‘‘paragraph (1)(B)’’ 
and inserting ‘‘subparagraph (A)(ii)’’. 
SEC. 3124. EXTENSION OF THE MEDICARE-DEPENDENT HOSPITAL 
(MDH) PROGRAM. 
(a) 
EXTENSION
OF
PAYMENT
METHODOLOGY.—Section 
1886(d)(5)(G) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(G)) 
is amended— 
(1) in clause (i), by striking ‘‘October 1, 2011’’ and inserting 
‘‘October 1, 2012’’; and 
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124 STAT. 425 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) in clause (ii)(II), by striking ‘‘October 1, 2011’’ and 
inserting ‘‘October 1, 2012’’. 
(b) CONFORMING AMENDMENTS.— 
(1) EXTENSION OF TARGET AMOUNT.—Section 1886(b)(3)(D) 
of the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is 
amended— 
(A) in the matter preceding clause (i), by striking 
‘‘October 1, 2011’’ and inserting ‘‘October 1, 2012’’; and 
(B) in clause (iv), by striking ‘‘through fiscal year 2011’’ 
and inserting ‘‘through fiscal year 2012’’. 
(2) PERMITTING HOSPITALS TO DECLINE RECLASSIFICATION.— 
Section 13501(e)(2) of the Omnibus Budget Reconciliation Act 
of 1993 (42 U.S.C. 1395ww note) is amended by striking 
‘‘through fiscal year 2011’’ and inserting ‘‘through fiscal year 
2012’’. 
SEC. 
3125. 
TEMPORARY 
IMPROVEMENTS 
TO 
THE 
MEDICARE 
INPATIENT HOSPITAL PAYMENT ADJUSTMENT FOR LOW- 
VOLUME HOSPITALS. 
Section 1886(d)(12) of the Social Security Act (42 U.S.C. 
1395ww(d)(12)) is amended— 
(1) in subparagraph (A), by inserting ‘‘or (D)’’ after 
‘‘subparagraph (B)’’; 
(2) in subparagraph (B), in the matter preceding clause 
(i), by striking ‘‘The Secretary’’ and inserting ‘‘For discharges 
occurring in fiscal years 2005 through 2010 and for discharges 
occurring in fiscal year 2013 and subsequent fiscal years, the 
Secretary’’; 
(3) in subparagraph (C)(i)— 
(A) by inserting ‘‘(or, with respect to fiscal years 2011 
and 2012, 15 road miles)’’ after ‘‘25 road miles’’; and 
(B) by inserting ‘‘(or, with respect to fiscal years 2011 
and 2012, 1,500 discharges of individuals entitled to, or 
enrolled for, benefits under part A)’’ after ‘‘800 discharges’’; 
and 
(4) by adding at the end the following new subparagraph: 
‘‘(D) TEMPORARY APPLICABLE PERCENTAGE INCREASE.— 
For discharges occurring in fiscal years 2011 and 2012, 
the Secretary shall determine an applicable percentage 
increase for purposes of subparagraph (A) using a contin-
uous linear sliding scale ranging from 25 percent for low- 
volume hospitals with 200 or fewer discharges of individ-
uals entitled to, or enrolled for, benefits under part A 
in the fiscal year to 0 percent for low-volume hospitals 
with greater than 1,500 discharges of such individuals 
in the fiscal year.’’. 
SEC. 3126. IMPROVEMENTS TO THE DEMONSTRATION PROJECT ON 
COMMUNITY HEALTH INTEGRATION MODELS IN CERTAIN 
RURAL COUNTIES. 
(a) REMOVAL OF LIMITATION ON NUMBER OF ELIGIBLE COUNTIES 
SELECTED.—Subsection (d)(3) of section 123 of the Medicare 
Improvements for Patients and Providers Act of 2008 (42 U.S.C. 
1395i–4 note) is amended by striking ‘‘not more than 6’’. 
(b) REMOVAL OF REFERENCES TO RURAL HEALTH CLINIC SERV-
ICES AND INCLUSION OF PHYSICIANS’ SERVICES IN SCOPE OF DEM-
ONSTRATION PROJECT.—Such section 123 is amended— 
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124 STAT. 426 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) in subsection (d)(4)(B)(i)(3), by striking subclause (III); 
and 
(2) in subsection (j)— 
(A) in paragraph (8), by striking subparagraph (B) 
and inserting the following: 
‘‘(B) Physicians’ services (as defined in section 1861(q) 
of the Social Security Act (42 U.S.C. 1395x(q)).’’; 
(B) by striking paragraph (9); and 
(C) by redesignating paragraph (10) as paragraph (9). 
SEC. 3127. MEDPAC STUDY ON ADEQUACY OF MEDICARE PAYMENTS 
FOR HEALTH CARE PROVIDERS SERVING IN RURAL 
AREAS. 
(a) STUDY.—The Medicare Payment Advisory Commission shall 
conduct a study on the adequacy of payments for items and services 
furnished by providers of services and suppliers in rural areas 
under the Medicare program under title XVIII of the Social Security 
Act (42 U.S.C. 1395 et seq.). Such study shall include an analysis 
of— 
(1) any adjustments in payments to providers of services 
and suppliers that furnish items and services in rural areas; 
(2) access by Medicare beneficiaries to items and services 
in rural areas; 
(3) the adequacy of payments to providers of services and 
suppliers that furnish items and services in rural areas; and 
(4) the quality of care furnished in rural areas. 
(b) REPORT.—Not later than January 1, 2011, the Medicare 
Payment Advisory Commission shall submit to Congress a report 
containing the results of the study conducted under subsection 
(a). Such report shall include recommendations on appropriate modi-
fications to any adjustments in payments to providers of services 
and suppliers that furnish items and services in rural areas, 
together with recommendations for such legislation and administra-
tive action as the Medicare Payment Advisory Commission deter-
mines appropriate. 
SEC. 3128. TECHNICAL CORRECTION RELATED TO CRITICAL ACCESS 
HOSPITAL SERVICES. 
(a) IN GENERAL.—Subsections (g)(2)(A) and (l)(8) of section 1834 
of the Social Security Act (42 U.S.C. 1395m) are each amended 
by inserting ‘‘101 percent of’’ before ‘‘the reasonable costs’’. 
(b) EFFECTIVE DATE.—The amendments made by subsection 
(a) shall take effect as if included in the enactment of section 
405(a) of the Medicare Prescription Drug, Improvement, and Mod-
ernization Act of 2003 (Public Law 108–173; 117 Stat. 2266). 
SEC. 3129. EXTENSION OF AND REVISIONS TO MEDICARE RURAL HOS-
PITAL FLEXIBILITY PROGRAM. 
(a) AUTHORIZATION.—Section 1820(j) of the Social Security Act 
(42 U.S.C. 1395i–4(j)) is amended— 
(1) by striking ‘‘2010, and for’’ and inserting ‘‘2010, for’’; 
and 
(2) by inserting ‘‘and for making grants to all States under 
subsection (g), such sums as may be necessary in each of 
fiscal years 2011 and 2012, to remain available until expended’’ 
before the period at the end. 
(b) USE OF FUNDS.—Section 1820(g)(3) of the Social Security 
Act (42 U.S.C. 1395i–4(g)(3)) is amended— 
42 USC 1395m 
note. 
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124 STAT. 427 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) in subparagraph (A), by inserting ‘‘and to assist such 
hospitals in participating in delivery system reforms under 
the provisions of and amendments made by the Patient Protec-
tion and Affordable Care Act, such as value-based purchasing 
programs, accountable care organizations under section 1899, 
the National pilot program on payment bundling under section 
1866D, and other delivery system reform programs determined 
appropriate by the Secretary’’ before the period at the end; 
and 
(2) in subparagraph (E)— 
(A) by striking ‘‘, and to offset’’ and inserting ‘‘, to 
offset’’; and 
(B) by inserting ‘‘and to participate in delivery system 
reforms under the provisions of and amendments made 
by the Patient Protection and Affordable Care Act, such 
as value-based purchasing programs, accountable care 
organizations under section 1899, the National pilot pro-
gram on payment bundling under section 1866D, and other 
delivery system reform programs determined appropriate 
by the Secretary’’ before the period at the end. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to grants made on or after January 1, 2010. 
PART III—IMPROVING PAYMENT ACCURACY 
SEC. 3131. PAYMENT ADJUSTMENTS FOR HOME HEALTH CARE. 
(a) REBASING HOME HEALTH PROSPECTIVE PAYMENT AMOUNT.— 
(1) IN GENERAL.—Section 1895(b)(3)(A) of the Social Secu-
rity Act (42 U.S.C. 1395fff(b)(3)(A)) is amended— 
(A) in clause (i)(III), by striking ‘‘For periods’’ and 
inserting ‘‘Subject to clause (iii), for periods’’; and 
(B) by adding at the end the following new clause: 
‘‘(iii) ADJUSTMENT
FOR
2013
AND
SUBSEQUENT 
YEARS.— 
‘‘(I) IN
GENERAL.—Subject to subclause (II), 
for 2013 and subsequent years, the amount (or 
amounts) that would otherwise be applicable under 
clause (i)(III) shall be adjusted by a percentage 
determined appropriate by the Secretary to reflect 
such factors as changes in the number of visits 
in an episode, the mix of services in an episode, 
the level of intensity of services in an episode, 
the average cost of providing care per episode, 
and other factors that the Secretary considers to 
be relevant. In conducting the analysis under the 
preceding sentence, the Secretary may consider 
differences 
between 
hospital-based 
and 
free-
standing agencies, between for-profit and nonprofit 
agencies, and between the resource costs of urban 
and rural agencies. Such adjustment shall be made 
before the update under subparagraph (B) is 
applied for the year. 
‘‘(II) TRANSITION.—The Secretary shall provide 
for a 4-year phase-in (in equal increments) of the 
adjustment under subclause (I), with such adjust-
ment being fully implemented for 2016. During 
each year of such phase-in, the amount of any 
42 USC 1395i–4 
note. 
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124 STAT. 428 
PUBLIC LAW 111–148—MAR. 23, 2010 
adjustment under subclause (I) for the year may 
not exceed 3.5 percent of the amount (or amounts) 
applicable under clause (i)(III) as of the date of 
enactment of the Patient Protection and Affordable 
Care Act.’’. 
(2) MEDPAC STUDY AND REPORT.— 
(A) STUDY.—The Medicare Payment Advisory Commis-
sion shall conduct a study on the implementation of the 
amendments made by paragraph (1). Such study shall 
include an analysis of the impact of such amendments 
on— 
(i) access to care; 
(ii) quality outcomes; 
(iii) the number of home health agencies; and 
(iv) rural agencies, urban agencies, for-profit agen-
cies, and nonprofit agencies. 
(B) REPORT.—Not later than January 1, 2015, the 
Medicare Payment Advisory Commission shall submit to 
Congress a report on the study conducted under subpara-
graph (A), together with recommendations for such legisla-
tion and administrative action as the Commission deter-
mines appropriate. 
(b) PROGRAM-SPECIFIC OUTLIER CAP.—Section 1895(b) of the 
Social Security Act (42 U.S.C. 1395fff(b)) is amended— 
(1) in paragraph (3)(C), by striking ‘‘the aggregate’’ and 
all that follows through the period at the end and inserting 
‘‘5 percent of the total payments estimated to be made based 
on the prospective payment system under this subsection for 
the period.’’; and 
(2) in paragraph (5)— 
(A) by striking ‘‘OUTLIERS.—The Secretary’’ and 
inserting the following: ‘‘OUTLIERS.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 
Secretary’’; 
(B) in subparagraph (A), as added by subparagraph 
(A), by striking ‘‘5 percent’’ and inserting ‘‘2.5 percent’’; 
and 
(C) by adding at the end the following new subpara-
graph: 
‘‘(B) PROGRAM SPECIFIC OUTLIER CAP.—The estimated 
total amount of additional payments or payment adjust-
ments made under subparagraph (A) with respect to a 
home health agency for a year (beginning with 2011) may 
not exceed an amount equal to 10 percent of the estimated 
total amount of payments made under this section (without 
regard to this paragraph) with respect to the home health 
agency for the year.’’. 
(c) APPLICATION OF THE MEDICARE RURAL HOME HEALTH ADD- 
ON
POLICY.—Section 421 of the Medicare Prescription Drug, 
Improvement, and Modernization Act of 2003 (Public Law 108– 
173; 117 Stat. 2283), as amended by section 5201(b) of the Deficit 
Reduction Act of 2005 (Public Law 109–171; 120 Stat. 46), is 
amended— 
(1) in the section heading, by striking ‘‘ONE-YEAR’’ and 
inserting ‘‘TEMPORARY’’; and 
(2) in subsection (a)— 
42 USC 1395fff 
note. 
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124 STAT. 429 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) by striking ‘‘, and episodes’’ and inserting ‘‘, epi-
sodes’’; 
(B) by inserting ‘‘and episodes and visits ending on 
or after April 1, 2010, and before January 1, 2016,’’ after 
‘‘January 1, 2007,’’; and 
(C) by inserting ‘‘(or, in the case of episodes and visits 
ending on or after April 1, 2010, and before January 1, 
2016, 3 percent)’’ before the period at the end. 
(d) STUDY AND REPORT ON THE DEVELOPMENT OF HOME HEALTH 
PAYMENT REFORMS IN ORDER TO ENSURE ACCESS TO CARE AND 
QUALITY SERVICES.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’) shall 
conduct a study to evaluate the costs and quality of care among 
efficient home health agencies relative to other such agencies 
in providing ongoing access to care and in treating Medicare 
beneficiaries with varying severity levels of illness. Such study 
shall include an analysis of the following: 
(A) Methods to revise the home health prospective 
payment system under section 1895 of the Social Security 
Act (42 U.S.C. 1395fff) to more accurately account for the 
costs related to patient severity of illness or to improving 
beneficiary access to care, including— 
(i) payment adjustments for services that may be 
under- or over-valued; 
(ii) necessary changes to reflect the resource use 
relative to providing home health services to low- 
income Medicare beneficiaries or Medicare bene-
ficiaries living in medically underserved areas; 
(iii) ways the outlier payment may be improved 
to more accurately reflect the cost of treating Medicare 
beneficiaries with high severity levels of illness; 
(iv) the role of quality of care incentives and pen-
alties in driving provider and patient behavior; 
(v) improvements in the application of a wage 
index; and 
(vi) other areas determined appropriate by the Sec-
retary. 
(B) The validity and reliability of responses on the 
OASIS instrument with particular emphasis on questions 
that relate to higher payment under the home health 
prospective payment system and higher outcome scores 
under Home Care Compare. 
(C) Additional research or payment revisions under 
the home health prospective payment system that may 
be necessary to set the payment rates for home health 
services based on costs of high-quality and efficient home 
health agencies or to improve Medicare beneficiary access 
to care. 
(D) A timetable for implementation of any appropriate 
changes based on the analysis of the matters described 
in subparagraphs (A), (B), and (C). 
(E) Other areas determined appropriate by the Sec-
retary. 
(2) CONSIDERATIONS.—In conducting the study under para-
graph (1), the Secretary shall consider whether certain factors 
42 USC 1395fff 
note. 
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124 STAT. 430 
PUBLIC LAW 111–148—MAR. 23, 2010 
should be used to measure patient severity of illness and access 
to care, such as— 
(A) population density and relative patient access to 
care; 
(B) variations in service costs for providing care to 
individuals who are dually eligible under the Medicare 
and Medicaid programs; 
(C) the presence of severe or chronic diseases, as evi-
denced by multiple, discontinuous home health episodes; 
(D) poverty status, as evidenced by the receipt of 
Supplemental Security Income under title XVI of the Social 
Security Act; 
(E) the absence of caregivers; 
(F) language barriers; 
(G) atypical transportation costs; 
(H) security costs; and 
(I) other factors determined appropriate by the Sec-
retary. 
(3) REPORT.—Not later than March 1, 2011, the Secretary 
shall submit to Congress a report on the study conducted under 
paragraph (1), together with recommendations for such legisla-
tion and administrative action as the Secretary determines 
appropriate. 
(4) CONSULTATIONS.—In conducting the study under para-
graph (1) and preparing the report under paragraph (3), the 
Secretary shall consult with— 
(A) stakeholders representing home health agencies; 
(B) groups representing Medicare beneficiaries; 
(C) the Medicare Payment Advisory Commission; 
(D) the Inspector General of the Department of Health 
and Human Services; and 
(E) the Comptroller General of the United States. 
SEC. 3132. HOSPICE REFORM. 
(a) HOSPICE CARE PAYMENT REFORMS.— 
(1) IN
GENERAL.—Section 1814(i) of the Social Security 
Act (42 U.S.C. 1395f(i)), as amended by section 3004(c), is 
amended— 
(A) by redesignating paragraph (6) as paragraph (7); 
and 
(B) by inserting after paragraph (5) the following new 
paragraph: 
‘‘(6)(A) The Secretary shall collect additional data and 
information as the Secretary determines appropriate to revise 
payments for hospice care under this subsection pursuant to 
subparagraph (D) and for other purposes as determined appro-
priate by the Secretary. The Secretary shall begin to collect 
such data by not later than January 1, 2011. 
‘‘(B) The additional data and information to be collected 
under subparagraph (A) may include data and information 
on— 
‘‘(i) charges and payments; 
‘‘(ii) the number of days of hospice care which are 
attributable to individuals who are entitled to, or enrolled 
for, benefits under part A; and 
‘‘(iii) with respect to each type of service included in 
hospice care— 
Deadline. 
Data and 
information 
collection. 
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124 STAT. 431 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(I) the number of days of hospice care attributable 
to the type of service; 
‘‘(II) the cost of the type of service; and 
‘‘(III) the amount of payment for the type of service; 
‘‘(iv) charitable contributions and other revenue of the 
hospice program; 
‘‘(v) the number of hospice visits; 
‘‘(vi) the type of practitioner providing the visit; and 
‘‘(vii) the length of the visit and other basic information 
with respect to the visit. 
‘‘(C) The Secretary may collect the additional data and 
information under subparagraph (A) on cost reports, claims, 
or other mechanisms as the Secretary determines to be appro-
priate. 
‘‘(D)(i) Notwithstanding the preceding paragraphs of this 
subsection, not earlier than October 1, 2013, the Secretary 
shall, by regulation, implement revisions to the methodology 
for determining the payment rates for routine home care and 
other services included in hospice care under this part, as 
the Secretary determines to be appropriate. Such revisions 
may be based on an analysis of data and information collected 
under subparagraph (A). Such revisions may include adjust-
ments to per diem payments that reflect changes in resource 
intensity in providing such care and services during the course 
of the entire episode of hospice care. 
‘‘(ii) Revisions in payment implemented pursuant to clause 
(i) shall result in the same estimated amount of aggregate 
expenditures under this title for hospice care furnished in the 
fiscal year in which such revisions in payment are implemented 
as would have been made under this title for such care in 
such fiscal year if such revisions had not been implemented. 
‘‘(E) The Secretary shall consult with hospice programs 
and the Medicare Payment Advisory Commission regarding 
the additional data and information to be collected under 
subparagraph (A) and the payment revisions under subpara-
graph (D).’’. 
(2) CONFORMING AMENDMENTS.—Section 1814(i)(1)(C) of the 
Social Security Act (42 U.S.C. 1395f(i)(1)(C)) is amended— 
(A) in clause (ii)— 
(i) in the matter preceding subclause (I), by 
inserting ‘‘(before the first fiscal year in which the 
payment revisions described in paragraph (6)(D) are 
implemented)’’ after ‘‘subsequent fiscal year’’; and 
(ii) in subclause (VII), by inserting ‘‘(before the 
first fiscal year in which the payment revisions 
described in paragraph (6)(D) are implemented), sub-
ject to clause (iv),’’ after ‘‘subsequent fiscal year’’; and 
(B) by adding at the end the following new clause: 
‘‘(iii) With respect to routine home care and other 
services included in hospice care furnished during fiscal 
years subsequent to the first fiscal year in which pay-
ment revisions described in paragraph (6)(D) are imple-
mented, the payment rates for such care and services 
shall be the payment rates in effect under this clause 
during the preceding fiscal year increased by, subject 
to clause (iv), the market basket percentage increase 
Deadline. 
Regulation. 
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124 STAT. 432 
PUBLIC LAW 111–148—MAR. 23, 2010 
(as defined in section 1886(b)(3)(B)(iii)) for the fiscal 
year.’’. 
(b) ADOPTION OF MEDPAC HOSPICE PROGRAM ELIGIBILITY RE-
CERTIFICATION RECOMMENDATIONS.—Section 1814(a)(7) of the Social 
Security Act (42 U.S.C. 1395f(a)(7)) is amended— 
(1) in subparagraph (B), by striking ‘‘and’’ at the end; 
and 
(2) by adding at the end the following new subparagraph: 
‘‘(D) on and after January 1, 2011— 
‘‘(i) a hospice physician or nurse practitioner has 
a face-to-face encounter with the individual to deter-
mine continued eligibility of the individual for hospice 
care prior to the 180th-day recertification and each 
subsequent recertification under subparagraph (A)(ii) 
and attests that such visit took place (in accordance 
with procedures established by the Secretary); and 
‘‘(ii) in the case of hospice care provided an indi-
vidual for more than 180 days by a hospice program 
for which the number of such cases for such program 
comprises more than a percent (specified by the Sec-
retary) of the total number of such cases for all pro-
grams under this title, the hospice care provided to 
such individual is medically reviewed (in accordance 
with procedures established by the Secretary); and’’. 
SEC. 3133. IMPROVEMENT TO MEDICARE DISPROPORTIONATE SHARE 
HOSPITAL (DSH) PAYMENTS. 
Section 1886 of the Social Security Act (42 U.S.C. 1395ww), 
as amended by sections 3001, 3008, and 3025, is amended— 
(1) in subsection (d)(5)(F)(i), by striking ‘‘For’’ and inserting 
‘‘Subject to subsection (r), for’’; and 
(2) by adding at the end the following new subsection: 
‘‘(r) ADJUSTMENTS TO MEDICARE DSH PAYMENTS.— 
‘‘(1) EMPIRICALLY JUSTIFIED DSH PAYMENTS.—For fiscal year 
2015 and each subsequent fiscal year, instead of the amount 
of disproportionate share hospital payment that would other-
wise be made under subsection (d)(5)(F) to a subsection (d) 
hospital for the fiscal year, the Secretary shall pay to the 
subsection (d) hospital 25 percent of such amount (which rep-
resents the empirically justified amount for such payment, as 
determined by the Medicare Payment Advisory Commission 
in its March 2007 Report to the Congress). 
‘‘(2) ADDITIONAL
PAYMENT.—In addition to the payment 
made to a subsection (d) hospital under paragraph (1), for 
fiscal year 2015 and each subsequent fiscal year, the Secretary 
shall pay to such subsection (d) hospitals an additional amount 
equal to the product of the following factors: 
‘‘(A) FACTOR
ONE.—A factor equal to the difference 
between— 
‘‘(i) the aggregate amount of payments that would 
be made to subsection (d) hospitals under subsection 
(d)(5)(F) if this subsection did not apply for such fiscal 
year (as estimated by the Secretary); and 
‘‘(ii) the aggregate amount of payments that are 
made to subsection (d) hospitals under paragraph (1) 
for such fiscal year (as so estimated). 
‘‘(B) FACTOR TWO.— 
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124 STAT. 433 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) FISCAL YEARS 2015, 2016, AND 2017.—For each 
of fiscal years 2015, 2016, and 2017, a factor equal 
to 1 minus the percent change (divided by 100) in 
the percent of individuals under the age of 65 who 
are uninsured, as determined by comparing the percent 
of such individuals— 
‘‘(I) who are uninsured in 2012, the last year 
before coverage expansion under the Patient 
Protection and Affordable Care Act (as calculated 
by the Secretary based on the most recent esti-
mates available from the Director of the Congres-
sional Budget Office before a vote in either House 
on such Act that, if determined in the affirmative, 
would clear such Act for enrollment); and 
‘‘(II) who are uninsured in the most recent 
period for which data is available (as so cal-
culated). 
‘‘(ii) 2018 AND SUBSEQUENT YEARS.—For fiscal year 
2018 and each subsequent fiscal year, a factor equal 
to 1 minus the percent change (divided by 100) in 
the percent of individuals who are uninsured, as deter-
mined by comparing the percent of individuals— 
‘‘(I) who are uninsured in 2012 (as estimated 
by the Secretary, based on data from the Census 
Bureau or other sources the Secretary determines 
appropriate, and certified by the Chief Actuary 
of the Centers for Medicare & Medicaid Services); 
and 
‘‘(II) who are uninsured in the most recent 
period for which data is available (as so estimated 
and certified). 
‘‘(C) FACTOR THREE.—A factor equal to the percent, 
for each subsection (d) hospital, that represents the 
quotient of— 
‘‘(i) the amount of uncompensated care for such 
hospital for a period selected by the Secretary (as 
estimated by the Secretary, based on appropriate data 
(including, in the case where the Secretary determines 
that alternative data is available which is a better 
proxy for the costs of subsection (d) hospitals for 
treating the uninsured, the use of such alternative 
data)); and 
‘‘(ii) the aggregate amount of uncompensated care 
for all subsection (d) hospitals that receive a payment 
under this subsection for such period (as so estimated, 
based on such data). 
‘‘(3) LIMITATIONS ON REVIEW.—There shall be no adminis-
trative or judicial review under section 1869, section 1878, 
or otherwise of the following: 
‘‘(A) Any estimate of the Secretary for purposes of 
determining the factors described in paragraph (2). 
‘‘(B) Any period selected by the Secretary for such 
purposes.’’. 
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124 STAT. 434 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 3134. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE. 
(a) IN GENERAL.—Section 1848(c)(2) of the Social Security Act 
(42 U.S.C. 1395w–4(c)(2)) is amended by adding at the end the 
following new subparagraphs: 
‘‘(K) POTENTIALLY MISVALUED CODES.— 
‘‘(i) IN GENERAL.—The Secretary shall— 
‘‘(I) periodically identify services as being 
potentially misvalued using criteria specified in 
clause (ii); and 
‘‘(II) review and make appropriate adjustments 
to the relative values established under this para-
graph for services identified as being potentially 
misvalued under subclause (I). 
‘‘(ii) IDENTIFICATION
OF
POTENTIALLY
MISVALUED 
CODES.—For 
purposes 
of 
identifying 
potentially 
misvalued services pursuant to clause (i)(I), the Sec-
retary shall examine (as the Secretary determines to 
be appropriate) codes (and families of codes as appro-
priate) for which there has been the fastest growth; 
codes (and families of codes as appropriate) that have 
experienced substantial changes in practice expenses; 
codes for new technologies or services within an appro-
priate period (such as 3 years) after the relative values 
are initially established for such codes; multiple codes 
that are frequently billed in conjunction with fur-
nishing a single service; codes with low relative values, 
particularly those that are often billed multiple times 
for a single treatment; codes which have not been 
subject to review since the implementation of the 
RBRVS (the so-called ‘Harvard-valued codes’); and such 
other codes determined to be appropriate by the Sec-
retary. 
‘‘(iii) REVIEW AND ADJUSTMENTS.— 
‘‘(I) The Secretary may use existing processes 
to receive recommendations on the review and 
appropriate adjustment of potentially misvalued 
services described in clause (i)(II). 
‘‘(II) The Secretary may conduct surveys, other 
data collection activities, studies, or other analyses 
as the Secretary determines to be appropriate to 
facilitate the review and appropriate adjustment 
described in clause (i)(II). 
‘‘(III) The Secretary may use analytic contrac-
tors to identify and analyze services identified 
under clause (i)(I), conduct surveys or collect data, 
and make recommendations on the review and 
appropriate adjustment of services described in 
clause (i)(II). 
‘‘(IV) The Secretary may coordinate the review 
and appropriate adjustment described in clause 
(i)(II) with the periodic review described in 
subparagraph (B). 
‘‘(V) As part of the review and adjustment 
described in clause (i)(II), including with respect 
to codes with low relative values described in 
clause (ii), the Secretary may make appropriate 
coding revisions (including using existing processes 
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124 STAT. 435 
PUBLIC LAW 111–148—MAR. 23, 2010 
for consideration of coding changes) which may 
include consolidation of individual services into 
bundled codes for payment under the fee schedule 
under subsection (b). 
‘‘(VI) The provisions of subparagraph (B)(ii)(II) 
shall apply to adjustments to relative value units 
made pursuant to this subparagraph in the same 
manner as such provisions apply to adjustments 
under subparagraph (B)(ii)(II). 
‘‘(L) VALIDATING RELATIVE VALUE UNITS.— 
‘‘(i) IN GENERAL.—The Secretary shall establish a 
process to validate relative value units under the fee 
schedule under subsection (b). 
‘‘(ii) COMPONENTS AND ELEMENTS OF WORK.—The 
process described in clause (i) may include validation 
of work elements (such as time, mental effort and 
professional judgment, technical skill and physical 
effort, and stress due to risk) involved with furnishing 
a service and may include validation of the pre-, post- 
, and intra-service components of work. 
‘‘(iii) SCOPE
OF
CODES.—The validation of work 
relative value units shall include a sampling of codes 
for services that is the same as the codes listed under 
subparagraph (K)(ii). 
‘‘(iv) METHODS.—The Secretary may conduct the 
validation under this subparagraph using methods 
described in subclauses (I) through (V) of subparagraph 
(K)(iii) as the Secretary determines to be appropriate. 
‘‘(v) ADJUSTMENTS.—The Secretary shall make 
appropriate adjustments to the work relative value 
units under the fee schedule under subsection (b). The 
provisions of subparagraph (B)(ii)(II) shall apply to 
adjustments to relative value units made pursuant 
to this subparagraph in the same manner as such 
provisions apply to adjustments under subparagraph 
(B)(ii)(II).’’. 
(b) IMPLEMENTATION.— 
(1) ADMINISTRATION.— 
(A) Chapter 35 of title 44, United States Code and 
the provisions of the Federal Advisory Committee Act (5 
U.S.C. App.) shall not apply to this section or the amend-
ment made by this section. 
(B) Notwithstanding any other provision of law, the 
Secretary may implement subparagraphs (K) and (L) of 
1848(c)(2) of the Social Security Act, as added by subsection 
(a), by program instruction or otherwise. 
(C) Section 4505(d) of the Balanced Budget Act of 
1997 is repealed. 
(D) Except for provisions related to confidentiality of 
information, the provisions of the Federal Acquisition Regu-
lation shall not apply to this section or the amendment 
made by this section. 
(2) FOCUSING CMS RESOURCES ON POTENTIALLY OVERVALUED 
CODES.—Section 1868(a) of the Social Security Act (42 U.S.C. 
1395ee(a)) is repealed. 
Repeal. 
Repeal. 
42 USC 1395w–4 
note. 
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124 STAT. 436 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 3135. MODIFICATION OF EQUIPMENT UTILIZATION FACTOR FOR 
ADVANCED IMAGING SERVICES. 
(a) ADJUSTMENT IN PRACTICE EXPENSE TO REFLECT HIGHER 
PRESUMED UTILIZATION.—Section 1848 of the Social Security Act 
(42 U.S.C. 1395w–4) is amended— 
(1) in subsection (b)(4)— 
(A) in subparagraph (B), by striking ‘‘subparagraph 
(A)’’ and inserting ‘‘this paragraph’’; and 
(B) by adding at the end the following new subpara-
graph: 
‘‘(C) ADJUSTMENT IN PRACTICE EXPENSE TO REFLECT 
HIGHER PRESUMED UTILIZATION.—Consistent with the meth-
odology for computing the number of practice expense rel-
ative value units under subsection (c)(2)(C)(ii) with respect 
to advanced diagnostic imaging services (as defined in sec-
tion 1834(e)(1)(B)) furnished on or after January 1, 2010, 
the Secretary shall adjust such number of units so it 
reflects— 
‘‘(i) in the case of services furnished on or after 
January 1, 2010, and before January 1, 2013, a 65 
percent (rather than 50 percent) presumed rate of utili-
zation of imaging equipment; 
‘‘(ii) in the case of services furnished on or after 
January 1, 2013, and before January 1, 2014, a 70 
percent (rather than 50 percent) presumed rate of utili-
zation of imaging equipment; and 
‘‘(iii) in the case of services furnished on or after 
January 1, 2014, a 75 percent (rather than 50 percent) 
presumed rate of utilization of imaging equipment.’’; 
and 
(2) in subsection (c)(2)(B)(v), by adding at the end the 
following new subclauses: 
‘‘(III) CHANGE IN PRESUMED UTILIZATION LEVEL 
OF CERTAIN ADVANCED DIAGNOSTIC IMAGING SERV-
ICES
FOR
2010
THROUGH
2012.—Effective for fee 
schedules established beginning with 2010 and 
ending with 2012, reduced expenditures attrib-
utable to the presumed rate of utilization of 
imaging equipment of 65 percent under subsection 
(b)(4)(C)(i) instead of a presumed rate of utilization 
of such equipment of 50 percent. 
‘‘(IV) CHANGE IN PRESUMED UTILIZATION LEVEL 
OF CERTAIN ADVANCED DIAGNOSTIC IMAGING SERV-
ICES FOR 2013.—Effective for fee schedules estab-
lished for 2013, reduced expenditures attributable 
to the presumed rate of utilization of imaging 
equipment 
of 
70 
percent 
under 
subsection 
(b)(4)(C)(ii) instead of a presumed rate of utiliza-
tion of such equipment of 50 percent. 
‘‘(V) CHANGE IN PRESUMED UTILIZATION LEVEL 
OF CERTAIN ADVANCED DIAGNOSTIC IMAGING SERV-
ICES FOR 2014 AND SUBSEQUENT YEARS.—Effective 
for fee schedules established beginning with 2014, 
reduced expenditures attributable to the presumed 
Time periods. 
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124 STAT. 437 
PUBLIC LAW 111–148—MAR. 23, 2010 
rate of utilization of imaging equipment of 75 per-
cent under subsection (b)(4)(C)(iii) instead of a pre-
sumed rate of utilization of such equipment of 
50 percent.’’. 
(b) ADJUSTMENT
IN TECHNICAL COMPONENT ‘‘DISCOUNT’’ ON 
SINGLE-SESSION IMAGING TO CONSECUTIVE BODY PARTS.—Section 
1848 of the Social Security Act (42 U.S.C. 1395w–4), as amended 
by subsection (a), is amended— 
(1) in subsection (b)(4), by adding at the end the following 
new subparagraph: 
‘‘(D) ADJUSTMENT IN TECHNICAL COMPONENT DISCOUNT 
ON SINGLE-SESSION IMAGING INVOLVING CONSECUTIVE BODY 
PARTS.—For services furnished on or after July 1, 2010, 
the Secretary shall increase the reduction in payments 
attributable to the multiple procedure payment reduction 
applicable to the technical component for imaging under 
the final rule published by the Secretary in the Federal 
Register on November 21, 2005 (part 405 of title 42, Code 
of Federal Regulations) from 25 percent to 50 percent.’’; 
and 
(2) in subsection (c)(2)(B)(v), by adding at the end the 
following new subclause: 
‘‘(VI) ADDITIONAL REDUCED PAYMENT FOR MUL-
TIPLE
IMAGING
PROCEDURES.—Effective for fee 
schedules established beginning with 2010 (but 
not applied for services furnished prior to July 
1, 2010), reduced expenditures attributable to the 
increase in the multiple procedure payment reduc-
tion from 25 to 50 percent (as described in sub-
section (b)(4)(D)).’’. 
(c) ANALYSIS BY THE CHIEF ACTUARY OF THE CENTERS FOR 
MEDICARE & MEDICAID SERVICES.—Not later than January 1, 2013, 
the Chief Actuary of the Centers for Medicare & Medicaid Services 
shall make publicly available an analysis of whether, for the period 
of 2010 through 2019, the cumulative expenditure reductions under 
title XVIII of the Social Security Act that are attributable to the 
adjustments under the amendments made by this section are pro-
jected to exceed $3,000,000,000. 
SEC. 3136. REVISION OF PAYMENT FOR POWER-DRIVEN WHEELCHAIRS. 
(a) IN GENERAL.—Section 1834(a)(7)(A) of the Social Security 
Act (42 U.S.C. 1395m(a)(7)(A)) is amended— 
(1) in clause (i)— 
(A) in subclause (II), by inserting ‘‘subclause (III) and’’ 
after ‘‘Subject to’’; and 
(B) by adding at the end the following new subclause: 
‘‘(III) SPECIAL RULE FOR POWER-DRIVEN WHEEL-
CHAIRS.—For purposes of payment for power- 
driven wheelchairs, subclause (II) shall be applied 
by substituting ‘15 percent’ and ‘6 percent’ for ‘10 
percent’ and ‘7.5 percent’, respectively.’’; and 
(2) in clause (iii)— 
(A) in the heading, by inserting ‘‘COMPLEX, REHABILITA-
TIVE’’ before ‘‘POWER-DRIVEN’’; and 
(B) by inserting ‘‘complex, rehabilitative’’ before 
‘‘power-driven’’. 
Deadline. 
Public 
information. 
Time period. 
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124 STAT. 438 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b) TECHNICAL AMENDMENT.—Section 1834(a)(7)(C)(ii)(II) of the 
Social Security Act (42 U.S.C. 1395m(a)(7)(C)(ii)(II)) is amended 
by striking ‘‘(A)(ii) or’’. 
(c) EFFECTIVE DATE.— 
(1) IN GENERAL.—Subject to paragraph (2), the amendments 
made by subsection (a) shall take effect on January 1, 2011, 
and shall apply to power-driven wheelchairs furnished on or 
after such date. 
(2) APPLICATION
TO
COMPETITIVE
BIDDING.—The amend-
ments made by subsection (a) shall not apply to payment made 
for items and services furnished pursuant to contracts entered 
into under section 1847 of the Social Security Act (42 U.S.C. 
1395w–3) prior to January 1, 2011, pursuant to the implementa-
tion of subsection (a)(1)(B)(i)(I) of such section 1847. 
SEC. 3137. HOSPITAL WAGE INDEX IMPROVEMENT. 
(a) EXTENSION OF SECTION 508 HOSPITAL RECLASSIFICATIONS.— 
(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 117 of the Medicare, Med-
icaid, and SCHIP Extension Act of 2007 (Public Law 110– 
173) and section 124 of the Medicare Improvements for Patients 
and Providers Act of 2008 (Public Law 110–275), is amended 
by striking ‘‘September 30, 2009’’ and inserting ‘‘September 
30, 2010’’. 
(2) USE OF PARTICULAR WAGE INDEX IN FISCAL YEAR 2010.— 
For purposes of implementation of the amendment made by 
this subsection during fiscal year 2010, the Secretary shall 
use the hospital wage index that was promulgated by the 
Secretary in the Federal Register on August 27, 2009 (74 Fed. 
Reg. 43754), and any subsequent corrections. 
(b) PLAN FOR REFORMING THE MEDICARE HOSPITAL WAGE INDEX 
SYSTEM.— 
(1) IN GENERAL.—Not later than December 31, 2011, the 
Secretary of Health and Human Services (in this section 
referred to as the ‘‘Secretary’’) shall submit to Congress a 
report that includes a plan to reform the hospital wage index 
system under section 1886 of the Social Security Act. 
(2) DETAILS.—In developing the plan under paragraph (1), 
the Secretary shall take into account the goals for reforming 
such system set forth in the Medicare Payment Advisory 
Commission June 2007 report entitled ‘‘Report to Congress: 
Promoting Greater Efficiency in Medicare’’, including estab-
lishing a new hospital compensation index system that— 
(A) uses Bureau of Labor Statistics data, or other data 
or methodologies, to calculate relative wages for each 
geographic area involved; 
(B) minimizes wage index adjustments between and 
within metropolitan statistical areas and statewide rural 
areas; 
(C) includes methods to minimize the volatility of wage 
index adjustments that result from implementation of 
policy, while maintaining budget neutrality in applying 
such adjustments; 
(D) takes into account the effect that implementation 
of the system would have on health care providers and 
on each region of the country; 
Deadline. 
Reports. 
42 USC 1395ww 
note. 
42 USC 1395ww 
note. 
42 USC 1395ww 
note. 
Applicability. 
42 USC 1395m 
note. 
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124 STAT. 439 
PUBLIC LAW 111–148—MAR. 23, 2010 
(E) addresses issues related to occupational mix, such 
as staffing practices and ratios, and any evidence on the 
effect on quality of care or patient safety as a result of 
the implementation of the system; and 
(F) provides for a transition. 
(3) CONSULTATION.—In developing the plan under para-
graph (1), the Secretary shall consult with relevant affected 
parties. 
(c) USE OF PARTICULAR CRITERIA FOR DETERMINING RECLASSI-
FICATIONS.—Notwithstanding any other provision of law, in making 
decisions on applications for reclassification of a subsection (d) 
hospital (as defined in paragraph (1)(B) of section 1886(d) of the 
Social Security Act (42 U.S.C. 1395ww(d)) for the purposes described 
in paragraph (10)(D)(v) of such section for fiscal year 2011 and 
each subsequent fiscal year (until the first fiscal year beginning 
on or after the date that is 1 year after the Secretary of Health 
and Human Services submits the report to Congress under sub-
section (b)), the Geographic Classification Review Board established 
under paragraph (10) of such section shall use the average hourly 
wage comparison criteria used in making such decisions as of Sep-
tember 30, 2008. The preceding sentence shall be effected in a 
budget neutral manner. 
SEC. 3138. TREATMENT OF CERTAIN CANCER HOSPITALS. 
Section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t)) 
is amended by adding at the end the following new paragraph: 
‘‘(18) AUTHORIZATION
OF
ADJUSTMENT
FOR
CANCER
HOS-
PITALS.— 
‘‘(A) STUDY.—The Secretary shall conduct a study to 
determine if, under the system under this subsection, costs 
incurred by hospitals described in section 1886(d)(1)(B)(v) 
with respect to ambulatory payment classification groups 
exceed those costs incurred by other hospitals furnishing 
services under this subsection (as determined appropriate 
by the Secretary). In conducting the study under this 
subparagraph, the Secretary shall take into consideration 
the cost of drugs and biologicals incurred by such hospitals. 
‘‘(B) AUTHORIZATION OF ADJUSTMENT.—Insofar as the 
Secretary determines under subparagraph (A) that costs 
incurred by hospitals described in section 1886(d)(1)(B)(v) 
exceed those costs incurred by other hospitals furnishing 
services under this subsection, the Secretary shall provide 
for an appropriate adjustment under paragraph (2)(E) to 
reflect those higher costs effective for services furnished 
on or after January 1, 2011.’’. 
SEC. 3139. PAYMENT FOR BIOSIMILAR BIOLOGICAL PRODUCTS. 
(a) IN GENERAL.—Section 1847A of the Social Security Act 
(42 U.S.C. 1395w–3a) is amended— 
(1) in subsection (b)— 
(A) in paragraph (1)— 
(i) in subparagraph (A), by striking ‘‘or’’ at the 
end; 
(ii) in subparagraph (B), by striking the period 
at the end and inserting ‘‘; or’’; and 
(iii) by adding at the end the following new 
subparagraph: 
Effective date. 
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124 STAT. 440 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(C) in the case of a biosimilar biological product (as 
defined in subsection (c)(6)(H)), the amount determined 
under paragraph (8).’’; and 
(B) by adding at the end the following new paragraph: 
‘‘(8) BIOSIMILAR BIOLOGICAL PRODUCT.—The amount speci-
fied in this paragraph for a biosimilar biological product 
described in paragraph (1)(C) is the sum of— 
‘‘(A) the average sales price as determined using the 
methodology described under paragraph (6) applied to a 
biosimilar biological product for all National Drug Codes 
assigned to such product in the same manner as such 
paragraph is applied to drugs described in such paragraph; 
and 
‘‘(B) 6 percent of the amount determined under para-
graph (4) for the reference biological product (as defined 
in subsection (c)(6)(I)).’’; and 
(2) in subsection (c)(6), by adding at the end the following 
new subparagraph: 
‘‘(H) BIOSIMILAR BIOLOGICAL PRODUCT.—The term ‘bio-
similar biological product’ means a biological product 
approved under an abbreviated application for a license 
of a biological product that relies in part on data or informa-
tion in an application for another biological product licensed 
under section 351 of the Public Health Service Act. 
‘‘(I) REFERENCE BIOLOGICAL PRODUCT.—The term ‘ref-
erence biological product’ means the biological product 
licensed under such section 351 that is referred to in the 
application described in subparagraph (H) of the biosimilar 
biological product.’’. 
(b) EFFECTIVE DATE.—The amendments made by subsection 
(a) shall apply to payments for biosimilar biological products begin-
ning with the first day of the second calendar quarter after enact-
ment of legislation providing for a biosimilar pathway (as deter-
mined by the Secretary). 
SEC. 3140. MEDICARE HOSPICE CONCURRENT CARE DEMONSTRATION 
PROGRAM. 
(a) ESTABLISHMENT.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’) shall 
establish a Medicare Hospice Concurrent Care demonstration 
program at participating hospice programs under which Medi-
care beneficiaries are furnished, during the same period, hos-
pice care and any other items or services covered under title 
XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) from 
funds otherwise paid under such title to such hospice programs. 
(2) DURATION.—The demonstration program under this sec-
tion shall be conducted for a 3-year period. 
(3) SITES.—The Secretary shall select not more than 15 
hospice programs at which the demonstration program under 
this section shall be conducted. Such hospice programs shall 
be located in urban and rural areas. 
(b) INDEPENDENT EVALUATION AND REPORTS.— 
(1) INDEPENDENT EVALUATION.—The Secretary shall pro-
vide for the conduct of an independent evaluation of the dem-
onstration program under this section. Such independent 
evaluation shall determine whether the demonstration program 
42 USC 1395d 
note. 
Applicability. 
42 USC 
1395w–3a note. 
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124 STAT. 441 
PUBLIC LAW 111–148—MAR. 23, 2010 
has improved patient care, quality of life, and cost-effectiveness 
for Medicare beneficiaries participating in the demonstration 
program. 
(2) REPORTS.—The Secretary shall submit to Congress a 
report containing the results of the evaluation conducted under 
paragraph (1), together with such recommendations as the Sec-
retary determines appropriate. 
(c) BUDGET NEUTRALITY.—With respect to the 3-year period 
of the demonstration program under this section, the Secretary 
shall ensure that the aggregate expenditures under title XVIII 
for such period shall not exceed the aggregate expenditures that 
would have been expended under such title if the demonstration 
program under this section had not been implemented. 
SEC. 3141. APPLICATION OF BUDGET NEUTRALITY ON A NATIONAL 
BASIS IN THE CALCULATION OF THE MEDICARE HOS-
PITAL WAGE INDEX FLOOR. 
In the case of discharges occurring on or after October 1, 
2010, for purposes of applying section 4410 of the Balanced Budget 
Act of 1997 (42 U.S.C. 1395ww note) and paragraph (h)(4) of section 
412.64 of title 42, Code of Federal Regulations, the Secretary of 
Health and Human Services shall administer subsection (b) of such 
section 4410 and paragraph (e) of such section 412.64 in the same 
manner as the Secretary administered such subsection (b) and 
paragraph (e) for discharges occurring during fiscal year 2008 
(through a uniform, national adjustment to the area wage index). 
SEC. 3142. HHS STUDY ON URBAN MEDICARE-DEPENDENT HOSPITALS. 
(a) STUDY.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’) shall 
conduct a study on the need for an additional payment for 
urban Medicare-dependent hospitals for inpatient hospital serv-
ices under section 1886 of the Social Security Act (42 U.S.C. 
1395ww). Such study shall include an analysis of— 
(A) the Medicare inpatient margins of urban Medicare- 
dependent hospitals, as compared to other hospitals which 
receive 1 or more additional payments or adjustments 
under such section (including those payments or adjust-
ments described in paragraph (2)(A)); and 
(B) whether payments to medicare-dependent, small 
rural hospitals under subsection (d)(5)(G) of such section 
should be applied to urban Medicare-dependent hospitals. 
(2) URBAN MEDICARE-DEPENDENT HOSPITAL DEFINED.—For 
purposes of this section, the term ‘‘urban Medicare-dependent 
hospital’’ means a subsection (d) hospital (as defined in sub-
section (d)(1)(B) of such section) that— 
(A) does not receive any additional payment or adjust-
ment under such section, such as payments for indirect 
medical education costs under subsection (d)(5)(B) of such 
section, disproportionate share payments under subsection 
(d)(5)(A) of such section, payments to a rural referral center 
under subsection (d)(5)(C) of such section, payments to 
a critical access hospital under section 1814(l) of such Act 
(42 U.S.C. 1395f(l)), payments to a sole community hospital 
under subsection (d)(5)(D) of such section 1886, or pay-
ments to a medicare-dependent, small rural hospital under 
subsection (d)(5)(G) of such section 1886; and 
42 USC 1395ww 
note. 
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124 STAT. 442 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) for which more than 60 percent of its inpatient 
days or discharges during 2 of the 3 most recently audited 
cost reporting periods for which the Secretary has a settled 
cost report were attributable to inpatients entitled to bene-
fits under part A of title XVIII of such Act. 
(b) REPORT.—Not later than 9 months after the date of enact-
ment of this Act, the Secretary shall submit to Congress a report 
containing the results of the study conducted under subsection 
(a), together with recommendations for such legislation and 
administrative action as the Secretary determines appropriate. 
SEC. 3143. PROTECTING HOME HEALTH BENEFITS. 
Nothing in the provisions of, or amendments made by, this 
Act shall result in the reduction of guaranteed home health benefits 
under title XVIII of the Social Security Act. 
Subtitle C—Provisions Relating to Part C 
SEC. 3201. MEDICARE ADVANTAGE PAYMENT. 
(a) MA BENCHMARK BASED ON PLAN’S COMPETITIVE BIDS.— 
(1) IN
GENERAL.—Section 1853(j) of the Social Security 
Act (42 U.S.C. 1395w–23(j)) is amended— 
(A) 
by 
striking 
‘‘AMOUNTS.—For 
purposes’’ 
and 
inserting ‘‘AMOUNTS.— 
‘‘(1) IN GENERAL.—For purposes’’; 
(B) by redesignating paragraphs (1) and (2) as subpara-
graphs (A) and (B), respectively, and indenting the subpara-
graphs appropriately; 
(C) in subparagraph (A), as redesignated by subpara-
graph (B)— 
(i) by redesignating subparagraphs (A) and (B) 
as clauses (i) and (ii), respectively, and indenting the 
clauses appropriately; and 
(ii) in clause (i), as redesignated by clause (i), 
by striking ‘‘an amount equal to’’ and all that follows 
through the end and inserting ‘‘an amount equal to— 
‘‘(I) for years before 2007, 1⁄12 of the annual 
MA capitation rate under section 1853(c)(1) for 
the area for the year, adjusted as appropriate for 
the purpose of risk adjustment; 
‘‘(II) for 2007 through 2011, 
1⁄12
of the 
applicable amount determined under subsection 
(k)(1) for the area for the year; 
‘‘(III) for 2012, the sum of— 
‘‘(aa) 2⁄3 of the quotient of— 
‘‘(AA) the applicable amount deter-
mined under subsection (k)(1) for the area 
for the year; and 
‘‘(BB) 12; and 
‘‘(bb) 1⁄3 of the MA competitive benchmark 
amount (determined under paragraph (2)) for 
the area for the month; 
‘‘(IV) for 2013, the sum of— 
‘‘(aa) 1⁄3 of the quotient of— 
42 USC 1395d 
note. 
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124 STAT. 443 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(AA) the applicable amount deter-
mined under subsection (k)(1) for the area 
for the year; and 
‘‘(BB) 12; and 
‘‘(bb) 2⁄3 of the MA competitive benchmark 
amount (as so determined) for the area for 
the month; 
‘‘(V) for 2014, the MA competitive benchmark 
amount for the area for a month in 2013 (as so 
determined), increased by the national per capita 
MA growth percentage, described in subsection 
(c)(6) for 2014, but not taking into account any 
adjustment under subparagraph (C) of such sub-
section for a year before 2004; and 
‘‘(VI) for 2015 and each subsequent year, the 
MA competitive benchmark amount (as so deter-
mined) for the area for the month; or’’; 
(iii) in clause (ii), as redesignated by clause (i), 
by striking ‘‘subparagraph (A)’’ and inserting ‘‘clause 
(i)’’; 
(D) by adding at the end the following new paragraphs: 
‘‘(2) 
COMPUTATION
OF
MA
COMPETITIVE
BENCHMARK 
AMOUNT.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B) and 
paragraph (3), for months in each year (beginning with 
2012) for each MA payment area the Secretary shall com-
pute an MA competitive benchmark amount equal to the 
weighted average of the unadjusted MA statutory non- 
drug 
monthly 
bid 
amount 
(as 
defined 
in 
section 
1854(b)(2)(E)) for each MA plan in the area, with the weight 
for each plan being equal to the average number of bene-
ficiaries enrolled under such plan in the reference month 
(as defined in section 1858(f)(4), except that, in applying 
such definition for purposes of this paragraph, ‘to compute 
the MA competitive benchmark amount under section 
1853(j)(2)’ shall be substituted for ‘to compute the percent-
age specified in subparagraph (A) and other relevant 
percentages under this part’). 
‘‘(B) WEIGHTING RULES.— 
‘‘(i) SINGLE
PLAN
RULE.—In the case of an MA 
payment area in which only a single MA plan is being 
offered, the weight under subparagraph (A) shall be 
equal to 1. 
‘‘(ii) USE
OF
SIMPLE
AVERAGE
AMONG
MULTIPLE 
PLANS IF NO PLANS OFFERED IN PREVIOUS YEAR.—In 
the case of an MA payment area in which no MA 
plan was offered in the previous year and more than 
1 MA plan is offered in the current year, the Secretary 
shall use a simple average of the unadjusted MA statu-
tory non-drug monthly bid amount (as so defined) for 
purposes of computing the MA competitive benchmark 
amount under subparagraph (A). 
‘‘(3) CAP ON MA COMPETITIVE BENCHMARK AMOUNT.—In no 
case shall the MA competitive benchmark amount for an area 
for a month in a year be greater than the applicable amount 
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124 STAT. 444 
PUBLIC LAW 111–148—MAR. 23, 2010 
that would (but for the application of this subsection) be deter-
mined under subsection (k)(1) for the area for the month in 
the year.’’; and 
(E) in subsection (k)(2)(B)(ii)(III), by striking ‘‘(j)(1)(A)’’ 
and inserting ‘‘(j)(1)(A)(i)’’. 
(2) CONFORMING AMENDMENTS.— 
(A) Section 1853(k)(2) of the Social Security Act (42 
U.S.C. 1395w–23(k)(2)) is amended— 
(i) in subparagraph (A), by striking ‘‘through 2010’’ 
and inserting ‘‘and subsequent years’’; and 
(ii) in subparagraph (C)— 
(I) in clause (iii), by striking ‘‘and’’ at the 
end; 
(II) in clause (iv), by striking the period at 
the end and inserting ‘‘; and’’; and 
(III) by adding at the end the following new 
clause: 
‘‘(v) for 2011 and subsequent years, 0.00.’’. 
(B) Section 1854(b) of the Social Security Act (42 U.S.C. 
1395w–24(b)) is amended— 
(i) in paragraph (3)(B)(i), by striking ‘‘1853(j)(1)’’ 
and inserting ‘‘1853(j)(1)(A)’’; and 
(ii) in paragraph (4)(B)(i), by striking ‘‘1853(j)(2)’’ 
and inserting ‘‘1853(j)(1)(B)’’. 
(C) Section 1858(f) of the Social Security Act (42 U.S.C. 
1395w–27(f)) is amended— 
(i) in paragraph (1), by striking ‘‘1853(j)(2)’’ and 
inserting ‘‘1853(j)(1)(B)’’; and 
(ii) in paragraph (3)(A), by striking ‘‘1853(j)(1)(A)’’ 
and inserting ‘‘1853(j)(1)(A)(i)’’. 
(D) Section 1860C–1(d)(1)(A) of the Social Security Act 
(42 U.S.C. 1395w–29(d)(1)(A)) is amended by striking 
‘‘1853(j)(1)(A)’’ and inserting ‘‘1853(j)(1)(A)(i)’’. 
(b) REDUCTION OF NATIONAL PER CAPITA GROWTH PERCENTAGE 
FOR 2011.—Section 1853(c)(6) of the Social Security Act (42 U.S.C. 
1395w–23(c)(6)) is amended— 
(1) in clause (v), by striking ‘‘and’’ at the end; 
(2) in clause (vi)— 
(A) by striking ‘‘for a year after 2002’’ and inserting 
‘‘for 2003 through 2010’’; and 
(B) by striking the period at the end and inserting 
a comma; and 
(C) by adding at the end the following new clauses: 
‘‘(vii) for 2011, 3 percentage points; and 
‘‘(viii) for a year after 2011, 0 percentage points.’’. 
(c) 
ENHANCEMENT
OF
BENEFICIARY
REBATES.—Section 
1854(b)(1)(C)(i) of the Social Security Act (42 U.S.C. 1395w– 
24(b)(1)(C)(i)) is amended by inserting ‘‘(or 100 percent in the case 
of plan years beginning on or after January 1, 2014)’’ after ‘‘75 
percent’’. 
(d) BIDDING RULES.— 
(1) REQUIREMENTS FOR INFORMATION SUBMITTED.—Section 
1854(a)(6)(A) of the Social Security Act (42 U.S.C. 1395w– 
24(a)(6)(A)) is amended, in the flush matter following clause 
(v), by adding at the end the following sentence: ‘‘Information 
to be submitted under this paragraph shall be certified by 
a qualified member of the American Academy of Actuaries 
Certification. 
42 USC 
1395w–27a. 
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124 STAT. 445 
PUBLIC LAW 111–148—MAR. 23, 2010 
and shall meet actuarial guidelines and rules established by 
the Secretary under subparagraph (B)(v).’’. 
(2) ESTABLISHMENT
OF
ACTUARIAL
GUIDELINES.—Section 
1854(a)(6)(B) of the Social Security Act (42 U.S.C. 1395w– 
24(a)(6)(B)) is amended— 
(A) in clause (i), by striking ‘‘(iii) and (iv)’’ and inserting 
‘‘(iii), (iv), and (v)’’; and 
(B) by adding at the end the following new clause: 
‘‘(v) ESTABLISHMENT OF ACTUARIAL GUIDELINES.— 
‘‘(I) IN GENERAL.—In order to establish fair 
MA 
competitive 
benchmarks 
under 
section 
1853(j)(1)(A)(i), the Secretary, acting through the 
Chief Actuary of the Centers for Medicare & Med-
icaid Services (in this clause referred to as the 
‘Chief Actuary’), shall establish— 
‘‘(aa) actuarial guidelines for the submis-
sion of bid information under this paragraph; 
and 
‘‘(bb) bidding rules that are appropriate 
to ensure accurate bids and fair competition 
among MA plans. 
‘‘(II) DENIAL OF BID AMOUNTS.—The Secretary 
shall deny monthly bid amounts submitted under 
subparagraph (A) that do not meet the actuarial 
guidelines and rules established under subclause 
(I). 
‘‘(III) REFUSAL TO ACCEPT CERTAIN BIDS DUE 
TO
MISREPRESENTATIONS
AND
FAILURES
TO
ADE-
QUATELY MEET REQUIREMENTS.—In the case where 
the Secretary determines that information sub-
mitted by an MA organization under subparagraph 
(A) contains consistent misrepresentations and 
failures to adequately meet requirements of the 
organization, the Secretary may refuse to accept 
any additional such bid amounts from the 
organization for the plan year and the Chief 
Actuary shall, if the Chief Actuary determines that 
the actuaries of the organization were complicit 
in those misrepresentations and failures, report 
those actuaries to the Actuarial Board for Coun-
seling and Discipline.’’. 
(3) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to bid amounts submitted on or after 
January 1, 2012. 
(e) MA LOCAL PLAN SERVICE AREAS.— 
(1) IN GENERAL.—Section 1853(d) of the Social Security 
Act (42 U.S.C. 1395w–23(d)) is amended— 
(A) in the subsection heading, by striking ‘‘MA REGION’’ 
and inserting ‘‘MA REGION; MA LOCAL PLAN SERVICE 
AREA’’; 
(B) in paragraph (1), by striking subparagraph (A) 
and inserting the following: 
‘‘(A) with respect to an MA local plan— 
‘‘(i) for years before 2012, an MA local area (as 
defined in paragraph (2)); and 
42 USC 
1395w–24 note. 
Determinations. 
Reports. 
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124 STAT. 446 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(ii) for 2012 and succeeding years, a service area 
that is an entire urban or rural area, as applicable 
(as described in paragraph (5)); and’’; and 
(C) by adding at the end the following new paragraph: 
‘‘(5) MA LOCAL PLAN SERVICE AREA.—For 2012 and suc-
ceeding years, the service area for an MA local plan shall 
be an entire urban or rural area in each State as follows: 
‘‘(A) URBAN AREAS.— 
‘‘(i) IN GENERAL.—Subject to clause (ii) and sub-
paragraphs (C) and (D), the service area for an MA 
local plan in an urban area shall be the Core Based 
Statistical Area (in this paragraph referred to as a 
‘CBSA’) or, if applicable, a conceptually similar alter-
native classification, as defined by the Director of the 
Office of Management and Budget. 
‘‘(ii) CBSA COVERING
MORE
THAN
ONE
STATE.— 
In the case of a CBSA (or alternative classification) 
that covers more than one State, the Secretary shall 
divide the CBSA (or alternative classification) into 
separate service areas with respect to each State cov-
ered by the CBSA (or alternative classification). 
‘‘(B) RURAL AREAS.—Subject to subparagraphs (C) and 
(D), the service area for an MA local plan in a rural 
area shall be a county that does not qualify for inclusion 
in a CBSA (or alternative classification), as defined by 
the Director of the Office of Management and Budget. 
‘‘(C) REFINEMENTS TO SERVICE AREAS.—For 2015 and 
succeeding years, in order to reflect actual patterns of 
health care service utilization, the Secretary may adjust 
the boundaries of service areas for MA local plans in urban 
areas and rural areas under subparagraphs (A) and (B), 
respectively, but may only do so based on recent analyses 
of actual patterns of care. 
‘‘(D) ADDITIONAL AUTHORITY TO MAKE LIMITED EXCEP-
TIONS
TO
SERVICE
AREA
REQUIREMENTS
FOR
MA
LOCAL 
PLANS.—The Secretary may, in addition to any adjustments 
under subparagraph (C), make limited exceptions to service 
area requirements otherwise applicable under this part 
for MA local plans that have in effect (as of the date 
of enactment of the Patient Protection and Affordable Care 
Act)— 
‘‘(i) agreements with another MA organization or 
MA plan that preclude the offering of benefits through-
out an entire service area; or 
‘‘(ii) limitations in their structural capacity to sup-
port adequate networks throughout an entire service 
area as a result of the delivery system model of the 
MA local plan.’’. 
(2) CONFORMING AMENDMENTS.— 
(A) IN GENERAL.— 
(i) Section 1851(b)(1) of the Social Security Act 
(42 U.S.C. 1395w–21(b)(1)) is amended by striking 
subparagraph (C). 
(ii) Section 1853(b)(1)(B)(i) of such Act (42 U.S.C. 
1395w–23(b)(1)(B)(i))— 
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124 STAT. 447 
PUBLIC LAW 111–148—MAR. 23, 2010 
(I) in the matter preceding subclause (I), by 
striking ‘‘MA payment area’’ and inserting ‘‘MA 
local area (as defined in subsection (d)(2))’’; and 
(II) in subclause (I), by striking ‘‘MA payment 
area’’ and inserting ‘‘MA local area (as so defined)’’. 
(iii) Section 1853(b)(4) of such Act (42 U.S.C. 
1395w–23(b)(4)) is amended by striking ‘‘Medicare 
Advantage payment area’’ and inserting ‘‘MA local area 
(as so defined)’’. 
(iv) Section 1853(c)(1) of such Act (42 U.S.C. 
1395w–23(c)(1)) is amended— 
(I) in the matter preceding subparagraph (A), 
by striking ‘‘a Medicare Advantage payment area 
that is’’; and 
(II) in subparagraph (D)(i), by striking ‘‘MA 
payment area’’ and inserting ‘‘MA local area (as 
defined in subsection (d)(2))’’. 
(v) Section 1854 of such Act (42 U.S.C. 1395w– 
24) is amended by striking subsection (h). 
(B) EFFECTIVE DATE.—The amendments made by this 
paragraph shall take effect on January 1, 2012. 
(f) PERFORMANCE BONUSES.— 
(1) MA PLANS.— 
(A) IN GENERAL.—Section 1853 of the Social Security 
Act (42 U.S.C. 1395w–23) is amended by adding at the 
end the following new subsection: 
‘‘(n) PERFORMANCE BONUSES.— 
‘‘(1) CARE COORDINATION AND MANAGEMENT PERFORMANCE 
BONUS.— 
‘‘(A) IN GENERAL.—For years beginning with 2014, sub-
ject to subparagraph (B), in the case of an MA plan that 
conducts 1 or more programs described in subparagraph 
(C) with respect to the year, the Secretary shall, in addition 
to any other payment provided under this part, make 
monthly payments, with respect to coverage of an indi-
vidual under this part, to the MA plan in an amount 
equal to the product of— 
‘‘(i) 0.5 percent of the national monthly per capita 
cost for expenditures for individuals enrolled under 
the original medicare fee-for-service program for the 
year; and 
‘‘(ii) the total number of programs described in 
clauses (i) through (ix) of subparagraph (C) that the 
Secretary determines the plan is conducting for the 
year under such subparagraph. 
‘‘(B) LIMITATION.—In no case may the total amount 
of payment with respect to a year under subparagraph 
(A) be greater than 2 percent of the national monthly 
per capita cost for expenditures for individuals enrolled 
under the original medicare fee-for-service program for the 
year, as determined prior to the application of risk adjust-
ment under paragraph (4). 
‘‘(C) PROGRAMS DESCRIBED.—The following programs 
are described in this paragraph: 
‘‘(i) Care management programs that— 
‘‘(I) target individuals with 1 or more chronic 
conditions; 
Effective date. 
Payments. 
42 USC 
1395w–21 note. 
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124 STAT. 448 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(II) identify gaps in care; and 
‘‘(III) facilitate improved care by using addi-
tional resources like nurses, nurse practitioners, 
and physician assistants. 
‘‘(ii) Programs that focus on patient education and 
self-management of health conditions, including inter-
ventions that— 
‘‘(I) help manage chronic conditions; 
‘‘(II) reduce declines in health status; and 
‘‘(III) foster patient and provider collaboration. 
‘‘(iii) Transitional care interventions that focus on 
care provided around a hospital inpatient episode, 
including programs that target post-discharge patient 
care in order to reduce unnecessary health complica-
tions and readmissions. 
‘‘(iv) Patient safety programs, including provisions 
for hospital-based patient safety programs in contracts 
that the Medicare Advantage organization offering the 
MA plan has with hospitals. 
‘‘(v) Financial policies that promote systematic 
coordination of care by primary care physicians across 
the full spectrum of specialties and sites of care, such 
as medical homes, capitation arrangements, or pay- 
for-performance programs. 
‘‘(vi) Programs that address, identify, and amelio-
rate health care disparities among principal at-risk 
subpopulations. 
‘‘(vii) Medication therapy management programs 
that are more extensive than is required under section 
1860D–4(c) (as determined by the Secretary). 
‘‘(viii) Health information technology programs, 
including clinical decision support and other tools to 
facilitate data collection and ensure patient-centered, 
appropriate care. 
‘‘(ix) Such other care management and coordination 
programs as the Secretary determines appropriate. 
‘‘(D) CONDUCT
OF
PROGRAM
IN
URBAN
AND
RURAL 
AREAS.—An MA plan may conduct a program described 
in subparagraph (C) in a manner appropriate for an urban 
or rural area, as applicable. 
‘‘(E) REPORTING OF DATA.—Each Medicare Advantage 
organization shall provide to the Secretary the information 
needed to determine whether they are eligible for a care 
coordination and management performance bonus at a time 
and in a manner specified by the Secretary. 
‘‘(F) PERIODIC AUDITING.—The Secretary shall provide 
for the annual auditing of programs described in subpara-
graph (C) for which an MA plan receives a care coordination 
and management performance bonus under this paragraph. 
The Comptroller General shall monitor auditing activities 
conducted under this subparagraph. 
‘‘(2) QUALITY PERFORMANCE BONUSES.— 
‘‘(A) QUALITY BONUS.—For years beginning with 2014, 
the Secretary shall, in addition to any other payment pro-
vided under this part, make monthly payments, with 
respect to coverage of an individual under this part, to 
an MA plan that achieves at least a 3 star rating (or 
Effective date. 
Payments. 
Deadline. 
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124 STAT. 449 
PUBLIC LAW 111–148—MAR. 23, 2010 
comparable rating) on a rating system described in 
subparagraph (C) in an amount equal to— 
‘‘(i) in the case of a plan that achieves a 3 star 
rating (or comparable rating) on such system 2 percent 
of the national monthly per capita cost for expenditures 
for individuals enrolled under the original medicare 
fee-for-service program for the year; and 
‘‘(ii) in the case of a plan that achieves a 4 or 
5 star rating (or comparable rating on such system, 
4 percent of such national monthly per capita cost 
for the year. 
‘‘(B) IMPROVED QUALITY BONUS.—For years beginning 
with 2014, in the case of an MA plan that does not receive 
a quality bonus under subparagraph (A) and is an improved 
quality MA plan with respect to the year (as identified 
by the Secretary), the Secretary shall, in addition to any 
other payment provided under this part, make monthly 
payments, with respect to coverage of an individual under 
this part, to the MA plan in an amount equal to 1 percent 
of such national monthly per capita cost for the year. 
‘‘(C) USE OF RATING SYSTEM.—For purposes of subpara-
graph (A), a rating system described in this paragraph 
is— 
‘‘(i) a rating system that uses up to 5 stars to 
rate clinical quality and enrollee satisfaction and 
performance at the Medicare Advantage contract or 
MA plan level; or 
‘‘(ii) such other system established by the Secretary 
that provides for the determination of a comparable 
quality performance rating to the rating system 
described in clause (i). 
‘‘(D) DATA USED IN DETERMINING SCORE.— 
‘‘(i) IN GENERAL.—The rating of an MA plan under 
the rating system described in subparagraph (C) with 
respect to a year shall be based on based on the most 
recent data available. 
‘‘(ii) PLANS THAT FAIL TO REPORT DATA.—An MA 
plan which does not report data that enables the Sec-
retary to rate the plan for purposes of subparagraph 
(A) or identify the plan for purposes of subparagraph 
(B) shall be counted, for purposes of such rating or 
identification, as having the lowest plan performance 
rating and the lowest percentage improvement, respec-
tively. 
‘‘(3) QUALITY BONUS FOR NEW AND LOW ENROLLMENT MA 
PLANS.— 
‘‘(A) NEW MA PLANS.—For years beginning with 2014, 
in the case of an MA plan that first submits a bid under 
section 1854(a)(1)(A) for 2012 or a subsequent year, only 
receives enrollments made during the coverage election 
periods described in section 1851(e), and is not able to 
receive a bonus under subparagraph (A) or (B) of paragraph 
(2) for the year, the Secretary shall, in addition to any 
other payment provided under this part, make monthly 
payments, with respect to coverage of an individual under 
this part, to the MA plan in an amount equal to 2 percent 
of national monthly per capita cost for expenditures for 
Effective date. 
Payments. 
Effective date. 
Payments. 
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124 STAT. 450 
PUBLIC LAW 111–148—MAR. 23, 2010 
individuals enrolled under the original medicare fee-for- 
service program for the year. In its fourth year of operation, 
the MA plan shall be paid in the same manner as other 
MA plans with comparable enrollment. 
‘‘(B) LOW
ENROLLMENT
PLANS.—For years beginning 
with 2014, in the case of an MA plan that has low enroll-
ment (as defined by the Secretary) and would not otherwise 
be able to receive a bonus under subparagraph (A) or 
(B) of paragraph (2) or subparagraph (A) of this paragraph 
for the year (referred to in this subparagraph as a ‘low 
enrollment plan’), the Secretary shall use a regional or 
local mean of the rating of all MA plans in the region 
or local area, as determined appropriate by the Secretary, 
on measures used to determine whether MA plans are 
eligible for a quality or an improved quality bonus, as 
applicable, to determine whether the low enrollment plan 
is eligible for a bonus under such a subparagraph. 
‘‘(4) RISK ADJUSTMENT.—The Secretary shall risk adjust 
a performance bonus under this subsection in the same manner 
as the Secretary risk adjusts beneficiary rebates described in 
section 1854(b)(1)(C). 
‘‘(5) 
NOTIFICATION.—The 
Secretary, 
in 
the 
annual 
announcement required under subsection (b)(1)(B) for 2014 and 
each succeeding year, shall notify the Medicare Advantage 
organization of any performance bonus (including a care 
coordination and management performance bonus under para-
graph (1), a quality performance bonus under paragraph (2), 
and a quality bonus for new and low enrollment plans under 
paragraph (3)) that the organization will receive under this 
subsection with respect to the year. The Secretary shall provide 
for the publication of the information described in the previous 
sentence on the Internet website of the Centers for Medicare 
& Medicaid Services.’’ 
(B) CONFORMING
AMENDMENT.—Section 1853(a)(1)(B) 
of the Social Security Act (42 U.S.C. 1395w–23(a)(1)(B)) 
is amended— 
(i) in clause (i), by inserting ‘‘and any performance 
bonus under subsection (n)’’ before the period at the 
end; and 
(ii) in clause (ii), by striking ‘‘(G)’’ and inserting 
‘‘(G), plus the amount (if any) of any performance bonus 
under subsection (n)’’. 
(2) APPLICATION
OF
PERFORMANCE
BONUSES
TO
MA 
REGIONAL PLANS.—Section 1858 of the Social Security Act (42 
U.S.C. 1395w–27a) is amended— 
(A) in subsection (f)(1), by striking ‘‘subsection (e)’’ 
and inserting ‘‘subsections (e) and (i)’’; and 
(B) by adding at the end the following new subsection: 
‘‘(i) APPLICATION OF PERFORMANCE BONUSES TO MA REGIONAL 
PLANS.—For years beginning with 2014, the Secretary shall apply 
the performance bonuses under section 1853(n) (relating to bonuses 
for care coordination and management, quality performance, and 
new and low enrollment MA plans) to MA regional plans in a 
similar manner as such performance bonuses apply to MA plans 
under such subsection.’’. 
(g) GRANDFATHERING SUPPLEMENTAL BENEFITS FOR CURRENT 
ENROLLEES AFTER IMPLEMENTATION OF COMPETITIVE BIDDING.— 
Effective date. 
Web posting. 
Effective date. 
Determination. 
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124 STAT. 451 
PUBLIC LAW 111–148—MAR. 23, 2010 
Section 1853 of the Social Security Act (42 U.S.C. 1395w–23), as 
amended by subsection (f), is amended by adding at the end the 
following new subsection: 
‘‘(o) GRANDFATHERING SUPPLEMENTAL BENEFITS FOR CURRENT 
ENROLLES AFTER IMPLEMENTATION OF COMPETITIVE BIDDING.— 
‘‘(1) IDENTIFICATION OF AREAS.—The Secretary shall iden-
tify MA local areas in which, with respect to 2009, average 
bids submitted by an MA organization under section 1854(a) 
for MA local plans in the area are not greater than 75 percent 
of the adjusted average per capita cost for the year involved, 
determined under section 1876(a)(4), for the area for individuals 
who are not enrolled in an MA plan under this part for the 
year, but adjusted to exclude costs attributable to payments 
under section 1848(o), 1886(n), and 1886(h). 
‘‘(2) ELECTION
TO
PROVIDE
REBATES
TO
GRANDFATHERED 
ENROLLEES.— 
‘‘(A) IN GENERAL.—For years beginning with 2012, each 
Medicare Advantage organization offering an MA local plan 
in an area identified by the Secretary under paragraph 
(1) may elect to provide rebates to grandfathered enrollees 
under section 1854(b)(1)(C). In the case where an MA 
organization makes such an election, the monthly per 
capita dollar amount of such rebates shall not exceed the 
applicable amount for the year (as defined in subparagraph 
(B)). 
‘‘(B) APPLICABLE AMOUNT.—For purposes of this sub-
section, the term ‘applicable amount’ means— 
‘‘(i) for 2012, the monthly per capita dollar amount 
of such rebates provided to enrollees under the MA 
local plan with respect to 2011; and 
‘‘(ii) for a subsequent year, 95 percent of the 
amount determined under this subparagraph for the 
preceding year. 
‘‘(3) SPECIAL RULES FOR PLANS IN IDENTIFIED AREAS.—Not-
withstanding any other provision of this part, the following 
shall apply with respect to each Medicare Advantage organiza-
tion offering an MA local plan in an area identified by the 
Secretary under paragraph (1) that makes an election described 
in paragraph (2): 
‘‘(A) PAYMENTS.—The amount of the monthly payment 
under this section to the Medicare Advantage organization, 
with respect to coverage of a grandfathered enrollee under 
this part in the area for a month, shall be equal to— 
‘‘(i) for 2012 and 2013, the sum of— 
‘‘(I) the bid amount under section 1854(a) for 
the MA local plan; and 
‘‘(II) the applicable amount (as defined in para-
graph (2)(B)) for the MA local plan for the year. 
‘‘(ii) for 2014 and subsequent years, the sum of— 
‘‘(I) the MA competitive benchmark amount 
under subsection (j)(1)(A)(i) for the area for the 
month, adjusted, only to the extent the Secretary 
determines necessary, to account for induced utili-
zation as a result of rebates provided to grand-
fathered enrollees (except that such adjustment 
shall not exceed 0.5 percent of such MA competi-
tive benchmark amount); and 
Applicability. 
Definition. 
Effective date. 
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124 STAT. 452 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(II) the applicable amount (as so defined) for 
the MA local plan for the year. 
‘‘(B) REQUIREMENT TO SUBMIT BIDS UNDER COMPETITIVE 
BIDDING.—The Medicare Advantage organization shall 
submit a single bid amount under section 1854(a) for the 
MA local plan. The Medicare Advantage organization shall 
remove from such bid amount any effects of induced 
demand for care that may result from the higher rebates 
available to grandfathered enrollees under this subsection. 
‘‘(C) NONAPPLICATION OF BONUS PAYMENTS AND ANY 
OTHER
REBATES.—The Medicare Advantage organization 
offering the MA local plan shall not be eligible for any 
bonus payment under subsection (n) or any rebate under 
this part (other than as provided under this subsection) 
with respect to grandfathered enrollees. 
‘‘(D) NONAPPLICATION OF UNIFORM BID AND PREMIUM 
AMOUNTS TO GRANDFATHERED ENROLLEES.—Section 1854(c) 
shall not apply with respect to the MA local plan. 
‘‘(E) NONAPPLICATION OF LIMITATION ON APPLICATION 
OF PLAN REBATES TOWARD PAYMENT OF PART B PREMIUM.— 
Notwithstanding clause (iii) of section 1854(b)(1)(C), in the 
case of a grandfathered enrollee, a rebate under such sec-
tion may be used for the purpose described in clause (ii)(III) 
of such section. 
‘‘(F) RISK
ADJUSTMENT.—The Secretary shall risk 
adjust rebates to grandfathered enrollees under this sub-
section in the same manner as the Secretary risk adjusts 
beneficiary rebates described in section 1854(b)(1)(C). 
‘‘(4) DEFINITION
OF
GRANDFATHERED
ENROLLEE.—In this 
subsection, the term ‘grandfathered enrollee’ means an indi-
vidual who is enrolled (effective as of the date of enactment 
of this subsection) in an MA local plan in an area that is 
identified by the Secretary under paragraph (1).’’. 
(h) TRANSITIONAL EXTRA BENEFITS.—Section 1853 of the Social 
Security Act (42 U.S.C. 1395w–23), as amended by subsections 
(f) and (g), is amended by adding at the end the following new 
subsection: 
‘‘(p) TRANSITIONAL EXTRA BENEFITS.— 
‘‘(1) IN GENERAL.—For years beginning with 2012, the Sec-
retary shall provide transitional rebates under section 
1854(b)(1)(C) for the provision of extra benefits (as specified 
by the Secretary) to enrollees described in paragraph (2). 
‘‘(2) ENROLLEES DESCRIBED.—An enrollee described in this 
paragraph is an individual who— 
‘‘(A) enrolls in an MA local plan in an applicable area; 
and 
‘‘(B) experiences a significant reduction in extra bene-
fits described in clause (ii) of section 1854(b)(1)(C) as a 
result of competitive bidding under this part (as determined 
by the Secretary). 
‘‘(3) APPLICABLE
AREAS.—In this subsection, the term 
‘applicable area’ means the following: 
‘‘(A) The 2 largest metropolitan statistical areas, if 
the Secretary determines that the total amount of such 
extra benefits for each enrollee for the month in those 
areas is greater than $100. 
‘‘(B) A county where— 
Definition. 
Effective date. 
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124 STAT. 453 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) the MA area-specific non-drug monthly bench-
mark amount for a month in 2011 is equal to the 
legacy urban floor amount (as described in subsection 
(c)(1)(B)(iii)), as determined by the Secretary for the 
area for 2011; 
‘‘(ii) the percentage of Medicare Advantage eligible 
beneficiaries in the county who are enrolled in an 
MA plan for 2009 is greater than 30 percent (as deter-
mined by the Secretary); and 
‘‘(iii) average bids submitted by an MA organiza-
tion under section 1854(a) for MA local plans in the 
county for 2011 are not greater than the adjusted 
average per capita cost for the year involved, deter-
mined under section 1876(a)(4), for the county for 
individuals who are not enrolled in an MA plan under 
this part for the year, but adjusted to exclude costs 
attributable to payments under section 1848(o), 
1886(n), and 1886(h). 
‘‘(C) If the Secretary determines appropriate, a county 
contiguous to an area or county described in subparagraph 
(A) or (B), respectively. 
‘‘(4) REVIEW OF PLAN BIDS.—In the case of a bid submitted 
by an MA organization under section 1854(a) for an MA local 
plan in an applicable area, the Secretary shall review such 
bid in order to ensure that extra benefits (as specified by 
the Secretary) are provided to enrollees described in paragraph 
(2). 
‘‘(5) FUNDING.—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 established under section 1841, in such proportion as 
the Secretary determines appropriate, of an amount not to 
exceed $5,000,000,000 for the period of fiscal years 2012 
through 2019 for the purpose of providing transitional rebates 
under section 1854(b)(1)(C) for the provision of extra benefits 
under this subsection.’’. 
(i) NONAPPLICATION
OF COMPETITIVE BIDDING
AND RELATED 
PROVISIONS AND CLARIFICATION OF MA PAYMENT AREA FOR PACE 
PROGRAMS.— 
(1) NONAPPLICATION OF COMPETITIVE BIDDING AND RELATED 
PROVISIONS FOR PACE PROGRAMS.—Section 1894 of the Social 
Security Act (42 U.S.C. 1395eee) is amended— 
(A) by redesignating subsections (h) and (i) as sub-
sections (i) and (j), respectively; 
(B) by inserting after subsection (g) the following new 
subsection: 
‘‘(h) NONAPPLICATION OF COMPETITIVE BIDDING AND RELATED 
PROVISIONS UNDER PART C.—With respect to a PACE program 
under this section, the following provisions (and regulations relating 
to such provisions) shall not apply: 
‘‘(1) Section 1853(j)(1)(A)(i), relating to MA area-specific 
non-drug monthly benchmark amount being based on competi-
tive bids. 
‘‘(2) Section 1853(d)(5), relating to the establishment of 
MA local plan service areas. 
‘‘(3) Section 1853(n), relating to the payment of performance 
bonuses. 
Determination. 
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124 STAT. 454 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(4) Section 1853(o), relating to grandfathering supple-
mental benefits for current enrollees after implementation of 
competitive bidding. 
‘‘(5) Section 1853(p), relating to transitional extra benefits.’’. 
(2) SPECIAL RULE FOR MA PAYMENT AREA FOR PACE PRO-
GRAMS.—Section 1853(d) of the Social Security Act (42 U.S.C. 
1395w–23(d)), as amended by subsection (e), is amended by 
adding at the end the following new paragraph: 
‘‘(6) SPECIAL RULE FOR MA PAYMENT AREA FOR PACE PRO-
GRAMS.—For years beginning with 2012, in the case of a PACE 
program under section 1894, the MA payment area shall be 
the MA local area (as defined in paragraph (2)).’’. 
SEC. 3202. BENEFIT PROTECTION AND SIMPLIFICATION. 
(a) LIMITATION ON VARIATION OF COST SHARING FOR CERTAIN 
BENEFITS.— 
(1) IN GENERAL.—Section 1852(a)(1)(B) of the Social Secu-
rity Act (42 U.S.C. 1395w–22(a)(1)(B)) is amended— 
(A) in clause (i), by inserting ‘‘, subject to clause (iii),’’ 
after ‘‘and B or’’; and 
(B) by adding at the end the following new clauses: 
‘‘(iii) LIMITATION ON VARIATION OF COST SHARING 
FOR
CERTAIN
BENEFITS.—Subject to clause (v), cost- 
sharing for services described in clause (iv) shall not 
exceed the cost-sharing required for those services 
under parts A and B. 
‘‘(iv) SERVICES DESCRIBED.—The following services 
are described in this clause: 
‘‘(I) Chemotherapy administration services. 
‘‘(II) Renal dialysis services (as defined in sec-
tion 1881(b)(14)(B)). 
‘‘(III) Skilled nursing care. 
‘‘(IV) Such other services that the Secretary 
determines appropriate (including services that the 
Secretary determines require a high level of 
predictability and transparency for beneficiaries). 
‘‘(v) EXCEPTION.—In the case of services described 
in clause (iv) for which there is no cost-sharing required 
under parts A and B, cost-sharing may be required 
for those services in accordance with clause (i).’’. 
(2) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to plan years beginning on or after January 
1, 2011. 
(b) APPLICATION
OF REBATES, PERFORMANCE BONUSES, AND 
PREMIUMS.— 
(1) APPLICATION OF REBATES.—Section 1854(b)(1)(C) of the 
Social Security Act (42 U.S.C. 1395w–24(b)(1)(C)) is amended— 
(A) in clause (ii), by striking ‘‘REBATE.—A rebate’’ and 
inserting ‘‘REBATE FOR PLAN YEARS BEFORE 2012.—For plan 
years before 2012, a rebate’’; 
(B) by redesignating clauses (iii) and (iv) as clauses 
(iv) and (v); and 
(C) by inserting after clause (ii) the following new 
clause: 
‘‘(iii) FORM OF REBATE FOR PLAN YEAR 2012 AND 
SUBSEQUENT PLAN YEARS.—For plan years beginning 
on or after January 1, 2012, a rebate required under 
Effective date. 
42 USC 
1395w–22 note. 
Effective date. 
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124 STAT. 455 
PUBLIC LAW 111–148—MAR. 23, 2010 
this subparagraph may not be used for the purpose 
described in clause (ii)(III) and shall be provided 
through the application of the amount of the rebate 
in the following priority order: 
‘‘(I) First, to use the most significant share 
to meaningfully reduce cost-sharing otherwise 
applicable for benefits under the original medicare 
fee-for-service program under parts A and B and 
for qualified prescription drug coverage under part 
D, including the reduction of any deductibles, co-
payments, and maximum limitations on out-of- 
pocket expenses otherwise applicable. Any reduc-
tion of maximum limitations on out-of-pocket 
expenses under the preceding sentence shall apply 
to all benefits under the original medicare fee- 
for-service program option. The Secretary may pro-
vide guidance on meaningfully reducing cost- 
sharing under this subclause, except that such 
guidance may not require a particular amount of 
cost-sharing or reduction in cost-sharing. 
‘‘(II) Second, to use the next most significant 
share to meaningfully provide coverage of preven-
tive and wellness health care benefits (as defined 
by the Secretary) which are not benefits under 
the original medicare fee-for-service program, such 
as smoking cessation, a free flu shot, and an 
annual physical examination. 
‘‘(III) Third, to use the remaining share to 
meaningfully provide coverage of other health care 
benefits which are not benefits under the original 
medicare fee-for-service program, such as eye 
examinations and dental coverage, and are not 
benefits described in subclause (II).’’. 
(2) APPLICATION
OF
PERFORMANCE
BONUSES.—Section 
1853(n) of the Social Security Act, as added by section 3201(f), 
is amended by adding at the end the following new paragraph: 
‘‘(6) APPLICATION
OF
PERFORMANCE
BONUSES.—For plan 
years beginning on or after January 1, 2014, any performance 
bonus paid to an MA plan under this subsection shall be 
used for the purposes, and in the priority order, described 
in subclauses (I) through (III) of section 1854(b)(1)(C)(iii).’’. 
(3) APPLICATION OF MA MONTHLY SUPPLEMENTARY BENE-
FICIARY PREMIUM.—Section 1854(b)(2)(C) of the Social Security 
Act (42 U.S.C. 1395w–24(b)(2)(C)) is amended— 
(A) by striking ‘‘PREMIUM.—The term’’ and inserting 
‘‘PREMIUM.— 
‘‘(i) IN GENERAL.—The term’’; and 
(B) by adding at the end the following new clause: 
‘‘(ii) APPLICATION OF MA MONTHLY SUPPLEMENTARY 
BENEFICIARY PREMIUM.—For plan years beginning on 
or after January 1, 2012, any MA monthly supple-
mentary beneficiary premium charged to an individual 
enrolled in an MA plan shall be used for the purposes, 
and in the priority order, described in subclauses (I) 
through (III) of paragraph (1)(C)(iii).’’. 
Effective date. 
Effective date. 
Applicability. 
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124 STAT. 456 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 3203. APPLICATION OF CODING INTENSITY ADJUSTMENT DURING 
MA PAYMENT TRANSITION. 
Section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 
1395w–23(a)(1)(C)) is amended by adding at the end the following 
new clause: 
‘‘(iii) APPLICATION OF CODING INTENSITY ADJUST-
MENT FOR 2011 AND SUBSEQUENT YEARS.— 
‘‘(I) REQUIREMENT TO APPLY IN 2011 THROUGH 
2013.—In order to ensure payment accuracy, the 
Secretary shall conduct an analysis of the dif-
ferences described in clause (ii)(I). The Secretary 
shall ensure that the results of such analysis are 
incorporated into the risk scores for 2011, 2012, 
and 2013. 
‘‘(II) AUTHORITY TO APPLY IN 2014 AND SUBSE-
QUENT YEARS.—The Secretary may, as appropriate, 
incorporate the results of such analysis into the 
risk scores for 2014 and subsequent years.’’. 
SEC. 3204. SIMPLIFICATION OF ANNUAL BENEFICIARY ELECTION 
PERIODS. 
(a) ANNUAL 45-DAY PERIOD
FOR DISENROLLMENT FROM MA 
PLANS TO ELECT TO RECEIVE BENEFITS UNDER THE ORIGINAL MEDI-
CARE FEE-FOR-SERVICE PROGRAM.— 
(1) IN GENERAL.—Section 1851(e)(2)(C) of the Social Secu-
rity Act (42 U.S.C. 1395w–1(e)(2)(C)) is amended to read as 
follows: 
‘‘(C) ANNUAL 45-DAY PERIOD FOR DISENROLLMENT FROM 
MA
PLANS
TO
ELECT
TO
RECEIVE
BENEFITS
UNDER
THE 
ORIGINAL MEDICARE FEE-FOR-SERVICE PROGRAM.—Subject to 
subparagraph (D), at any time during the first 45 days 
of a year (beginning with 2011), an individual who is 
enrolled in a Medicare Advantage plan may change the 
election under subsection (a)(1), but only with respect to 
coverage under the original medicare fee-for-service pro-
gram under parts A and B, and may elect qualified 
prescription drug coverage in accordance with section 
1860D–1.’’. 
(2) EFFECTIVE DATE.—The amendment made by paragraph 
(1) shall apply with respect to 2011 and succeeding years. 
(b) TIMING OF THE ANNUAL, COORDINATED ELECTION PERIOD 
UNDER PARTS C AND D.—Section 1851(e)(3)(B) of the Social Security 
Act (42 U.S.C. 1395w–1(e)(3)(B)) is amended— 
(1) in clause (iii), by striking ‘‘and’’ at the end; 
(2) in clause (iv)— 
(A) by striking ‘‘and succeeding years’’ and inserting 
‘‘, 2008, 2009, and 2010’’; and 
(B) by striking the period at the end and inserting 
‘‘; and’’; and 
(3) by adding at the end the following new clause: 
‘‘(v) with respect to 2012 and succeeding years, 
the period beginning on October 15 and ending on 
December 7 of the year before such year.’’. 
42 USC 
1395w–21. 
42 USC 
1395w–21 note. 
Effective date. 
42 USC 
1395w–21. 
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124 STAT. 457 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 3205. EXTENSION FOR SPECIALIZED MA PLANS FOR SPECIAL 
NEEDS INDIVIDUALS. 
(a) EXTENSION OF SNP AUTHORITY.—Section 1859(f)(1) of the 
Social Security Act (42 U.S.C. 1395w–28(f)(1)), as amended by sec-
tion 164(a) of the Medicare Improvements for Patients and Pro-
viders Act of 2008 (Public Law 110–275), is amended by striking 
‘‘2011’’ and inserting ‘‘2014’’. 
(b) AUTHORITY TO APPLY FRAILTY ADJUSTMENT UNDER PACE 
PAYMENT RULES.—Section 1853(a)(1)(B) of the Social Security Act 
(42 U.S.C. 1395w–23(a)(1)(B)) is amended by adding at the end 
the following new clause: 
‘‘(iv) AUTHORITY
TO
APPLY
FRAILTY
ADJUSTMENT 
UNDER PACE PAYMENT RULES FOR CERTAIN SPECIALIZED 
MA PLANS FOR SPECIAL NEEDS INDIVIDUALS.— 
‘‘(I) IN
GENERAL.—Notwithstanding the pre-
ceding provisions of this paragraph, for plan year 
2011 and subsequent plan years, in the case of 
a plan described in subclause (II), the Secretary 
may apply the payment rules under section 1894(d) 
(other than paragraph (3) of such section) rather 
than the payment rules that would otherwise apply 
under this part, but only to the extent necessary 
to reflect the costs of treating high concentrations 
of frail individuals. 
‘‘(II) PLAN
DESCRIBED.—A plan described in 
this subclause is a specialized MA plan for special 
needs 
individuals 
described 
in 
section 
1859(b)(6)(B)(ii) that is fully integrated with 
capitated contracts with States for Medicaid bene-
fits, including long-term care, and that have 
similar average levels of frailty (as determined 
by the Secretary) as the PACE program.’’. 
(c) TRANSITION
AND EXCEPTION REGARDING RESTRICTION
ON 
ENROLLMENT.—Section 1859(f) of the Social Security Act (42 U.S.C. 
1395w–28(f)) is amended by adding at the end the following new 
paragraph: 
‘‘(6) TRANSITION AND EXCEPTION REGARDING RESTRICTION 
ON ENROLLMENT.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (C), the 
Secretary shall establish procedures for the transition of 
applicable individuals to— 
‘‘(i) a Medicare Advantage plan that is not a 
specialized MA plan for special needs individuals (as 
defined in subsection (b)(6)); or 
‘‘(ii) the original medicare fee-for-service program 
under parts A and B. 
‘‘(B) APPLICABLE INDIVIDUALS.—For purposes of clause 
(i), the term ‘applicable individual’ means an individual 
who— 
‘‘(i) is enrolled under a specialized MA plan for 
special needs individuals (as defined in subsection 
(b)(6)); and 
‘‘(ii) is not within the 1 or more of the classes 
of special needs individuals to which enrollment under 
the plan is restricted to. 
‘‘(C) EXCEPTION.—The Secretary shall provide for an 
exception to the transition described in subparagraph (A) 
Definition. 
Procedures. 
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124 STAT. 458 
PUBLIC LAW 111–148—MAR. 23, 2010 
for a limited period of time for individuals enrolled under 
a specialized MA plan for special needs individuals 
described in subsection (b)(6)(B)(ii) who are no longer 
eligible for medical assistance under title XIX. 
‘‘(D) TIMELINE FOR INITIAL TRANSITION.—The Secretary 
shall ensure that applicable individuals enrolled in a 
specialized MA plan for special needs individuals (as 
defined in subsection (b)(6)) prior to January 1, 2010, are 
transitioned to a plan or the program described in subpara-
graph (A) by not later than January 1, 2013.’’. 
(d) TEMPORARY EXTENSION
OF AUTHORITY TO OPERATE
BUT 
NO SERVICE AREA EXPANSION FOR DUAL SPECIAL NEEDS PLANS 
THAT DO NOT MEET CERTAIN REQUIREMENTS.—Section 164(c)(2) 
of the Medicare Improvements for Patients and Providers Act of 
2008 (Public Law 110–275) is amended by striking ‘‘December 31, 
2010’’ and inserting ‘‘December 31, 2012’’. 
(e) AUTHORITY TO REQUIRE SPECIAL NEEDS PLANS BE NCQA 
APPROVED.—Section 1859(f) of the Social Security Act (42 U.S.C. 
1395w–28(f)), as amended by subsections (a) and (c), is amended— 
(1) in paragraph (2), by adding at the end the following 
new subparagraph: 
‘‘(C) If applicable, the plan meets the requirement 
described in paragraph (7).’’; 
(2) in paragraph (3), by adding at the end the following 
new subparagraph: 
‘‘(E) If applicable, the plan meets the requirement 
described in paragraph (7).’’; 
(3) in paragraph (4), by adding at the end the following 
new subparagraph: 
‘‘(C) If applicable, the plan meets the requirement 
described in paragraph (7).’’; and 
(4) by adding at the end the following new paragraph: 
‘‘(7) AUTHORITY TO REQUIRE SPECIAL NEEDS PLANS BE NCQA 
APPROVED.—For 2012 and subsequent years, the Secretary shall 
require that a Medicare Advantage organization offering a 
specialized MA plan for special needs individuals be approved 
by the National Committee for Quality Assurance (based on 
standards established by the Secretary).’’. 
(f) RISK ADJUSTMENT.—Section 1853(a)(1)(C) of the Social Secu-
rity Act (42 U.S.C. 1395i–23(a)(1)(C)) is amended by adding at 
the end the following new clause: 
‘‘(iii) IMPROVEMENTS TO RISK ADJUSTMENT FOR SPE-
CIAL NEEDS INDIVIDUALS WITH CHRONIC HEALTH CONDI-
TIONS.— 
‘‘(I) IN GENERAL.—For 2011 and subsequent 
years, for purposes of the adjustment under clause 
(i) with respect to individuals described in sub-
clause (II), the Secretary shall use a risk score 
that reflects the known underlying risk profile and 
chronic health status of similar individuals. Such 
risk score shall be used instead of the default 
risk score for new enrollees in Medicare Advantage 
plans that are not specialized MA plans for special 
needs individuals (as defined in section 1859(b)(6)). 
‘‘(II) INDIVIDUALS DESCRIBED.—An individual 
described in this subclause is a special needs indi-
vidual described in subsection (b)(6)(B)(iii) who 
42 USC 
1395w–23. 
Standards. 
42 USC 
1395w–28 note. 
Deadline. 
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124 STAT. 459 
PUBLIC LAW 111–148—MAR. 23, 2010 
enrolls in a specialized MA plan for special needs 
individuals on or after January 1, 2011. 
‘‘(III) EVALUATION.—For 2011 and periodically 
thereafter, the Secretary shall evaluate and revise 
the risk adjustment system under this subpara-
graph in order to, as accurately as possible, 
account for higher medical and care coordination 
costs associated with frailty, individuals with mul-
tiple, comorbid chronic conditions, and individuals 
with a diagnosis of mental illness, and also to 
account for costs that may be associated with 
higher concentrations of beneficiaries with those 
conditions. 
‘‘(IV) PUBLICATION OF EVALUATION AND REVI-
SIONS.—The Secretary shall publish, as part of 
an announcement under subsection (b), a descrip-
tion of any evaluation conducted under subclause 
(III) during the preceding year and any revisions 
made under such subclause as a result of such 
evaluation.’’. 
(g) TECHNICAL CORRECTION.—Section 1859(f)(5) of the Social 
Security Act (42 U.S.C. 1395w–28(f)(5)) is amended, in the matter 
preceding subparagraph (A), by striking ‘‘described in subsection 
(b)(6)(B)(i)’’. 
SEC. 3206. EXTENSION OF REASONABLE COST CONTRACTS. 
Section 1876(h)(5)(C)(ii) of the Social Security Act (42 U.S.C. 
1395mm(h)(5)(C)(ii)) is amended, in the matter preceding subclause 
(I), by striking ‘‘January 1, 2010’’ and inserting ‘‘January 1, 2013’’. 
SEC. 3207. TECHNICAL CORRECTION TO MA PRIVATE FEE-FOR- 
SERVICE PLANS. 
For plan year 2011 and subsequent plan years, to the extent 
that the Secretary of Health and Human Services is applying the 
2008 service area extension waiver policy (as modified in the April 
11, 2008, Centers for Medicare & Medicaid Services’ memorandum 
with the subject ‘‘2009 Employer Group Waiver-Modification of the 
2008 Service Area Extension Waiver Granted to Certain MA Local 
Coordinated Care Plans’’) to Medicare Advantage coordinated care 
plans, the Secretary shall extend the application of such waiver 
policy to employers who contract directly with the Secretary as 
a Medicare Advantage private fee-for-service plan under section 
1857(i)(2) of the Social Security Act (42 U.S.C. 1395w–27(i)(2)) 
and that had enrollment as of October 1, 2009. 
SEC. 3208. MAKING SENIOR HOUSING FACILITY DEMONSTRATION 
PERMANENT. 
(a) IN GENERAL.—Section 1859 of the Social Security Act (42 
U.S.C. 1395w–28) is amended by adding at the end the following 
new subsection: 
‘‘(g) SPECIAL RULES FOR SENIOR HOUSING FACILITY PLANS.— 
‘‘(1) IN GENERAL.—In the case of a Medicare Advantage 
senior housing facility plan described in paragraph (2), notwith-
standing any other provision of this part to the contrary and 
in accordance with regulations of the Secretary, the service 
area of such plan may be limited to a senior housing facility 
in a geographic area. 
Applicability. 
42 USC 
1395w–27 note. 
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124 STAT. 460 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) MEDICARE ADVANTAGE SENIOR HOUSING FACILITY PLAN 
DESCRIBED.—For purposes of this subsection, a Medicare 
Advantage senior housing facility plan is a Medicare Advantage 
plan that— 
‘‘(A) restricts enrollment of individuals under this part 
to individuals who reside in a continuing care retirement 
community (as defined in section 1852(l)(4)(B)); 
‘‘(B) provides primary care services onsite and has 
a ratio of accessible physicians to beneficiaries that the 
Secretary determines is adequate; 
‘‘(C) provides transportation services for beneficiaries 
to specialty providers outside of the facility; and 
‘‘(D) has participated (as of December 31, 2009) in 
a demonstration project established by the Secretary under 
which such a plan was offered for not less than 1 year.’’. 
(b) EFFECTIVE DATE.—The amendment made by this section 
shall take effect on January 1, 2010, and shall apply to plan 
years beginning on or after such date. 
SEC. 3209. AUTHORITY TO DENY PLAN BIDS. 
(a) IN GENERAL.—Section 1854(a)(5) of the Social Security Act 
(42 U.S.C. 1395w–24(a)(5)) is amended by adding at the end the 
following new subparagraph: 
‘‘(C) REJECTION OF BIDS.— 
‘‘(i) IN GENERAL.—Nothing in this section shall be 
construed as requiring the Secretary to accept any 
or every bid submitted by an MA organization under 
this subsection. 
‘‘(ii) AUTHORITY
TO
DENY
BIDS
THAT
PROPOSE 
SIGNIFICANT INCREASES IN COST SHARING OR DECREASES 
IN BENEFITS.—The Secretary may deny a bid submitted 
by an MA organization for an MA plan if it proposes 
significant increases in cost sharing or decreases in 
benefits offered under the plan.’’. 
(b) APPLICATION UNDER PART D.—Section 1860D–11(d) of such 
Act (42 U.S.C. 1395w–111(d)) is amended by adding at the end 
the following new paragraph: 
‘‘(3) REJECTION
OF
BIDS.—Paragraph (5)(C) of section 
1854(a) shall apply with respect to bids submitted by a PDP 
sponsor under subsection (b) in the same manner as such 
paragraph applies to bids submitted by an MA organization 
under such section 1854(a).’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to bids submitted for contract years beginning on or 
after January 1, 2011. 
SEC. 3210. DEVELOPMENT OF NEW STANDARDS FOR CERTAIN 
MEDIGAP PLANS. 
(a) IN GENERAL.—Section 1882 of the Social Security Act (42 
U.S.C. 1395ss) is amended by adding at the end the following 
new subsection: 
‘‘(y) DEVELOPMENT OF NEW STANDARDS FOR CERTAIN MEDICARE 
SUPPLEMENTAL POLICIES.— 
‘‘(1) IN GENERAL.—The Secretary shall request the National 
Association of Insurance Commissioners to review and revise 
the standards for benefit packages described in paragraph (2) 
under subsection (p)(1), to otherwise update standards to 
include requirements for nominal cost sharing to encourage 
42 USC 
1395w–24 note. 
Applicability. 
42 USC 
1395w–28 note. 
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124 STAT. 461 
PUBLIC LAW 111–148—MAR. 23, 2010 
the use of appropriate physicians’ services under part B. Such 
revisions shall be based on evidence published in peer-reviewed 
journals or current examples used by integrated delivery sys-
tems and made consistent with the rules applicable under 
subsection (p)(1)(E) with the reference to the ‘1991 NAIC Model 
Regulation’ deemed a reference to the NAIC Model Regulation 
as published in the Federal Register on December 4, 1998, 
and as subsequently updated by the National Association of 
Insurance Commissioners to reflect previous changes in law 
and the reference to ‘date of enactment of this subsection’ 
deemed a reference to the date of enactment of the Patient 
Protection and Affordable Care Act. To the extent practicable, 
such revision shall provide for the implementation of revised 
standards for benefit packages as of January 1, 2015. 
‘‘(2) BENEFIT PACKAGES DESCRIBED.—The benefit packages 
described in this paragraph are benefit packages classified as 
‘C’ and ‘F’.’’. 
(b) CONFORMING AMENDMENT.—Section 1882(o)(1) of the Social 
Security Act (42 U.S.C. 1395ss(o)(1)) is amended by striking ‘‘, 
and (w)’’ and inserting ‘‘(w), and (y)’’. 
Subtitle D—Medicare Part D Improve-
ments for Prescription Drug Plans and 
MA–PD Plans 
SEC. 3301. MEDICARE COVERAGE GAP DISCOUNT PROGRAM. 
(a) CONDITION FOR COVERAGE OF DRUGS UNDER PART D.— 
Part D of Title XVIII of the Social Security Act (42 U.S.C. 1395w– 
101 et seq.), is amended by adding at the end the following new 
section: 
‘‘CONDITION FOR COVERAGE OF DRUGS UNDER THIS PART 
‘‘SEC. 1860D–43. (a) IN GENERAL.—In order for coverage to 
be available under this part for covered part D drugs (as defined 
in section 1860D–2(e)) of a manufacturer, the manufacturer must— 
‘‘(1) participate in the Medicare coverage gap discount pro-
gram under section 1860D–14A; 
‘‘(2) have entered into and have in effect an agreement 
described in subsection (b) of such section with the Secretary; 
and 
‘‘(3) have entered into and have in effect, under terms 
and conditions specified by the Secretary, a contract with a 
third party that the Secretary has entered into a contract 
with under subsection (d)(3) of such section. 
‘‘(b) EFFECTIVE DATE.—Subsection (a) shall apply to covered 
part D drugs dispensed under this part on or after July 1, 2010. 
‘‘(c) AUTHORIZING COVERAGE FOR DRUGS NOT COVERED UNDER 
AGREEMENTS.—Subsection (a) shall not apply to the dispensing 
of a covered part D drug if— 
‘‘(1) the Secretary has made a determination that the avail-
ability of the drug is essential to the health of beneficiaries 
under this part; or 
Determination. 
Contracts. 
42 USC 
1395w–153. 
Effective date. 
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124 STAT. 462 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) the Secretary determines that in the period beginning 
on July 1, 2010, and ending on December 31, 2010, there 
were extenuating circumstances. 
‘‘(d) DEFINITION OF MANUFACTURER.—In this section, the term 
‘manufacturer’ has the meaning given such term in section 1860D– 
14A(g)(5).’’. 
(b) MEDICARE COVERAGE GAP DISCOUNT PROGRAM.—Part D 
of title XVIII of the Social Security Act (42 U.S.C. 1395w–101) 
is amended by inserting after section 1860D–14 the following new 
section: 
‘‘MEDICARE COVERAGE GAP DISCOUNT PROGRAM 
‘‘SEC. 1860D–14A. (a) ESTABLISHMENT.—The Secretary shall 
establish a Medicare coverage gap discount program (in this section 
referred to as the ‘program’) by not later than July 1, 2010. Under 
the program, the Secretary shall enter into agreements described 
in subsection (b) with manufacturers and provide for the perform-
ance of the duties described in subsection (c)(1). The Secretary 
shall establish a model agreement for use under the program by 
not later than April 1, 2010, in consultation with manufacturers, 
and allow for comment on such model agreement. 
‘‘(b) TERMS OF AGREEMENT.— 
‘‘(1) IN GENERAL.— 
‘‘(A) AGREEMENT.—An agreement under this section 
shall require the manufacturer to provide applicable bene-
ficiaries access to discounted prices for applicable drugs 
of the manufacturer. 
‘‘(B) PROVISION OF DISCOUNTED PRICES AT THE POINT- 
OF-SALE.—Except as provided in subsection (c)(1)(A)(iii), 
such discounted prices shall be provided to the applicable 
beneficiary at the pharmacy or by the mail order service 
at the point-of-sale of an applicable drug. 
‘‘(C) TIMING OF AGREEMENT.— 
‘‘(i) SPECIAL
RULE
FOR
2010
AND
2011.—In order 
for an agreement with a manufacturer to be in effect 
under this section with respect to the period beginning 
on July 1, 2010, and ending on December 31, 2011, 
the manufacturer shall enter into such agreement not 
later than May 1, 2010. 
‘‘(ii) 2012 AND SUBSEQUENT YEARS.—In order for 
an agreement with a manufacturer to be in effect under 
this section with respect to plan year 2012 or a subse-
quent plan year, the manufacturer shall enter into 
such agreement (or such agreement shall be renewed 
under paragraph (4)(A)) not later than January 30 
of the preceding year. 
‘‘(2) PROVISION OF APPROPRIATE DATA.—Each manufacturer 
with an agreement in effect under this section shall collect 
and have available appropriate data, as determined by the 
Secretary, to ensure that it can demonstrate to the Secretary 
compliance with the requirements under the program. 
‘‘(3) COMPLIANCE WITH REQUIREMENTS FOR ADMINISTRATION 
OF PROGRAM.—Each manufacturer with an agreement in effect 
under this section shall comply with requirements imposed 
by the Secretary or a third party with a contract under sub-
section (d)(3), as applicable, for purposes of administering the 
Determination. 
Deadlines. 
Contracts. 
Deadlines. 
42 USC 
1395w–114a. 
Determination. 
Time period. 
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124 STAT. 463 
PUBLIC LAW 111–148—MAR. 23, 2010 
program, including any determination under clause (i) of sub-
section (c)(1)(A) or procedures established under such sub-
section (c)(1)(A). 
‘‘(4) LENGTH OF AGREEMENT.— 
‘‘(A) IN GENERAL.—An agreement under this section 
shall be effective for an initial period of not less than 
18 months and shall be automatically renewed for a period 
of not less than 1 year unless terminated under subpara-
graph (B). 
‘‘(B) TERMINATION.— 
‘‘(i) BY THE SECRETARY.—The Secretary may pro-
vide for termination of an agreement under this section 
for a knowing and willful violation of the requirements 
of the agreement or other good cause shown. Such 
termination shall not be effective earlier than 30 days 
after the date of notice to the manufacturer of such 
termination. The Secretary shall provide, upon request, 
a manufacturer with a hearing concerning such a 
termination, and such hearing shall take place prior 
to the effective date of the termination with sufficient 
time for such effective date to be repealed if the Sec-
retary determines appropriate. 
‘‘(ii) BY A MANUFACTURER.—A manufacturer may 
terminate an agreement under this section for any 
reason. Any such termination shall be effective, with 
respect to a plan year— 
‘‘(I) if the termination occurs before January 
30 of a plan year, as of the day after the end 
of the plan year; and 
‘‘(II) if the termination occurs on or after 
January 30 of a plan year, as of the day after 
the end of the succeeding plan year. 
‘‘(iii) EFFECTIVENESS OF TERMINATION.—Any termi-
nation under this subparagraph shall not affect dis-
counts for applicable drugs of the manufacturer that 
are due under the agreement before the effective date 
of its termination. 
‘‘(iv) NOTICE TO THIRD PARTY.—The Secretary shall 
provide notice of such termination to a third party 
with a contract under subsection (d)(3) within not less 
than 30 days before the effective date of such termi-
nation. 
‘‘(c) DUTIES DESCRIBED AND SPECIAL RULE FOR SUPPLEMENTAL 
BENEFITS.— 
‘‘(1) DUTIES DESCRIBED.—The duties described in this sub-
section are the following: 
‘‘(A) ADMINISTRATION OF PROGRAM.—Administering the 
program, including— 
‘‘(i) the determination of the amount of the dis-
counted price of an applicable drug of a manufacturer; 
‘‘(ii) except as provided in clause (iii), the establish-
ment of procedures under which discounted prices are 
provided to applicable beneficiaries at pharmacies or 
by mail order service at the point-of-sale of an 
applicable drug; 
‘‘(iii) in the case where, during the period beginning 
on July 1, 2010, and ending on December 31, 2011, 
Determination. 
Procedures. 
Deadline. 
Notice. 
Time period. 
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124 STAT. 464 
PUBLIC LAW 111–148—MAR. 23, 2010 
it is not practicable to provide such discounted prices 
at the point-of-sale (as described in clause (ii)), the 
establishment of procedures to provide such discounted 
prices as soon as practicable after the point-of-sale; 
‘‘(iv) the establishment of procedures to ensure 
that, not later than the applicable number of calendar 
days after the dispensing of an applicable drug by 
a pharmacy or mail order service, the pharmacy or 
mail order service is reimbursed for an amount equal 
to the difference between— 
‘‘(I) the negotiated price of the applicable drug; 
and 
‘‘(II) the discounted price of the applicable 
drug; 
‘‘(v) the establishment of procedures to ensure that 
the discounted price for an applicable drug under this 
section is applied before any coverage or financial 
assistance under other health benefit plans or pro-
grams that provide coverage or financial assistance 
for the purchase or provision of prescription drug cov-
erage on behalf of applicable beneficiaries as the Sec-
retary may specify; 
‘‘(vi) the establishment of procedures to implement 
the special rule for supplemental benefits under para-
graph (2); and 
‘‘(vii) providing a reasonable dispute resolution 
mechanism to resolve disagreements between manufac-
turers, applicable beneficiaries, and the third party 
with a contract under subsection (d)(3). 
‘‘(B) MONITORING COMPLIANCE.— 
‘‘(i) IN
GENERAL.—The Secretary shall monitor 
compliance by a manufacturer with the terms of an 
agreement under this section. 
‘‘(ii) NOTIFICATION.—If a third party with a con-
tract under subsection (d)(3) determines that the 
manufacturer is not in compliance with such agree-
ment, the third party shall notify the Secretary of 
such noncompliance for appropriate enforcement under 
subsection (e). 
‘‘(C) COLLECTION OF DATA FROM PRESCRIPTION DRUG 
PLANS AND MA–PD PLANS.—The Secretary may collect appro-
priate data from prescription drug plans and MA–PD plans 
in a timeframe that allows for discounted prices to be 
provided for applicable drugs under this section. 
‘‘(2) SPECIAL RULE FOR SUPPLEMENTAL BENEFITS.—For plan 
year 2010 and each subsequent plan year, in the case where 
an applicable beneficiary has supplemental benefits with 
respect to applicable drugs under the prescription drug plan 
or MA–PD plan that the applicable beneficiary is enrolled in, 
the applicable beneficiary shall not be provided a discounted 
price for an applicable drug under this section until after such 
supplemental benefits have been applied with respect to the 
applicable drug. 
‘‘(d) ADMINISTRATION.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), the Secretary 
shall provide for the implementation of this section, including 
the performance of the duties described in subsection (c)(1). 
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124 STAT. 465 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) LIMITATION.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), in pro-
viding for such implementation, the Secretary shall not 
receive or distribute any funds of a manufacturer under 
the program. 
‘‘(B) EXCEPTION.—The limitation under subparagraph 
(A) shall not apply to the Secretary with respect to drugs 
dispensed during the period beginning on July 1, 2010, 
and ending on December 31, 2010, but only if the Secretary 
determines that the exception to such limitation under 
this subparagraph is necessary in order for the Secretary 
to begin implementation of this section and provide 
applicable beneficiaries timely access to discounted prices 
during such period. 
‘‘(3) CONTRACT WITH THIRD PARTIES.—The Secretary shall 
enter into a contract with 1 or more third parties to administer 
the requirements established by the Secretary in order to carry 
out this section. At a minimum, the contract with a third 
party under the preceding sentence shall require that the third 
party— 
‘‘(A) receive and transmit information between the Sec-
retary, manufacturers, and other individuals or entities 
the Secretary determines appropriate; 
‘‘(B) receive, distribute, or facilitate the distribution 
of funds of manufacturers to appropriate individuals or 
entities in order to meet the obligations of manufacturers 
under agreements under this section; 
‘‘(C) provide adequate and timely information to manu-
facturers, consistent with the agreement with the manufac-
turer under this section, as necessary for the manufacturer 
to fulfill its obligations under this section; and 
‘‘(D) permit manufacturers to conduct periodic audits, 
directly or through contracts, of the data and information 
used by the third party to determine discounts for 
applicable drugs of the manufacturer under the program. 
‘‘(4) PERFORMANCE
REQUIREMENTS.—The Secretary shall 
establish performance requirements for a third party with a 
contract under paragraph (3) and safeguards to protect the 
independence and integrity of the activities carried out by the 
third party under the program under this section. 
‘‘(5) IMPLEMENTATION.—The Secretary may implement the 
program under this section by program instruction or otherwise. 
‘‘(6) ADMINISTRATION.—Chapter 35 of title 44, United States 
Code, shall not apply to the program under this section. 
‘‘(e) ENFORCEMENT.— 
‘‘(1) AUDITS.—Each manufacturer with an agreement in 
effect under this section shall be subject to periodic audit by 
the Secretary. 
‘‘(2) CIVIL MONEY PENALTY.— 
‘‘(A) IN GENERAL.—The Secretary shall impose a civil 
money penalty on a manufacturer that fails to provide 
applicable beneficiaries discounts for applicable drugs of 
the manufacturer in accordance with such agreement for 
each such failure in an amount the Secretary determines 
is commensurate with the sum of— 
Determination. 
Time period. 
Determination. 
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124 STAT. 466 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) the amount that the manufacturer would have 
paid with respect to such discounts under the agree-
ment, which will then be used to pay the discounts 
which the manufacturer had failed to provide; and 
‘‘(ii) 25 percent of such amount. 
‘‘(B) APPLICATION.—The provisions of section 1128A 
(other than subsections (a) and (b)) shall apply to a civil 
money penalty under this paragraph in the same manner 
as such provisions apply to a penalty or proceeding under 
section 1128A(a). 
‘‘(f) CLARIFICATION REGARDING AVAILABILITY OF OTHER COV-
ERED PART D DRUGS.—Nothing in this section shall prevent an 
applicable beneficiary from purchasing a covered part D drug that 
is not an applicable drug (including a generic drug or a drug 
that is not on the formulary of the prescription drug plan or MA– 
PD plan that the applicable beneficiary is enrolled in). 
‘‘(g) DEFINITIONS.—In this section: 
‘‘(1) APPLICABLE BENEFICIARY.—The term ‘applicable bene-
ficiary’ means an individual who, on the date of dispensing 
an applicable drug— 
‘‘(A) is enrolled in a prescription drug plan or an MA– 
PD plan; 
‘‘(B) is not enrolled in a qualified retiree prescription 
drug plan; 
‘‘(C) is not entitled to an income-related subsidy under 
section 1860D–14(a); 
‘‘(D) is not subject to a reduction in premium subsidy 
under section 1839(i); and 
‘‘(E) who— 
‘‘(i) has reached or exceeded the initial coverage 
limit under section 1860D–2(b)(3) during the year; and 
‘‘(ii) has not incurred costs for covered part D 
drugs in the year equal to the annual out-of-pocket 
threshold specified in section 1860D–2(b)(4)(B). 
‘‘(2) APPLICABLE DRUG.—The term ‘applicable drug’ means, 
with respect to an applicable beneficiary, a covered part D 
drug— 
‘‘(A) approved under a new drug application under 
section 505(b) of the Federal Food, Drug, and Cosmetic 
Act or, in the case of a biologic product, licensed under 
section 351 of the Public Health Service Act (other than 
a product licensed under subsection (k) of such section 
351); and 
‘‘(B)(i) if the PDP sponsor of the prescription drug 
plan or the MA organization offering the MA–PD plan 
uses a formulary, which is on the formulary of the prescrip-
tion drug plan or MA–PD plan that the applicable bene-
ficiary is enrolled in; 
‘‘(ii) if the PDP sponsor of the prescription drug plan 
or the MA organization offering the MA–PD plan does 
not use a formulary, for which benefits are available under 
the prescription drug plan or MA–PD plan that the 
applicable beneficiary is enrolled in; or 
‘‘(iii) is provided through an exception or appeal. 
‘‘(3) APPLICABLE NUMBER OF CALENDAR DAYS.—The term 
‘applicable number of calendar days’ means— 
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124 STAT. 467 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) with respect to claims for reimbursement sub-
mitted electronically, 14 days; and 
‘‘(B) with respect to claims for reimbursement sub-
mitted otherwise, 30 days. 
‘‘(4) DISCOUNTED PRICE.— 
‘‘(A) IN GENERAL.—The term ‘discounted price’ means 
50 percent of the negotiated price of the applicable drug 
of a manufacturer. 
‘‘(B) CLARIFICATION.—Nothing in this section shall be 
construed as affecting the responsibility of an applicable 
beneficiary for payment of a dispensing fee for an applicable 
drug. 
‘‘(C) SPECIAL CASE FOR CERTAIN CLAIMS.—In the case 
where the entire amount of the negotiated price of an 
individual claim for an applicable drug with respect to 
an applicable beneficiary does not fall at or above the 
initial coverage limit under section 1860D–2(b)(3) and 
below the annual out-of-pocket threshold specified in sec-
tion 1860D–2(b)(4)(B) for the year, the manufacturer of 
the applicable drug shall provide the discounted price under 
this section on only the portion of the negotiated price 
of the applicable drug that falls at or above such initial 
coverage limit and below such annual out-of-pocket 
threshold. 
‘‘(5) MANUFACTURER.—The term ‘manufacturer’ means any 
entity which is engaged in the production, preparation, propaga-
tion, compounding, conversion, or processing of prescription 
drug products, either directly or indirectly by extraction from 
substances of natural origin, or independently by means of 
chemical synthesis, or by a combination of extraction and chem-
ical synthesis. Such term does not include a wholesale dis-
tributor of drugs or a retail pharmacy licensed under State 
law. 
‘‘(6) NEGOTIATED PRICE.—The term ‘negotiated price’ has 
the meaning given such term in section 423.100 of title 42, 
Code of Federal Regulations (as in effect on the date of enact-
ment of this section), except that such negotiated price shall 
not include any dispensing fee for the applicable drug. 
‘‘(7) QUALIFIED
RETIREE
PRESCRIPTION
DRUG
PLAN.—The 
term ‘qualified retiree prescription drug plan’ has the meaning 
given such term in section 1860D–22(a)(2).’’. 
(c) INCLUSION IN INCURRED COSTS.— 
(1) IN GENERAL.—Section 1860D–2(b)(4) of the Social Secu-
rity Act (42 U.S.C. 1395w–102(b)(4)) is amended— 
(A) in subparagraph (C), in the matter preceding clause 
(i), by striking ‘‘In applying’’ and inserting ‘‘Except as pro-
vided in subparagraph (E), in applying’’; and 
(B) by adding at the end the following new subpara-
graph: 
‘‘(E) INCLUSION OF COSTS OF APPLICABLE DRUGS UNDER 
MEDICARE COVERAGE GAP DISCOUNT PROGRAM.—In applying 
subparagraph (A), incurred costs shall include the nego-
tiated price (as defined in paragraph (6) of section 1860D– 
14A(g)) of an applicable drug (as defined in paragraph 
(2) of such section) of a manufacturer that is furnished 
to an applicable beneficiary (as defined in paragraph (1) 
of such section) under the Medicare coverage gap discount 
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124 STAT. 468 
PUBLIC LAW 111–148—MAR. 23, 2010 
program under section 1860D–14A, regardless of whether 
part of such costs were paid by a manufacturer under 
such program.’’. 
(2) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to costs incurred on or after July 1, 2010. 
(d) CONFORMING AMENDMENT PERMITTING PRESCRIPTION DRUG 
DISCOUNTS.— 
(1) IN GENERAL.—Section 1128B(b)(3) of the Social Security 
Act (42 U.S.C. 1320a–7b(b)(3)) is amended— 
(A) by striking ‘‘and’’ at the end of subparagraph (G); 
(B) in the subparagraph (H) added by section 237(d) 
of the Medicare Prescription Drug, Improvement, and Mod-
ernization Act of 2003 (Public Law 108–173; 117 Stat. 
2213)— 
(i) by moving such subparagraph 2 ems to the 
left; and 
(ii) by striking the period at the end and inserting 
a semicolon; 
(C) in the subparagraph (H) added by section 431(a) 
of such Act (117 Stat. 2287)— 
(i) by redesignating such subparagraph as subpara-
graph (I); 
(ii) by moving such subparagraph 2 ems to the 
left; and 
(iii) by striking the period at the end and inserting 
‘‘; and’’; and 
(D) by adding at the end the following new subpara-
graph: 
‘‘(J) a discount in the price of an applicable drug (as 
defined in paragraph (2) of section 1860D–14A(g)) of a 
manufacturer that is furnished to an applicable beneficiary 
(as defined in paragraph (1) of such section) under the 
Medicare coverage gap discount program under section 
1860D–14A.’’. 
(2) CONFORMING AMENDMENT TO DEFINITION OF BEST PRICE 
UNDER
MEDICAID.—Section 1927(c)(1)(C)(i)(VI) of the Social 
Security Act (42 U.S.C. 1396r–8(c)(1)(C)(i)(VI)) is amended by 
inserting ‘‘, or any discounts provided by manufacturers under 
the Medicare coverage gap discount program under section 
1860D–14A’’ before the period at the end. 
(3) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to drugs dispensed on or after July 1, 
2010. 
SEC. 3302. IMPROVEMENT IN DETERMINATION OF MEDICARE PART 
D LOW-INCOME BENCHMARK PREMIUM. 
(a) IN GENERAL.—Section 1860D–14(b)(2)(B)(iii) of the Social 
Security Act (42 U.S.C. 1395w–114(b)(2)(B)(iii)) is amended by 
inserting ‘‘, determined without regard to any reduction in such 
premium as a result of any beneficiary rebate under section 
1854(b)(1)(C) or bonus payment under section 1853(n)’’ before the 
period at the end. 
(b) EFFECTIVE DATE.—The amendment made by subsection (a) 
shall apply to premiums for months beginning on or after January 
1, 2011. 
42 USC 
1395w–114 note. 
42 USC 
1320a–76 note. 
42 USC 
1395w–102 note. 
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124 STAT. 469 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 3303. VOLUNTARY DE MINIMIS POLICY FOR SUBSIDY ELIGIBLE 
INDIVIDUALS UNDER PRESCRIPTION DRUG PLANS AND 
MA–PD PLANS. 
(a) IN GENERAL.—Section 1860D–14(a) of the Social Security 
Act (42 U.S.C. 1395w–114(a)) is amended by adding at the end 
the following new paragraph: 
‘‘(5) WAIVER
OF
DE
MINIMIS
PREMIUMS.—The Secretary 
shall, under procedures established by the Secretary, permit 
a prescription drug plan or an MA–PD plan to waive the 
monthly beneficiary premium for a subsidy eligible individual 
if the amount of such premium is de minimis. If such premium 
is waived under the plan, the Secretary shall not reassign 
subsidy eligible individuals enrolled in the plan to other plans 
based on the fact that the monthly beneficiary premium under 
the plan was greater than the low-income benchmark premium 
amount.’’. 
(b) AUTHORIZING
THE SECRETARY TO AUTO-ENROLL SUBSIDY 
ELIGIBLE INDIVIDUALS
IN PLANS THAT WAIVE DE MINIMIS PRE-
MIUMS.—Section 1860D–1(b)(1) of the Social Security Act (42 U.S.C. 
1395w–101(b)(1)) is amended— 
(1) in subparagraph (C), by inserting ‘‘except as provided 
in subparagraph (D),’’ after ‘‘shall include,’’ 
(2) by adding at the end the following new subparagraph: 
‘‘(D) SPECIAL RULE FOR PLANS THAT WAIVE DE MINIMIS 
PREMIUMS.—The process established under subparagraph 
(A) may include, in the case of a part D eligible individual 
who is a subsidy eligible individual (as defined in section 
1860D–14(a)(3)) who has failed to enroll in a prescription 
drug plan or an MA–PD plan, for the enrollment in a 
prescription drug plan or MA–PD plan that has waived 
the monthly beneficiary premium for such subsidy eligible 
individual under section 1860D–14(a)(5). If there is more 
than one such plan available, the Secretary shall enroll 
such an individual under the preceding sentence on a 
random basis among all such plans in the PDP region. 
Nothing in the previous sentence shall prevent such an 
individual from declining or changing such enrollment.’’. 
(c) EFFECTIVE DATE.—The amendments made by this subsection 
shall apply to premiums for months, and enrollments for plan 
years, beginning on or after January 1, 2011. 
SEC. 3304. SPECIAL RULE FOR WIDOWS AND WIDOWERS REGARDING 
ELIGIBILITY FOR LOW-INCOME ASSISTANCE. 
(a) IN GENERAL.—Section 1860D–14(a)(3)(B) of the Social Secu-
rity Act (42 U.S.C. 1395w–114(a)(3)(B)) is amended by adding at 
the end the following new clause: 
‘‘(vi) SPECIAL RULE FOR WIDOWS AND WIDOWERS.— 
Notwithstanding the preceding provisions of this 
subparagraph, in the case of an individual whose 
spouse dies during the effective period for a determina-
tion or redetermination that has been made under 
this subparagraph, such effective period shall be 
extended through the date that is 1 year after the 
date on which the determination or redetermination 
would (but for the application of this clause) otherwise 
cease to be effective.’’. 
42 USC 
1395w–101 note. 
Procedures. 
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124 STAT. 470 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b) EFFECTIVE DATE.—The amendment made by subsection (a) 
shall take effect on January 1, 2011. 
SEC. 3305. IMPROVED INFORMATION FOR SUBSIDY ELIGIBLE INDIVID-
UALS REASSIGNED TO PRESCRIPTION DRUG PLANS AND 
MA–PD PLANS. 
Section 1860D–14 of the Social Security Act (42 U.S.C. 1395w– 
114) is amended— 
(1) by redesignating subsection (d) as subsection (e); and 
(2) by inserting after subsection (c) the following new sub-
section: 
‘‘(d) FACILITATION
OF REASSIGNMENTS.—Beginning not later 
than January 1, 2011, the Secretary shall, in the case of a subsidy 
eligible individual who is enrolled in one prescription drug plan 
and is subsequently reassigned by the Secretary to a new prescrip-
tion drug plan, provide the individual, within 30 days of such 
reassignment, with— 
‘‘(1) information on formulary differences between the 
individual’s former plan and the plan to which the individual 
is reassigned with respect to the individual’s drug regimens; 
and 
‘‘(2) a description of the individual’s right to request a 
coverage determination, exception, or reconsideration under sec-
tion 1860D–4(g), bring an appeal under section 1860D–4(h), 
or resolve a grievance under section 1860D–4(f).’’. 
SEC. 3306. FUNDING OUTREACH AND ASSISTANCE FOR LOW-INCOME 
PROGRAMS. 
(a) ADDITIONAL FUNDING FOR STATE HEALTH INSURANCE PRO-
GRAMS.—Subsection (a)(1)(B) of section 119 of the Medicare 
Improvements for Patients and Providers Act of 2008 (42 U.S.C. 
1395b–3 note) is amended by striking ‘‘(42 U.S.C. 1395w–23(f))’’ 
and all that follows through the period at the end and inserting 
‘‘(42 U.S.C. 1395w–23(f)), to the Centers for Medicare & Medicaid 
Services Program Management Account— 
‘‘(i) for fiscal year 2009, of $7,500,000; and 
‘‘(ii) for the period of fiscal years 2010 through 
2012, of $15,000,000. 
Amounts appropriated under this subparagraph shall 
remain available until expended.’’. 
(b) ADDITIONAL FUNDING
FOR AREA AGENCIES
ON AGING.— 
Subsection (b)(1)(B) of such section 119 is amended by striking 
‘‘(42 U.S.C. 1395w–23(f))’’ and all that follows through the period 
at the end and inserting ‘‘(42 U.S.C. 1395w–23(f)), to the Adminis-
tration on Aging— 
‘‘(i) for fiscal year 2009, of $7,500,000; and 
‘‘(ii) for the period of fiscal years 2010 through 
2012, of $15,000,000. 
Amounts appropriated under this subparagraph shall 
remain available until expended.’’. 
(c) ADDITIONAL FUNDING FOR AGING AND DISABILITY RESOURCE 
CENTERS.—Subsection (c)(1)(B) of such section 119 is amended by 
striking ‘‘(42 U.S.C. 1395w–23(f))’’ and all that follows through 
the period at the end and inserting ‘‘(42 U.S.C. 1395w–23(f)), to 
the Administration on Aging— 
‘‘(i) for fiscal year 2009, of $5,000,000; and 
‘‘(ii) for the period of fiscal years 2010 through 
2012, of $10,000,000. 
Deadlines. 
42 USC 
1395w–114 note. 
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124 STAT. 471 
PUBLIC LAW 111–148—MAR. 23, 2010 
Amounts appropriated under this subparagraph shall 
remain available until expended.’’. 
(d) ADDITIONAL FUNDING FOR CONTRACT WITH THE NATIONAL 
CENTER FOR BENEFITS AND OUTREACH ENROLLMENT.—Subsection 
(d)(2) of such section 119 is amended by striking ‘‘(42 U.S.C. 1395w– 
23(f))’’ and all that follows through the period at the end and 
inserting ‘‘(42 U.S.C. 1395w–23(f)), to the Administration on 
Aging— 
‘‘(i) for fiscal year 2009, of $5,000,000; and 
‘‘(ii) for the period of fiscal years 2010 through 
2012, of $5,000,000. 
Amounts appropriated under this subparagraph shall 
remain available until expended.’’. 
(e) SECRETARIAL AUTHORITY TO ENLIST SUPPORT
IN CON-
DUCTING CERTAIN OUTREACH ACTIVITIES.—Such section 119 is 
amended by adding at the end the following new subsection: 
‘‘(g) SECRETARIAL AUTHORITY TO ENLIST SUPPORT
IN CON-
DUCTING
CERTAIN
OUTREACH
ACTIVITIES.—The Secretary may 
request that an entity awarded a grant under this section support 
the conduct of outreach activities aimed at preventing disease and 
promoting wellness. Notwithstanding any other provision of this 
section, an entity may use a grant awarded under this subsection 
to support the conduct of activities described in the preceding 
sentence.’’. 
SEC. 3307. IMPROVING FORMULARY REQUIREMENTS FOR PRESCRIP-
TION DRUG PLANS AND MA–PD PLANS WITH RESPECT 
TO CERTAIN CATEGORIES OR CLASSES OF DRUGS. 
(a) IMPROVING FORMULARY REQUIREMENTS.—Section 1860D– 
4(b)(3)(G) of the Social Security Act is amended to read as follows: 
‘‘(G) REQUIRED INCLUSION OF DRUGS IN CERTAIN CAT-
EGORIES AND CLASSES.— 
‘‘(i) FORMULARY REQUIREMENTS.— 
‘‘(I) IN
GENERAL.—Subject to subclause (II), 
a PDP sponsor offering a prescription drug plan 
shall be required to include all covered part D 
drugs in the categories and classes identified by 
the Secretary under clause (ii)(I). 
‘‘(II) EXCEPTIONS.—The Secretary may estab-
lish exceptions that permit a PDP sponsor offering 
a prescription drug plan to exclude from its for-
mulary a particular covered part D drug in a cat-
egory or class that is otherwise required to be 
included in the formulary under subclause (I) (or 
to otherwise limit access to such a drug, including 
through prior authorization or utilization manage-
ment). 
‘‘(ii) IDENTIFICATION
OF
DRUGS
IN
CERTAIN
CAT-
EGORIES AND CLASSES.— 
‘‘(I) IN GENERAL.—Subject to clause (iv), the 
Secretary shall identify, as appropriate, categories 
and classes of drugs for which the Secretary deter-
mines are of clinical concern. 
‘‘(II) CRITERIA.—The Secretary shall use cri-
teria established by the Secretary in making any 
determination under subclause (I). 
42 USC 
1395w–104. 
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124 STAT. 472 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(iii) IMPLEMENTATION.—The Secretary shall estab-
lish the criteria under clause (ii)(II) and any exceptions 
under clause (i)(II) through the promulgation of a regu-
lation which includes a public notice and comment 
period. 
‘‘(iv) REQUIREMENT FOR CERTAIN CATEGORIES AND 
CLASSES
UNTIL
CRITERIA
ESTABLISHED.—Until such 
time as the Secretary establishes the criteria under 
clause (ii)(II) the following categories and classes of 
drugs shall be identified under clause (ii)(I): 
‘‘(I) Anticonvulsants. 
‘‘(II) Antidepressants. 
‘‘(III) Antineoplastics. 
‘‘(IV) Antipsychotics. 
‘‘(V) Antiretrovirals. 
‘‘(VI) Immunosuppressants for the treatment 
of transplant rejection.’’. 
(b) EFFECTIVE DATE.—The amendments made by this section 
shall apply to plan year 2011 and subsequent plan years. 
SEC. 3308. REDUCING PART D PREMIUM SUBSIDY FOR HIGH-INCOME 
BENEFICIARIES. 
(a) INCOME-RELATED INCREASE IN PART D PREMIUM.— 
(1) IN GENERAL.—Section 1860D–13(a) of the Social Secu-
rity Act (42 U.S.C. 1395w–113(a)) is amended by adding at 
the end the following new paragraph: 
‘‘(7) INCREASE IN BASE BENEFICIARY PREMIUM BASED ON 
INCOME.— 
‘‘(A) IN GENERAL.—In the case of an individual whose 
modified adjusted gross income exceeds the threshold 
amount applicable under paragraph (2) of section 1839(i) 
(including application of paragraph (5) of such section) 
for the calendar year, the monthly amount of the bene-
ficiary premium applicable under this section for a month 
after December 2010 shall be increased by the monthly 
adjustment amount specified in subparagraph (B). 
‘‘(B) MONTHLY
ADJUSTMENT
AMOUNT.—The monthly 
adjustment amount specified in this subparagraph for an 
individual for a month in a year is equal to the product 
of— 
‘‘(i) the quotient obtained by dividing— 
‘‘(I) the applicable percentage determined 
under paragraph (3)(C) of section 1839(i) (including 
application of paragraph (5) of such section) for 
the individual for the calendar year reduced by 
25.5 percent; by 
‘‘(II) 25.5 percent; and 
‘‘(ii) the base beneficiary premium (as computed 
under paragraph (2)). 
‘‘(C) MODIFIED ADJUSTED GROSS INCOME.—For purposes 
of this paragraph, the term ‘modified adjusted gross income’ 
has the meaning given such term in subparagraph (A) 
of section 1839(i)(4), determined for the taxable year 
applicable under subparagraphs (B) and (C) of such section. 
‘‘(D) DETERMINATION
BY
COMMISSIONER
OF
SOCIAL 
SECURITY.—The Commissioner of Social Security shall 
make any determination necessary to carry out the income- 
42 USC 
1395w–104 note. 
Regulations. 
Public 
information. 
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124 STAT. 473 
PUBLIC LAW 111–148—MAR. 23, 2010 
related increase in the base beneficiary premium under 
this paragraph. 
‘‘(E) PROCEDURES TO ASSURE CORRECT INCOME-RELATED 
INCREASE IN BASE BENEFICIARY PREMIUM.— 
‘‘(i) DISCLOSURE OF BASE BENEFICIARY PREMIUM.— 
Not later than September 15 of each year beginning 
with 2010, the Secretary shall disclose to the Commis-
sioner of Social Security the amount of the base bene-
ficiary premium (as computed under paragraph (2)) 
for the purpose of carrying out the income-related 
increase in the base beneficiary premium under this 
paragraph with respect to the following year. 
‘‘(ii) ADDITIONAL
DISCLOSURE.—Not later than 
October 15 of each year beginning with 2010, the Sec-
retary shall disclose to the Commissioner of Social 
Security the following information for the purpose of 
carrying out the income-related increase in the base 
beneficiary premium under this paragraph with respect 
to the following year: 
‘‘(I) The modified adjusted gross income 
threshold applicable under paragraph (2) of section 
1839(i) (including application of paragraph (5) of 
such section). 
‘‘(II) The applicable percentage determined 
under paragraph (3)(C) of section 1839(i) (including 
application of paragraph (5) of such section). 
‘‘(III) The monthly adjustment amount speci-
fied in subparagraph (B). 
‘‘(IV) Any other information the Commissioner 
of Social Security determines necessary to carry 
out the income-related increase in the base bene-
ficiary premium under this paragraph. 
‘‘(F) RULE
OF
CONSTRUCTION.—The formula used to 
determine the monthly adjustment amount specified under 
subparagraph (B) shall only be used for the purpose of 
determining such monthly adjustment amount under such 
subparagraph.’’. 
(2) COLLECTION OF MONTHLY ADJUSTMENT AMOUNT.—Sec-
tion 1860D–13(c) of the Social Security Act (42 U.S.C. 1395w– 
113(c)) is amended— 
(A) in paragraph (1), by striking ‘‘(2) and (3)’’ and 
inserting ‘‘(2), (3), and (4)’’; and 
(B) by adding at the end the following new paragraph: 
‘‘(4) COLLECTION OF MONTHLY ADJUSTMENT AMOUNT.— 
‘‘(A) IN GENERAL.—Notwithstanding any provision of 
this subsection or section 1854(d)(2), subject to subpara-
graph (B), the amount of the income-related increase in 
the base beneficiary premium for an individual for a month 
(as determined under subsection (a)(7)) shall be paid 
through withholding from benefit payments in the manner 
provided under section 1840. 
‘‘(B) AGREEMENTS.—In the case where the monthly ben-
efit payments of an individual that are withheld under 
subparagraph (A) are insufficient to pay the amount 
described in such subparagraph, the Commissioner of 
Social Security shall enter into agreements with the Sec-
retary, the Director of the Office of Personnel Management, 
Deadlines. 
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124 STAT. 474 
PUBLIC LAW 111–148—MAR. 23, 2010 
and the Railroad Retirement Board as necessary in order 
to allow other agencies to collect the amount described 
in subparagraph (A) that was not withheld under such 
subparagraph.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) MEDICARE.—Section 1860D–13(a)(1) of the Social Secu-
rity Act (42 U.S.C. 1395w–113(a)(1)) is amended— 
(A) by redesignating subparagraph (F) as subparagraph 
(G); 
(B) in subparagraph (G), as redesignated by subpara-
graph (A), by striking ‘‘(D) and (E)’’ and inserting ‘‘(D), 
(E), and (F)’’; and 
(C) by inserting after subparagraph (E) the following 
new subparagraph: 
‘‘(F) INCREASE BASED ON INCOME.—The monthly bene-
ficiary premium shall be increased pursuant to paragraph 
(7).’’. 
(2) INTERNAL REVENUE CODE.—Section 6103(l)(20) of the 
Internal Revenue Code of 1986 (relating to disclosure of return 
information to carry out Medicare part B premium subsidy 
adjustment) is amended— 
(A) in the heading, by inserting ‘‘AND PART D BASE 
BENEFICIARY PREMIUM INCREASE’’ after ‘‘PART B PREMIUM 
SUBSIDY ADJUSTMENT’’; 
(B) in subparagraph (A)— 
(i) in the matter preceding clause (i), by inserting 
‘‘or increase under section 1860D–13(a)(7)’’ after 
‘‘1839(i)’’; and 
(ii) in clause (vii), by inserting after ‘‘subsection 
(i) of such section’’ the following: ‘‘or increase under 
section 1860D–13(a)(7) of such Act’’; and 
(C) in subparagraph (B)— 
(i) by striking ‘‘Return information’’ and inserting 
the following: 
‘‘(i) IN GENERAL.—Return information’’; 
(ii) by inserting ‘‘or increase under such section 
1860D–13(a)(7)’’ before the period at the end; 
(iii) as amended by clause (i), by inserting ‘‘or 
for the purpose of resolving taxpayer appeals with 
respect to any such premium adjustment or increase’’ 
before the period at the end; and 
(iv) by adding at the end the following new clause: 
‘‘(ii) DISCLOSURE
TO
OTHER
AGENCIES.—Officers, 
employees, and contractors of the Social Security 
Administration may disclose— 
‘‘(I) the taxpayer identity information and the 
amount of the premium subsidy adjustment or 
premium increase with respect to a taxpayer 
described 
in 
subparagraph 
(A) 
to 
officers, 
employees, and contractors of the Centers for Medi-
care and Medicaid Services, to the extent that 
such disclosure is necessary for the collection of 
the premium subsidy amount or the increased pre-
mium amount, 
‘‘(II) the taxpayer identity information and the 
amount of the premium subsidy adjustment or 
the increased premium amount with respect to 
26 USC 6103. 
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124 STAT. 475 
PUBLIC LAW 111–148—MAR. 23, 2010 
a taxpayer described in subparagraph (A) to offi-
cers and employees of the Office of Personnel 
Management and the Railroad Retirement Board, 
to the extent that such disclosure is necessary 
for the collection of the premium subsidy amount 
or the increased premium amount, 
‘‘(III) return information with respect to a tax-
payer described in subparagraph (A) to officers 
and employees of the Department of Health and 
Human Services to the extent necessary to resolve 
administrative appeals of such premium subsidy 
adjustment or increased premium, and 
‘‘(IV) return information with respect to a tax-
payer described in subparagraph (A) to officers 
and employees of the Department of Justice for 
use in judicial proceedings to the extent necessary 
to carry out the purposes described in clause (i).’’. 
SEC. 3309. ELIMINATION OF COST SHARING FOR CERTAIN DUAL 
ELIGIBLE INDIVIDUALS. 
Section 1860D–14(a)(1)(D)(i) of the Social Security Act (42 
U.S.C. 1395w–114(a)(1)(D)(i)) is amended by inserting ‘‘or, effective 
on a date specified by the Secretary (but in no case earlier than 
January 1, 2012), who would be such an institutionalized individual 
or couple, if the full-benefit dual eligible individual were not 
receiving services under a home and community-based waiver 
authorized for a State under section 1115 or subsection (c) or 
(d) of section 1915 or under a State plan amendment under sub-
section (i) of such section or services provided through enrollment 
in a medicaid managed care organization with a contract under 
section 1903(m) or under section 1932’’ after ‘‘1902(q)(1)(B))’’. 
SEC. 3310. REDUCING WASTEFUL DISPENSING OF OUTPATIENT 
PRESCRIPTION DRUGS IN LONG-TERM CARE FACILITIES 
UNDER PRESCRIPTION DRUG PLANS AND MA–PD PLANS. 
(a) IN GENERAL.—Section 1860D–4(c) of the Social Security 
Act (42 U.S.C. 1395w–104(c)) is amended by adding at the end 
the following new paragraph: 
‘‘(3) REDUCING
WASTEFUL
DISPENSING
OF
OUTPATIENT 
PRESCRIPTION DRUGS IN LONG-TERM CARE FACILITIES.—The Sec-
retary shall require PDP sponsors of prescription drug plans 
to utilize specific, uniform dispensing techniques, as determined 
by the Secretary, in consultation with relevant stakeholders 
(including representatives of nursing facilities, residents of 
nursing 
facilities, 
pharmacists, 
the 
pharmacy 
industry 
(including retail and long-term care pharmacy), prescription 
drug plans, MA–PD plans, and any other stakeholders the 
Secretary determines appropriate), such as weekly, daily, or 
automated dose dispensing, when dispensing covered part D 
drugs to enrollees who reside in a long-term care facility in 
order to reduce waste associated with 30-day fills.’’. 
(b) EFFECTIVE DATE.—The amendment made by subsection (a) 
shall apply to plan years beginning on or after January 1, 2012. 
SEC. 3311. IMPROVED MEDICARE PRESCRIPTION DRUG PLAN AND MA– 
PD PLAN COMPLAINT SYSTEM. 
(a) IN GENERAL.—The Secretary shall develop and maintain 
a complaint system, that is widely known and easy to use, to 
42 USC 
1395w–154. 
42 USC 
1395w–104 note. 
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124 STAT. 476 
PUBLIC LAW 111–148—MAR. 23, 2010 
collect and maintain information on MA–PD plan and prescription 
drug plan complaints that are received (including by telephone, 
letter, e-mail, or any other means) by the Secretary (including 
by a regional office of the Department of Health and Human Serv-
ices, the Medicare Beneficiary Ombudsman, a subcontractor, a car-
rier, a fiscal intermediary, and a Medicare administrative contractor 
under section 1874A of the Social Security Act (42 U.S.C. 1395kk)) 
through the date on which the complaint is resolved. The system 
shall be able to report and initiate appropriate interventions and 
monitoring based on substantial complaints and to guide quality 
improvement. 
(b) MODEL ELECTRONIC COMPLAINT FORM.—The Secretary shall 
develop a model electronic complaint form to be used for reporting 
plan complaints under the system. Such form shall be prominently 
displayed on the front page of the Medicare.gov Internet website 
and on the Internet website of the Medicare Beneficiary Ombuds-
man. 
(c) ANNUAL REPORTS BY THE SECRETARY.—The Secretary shall 
submit to Congress annual reports on the system. Such reports 
shall include an analysis of the number and types of complaints 
reported in the system, geographic variations in such complaints, 
the timeliness of agency or plan responses to such complaints, 
and the resolution of such complaints. 
(d) DEFINITIONS.—In this section: 
(1) MA–PD PLAN.—The term ‘‘MA–PD plan’’ has the 
meaning given such term in section 1860D–41(a)(9) of such 
Act (42 U.S.C. 1395w–151(a)(9)). 
(2) PRESCRIPTION DRUG PLAN.—The term ‘‘prescription drug 
plan’’ has the meaning given such term in section 1860D– 
41(a)(14) of such Act (42 U.S.C. 1395w–151(a)(14)). 
(3) SECRETARY.—The term ‘‘Secretary’’ means the Secretary 
of Health and Human Services. 
(4) SYSTEM.—The term ‘‘system’’ means the plan complaint 
system developed and maintained under subsection (a). 
SEC. 3312. UNIFORM EXCEPTIONS AND APPEALS PROCESS FOR 
PRESCRIPTION DRUG PLANS AND MA–PD PLANS. 
(a) IN GENERAL.—Section 1860D–4(b)(3) of the Social Security 
Act (42 U.S.C. 1395w–104(b)(3)) is amended by adding at the end 
the following new subparagraph: 
‘‘(H) USE OF SINGLE, UNIFORM EXCEPTIONS AND APPEALS 
PROCESS.—Notwithstanding any other provision of this 
part, each PDP sponsor of a prescription drug plan shall— 
‘‘(i) use a single, uniform exceptions and appeals 
process (including, to the extent the Secretary deter-
mines feasible, a single, uniform model form for use 
under such process) with respect to the determination 
of prescription drug coverage for an enrollee under 
the plan; and 
‘‘(ii) provide instant access to such process by 
enrollees through a toll-free telephone number and 
an Internet website.’’. 
(b) EFFECTIVE DATE.—The amendment made by subsection (a) 
shall apply to exceptions and appeals on or after January 1, 2012. 
42 USC 
1395w–104 note. 
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124 STAT. 477 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 3313. OFFICE OF THE INSPECTOR GENERAL STUDIES AND 
REPORTS. 
(a) STUDY
AND ANNUAL REPORT
ON PART D FORMULARIES’ 
INCLUSION OF DRUGS COMMONLY USED BY DUAL ELIGIBLES.— 
(1) STUDY.—The Inspector General of the Department of 
Health and Human Services shall conduct a study of the extent 
to which formularies used by prescription drug plans and MA– 
PD plans under part D include drugs commonly used by full- 
benefit dual eligible individuals (as defined in section 1935(c)(6) 
of the Social Security Act (42 U.S.C. 1396u–5(c)(6))). 
(2) ANNUAL REPORTS.—Not later than July 1 of each year 
(beginning with 2011), the Inspector General shall submit to 
Congress a report on the study conducted under paragraph 
(1), together with such recommendations as the Inspector Gen-
eral determines appropriate. 
(b) STUDY AND REPORT ON PRESCRIPTION DRUG PRICES UNDER 
MEDICARE PART D AND MEDICAID.— 
(1) STUDY.— 
(A) IN GENERAL.—The Inspector General of the Depart-
ment of Health and Human Services shall conduct a study 
on prices for covered part D drugs under the Medicare 
prescription drug program under part D of title XVIII 
of the Social Security Act and for covered outpatient drugs 
under title XIX. Such study shall include the following: 
(i) A comparison, with respect to the 200 most 
frequently dispensed covered part D drugs under such 
program and covered outpatient drugs under such title 
(as determined by the Inspector General based on 
volume and expenditures), of— 
(I) the prices paid for covered part D drugs 
by PDP sponsors of prescription drug plans and 
Medicare Advantage organizations offering MA– 
PD plans; and 
(II) the prices paid for covered outpatient 
drugs by a State plan under title XIX. 
(ii) An assessment of— 
(I) the financial impact of any discrepancies 
in such prices on the Federal Government; and 
(II) the financial impact of any such discrep-
ancies on enrollees under part D or individuals 
eligible for medical assistance under a State plan 
under title XIX. 
(B) PRICE.—For purposes of subparagraph (A), the 
price of a covered part D drug or a covered outpatient 
drug shall include any rebate or discount under such pro-
gram or such title, respectively, including any negotiated 
price concession described in section 1860D–2(d)(1)(B) of 
the Social Security Act (42 U.S.C. 1395w–102(d)(1)(B)) or 
rebate under an agreement under section 1927 of the Social 
Security Act (42 U.S.C. 1396r–8). 
(C) AUTHORITY TO COLLECT ANY NECESSARY INFORMA-
TION.—Notwithstanding any other provision of law, the 
Inspector General of the Department of Health and Human 
Services shall be able to collect any information related 
to the prices of covered part D drugs under such program 
42 USC 
1395w–101 note. 
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124 STAT. 478 
PUBLIC LAW 111–148—MAR. 23, 2010 
and covered outpatient drugs under such title XIX nec-
essary to carry out the comparison under subparagraph 
(A). 
(2) REPORT.— 
(A) IN GENERAL.—Not later than October 1, 2011, sub-
ject to subparagraph (B), the Inspector General shall 
submit to Congress a report containing the results of the 
study conducted under paragraph (1), together with rec-
ommendations for such legislation and administrative 
action as the Inspector General determines appropriate. 
(B) 
LIMITATION
ON
INFORMATION
CONTAINED
IN 
REPORT.—The report submitted under subparagraph (A) 
shall not include any information that the Inspector Gen-
eral determines is proprietary or is likely to negatively 
impact the ability of a PDP sponsor or a State plan under 
title XIX to negotiate prices for covered part D drugs or 
covered outpatient drugs, respectively. 
(3) DEFINITIONS.—In this section: 
(A) COVERED PART D DRUG.—The term ‘‘covered part 
D drug’’ has the meaning given such term in section 1860D– 
2(e) of the Social Security Act (42 U.S.C. 1395w–102(e)). 
(B) COVERED OUTPATIENT DRUG.—The term ‘‘covered 
outpatient drug’’ has the meaning given such term in sec-
tion 1927(k) of such Act (42 U.S.C. 1396r(k)). 
(C) MA–PD PLAN.—The term ‘‘MA–PD plan’’ has the 
meaning given such term in section 1860D–41(a)(9) of such 
Act (42 U.S.C. 1395w–151(a)(9)). 
(D) MEDICARE ADVANTAGE ORGANIZATION.—The term 
‘‘Medicare Advantage organization’’ has the meaning given 
such term in section 1859(a)(1) of such Act (42 U.S.C. 
1395w–28)(a)(1)). 
(E) PDP SPONSOR.—The term ‘‘PDP sponsor’’ has the 
meaning given such term in section 1860D–41(a)(13) of 
such Act (42 U.S.C. 1395w–151(a)(13)). 
(F) PRESCRIPTION DRUG PLAN.—The term ‘‘prescription 
drug plan’’ has the meaning given such term in section 
1860D–41(a)(14) of such Act (42 U.S.C. 1395w–151(a)(14)). 
SEC. 3314. INCLUDING COSTS INCURRED BY AIDS DRUG ASSISTANCE 
PROGRAMS AND INDIAN HEALTH SERVICE IN PROVIDING 
PRESCRIPTION DRUGS TOWARD THE ANNUAL OUT-OF- 
POCKET THRESHOLD UNDER PART D. 
(a) IN GENERAL.—Section 1860D–2(b)(4)(C) of the Social Secu-
rity Act (42 U.S.C. 1395w–102(b)(4)(C)) is amended— 
(1) in clause (i), by striking ‘‘and’’ at the end; 
(2) in clause (ii)— 
(A) by striking ‘‘such costs shall be treated as incurred 
only if’’ and inserting ‘‘subject to clause (iii), such costs 
shall be treated as incurred only if’’; 
(B) by striking ‘‘, under section 1860D–14, or under 
a State Pharmaceutical Assistance Program’’; and 
(C) by striking the period at the end and inserting 
‘‘; and’’; and 
(3) by inserting after clause (ii) the following new clause: 
‘‘(iii) such costs shall be treated as incurred and 
shall not be considered to be reimbursed under clause 
(ii) if such costs are borne or paid— 
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124 STAT. 479 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(I) under section 1860D–14; 
‘‘(II) under a State Pharmaceutical Assistance 
Program; 
‘‘(III) by the Indian Health Service, an Indian 
tribe or tribal organization, or an urban Indian 
organization (as defined in section 4 of the Indian 
Health Care Improvement Act); or 
‘‘(IV) under an AIDS Drug Assistance Program 
under part B of title XXVI of the Public Health 
Service Act.’’. 
(b) EFFECTIVE DATE.—The amendments made by subsection 
(a) shall apply to costs incurred on or after January 1, 2011. 
SEC. 3315. IMMEDIATE REDUCTION IN COVERAGE GAP IN 2010. 
Section 1860D–2(b) of the Social Security Act (42 U.S.C. 1395w– 
102(b)) is amended— 
(1) in paragraph (3)(A), by striking ‘‘paragraph (4)’’ and 
inserting ‘‘paragraphs (4) and (7)’’; and 
(2) by adding at the end the following new paragraph: 
‘‘(7) INCREASE IN INITIAL COVERAGE LIMIT IN 2010.— 
‘‘(A) IN
GENERAL.—For the plan year beginning on 
January 1, 2010, the initial coverage limit described in 
paragraph (3)(B) otherwise applicable shall be increased 
by $500. 
‘‘(B) APPLICATION.—In applying subparagraph (A)— 
‘‘(i) except as otherwise provided in this subpara-
graph, there shall be no change in the premiums, bids, 
or any other parameters under this part or part C; 
‘‘(ii) costs that would be treated as incurred costs 
for purposes of applying paragraph (4) but for the 
application of subparagraph (A) shall continue to be 
treated as incurred costs; 
‘‘(iii) the Secretary shall establish procedures, 
which may include a reconciliation process, to fully 
reimburse PDP sponsors with respect to prescription 
drug plans and MA organizations with respect to MA– 
PD plans for the reduction in beneficiary cost sharing 
associated with the application of subparagraph (A); 
‘‘(iv) the Secretary shall develop an estimate of 
the additional increased costs attributable to the 
application of this paragraph for increased drug utiliza-
tion and financing and administrative costs and shall 
use such estimate to adjust payments to PDP sponsors 
with respect to prescription drug plans under this part 
and MA organizations with respect to MA–PD plans 
under part C; and 
‘‘(v) the Secretary shall establish procedures for 
retroactive reimbursement of part D eligible individ-
uals who are covered under such a plan for costs which 
are incurred before the date of initial implementation 
of subparagraph (A) and which would be reimbursed 
under such a plan if such implementation occurred 
as of January 1, 2010. 
‘‘(C) NO EFFECT ON SUBSEQUENT YEARS.—The increase 
under subparagraph (A) shall only apply with respect to 
the plan year beginning on January 1, 2010, and the initial 
coverage limit for plan years beginning on or after January 
Applicability. 
Time periods. 
Procedures. 
Procedures. 
Effective date. 
42 USC 
1395w–102 
note. 
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124 STAT. 480 
PUBLIC LAW 111–148—MAR. 23, 2010 
1, 2011, shall be determined as if subparagraph (A) had 
never applied.’’. 
Subtitle E—Ensuring Medicare 
Sustainability 
SEC. 3401. REVISION OF CERTAIN MARKET BASKET UPDATES AND 
INCORPORATION OF PRODUCTIVITY IMPROVEMENTS 
INTO MARKET BASKET UPDATES THAT DO NOT ALREADY 
INCORPORATE SUCH IMPROVEMENTS. 
(a) INPATIENT ACUTE HOSPITALS.—Section 1886(b)(3)(B) of the 
Social Security Act (42 U.S.C. 1395ww(b)(3)(B)), as amended by 
section 3001(a)(3), is further amended— 
(1) in clause (i)(XX), by striking ‘‘clause (viii)’’ and inserting 
‘‘clauses (viii), (ix), (xi), and (xii)’’; 
(2) in the first sentence of clause (viii), by inserting ‘‘of 
such applicable percentage increase (determined without regard 
to clause (ix), (xi), or (xii))’’ after ‘‘one-quarter’’; 
(3) in the first sentence of clause (ix)(I), by inserting ‘‘(deter-
mined without regard to clause (viii), (xi), or (xii))’’ after ‘‘clause 
(i)’’ the second time it appears; and 
(4) by adding at the end the following new clauses: 
‘‘(xi)(I) For 2012 and each subsequent fiscal year, after deter-
mining the applicable percentage increase described in clause (i) 
and after application of clauses (viii) and (ix), such percentage 
increase shall be reduced by the productivity adjustment described 
in subclause (II). 
‘‘(II) The productivity adjustment described in this subclause, 
with respect to a percentage, factor, or update for a fiscal year, 
year, cost reporting period, or other annual period, is a productivity 
adjustment equal to the 10-year moving average of changes in 
annual economy-wide private nonfarm business multi-factor produc-
tivity (as projected by the Secretary for the 10-year period ending 
with the applicable fiscal year, year, cost reporting period, or other 
annual period). 
‘‘(III) The application of subclause (I) may result in the 
applicable percentage increase described in clause (i) being less 
than 0.0 for a fiscal year, and may result in payment rates under 
this section for a fiscal year being less than such payment rates 
for the preceding fiscal year. 
‘‘(xii) After determining the applicable percentage increase 
described in clause (i), and after application of clauses (viii), (ix), 
and (xi), the Secretary shall reduce such applicable percentage 
increase— 
‘‘(I) for each of fiscal years 2010 and 2011, by 0.25 percent-
age point; and 
‘‘(II) subject to clause (xiii), for each of fiscal years 2012 
through 2019, by 0.2 percentage point. 
The application of this clause may result in the applicable percent-
age increase described in clause (i) being less than 0.0 for a fiscal 
year, and may result in payment rates under this section for a 
fiscal year being less than such payment rates for the preceding 
fiscal year. 
‘‘(xiii) Clause (xii) shall be applied with respect to any of fiscal 
years 2014 through 2019 by substituting ‘0.0 percentage points’ 
for ‘0.2 percentage point’, if for such fiscal year— 
Applicability. 
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124 STAT. 481 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(I) the excess (if any) of— 
‘‘(aa) the total percentage of the non-elderly insured 
population for the preceding fiscal year (based on the most 
recent estimates available from the Director of the Congres-
sional Budget Office before a vote in either House on the 
Patient Protection and Affordable Care Act that, if deter-
mined in the affirmative, would clear such Act for enroll-
ment); over 
‘‘(bb) the total percentage of the non-elderly insured 
population for such preceding fiscal year (as estimated 
by the Secretary); exceeds 
‘‘(II) 5 percentage points.’’. 
(b) SKILLED NURSING FACILITIES.—Section 1888(e)(5)(B) of the 
Social Security Act (42 U.S.C. 1395yy(e)(5)(B)) is amended— 
(1) by striking ‘‘PERCENTAGE.—The term’’ and inserting 
‘‘PERCENTAGE.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), the term’’; 
and 
(2) by adding at the end the following new clause: 
‘‘(ii) ADJUSTMENT.—For fiscal year 2012 and each 
subsequent fiscal year, after determining the percent-
age described in clause (i), the Secretary shall reduce 
such percentage by the productivity adjustment 
described in section 1886(b)(3)(B)(xi)(II). The applica-
tion of the preceding sentence may result in such 
percentage being less than 0.0 for a fiscal year, and 
may result in payment rates under this subsection 
for a fiscal year being less than such payment rates 
for the preceding fiscal year.’’. 
(c) LONG-TERM CARE HOSPITALS.—Section 1886(m) of the Social 
Security Act (42 U.S.C. 1395ww(m)) is amended by adding at the 
end the following new paragraphs: 
‘‘(3) IMPLEMENTATION FOR RATE YEAR 2010 AND SUBSEQUENT 
YEARS.— 
‘‘(A) IN
GENERAL.—In implementing the system 
described in paragraph (1) for rate year 2010 and each 
subsequent rate year, any annual update to a standard 
Federal rate for discharges for the hospital during the 
rate year, shall be reduced— 
‘‘(i) for rate year 2012 and each subsequent rate 
year, by the productivity adjustment described in sec-
tion 1886(b)(3)(B)(xi)(II); and 
‘‘(ii) for each of rate years 2010 through 2019, 
by the other adjustment described in paragraph (4). 
‘‘(B) SPECIAL RULE.—The application of this paragraph 
may result in such annual 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 payment rates for the preceding rate 
year. 
‘‘(4) OTHER ADJUSTMENT.— 
‘‘(A) IN GENERAL.—For purposes of paragraph (3)(A)(ii), 
the other adjustment described in this paragraph is— 
‘‘(i) for each of rate years 2010 and 2011, 0.25 
percentage point; and 
‘‘(ii) subject to subparagraph (B), for each of rate 
years 2012 through 2019, 0.2 percentage point. 
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124 STAT. 482 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) REDUCTION
OF
OTHER
ADJUSTMENT.—Subpara-
graph (A)(ii) shall be applied with respect to any of rate 
years 2014 through 2019 by substituting ‘0.0 percentage 
points’ for ‘0.2 percentage point’, if for such rate year— 
‘‘(i) the excess (if any) of— 
‘‘(I) the total percentage of the non-elderly 
insured population for the preceding rate year 
(based on the most recent estimates available from 
the Director of the Congressional Budget Office 
before a vote in either House on the Patient Protec-
tion and Affordable Care Act that, if determined 
in the affirmative, would clear such Act for enroll-
ment); over 
‘‘(II) the total percentage of the non-elderly 
insured population for such preceding rate year 
(as estimated by the Secretary); exceeds 
‘‘(ii) 5 percentage points.’’. 
(d) INPATIENT REHABILITATION FACILITIES.—Section 1886(j)(3) 
of the Social Security Act (42 U.S.C. 1395ww(j)(3)) is amended— 
(1) in subparagraph (C)— 
(A) by striking ‘‘FACTOR.—For purposes’’ and inserting 
‘‘FACTOR.— 
‘‘(i) IN GENERAL.—For purposes’’; 
(B) by inserting ‘‘subject to clause (ii)’’ before the period 
at the end of the first sentence of clause (i), as added 
by paragraph (1); and 
(C) by adding at the end the following new clause: 
‘‘(ii) PRODUCTIVITY AND OTHER ADJUSTMENT.—After 
establishing the increase factor described in clause (i) 
for a fiscal year, the Secretary shall reduce such 
increase factor— 
‘‘(I) for fiscal year 2012 and each subsequent 
fiscal 
year, 
by 
the 
productivity 
adjustment 
described in section 1886(b)(3)(B)(xi)(II); and 
‘‘(II) for each of fiscal years 2010 through 2019, 
by the other adjustment described in subparagraph 
(D). 
The application of this clause may result in the 
increase factor under this subparagraph being less 
than 0.0 for a fiscal year, and may result in payment 
rates under this subsection for a fiscal year being 
less than such payment rates for the preceding fiscal 
year.’’; and 
(2) by adding at the end the following new subparagraph: 
‘‘(D) OTHER ADJUSTMENT.— 
‘‘(i) IN GENERAL.—For purposes of subparagraph 
(C)(ii)(II), the other adjustment described in this 
subparagraph is— 
‘‘(I) for each of fiscal years 2010 and 2011, 
0.25 percentage point; and 
‘‘(II) subject to clause (ii), for each of fiscal 
years 2012 through 2019, 0.2 percentage point. 
‘‘(ii) REDUCTION OF OTHER ADJUSTMENT.—Clause 
(i)(II) shall be applied with respect to any of fiscal 
years 2014 through 2019 by substituting ‘0.0 percent-
age points’ for ‘0.2 percentage point’, if for such fiscal 
year— 
Applicability. 
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124 STAT. 483 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(I) the excess (if any) of— 
‘‘(aa) the total percentage of the non- 
elderly insured population for the preceding 
fiscal year (based on the most recent estimates 
available from the Director of the Congres-
sional Budget Office before a vote in either 
House on the Patient Protection and Afford-
able Care Act that, if determined in the 
affirmative, would clear such Act for enroll-
ment); over 
‘‘(bb) the total percentage of the non- 
elderly insured population for such preceding 
fiscal year (as estimated by the Secretary); 
exceeds 
‘‘(II) 5 percentage points.’’. 
(e) HOME HEALTH AGENCIES.—Section 1895(b)(3)(B) of the 
Social Security Act (42 U.S.C. 1395fff(b)(3)(B)) is amended— 
(1) in clause (ii)(V), by striking ‘‘clause (v)’’ and inserting 
‘‘clauses (v) and (vi)’’; and 
(2) by adding at the end the following new clause: 
‘‘(vi) ADJUSTMENTS.—After determining the home 
health market basket percentage increase under clause 
(iii), and after application of clause (v), the Secretary 
shall reduce such percentage— 
‘‘(I) for 2015 and each subsequent year, by 
the productivity adjustment described in section 
1886(b)(3)(B)(xi)(II); and 
‘‘(II) for each of 2011 and 2012, by 1 percentage 
point. 
The application of this clause may result in the home 
health market basket percentage increase under clause 
(iii) being less than 0.0 for a year, and may result 
in payment rates under the system under this sub-
section for a year being less than such payment rates 
for the preceding year.’’. 
(f) PSYCHIATRIC HOSPITALS.—Section 1886 of the Social Security 
Act, as amended by sections 3001, 3008, 3025, and 3133, is amended 
by adding at the end the following new subsection: 
‘‘(s) PROSPECTIVE PAYMENT FOR PSYCHIATRIC HOSPITALS.— 
‘‘(1) REFERENCE TO ESTABLISHMENT AND IMPLEMENTATION 
OF SYSTEM.—For provisions related to the establishment and 
implementation of a prospective payment system for payments 
under this title for inpatient hospital services furnished by 
psychiatric hospitals (as described in clause (i) of subsection 
(d)(1)(B)) and psychiatric units (as described in the matter 
following clause (v) of such subsection), see section 124 of 
the Medicare, Medicaid, and SCHIP Balanced Budget Refine-
ment Act of 1999. 
‘‘(2) IMPLEMENTATION FOR RATE YEAR BEGINNING IN 2010 
AND SUBSEQUENT RATE YEARS.— 
‘‘(A) IN
GENERAL.—In implementing the system 
described in paragraph (1) for the rate year beginning 
in 2010 and any subsequent rate year, any update to a 
base rate for days during the rate year for a psychiatric 
hospital or unit, respectively, shall be reduced— 
42 USC 1395ww. 
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124 STAT. 484 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) for the rate year beginning in 2012 and each 
subsequent rate year, by the productivity adjustment 
described in section 1886(b)(3)(B)(xi)(II); and 
‘‘(ii) for each of the rate years beginning in 2010 
through 2019, by the other adjustment described in 
paragraph (3). 
‘‘(B) SPECIAL RULE.—The application of this paragraph 
may result in such 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 payment rates for the preceding rate year. 
‘‘(3) OTHER ADJUSTMENT.— 
‘‘(A) IN GENERAL.—For purposes of paragraph (2)(A)(ii), 
the other adjustment described in this paragraph is— 
‘‘(i) for each of the rate years beginning in 2010 
and 2011, 0.25 percentage point; and 
‘‘(ii) subject to subparagraph (B), for each of the 
rate years beginning in 2012 through 2019, 0.2 percent-
age point. 
‘‘(B) REDUCTION
OF
OTHER
ADJUSTMENT.—Subpara-
graph (A)(ii) shall be applied with respect to any of rate 
years 2014 through 2019 by substituting ‘0.0 percentage 
points’ for ‘0.2 percentage point’, if for such rate year— 
‘‘(i) the excess (if any) of— 
‘‘(I) the total percentage of the non-elderly 
insured population for the preceding rate year 
(based on the most recent estimates available from 
the Director of the Congressional Budget Office 
before a vote in either House on the Patient Protec-
tion and Affordable Care Act that, if determined 
in the affirmative, would clear such Act for enroll-
ment); over 
‘‘(II) the total percentage of the non-elderly 
insured population for such preceding rate year 
(as estimated by the Secretary); exceeds 
‘‘(ii) 5 percentage points.’’. 
(g) HOSPICE CARE.—Section 1814(i)(1)(C) of the Social Security 
Act (42 U.S.C. 1395f(i)(1)(C)), as amended by section 3132, is 
amended by adding at the end the following new clauses: 
‘‘(iv) After determining the market basket percentage increase 
under clause (ii)(VII) or (iii), as applicable, with respect to fiscal 
year 2013 and each subsequent fiscal year, the Secretary shall 
reduce such percentage— 
‘‘(I) for 2013 and each subsequent fiscal year, by the produc-
tivity adjustment described in section 1886(b)(3)(B)(xi)(II); and 
‘‘(II) subject to clause (v), for each of fiscal years 2013 
through 2019, by 0.5 percentage point. 
The application of this clause may result in the market basket 
percentage increase under clause (ii)(VII) or (iii), as applicable, 
being less than 0.0 for a fiscal year, and may result in payment 
rates under this subsection for a fiscal year being less than such 
payment rates for the preceding fiscal year. 
‘‘(v) Clause (iv)(II) shall be applied with respect to any of 
fiscal years 2014 through 2019 by substituting ‘0.0 percentage 
points’ for ‘0.5 percentage point’, if for such fiscal year— 
‘‘(I) the excess (if any) of— 
Applicability. 
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124 STAT. 485 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(aa) the total percentage of the non-elderly insured 
population for the preceding fiscal year (based on the most 
recent estimates available from the Director of the Congres-
sional Budget Office before a vote in either House on the 
Patient Protection and Affordable Care Act that, if deter-
mined in the affirmative, would clear such Act for enroll-
ment); over 
‘‘(bb) the total percentage of the non-elderly insured 
population for such preceding fiscal year (as estimated 
by the Secretary); exceeds 
‘‘(II) 5 percentage points.’’. 
(h) DIALYSIS.—Section 1881(b)(14)(F) of the Social Security Act 
(42 U.S.C. 1395rr(b)(14)(F)) is amended— 
(1) in clause (i)— 
(A) by inserting ‘‘(I)’’ after ‘‘(F)(i)’’ 
(B) in subclause (I), as inserted by subparagraph (A)— 
(i) by striking ‘‘clause (ii)’’ and inserting ‘‘subclause 
(II) and clause (ii)’’; and 
(ii) by striking ‘‘minus 1.0 percentage point’’; and 
(C) by adding at the end the following new subclause: 
‘‘(II) For 2012 and each subsequent year, after determining 
the increase factor described in subclause (I), the Secretary shall 
reduce such increase factor by the productivity adjustment described 
in section 1886(b)(3)(B)(xi)(II). The application of the preceding 
sentence may result in such increase factor being less than 0.0 
for a year, and may result in payment rates under the payment 
system under this paragraph for a year being less than such pay-
ment rates for the preceding year.’’; and 
(2) in clause (ii)(II)— 
(A) by striking ‘‘The’’ and inserting ‘‘Subject to clause 
(i)(II), the’’; and 
(B) by striking ‘‘clause (i) minus 1.0 percentage point’’ 
and inserting ‘‘clause (i)(I)’’. 
(i) OUTPATIENT HOSPITALS.—Section 1833(t)(3) of the Social 
Security Act (42 U.S.C. 1395l(t)(3)) is amended— 
(1) in subparagraph (C)(iv), by inserting ‘‘and subparagraph 
(F) of this paragraph’’ after ‘‘(17)’’; and 
(2) by adding at the end the following new subparagraphs: 
‘‘(F) PRODUCTIVITY
AND
OTHER
ADJUSTMENT.—After 
determining the OPD fee schedule increase factor under 
subparagraph (C)(iv), the Secretary shall reduce such 
increase factor— 
‘‘(i) for 2012 and subsequent years, by the produc-
tivity 
adjustment 
described 
in 
section 
1886(b)(3)(B)(xi)(II); and 
‘‘(ii) for each of 2010 through 2019, by the adjust-
ment described in subparagraph (G). 
The application of this subparagraph may result in the 
increase factor under subparagraph (C)(iv) being less than 
0.0 for a year, and may result in payment rates under 
the payment system under this subsection for a year being 
less than such payment rates for the preceding year. 
‘‘(G) OTHER ADJUSTMENT.— 
‘‘(i) ADJUSTMENT.—For purposes of subparagraph 
(F)(ii), the adjustment described in this subparagraph 
is— 
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124 STAT. 486 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(I) for each of 2010 and 2011, 0.25 percentage 
point; and 
‘‘(II) subject to clause (ii), for each of 2012 
through 2019, 0.2 percentage point. 
‘‘(ii) REDUCTION OF OTHER ADJUSTMENT.—Clause 
(i)(II) shall be applied with respect to any of 2014 
through 2019 by substituting ‘0.0 percentage points’ 
for ‘0.2 percentage point’, if for such year— 
‘‘(I) the excess (if any) of— 
‘‘(aa) the total percentage of the non- 
elderly insured population for the preceding 
year (based on the most recent estimates avail-
able from the Director of the Congressional 
Budget Office before a vote in either House 
on the Patient Protection and Affordable Care 
Act that, if determined in the affirmative, 
would clear such Act for enrollment); over 
‘‘(bb) the total percentage of the non- 
elderly insured population for such preceding 
year (as estimated by the Secretary); exceeds 
‘‘(II) 5 percentage points.’’. 
(j) AMBULANCE SERVICES.—Section 1834(l)(3) of the Social Secu-
rity Act (42 U.S.C. 1395m(l)(3)) is amended— 
(1) in subparagraph (A), by striking ‘‘and’’ at the end; 
(2) in subparagraph (B)— 
(A) by inserting ‘‘, subject to subparagraph (C) and 
the 
succeeding 
sentence 
of 
this 
paragraph,’’ 
after 
‘‘increased’’; and 
(B) by striking the period at the end and inserting 
‘‘; and’’; 
(3) by adding at the end the following new subparagraph: 
‘‘(C) for 2011 and each subsequent year, after deter-
mining the percentage increase under subparagraph (B) 
for the year, reduce such percentage increase by the produc-
tivity adjustment described in section 1886(b)(3)(B)(xi)(II).’’; 
and 
(4) by adding at the end the following flush sentence: 
‘‘The application of subparagraph (C) may result in the percent-
age increase under subparagraph (B) being less than 0.0 for 
a year, and may result in payment rates under the fee schedule 
under this subsection for a year being less than such payment 
rates for the preceding year.’’. 
(k) 
AMBULATORY
SURGICAL
CENTER
SERVICES.—Section 
1833(i)(2)(D) of the Social Security Act (42 U.S.C. 1395l(i)(2)(D)) 
is amended— 
(1) by redesignating clause (v) as clause (vi); and 
(2) by inserting after clause (iv) the following new clause: 
‘‘(v) In implementing the system described in 
clause (i) for 2011 and each subsequent year, any 
annual update under such system for the year, after 
application of clause (iv), shall be reduced by the 
productivity 
adjustment 
described 
in 
section 
1886(b)(3)(B)(xi)(II). The application of the preceding 
sentence may result in such update being less than 
0.0 for a year, and may result in payment rates under 
the system described in clause (i) for a year being 
less than such payment rates for the preceding year.’’. 
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124 STAT. 487 
PUBLIC LAW 111–148—MAR. 23, 2010 
(l) LABORATORY SERVICES.—Section 1833(h)(2)(A) of the Social 
Security Act (42 U.S.C. 1395l(h)(2)(A)) is amended— 
(1) in clause (i)— 
(A) by inserting ‘‘, subject to clause (iv),’’ after ‘‘year) 
by’’; and 
(B) by striking ‘‘through 2013’’ and inserting ‘‘and 
2010’’; and 
(2) by adding at the end the following new clause: 
‘‘(iv) After determining the adjustment to the fee 
schedules under clause (i), the Secretary shall reduce 
such adjustment— 
‘‘(I) for 2011 and each subsequent year, by 
the productivity adjustment described in section 
1886(b)(3)(B)(xi)(II); and 
‘‘(II) for each of 2011 through 2015, by 1.75 
percentage points. 
Subclause (I) shall not apply in a year where the 
adjustment to the fee schedules determined under 
clause (i) is 0.0 or a percentage decrease for a year. 
The application of the productivity adjustment under 
subclause (I) shall not result in an adjustment to the 
fee schedules under clause (i) being less than 0.0 for 
a year. The application of subclause (II) may result 
in an adjustment to the fee schedules under clause 
(i) being less than 0.0 for a year, and may result 
in payment rates for a year being less than such pay-
ment rates for the preceding year.’’. 
(m) 
CERTAIN
DURABLE
MEDICAL
EQUIPMENT.—Section 
1834(a)(14) of the Social Security Act (42 U.S.C. 1395m(a)(14)) 
is amended— 
(1) in subparagraph (K)— 
(A) by striking ‘‘2011, 2012, and 2013,’’; and 
(B) by inserting ‘‘and’’ after the semicolon at the end; 
(2) by striking subparagraphs (L) and (M) and inserting 
the following new subparagraph: 
‘‘(L) for 2011 and each subsequent year— 
‘‘(i) the percentage increase in the consumer price 
index for all urban consumers (United States city aver-
age) for the 12-month period ending with June of the 
previous year, reduced by— 
‘‘(ii) the productivity adjustment described in sec-
tion 1886(b)(3)(B)(xi)(II).’’; and 
(3) by adding at the end the following flush sentence: 
‘‘The application of subparagraph (L)(ii) may result in the cov-
ered item update under this paragraph being less than 0.0 
for a year, and may result in payment rates under this sub-
section for a year being less than such payment rates for 
the preceding year.’’. 
(n) PROSTHETIC DEVICES, ORTHOTICS, AND PROSTHETICS.—Sec-
tion 1834(h)(4) of the Social Security Act (42 U.S.C. 1395m(h)(4)) 
is amended— 
(1) in subparagraph (A)— 
(A) in clause (ix), by striking ‘‘and’’ at the end; 
(B) in clause (x)— 
(i) by striking ‘‘a subsequent year’’ and inserting 
‘‘for each of 2007 through 2010’’; and 
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124 STAT. 488 
PUBLIC LAW 111–148—MAR. 23, 2010 
(ii) by inserting ‘‘and’’ after the semicolon at the 
end; 
(C) by adding at the end the following new clause: 
‘‘(xi) for 2011 and each subsequent year— 
‘‘(I) the percentage increase in the consumer 
price index for all urban consumers (United States 
city average) for the 12-month period ending with 
June of the previous year, reduced by— 
‘‘(II) the productivity adjustment described in 
section 1886(b)(3)(B)(xi)(II).’’; and 
(D) by adding at the end the following flush sentence: 
‘‘The application of subparagraph (A)(xi)(II) may result in the 
applicable percentage increase under subparagraph (A) being 
less than 0.0 for a year, and may result in payment rates 
under this subsection for a year being less than such payment 
rates for the preceding year.’’. 
(o) OTHER ITEMS.—Section 1842(s)(1) of the Social Security 
Act (42 U.S.C. 1395u(s)(1)) is amended— 
(1) in the first sentence, by striking ‘‘Subject to’’ and 
inserting ‘‘(A) Subject to’’; 
(2) by striking the second sentence and inserting the fol-
lowing new subparagraph: 
‘‘(B) Any fee schedule established under this paragraph 
for such item or service shall be updated— 
‘‘(i) for years before 2011— 
‘‘(I) subject to subclause (II), by the percentage 
increase in the consumer price index for all urban 
consumers (United States city average) for the 12- 
month period ending with June of the preceding 
year; and 
‘‘(II) for items and services described in para-
graph (2)(D) for 2009, section 1834(a)(14)(J) shall 
apply under this paragraph instead of the percent-
age increase otherwise applicable; and 
‘‘(ii) for 2011 and subsequent years— 
‘‘(I) the percentage increase in the consumer 
price index for all urban consumers (United States 
city average) for the 12-month period ending with 
June of the previous year, reduced by— 
‘‘(II) the productivity adjustment described in 
section 1886(b)(3)(B)(xi)(II).’’; and 
(3) by adding at the end the following flush sentence: 
‘‘The application of subparagraph (B)(ii)(II) may result in the 
update under this paragraph being less than 0.0 for a year, 
and may result in payment rates under any fee schedule estab-
lished under this paragraph for a year being less than such 
payment rates for the preceding year.’’. 
(p) NO APPLICATION PRIOR TO APRIL 1, 2010.—Notwithstanding 
the preceding provisions of this section, the amendments made 
by subsections (a), (c), and (d) shall not apply to discharges occurring 
before April 1, 2010. 
SEC. 3402. TEMPORARY ADJUSTMENT TO THE CALCULATION OF PART 
B PREMIUMS. 
Section 1839(i) of the Social Security Act (42 U.S.C. 1395r(i)) 
is amended— 
42 USC 
1395ww note. 
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124 STAT. 489 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) in paragraph (2), in the matter preceding subparagraph 
(A), by inserting ‘‘subject to paragraph (6),’’ after ‘‘subsection,’’; 
(2) in paragraph (3)(A)(i), by striking ‘‘The applicable’’ and 
inserting ‘‘Subject to paragraph (6), the applicable’’; 
(3) by redesignating paragraph (6) as paragraph (7); and 
(4) by inserting after paragraph (5) the following new para-
graph: 
‘‘(6) TEMPORARY ADJUSTMENT TO INCOME THRESHOLDS.— 
Notwithstanding any other provision of this subsection, during 
the period beginning on January 1, 2011, and ending on 
December 31, 2019— 
‘‘(A) the threshold amount otherwise applicable under 
paragraph (2) shall be equal to such amount for 2010; 
and 
‘‘(B) the dollar amounts otherwise applicable under 
paragraph (3)(C)(i) shall be equal to such dollar amounts 
for 2010.’’. 
SEC. 3403. INDEPENDENT MEDICARE ADVISORY BOARD. 
(a) BOARD.— 
(1) IN GENERAL.—Title XVIII of the Social Security Act 
(42 U.S.C. 1395 et seq.), as amended by section 3022, is 
amended by adding at the end the following new section: 
‘‘INDEPENDENT MEDICARE ADVISORY BOARD 
‘‘SEC. 1899A. (a) ESTABLISHMENT.—There is established an 
independent board to be known as the ‘Independent Medicare 
Advisory Board’. 
‘‘(b) PURPOSE.—It is the purpose of this section to, in accordance 
with the following provisions of this section, reduce the per capita 
rate of growth in Medicare spending— 
‘‘(1) by requiring the Chief Actuary of the Centers for 
Medicare & Medicaid Services to determine in each year to 
which this section applies (in this section referred to as ‘a 
determination year’) the projected per capita growth rate under 
Medicare for the second year following the determination year 
(in this section referred to as ‘an implementation year’); 
‘‘(2) if the projection for the implementation year exceeds 
the target growth rate for that year, by requiring the Board 
to develop and submit during the first year following the deter-
mination year (in this section referred to as ‘a proposal year’) 
a proposal containing recommendations to reduce the Medicare 
per capita growth rate to the extent required by this section; 
and 
‘‘(3) by requiring the Secretary to implement such proposals 
unless Congress enacts legislation pursuant to this section. 
‘‘(c) BOARD PROPOSALS.— 
‘‘(1) DEVELOPMENT.— 
‘‘(A) IN GENERAL.—The Board shall develop detailed 
and specific proposals related to the Medicare program 
in accordance with the succeeding provisions of this section. 
‘‘(B) ADVISORY REPORTS.—Beginning January 15, 2014, 
the Board may develop and submit to Congress advisory 
reports on matters related to the Medicare program, regard-
less of whether or not the Board submitted a proposal 
for such year. Such a report may, for years prior to 2020, 
42 USC 1395kkk. 
Time period. 
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124 STAT. 490 
PUBLIC LAW 111–148—MAR. 23, 2010 
include recommendations regarding improvements to pay-
ment systems for providers of services and suppliers who 
are not otherwise subject to the scope of the Board’s rec-
ommendations in a proposal under this section. Any 
advisory report submitted under this subparagraph shall 
not be subject to the rules for congressional consideration 
under subsection (d). 
‘‘(2) PROPOSALS.— 
‘‘(A) REQUIREMENTS.—Each proposal submitted under 
this section in a proposal year shall meet each of the 
following requirements: 
‘‘(i) If the Chief Actuary of the Centers for Medicare 
& Medicaid Services has made a determination under 
paragraph (7)(A) in the determination year, the pro-
posal shall include recommendations so that the pro-
posal as a whole (after taking into account rec-
ommendations under clause (v)) will result in a net 
reduction in total Medicare program spending in the 
implementation year that is at least equal to the 
applicable savings target established under paragraph 
(7)(B) for such implementation year. In determining 
whether a proposal meets the requirement of the pre-
ceding sentence, reductions in Medicare program 
spending during the 3-month period immediately pre-
ceding the implementation year shall be counted to 
the extent that such reductions are a result of the 
implementation of recommendations contained in the 
proposal for a change in the payment rate for an item 
or service that was effective during such period pursu-
ant to subsection (e)(2)(A). 
‘‘(ii) The proposal shall not include any rec-
ommendation to ration health care, raise revenues or 
Medicare beneficiary premiums under section 1818, 
1818A, or 1839, increase Medicare beneficiary cost- 
sharing (including deductibles, coinsurance, and copay-
ments), or otherwise restrict benefits or modify eligi-
bility criteria. 
‘‘(iii) In the case of proposals submitted prior to 
December 31, 2018, the proposal shall not include any 
recommendation that would reduce payment rates for 
items and services furnished, prior to December 31, 
2019, by providers of services (as defined in section 
1861(u)) and suppliers (as defined in section 1861(d)) 
scheduled, pursuant to the amendments made by sec-
tion 3401 of the Patient Protection and Affordable Care 
Act, to receive a reduction to the inflationary payment 
updates of such providers of services and suppliers 
in excess of a reduction due to productivity in a year 
in which such recommendations would take effect. 
‘‘(iv) As appropriate, the proposal shall include 
recommendations to reduce Medicare payments under 
parts C and D, such as reductions in direct subsidy 
payments to Medicare Advantage and prescription drug 
plans specified under paragraph (1) and (2) of section 
1860D–15(a) 
that 
are 
related 
to 
administrative 
expenses (including profits) for basic coverage, denying 
high bids or removing high bids for prescription drug 
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124 STAT. 491 
PUBLIC LAW 111–148—MAR. 23, 2010 
coverage from the calculation of the national average 
monthly bid amount under section 1860D–13(a)(4), and 
reductions in payments to Medicare Advantage plans 
under clauses (i) and (ii) of section 1853(a)(1)(B) that 
are related to administrative expenses (including 
profits) and performance bonuses for Medicare Advan-
tage plans under section 1853(n). Any such rec-
ommendation shall not affect the base beneficiary pre-
mium percentage specified under 1860D–13(a). 
‘‘(v) The proposal shall include recommendations 
with respect to administrative funding for the Sec-
retary to carry out the recommendations contained 
in the proposal. 
‘‘(vi) The proposal shall only include recommenda-
tions related to the Medicare program. 
‘‘(B) ADDITIONAL CONSIDERATIONS.—In developing and 
submitting each proposal under this section in a proposal 
year, the Board shall, to the extent feasible— 
‘‘(i) give priority to recommendations that extend 
Medicare solvency; 
‘‘(ii) include recommendations that— 
‘‘(I) improve the health care delivery system 
and health outcomes, including by promoting 
integrated care, care coordination, prevention and 
wellness, and quality and efficiency improvement; 
and 
‘‘(II) protect and improve Medicare bene-
ficiaries’ access to necessary and evidence-based 
items and services, including in rural and frontier 
areas; 
‘‘(iii) include recommendations that target reduc-
tions in Medicare program spending to sources of 
excess cost growth; 
‘‘(iv) consider the effects on Medicare beneficiaries 
of changes in payments to providers of services (as 
defined in section 1861(u)) and suppliers (as defined 
in section 1861(d)); 
‘‘(v) consider the effects of the recommendations 
on providers of services and suppliers with actual or 
projected negative cost margins or payment updates; 
and 
‘‘(vi) consider the unique needs of Medicare bene-
ficiaries who are dually eligible for Medicare and the 
Medicaid program under title XIX. 
‘‘(C) NO
INCREASE
IN
TOTAL
MEDICARE
PROGRAM 
SPENDING.—Each proposal submitted under this section 
shall be designed in such a manner that implementation 
of the recommendations contained in the proposal would 
not be expected to result, over the 10-year period starting 
with the implementation year, in any increase in the total 
amount of net Medicare program spending relative to the 
total amount of net Medicare program spending that would 
have occurred absent such implementation. 
‘‘(D) CONSULTATION WITH MEDPAC.—The Board shall 
submit a draft copy of each proposal to be submitted under 
this section to the Medicare Payment Advisory Commission 
established under section 1805 for its review. The Board 
Deadline. 
Submission. 
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124 STAT. 492 
PUBLIC LAW 111–148—MAR. 23, 2010 
shall submit such draft copy by not later than September 
1 of the determination year. 
‘‘(E) REVIEW AND COMMENT BY THE SECRETARY.—The 
Board shall submit a draft copy of each proposal to be 
submitted to Congress under this section to the Secretary 
for the Secretary’s review and comment. The Board shall 
submit such draft copy by not later than September 1 
of the determination year. Not later than March 1 of the 
submission year, the Secretary shall submit a report to 
Congress on the results of such review, unless the Secretary 
submits a proposal under paragraph (5)(A) in that year. 
‘‘(F) CONSULTATIONS.—In carrying out its duties under 
this section, the Board shall engage in regular consultations 
with the Medicaid and CHIP Payment and Access Commis-
sion under section 1900. 
‘‘(3) TRANSMISSION OF BOARD PROPOSAL TO PRESIDENT.— 
‘‘(A) IN GENERAL.— 
‘‘(i) IN
GENERAL.—Except as provided in clause 
(ii) and subsection (f)(3)(B), the Board shall transmit 
a proposal under this section to the President on 
January 15 of each year (beginning with 2014). 
‘‘(ii) EXCEPTION.—The Board shall not submit a 
proposal under clause (i) in a proposal year if the 
year is— 
‘‘(I) a year for which the Chief Actuary of 
the Centers for Medicare & Medicaid Services 
makes a determination in the determination year 
under paragraph (6)(A) that the growth rate 
described in clause (i) of such paragraph does not 
exceed the growth rate described in clause (ii) 
of such paragraph; 
‘‘(II) a year in which the Chief Actuary of 
the Centers for Medicare & Medicaid Services 
makes a determination in the determination year 
that the projected percentage increase (if any) for 
the medical care expenditure category of the Con-
sumer Price Index for All Urban Consumers 
(United States city average) for the implementa-
tion year is less than the projected percentage 
increase (if any) in the Consumer Price Index for 
All Urban Consumers (all items; United States 
city average) for such implementation year; or 
‘‘(III) for proposal year 2019 and subsequent 
proposal years, a year in which the Chief Actuary 
of the Centers for Medicare & Medicaid Services 
makes a determination in the determination year 
that the growth rate described in paragraph (8) 
exceeds the growth rate described in paragraph 
(6)(A)(i). 
‘‘(iii) START-UP
PERIOD.—The Board may not 
submit a proposal under clause (i) prior to January 
15, 2014. 
‘‘(B) REQUIRED
INFORMATION.—Each proposal sub-
mitted by the Board under subparagraph (A)(i) shall 
include— 
‘‘(i) the recommendations described in paragraph 
(2)(A)(i); 
Deadline. 
Reports. 
Submission. 
Deadlines. 
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124 STAT. 493 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(ii) an explanation of each recommendation con-
tained in the proposal and the reasons for including 
such recommendation; 
‘‘(iii) an actuarial opinion by the Chief Actuary 
of the Centers for Medicare & Medicaid Services certi-
fying that the proposal meets the requirements of sub-
paragraphs (A)(i) and (C) of paragraph (2); 
‘‘(iv) a legislative proposal that implements the 
recommendations; and 
‘‘(v) other information determined appropriate by 
the Board. 
‘‘(4) 
PRESIDENTIAL
SUBMISSION
TO
CONGRESS.—Upon 
receiving a proposal from the Board under paragraph (3)(A)(i) 
or the Secretary under paragraph (5), the President shall imme-
diately submit such proposal to Congress. 
‘‘(5) CONTINGENT
SECRETARIAL
DEVELOPMENT
OF
PRO-
POSAL.—If, with respect to a proposal year, the Board is 
required, to but fails, to submit a proposal to the President 
by the deadline applicable under paragraph (3)(A)(i), the Sec-
retary shall develop a detailed and specific proposal that satis-
fies the requirements of subparagraphs (A) and (C) (and, to 
the extent feasible, subparagraph (B)) of paragraph (2) and 
contains the information required paragraph (3)(B)). By not 
later than January 25 of the year, the Secretary shall 
transmit— 
‘‘(A) such proposal to the President; and 
‘‘(B) a copy of such proposal to the Medicare Payment 
Advisory Commission for its review. 
‘‘(6) PER
CAPITA
GROWTH
RATE
PROJECTIONS
BY
CHIEF 
ACTUARY.— 
‘‘(A) IN GENERAL.—Subject to subsection (f)(3)(A), not 
later than April 30, 2013, and annually thereafter, the 
Chief Actuary of the Centers for Medicare & Medicaid 
Services shall determine in each such year whether— 
‘‘(i) the projected Medicare per capita growth rate 
for the implementation year (as determined under 
subparagraph (B)); exceeds 
‘‘(ii) the projected Medicare per capita target 
growth rate for the implementation year (as deter-
mined under subparagraph (C)). 
‘‘(B) MEDICARE PER CAPITA GROWTH RATE.— 
‘‘(i) IN GENERAL.—For purposes of this section, the 
Medicare per capita growth rate for an implementation 
year shall be calculated as the projected 5-year average 
(ending with such year) of the growth in Medicare 
program spending per unduplicated enrollee. 
‘‘(ii) REQUIREMENT.—The projection under clause 
(i) shall— 
‘‘(I) to the extent that there is projected to 
be a negative update to the single conversion factor 
applicable to payments for physicians’ services 
under section 1848(d) furnished in the proposal 
year or the implementation year, assume that such 
update for such services is 0 percent rather than 
the negative percent that would otherwise apply; 
and 
Deadlines. 
Determination. 
Deadline. 
Transmission. 
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124 STAT. 494 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(II) take into account any delivery system 
reforms or other payment changes that have been 
enacted or published in final rules but not yet 
implemented as of the making of such calculation. 
‘‘(C) MEDICARE PER CAPITA TARGET GROWTH RATE.— 
For purposes of this section, the Medicare per capita target 
growth rate for an implementation year shall be calculated 
as the projected 5-year average (ending with such year) 
percentage increase in— 
‘‘(i) with respect to a determination year that is 
prior to 2018, the average of the projected percentage 
increase (if any) in— 
‘‘(I) the Consumer Price Index for All Urban 
Consumers (all items; United States city average); 
and 
‘‘(II) the medical care expenditure category of 
the Consumer Price Index for All Urban Con-
sumers (United States city average); and 
‘‘(ii) with respect to a determination year that is 
after 2017, the nominal gross domestic product per 
capita plus 1.0 percentage point. 
‘‘(7) SAVINGS REQUIREMENT.— 
‘‘(A) IN GENERAL.—If, with respect to a determination 
year, the Chief Actuary of the Centers for Medicare & 
Medicaid Services makes a determination under paragraph 
(6)(A) that the growth rate described in clause (i) of such 
paragraph exceeds the growth rate described in clause 
(ii) of such paragraph, the Chief Actuary shall establish 
an applicable savings target for the implementation year. 
‘‘(B) APPLICABLE SAVINGS TARGET.—For purposes of this 
section, the applicable savings target for an implementation 
year shall be an amount equal to the product of— 
‘‘(i) the total amount of projected Medicare program 
spending for the proposal year; and 
‘‘(ii) the applicable percent for the implementation 
year. 
‘‘(C) APPLICABLE PERCENT.—For purposes of subpara-
graph (B), the applicable percent for an implementation 
year is the lesser of— 
‘‘(i) in the case of— 
‘‘(I) implementation year 2015, 0.5 percent; 
‘‘(II) implementation year 2016, 1.0 percent; 
‘‘(III) implementation year 2017, 1.25 percent; 
and 
‘‘(IV) implementation year 2018 or any subse-
quent implementation year, 1.5 percent; and 
‘‘(ii) the projected excess for the implementation 
year (expressed as a percent) determined under 
subparagraph (A). 
‘‘(8) PER CAPITA RATE OF GROWTH IN NATIONAL HEALTH 
EXPENDITURES.—In each determination year (beginning in 
2018), the Chief Actuary of the Centers for Medicare & Med-
icaid Services shall project the per capita rate of growth in 
national health expenditures for the implementation year. Such 
rate of growth for an implementation year shall be calculated 
as the projected 5-year average (ending with such year) percent-
age increase in national health care expenditures. 
Effective date. 
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124 STAT. 495 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(d) CONGRESSIONAL CONSIDERATION.— 
‘‘(1) INTRODUCTION.— 
‘‘(A) IN GENERAL.—On the day on which a proposal 
is submitted by the President to the House of Representa-
tives and the Senate under subsection (c)(4), the legislative 
proposal (described in subsection (c)(3)(B)(iv)) contained in 
the proposal shall be introduced (by request) in the Senate 
by the majority leader of the Senate or by Members of 
the Senate designated by the majority leader of the Senate 
and shall be introduced (by request) in the House by the 
majority leader of the House or by Members of the House 
designated by the majority leader of the House. 
‘‘(B) NOT IN SESSION.—If either House is not in session 
on the day on which such legislative proposal is submitted, 
the legislative proposal shall be introduced in that House, 
as provided in subparagraph (A), on the first day thereafter 
on which that House is in session. 
‘‘(C) ANY MEMBER.—If the legislative proposal is not 
introduced in either House within 5 days on which that 
House is in session after the day on which the legislative 
proposal is submitted, then any Member of that House 
may introduce the legislative proposal. 
‘‘(D) REFERRAL.—The legislation introduced under this 
paragraph shall be referred by the Presiding Officers of 
the respective Houses to the Committee on Finance in 
the Senate and to the Committee on Energy and Commerce 
and the Committee on Ways and Means in the House 
of Representatives. 
‘‘(2) COMMITTEE CONSIDERATION OF PROPOSAL.— 
‘‘(A) REPORTING BILL.—Not later than April 1 of any 
proposal year in which a proposal is submitted by the 
President to Congress under this section, the Committee 
on Ways and Means and the Committee on Energy and 
Commerce of the House of Representatives and the Com-
mittee on Finance of the Senate may report the bill referred 
to the Committee under paragraph (1)(D) with committee 
amendments related to the Medicare program. 
‘‘(B) CALCULATIONS.—In determining whether a com-
mittee amendment meets the requirement of subparagraph 
(A), the reductions in Medicare program spending during 
the 3-month period immediately preceding the implementa-
tion year shall be counted to the extent that such reductions 
are a result of the implementation provisions in the com-
mittee amendment for a change in the payment rate for 
an item or service that was effective during such period 
pursuant to such amendment. 
‘‘(C) COMMITTEE JURISDICTION.—Notwithstanding rule 
XV of the Standing Rules of the Senate, a committee 
amendment described in subparagraph (A) may include 
matter not within the jurisdiction of the Committee on 
Finance if that matter is relevant to a proposal contained 
in the bill submitted under subsection (c)(3). 
‘‘(D) DISCHARGE.—If, with respect to the House 
involved, the committee has not reported the bill by the 
date required by subparagraph (A), the committee shall 
be discharged from further consideration of the proposal. 
Deadline. 
Proposal. 
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124 STAT. 496 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(3) LIMITATION ON CHANGES TO THE BOARD RECOMMENDA-
TIONS.— 
‘‘(A) IN GENERAL.—It shall not be in order in the Senate 
or the House of Representatives to consider any bill, resolu-
tion, or amendment, pursuant to this subsection or con-
ference report thereon, that fails to satisfy the requirements 
of subparagraphs (A)(i) and (C) of subsection (c)(2). 
‘‘(B) LIMITATION
ON
CHANGES
TO
THE
BOARD
REC-
OMMENDATIONS
IN
OTHER
LEGISLATION.—It shall not be 
in order in the Senate or the House of Representatives 
to consider any bill, resolution, amendment, or conference 
report (other than pursuant to this section) that would 
repeal or otherwise change the recommendations of the 
Board if that change would fail to satisfy the requirements 
of subparagraphs (A)(i) and (C) of subsection (c)(2). 
‘‘(C) LIMITATION ON CHANGES TO THIS SUBSECTION.— 
It shall not be in order in the Senate or the House of 
Representatives to consider any bill, resolution, amend-
ment, or conference report that would repeal or otherwise 
change this subsection. 
‘‘(D) WAIVER.—This paragraph may be waived or sus-
pended in the Senate only by the affirmative vote of three- 
fifths of the Members, duly chosen and sworn. 
‘‘(E) APPEALS.—An affirmative vote of three-fifths of 
the Members of the Senate, duly chosen and sworn, shall 
be required in the Senate to sustain an appeal of the 
ruling of the Chair on a point of order raised under this 
paragraph. 
‘‘(4) EXPEDITED PROCEDURE.— 
‘‘(A) CONSIDERATION.—A motion to proceed to the 
consideration of the bill in the Senate is not debatable. 
‘‘(B) AMENDMENT.— 
‘‘(i) TIME LIMITATION.—Debate in the Senate on 
any amendment to a bill under this section shall be 
limited to 1 hour, to be equally divided between, and 
controlled by, the mover and the manager of the bill, 
and debate on any amendment to an amendment, 
debatable motion, or appeal shall be limited to 30 
minutes, to be equally divided between, and controlled 
by, the mover and the manager of the bill, except 
that in the event the manager of the bill is in favor 
of any such amendment, motion, or appeal, the time 
in opposition thereto shall be controlled by the minority 
leader or such leader’s designee. 
‘‘(ii) GERMANE.—No amendment that is not ger-
mane to the provisions of such bill shall be received. 
‘‘(iii) ADDITIONAL TIME.—The leaders, or either of 
them, may, from the time under their control on the 
passage of the bill, allot additional time to any Senator 
during the consideration of any amendment, debatable 
motion, or appeal. 
‘‘(iv) AMENDMENT NOT IN ORDER.—It shall not be 
in order to consider an amendment that would cause 
the bill to result in a net reduction in total Medicare 
program spending in the implementation year that 
is less than the applicable savings target established 
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124 STAT. 497 
PUBLIC LAW 111–148—MAR. 23, 2010 
under subsection (c)(7)(B) for such implementation 
year. 
‘‘(v) WAIVER AND APPEALS.—This paragraph may 
be waived or suspended in the Senate only by the 
affirmative vote of three-fifths of the Members, duly 
chosen and sworn. An affirmative vote of three-fifths 
of the Members of the Senate, duly chosen and sworn, 
shall be required in the Senate to sustain an appeal 
of the ruling of the Chair on a point of order raised 
under this section. 
‘‘(C) CONSIDERATION BY THE OTHER HOUSE.— 
‘‘(i) IN GENERAL.—The expedited procedures pro-
vided in this subsection for the consideration of a bill 
introduced pursuant to paragraph (1) shall not apply 
to such a bill that is received by one House from 
the other House if such a bill was not introduced 
in the receiving House. 
‘‘(ii) BEFORE PASSAGE.—If a bill that is introduced 
pursuant to paragraph (1) is received by one House 
from the other House, after introduction but before 
disposition of such a bill in the receiving House, then 
the following shall apply: 
‘‘(I) The receiving House shall consider the 
bill introduced in that House through all stages 
of consideration up to, but not including, passage. 
‘‘(II) The question on passage shall be put 
on the bill of the other House as amended by 
the language of the receiving House. 
‘‘(iii) AFTER PASSAGE.—If a bill introduced pursuant 
to paragraph (1) is received by one House from the 
other House, after such a bill is passed by the receiving 
House, then the vote on passage of the bill that origi-
nates in the receiving House shall be considered to 
be the vote on passage of the bill received from the 
other House as amended by the language of the 
receiving House. 
‘‘(iv) DISPOSITION.—Upon disposition of a bill intro-
duced pursuant to paragraph (1) that is received by 
one House from the other House, it shall no longer 
be in order to consider the bill that originates in the 
receiving House. 
‘‘(v) LIMITATION.—Clauses (ii), (iii), and (iv) shall 
apply only to a bill received by one House from the 
other House if the bill— 
‘‘(I) is related only to the program under this 
title; and 
‘‘(II) satisfies the requirements of subpara-
graphs (A)(i) and (C) of subsection (c)(2). 
‘‘(D) SENATE LIMITS ON DEBATE.— 
‘‘(i) IN GENERAL.—In the Senate, consideration of 
the bill and on all debatable motions and appeals in 
connection therewith shall not exceed a total of 30 
hours, which shall be divided equally between the 
majority and minority leaders or their designees. 
‘‘(ii) MOTION TO FURTHER LIMIT DEBATE.—A motion 
to further limit debate on the bill is in order and 
is not debatable. 
Applicability. 
Applicability. 
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124 STAT. 498 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(iii) MOTION OR APPEAL.—Any debatable motion 
or appeal is debatable for not to exceed 1 hour, to 
be divided equally between those favoring and those 
opposing the motion or appeal. 
‘‘(iv) FINAL DISPOSITION.—After 30 hours of consid-
eration, the Senate shall proceed, without any further 
debate on any question, to vote on the final disposition 
thereof to the exclusion of all amendments not then 
pending before the Senate at that time and to the 
exclusion of all motions, except a motion to table, or 
to reconsider and one quorum call on demand to estab-
lish the presence of a quorum (and motions required 
to establish a quorum) immediately before the final 
vote begins. 
‘‘(E) CONSIDERATION IN CONFERENCE.— 
‘‘(i) IN GENERAL.—Consideration in the Senate and 
the House of Representatives on the conference report 
or any messages between Houses shall be limited to 
10 hours, equally divided and controlled by the 
majority and minority leaders of the Senate or their 
designees and the Speaker of the House of Representa-
tives and the minority leader of the House of Rep-
resentatives or their designees. 
‘‘(ii) TIME LIMITATION.—Debate in the Senate on 
any amendment under this subparagraph shall be lim-
ited to 1 hour, to be equally divided between, and 
controlled by, the mover and the manager of the bill, 
and debate on any amendment to an amendment, 
debatable motion, or appeal shall be limited to 30 
minutes, to be equally divided between, and controlled 
by, the mover and the manager of the bill, except 
that in the event the manager of the bill is in favor 
of any such amendment, motion, or appeal, the time 
in opposition thereto shall be controlled by the minority 
leader or such leader’s designee. 
‘‘(iii) FINAL DISPOSITION.—After 10 hours of consid-
eration, the Senate shall proceed, without any further 
debate on any question, to vote on the final disposition 
thereof to the exclusion of all motions not then pending 
before the Senate at that time or necessary to resolve 
the differences between the Houses and to the exclu-
sion of all other motions, except a motion to table, 
or to reconsider and one quorum call on demand to 
establish the presence of a quorum (and motions 
required to establish a quorum) immediately before 
the final vote begins. 
‘‘(iv) LIMITATION.—Clauses (i) through (iii) shall 
only apply to a conference report, message or the 
amendments thereto if the conference report, message, 
or an amendment thereto— 
‘‘(I) is related only to the program under this 
title; and 
‘‘(II) satisfies the requirements of subpara-
graphs (A)(i) and (C) of subsection (c)(2). 
‘‘(F) VETO.—If the President vetoes the bill debate on 
a veto message in the Senate under this subsection shall 
Applicability. 
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124 STAT. 499 
PUBLIC LAW 111–148—MAR. 23, 2010 
be 1 hour equally divided between the majority and 
minority leaders or their designees. 
‘‘(5) RULES OF THE SENATE AND HOUSE OF REPRESENTA-
TIVES.—This subsection and subsection (f)(2) are enacted by 
Congress— 
‘‘(A) as an exercise of the rulemaking power of the 
Senate and the House of Representatives, respectively, and 
is deemed to be part of the rules of each House, respec-
tively, but applicable only with respect to the procedure 
to be followed in that House in the case of bill under 
this section, and it supersedes other rules only to the 
extent that it is inconsistent with such rules; and 
‘‘(B) with full recognition of the constitutional right 
of either House to change the rules (so far as they relate 
to the procedure of that House) at any time, in the same 
manner, and to the same extent as in the case of any 
other rule of that House. 
‘‘(e) IMPLEMENTATION OF PROPOSAL.— 
‘‘(1) IN GENERAL.—Notwithstanding any other provision of 
law, the Secretary shall, except as provided in paragraph (3), 
implement the recommendations contained in a proposal sub-
mitted by the President to Congress pursuant to this section 
on August 15 of the year in which the proposal is so submitted. 
‘‘(2) APPLICATION.— 
‘‘(A) IN
GENERAL.—A recommendation described in 
paragraph (1) shall apply as follows: 
‘‘(i) In the case of a recommendation that is a 
change in the payment rate for an item or service 
under Medicare in which payment rates change on 
a fiscal year basis (or a cost reporting period basis 
that relates to a fiscal year), on a calendar year basis 
(or a cost reporting period basis that relates to a cal-
endar year), or on a rate year basis (or a cost reporting 
period basis that relates to a rate year), such rec-
ommendation shall apply to items and services fur-
nished on the first day of the first fiscal year, calendar 
year, or rate year (as the case may be) that begins 
after such August 15. 
‘‘(ii) In the case of a recommendation relating to 
payments to plans under parts C and D, such rec-
ommendation shall apply to plan years beginning on 
the first day of the first calendar year that begins 
after such August 15. 
‘‘(iii) In the case of any other recommendation, 
such recommendation shall be addressed in the regular 
regulatory process timeframe and shall apply as soon 
as practicable. 
‘‘(B) INTERIM FINAL RULEMAKING.—The Secretary may 
use interim final rulemaking to implement any rec-
ommendation described in paragraph (1). 
‘‘(3) EXCEPTION.—The Secretary shall not be required to 
implement the recommendations contained in a proposal sub-
mitted in a proposal year by the President to Congress pursuant 
to this section if— 
‘‘(A) prior to August 15 of the proposal year, Federal 
legislation is enacted that includes the following provision: 
‘This Act supercedes the recommendations of the Board 
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124 STAT. 500 
PUBLIC LAW 111–148—MAR. 23, 2010 
contained in the proposal submitted, in the year which 
includes the date of enactment of this Act, to Congress 
under section 1899A of the Social Security Act.’; and 
‘‘(B) in the case of implementation year 2020 and subse-
quent implementation years, a joint resolution described 
in subsection (f)(1) is enacted not later than August 15, 
2017. 
‘‘(4) NO
AFFECT
ON
AUTHORITY
TO
IMPLEMENT
CERTAIN 
PROVISIONS.—Nothing in paragraph (3) shall be construed to 
affect the authority of the Secretary to implement any rec-
ommendation contained in a proposal or advisory report under 
this section to the extent that the Secretary otherwise has 
the authority to implement such recommendation administra-
tively. 
‘‘(5) LIMITATION ON REVIEW.—There shall be no administra-
tive or judicial review under section 1869, section 1878, or 
otherwise of the implementation by the Secretary under this 
subsection of the recommendations contained in a proposal. 
‘‘(f) JOINT
RESOLUTION
REQUIRED
TO
DISCONTINUE
THE 
BOARD.— 
‘‘(1) IN GENERAL.—For purposes of subsection (e)(3)(B), a 
joint resolution described in this paragraph means only a joint 
resolution— 
‘‘(A) that is introduced in 2017 by not later than Feb-
ruary 1 of such year; 
‘‘(B) which does not have a preamble; 
‘‘(C) the title of which is as follows: ‘Joint resolution 
approving the discontinuation of the process for consider-
ation and automatic implementation of the annual proposal 
of the Independent Medicare Advisory Board under section 
1899A of the Social Security Act’; and 
‘‘(D) the matter after the resolving clause of which 
is as follows: ‘That Congress approves the discontinuation 
of the process for consideration and automatic implementa-
tion of the annual proposal of the Independent Medicare 
Advisory Board under section 1899A of the Social Security 
Act.’. 
‘‘(2) PROCEDURE.— 
‘‘(A) REFERRAL.—A joint resolution described in para-
graph (1) shall be referred to the Committee on Ways 
and Means and the Committee on Energy and Commerce 
of the House of Representatives and the Committee on 
Finance of the Senate. 
‘‘(B) DISCHARGE.—In the Senate, if the committee to 
which is referred a joint resolution described in paragraph 
(1) has not reported such joint resolution (or an identical 
joint resolution) at the end of 20 days after the joint resolu-
tion described in paragraph (1) is introduced, such com-
mittee may be discharged from further consideration of 
such joint resolution upon a petition supported in writing 
by 30 Members of the Senate, and such joint resolution 
shall be placed on the calendar. 
‘‘(C) CONSIDERATION.— 
‘‘(i) IN GENERAL.—In the Senate, when the com-
mittee to which a joint resolution is referred has 
reported, or when a committee is discharged (under 
subparagraph (C)) from further consideration of a joint 
Deadline. 
Petition. 
Definition. 
Deadline. 
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124 STAT. 501 
PUBLIC LAW 111–148—MAR. 23, 2010 
resolution described in paragraph (1), it is at any time 
thereafter in order (even though a previous motion 
to the same effect has been disagreed to) for a motion 
to proceed to the consideration of the joint resolution 
to be made, and all points of order against the joint 
resolution (and against consideration of the joint reso-
lution) are waived, except for points of order under 
the Congressional Budget act of 1974 or under budget 
resolutions pursuant to that Act. The motion is not 
debatable. A motion to reconsider the vote by which 
the motion is agreed to or disagreed to shall not be 
in order. If a motion to proceed to the consideration 
of the joint resolution is agreed to, the joint resolution 
shall remain the unfinished business of the Senate 
until disposed of. 
‘‘(ii) DEBATE LIMITATION.—In the Senate, consider-
ation of the joint resolution, and on all debatable 
motions and appeals in connection therewith, shall 
be limited to not more than 10 hours, which shall 
be divided equally between the majority leader and 
the minority leader, or their designees. A motion fur-
ther to limit debate is in order and not debatable. 
An amendment to, or a motion to postpone, or a motion 
to proceed to the consideration of other business, or 
a motion to recommit the joint resolution is not in 
order. 
‘‘(iii) PASSAGE.—In the Senate, immediately fol-
lowing the conclusion of the debate on a joint resolution 
described in paragraph (1), and a single quorum call 
at the conclusion of the debate if requested in accord-
ance with the rules of the Senate, the vote on passage 
of the joint resolution shall occur. 
‘‘(iv) APPEALS.—Appeals from the decisions of the 
Chair relating to the application of the rules of the 
Senate to the procedure relating to a joint resolution 
described in paragraph (1) shall be decided without 
debate. 
‘‘(D) OTHER HOUSE ACTS FIRST.—If, before the passage 
by 1 House of a joint resolution of that House described 
in paragraph (1), that House receives from the other House 
a joint resolution described in paragraph (1), then the 
following procedures shall apply: 
‘‘(i) The joint resolution of the other House shall 
not be referred to a committee. 
‘‘(ii) With respect to a joint resolution described 
in paragraph (1) of the House receiving the joint resolu-
tion— 
‘‘(I) the procedure in that House shall be the 
same as if no joint resolution had been received 
from the other House; but 
‘‘(II) the vote on final passage shall be on 
the joint resolution of the other House. 
‘‘(E) EXCLUDED DAYS.—For purposes of determining the 
period specified in subparagraph (B), there shall be 
excluded any days either House of Congress is adjourned 
for more than 3 days during a session of Congress. 
Applicability. 
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124 STAT. 502 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(F) MAJORITY REQUIRED FOR ADOPTION.—A joint reso-
lution considered under this subsection shall require an 
affirmative vote of three-fifths of the Members, duly chosen 
and sworn, for adoption. 
‘‘(3) TERMINATION.—If a joint resolution described in para-
graph (1) is enacted not later than August 15, 2017— 
‘‘(A) the Chief Actuary of the Medicare & Medicaid 
Services shall not— 
‘‘(i) make any determinations under subsection 
(c)(6) after May 1, 2017; or 
‘‘(ii) provide any opinion pursuant to subsection 
(c)(3)(B)(iii) after January 16, 2018; 
‘‘(B) the Board shall not submit any proposals or 
advisory reports to Congress under this section after 
January 16, 2018; and 
‘‘(C) the Board and the consumer advisory council 
under subsection (k) shall terminate on August 16, 2018. 
‘‘(g) BOARD MEMBERSHIP; TERMS
OF OFFICE; CHAIRPERSON; 
REMOVAL.— 
‘‘(1) MEMBERSHIP.— 
‘‘(A) IN GENERAL.—The Board shall be composed of— 
‘‘(i) 15 members appointed by the President, by 
and with the advice and consent of the Senate; and 
‘‘(ii) the Secretary, the Administrator of the Center 
for Medicare & Medicaid Services, and the Adminis-
trator of the Health Resources and Services Adminis-
tration, all of whom shall serve ex officio as nonvoting 
members of the Board. 
‘‘(B) QUALIFICATIONS.— 
‘‘(i) IN GENERAL.—The appointed membership of 
the Board shall include individuals with national rec-
ognition for their expertise in health finance and 
economics, actuarial science, health facility manage-
ment, health plans and integrated delivery systems, 
reimbursement of health facilities, allopathic and osteo-
pathic physicians, and other providers of health serv-
ices, and other related fields, who provide a mix of 
different professionals, broad geographic representa-
tion, and a balance between urban and rural represent-
atives. 
‘‘(ii) INCLUSION.—The appointed membership of the 
Board shall include (but not be limited to) physicians 
and other health professionals, experts in the area 
of pharmaco-economics or prescription drug benefit pro-
grams, employers, third-party payers, individuals 
skilled in the conduct and interpretation of biomedical, 
health services, and health economics research and 
expertise in outcomes and effectiveness research and 
technology assessment. Such membership shall also 
include representatives of consumers and the elderly. 
‘‘(iii) MAJORITY
NONPROVIDERS.—Individuals who 
are directly involved in the provision or management 
of the delivery of items and services covered under 
this title shall not constitute a majority of the 
appointed membership of the Board. 
‘‘(C) ETHICAL DISCLOSURE.—The President shall estab-
lish a system for public disclosure by appointed members 
President. 
Public 
information. 
President. 
Appointments. 
Deadlines. 
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124 STAT. 503 
PUBLIC LAW 111–148—MAR. 23, 2010 
of the Board of financial and other potential conflicts of 
interest relating to such members. Appointed members of 
the Board shall be treated as officers in the executive 
branch for purposes of applying title I of the Ethics in 
Government Act of 1978 (Public Law 95–521). 
‘‘(D) CONFLICTS OF INTEREST.—No individual may serve 
as an appointed member if that individual engages in any 
other business, vocation, or employment. 
‘‘(E) CONSULTATION
WITH
CONGRESS.—In selecting 
individuals for nominations for appointments to the Board, 
the President shall consult with— 
‘‘(i) the majority leader of the Senate concerning 
the appointment of 3 members; 
‘‘(ii) the Speaker of the House of Representatives 
concerning the appointment of 3 members; 
‘‘(iii) the minority leader of the Senate concerning 
the appointment of 3 members; and 
‘‘(iv) the minority leader of the House of Represent-
atives concerning the appointment of 3 members. 
‘‘(2) TERM OF OFFICE.—Each appointed member shall hold 
office for a term of 6 years except that— 
‘‘(A) a member may not serve more than 2 full consecu-
tive terms (but may be reappointed to 2 full consecutive 
terms after being appointed to fill a vacancy on the Board); 
‘‘(B) a member appointed to fill a vacancy occurring 
prior to the expiration of the term for which that member’s 
predecessor was appointed shall be appointed for the 
remainder of such term; 
‘‘(C) a member may continue to serve after the expira-
tion of the member’s term until a successor has taken 
office; and 
‘‘(D) of the members first appointed under this section, 
5 shall be appointed for a term of 1 year, 5 shall be 
appointed for a term of 3 years, and 5 shall be appointed 
for a term of 6 years, the term of each to be designated 
by the President at the time of nomination. 
‘‘(3) CHAIRPERSON.— 
‘‘(A) IN GENERAL.—The Chairperson shall be appointed 
by the President, by and with the advice and consent 
of the Senate, from among the members of the Board. 
‘‘(B) DUTIES.—The Chairperson shall be the principal 
executive officer of the Board, and shall exercise all of 
the executive and administrative functions of the Board, 
including functions of the Board with respect to— 
‘‘(i) the appointment and supervision of personnel 
employed by the Board; 
‘‘(ii) the distribution of business among personnel 
appointed and supervised by the Chairperson and 
among administrative units of the Board; and 
‘‘(iii) the use and expenditure of funds. 
‘‘(C) GOVERNANCE.—In carrying out any of the func-
tions under subparagraph (B), the Chairperson shall be 
governed by the general policies established by the Board 
and by the decisions, findings, and determinations the 
Board shall by law be authorized to make. 
Appointment. 
President. 
President. 
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124 STAT. 504 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(D) REQUESTS FOR APPROPRIATIONS.—Requests or esti-
mates for regular, supplemental, or deficiency appropria-
tions on behalf of the Board may not be submitted by 
the Chairperson without the prior approval of a majority 
vote of the Board. 
‘‘(4) REMOVAL.—Any appointed member may be removed 
by the President for neglect of duty or malfeasance in office, 
but for no other cause. 
‘‘(h) VACANCIES; QUORUM; SEAL; VICE CHAIRPERSON; VOTING 
ON REPORTS.— 
‘‘(1) VACANCIES.—No vacancy on the Board shall impair 
the right of the remaining members to exercise all the powers 
of the Board. 
‘‘(2) QUORUM.—A majority of the appointed members of 
the Board shall constitute a quorum for the transaction of 
business, but a lesser number of members may hold hearings. 
‘‘(3) SEAL.—The Board shall have an official seal, of which 
judicial notice shall be taken. 
‘‘(4) VICE CHAIRPERSON.—The Board shall annually elect 
a Vice Chairperson to act in the absence or disability of the 
Chairperson or in case of a vacancy in the office of the Chair-
person. 
‘‘(5) VOTING ON PROPOSALS.—Any proposal of the Board 
must be approved by the majority of appointed members 
present. 
‘‘(i) POWERS OF THE BOARD.— 
‘‘(1) HEARINGS.—The Board may hold such hearings, sit 
and act at such times and places, take such testimony, and 
receive such evidence as the Board considers advisable to carry 
out this section. 
‘‘(2) AUTHORITY TO INFORM RESEARCH PRIORITIES FOR DATA 
COLLECTION.—The Board may advise the Secretary on priorities 
for health services research, particularly as such priorities per-
tain to necessary changes and issues regarding payment 
reforms under Medicare. 
‘‘(3) OBTAINING
OFFICIAL
DATA.—The Board may secure 
directly from any department or agency of the United States 
information necessary to enable it to carry out this section. 
Upon request of the Chairperson, the head of that department 
or agency shall furnish that information to the Board on an 
agreed upon schedule. 
‘‘(4) POSTAL
SERVICES.—The Board may use the United 
States mails in the same manner and under the same conditions 
as other departments and agencies of the Federal Government. 
‘‘(5) GIFTS.—The Board may accept, use, and dispose of 
gifts or donations of services or property. 
‘‘(6) OFFICES.—The Board shall maintain a principal office 
and such field offices as it determines necessary, and may 
meet and exercise any of its powers at any other place. 
‘‘(j) PERSONNEL MATTERS.— 
‘‘(1) COMPENSATION OF MEMBERS AND CHAIRPERSON.—Each 
appointed member, other than the Chairperson, shall be com-
pensated at a rate equal to the annual rate of basic pay pre-
scribed for level III of the Executive Schedule under section 
5315 of title 5, United States Code. The Chairperson shall 
be compensated at a rate equal to the daily equivalent of 
the annual rate of basic pay prescribed for level II of the 
Deadline. 
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124 STAT. 505 
PUBLIC LAW 111–148—MAR. 23, 2010 
Executive Schedule under section 5315 of title 5, United States 
Code. 
‘‘(2) TRAVEL EXPENSES.—The appointed members shall be 
allowed travel expenses, including per diem in lieu of subsist-
ence, at rates authorized for employees of agencies under sub-
chapter I of chapter 57 of title 5, United States Code, while 
away from their homes or regular places of business in the 
performance of services for the Board. 
‘‘(3) STAFF.— 
‘‘(A) IN
GENERAL.—The Chairperson may, without 
regard to the civil service laws and regulations, appoint 
and terminate an executive director and such other addi-
tional personnel as may be necessary to enable the Board 
to perform its duties. The employment of an executive 
director shall be subject to confirmation by the Board. 
‘‘(B) COMPENSATION.—The Chairperson may fix the 
compensation of the executive director and other personnel 
without regard to chapter 51 and subchapter III of chapter 
53 of title 5, United States Code, relating to classification 
of positions and General Schedule pay rates, except that 
the rate of pay for the executive director and other per-
sonnel may not exceed the rate payable for level V of 
the Executive Schedule under section 5316 of such title. 
‘‘(4) DETAIL
OF
GOVERNMENT
EMPLOYEES.—Any Federal 
Government employee may be detailed to the Board without 
reimbursement, and such detail shall be without interruption 
or loss of civil service status or privilege. 
‘‘(5) PROCUREMENT OF TEMPORARY AND INTERMITTENT SERV-
ICES.—The Chairperson may procure temporary and intermit-
tent services under section 3109(b) of title 5, United States 
Code, at rates for individuals which do not exceed the daily 
equivalent of the annual rate of basic pay prescribed for level 
V of the Executive Schedule under section 5316 of such title. 
‘‘(k) CONSUMER ADVISORY COUNCIL.— 
‘‘(1) IN GENERAL.—There is established a consumer advisory 
council to advise the Board on the impact of payment policies 
under this title on consumers. 
‘‘(2) MEMBERSHIP.— 
‘‘(A) 
NUMBER
AND
APPOINTMENT.—The 
consumer 
advisory council shall be composed of 10 consumer rep-
resentatives appointed by the Comptroller General of the 
United States, 1 from among each of the 10 regions estab-
lished by the Secretary as of the date of enactment of 
this section. 
‘‘(B) QUALIFICATIONS.—The membership of the council 
shall represent the interests of consumers and particular 
communities. 
‘‘(3) DUTIES.—The consumer advisory council shall, subject 
to the call of the Board, meet not less frequently than 2 times 
each year in the District of Columbia. 
‘‘(4) OPEN MEETINGS.—Meetings of the consumer advisory 
council shall be open to the public. 
‘‘(5) ELECTION
OF
OFFICERS.—Members of the consumer 
advisory council shall elect their own officers. 
‘‘(6) APPLICATION OF FACA.—The Federal Advisory Com-
mittee Act (5 U.S.C. App.) shall apply to the consumer advisory 
council except that section 14 of such Act shall not apply. 
Deadlines. 
Establishment. 
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124 STAT. 506 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(l) DEFINITIONS.—In this section: 
‘‘(1) BOARD; CHAIRPERSON; MEMBER.—The terms ‘Board’, 
‘Chairperson’, and ‘Member’ mean the Independent Medicare 
Advisory Board established under subsection (a) and the Chair-
person and any Member thereof, respectively. 
‘‘(2) MEDICARE.—The term ‘Medicare’ means the program 
established under this title, including parts A, B, C, and D. 
‘‘(3) MEDICARE
BENEFICIARY.—The term ‘Medicare bene-
ficiary’ means an individual who is entitled to, or enrolled 
for, benefits under part A or enrolled for benefits under part 
B. 
‘‘(4) MEDICARE PROGRAM SPENDING.—The term ‘Medicare 
program spending’ means program spending under parts A, 
B, and D net of premiums. 
‘‘(m) FUNDING.— 
‘‘(1) IN GENERAL.—There are appropriated to the Board 
to carry out its duties and functions— 
‘‘(A) for fiscal year 2012, $15,000,000; and 
‘‘(B) for each subsequent fiscal year, the amount appro-
priated under this paragraph for the previous fiscal year 
increased by the annual percentage increase in the Con-
sumer Price Index for All Urban Consumers (all items; 
United States city average) as of June of the previous 
fiscal year. 
‘‘(2) FROM TRUST FUNDS.—Sixty percent of amounts appro-
priated under paragraph (1) shall be derived by transfer from 
the Federal Hospital Insurance Trust Fund under section 1817 
and 40 percent of amounts appropriated under such paragraph 
shall be derived by transfer from the Federal Supplementary 
Medical Insurance Trust Fund under section 1841.’’. 
(2) LOBBYING COOLING-OFF PERIOD FOR MEMBERS OF THE 
INDEPENDENT
MEDICARE
ADVISORY
BOARD.—Section 207(c) of 
title 18, United States Code, is amended by inserting at the 
end the following: 
‘‘(3) MEMBERS OF THE INDEPENDENT MEDICARE ADVISORY 
BOARD.— 
‘‘(A) IN
GENERAL.—Paragraph (1) shall apply to a 
member of the Independent Medicare Advisory Board under 
section 1899A. 
‘‘(B) AGENCIES AND CONGRESS.—For purposes of para-
graph (1), the agency in which the individual described 
in subparagraph (A) served shall be considered to be the 
Independent Medicare Advisory Board, the Department of 
Health and Human Services, and the relevant committees 
of jurisdiction of Congress, including the Committee on 
Ways and Means and the Committee on Energy and Com-
merce of the House of Representatives and the Committee 
on Finance of the Senate.’’. 
(b) GAO STUDY
AND
REPORT
ON
DETERMINATION
AND 
IMPLEMENTATION OF PAYMENT AND COVERAGE POLICIES UNDER THE 
MEDICARE PROGRAM.— 
(1) INITIAL STUDY AND REPORT.— 
(A) STUDY.—The Comptroller General of the United 
States (in this section referred to as the ‘‘Comptroller Gen-
eral’’) shall conduct a study on changes to payment policies, 
methodologies, and rates and coverage policies and meth-
odologies under the Medicare program under title XVIII 
42 USC 
1395kkk–1. 
Applicability. 
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124 STAT. 507 
PUBLIC LAW 111–148—MAR. 23, 2010 
of the Social Security Act as a result of the recommenda-
tions contained in the proposals made by the Independent 
Medicare Advisory Board under section 1899A of such Act 
(as added by subsection (a)), including an analysis of the 
effect of such recommendations on— 
(i) Medicare beneficiary access to providers and 
items and services; 
(ii) the affordability of Medicare premiums and 
cost-sharing (including deductibles, coinsurance, and 
copayments); 
(iii) the potential impact of changes on other 
government or private-sector purchasers and payers 
of care; and 
(iv) quality of patient care, including patient 
experience, outcomes, and other measures of care. 
(B) REPORT.—Not later than July 1, 2015, the Comp-
troller General shall submit to Congress a report containing 
the results of the study conducted under subparagraph 
(A), together with recommendations for such legislation 
and administrative action as the Comptroller General 
determines appropriate. 
(2) SUBSEQUENT STUDIES AND REPORTS.—The Comptroller 
General shall periodically conduct such additional studies and 
submit reports to Congress on changes to Medicare payments 
policies, methodologies, and rates and coverage policies and 
methodologies as the Comptroller General determines appro-
priate, in consultation with the Committee on Ways and Means 
and the Committee on Energy and Commerce of the House 
of Representatives and the Committee on Finance of the Senate. 
(c) CONFORMING AMENDMENTS.—Section 1805(b) of the Social 
Security Act (42 U.S.C. 1395b–6(b)) is amended— 
(1) by redesignating paragraphs (4) through (8) as para-
graphs (5) through (9), respectively; and 
(2) by inserting after paragraph (3) the following: 
‘‘(4) REVIEW AND COMMENT ON THE INDEPENDENT MEDICARE 
ADVISORY
BOARD
OR
SECRETARIAL
PROPOSAL.—If the Inde-
pendent Medicare Advisory Board (as established under sub-
section (a) of section 1899A) or the Secretary submits a proposal 
to the Commission under such section in a year, the Commis-
sion shall review the proposal and, not later than March 1 
of that year, submit to the Committee on Ways and Means 
and the Committee on Energy and Commerce of the House 
of Representatives and the Committee on Finance of the Senate 
written comments on such proposal. Such comments may 
include such recommendations as the Commission deems appro-
priate.’’. 
Subtitle F—Health Care Quality 
Improvements 
SEC. 3501. HEALTH CARE DELIVERY SYSTEM RESEARCH; QUALITY 
IMPROVEMENT TECHNICAL ASSISTANCE. 
Part D of title IX of the Public Health Service Act, as amended 
by section 3013, is further amended by adding at the end the 
following: 
Deadline. 
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124 STAT. 508 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘Subpart II—Health Care Quality Improvement 
Programs 
‘‘SEC. 933. HEALTH CARE DELIVERY SYSTEM RESEARCH. 
‘‘(a) PURPOSE.—The purposes of this section are to— 
‘‘(1) enable the Director to identify, develop, evaluate, 
disseminate, and provide training in innovative methodologies 
and strategies for quality improvement practices in the delivery 
of health care services that represent best practices (referred 
to as ‘best practices’) in health care quality, safety, and value; 
and 
‘‘(2) ensure that the Director is accountable for imple-
menting a model to pursue such research in a collaborative 
manner with other related Federal agencies. 
‘‘(b) GENERAL FUNCTIONS
OF
THE CENTER.—The Center for 
Quality Improvement and Patient Safety of the Agency for 
Healthcare Research and Quality (referred to in this section as 
the ‘Center’), or any other relevant agency or department designated 
by the Director, shall— 
‘‘(1) carry out its functions using research from a variety 
of disciplines, which may include epidemiology, health services, 
sociology, psychology, human factors engineering, biostatistics, 
health economics, clinical research, and health informatics; 
‘‘(2) conduct or support activities consistent with the pur-
poses described in subsection (a), and for— 
‘‘(A) best practices for quality improvement practices 
in the delivery of health care services; and 
‘‘(B) that include changes in processes of care and 
the redesign of systems used by providers that will reliably 
result in intended health outcomes, improve patient safety, 
and reduce medical errors (such as skill development for 
health care providers in team-based health care delivery 
and rapid cycle process improvement) and facilitate adop-
tion of improved workflow; 
‘‘(3) identify health care providers, including health care 
systems, single institutions, and individual providers, that— 
‘‘(A) deliver consistently high-quality, efficient health 
care services (as determined by the Secretary); and 
‘‘(B) employ best practices that are adaptable and scal-
able to diverse health care settings or effective in improving 
care across diverse settings; 
‘‘(4) assess research, evidence, and knowledge about what 
strategies and methodologies are most effective in improving 
health care delivery; 
‘‘(5) find ways to translate such information rapidly and 
effectively into practice, and document the sustainability of 
those improvements; 
‘‘(6) create strategies for quality improvement through the 
development of tools, methodologies, and interventions that 
can successfully reduce variations in the delivery of health 
care; 
‘‘(7) identify, measure, and improve organizational, human, 
or other causative factors, including those related to the culture 
and system design of a health care organization, that contribute 
to the success and sustainability of specific quality improvement 
and patient safety strategies; 
42 USC 299b–33. 
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124 STAT. 509 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(8) provide for the development of best practices in the 
delivery of health care services that— 
‘‘(A) have a high likelihood of success, based on struc-
tured review of empirical evidence; 
‘‘(B) are specified with sufficient detail of the individual 
processes, steps, training, skills, and knowledge required 
for implementation and incorporation into workflow of 
health care practitioners in a variety of settings; 
‘‘(C) are designed to be readily adapted by health care 
providers in a variety of settings; and 
‘‘(D) where applicable, assist health care providers in 
working with other health care providers across the con-
tinuum of care and in engaging patients and their families 
in improving the care and patient health outcomes; 
‘‘(9) provide for the funding of the activities of organizations 
with recognized expertise and excellence in improving the 
delivery of health care services, including children’s health 
care, by involving multiple disciplines, managers of health care 
entities, broad development and training, patients, caregivers 
and families, and frontline health care workers, including activi-
ties for the examination of strategies to share best quality 
improvement practices and to promote excellence in the delivery 
of health care services; and 
‘‘(10) build capacity at the State and community level to 
lead quality and safety efforts through education, training, 
and mentoring programs to carry out the activities under para-
graphs (1) through (9). 
‘‘(c) RESEARCH FUNCTIONS OF CENTER.— 
‘‘(1) IN
GENERAL.—The Center shall support, such as 
through a contract or other mechanism, research on health 
care delivery system improvement and the development of tools 
to facilitate adoption of best practices that improve the quality, 
safety, and efficiency of health care delivery services. Such 
support may include establishing a Quality Improvement Net-
work Research Program for the purpose of testing, scaling, 
and disseminating of interventions to improve quality and effi-
ciency in health care. Recipients of funding under the Program 
may include national, State, multi-State, or multi-site quality 
improvement networks. 
‘‘(2) RESEARCH
REQUIREMENTS.—The research conducted 
pursuant to paragraph (1) shall— 
‘‘(A) address the priorities identified by the Secretary 
in the national strategic plan established under section 
399HH; 
‘‘(B) identify areas in which evidence is insufficient 
to identify strategies and methodologies, taking into consid-
eration areas of insufficient evidence identified by the 
entity with a contract under section 1890(a) of the Social 
Security Act in the report required under section 399JJ; 
‘‘(C) address concerns identified by health care institu-
tions and providers and communicated through the Center 
pursuant to subsection (d); 
‘‘(D) reduce preventable morbidity, mortality, and asso-
ciated costs of morbidity and mortality by building capacity 
for patient safety research; 
‘‘(E) support the discovery of processes for the reliable, 
safe, efficient, and responsive delivery of health care, taking 
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124 STAT. 510 
PUBLIC LAW 111–148—MAR. 23, 2010 
into account discoveries from clinical research and 
comparative effectiveness research; 
‘‘(F) allow communication of research findings and 
translate evidence into practice recommendations that are 
adaptable to a variety of settings, and which, as soon 
as practicable after the establishment of the Center, shall 
include— 
‘‘(i) the implementation of a national application 
of Intensive Care Unit improvement projects relating 
to the adult (including geriatric), pediatric, and neo-
natal patient populations; 
‘‘(ii) practical methods for addressing health care 
associated infections, including Methicillin-Resistant 
Staphylococcus 
Aureus 
and 
Vancomycin-Resistant 
Entercoccus infections and other emerging infections; 
and 
‘‘(iii) practical methods for reducing preventable 
hospital admissions and readmissions; 
‘‘(G) expand demonstration projects for improving the 
quality of children’s health care and the use of health 
information technology, such as through Pediatric Quality 
Improvement Collaboratives and Learning Networks, con-
sistent with provisions of section 1139A of the Social Secu-
rity Act for assessing and improving quality, where 
applicable; 
‘‘(H) identify and mitigate hazards by— 
‘‘(i) analyzing events reported to patient safety 
reporting systems and patient safety organizations; 
and 
‘‘(ii) using the results of such analyses to develop 
scientific methods of response to such events; 
‘‘(I) include the conduct of systematic reviews of 
existing practices that improve the quality, safety, and 
efficiency of health care delivery, as well as new research 
on improving such practices; and 
‘‘(J) include the examination of how to measure and 
evaluate the progress of quality and patient safety activi-
ties. 
‘‘(d) DISSEMINATION OF RESEARCH FINDINGS.— 
‘‘(1) PUBLIC AVAILABILITY.—The Director shall make the 
research findings of the Center available to the public through 
multiple media and appropriate formats to reflect the varying 
needs of health care providers and consumers and diverse levels 
of health literacy. 
‘‘(2) LINKAGE TO HEALTH INFORMATION TECHNOLOGY.—The 
Secretary shall ensure that research findings and results gen-
erated by the Center are shared with the Office of the National 
Coordinator of Health Information Technology and used to 
inform the activities of the health information technology exten-
sion program under section 3012, as well as any relevant stand-
ards, certification criteria, or implementation specifications. 
‘‘(e) PRIORITIZATION.—The Director shall identify and regularly 
update a list of processes or systems on which to focus research 
and dissemination activities of the Center, taking into account— 
‘‘(1) the cost to Federal health programs; 
‘‘(2) consumer assessment of health care experience; 
Lists. 
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124 STAT. 511 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(3) provider assessment of such processes or systems and 
opportunities to minimize distress and injury to the health 
care workforce; 
‘‘(4) the potential impact of such processes or systems on 
health status and function of patients, including vulnerable 
populations including children; 
‘‘(5) the areas of insufficient evidence identified under sub-
section (c)(2)(B); and 
‘‘(6) the evolution of meaningful use of health information 
technology, as defined in section 3000. 
‘‘(f) COORDINATION.—The Center shall coordinate its activities 
with activities conducted by the Center for Medicare and Medicaid 
Innovation established under section 1115A of the Social Security 
Act. 
‘‘(g) FUNDING.—There is authorized to be appropriated to carry 
out this section $20,000,000 for fiscal years 2010 through 2014. 
‘‘SEC. 934. QUALITY IMPROVEMENT TECHNICAL ASSISTANCE AND 
IMPLEMENTATION. 
‘‘(a) IN GENERAL.—The Director, through the Center for Quality 
Improvement and Patient Safety of the Agency for Healthcare 
Research and Quality (referred to in this section as the ‘Center’), 
shall award— 
‘‘(1) technical assistance grants or contracts to eligible enti-
ties to provide technical support to institutions that deliver 
health care and health care providers (including rural and 
urban providers of services and suppliers with limited infra-
structure and financial resources to implement and support 
quality improvement activities, providers of services and sup-
pliers with poor performance scores, and providers of services 
and suppliers for which there are disparities in care among 
subgroups of patients) so that such institutions and providers 
understand, adapt, and implement the models and practices 
identified in the research conducted by the Center, including 
the Quality Improvement Networks Research Program; and 
‘‘(2) implementation grants or contracts to eligible entities 
to implement the models and practices described under para-
graph (1). 
‘‘(b) ELIGIBLE ENTITIES.— 
‘‘(1) TECHNICAL
ASSISTANCE
AWARD.—To be eligible to 
receive a technical assistance grant or contract under subsection 
(a)(1), an entity— 
‘‘(A) may be a health care provider, health care provider 
association, professional society, health care worker 
organization, Indian health organization, quality improve-
ment organization, patient safety organization, local quality 
improvement collaborative, the Joint Commission, aca-
demic health center, university, physician-based research 
network, primary care extension program established under 
section 399W, a Federal Indian Health Service program 
or a health program operated by an Indian tribe (as defined 
in section 4 of the Indian Health Care Improvement Act), 
or any other entity identified by the Secretary; and 
‘‘(B) shall have demonstrated expertise in providing 
information and technical support and assistance to health 
care providers regarding quality improvement. 
Grants. 
Contracts. 
42 USC 299b–34. 
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124 STAT. 512 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) IMPLEMENTATION AWARD.—To be eligible to receive an 
implementation grant or contract under subsection (a)(2), an 
entity— 
‘‘(A) may be a hospital or other health care provider 
or consortium or providers, as determined by the Secretary; 
and 
‘‘(B) shall have demonstrated expertise in providing 
information and technical support and assistance to health 
care providers regarding quality improvement. 
‘‘(c) APPLICATION.— 
‘‘(1) TECHNICAL ASSISTANCE AWARD.—To receive a technical 
assistance grant or contract under subsection (a)(1), an eligible 
entity shall submit an application to the Secretary at such 
time, in such manner, and containing— 
‘‘(A) a plan for a sustainable business model that may 
include a system of— 
‘‘(i) charging fees to institutions and providers that 
receive technical support from the entity; and 
‘‘(ii) reducing or eliminating such fees for such 
institutions and providers that serve low-income popu-
lations; and 
‘‘(B) such other information as the Director may 
require. 
‘‘(2) IMPLEMENTATION AWARD.—To receive a grant or con-
tract under subsection (a)(2), an eligible entity shall submit 
an application to the Secretary at such time, in such manner, 
and containing— 
‘‘(A) a plan for implementation of a model or practice 
identified in the research conducted by the Center 
including— 
‘‘(i) financial cost, staffing requirements, and 
timeline for implementation; and 
‘‘(ii) pre- and projected post-implementation quality 
measure performance data in targeted improvement 
areas identified by the Secretary; and 
‘‘(B) such other information as the Director may 
require. 
‘‘(d) MATCHING FUNDS.—The Director may not award a grant 
or contract under this section to an entity unless the entity agrees 
that it will make available (directly or through contributions from 
other public or private entities) non-Federal contributions toward 
the activities to be carried out under the grant or contract in 
an amount equal to $1 for each $5 of Federal funds provided 
under the grant or contract. Such non-Federal matching funds 
may be provided directly or through donations from public or private 
entities and may be in cash or in-kind, fairly evaluated, including 
plant, equipment, or services. 
‘‘(e) EVALUATION.— 
‘‘(1) IN GENERAL.—The Director shall evaluate the perform-
ance of each entity that receives a grant or contract under 
this section. The evaluation of an entity shall include a study 
of— 
‘‘(A) the success of such entity in achieving the 
implementation, by the health care institutions and pro-
viders assisted by such entity, of the models and practices 
identified in the research conducted by the Center under 
section 933; 
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124 STAT. 513 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) the perception of the health care institutions and 
providers assisted by such entity regarding the value of 
the entity; and 
‘‘(C) where practicable, better patient health outcomes 
and lower cost resulting from the assistance provided by 
such entity. 
‘‘(2) EFFECT
OF
EVALUATION.—Based on the outcome of 
the evaluation of the entity under paragraph (1), the Director 
shall determine whether to renew a grant or contract with 
such entity under this section. 
‘‘(f) COORDINATION.—The entities that receive a grant or con-
tract under this section shall coordinate with health information 
technology regional extension centers under section 3012(c) and 
the primary care extension program established under section 399W 
regarding the dissemination of quality improvement, system 
delivery reform, and best practices information.’’. 
SEC. 3502. ESTABLISHING COMMUNITY HEALTH TEAMS TO SUPPORT 
THE PATIENT-CENTERED MEDICAL HOME. 
(a) IN GENERAL.—The Secretary of Health and Human Services 
(referred to in this section as the ‘‘Secretary’’) shall establish a 
program to provide grants to or enter into contracts with eligible 
entities to establish community-based interdisciplinary, interprofes-
sional teams (referred to in this section as ‘‘health teams’’) to 
support primary care practices, including obstetrics and gynecology 
practices, within the hospital service areas served by the eligible 
entities. Grants or contracts shall be used to— 
(1) establish health teams to provide support services to 
primary care providers; and 
(2) provide capitated payments to primary care providers 
as determined by the Secretary. 
(b) ELIGIBLE ENTITIES.—To be eligible to receive a grant or 
contract under subsection (a), an entity shall— 
(1)(A) be a State or State-designated entity; or 
(B) be an Indian tribe or tribal organization, as defined 
in section 4 of the Indian Health Care Improvement Act; 
(2) submit a plan for achieving long-term financial sustain-
ability within 3 years; 
(3) submit a plan for incorporating prevention initiatives 
and patient education and care management resources into 
the delivery of health care that is integrated with community- 
based prevention and treatment resources, where available; 
(4) ensure that the health team established by the entity 
includes an interdisciplinary, interprofessional team of health 
care providers, as determined by the Secretary; such team 
may include medical specialists, nurses, pharmacists, nutrition-
ists, dieticians, social workers, behavioral and mental health 
providers (including substance use disorder prevention and 
treatment providers), doctors of chiropractic, licensed com-
plementary and alternative medicine practitioners, and physi-
cians’ assistants; 
(5) agree to provide services to eligible individuals with 
chronic conditions, as described in section 1945 of the Social 
Security Act (as added by section 2703), in accordance with 
the payment methodology established under subsection (c) of 
such section; and 
Plans. 
Plans. 
Deadline. 
Grants. 
Contracts. 
42 USC 256a–1. 
Determination. 
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124 STAT. 514 
PUBLIC LAW 111–148—MAR. 23, 2010 
(6) submit to the Secretary an application at such time, 
in such manner, and containing such information as the Sec-
retary may require. 
(c) REQUIREMENTS FOR HEALTH TEAMS.—A health team estab-
lished pursuant to a grant or contract under subsection (a) shall— 
(1) establish contractual agreements with primary care pro-
viders to provide support services; 
(2) support patient-centered medical homes, defined as a 
mode of care that includes— 
(A) personal physicians; 
(B) whole person orientation; 
(C) coordinated and integrated care; 
(D) safe and high-quality care through evidence- 
informed medicine, appropriate use of health information 
technology, and continuous quality improvements; 
(E) expanded access to care; and 
(F) payment that recognizes added value from addi-
tional components of patient-centered care; 
(3) collaborate with local primary care providers and 
existing State and community based resources to coordinate 
disease prevention, chronic disease management, transitioning 
between health care providers and settings and case manage-
ment for patients, including children, with priority given to 
those amenable to prevention and with chronic diseases or 
conditions identified by the Secretary; 
(4) in collaboration with local health care providers, develop 
and implement interdisciplinary, interprofessional care plans 
that integrate clinical and community preventive and health 
promotion services for patients, including children, with a pri-
ority given to those amenable to prevention and with chronic 
diseases or conditions identified by the Secretary; 
(5) incorporate health care providers, patients, caregivers, 
and authorized representatives in program design and over-
sight; 
(6) provide support necessary for local primary care pro-
viders to— 
(A) coordinate and provide access to high-quality health 
care services; 
(B) coordinate and provide access to preventive and 
health promotion services; 
(C) provide access to appropriate specialty care and 
inpatient services; 
(D) provide quality-driven, cost-effective, culturally 
appropriate, and patient- and family-centered health care; 
(E) provide access to pharmacist-delivered medication 
management services, including medication reconciliation; 
(F) provide coordination of the appropriate use of com-
plementary and alternative (CAM) services to those who 
request such services; 
(G) promote effective strategies for treatment planning, 
monitoring health outcomes and resource use, sharing 
information, treatment decision support, and organizing 
care to avoid duplication of service and other medical 
management approaches intended to improve quality and 
value of health care services; 
(H) provide local access to the continuum of health 
care services in the most appropriate setting, including 
Plans. 
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124 STAT. 515 
PUBLIC LAW 111–148—MAR. 23, 2010 
access to individuals that implement the care plans of 
patients and coordinate care, such as integrative health 
care practitioners; 
(I) collect and report data that permits evaluation of 
the success of the collaborative effort on patient outcomes, 
including collection of data on patient experience of care, 
and identification of areas for improvement; and 
(J) establish a coordinated system of early identifica-
tion and referral for children at risk for developmental 
or behavioral problems such as through the use of infolines, 
health information technology, or other means as deter-
mined by the Secretary; 
(7) provide 24-hour care management and support during 
transitions in care settings including— 
(A) a transitional care program that provides onsite 
visits from the care coordinator, assists with the develop-
ment of discharge plans and medication reconciliation upon 
admission to and discharge from the hospitals, nursing 
home, or other institution setting; 
(B) discharge planning and counseling support to pro-
viders, patients, caregivers, and authorized representatives; 
(C) assuring that post-discharge care plans include 
medication management, as appropriate; 
(D) referrals for mental and behavioral health services, 
which may include the use of infolines; and 
(E) transitional health care needs from adolescence 
to adulthood; 
(8) serve as a liaison to community prevention and treat-
ment programs; 
(9) demonstrate a capacity to implement and maintain 
health information technology that meets the requirements of 
certified EHR technology (as defined in section 3000 of the 
Public Health Service Act (42 U.S.C. 300jj)) to facilitate 
coordination among members of the applicable care team and 
affiliated primary care practices; and 
(10) where applicable, report to the Secretary information 
on quality measures used under section 399JJ of the Public 
Health Service Act. 
(d) REQUIREMENT FOR PRIMARY CARE PROVIDERS.—A provider 
who contracts with a care team shall— 
(1) provide a care plan to the care team for each patient 
participant; 
(2) provide access to participant health records; and 
(3) meet regularly with the care team to ensure integration 
of care. 
(e) REPORTING TO SECRETARY.—An entity that receives a grant 
or contract under subsection (a) shall submit to the Secretary a 
report that describes and evaluates, as requested by the Secretary, 
the activities carried out by the entity under subsection (c). 
(f) DEFINITION OF PRIMARY CARE.—In this section, the term 
‘‘primary care’’ means the provision of integrated, accessible health 
care services by clinicians who are accountable for addressing a 
large majority of personal health care needs, developing a sustained 
partnership with patients, and practicing in the context of family 
and community. 
Records. 
Plans. 
Reports. 
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124 STAT. 516 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 3503. MEDICATION MANAGEMENT SERVICES IN TREATMENT OF 
CHRONIC DISEASE. 
Title IX of the Public Health Service Act (42 U.S.C. 299 et 
seq.), as amended by section 3501, is further amended by inserting 
after section 934 the following: 
‘‘SEC. 935. GRANTS OR CONTRACTS TO IMPLEMENT MEDICATION 
MANAGEMENT SERVICES IN TREATMENT OF CHRONIC 
DISEASES. 
‘‘(a) IN GENERAL.—The Secretary, acting through the Patient 
Safety Research Center established in section 933 (referred to in 
this section as the ‘Center’), shall establish a program to provide 
grants or contracts to eligible entities to implement medication 
management (referred to in this section as ‘MTM’) services provided 
by licensed pharmacists, as a collaborative, multidisciplinary, inter- 
professional approach to the treatment of chronic diseases for tar-
geted individuals, to improve the quality of care and reduce overall 
cost in the treatment of such diseases. The Secretary shall com-
mence the program under this section not later than May 1, 2010. 
‘‘(b) ELIGIBLE ENTITIES.—To be eligible to receive a grant or 
contract under subsection (a), an entity shall— 
‘‘(1) provide a setting appropriate for MTM services, as 
recommended by the experts described in subsection (e); 
‘‘(2) submit to the Secretary a plan for achieving long- 
term financial sustainability; 
‘‘(3) where applicable, submit a plan for coordinating MTM 
services through local community health teams established in 
section 3502 of the Patient Protection and Affordable Care 
Act or in collaboration with primary care extension programs 
established in section 399W; 
‘‘(4) submit a plan for meeting the requirements under 
subsection (c); and 
‘‘(5) submit to the Secretary such other information as 
the Secretary may require. 
‘‘(c) MTM SERVICES
TO TARGETED INDIVIDUALS.—The MTM 
services provided with the assistance of a grant or contract awarded 
under subsection (a) shall, as allowed by State law including 
applicable collaborative pharmacy practice agreements, include— 
‘‘(1) performing or obtaining necessary assessments of the 
health and functional status of each patient receiving such 
MTM services; 
‘‘(2) formulating a medication treatment plan according 
to therapeutic goals agreed upon by the prescriber and the 
patient or caregiver or authorized representative of the patient; 
‘‘(3) selecting, initiating, modifying, recommending changes 
to, or administering medication therapy; 
‘‘(4) monitoring, which may include access to, ordering, 
or performing laboratory assessments, and evaluating the 
response of the patient to therapy, including safety and 
effectiveness; 
‘‘(5) performing an initial comprehensive medication review 
to identify, resolve, and prevent medication-related problems, 
including adverse drug events, quarterly targeted medication 
reviews for ongoing monitoring, and additional followup inter-
ventions on a schedule developed collaboratively with the pre-
scriber; 
Plans. 
Deadline. 
42 USC 299b–35. 
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124 STAT. 517 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(6) documenting the care delivered and communicating 
essential information about such care, including a summary 
of the medication review, and the recommendations of the 
pharmacist to other appropriate health care providers of the 
patient in a timely fashion; 
‘‘(7) providing education and training designed to enhance 
the understanding and appropriate use of the medications by 
the patient, caregiver, and other authorized representative; 
‘‘(8) providing information, support services, and resources 
and strategies designed to enhance patient adherence with 
therapeutic regimens; 
‘‘(9) coordinating and integrating MTM services within the 
broader health care management services provided to the 
patient; and 
‘‘(10) such other patient care services allowed under phar-
macist scopes of practice in use in other Federal programs 
that have implemented MTM services. 
‘‘(d) TARGETED
INDIVIDUALS.—MTM services provided by 
licensed pharmacists under a grant or contract awarded under 
subsection (a) shall be offered to targeted individuals who— 
‘‘(1) take 4 or more prescribed medications (including over- 
the-counter medications and dietary supplements); 
‘‘(2) take any ‘high risk’ medications; 
‘‘(3) have 2 or more chronic diseases, as identified by the 
Secretary; or 
‘‘(4) have undergone a transition of care, or other factors, 
as determined by the Secretary, that are likely to create a 
high risk of medication-related problems. 
‘‘(e) CONSULTATION WITH EXPERTS.—In designing and imple-
menting MTM services provided under grants or contracts awarded 
under subsection (a), the Secretary shall consult with Federal, 
State, private, public-private, and academic entities, pharmacy and 
pharmacist organizations, health care organizations, consumer 
advocates, chronic disease groups, and other stakeholders involved 
with the research, dissemination, and implementation of phar-
macist-delivered MTM services, as the Secretary determines appro-
priate. The Secretary, in collaboration with this group, shall deter-
mine whether it is possible to incorporate rapid cycle process 
improvement concepts in use in other Federal programs that have 
implemented MTM services. 
‘‘(f) REPORTING TO THE SECRETARY.—An entity that receives 
a grant or contract under subsection (a) shall submit to the Sec-
retary a report that describes and evaluates, as requested by the 
Secretary, the activities carried out under subsection (c), including 
quality measures endorsed by the entity with a contract under 
section 1890 of the Social Security Act, as determined by the Sec-
retary. 
‘‘(g) EVALUATION AND REPORT.—The Secretary shall submit to 
the relevant committees of Congress a report which shall— 
‘‘(1) assess the clinical effectiveness of pharmacist-provided 
services under the MTM services program, as compared to 
usual care, including an evaluation of whether enrollees main-
tained better health with fewer hospitalizations and emergency 
room visits than similar patients not enrolled in the program; 
‘‘(2) assess changes in overall health care resource use 
by targeted individuals; 
Determination. 
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124 STAT. 518 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(3) assess patient and prescriber satisfaction with MTM 
services; 
‘‘(4) assess the impact of patient-cost sharing requirements 
on medication adherence and recommendations for modifica-
tions; 
‘‘(5) identify and evaluate other factors that may impact 
clinical 
and 
economic 
outcomes, 
including 
demographic 
characteristics, clinical characteristics, and health services use 
of the patient, as well as characteristics of the regimen, phar-
macy benefit, and MTM services provided; and 
‘‘(6) evaluate the extent to which participating pharmacists 
who maintain a dispensing role have a conflict of interest 
in the provision of MTM services, and if such conflict is found, 
provide recommendations on how such a conflict might be 
appropriately addressed. 
‘‘(h) GRANTS
OR
CONTRACTS
TO
FUND
DEVELOPMENT
OF 
PERFORMANCE MEASURES.—The Secretary may, through the quality 
measure development program under section 931 of the Public 
Health Service Act, award grants or contracts to eligible entities 
for the purpose of funding the development of performance measures 
that assess the use and effectiveness of medication therapy manage-
ment services.’’. 
SEC. 3504. DESIGN AND IMPLEMENTATION OF REGIONALIZED SYS-
TEMS FOR EMERGENCY CARE. 
(a) IN GENERAL.—Title XII of the Public Health Service Act 
(42 U.S.C. 300d et seq.) is amended— 
(1) in section 1203— 
(A) in the section heading, by inserting ‘‘FOR TRAUMA 
SYSTEMS’’ after ‘‘GRANTS’’; and 
(B) in subsection (a), by striking ‘‘Administrator of 
the Health Resources and Services Administration’’ and 
inserting ‘‘Assistant Secretary for Preparedness and 
Response’’; 
(2) by inserting after section 1203 the following: 
‘‘SEC. 1204. COMPETITIVE GRANTS FOR REGIONALIZED SYSTEMS FOR 
EMERGENCY CARE RESPONSE. 
‘‘(a) IN GENERAL.—The Secretary, acting through the Assistant 
Secretary for Preparedness and Response, shall award not fewer 
than 4 multiyear contracts or competitive grants to eligible entities 
to support pilot projects that design, implement, and evaluate 
innovative models of regionalized, comprehensive, and accountable 
emergency care and trauma systems. 
‘‘(b) ELIGIBLE ENTITY; REGION.—In this section: 
‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible entity’ means— 
‘‘(A) a State or a partnership of 1 or more States 
and 1 or more local governments; or 
‘‘(B) an Indian tribe (as defined in section 4 of the 
Indian Health Care Improvement Act) or a partnership 
of 1 or more Indian tribes. 
‘‘(2) REGION.—The term ‘region’ means an area within a 
State, an area that lies within multiple States, or a similar 
area (such as a multicounty area), as determined by the Sec-
retary. 
‘‘(3) EMERGENCY SERVICES.—The term ‘emergency services’ 
includes acute, prehospital, and trauma care. 
Definitions. 
Contracts. 
42 USC 300d–6. 
42 USC 300d–5. 
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124 STAT. 519 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(c) PILOT PROJECTS.—The Secretary shall award a contract 
or grant under subsection (a) to an eligible entity that proposes 
a pilot project to design, implement, and evaluate an emergency 
medical and trauma system that— 
‘‘(1) coordinates with public health and safety services, 
emergency medical services, medical facilities, trauma centers, 
and other entities in a region to develop an approach to emer-
gency medical and trauma system access throughout the region, 
including 9–1–1 Public Safety Answering Points and emergency 
medical dispatch; 
‘‘(2) includes a mechanism, such as a regional medical 
direction or transport communications system, that operates 
throughout the region to ensure that the patient is taken to 
the medically appropriate facility (whether an initial facility 
or a higher-level facility) in a timely fashion; 
‘‘(3) allows for the tracking of prehospital and hospital 
resources, including inpatient bed capacity, emergency depart-
ment capacity, trauma center capacity, on-call specialist cov-
erage, ambulance diversion status, and the coordination of such 
tracking with regional communications and hospital destination 
decisions; and 
‘‘(4) includes a consistent region-wide prehospital, hospital, 
and interfacility data management system that— 
‘‘(A) submits data to the National EMS Information 
System, the National Trauma Data Bank, and others; 
‘‘(B) reports data to appropriate Federal and State 
databanks and registries; and 
‘‘(C) contains information sufficient to evaluate key 
elements of prehospital care, hospital destination decisions, 
including initial hospital and interfacility decisions, and 
relevant health outcomes of hospital care. 
‘‘(d) APPLICATION.— 
‘‘(1) IN GENERAL.—An eligible entity that seeks a contract 
or grant described in subsection (a) shall submit to the Sec-
retary an application at such time and in such manner as 
the Secretary may require. 
‘‘(2) APPLICATION
INFORMATION.—Each application shall 
include— 
‘‘(A) an assurance from the eligible entity that the 
proposed system— 
‘‘(i) has been coordinated with the applicable State 
Office of Emergency Medical Services (or equivalent 
State office); 
‘‘(ii) includes consistent indirect and direct medical 
oversight of prehospital, hospital, and interfacility 
transport throughout the region; 
‘‘(iii) coordinates prehospital treatment and triage, 
hospital 
destination, 
and 
interfacility 
transport 
throughout the region; 
‘‘(iv) includes a categorization or designation 
system for special medical facilities throughout the 
region that is integrated with transport and destination 
protocols; 
‘‘(v) includes a regional medical direction, patient 
tracking, and resource allocation system that supports 
day-to-day emergency care and surge capacity and is 
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124 STAT. 520 
PUBLIC LAW 111–148—MAR. 23, 2010 
integrated with other components of the national and 
State emergency preparedness system; and 
‘‘(vi) addresses pediatric concerns related to 
integration, planning, preparedness, and coordination 
of emergency medical services for infants, children and 
adolescents; and 
‘‘(B) such other information as the Secretary may 
require. 
‘‘(e) REQUIREMENT OF MATCHING FUNDS.— 
‘‘(1) IN GENERAL.—The Secretary may not make a grant 
under this section unless the State (or consortia of States) 
involved agrees, with respect to the costs to be incurred by 
the State (or consortia) in carrying out the purpose for which 
such grant was made, to make available non-Federal contribu-
tions (in cash or in kind under paragraph (2)) toward such 
costs in an amount equal to not less than $1 for each $3 
of Federal funds provided in the grant. Such contributions 
may be made directly or through donations from public or 
private entities. 
‘‘(2) NON-FEDERAL CONTRIBUTIONS.—Non-Federal contribu-
tions required in paragraph (1) may be in cash or in kind, 
fairly evaluated, including equipment or services (and excluding 
indirect or overhead costs). Amounts provided by the Federal 
Government, or services assisted or subsidized to any signifi-
cant extent by the Federal Government, may not be included 
in determining the amount of such non-Federal contributions. 
‘‘(f) PRIORITY.—The Secretary shall give priority for the award 
of the contracts or grants described in subsection (a) to any eligible 
entity that serves a population in a medically underserved area 
(as defined in section 330(b)(3)). 
‘‘(g) REPORT.—Not later than 90 days after the completion 
of a pilot project under subsection (a), the recipient of such contract 
or grant described in shall submit to the Secretary a report con-
taining the results of an evaluation of the program, including an 
identification of— 
‘‘(1) the impact of the regional, accountable emergency care 
and trauma system on patient health outcomes for various 
critical care categories, such as trauma, stroke, cardiac emer-
gencies, neurological emergencies, and pediatric emergencies; 
‘‘(2) the system characteristics that contribute to the 
effectiveness and efficiency of the program (or lack thereof); 
‘‘(3) methods of assuring the long-term financial sustain-
ability of the emergency care and trauma system; 
‘‘(4) the State and local legislation necessary to implement 
and to maintain the system; 
‘‘(5) the barriers to developing regionalized, accountable 
emergency care and trauma systems, as well as the methods 
to overcome such barriers; and 
‘‘(6) recommendations on the utilization of available funding 
for future regionalization efforts. 
‘‘(h) DISSEMINATION
OF FINDINGS.—The Secretary shall, as 
appropriate, disseminate to the public and to the appropriate 
Committees of the Congress, the information contained in a report 
made under subsection (g).’’; and 
(3) in section 1232— 
(A) in subsection (a), by striking ‘‘appropriated’’ and 
all that follows through the period at the end and inserting 
42 USC 300d–32. 
Public 
information. 
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124 STAT. 521 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘appropriated $24,000,000 for each of fiscal years 2010 
through 2014.’’; and 
(B) by inserting after subsection (c) the following: 
‘‘(d) AUTHORITY.—For the purpose of carrying out parts A 
through C, beginning on the date of enactment of the Patient 
Protection and Affordable Care Act, the Secretary shall transfer 
authority in administering grants and related authorities under 
such parts from the Administrator of the Health Resources and 
Services Administration to the Assistant Secretary for Preparedness 
and Response.’’. 
(b) SUPPORT FOR EMERGENCY MEDICINE RESEARCH.—Part H 
of title IV of the Public Health Service Act (42 U.S.C. 289 et 
seq.) is amended by inserting after the section 498C the following: 
‘‘SEC. 498D. SUPPORT FOR EMERGENCY MEDICINE RESEARCH. 
‘‘(a) EMERGENCY MEDICAL RESEARCH.—The Secretary shall sup-
port Federal programs administered by the National Institutes 
of Health, the Agency for Healthcare Research and Quality, the 
Health Resources and Services Administration, the Centers for 
Disease Control and Prevention, and other agencies involved in 
improving the emergency care system to expand and accelerate 
research in emergency medical care systems and emergency medi-
cine, including— 
‘‘(1) the basic science of emergency medicine; 
‘‘(2) the model of service delivery and the components of 
such models that contribute to enhanced patient health out-
comes; 
‘‘(3) the translation of basic scientific research into 
improved practice; and 
‘‘(4) the development of timely and efficient delivery of 
health services. 
‘‘(b) PEDIATRIC EMERGENCY MEDICAL RESEARCH.—The Sec-
retary shall support Federal programs administered by the National 
Institutes of Health, the Agency for Healthcare Research and 
Quality, the Health Resources and Services Administration, the 
Centers for Disease Control and Prevention, and other agencies 
to coordinate and expand research in pediatric emergency medical 
care systems and pediatric emergency medicine, including— 
‘‘(1) an examination of the gaps and opportunities in pedi-
atric emergency care research and a strategy for the optimal 
organization and funding of such research; 
‘‘(2) the role of pediatric emergency services as an 
integrated component of the overall health system; 
‘‘(3) system-wide pediatric emergency care planning, 
preparedness, coordination, and funding; 
‘‘(4) pediatric training in professional education; and 
‘‘(5) research in pediatric emergency care, specifically on 
the efficacy, safety, and health outcomes of medications used 
for infants, children, and adolescents in emergency care settings 
in order to improve patient safety. 
‘‘(c) IMPACT RESEARCH.—The Secretary shall support research 
to determine the estimated economic impact of, and savings that 
result from, the implementation of coordinated emergency care sys-
tems. 
‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated to carry out this section such sums as may 
be necessary for each of fiscal years 2010 through 2014.’’. 
42 USC 289g–4. 
Effective date. 
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124 STAT. 522 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 3505. TRAUMA CARE CENTERS AND SERVICE AVAILABILITY. 
(a) TRAUMA CARE CENTERS.— 
(1) GRANTS FOR TRAUMA CARE CENTERS.—Section 1241 of 
the Public Health Service Act (42 U.S.C. 300d–41) is amended 
by striking subsections (a) and (b) and inserting the following: 
‘‘(a) IN GENERAL.—The Secretary shall establish 3 programs 
to award grants to qualified public, nonprofit Indian Health Service, 
Indian tribal, and urban Indian trauma centers— 
‘‘(1) to assist in defraying substantial uncompensated care 
costs; 
‘‘(2) to further the core missions of such trauma centers, 
including by addressing costs associated with patient stabiliza-
tion and transfer, trauma education and outreach, coordination 
with local and regional trauma systems, essential personnel 
and other fixed costs, and expenses associated with employee 
and non-employee physician services; and 
‘‘(3) to provide emergency relief to ensure the continued 
and future availability of trauma services. 
‘‘(b) MINIMUM QUALIFICATIONS OF TRAUMA CENTERS.— 
‘‘(1) PARTICIPATION
IN
TRAUMA
CARE
SYSTEM
OPERATING 
UNDER CERTAIN PROFESSIONAL GUIDELINES.—Except as provided 
in paragraph (2), the Secretary may not award a grant to 
a trauma center under subsection (a) unless the trauma center 
is a participant in a trauma system that substantially complies 
with section 1213. 
‘‘(2) EXEMPTION.—Paragraph (1) shall not apply to trauma 
centers that are located in States with no existing trauma 
care system. 
‘‘(3) QUALIFICATION
FOR
SUBSTANTIAL
UNCOMPENSATED 
CARE COSTS.—The Secretary shall award substantial uncompen-
sated care grants under subsection (a)(1) only to trauma centers 
meeting at least 1 of the criteria in 1 of the following 3 cat-
egories: 
‘‘(A) CATEGORY A.—The criteria for category A are as 
follows: 
‘‘(i) At least 40 percent of the visits in the emer-
gency department of the hospital in which the trauma 
center is located were charity or self-pay patients. 
‘‘(ii) At least 50 percent of the visits in such emer-
gency department were Medicaid (under title XIX of 
the Social Security Act (42 U.S.C. 1396 et seq.)) and 
charity and self-pay patients combined. 
‘‘(B) CATEGORY B.—The criteria for category B are as 
follows: 
‘‘(i) At least 35 percent of the visits in the emer-
gency department were charity or self-pay patients. 
‘‘(ii) At least 50 percent of the visits in the emer-
gency department were Medicaid and charity and self- 
pay patients combined. 
‘‘(C) CATEGORY C.—The criteria for category C are as 
follows: 
‘‘(i) At least 20 percent of the visits in the emer-
gency department were charity or self-pay patients. 
‘‘(ii) At least 30 percent of the visits in the emer-
gency department were Medicaid and charity and self- 
pay patients combined. 
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124 STAT. 523 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(4) TRAUMA CENTERS IN 1115 WAIVER STATES.—Notwith-
standing paragraph (3), the Secretary may award a substantial 
uncompensated care grant to a trauma center under subsection 
(a)(1) if the trauma center qualifies for funds under a Low 
Income Pool or Safety Net Care Pool established through a 
waiver approved under section 1115 of the Social Security 
Act (42 U.S.C. 1315). 
‘‘(5) DESIGNATION.—The Secretary may not award a grant 
to a trauma center unless such trauma center is verified by 
the American College of Surgeons or designated by an equiva-
lent State or local agency. 
‘‘(c) ADDITIONAL REQUIREMENTS.—The Secretary may not award 
a grant to a trauma center under subsection (a)(1) unless such 
trauma center— 
‘‘(1) submits to the Secretary a plan satisfactory to the 
Secretary that demonstrates a continued commitment to 
serving trauma patients regardless of their ability to pay; and 
‘‘(2) has policies in place to assist patients who cannot 
pay for part or all of the care they receive, including a sliding 
fee scale, and to ensure fair billing and collection practices.’’. 
(2) CONSIDERATIONS IN MAKING GRANTS.—Section 1242 of 
the Public Health Service Act (42 U.S.C. 300d–42) is amended 
by striking subsections (a) and (b) and inserting the following: 
‘‘(a) SUBSTANTIAL UNCOMPENSATED CARE AWARDS.— 
‘‘(1) IN GENERAL.—The Secretary shall establish an award 
basis for each eligible trauma center for grants under section 
1241(a)(1) according to the percentage described in paragraph 
(2), subject to the requirements of section 1241(b)(3). 
‘‘(2) PERCENTAGES.—The applicable percentages are as fol-
lows: 
‘‘(A) With respect to a category A trauma center, 100 
percent of the uncompensated care costs. 
‘‘(B) With respect to a category B trauma center, not 
more than 75 percent of the uncompensated care costs. 
‘‘(C) With respect to a category C trauma center, not 
more than 50 percent of the uncompensated care costs. 
‘‘(b) CORE MISSION AWARDS.— 
‘‘(1) IN
GENERAL.—In awarding grants under section 
1241(a)(2), the Secretary shall— 
‘‘(A) reserve 25 percent of the amount allocated for 
core mission awards for Level III and Level IV trauma 
centers; and 
‘‘(B) reserve 25 percent of the amount allocated for 
core mission awards for large urban Level I and II trauma 
centers— 
‘‘(i) that have at least 1 graduate medical education 
fellowship in trauma or trauma related specialties for 
which demand is exceeding supply; 
‘‘(ii) for which— 
‘‘(I) annual uncompensated care costs exceed 
$10,000,000; or 
‘‘(II) at least 20 percent of emergency depart-
ment visits are charity or self-pay or Medicaid 
patients; and 
‘‘(iii) 
that 
are 
not 
eligible 
for 
substantial 
uncompensated care awards under section 1241(a)(1). 
Plans. 
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124 STAT. 524 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(c) EMERGENCY AWARDS.—In awarding grants under section 
1241(a)(3), the Secretary shall— 
‘‘(1) give preference to any application submitted by a 
trauma center that provides trauma care in a geographic area 
in which the availability of trauma care has significantly 
decreased or will significantly decrease if the center is forced 
to close or downgrade service or growth in demand for trauma 
services exceeds capacity; and 
‘‘(2) reallocate any emergency awards funds not obligated 
due to insufficient, or a lack of qualified, applications to the 
significant uncompensated care award program.’’. 
(3) CERTAIN
AGREEMENTS.—Section 1243 of the Public 
Health Service Act (42 U.S.C. 300d–43) is amended by striking 
subsections (a), (b), and (c) and inserting the following: 
‘‘(a) MAINTENANCE OF FINANCIAL SUPPORT.—The Secretary may 
require a trauma center receiving a grant under section 1241(a) 
to maintain access to trauma services at comparable levels to the 
prior year during the grant period. 
‘‘(b) TRAUMA CARE REGISTRY.—The Secretary may require the 
trauma center receiving a grant under section 1241(a) to provide 
data to a national and centralized registry of trauma cases, in 
accordance with guidelines developed by the American College of 
Surgeons, and as the Secretary may otherwise require.’’. 
(4) GENERAL
PROVISIONS.—Section 1244 of the Public 
Health Service Act (42 U.S.C. 300d–44) is amended by striking 
subsections (a), (b), and (c) and inserting the following: 
‘‘(a) APPLICATION.—The Secretary may not award a grant to 
a trauma center under section 1241(a) unless such center submits 
an application for the grant to the Secretary and the application 
is in such form, is made in such manner, and contains such agree-
ments, assurances, and information as the Secretary determines 
to be necessary to carry out this part. 
‘‘(b) LIMITATION ON DURATION OF SUPPORT.—The period during 
which a trauma center receives payments under a grant under 
section 1241(a)(3) shall be for 3 fiscal years, except that the Sec-
retary may waive such requirement for a center and authorize 
such center to receive such payments for 1 additional fiscal year. 
‘‘(c) LIMITATION ON AMOUNT OF GRANT.—Notwithstanding sec-
tion 1242(a), a grant under section 1241 may not be made in 
an amount exceeding $2,000,000 for each fiscal year. 
‘‘(d) 
ELIGIBILITY.—Except 
as 
provided 
in 
section 
1242(b)(1)(B)(iii), acquisition of, or eligibility for, a grant under 
section 1241(a) shall not preclude a trauma center from being 
eligible for other grants described in such section. 
‘‘(e) FUNDING DISTRIBUTION.—Of the total amount appropriated 
for a fiscal year under section 1245, 70 percent shall be used 
for 
substantial 
uncompensated 
care 
awards 
under 
section 
1241(a)(1), 20 percent shall be used for core mission awards under 
section 1241(a)(2), and 10 percent shall be used for emergency 
awards under section 1241(a)(3). 
‘‘(f) MINIMUM ALLOWANCE.—Notwithstanding subsection (e), if 
the amount appropriated for a fiscal year under section 1245 is 
less than $25,000,000, all available funding for such fiscal year 
shall be used for substantial uncompensated care awards under 
section 1241(a)(1). 
‘‘(g) SUBSTANTIAL UNCOMPENSATED CARE AWARD DISTRIBUTION 
AND PROPORTIONAL SHARE.—Notwithstanding section 1242(a), of 
Waiver authority. 
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124 STAT. 525 
PUBLIC LAW 111–148—MAR. 23, 2010 
the amount appropriated for substantial uncompensated care grants 
for a fiscal year, the Secretary shall— 
‘‘(1) make available— 
‘‘(A) 50 percent of such funds for category A trauma 
center grantees; 
‘‘(B) 35 percent of such funds for category B trauma 
center grantees; and 
‘‘(C) 15 percent of such funds for category C trauma 
center grantees; and 
‘‘(2) provide available funds within each category in a 
manner proportional to the award basis specified in section 
1242(a)(2) to each eligible trauma center. 
‘‘(h) REPORT.—Beginning 2 years after the date of enactment 
of the Patient Protection and Affordable Care Act, and every 2 
years thereafter, the Secretary shall biennially report to Congress 
regarding the status of the grants made under section 1241 and 
on the overall financial stability of trauma centers.’’. 
(5) AUTHORIZATION OF APPROPRIATIONS.—Section 1245 of 
the Public Health Service Act (42 U.S.C. 300d–45) is amended 
to read as follows: 
‘‘SEC. 1245. AUTHORIZATION OF APPROPRIATIONS. 
‘‘For the purpose of carrying out this part, there are authorized 
to be appropriated $100,000,000 for fiscal year 2009, and such 
sums as may be necessary for each of fiscal years 2010 through 
2015. Such authorization of appropriations is in addition to any 
other authorization of appropriations or amounts that are available 
for such purpose.’’. 
(6) DEFINITION.—Part D of title XII of the Public Health 
Service Act (42 U.S.C. 300d–41 et seq.) is amended by adding 
at the end the following: 
‘‘SEC. 1246. DEFINITION. 
‘‘In this part, the term ‘uncompensated care costs’ means 
unreimbursed costs from serving self-pay, charity, or Medicaid 
patients, without regard to payment under section 1923 of the 
Social Security Act, all of which are attributable to emergency 
care and trauma care, including costs related to subsequent 
inpatient admissions to the hospital.’’. 
(b) TRAUMA SERVICE AVAILABILITY.—Title XII of the Public 
Health Service Act (42 U.S.C. 300d et seq.) is amended by adding 
at the end the following: 
‘‘PART H—TRAUMA SERVICE AVAILABILITY 
‘‘SEC. 1281. GRANTS TO STATES. 
‘‘(a) ESTABLISHMENT.—To promote universal access to trauma 
care services provided by trauma centers and trauma-related physi-
cian specialties, the Secretary shall provide funding to States to 
enable such States to award grants to eligible entities for the 
purposes described in this section. 
‘‘(b) AWARDING OF GRANTS BY STATES.—Each State may award 
grants to eligible entities within the State for the purposes described 
in subparagraph (d). 
‘‘(c) ELIGIBILITY.— 
‘‘(1) IN GENERAL.—To be eligible to receive a grant under 
subsection (b) an entity shall— 
‘‘(A) be— 
42 USC 300d–81. 
42 USC 300d–46. 
42 USC 300d–45. 
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124 STAT. 526 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) a public or nonprofit trauma center or consor-
tium thereof that meets that requirements of para-
graphs (1), (2), and (5) of section 1241(b); 
‘‘(ii) a safety net public or nonprofit trauma center 
that meets the requirements of paragraphs (1) through 
(5) of section 1241(b); or 
‘‘(iii) a hospital in an underserved area (as defined 
by the State) that seeks to establish new trauma serv-
ices; and 
‘‘(B) submit to the State an application at such time, 
in such manner, and containing such information as the 
State may require. 
‘‘(2) LIMITATION.—A State shall use at least 40 percent 
of the amount available to the State under this part for a 
fiscal year to award grants to safety net trauma centers 
described in paragraph (1)(A)(ii). 
‘‘(d) USE OF FUNDS.—The recipient of a grant under subsection 
(b) shall carry out 1 or more of the following activities consistent 
with subsection (b): 
‘‘(1) Providing trauma centers with funding to support 
physician compensation in trauma-related physician specialties 
where shortages exist in the region involved, with priority 
provided to safety net trauma centers described in subsection 
(c)(1)(A)(ii). 
‘‘(2) Providing for individual safety net trauma center fiscal 
stability and costs related to having service that is available 
24 hours a day, 7 days a week, with priority provided to 
safety net trauma centers described in subsection (c)(1)(A)(ii) 
located in urban, border, and rural areas. 
‘‘(3) Reducing trauma center overcrowding at specific 
trauma centers related to throughput of trauma patients. 
‘‘(4) Establishing new trauma services in underserved areas 
as defined by the State. 
‘‘(5) Enhancing collaboration between trauma centers and 
other hospitals and emergency medical services personnel 
related to trauma service availability. 
‘‘(6) Making capital improvements to enhance access and 
expedite trauma care, including providing helipads and associ-
ated safety infrastructure. 
‘‘(7) Enhancing trauma surge capacity at specific trauma 
centers. 
‘‘(8) Ensuring expedient receipt of trauma patients trans-
ported by ground or air to the appropriate trauma center. 
‘‘(9) Enhancing interstate trauma center collaboration. 
‘‘(e) LIMITATION.— 
‘‘(1) IN
GENERAL.—A State may use not more than 20 
percent of the amount available to the State under this part 
for a fiscal year for administrative costs associated with 
awarding grants and related costs. 
‘‘(2) MAINTENANCE OF EFFORT.—The Secretary may not pro-
vide funding to a State under this part unless the State agrees 
that such funds will be used to supplement and not supplant 
State funding otherwise available for the activities and costs 
described in this part. 
‘‘(f) DISTRIBUTION OF FUNDS.—The following shall apply with 
respect to grants provided in this part: 
Applicability. 
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124 STAT. 527 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) LESS THAN $10,000,000.—If the amount of appropriations 
for this part in a fiscal year is less than $10,000,000, the 
Secretary shall divide such funding evenly among only those 
States that have 1 or more trauma centers eligible for funding 
under section 1241(b)(3)(A). 
‘‘(2) LESS THAN $20,000,000.—If the amount of appropriations 
in a fiscal year is less than $20,000,000, the Secretary shall 
divide such funding evenly among only those States that have 
1 or more trauma centers eligible for funding under subpara-
graphs (A) and (B) of section 1241(b)(3). 
‘‘(3) LESS THAN $30,000,000.—If the amount of appropriations 
for this part in a fiscal year is less than $30,000,000, the 
Secretary shall divide such funding evenly among only those 
States that have 1 or more trauma centers eligible for funding 
under section 1241(b)(3). 
‘‘(4) $30,000,000 OR MORE.—If the amount of appropriations 
for this part in a fiscal year is $30,000,000 or more, the Sec-
retary shall divide such funding evenly among all States. 
‘‘SEC. 1282. AUTHORIZATION OF APPROPRIATIONS. 
‘‘For the purpose of carrying out this part, there is authorized 
to be appropriated $100,000,000 for each of fiscal years 2010 
through 2015.’’. 
SEC. 3506. PROGRAM TO FACILITATE SHARED DECISIONMAKING. 
Part D of title IX of the Public Health Service Act, as amended 
by section 3503, is further amended by adding at the end the 
following: 
‘‘SEC. 936. PROGRAM TO FACILITATE SHARED DECISIONMAKING. 
‘‘(a) PURPOSE.—The purpose of this section is to facilitate 
collaborative processes between patients, caregivers or authorized 
representatives, and clinicians that engages the patient, caregiver 
or authorized representative in decisionmaking, provides patients, 
caregivers or authorized representatives with information about 
trade-offs among treatment options, and facilitates the incorporation 
of patient preferences and values into the medical plan. 
‘‘(b) DEFINITIONS.—In this section: 
‘‘(1) PATIENT DECISION AID.—The term ‘patient decision aid’ 
means an educational tool that helps patients, caregivers or 
authorized representatives understand and communicate their 
beliefs and preferences related to their treatment options, and 
to decide with their health care provider what treatments are 
best for them based on their treatment options, scientific evi-
dence, circumstances, beliefs, and preferences. 
‘‘(2) PREFERENCE SENSITIVE CARE.—The term ‘preference 
sensitive care’ means medical care for which the clinical evi-
dence does not clearly support one treatment option such that 
the appropriate course of treatment depends on the values 
of the patient or the preferences of the patient, caregivers 
or authorized representatives regarding the benefits, harms 
and scientific evidence for each treatment option, the use of 
such care should depend on the informed patient choice among 
clinically appropriate treatment options. 
‘‘(c) ESTABLISHMENT OF INDEPENDENT STANDARDS FOR PATIENT 
DECISION AIDS FOR PREFERENCE SENSITIVE CARE.— 
‘‘(1) CONTRACT WITH ENTITY TO ESTABLISH STANDARDS AND 
CERTIFY PATIENT DECISION AIDS.— 
42 USC 299b–36. 
42 USC 300d–82. 
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124 STAT. 528 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) IN
GENERAL.—For purposes of supporting con-
sensus-based standards for patient decision aids for pref-
erence sensitive care and a certification process for patient 
decision aids for use in the Federal health programs and 
by other interested parties, the Secretary shall have in 
effect a contract with the entity with a contract under 
section 1890 of the Social Security Act. Such contract shall 
provide that the entity perform the duties described in 
paragraph (2). 
‘‘(B) TIMING FOR FIRST CONTRACT.—As soon as prac-
ticable after the date of the enactment of this section, 
the Secretary shall enter into the first contract under 
subparagraph (A). 
‘‘(C) PERIOD OF CONTRACT.—A contract under subpara-
graph (A) shall be for a period of 18 months (except such 
contract may be renewed after a subsequent bidding 
process). 
‘‘(2) DUTIES.—The following duties are described in this 
paragraph: 
‘‘(A) DEVELOP AND IDENTIFY STANDARDS FOR PATIENT 
DECISION AIDS.—The entity shall synthesize evidence and 
convene a broad range of experts and key stakeholders 
to develop and identify consensus-based standards to 
evaluate patient decision aids for preference sensitive care. 
‘‘(B) ENDORSE PATIENT DECISION AIDS.—The entity shall 
review patient decision aids and develop a certification 
process whether patient decision aids meet the standards 
developed and identified under subparagraph (A). The 
entity shall give priority to the review and certification 
of patient decision aids for preference sensitive care. 
‘‘(d) PROGRAM TO DEVELOP, UPDATE AND PATIENT DECISION 
AIDS TO ASSIST HEALTH CARE PROVIDERS AND PATIENTS.— 
‘‘(1) IN
GENERAL.—The Secretary, acting through the 
Director, and in coordination with heads of other relevant agen-
cies, such as the Director of the Centers for Disease Control 
and Prevention and the Director of the National Institutes 
of Health, shall establish a program to award grants or con-
tracts— 
‘‘(A) to develop, update, and produce patient decision 
aids for preference sensitive care to assist health care 
providers in educating patients, caregivers, and authorized 
representatives concerning the relative safety, relative 
effectiveness (including possible health outcomes and 
impact on functional status), and relative cost of treatment 
or, where appropriate, palliative care options; 
‘‘(B) to test such materials to ensure such materials 
are balanced and evidence based in aiding health care 
providers and patients, caregivers, and authorized rep-
resentatives to make informed decisions about patient care 
and can be easily incorporated into a broad array of practice 
settings; and 
‘‘(C) to educate providers on the use of such materials, 
including through academic curricula. 
‘‘(2) REQUIREMENTS FOR PATIENT DECISION AIDS.—Patient 
decision aids developed and produced pursuant to a grant or 
contract under paragraph (1)— 
Grants. 
Contracts. 
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124 STAT. 529 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) shall be designed to engage patients, caregivers, 
and authorized representatives in informed decisionmaking 
with health care providers; 
‘‘(B) shall present up-to-date clinical evidence about 
the risks and benefits of treatment options in a form and 
manner that is age-appropriate and can be adapted for 
patients, caregivers, and authorized representatives from 
a variety of cultural and educational backgrounds to reflect 
the varying needs of consumers and diverse levels of health 
literacy; 
‘‘(C) shall, where appropriate, explain why there is 
a lack of evidence to support one treatment option over 
another; and 
‘‘(D) shall address health care decisions across the age 
span, including those affecting vulnerable populations 
including children. 
‘‘(3) DISTRIBUTION.—The Director shall ensure that patient 
decision aids produced with grants or contracts under this 
section are available to the public. 
‘‘(4) NONDUPLICATION
OF
EFFORTS.—The Director shall 
ensure that the activities under this section of the Agency 
and other agencies, including the Centers for Disease Control 
and Prevention and the National Institutes of Health, are free 
of unnecessary duplication of effort. 
‘‘(e) 
GRANTS
TO
SUPPORT
SHARED
DECISIONMAKING 
IMPLEMENTATION.— 
‘‘(1) IN GENERAL.—The Secretary shall establish a program 
to provide for the phased-in development, implementation, and 
evaluation of shared decisionmaking using patient decision aids 
to meet the objective of improving the understanding of patients 
of their medical treatment options. 
‘‘(2) SHARED DECISIONMAKING RESOURCE CENTERS.— 
‘‘(A) IN GENERAL.—The Secretary shall provide grants 
for the establishment and support of Shared Decision-
making Resource Centers (referred to in this subsection 
as ‘Centers’) to provide technical assistance to providers 
and to develop and disseminate best practices and other 
information 
to 
support 
and 
accelerate 
adoption, 
implementation, and effective use of patient decision aids 
and shared decisionmaking by providers. 
‘‘(B) OBJECTIVES.—The objective of a Center is to 
enhance and promote the adoption of patient decision aids 
and shared decisionmaking through— 
‘‘(i) providing assistance to eligible providers with 
the implementation and effective use of, and training 
on, patient decision aids; and 
‘‘(ii) the dissemination of best practices and 
research on the implementation and effective use of 
patient decision aids. 
‘‘(3) SHARED DECISIONMAKING PARTICIPATION GRANTS.— 
‘‘(A) IN GENERAL.—The Secretary shall provide grants 
to health care providers for the development and 
implementation of shared decisionmaking techniques and 
to assess the use of such techniques. 
‘‘(B) PREFERENCE.—In order to facilitate the use of 
best practices, the Secretary shall provide a preference 
in making grants under this subsection to health care 
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124 STAT. 530 
PUBLIC LAW 111–148—MAR. 23, 2010 
providers who participate in training by Shared Decision-
making Resource Centers or comparable training. 
‘‘(C) LIMITATION.—Funds under this paragraph shall 
not be used to purchase or implement use of patient deci-
sion aids other than those certified under the process 
identified in subsection (c). 
‘‘(4) GUIDANCE.—The Secretary may issue guidance to 
eligible grantees under this subsection on the use of patient 
decision aids. 
‘‘(f) FUNDING.—For purposes of carrying out this section there 
are authorized to be appropriated such sums as may be necessary 
for fiscal year 2010 and each subsequent fiscal year.’’. 
SEC. 3507. PRESENTATION OF PRESCRIPTION DRUG BENEFIT AND 
RISK INFORMATION. 
(a) IN GENERAL.—The Secretary of Health and Human Services 
(referred to in this section as the ‘‘Secretary’’), acting through the 
Commissioner of Food and Drugs, shall determine whether the 
addition of quantitative summaries of the benefits and risks of 
prescription drugs in a standardized format (such as a table or 
drug facts box) to the promotional labeling or print advertising 
of such drugs would improve health care decisionmaking by clini-
cians and patients and consumers. 
(b) REVIEW AND CONSULTATION.—In making the determination 
under subsection (a), the Secretary shall review all available sci-
entific evidence and research on decisionmaking and social and 
cognitive psychology and consult with drug manufacturers, clini-
cians, patients and consumers, experts in health literacy, represent-
atives of racial and ethnic minorities, and experts in women’s 
and pediatric health. 
(c) REPORT.—Not later than 1 year after the date of enactment 
of this Act, the Secretary shall submit to Congress a report that 
provides— 
(1) the determination by the Secretary under subsection 
(a); and 
(2) the reasoning and analysis underlying that determina-
tion. 
(d) AUTHORITY.—If the Secretary determines under subsection 
(a) that the addition of quantitative summaries of the benefits 
and risks of prescription drugs in a standardized format (such 
as a table or drug facts box) to the promotional labeling or print 
advertising of such drugs would improve health care decisionmaking 
by clinicians and patients and consumers, then the Secretary, not 
later than 3 years after the date of submission of the report under 
subsection (c), shall promulgate proposed regulations as necessary 
to implement such format. 
(e) CLARIFICATION.—Nothing in this section shall be construed 
to restrict the existing authorities of the Secretary with respect 
to benefit and risk information. 
SEC. 3508. DEMONSTRATION PROGRAM TO INTEGRATE QUALITY 
IMPROVEMENT AND PATIENT SAFETY TRAINING INTO 
CLINICAL EDUCATION OF HEALTH PROFESSIONALS. 
(a) IN GENERAL.—The Secretary may award grants to eligible 
entities or consortia under this section to carry out demonstration 
projects to develop and implement academic curricula that 
integrates quality improvement and patient safety in the clinical 
42 USC 294j. 
Deadline. 
Regulations. 
Determination. 
21 USC 352 note. 
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124 STAT. 531 
PUBLIC LAW 111–148—MAR. 23, 2010 
education of health professionals. Such awards shall be made on 
a competitive basis and pursuant to peer review. 
(b) ELIGIBILITY.—To be eligible to receive a grant under sub-
section (a), an entity or consortium shall— 
(1) submit to the Secretary an application at such time, 
in such manner, and containing such information as the Sec-
retary may require; 
(2) be or include— 
(A) a health professions school; 
(B) a school of public health; 
(C) a school of social work; 
(D) a school of nursing; 
(E) a school of pharmacy; 
(F) an institution with a graduate medical education 
program; or 
(G) a school of health care administration; 
(3) collaborate in the development of curricula described 
in subsection (a) with an organization that accredits such school 
or institution; 
(4) provide for the collection of data regarding the effective-
ness of the demonstration project; and 
(5) provide matching funds in accordance with subsection 
(c). 
(c) MATCHING FUNDS.— 
(1) IN
GENERAL.—The Secretary may award a grant to 
an entity or consortium under this section only if the entity 
or consortium agrees to make available non-Federal contribu-
tions toward the costs of the program to be funded under 
the grant in an amount that is not less than $1 for each 
$5 of Federal funds provided under the grant. 
(2) DETERMINATION OF AMOUNT CONTRIBUTED.—Non-Fed-
eral contributions under paragraph (1) may be in cash or in- 
kind, fairly evaluated, including equipment or services. 
Amounts provided by the Federal Government, or services 
assisted or subsidized to any significant extent by the Federal 
Government, may not be included in determining the amount 
of such contributions. 
(d) EVALUATION.—The Secretary shall take such action as may 
be necessary to evaluate the projects funded under this section 
and publish, make publicly available, and disseminate the results 
of such evaluations on as wide a basis as is practicable. 
(e) REPORTS.—Not later than 2 years after the date of enact-
ment of this section, and annually thereafter, the Secretary shall 
submit to the Committee on Health, Education, Labor, and Pensions 
and the Committee on Finance of the Senate and the Committee 
on Energy and Commerce and the Committee on Ways and Means 
of the House of Representatives a report that— 
(1) describes the specific projects supported under this sec-
tion; and 
(2) contains recommendations for Congress based on the 
evaluation conducted under subsection (d). 
SEC. 3509. IMPROVING WOMEN’S HEALTH. 
(a) HEALTH
AND
HUMAN
SERVICES
OFFICE
ON
WOMEN’S 
HEALTH.— 
Publication. 
Public 
information. 
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124 STAT. 532 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) ESTABLISHMENT.—Part A of title II of the Public Health 
Service Act (42 U.S.C. 202 et seq.) is amended by adding 
at the end the following: 
‘‘SEC. 229. HEALTH AND HUMAN SERVICES OFFICE ON WOMEN’S 
HEALTH. 
‘‘(a) ESTABLISHMENT OF OFFICE.—There is established within 
the Office of the Secretary, an Office on Women’s Health (referred 
to in this section as the ‘Office’). The Office shall be headed by 
a Deputy Assistant Secretary for Women’s Health who may report 
to the Secretary. 
‘‘(b) DUTIES.—The Secretary, acting through the Office, with 
respect to the health concerns of women, shall— 
‘‘(1) establish short-range and long-range goals and objec-
tives within the Department of Health and Human Services 
and, as relevant and appropriate, coordinate with other appro-
priate offices on activities within the Department that relate 
to disease prevention, health promotion, service delivery, 
research, and public and health care professional education, 
for issues of particular concern to women throughout their 
lifespan; 
‘‘(2) provide expert advice and consultation to the Secretary 
concerning scientific, legal, ethical, and policy issues relating 
to women’s health; 
‘‘(3) monitor the Department of Health and Human Serv-
ices’ offices, agencies, and regional activities regarding women’s 
health and identify needs regarding the coordination of activi-
ties, including intramural and extramural multidisciplinary 
activities; 
‘‘(4) establish a Department of Health and Human Services 
Coordinating Committee on Women’s Health, which shall be 
chaired by the Deputy Assistant Secretary for Women’s Health 
and composed of senior level representatives from each of the 
agencies and offices of the Department of Health and Human 
Services; 
‘‘(5) establish a National Women’s Health Information 
Center to— 
‘‘(A) facilitate the exchange of information regarding 
matters relating to health information, health promotion, 
preventive health services, research advances, and edu-
cation in the appropriate use of health care; 
‘‘(B) facilitate access to such information; 
‘‘(C) assist in the analysis of issues and problems 
relating to the matters described in this paragraph; and 
‘‘(D) provide technical assistance with respect to the 
exchange of information (including facilitating the develop-
ment of materials for such technical assistance); 
‘‘(6) coordinate efforts to promote women’s health programs 
and policies with the private sector; and 
‘‘(7) through publications and any other means appropriate, 
provide for the exchange of information between the Office 
and recipients of grants, contracts, and agreements under sub-
section (c), and between the Office and health professionals 
and the general public. 
‘‘(c) GRANTS AND CONTRACTS REGARDING DUTIES.— 
Establishment. 
42 USC 237a. 
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124 STAT. 533 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) AUTHORITY.—In carrying out subsection (b), the Sec-
retary may make grants to, and enter into cooperative agree-
ments, contracts, and interagency agreements with, public and 
private entities, agencies, and organizations. 
‘‘(2) EVALUATION AND DISSEMINATION.—The Secretary shall 
directly or through contracts with public and private entities, 
agencies, and organizations, provide for evaluations of projects 
carried out with financial assistance provided under paragraph 
(1) and for the dissemination of information developed as a 
result of such projects. 
‘‘(d) REPORTS.—Not later than 1 year after the date of enact-
ment of this section, and every second year thereafter, the Secretary 
shall prepare and submit to the appropriate committees of Congress 
a report describing the activities carried out under this section 
during the period for which the report is being prepared. 
‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of 
carrying out this section, there are authorized to be appropriated 
such sums as may be necessary for each of the fiscal years 2010 
through 2014.’’. 
(2) TRANSFER OF FUNCTIONS.—There are transferred to the 
Office on Women’s Health (established under section 229 of 
the Public Health Service Act, as added by this section), all 
functions exercised by the Office on Women’s Health of the 
Public Health Service prior to the date of enactment of this 
section, including all personnel and compensation authority, 
all delegation and assignment authority, and all remaining 
appropriations. All orders, determinations, rules, regulations, 
permits, agreements, grants, contracts, certificates, licenses, 
registrations, privileges, and other administrative actions 
that— 
(A) have been issued, made, granted, or allowed to 
become effective by the President, any Federal agency or 
official thereof, or by a court of competent jurisdiction, 
in the performance of functions transferred under this para-
graph; and 
(B) are in effect at the time this section takes effect, 
or were final before the date of enactment of this section 
and are to become effective on or after such date, 
shall continue in effect according to their terms until modified, 
terminated, superseded, set aside, or revoked in accordance 
with law by the President, the Secretary, or other authorized 
official, a court of competent jurisdiction, or by operation of 
law. 
(b) CENTERS FOR DISEASE CONTROL AND PREVENTION OFFICE 
OF WOMEN’S HEALTH.—Part A of title III of the Public Health 
Service Act (42 U.S.C. 241 et seq.) is amended by adding at the 
end the following: 
‘‘SEC. 310A. CENTERS FOR DISEASE CONTROL AND PREVENTION 
OFFICE OF WOMEN’S HEALTH. 
‘‘(a) ESTABLISHMENT.—There is established within the Office 
of the Director of the Centers for Disease Control and Prevention, 
an office to be known as the Office of Women’s Health (referred 
to in this section as the ‘Office’). The Office shall be headed by 
a director who shall be appointed by the Director of such Centers. 
‘‘(b) PURPOSE.—The Director of the Office shall— 
42 USC 242s. 
42 USC 237a 
note. 
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124 STAT. 534 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) report to the Director of the Centers for Disease Control 
and Prevention on the current level of the Centers’ activity 
regarding women’s health conditions across, where appropriate, 
age, biological, and sociocultural contexts, in all aspects of 
the Centers’ work, including prevention programs, public and 
professional education, services, and treatment; 
‘‘(2) establish short-range and long-range goals and objec-
tives within the Centers for women’s health and, as relevant 
and appropriate, coordinate with other appropriate offices on 
activities within the Centers that relate to prevention, research, 
education and training, service delivery, and policy develop-
ment, for issues of particular concern to women; 
‘‘(3) identify projects in women’s health that should be 
conducted or supported by the Centers; 
‘‘(4) consult with health professionals, nongovernmental 
organizations, consumer organizations, women’s health profes-
sionals, and other individuals and groups, as appropriate, on 
the policy of the Centers with regard to women; and 
‘‘(5) serve as a member of the Department of Health and 
Human Services Coordinating Committee on Women’s Health 
(established under section 229(b)(4)). 
‘‘(c) DEFINITION.—As used in this section, the term ‘women’s 
health conditions’, with respect to women of all age, ethnic, and 
racial groups, means diseases, disorders, and conditions— 
‘‘(1) unique to, significantly more serious for, or significantly 
more prevalent in women; and 
‘‘(2) for which the factors of medical risk or type of medical 
intervention are different for women, or for which there is 
reasonable evidence that indicates that such factors or types 
may be different for women. 
‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of 
carrying out this section, there are authorized to be appropriated 
such sums as may be necessary for each of the fiscal years 2010 
through 2014.’’. 
(c) OFFICE
OF WOMEN’S HEALTH RESEARCH.—Section 486(a) 
of the Public Health Service Act (42 U.S.C. 287d(a)) is amended 
by inserting ‘‘and who shall report directly to the Director’’ before 
the period at the end thereof. 
(d) SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINIS-
TRATION.—Section 501(f) of the Public Health Service Act (42 U.S.C. 
290aa(f)) is amended— 
(1) in paragraph (1), by inserting ‘‘who shall report directly 
to the Administrator’’ before the period; 
(2) by redesignating paragraph (4) as paragraph (5); and 
(3) by inserting after paragraph (3), the following: 
‘‘(4) OFFICE.—Nothing in this subsection shall be construed 
to preclude the Secretary from establishing within the Sub-
stance Abuse and Mental Health Administration an Office of 
Women’s Health.’’. 
(e) AGENCY FOR HEALTHCARE RESEARCH AND QUALITY ACTIVI-
TIES REGARDING WOMEN’S HEALTH.—Part C of title IX of the Public 
Health Service Act (42 U.S.C. 299c et seq.) is amended— 
(1) by redesignating sections 925 and 926 as sections 926 
and 927, respectively; and 
(2) by inserting after section 924 the following: 
42 USC 299b–25, 
299b–26. 
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124 STAT. 535 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 925. ACTIVITIES REGARDING WOMEN’S HEALTH. 
‘‘(a) ESTABLISHMENT.—There is established within the Office 
of the Director, an Office of Women’s Health and Gender-Based 
Research (referred to in this section as the ‘Office’). The Office 
shall be headed by a director who shall be appointed by the Director 
of Healthcare and Research Quality. 
‘‘(b) PURPOSE.—The official designated under subsection (a) 
shall— 
‘‘(1) report to the Director on the current Agency level 
of activity regarding women’s health, across, where appropriate, 
age, biological, and sociocultural contexts, in all aspects of 
Agency work, including the development of evidence reports 
and clinical practice protocols and the conduct of research into 
patient outcomes, delivery of health care services, quality of 
care, and access to health care; 
‘‘(2) establish short-range and long-range goals and objec-
tives within the Agency for research important to women’s 
health and, as relevant and appropriate, coordinate with other 
appropriate offices on activities within the Agency that relate 
to health services and medical effectiveness research, for issues 
of particular concern to women; 
‘‘(3) identify projects in women’s health that should be 
conducted or supported by the Agency; 
‘‘(4) consult with health professionals, nongovernmental 
organizations, consumer organizations, women’s health profes-
sionals, and other individuals and groups, as appropriate, on 
Agency policy with regard to women; and 
‘‘(5) serve as a member of the Department of Health and 
Human Services Coordinating Committee on Women’s Health 
(established under section 229(b)(4)).’’. 
‘‘(c) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of 
carrying out this section, there are authorized to be appropriated 
such sums as may be necessary for each of the fiscal years 2010 
through 2014.’’. 
(f) HEALTH RESOURCES AND SERVICES ADMINISTRATION OFFICE 
OF WOMEN’S HEALTH.—Title VII of the Social Security Act (42 
U.S.C. 901 et seq.) is amended by adding at the end the following: 
‘‘SEC. 713. OFFICE OF WOMEN’S HEALTH. 
‘‘(a) ESTABLISHMENT.—The Secretary shall establish within the 
Office of the Administrator of the Health Resources and Services 
Administration, an office to be known as the Office of Women’s 
Health. The Office shall be headed by a director who shall be 
appointed by the Administrator. 
‘‘(b) PURPOSE.—The Director of the Office shall— 
‘‘(1) report to the Administrator on the current Administra-
tion level of activity regarding women’s health across, where 
appropriate, age, biological, and sociocultural contexts; 
‘‘(2) establish short-range and long-range goals and objec-
tives within the Health Resources and Services Administration 
for women’s health and, as relevant and appropriate, coordinate 
with other appropriate offices on activities within the Adminis-
tration that relate to health care provider training, health 
service delivery, research, and demonstration projects, for 
issues of particular concern to women; 
‘‘(3) identify projects in women’s health that should be 
conducted or supported by the bureaus of the Administration; 
42 USC 914. 
42 USC 
299b–24a. 
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124 STAT. 536 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(4) consult with health professionals, nongovernmental 
organizations, consumer organizations, women’s health profes-
sionals, and other individuals and groups, as appropriate, on 
Administration policy with regard to women; and 
‘‘(5) serve as a member of the Department of Health and 
Human Services Coordinating Committee on Women’s Health 
(established under section 229(b)(4) of the Public Health Service 
Act). 
‘‘(c) CONTINUED ADMINISTRATION OF EXISTING PROGRAMS.—The 
Director of the Office shall assume the authority for the develop-
ment, implementation, administration, and evaluation of any 
projects carried out through the Health Resources and Services 
Administration relating to women’s health on the date of enactment 
of this section. 
‘‘(d) DEFINITIONS.—For purposes of this section: 
‘‘(1) ADMINISTRATION.—The term ‘Administration’ means 
the Health Resources and Services Administration. 
‘‘(2) ADMINISTRATOR.—The term ‘Administrator’ means the 
Administrator of the Health Resources and Services Adminis-
tration. 
‘‘(3) OFFICE.—The term ‘Office’ means the Office of Women’s 
Health established under this section in the Administration. 
‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of 
carrying out this section, there are authorized to be appropriated 
such sums as may be necessary for each of the fiscal years 2010 
through 2014.’’. 
(g) FOOD
AND DRUG ADMINISTRATION OFFICE
OF WOMEN’S 
HEALTH.—Chapter X of the Federal Food, Drug, and Cosmetic Act 
(21 U.S.C. 391 et seq.) is amended by adding at the end the 
following: 
‘‘SEC. 1011. OFFICE OF WOMEN’S HEALTH. 
‘‘(a) ESTABLISHMENT.—There is established within the Office 
of the Commissioner, an office to be known as the Office of Women’s 
Health (referred to in this section as the ‘Office’). The Office shall 
be headed by a director who shall be appointed by the Commissioner 
of Food and Drugs. 
‘‘(b) PURPOSE.—The Director of the Office shall— 
‘‘(1) report to the Commissioner of Food and Drugs on 
current Food and Drug Administration (referred to in this 
section as the ‘Administration’) levels of activity regarding 
women’s participation in clinical trials and the analysis of 
data by sex in the testing of drugs, medical devices, and 
biological products across, where appropriate, age, biological, 
and sociocultural contexts; 
‘‘(2) establish short-range and long-range goals and objec-
tives within the Administration for issues of particular concern 
to women’s health within the jurisdiction of the Administration, 
including, where relevant and appropriate, adequate inclusion 
of women and analysis of data by sex in Administration proto-
cols and policies; 
‘‘(3) provide information to women and health care pro-
viders on those areas in which differences between men and 
women exist; 
‘‘(4) consult with pharmaceutical, biologics, and device 
manufacturers, health professionals with expertise in women’s 
21 USC 399b. 
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124 STAT. 537 
PUBLIC LAW 111–148—MAR. 23, 2010 
issues, consumer organizations, and women’s health profes-
sionals on Administration policy with regard to women; 
‘‘(5) make annual estimates of funds needed to monitor 
clinical trials and analysis of data by sex in accordance with 
needs that are identified; and 
‘‘(6) serve as a member of the Department of Health and 
Human Services Coordinating Committee on Women’s Health 
(established under section 229(b)(4) of the Public Health Service 
Act). 
‘‘(c) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of 
carrying out this section, there are authorized to be appropriated 
such sums as may be necessary for each of the fiscal years 2010 
through 2014.’’. 
(h) NO NEW REGULATORY AUTHORITY.—Nothing in this section 
and the amendments made by this section may be construed as 
establishing regulatory authority or modifying any existing regu-
latory authority. 
(i) LIMITATION ON TERMINATION.—Notwithstanding any other 
provision of law, a Federal office of women’s health (including 
the Office of Research on Women’s Health of the National Institutes 
of Health) or Federal appointive position with primary responsibility 
over women’s health issues (including the Associate Administrator 
for Women’s Services under the Substance Abuse and Mental 
Health Services Administration) that is in existence on the date 
of enactment of this section shall not be terminated, reorganized, 
or have any of it’s powers or duties transferred unless such termi-
nation, reorganization, or transfer is approved by Congress through 
the adoption of a concurrent resolution of approval. 
(j) RULE OF CONSTRUCTION.—Nothing in this section (or the 
amendments made by this section) shall be construed to limit 
the authority of the Secretary of Health and Human Services with 
respect to women’s health, or with respect to activities carried 
out through the Department of Health and Human Services on 
the date of enactment of this section. 
SEC. 3510. PATIENT NAVIGATOR PROGRAM. 
Section 340A of the Public Health Service Act (42 U.S.C. 256a) 
is amended— 
(1) by striking subsection (d)(3) and inserting the following: 
‘‘(3) LIMITATIONS ON GRANT PERIOD.—In carrying out this 
section, the Secretary shall ensure that the total period of 
a grant does not exceed 4 years.’’; 
(2) in subsection (e), by adding at the end the following: 
‘‘(3) MINIMUM CORE PROFICIENCIES.—The Secretary shall 
not award a grant to an entity under this section unless such 
entity provides assurances that patient navigators recruited, 
assigned, trained, or employed using grant funds meet min-
imum core proficiencies, as defined by the entity that submits 
the application, that are tailored for the main focus or interven-
tion of the navigator involved.’’; and 
(3) in subsection (m)— 
(A) in paragraph (1), by striking ‘‘and $3,500,000 for 
fiscal year 2010.’’ and inserting ‘‘$3,500,000 for fiscal year 
2010, and such sums as may be necessary for each of 
fiscal years 2011 through 2015.’’; and 
(B) in paragraph (2), by striking ‘‘2010’’ and inserting 
‘‘2015’’. 
42 USC 237a 
note. 
42 USC 237a 
note. 
42 USC 237a 
note. 
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124 STAT. 538 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 3511. AUTHORIZATION OF APPROPRIATIONS. 
Except where otherwise provided in this subtitle (or an amend-
ment made by this subtitle), there is authorized to be appropriated 
such sums as may be necessary to carry out this subtitle (and 
such amendments made by this subtitle). 
Subtitle G—Protecting and Improving 
Guaranteed Medicare Benefits 
SEC. 3601. PROTECTING AND IMPROVING GUARANTEED MEDICARE 
BENEFITS. 
(a) PROTECTING GUARANTEED MEDICARE BENEFITS.—Nothing 
in the provisions of, or amendments made by, this Act shall result 
in a reduction of guaranteed benefits under title XVIII of the 
Social Security Act. 
(b) ENSURING THAT MEDICARE SAVINGS BENEFIT THE MEDICARE 
PROGRAM AND MEDICARE BENEFICIARIES.—Savings generated for 
the Medicare program under title XVIII of the Social Security 
Act under the provisions of, and amendments made by, this Act 
shall extend the solvency of the Medicare trust funds, reduce Medi-
care premiums and other cost-sharing for beneficiaries, and improve 
or expand guaranteed Medicare benefits and protect access to Medi-
care providers. 
SEC. 3602. NO CUTS IN GUARANTEED BENEFITS. 
Nothing in this Act shall result in the reduction or elimination 
of any benefits guaranteed by law to participants in Medicare 
Advantage plans. 
TITLE IV—PREVENTION OF CHRONIC 
DISEASE 
AND 
IMPROVING 
PUBLIC 
HEALTH 
Subtitle A—Modernizing Disease 
Prevention and Public Health Systems 
SEC. 4001. NATIONAL PREVENTION, HEALTH PROMOTION AND PUBLIC 
HEALTH COUNCIL. 
(a) ESTABLISHMENT.—The President shall establish, within the 
Department of Health and Human Services, a council to be known 
as the ‘‘National Prevention, Health Promotion and Public Health 
Council’’ (referred to in this section as the ‘‘Council’’). 
(b) CHAIRPERSON.—The President shall appoint the Surgeon 
General to serve as the chairperson of the Council. 
(c) COMPOSITION.—The Council shall be composed of— 
(1) the Secretary of Health and Human Services; 
(2) the Secretary of Agriculture; 
(3) the Secretary of Education; 
(4) the Chairman of the Federal Trade Commission; 
(5) the Secretary of Transportation; 
(6) the Secretary of Labor; 
(7) the Secretary of Homeland Security; 
President. 
Appointment. 
President. 
42 USC 300u–10. 
42 USC 
1395w–21 note. 
42 USC 1395 
note. 
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124 STAT. 539 
PUBLIC LAW 111–148—MAR. 23, 2010 
(8) the Administrator of the Environmental Protection 
Agency; 
(9) the Director of the Office of National Drug Control 
Policy; 
(10) the Director of the Domestic Policy Council; 
(11) the Assistant Secretary for Indian Affairs; 
(12) the Chairman of the Corporation for National and 
Community Service; and 
(13) the head of any other Federal agency that the chair-
person determines is appropriate. 
(d) PURPOSES AND DUTIES.—The Council shall— 
(1) provide coordination and leadership at the Federal level, 
and among all Federal departments and agencies, with respect 
to prevention, wellness and health promotion practices, the 
public health system, and integrative health care in the United 
States; 
(2) after obtaining input from relevant stakeholders, 
develop a national prevention, health promotion, public health, 
and integrative health care strategy that incorporates the most 
effective and achievable means of improving the health status 
of Americans and reducing the incidence of preventable illness 
and disability in the United States; 
(3) provide recommendations to the President and Congress 
concerning the most pressing health issues confronting the 
United States and changes in Federal policy to achieve national 
wellness, health promotion, and public health goals, including 
the reduction of tobacco use, sedentary behavior, and poor 
nutrition; 
(4) consider and propose evidence-based models, policies, 
and innovative approaches for the promotion of transformative 
models of prevention, integrative health, and public health 
on individual and community levels across the United States; 
(5) establish processes for continual public input, including 
input from State, regional, and local leadership communities 
and other relevant stakeholders, including Indian tribes and 
tribal organizations; 
(6) submit the reports required under subsection (g); and 
(7) carry out other activities determined appropriate by 
the President. 
(e) MEETINGS.—The Council shall meet at the call of the Chair-
person. 
(f) ADVISORY GROUP.— 
(1) IN GENERAL.—The President shall establish an Advisory 
Group to the Council to be known as the ‘‘Advisory Group 
on Prevention, Health Promotion, and Integrative and Public 
Health’’ (hereafter referred to in this section as the ‘‘Advisory 
Group’’). The Advisory Group shall be within the Department 
of Health and Human Services and report to the Surgeon 
General. 
(2) COMPOSITION.— 
(A) IN GENERAL.—The Advisory Group shall be com-
posed of not more than 25 non-Federal members to be 
appointed by the President. 
(B) REPRESENTATION.—In appointing members under 
subparagraph (A), the President shall ensure that the 
Advisory Group includes a diverse group of licensed health 
Establishment. 
President. 
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124 STAT. 540 
PUBLIC LAW 111–148—MAR. 23, 2010 
professionals, including integrative health practitioners 
who have expertise in— 
(i) worksite health promotion; 
(ii) community services, including community 
health centers; 
(iii) preventive medicine; 
(iv) health coaching; 
(v) public health education; 
(vi) geriatrics; and 
(vii) rehabilitation medicine. 
(3) PURPOSES
AND
DUTIES.—The Advisory Group shall 
develop policy and program recommendations and advise the 
Council on lifestyle-based chronic disease prevention and 
management, integrative health care practices, and health pro-
motion. 
(g) 
NATIONAL
PREVENTION
AND
HEALTH
PROMOTION 
STRATEGY.—Not later than 1 year after the date of enactment 
of this Act, the Chairperson, in consultation with the Council, 
shall develop and make public a national prevention, health pro-
motion and public health strategy, and shall review and revise 
such strategy periodically. Such strategy shall— 
(1) set specific goals and objectives for improving the health 
of the United States through federally-supported prevention, 
health promotion, and public health programs, consistent with 
ongoing goal setting efforts conducted by specific agencies; 
(2) establish specific and measurable actions and timelines 
to carry out the strategy, and determine accountability for 
meeting those timelines, within and across Federal departments 
and agencies; and 
(3) make recommendations to improve Federal efforts 
relating to prevention, health promotion, public health, and 
integrative health care practices to ensure Federal efforts are 
consistent with available standards and evidence. 
(h) REPORT.—Not later than July 1, 2010, and annually there-
after through January 1, 2015, the Council shall submit to the 
President and the relevant committees of Congress, a report that— 
(1) describes the activities and efforts on prevention, health 
promotion, and public health and activities to develop a national 
strategy conducted by the Council during the period for which 
the report is prepared; 
(2) describes the national progress in meeting specific 
prevention, health promotion, and public health goals defined 
in the strategy and further describes corrective actions rec-
ommended by the Council and taken by relevant agencies and 
organizations to meet these goals; 
(3) contains a list of national priorities on health promotion 
and disease prevention to address lifestyle behavior modifica-
tion (smoking cessation, proper nutrition, appropriate exercise, 
mental health, behavioral health, substance use disorder, and 
domestic violence screenings) and the prevention measures for 
the 5 leading disease killers in the United States; 
(4) contains specific science-based initiatives to achieve the 
measurable goals of Healthy People 2010 regarding nutrition, 
exercise, and smoking cessation, and targeting the 5 leading 
disease killers in the United States; 
(5) contains specific plans for consolidating Federal health 
programs and Centers that exist to promote healthy behavior 
Deadline. 
Public 
information. 
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124 STAT. 541 
PUBLIC LAW 111–148—MAR. 23, 2010 
and reduce disease risk (including eliminating programs and 
offices determined to be ineffective in meeting the priority 
goals of Healthy People 2010); 
(6) contains specific plans to ensure that all Federal health 
care programs are fully coordinated with science-based preven-
tion recommendations by the Director of the Centers for Disease 
Control and Prevention; and 
(7) contains specific plans to ensure that all non-Depart-
ment of Health and Human Services prevention programs are 
based on the science-based guidelines developed by the Centers 
for Disease Control and Prevention under paragraph (4). 
(i) PERIODIC REVIEWS.—The Secretary and the Comptroller 
General of the United States shall jointly conduct periodic reviews, 
not less than every 5 years, and evaluations of every Federal 
disease prevention and health promotion initiative, program, and 
agency. Such reviews shall be evaluated based on effectiveness 
in meeting metrics-based goals with an analysis posted on such 
agencies’ public Internet websites. 
SEC. 4002. PREVENTION AND PUBLIC HEALTH FUND. 
(a) PURPOSE.—It is the purpose of this section to establish 
a Prevention and Public Health Fund (referred to in this section 
as the ‘‘Fund’’), to be administered through the Department of 
Health and Human Services, Office of the Secretary, to provide 
for expanded and sustained national investment in prevention and 
public health programs to improve health and help restrain the 
rate of growth in private and public sector health care costs. 
(b) FUNDING.—There are hereby authorized to be appropriated, 
and appropriated, to the Fund, out of any monies in the Treasury 
not otherwise appropriated— 
(1) for fiscal year 2010, $500,000,000; 
(2) for fiscal year 2011, $750,000,000; 
(3) for fiscal year 2012, $1,000,000,000; 
(4) for fiscal year 2013, $1,250,000,000; 
(5) for fiscal year 2014, $1,500,000,000; and 
(6) for fiscal year 2015, and each fiscal year thereafter, 
$2,000,000,000. 
(c) USE OF FUND.—The Secretary shall transfer amounts in 
the Fund to accounts within the Department of Health and Human 
Services to increase funding, over the fiscal year 2008 level, for 
programs authorized by the Public Health Service Act, for preven-
tion, wellness, and public health activities including prevention 
research and health screenings, such as the Community Trans-
formation grant program, the Education and Outreach Campaign 
for Preventive Benefits, and immunization programs. 
(d) TRANSFER AUTHORITY.—The Committee on Appropriations 
of the Senate and the Committee on Appropriations of the House 
of Representatives may provide for the transfer of funds in the 
Fund to eligible activities under this section, subject to subsection 
(c). 
SEC. 4003. CLINICAL AND COMMUNITY PREVENTIVE SERVICES. 
(a) PREVENTIVE SERVICES TASK FORCE.—Section 915 of the 
Public Health Service Act (42 U.S.C. 299b–4) is amended by striking 
subsection (a) and inserting the following: 
‘‘(a) PREVENTIVE SERVICES TASK FORCE.— 
‘‘(1) ESTABLISHMENT AND PURPOSE.—The Director shall con-
vene an independent Preventive Services Task Force (referred 
42 USC 300u–11. 
Web posting. 
Deadlines. 
Evaluations. 
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124 STAT. 542 
PUBLIC LAW 111–148—MAR. 23, 2010 
to in this subsection as the ‘Task Force’) to be composed of 
individuals with appropriate expertise. Such Task Force shall 
review the scientific evidence related to the effectiveness, appro-
priateness, and cost-effectiveness of clinical preventive services 
for the purpose of developing recommendations for the health 
care community, and updating previous clinical preventive rec-
ommendations, to be published in the Guide to Clinical Preven-
tive Services (referred to in this section as the ‘Guide’), for 
individuals and organizations delivering clinical services, 
including primary care professionals, health care systems, 
professional societies, employers, community organizations, 
non-profit organizations, Congress and other policy-makers, 
governmental public health agencies, health care quality 
organizations, and organizations developing national health 
objectives. Such recommendations shall consider clinical 
preventive best practice recommendations from the Agency for 
Healthcare Research and Quality, the National Institutes of 
Health, the Centers for Disease Control and Prevention, the 
Institute of Medicine, specialty medical associations, patient 
groups, and scientific societies. 
‘‘(2) DUTIES.—The duties of the Task Force shall include— 
‘‘(A) the development of additional topic areas for new 
recommendations and interventions related to those topic 
areas, including those related to specific sub-populations 
and age groups; 
‘‘(B) at least once during every 5-year period, review 
interventions and update recommendations related to 
existing topic areas, including new or improved techniques 
to assess the health effects of interventions; 
‘‘(C) improved integration with Federal Government 
health objectives and related target setting for health 
improvement; 
‘‘(D) the enhanced dissemination of recommendations; 
‘‘(E) the provision of technical assistance to those 
health care professionals, agencies and organizations that 
request help in implementing the Guide recommendations; 
and 
‘‘(F) the submission of yearly reports to Congress and 
related agencies identifying gaps in research, such as 
preventive services that receive an insufficient evidence 
statement, and recommending priority areas that deserve 
further examination, including areas related to populations 
and age groups not adequately addressed by current rec-
ommendations. 
‘‘(3) ROLE OF AGENCY.—The Agency shall provide ongoing 
administrative, research, and technical support for the oper-
ations of the Task Force, including coordinating and supporting 
the dissemination of the recommendations of the Task Force, 
ensuring adequate staff resources, and assistance to those 
organizations requesting it for implementation of the Guide’s 
recommendations. 
‘‘(4) COORDINATION WITH COMMUNITY PREVENTIVE SERVICES 
TASK FORCE.—The Task Force shall take appropriate steps to 
coordinate its work with the Community Preventive Services 
Task Force and the Advisory Committee on Immunization Prac-
tices, including the examination of how each task force’s rec-
ommendations interact at the nexus of clinic and community. 
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124 STAT. 543 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(5) OPERATION.—Operation. In carrying out the duties 
under paragraph (2), the Task Force is not subject to the 
provisions of Appendix 2 of title 5, United States Code. 
‘‘(6) INDEPENDENCE.—All members of the Task Force con-
vened under this subsection, and any recommendations made 
by such members, shall be independent and, to the extent 
practicable, not subject to political pressure. 
‘‘(7) 
AUTHORIZATION
OF
APPROPRIATIONS.—There 
are 
authorized to be appropriated such sums as may be necessary 
for each fiscal year to carry out the activities of the Task 
Force.’’. 
(b) COMMUNITY PREVENTIVE SERVICES TASK FORCE.— 
(1) IN GENERAL.—Part P of title III of the Public Health 
Service Act, as amended by paragraph (2), is amended by 
adding at the end the following: 
‘‘SEC. 399U. COMMUNITY PREVENTIVE SERVICES TASK FORCE. 
‘‘(a) ESTABLISHMENT AND PURPOSE.—The Director of the Cen-
ters for Disease Control and Prevention shall convene an inde-
pendent Community Preventive Services Task Force (referred to 
in this subsection as the ‘Task Force’) to be composed of individuals 
with appropriate expertise. Such Task Force shall review the sci-
entific evidence related to the effectiveness, appropriateness, and 
cost-effectiveness of community preventive interventions for the 
purpose of developing recommendations, to be published in the 
Guide to Community Preventive Services (referred to in this section 
as the ‘Guide’), for individuals and organizations delivering popu-
lation-based services, including primary care professionals, health 
care 
systems, 
professional 
societies, 
employers, 
community 
organizations, non-profit organizations, schools, governmental 
public health agencies, Indian tribes, tribal organizations and urban 
Indian organizations, medical groups, Congress and other policy- 
makers. Community preventive services include any policies, pro-
grams, processes or activities designed to affect or otherwise 
affecting health at the population level. 
‘‘(b) DUTIES.—The duties of the Task Force shall include— 
‘‘(1) the development of additional topic areas for new rec-
ommendations and interventions related to those topic areas, 
including those related to specific populations and age groups, 
as well as the social, economic and physical environments that 
can have broad effects on the health and disease of populations 
and health disparities among sub-populations and age groups; 
‘‘(2) at least once during every 5-year period, review inter-
ventions and update recommendations related to existing topic 
areas, including new or improved techniques to assess the 
health effects of interventions, including health impact assess-
ment and population health modeling; 
‘‘(3) improved integration with Federal Government health 
objectives and related target setting for health improvement; 
‘‘(4) the enhanced dissemination of recommendations; 
‘‘(5) the provision of technical assistance to those health 
care professionals, agencies, and organizations that request 
help in implementing the Guide recommendations; and 
‘‘(6) providing yearly reports to Congress and related agen-
cies identifying gaps in research and recommending priority 
areas that deserve further examination, including areas related 
Review. 
Recommenda- 
tions. 
Publication. 
42 USC 280g–10. 
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124 STAT. 544 
PUBLIC LAW 111–148—MAR. 23, 2010 
to populations and age groups not adequately addressed by 
current recommendations. 
‘‘(c) ROLE
OF AGENCY.—The Director shall provide ongoing 
administrative, research, and technical support for the operations 
of the Task Force, including coordinating and supporting the 
dissemination of the recommendations of the Task Force, ensuring 
adequate staff resources, and assistance to those organizations 
requesting it for implementation of Guide recommendations. 
‘‘(d) COORDINATION WITH PREVENTIVE SERVICES TASK FORCE.— 
The Task Force shall take appropriate steps to coordinate its work 
with the U.S. Preventive Services Task Force and the Advisory 
Committee on Immunization Practices, including the examination 
of how each task force’s recommendations interact at the nexus 
of clinic and community. 
‘‘(e) OPERATION.—In carrying out the duties under subsection 
(b), the Task Force shall not be subject to the provisions of Appendix 
2 of title 5, United States Code. 
‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated such sums as may be necessary for each fiscal 
year to carry out the activities of the Task Force.’’. 
(2) TECHNICAL AMENDMENTS.— 
(A) Section 399R of the Public Health Service Act 
(as added by section 2 of the ALS Registry Act (Public 
Law 110–373; 122 Stat. 4047)) is redesignated as section 
399S. 
(B) Section 399R of such Act (as added by section 
3 of the Prenatally and Postnatally Diagnosed Conditions 
Awareness Act (Public Law 110–374; 122 Stat. 4051)) is 
redesignated as section 399T. 
SEC. 4004. EDUCATION AND OUTREACH CAMPAIGN REGARDING 
PREVENTIVE BENEFITS. 
(a) IN GENERAL.—The Secretary of Health and Human Services 
(referred to in this section as the ‘‘Secretary’’) shall provide for 
the planning and implementation of a national public–private part-
nership for a prevention and health promotion outreach and edu-
cation campaign to raise public awareness of health improvement 
across the life span. Such campaign shall include the dissemination 
of information that— 
(1) describes the importance of utilizing preventive services 
to promote wellness, reduce health disparities, and mitigate 
chronic disease; 
(2) promotes the use of preventive services recommended 
by the United States Preventive Services Task Force and the 
Community Preventive Services Task Force; 
(3) encourages healthy behaviors linked to the prevention 
of chronic diseases; 
(4) explains the preventive services covered under health 
plans offered through a Gateway; 
(5) describes additional preventive care supported by the 
Centers for Disease Control and Prevention, the Health 
Resources and Services Administration, the Substance Abuse 
and Mental Health Services Administration, the Advisory Com-
mittee on Immunization Practices, and other appropriate agen-
cies; and 
(6) includes general health promotion information. 
42 USC 300u–12. 
42 USC 280g–8. 
42 USC 280g–7. 
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124 STAT. 545 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b) CONSULTATION.—In coordinating the campaign under sub-
section (a), the Secretary shall consult with the Institute of Medicine 
to provide ongoing advice on evidence-based scientific information 
for policy, program development, and evaluation. 
(c) MEDIA CAMPAIGN.— 
(1) IN
GENERAL.—Not later than 1 year after the date 
of enactment of this Act, the Secretary, acting through the 
Director of the Centers for Disease Control and Prevention, 
shall establish and implement a national science-based media 
campaign on health promotion and disease prevention. 
(2) REQUIREMENT
OF
CAMPAIGN.—The campaign imple-
mented under paragraph (1)— 
(A) shall be designed to address proper nutrition, reg-
ular exercise, smoking cessation, obesity reduction, the 5 
leading disease killers in the United States, and secondary 
prevention through disease screening promotion; 
(B) shall be carried out through competitively bid con-
tracts awarded to entities providing for the professional 
production and design of such campaign; 
(C) may include the use of television, radio, Internet, 
and other commercial marketing venues and may be tar-
geted to specific age groups based on peer-reviewed social 
research; 
(D) shall not be duplicative of any other Federal efforts 
relating to health promotion and disease prevention; and 
(E) may include the use of humor and nationally recog-
nized positive role models. 
(3) EVALUATION.—The Secretary shall ensure that the cam-
paign implemented under paragraph (1) is subject to an inde-
pendent evaluation every 2 years and shall report every 2 
years to Congress on the effectiveness of such campaigns 
towards meeting science-based metrics. 
(d) WEBSITE.—The Secretary, in consultation with private- 
sector experts, shall maintain or enter into a contract to maintain 
an Internet website to provide science-based information on guide-
lines for nutrition, regular exercise, obesity reduction, smoking ces-
sation, and specific chronic disease prevention. Such website shall 
be designed to provide information to health care providers and 
consumers. 
(e) DISSEMINATION
OF INFORMATION THROUGH PROVIDERS.— 
The Secretary, acting through the Centers for Disease Control and 
Prevention, shall develop and implement a plan for the dissemina-
tion of health promotion and disease prevention information con-
sistent with national priorities, to health care providers who partici-
pate in Federal programs, including programs administered by the 
Indian Health Service, the Department of Veterans Affairs, the 
Department of Defense, and the Health Resources and Services 
Administration, and Medicare and Medicaid. 
(f) PERSONALIZED PREVENTION PLANS.— 
(1) CONTRACT.—The Secretary, acting through the Director 
of the Centers for Disease Control and Prevention, shall enter 
into a contract with a qualified entity for the development 
and operation of a Federal Internet website personalized 
prevention plan tool. 
(2) USE.—The website developed under paragraph (1) shall 
be designed to be used as a source of the most up-to-date 
scientific evidence relating to disease prevention for use by 
Web site. 
Plans. 
Deadlines. 
Reports. 
Deadline. 
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124 STAT. 546 
PUBLIC LAW 111–148—MAR. 23, 2010 
individuals. Such website shall contain a component that 
enables an individual to determine their disease risk (based 
on personal health and family history, BMI, and other relevant 
information) relating to the 5 leading diseases in the United 
States, and obtain personalized suggestions for preventing such 
diseases. 
(g) INTERNET PORTAL.—The Secretary shall establish an Inter-
net portal for accessing risk-assessment tools developed and main-
tained by private and academic entities. 
(h) PRIORITY FUNDING.—Funding for the activities authorized 
under this section shall take priority over funding provided through 
the Centers for Disease Control and Prevention for grants to States 
and other entities for similar purposes and goals as provided for 
in this section. Not to exceed $500,000,000 shall be expended on 
the campaigns and activities required under this section. 
(i) PUBLIC AWARENESS OF PREVENTIVE AND OBESITY-RELATED 
SERVICES.— 
(1) INFORMATION TO STATES.—The Secretary of Health and 
Human Services shall provide guidance and relevant informa-
tion to States and health care providers regarding preventive 
and obesity-related services that are available to Medicaid 
enrollees, including obesity screening and counseling for chil-
dren and adults. 
(2) INFORMATION TO ENROLLEES.—Each State shall design 
a public awareness campaign to educate Medicaid enrollees 
regarding availability and coverage of such services, with the 
goal of reducing incidences of obesity. 
(3) REPORT.—Not later than January 1, 2011, and every 
3 years thereafter through January 1, 2017, the Secretary 
of Health and Human Services shall report to Congress on 
the status and effectiveness of efforts under paragraphs (1) 
and (2), including summaries of the States’ efforts to increase 
awareness of coverage of obesity-related services. 
(j) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated such sums as may be necessary to carry out 
this section. 
Subtitle B—Increasing Access to Clinical 
Preventive Services 
SEC. 4101. SCHOOL-BASED HEALTH CENTERS. 
(a) GRANTS FOR THE ESTABLISHMENT OF SCHOOL-BASED HEALTH 
CENTERS.— 
(1) PROGRAM.—The Secretary of Health and Human Serv-
ices (in this subsection referred to as the ‘‘Secretary’’) shall 
establish a program to award grants to eligible entities to 
support the operation of school-based health centers. 
(2) ELIGIBILITY.—To be eligible for a grant under this sub-
section, an entity shall— 
(A) be a school-based health center or a sponsoring 
facility of a school-based health center; and 
(B) submit an application at such time, in such manner, 
and containing such information as the Secretary may 
require, including at a minimum an assurance that funds 
awarded under the grant shall not be used to provide 
42 USC 280h–4. 
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124 STAT. 547 
PUBLIC LAW 111–148—MAR. 23, 2010 
any service that is not authorized or allowed by Federal, 
State, or local law. 
(3) PREFERENCE.—In awarding grants under this section, 
the Secretary shall give preference to awarding grants for 
school-based health centers that serve a large population of 
children eligible for medical assistance under the State Med-
icaid plan under title XIX of the Social Security Act or under 
a waiver of such plan or children eligible for child health 
assistance under the State child health plan under title XXI 
of that Act (42 U.S.C. 1397aa et seq.). 
(4) LIMITATION ON USE OF FUNDS.—An eligible entity shall 
use funds provided under a grant awarded under this sub-
section only for expenditures for facilities (including the acquisi-
tion or improvement of land, or the acquisition, construction, 
expansion, replacement, or other improvement of any building 
or other facility), equipment, or similar expenditures, as speci-
fied by the Secretary. No funds provided under a grant awarded 
under this section shall be used for expenditures for personnel 
or to provide health services. 
(5) APPROPRIATIONS.—Out of any funds in the Treasury 
not otherwise appropriated, there is appropriated for each of 
fiscal years 2010 through 2013, $50,000,000 for the purpose 
of carrying out this subsection. Funds appropriated under this 
paragraph shall remain available until expended. 
(6) DEFINITIONS.—In this subsection, the terms ‘‘school- 
based health center’’ and ‘‘sponsoring facility’’ have the 
meanings given those terms in section 2110(c)(9) of the Social 
Security Act (42 U.S.C. 1397jj(c)(9)). 
(b) GRANTS
FOR
THE OPERATION
OF SCHOOL-BASED HEALTH 
CENTERS.—Part Q of title III of the Public Health Service Act 
(42 U.S.C. 280h et seq.) is amended by adding at the end the 
following: 
‘‘SEC. 399Z–1. SCHOOL-BASED HEALTH CENTERS. 
‘‘(a) DEFINITIONS; ESTABLISHMENT OF CRITERIA.—In this section: 
‘‘(1) COMPREHENSIVE PRIMARY HEALTH SERVICES.—The term 
‘comprehensive primary health services’ means the core services 
offered by school-based health centers, which shall include the 
following: 
‘‘(A) PHYSICAL.—Comprehensive health assessments, 
diagnosis, and treatment of minor, acute, and chronic med-
ical conditions, and referrals to, and follow-up for, specialty 
care and oral health services. 
‘‘(B) MENTAL HEALTH.—Mental health and substance 
use disorder assessments, crisis intervention, counseling, 
treatment, and referral to a continuum of services including 
emergency psychiatric care, community support programs, 
inpatient care, and outpatient programs. 
‘‘(2) MEDICALLY
UNDERSERVED
CHILDREN
AND
ADOLES-
CENTS.— 
‘‘(A) IN
GENERAL.—The term ‘medically underserved 
children and adolescents’ means a population of children 
and adolescents who are residents of an area designated 
as a medically underserved area or a health professional 
shortage area by the Secretary. 
‘‘(B) CRITERIA.—The Secretary shall prescribe criteria 
for determining the specific shortages of personal health 
42 USC 280h–5. 
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124 STAT. 548 
PUBLIC LAW 111–148—MAR. 23, 2010 
services for medically underserved children and adolescents 
under subparagraph (A) that shall— 
‘‘(i) take into account any comments received by 
the Secretary from the chief executive officer of a State 
and local officials in a State; and 
‘‘(ii) include factors indicative of the health status 
of such children and adolescents of an area, including 
the ability of the residents of such area to pay for 
health services, the accessibility of such services, the 
availability of health professionals to such children 
and adolescents, and other factors as determined 
appropriate by the Secretary. 
‘‘(3) SCHOOL-BASED
HEALTH
CENTER.—The term ‘school- 
based health center’ means a health clinic that— 
‘‘(A) meets the definition of a school-based health center 
under section 2110(c)(9)(A) of the Social Security Act and 
is administered by a sponsoring facility (as defined in sec-
tion 2110(c)(9)(B) of the Social Security Act); 
‘‘(B) provides, at a minimum, comprehensive primary 
health services during school hours to children and adoles-
cents by health professionals in accordance with established 
standards, community practice, reporting laws, and other 
State laws, including parental consent and notification laws 
that are not inconsistent with Federal law; and 
‘‘(C) does not perform abortion services. 
‘‘(b) AUTHORITY TO AWARD GRANTS.—The Secretary shall award 
grants for the costs of the operation of school-based health centers 
(referred to in this section as ‘SBHCs’) that meet the requirements 
of this section. 
‘‘(c) APPLICATIONS.—To be eligible to receive a grant under 
this section, an entity shall— 
‘‘(1) be an SBHC (as defined in subsection (a)(3)); and 
‘‘(2) submit to the Secretary an application at such time, 
in such manner, and containing— 
‘‘(A) evidence that the applicant meets all criteria nec-
essary to be designated an SBHC; 
‘‘(B) evidence of local need for the services to be pro-
vided by the SBHC; 
‘‘(C) an assurance that— 
‘‘(i) SBHC services will be provided to those chil-
dren and adolescents for whom parental or guardian 
consent has been obtained in cooperation with Federal, 
State, and local laws governing health care service 
provision to children and adolescents; 
‘‘(ii) the SBHC has made and will continue to 
make every reasonable effort to establish and maintain 
collaborative relationships with other health care pro-
viders in the catchment area of the SBHC; 
‘‘(iii) the SBHC will provide on-site access during 
the academic day when school is in session and 24- 
hour coverage through an on-call system and through 
its backup health providers to ensure access to services 
on a year-round basis when the school or the SBHC 
is closed; 
‘‘(iv) the SBHC will be integrated into the school 
environment and will coordinate health services with 
school personnel, such as administrators, teachers, 
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124 STAT. 549 
PUBLIC LAW 111–148—MAR. 23, 2010 
nurses, counselors, and support personnel, as well as 
with other community providers co-located at the 
school; 
‘‘(v) the SBHC sponsoring facility assumes all 
responsibility for the SBHC administration, operations, 
and oversight; and 
‘‘(vi) the SBHC will comply with Federal, State, 
and local laws concerning patient privacy and student 
records, including regulations promulgated under the 
Health Insurance Portability and Accountability Act 
of 1996 and section 444 of the General Education Provi-
sions Act; and 
‘‘(D) such other information as the Secretary may 
require. 
‘‘(d) PREFERENCES AND CONSIDERATION.—In reviewing applica-
tions: 
‘‘(1) The Secretary may give preference to applicants who 
demonstrate an ability to serve the following: 
‘‘(A) Communities that have evidenced barriers to pri-
mary health care and mental health and substance use 
disorder prevention services for children and adolescents. 
‘‘(B) Communities with high per capita numbers of 
children and adolescents who are uninsured, underinsured, 
or enrolled in public health insurance programs. 
‘‘(C) Populations of children and adolescents that have 
historically demonstrated difficulty in accessing health and 
mental health and substance use disorder prevention serv-
ices. 
‘‘(2) The Secretary may give consideration to whether an 
applicant has received a grant under subsection (a) of section 
4101 of the Patient Protection and Affordable Care Act. 
‘‘(e) WAIVER OF REQUIREMENTS.—The Secretary may— 
‘‘(1) under appropriate circumstances, waive the application 
of all or part of the requirements of this subsection with respect 
to an SBHC for not to exceed 2 years; and 
‘‘(2) upon a showing of good cause, waive the requirement 
that the SBHC provide all required comprehensive primary 
health services for a designated period of time to be determined 
by the Secretary. 
‘‘(f) USE OF FUNDS.— 
‘‘(1) FUNDS.—Funds awarded under a grant under this 
section— 
‘‘(A) may be used for— 
‘‘(i) acquiring and leasing equipment (including the 
costs of amortizing the principle of, and paying interest 
on, loans for such equipment); 
‘‘(ii) providing training related to the provision of 
required comprehensive primary health services and 
additional health services; 
‘‘(iii) the management and operation of health 
center programs; 
‘‘(iv) the payment of salaries for physicians, nurses, 
and other personnel of the SBHC; and 
‘‘(B) may not be used to provide abortions. 
‘‘(2) CONSTRUCTION.—The Secretary may award grants 
which may be used to pay the costs associated with expanding 
and modernizing existing buildings for use as an SBHC, 
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124 STAT. 550 
PUBLIC LAW 111–148—MAR. 23, 2010 
including the purchase of trailers or manufactured buildings 
to install on the school property. 
‘‘(3) LIMITATIONS.— 
‘‘(A) IN
GENERAL.—Any provider of services that is 
determined by a State to be in violation of a State law 
described in subsection (a)(3)(B) with respect to activities 
carried out at a SBHC shall not be eligible to receive 
additional funding under this section. 
‘‘(B) NO OVERLAPPING GRANT PERIOD.—No entity that 
has received funding under section 330 for a grant period 
shall be eligible for a grant under this section for with 
respect to the same grant period. 
‘‘(g) MATCHING REQUIREMENT.— 
‘‘(1) IN GENERAL.—Each eligible entity that receives a grant 
under this section shall provide, from non-Federal sources, 
an amount equal to 20 percent of the amount of the grant 
(which may be provided in cash or in-kind) to carry out the 
activities supported by the grant. 
‘‘(2) WAIVER.—The Secretary may waive all or part of the 
matching requirement described in paragraph (1) for any fiscal 
year for the SBHC if the Secretary determines that applying 
the matching requirement to the SBHC would result in serious 
hardship or an inability to carry out the purposes of this 
section. 
‘‘(h) SUPPLEMENT, NOT SUPPLANT.—Grant funds provided under 
this section shall be used to supplement, not supplant, other Federal 
or State funds. 
‘‘(i) EVALUATION.—The Secretary shall develop and implement 
a plan for evaluating SBHCs and monitoring quality performance 
under the awards made under this section. 
‘‘(j) AGE APPROPRIATE SERVICES.—An eligible entity receiving 
funds under this section shall only provide age appropriate services 
through a SBHC funded under this section to an individual. 
‘‘(k) PARENTAL CONSENT.—An eligible entity receiving funds 
under this section shall not provide services through a SBHC funded 
under this section to an individual without the consent of the 
parent or guardian of such individual if such individual is consid-
ered a minor under applicable State law. 
‘‘(l) AUTHORIZATION OF APPROPRIATIONS.—For purposes of car-
rying out this section, there are authorized to be appropriated 
such sums as may be necessary for each of the fiscal years 2010 
through 2014.’’. 
SEC. 4102. ORAL HEALTHCARE PREVENTION ACTIVITIES. 
(a) IN GENERAL.—Title III of the Public Health Service Act 
(42 U.S.C. 241 et seq.), as amended by section 3025, is amended 
by adding at the end the following: 
‘‘PART T—ORAL HEALTHCARE PREVENTION 
ACTIVITIES 
‘‘SEC. 399LL. ORAL HEALTHCARE PREVENTION EDUCATION CAMPAIGN. 
‘‘(a) ESTABLISHMENT.—The Secretary, acting through the 
Director of the Centers for Disease Control and Prevention and 
in consultation with professional oral health organizations, shall, 
subject to the availability of appropriations, establish a 5-year 
national, public education campaign (referred to in this section 
42 USC 280k. 
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124 STAT. 551 
PUBLIC LAW 111–148—MAR. 23, 2010 
as the ‘campaign’) that is focused on oral healthcare prevention 
and education, including prevention of oral disease such as early 
childhood and other caries, periodontal disease, and oral cancer. 
‘‘(b) REQUIREMENTS.—In establishing the campaign, the Sec-
retary shall— 
‘‘(1) ensure that activities are targeted towards specific 
populations such as children, pregnant women, parents, the 
elderly, individuals with disabilities, and ethnic and racial 
minority populations, including Indians, Alaska Natives and 
Native Hawaiians (as defined in section 4(c) of the Indian 
Health Care Improvement Act) in a culturally and linguistically 
appropriate manner; and 
‘‘(2) utilize science-based strategies to convey oral health 
prevention messages that include, but are not limited to, 
community water fluoridation and dental sealants. 
‘‘(c) PLANNING AND IMPLEMENTATION.—Not later than 2 years 
after the date of enactment of this section, the Secretary shall 
begin implementing the 5-year campaign. During the 2-year period 
referred to in the previous sentence, the Secretary shall conduct 
planning activities with respect to the campaign. 
‘‘SEC. 399LL–1. RESEARCH-BASED DENTAL CARIES DISEASE MANAGE-
MENT. 
‘‘(a) IN GENERAL.—The Secretary, acting through the Director 
of the Centers for Disease Control and Prevention, shall award 
demonstration grants to eligible entities to demonstrate the 
effectiveness of research-based dental caries disease management 
activities. 
‘‘(b) ELIGIBILITY.—To be eligible for a grant under this section, 
an entity shall— 
‘‘(1) be a community-based provider of dental services (as 
defined by the Secretary), including a Federally-qualified health 
center, a clinic of a hospital owned or operated by a State 
(or by an instrumentality or a unit of government within a 
State), a State or local department of health, a dental program 
of the Indian Health Service, an Indian tribe or tribal organiza-
tion, or an urban Indian organization (as such terms are defined 
in section 4 of the Indian Health Care Improvement Act), 
a health system provider, a private provider of dental services, 
medical, dental, public health, nursing, nutrition educational 
institutions, or national organizations involved in improving 
children’s oral health; and 
‘‘(2) submit to the Secretary an application at such time, 
in such manner, and containing such information as the Sec-
retary may require. 
‘‘(c) USE OF FUNDS.—A grantee shall use amounts received 
under a grant under this section to demonstrate the effectiveness 
of research-based dental caries disease management activities. 
‘‘(d) USE OF INFORMATION.—The Secretary shall utilize informa-
tion generated from grantees under this section in planning and 
implementing the public education campaign under section 399LL. 
‘‘SEC. 399LL–2. AUTHORIZATION OF APPROPRIATIONS. 
‘‘There is authorized to be appropriated to carry out this part, 
such sums as may be necessary.’’. 
(b) SCHOOL-BASED SEALANT PROGRAMS.—Section 317M(c)(1) of 
the Public Health Service Act (42 U.S.C. 247b–14(c)(1)) is amended 
by striking ‘‘may award grants to States and Indian tribes’’ and 
42 USC 280k–2. 
Submission. 
Grants. 
42 USC 280k–1. 
Deadline. 
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124 STAT. 552 
PUBLIC LAW 111–148—MAR. 23, 2010 
inserting ‘‘shall award a grant to each of the 50 States and terri-
tories and to Indians, Indian tribes, tribal organizations and urban 
Indian organizations (as such terms are defined in section 4 of 
the Indian Health Care Improvement Act)’’. 
(c) ORAL HEALTH INFRASTRUCTURE.—Section 317M of the Public 
Health Service Act (42 U.S.C. 247b–14) is amended— 
(1) by redesignating subsections (d) and (e) as subsections 
(e) and (f), respectively; and 
(2) by inserting after subsection (c), the following: 
‘‘(d) ORAL HEALTH INFRASTRUCTURE.— 
‘‘(1) COOPERATIVE
AGREEMENTS.—The Secretary, acting 
through the Director of the Centers for Disease Control and 
Prevention, shall enter into cooperative agreements with State, 
territorial, and Indian tribes or tribal organizations (as those 
terms are defined in section 4 of the Indian Health Care 
Improvement Act) to establish oral health leadership and pro-
gram guidance, oral health data collection and interpretation, 
(including determinants of poor oral health among vulnerable 
populations), a multi-dimensional delivery system for oral 
health, and to implement science-based programs (including 
dental sealants and community water fluoridation) to improve 
oral health. 
‘‘(2) AUTHORIZATION OF APPROPRIATIONS.—There is author-
ized to be appropriated such sums as necessary to carry out 
this subsection for fiscal years 2010 through 2014.’’. 
(d) UPDATING NATIONAL ORAL HEALTHCARE SURVEILLANCE 
ACTIVITIES.— 
(1) PRAMS.— 
(A) IN GENERAL.—The Secretary of Health and Human 
Services (referred to in this subsection as the ‘‘Secretary’’) 
shall carry out activities to update and improve the Preg-
nancy Risk Assessment Monitoring System (referred to 
in this section as ‘‘PRAMS’’) as it relates to oral healthcare. 
(B) STATE REPORTS AND MANDATORY MEASUREMENTS.— 
(i) IN GENERAL.—Not later than 5 years after the 
date of enactment of this Act, and every 5 years there-
after, a State shall submit to the Secretary a report 
concerning activities conducted within the State under 
PRAMS. 
(ii) 
MEASUREMENTS.—The 
oral 
healthcare 
measurements developed by the Secretary for use 
under PRAMS shall be mandatory with respect to 
States for purposes of the State reports under clause 
(i). 
(C) FUNDING.—There is authorized to be appropriated 
to carry out this paragraph, such sums as may be nec-
essary. 
(2) 
NATIONAL
HEALTH
AND
NUTRITION
EXAMINATION 
SURVEY.—The Secretary shall develop oral healthcare compo-
nents that shall include tooth-level surveillance for inclusion 
in the National Health and Nutrition Examination Survey. 
Such components shall be updated by the Secretary at least 
every 6 years. For purposes of this paragraph, the term ‘‘tooth- 
level surveillance’’ means a clinical examination where an 
examiner looks at each dental surface, on each tooth in the 
mouth and as expanded by the Division of Oral Health of 
the Centers for Disease Control and Prevention. 
Definition. 
Deadline. 
42 USC 280k–3. 
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124 STAT. 553 
PUBLIC LAW 111–148—MAR. 23, 2010 
(3) MEDICAL EXPENDITURES PANEL SURVEY.—The Secretary 
shall ensure that the Medical Expenditures Panel Survey by 
the Agency for Healthcare Research and Quality includes the 
verification of dental utilization, expenditure, and coverage 
findings through conduct of a look-back analysis. 
(4) NATIONAL ORAL HEALTH SURVEILLANCE SYSTEM.— 
(A) APPROPRIATIONS.—There is authorized to be appro-
priated, such sums as may be necessary for each of fiscal 
years 2010 through 2014 to increase the participation of 
States in the National Oral Health Surveillance System 
from 16 States to all 50 States, territories, and District 
of Columbia. 
(B) REQUIREMENTS.—The Secretary shall ensure that 
the National Oral Health Surveillance System include the 
measurement of early childhood caries. 
SEC. 4103. MEDICARE COVERAGE OF ANNUAL WELLNESS VISIT PRO-
VIDING A PERSONALIZED PREVENTION PLAN. 
(a) COVERAGE OF PERSONALIZED PREVENTION PLAN SERVICES.— 
(1) IN GENERAL.—Section 1861(s)(2) of the Social Security 
Act (42 U.S.C. 1395x(s)(2)) is amended— 
(A) in subparagraph (DD), by striking ‘‘and’’ at the 
end; 
(B) in subparagraph (EE), by adding ‘‘and’’ at the end; 
and 
(C) by adding at the end the following new subpara-
graph: 
‘‘(FF) personalized prevention plan services (as defined in 
subsection (hhh));’’. 
(2) CONFORMING AMENDMENTS.—Clauses (i) and (ii) of sec-
tion 1861(s)(2)(K) of the Social Security Act (42 U.S.C. 
1395x(s)(2)(K)) are each amended by striking ‘‘subsection 
(ww)(1)’’ and inserting ‘‘subsections (ww)(1) and (hhh)’’. 
(b) PERSONALIZED PREVENTION PLAN SERVICES DEFINED.—Sec-
tion 1861 of the Social Security Act (42 U.S.C. 1395x) is amended 
by adding at the end the following new subsection: 
‘‘Annual Wellness Visit 
‘‘(hhh)(1) The term ‘personalized prevention plan services’ 
means the creation of a plan for an individual— 
‘‘(A) that includes a health risk assessment (that meets 
the guidelines established by the Secretary under paragraph 
(4)(A)) of the individual that is completed prior to or as part 
of the same visit with a health professional described in para-
graph (3); and 
‘‘(B) that— 
‘‘(i) takes into account the results of the health risk 
assessment; and 
‘‘(ii) may contain the elements described in paragraph 
(2). 
‘‘(2) Subject to paragraph (4)(H), the elements described in 
this paragraph are the following: 
‘‘(A) The establishment of, or an update to, the individual’s 
medical and family history. 
‘‘(B) A list of current providers and suppliers that are 
regularly involved in providing medical care to the individual 
(including a list of all prescribed medications). 
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124 STAT. 554 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(C) A measurement of height, weight, body mass index 
(or waist circumference, if appropriate), blood pressure, and 
other routine measurements. 
‘‘(D) Detection of any cognitive impairment. 
‘‘(E) The establishment of, or an update to, the following: 
‘‘(i) A screening schedule for the next 5 to 10 years, 
as appropriate, based on recommendations of the United 
States Preventive Services Task Force and the Advisory 
Committee on Immunization Practices, and the individual’s 
health status, screening history, and age-appropriate 
preventive services covered under this title. 
‘‘(ii) A list of risk factors and conditions for which 
primary, secondary, or tertiary prevention interventions 
are recommended or are underway, including any mental 
health conditions or any such risk factors or conditions 
that have been identified through an initial preventive 
physical examination (as described under subsection 
(ww)(1)), and a list of treatment options and their associ-
ated risks and benefits. 
‘‘(F) The furnishing of personalized health advice and a 
referral, as appropriate, to health education or preventive coun-
seling services or programs aimed at reducing identified risk 
factors and improving self-management, or community-based 
lifestyle interventions to reduce health risks and promote self- 
management and wellness, including weight loss, physical 
activity, smoking cessation, fall prevention, and nutrition. 
‘‘(G) Any other element determined appropriate by the 
Secretary. 
‘‘(3) A health professional described in this paragraph is— 
‘‘(A) a physician; 
‘‘(B) a practitioner described in clause (i) of section 
1842(b)(18)(C); or 
‘‘(C) a medical professional (including a health educator, 
registered dietitian, or nutrition professional) or a team of 
medical professionals, as determined appropriate by the Sec-
retary, under the supervision of a physician. 
‘‘(4)(A) For purposes of paragraph (1)(A), the Secretary, not 
later than 1 year after the date of enactment of this subsection, 
shall establish publicly available guidelines for health risk assess-
ments. Such guidelines shall be developed in consultation with 
relevant groups and entities and shall provide that a health risk 
assessment— 
‘‘(i) identify chronic diseases, injury risks, modifiable risk 
factors, and urgent health needs of the individual; and 
‘‘(ii) may be furnished— 
‘‘(I) through an interactive telephonic or web-based 
program that meets the standards established under 
subparagraph (B); 
‘‘(II) during an encounter with a health care profes-
sional; 
‘‘(III) through community-based prevention programs; 
or 
‘‘(IV) through any other means the Secretary deter-
mines appropriate to maximize accessibility and ease of 
use by beneficiaries, while ensuring the privacy of such 
beneficiaries. 
Deadline. 
Public 
information. 
Guidelines. 
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124 STAT. 555 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) Not later than 1 year after the date of enactment of 
this subsection, the Secretary shall establish standards for inter-
active telephonic or web-based programs used to furnish health 
risk assessments under subparagraph (A)(ii)(I). The Secretary may 
utilize any health risk assessment developed under section 4004(f) 
of the Patient Protection and Affordable Care Act as part of the 
requirement to develop a personalized prevention plan to comply 
with this subparagraph. 
‘‘(C)(i) Not later than 18 months after the date of enactment 
of this subsection, the Secretary shall develop and make available 
to the public a health risk assessment model. Such model shall 
meet the guidelines under subparagraph (A) and may be used 
to meet the requirement under paragraph (1)(A). 
‘‘(ii) Any health risk assessment that meets the guidelines 
under subparagraph (A) and is approved by the Secretary may 
be used to meet the requirement under paragraph (1)(A). 
‘‘(D) The Secretary may coordinate with community-based enti-
ties (including State Health Insurance Programs, Area Agencies 
on Aging, Aging and Disability Resource Centers, and the Adminis-
tration on Aging) to— 
‘‘(i) ensure that health risk assessments are accessible to 
beneficiaries; and 
‘‘(ii) provide appropriate support for the completion of 
health risk assessments by beneficiaries. 
‘‘(E) The Secretary shall establish procedures to make bene-
ficiaries and providers aware of the requirement that a beneficiary 
complete a health risk assessment prior to or at the same time 
as receiving personalized prevention plan services. 
‘‘(F) To the extent practicable, the Secretary shall encourage 
the use of, integration with, and coordination of health information 
technology (including use of technology that is compatible with 
electronic medical records and personal health records) and may 
experiment with the use of personalized technology to aid in the 
development of self-management skills and management of and 
adherence to provider recommendations in order to improve the 
health status of beneficiaries. 
‘‘(G)(i) A beneficiary shall only be eligible to receive an initial 
preventive physical examination (as defined under subsection 
(ww)(1)) at any time during the 12-month period after the date 
that the beneficiary’s coverage begins under part B and shall be 
eligible to receive personalized prevention plan services under this 
subsection provided that the beneficiary has not received such serv-
ices within the preceding 12-month period. 
‘‘(ii) The Secretary shall establish procedures to make bene-
ficiaries aware of the option to select an initial preventive physical 
examination or personalized prevention plan services during the 
period of 12 months after the date that a beneficiary’s coverage 
begins under part B, which shall include information regarding 
any relevant differences between such services. 
‘‘(H) The Secretary shall issue guidance that— 
‘‘(i) identifies elements under paragraph (2) that are 
required to be provided to a beneficiary as part of their first 
visit for personalized prevention plan services; and 
‘‘(ii) establishes a yearly schedule for appropriate provision 
of such elements thereafter.’’. 
(c) PAYMENT AND ELIMINATION OF COST-SHARING.— 
Guidance. 
Procedures. 
Procedures. 
Deadline. 
Public 
information. 
Assessment 
model. 
Deadline. 
Standards. 
Communications 
and tele- 
communications. 
Web site. 
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124 STAT. 556 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) PAYMENT AND ELIMINATION OF COINSURANCE.—Section 
1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) 
is amended— 
(A) in subparagraph (N), by inserting ‘‘other than 
personalized prevention plan services (as defined in section 
1861(hhh)(1))’’ after ‘‘(as defined in section 1848(j)(3))’’; 
(B) by striking ‘‘and’’ before ‘‘(W)’’; and 
(C) by inserting before the semicolon at the end the 
following: ‘‘, and (X) with respect to personalized prevention 
plan services (as defined in section 1861(hhh)(1)), the 
amount paid shall be 100 percent of the lesser of the 
actual charge for the services or the amount determined 
under the payment basis determined under section 1848’’. 
(2) PAYMENT
UNDER
PHYSICIAN
FEE
SCHEDULE.—Section 
1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) 
is amended by inserting ‘‘(2)(FF) (including administration of 
the health risk assessment) ,’’ after ‘‘(2)(EE),’’. 
(3) ELIMINATION OF COINSURANCE IN OUTPATIENT HOSPITAL 
SETTINGS.— 
(A) EXCLUSION
FROM
OPD
FEE
SCHEDULE.—Section 
1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 
1395l(t)(1)(B)(iv)) is amended by striking ‘‘and diagnostic 
mammography’’ and inserting ‘‘, diagnostic mammography, 
or personalized prevention plan services (as defined in sec-
tion 1861(hhh)(1))’’. 
(B) CONFORMING AMENDMENTS.—Section 1833(a)(2) of 
the Social Security Act (42 U.S.C. 1395l(a)(2)) is amended— 
(i) in subparagraph (F), by striking ‘‘and’’ at the 
end; 
(ii) in subparagraph (G)(ii), by striking the comma 
at the end and inserting ‘‘; and’’; and 
(iii) by inserting after subparagraph (G)(ii) the fol-
lowing new subparagraph: 
‘‘(H) with respect to personalized prevention plan serv-
ices (as defined in section 1861(hhh)(1)) furnished by an 
outpatient department of a hospital, the amount deter-
mined under paragraph (1)(X),’’. 
(4) WAIVER OF APPLICATION OF DEDUCTIBLE.—The first sen-
tence of section 1833(b) of the Social Security Act (42 U.S.C. 
1395l(b)) is amended— 
(A) by striking ‘‘and’’ before ‘‘(9)’’; and 
(B) by inserting before the period the following: ‘‘, 
and (10) such deductible shall not apply with respect to 
personalized prevention plan services (as defined in section 
1861(hhh)(1))’’. 
(d) FREQUENCY LIMITATION.—Section 1862(a) of the Social Secu-
rity Act (42 U.S.C. 1395y(a)) is amended— 
(1) in paragraph (1)— 
(A) in subparagraph (N), by striking ‘‘and’’ at the end; 
(B) in subparagraph (O), by striking the semicolon 
at the end and inserting ‘‘, and’’; and 
(C) by adding at the end the following new subpara-
graph: 
‘‘(P) in the case of personalized prevention plan services 
(as defined in section 1861(hhh)(1)), which are performed more 
frequently than is covered under such section;’’; and 
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124 STAT. 557 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) in paragraph (7), by striking ‘‘or (K)’’ and inserting 
‘‘(K), or (P)’’. 
(e) EFFECTIVE DATE.—The amendments made by this section 
shall apply to services furnished on or after January 1, 2011. 
SEC. 4104. REMOVAL OF BARRIERS TO PREVENTIVE SERVICES IN 
MEDICARE. 
(a) DEFINITION OF PREVENTIVE SERVICES.—Section 1861(ddd) 
of the Social Security Act (42 U.S.C. 1395x(ddd)) is amended— 
(1) in the heading, by inserting ‘‘; Preventive Services’’ 
after ‘‘Services’’; 
(2) in paragraph (1), by striking ‘‘not otherwise described 
in this title’’ and inserting ‘‘not described in subparagraph 
(A) or (C) of paragraph (3)’’; and 
(3) by adding at the end the following new paragraph: 
‘‘(3) The term ‘preventive services’ means the following: 
‘‘(A) The screening and preventive services described in 
subsection (ww)(2) (other than the service described in subpara-
graph (M) of such subsection). 
‘‘(B) An initial preventive physical examination (as defined 
in subsection (ww)). 
‘‘(C) Personalized prevention plan services (as defined in 
subsection (hhh)(1)).’’. 
(b) COINSURANCE.— 
(1) GENERAL APPLICATION.— 
(A) IN GENERAL.—Section 1833(a)(1) of the Social Secu-
rity Act (42 U.S.C. 1395l(a)(1)), as amended by section 
4103(c)(1), is amended— 
(i) in subparagraph (T), by inserting ‘‘(or 100 per-
cent if such services are recommended with a grade 
of A or B by the United States Preventive Services 
Task Force for any indication or population and are 
appropriate for the individual)’’ after ‘‘80 percent’’; 
(ii) in subparagraph (W)— 
(I) in clause (i), by inserting ‘‘(if such subpara-
graph were applied, by substituting ‘100 percent’ 
for ‘80 percent’)’’ after ‘‘subparagraph (D)’’; and 
(II) in clause (ii), by striking ‘‘80 percent’’ and 
inserting ‘‘100 percent’’; 
(iii) by striking ‘‘and’’ before ‘‘(X)’’; and 
(iv) by inserting before the semicolon at the end 
the following: ‘‘, and (Y) with respect to preventive 
services described in subparagraphs (A) and (B) of 
section 1861(ddd)(3) that are appropriate for the indi-
vidual and, in the case of such services described in 
subparagraph (A), are recommended with a grade of 
A or B by the United States Preventive Services Task 
Force for any indication or population, the amount 
paid shall be 100 percent of the lesser of the actual 
charge for the services or the amount determined under 
the fee schedule that applies to such services under 
this part’’. 
(2) ELIMINATION OF COINSURANCE IN OUTPATIENT HOSPITAL 
SETTINGS.— 
(A) EXCLUSION
FROM
OPD
FEE
SCHEDULE.—Section 
1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 
42 USC 1395l 
note. 
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124 STAT. 558 
PUBLIC LAW 111–148—MAR. 23, 2010 
1395l(t)(1)(B)(iv)), as amended by section 4103(c)(3)(A), is 
amended— 
(i) by striking ‘‘or’’ before ‘‘personalized prevention 
plan services’’; and 
(ii) by inserting before the period the following: 
‘‘, or preventive services described in subparagraphs 
(A) and (B) of section 1861(ddd)(3) that are appropriate 
for the individual and, in the case of such services 
described in subparagraph (A), are recommended with 
a grade of A or B by the United States Preventive 
Services Task Force for any indication or population’’. 
(B) CONFORMING AMENDMENTS.—Section 1833(a)(2) of 
the Social Security Act (42 U.S.C. 1395l(a)(2)), as amended 
by section 4103(c)(3)(B), is amended— 
(i) in subparagraph (G)(ii), by striking ‘‘and’’ after 
the semicolon at the end; 
(ii) in subparagraph (H), by striking the comma 
at the end and inserting ‘‘; and’’; and 
(iii) by inserting after subparagraph (H) the fol-
lowing new subparagraph: 
‘‘(I) with respect to preventive services described in 
subparagraphs (A) and (B) of section 1861(ddd)(3) that 
are appropriate for the individual and are furnished by 
an outpatient department of a hospital and, in the case 
of such services described in subparagraph (A), are rec-
ommended with a grade of A or B by the United States 
Preventive Services Task Force for any indication or popu-
lation, the amount determined under paragraph (1)(W) or 
(1)(Y),’’. 
(c) WAIVER OF APPLICATION OF DEDUCTIBLE FOR PREVENTIVE 
SERVICES
AND COLORECTAL CANCER SCREENING TESTS.—Section 
1833(b) of the Social Security Act (42 U.S.C. 1395l(b)), as amended 
by section 4103(c)(4), is amended— 
(1) in paragraph (1), by striking ‘‘items and services 
described in section 1861(s)(10)(A)’’ and inserting ‘‘preventive 
services described in subparagraph (A) of section 1861(ddd)(3) 
that are recommended with a grade of A or B by the United 
States Preventive Services Task Force for any indication or 
population and are appropriate for the individual.’’; and 
(2) by adding at the end the following new sentence: ‘‘Para-
graph (1) of the first sentence of this subsection shall apply 
with respect to a colorectal cancer screening test regardless 
of the code that is billed for the establishment of a diagnosis 
as a result of the test, or for the removal of tissue or other 
matter or other procedure that is furnished in connection with, 
as a result of, and in the same clinical encounter as the 
screening test.’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall apply to items and services furnished on or after January 
1, 2011. 
SEC. 4105. EVIDENCE-BASED COVERAGE OF PREVENTIVE SERVICES 
IN MEDICARE. 
(a) AUTHORITY TO MODIFY OR ELIMINATE COVERAGE OF CERTAIN 
PREVENTIVE SERVICES.—Section 1834 of the Social Security Act 
(42 U.S.C. 1395m) is amended by adding at the end the following 
new subsection: 
42 USC 1395l 
note. 
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124 STAT. 559 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(n) AUTHORITY TO MODIFY OR ELIMINATE COVERAGE OF CER-
TAIN PREVENTIVE SERVICES.—Notwithstanding any other provision 
of this title, effective beginning on January 1, 2010, if the Secretary 
determines appropriate, the Secretary may— 
‘‘(1) modify— 
‘‘(A) the coverage of any preventive service described 
in subparagraph (A) of section 1861(ddd)(3) to the extent 
that such modification is consistent with the recommenda-
tions of the United States Preventive Services Task Force; 
and 
‘‘(B) the services included in the initial preventive phys-
ical examination described in subparagraph (B) of such 
section; and 
‘‘(2) provide that no payment shall be made under this 
title for a preventive service described in subparagraph (A) 
of such section that has not received a grade of A, B, C, 
or I by such Task Force.’’. 
(b) CONSTRUCTION.—Nothing in the amendment made by para-
graph (1) shall be construed to affect the coverage of diagnostic 
or treatment services under title XVIII of the Social Security Act. 
SEC. 4106. IMPROVING ACCESS TO PREVENTIVE SERVICES FOR 
ELIGIBLE ADULTS IN MEDICAID. 
(a) 
CLARIFICATION
OF
INCLUSION
OF
SERVICES.—Section 
1905(a)(13) of the Social Security Act (42 U.S.C. 1396d(a)(13)) is 
amended to read as follows: 
‘‘(13) other diagnostic, screening, preventive, and rehabilita-
tive services, including— 
‘‘(A) any clinical preventive services that are assigned 
a grade of A or B by the United States Preventive Services 
Task Force; 
‘‘(B) with respect to an adult individual, approved vac-
cines recommended by the Advisory Committee on 
Immunization Practices (an advisory committee established 
by the Secretary, acting through the Director of the Centers 
for Disease Control and Prevention) and their administra-
tion; and 
‘‘(C) any medical or remedial services (provided in a 
facility, a home, or other setting) recommended by a physi-
cian or other licensed practitioner of the healing arts within 
the scope of their practice under State law, for the max-
imum reduction of physical or mental disability and res-
toration of an individual to the best possible functional 
level;’’. 
(b) INCREASED FMAP.—Section 1905(b) of the Social Security 
Act (42 U.S.C. 1396d(b)), as amended by sections 2001(a)(3)(A) 
and 2004(c)(1), is amended in the first sentence— 
(1) by striking ‘‘, and (4)’’ and inserting ‘‘, (4)’’; and 
(2) by inserting before the period the following: ‘‘, and 
(5) in the case of a State that provides medical assistance 
for services and vaccines described in subparagraphs (A) and 
(B) of subsection (a)(13), and prohibits cost-sharing for such 
services and vaccines, the Federal medical assistance percent-
age, as determined under this subsection and subsection (y) 
(without regard to paragraph (1)(C) of such subsection), shall 
be increased by 1 percentage point with respect to medical 
42 USC 1395m 
note. 
Effective date. 
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124 STAT. 560 
PUBLIC LAW 111–148—MAR. 23, 2010 
assistance for such services and vaccines and for items and 
services described in subsection (a)(4)(D)’’. 
(c) EFFECTIVE DATE.—The amendments made under this section 
shall take effect on January 1, 2013. 
SEC. 4107. COVERAGE OF COMPREHENSIVE TOBACCO CESSATION 
SERVICES FOR PREGNANT WOMEN IN MEDICAID. 
(a) 
REQUIRING
COVERAGE
OF
COUNSELING
AND 
PHARMACOTHERAPY FOR CESSATION OF TOBACCO USE BY PREGNANT 
WOMEN.—Section 1905 of the Social Security Act (42 U.S.C. 1396d), 
as amended by sections 2001(a)(3)(B) and 2303, is further 
amended— 
(1) in subsection (a)(4)— 
(A) by striking ‘‘and’’ before ‘‘(C)’’; and 
(B) by inserting before the semicolon at the end the 
following new subparagraph: ‘‘; and (D) counseling and 
pharmacotherapy for cessation of tobacco use by pregnant 
women (as defined in subsection (bb))’’; and 
(2) by adding at the end the following: 
‘‘(bb)(1) For purposes of this title, the term ‘counseling and 
pharmacotherapy for cessation of tobacco use by pregnant women’ 
means 
diagnostic, 
therapy, 
and 
counseling 
services 
and 
pharmacotherapy (including the coverage of prescription and non-
prescription tobacco cessation agents approved by the Food and 
Drug Administration) for cessation of tobacco use by pregnant 
women who use tobacco products or who are being treated for 
tobacco use that is furnished— 
‘‘(A) by or under the supervision of a physician; or 
‘‘(B) by any other health care professional who— 
‘‘(i) is legally authorized to furnish such services under 
State law (or the State regulatory mechanism provided 
by State law) of the State in which the services are fur-
nished; and 
‘‘(ii) is authorized to receive payment for other services 
under this title or is designated by the Secretary for this 
purpose. 
‘‘(2) Subject to paragraph (3), such term is limited to— 
‘‘(A) services recommended with respect to pregnant women 
in ‘Treating Tobacco Use and Dependence: 2008 Update: A 
Clinical Practice Guideline’, published by the Public Health 
Service in May 2008, or any subsequent modification of such 
Guideline; and 
‘‘(B) such other services that the Secretary recognizes to 
be effective for cessation of tobacco use by pregnant women. 
‘‘(3) Such term shall not include coverage for drugs or biologicals 
that are not otherwise covered under this title.’’. 
(b) EXCEPTION FROM OPTIONAL RESTRICTION UNDER MEDICAID 
PRESCRIPTION DRUG COVERAGE.—Section 1927(d)(2)(F) of the Social 
Security Act (42 U.S.C. 1396r–8(d)(2)(F)), as redesignated by section 
2502(a), is amended by inserting before the period at the end 
the following: ‘‘, except, in the case of pregnant women when rec-
ommended in accordance with the Guideline referred to in section 
1905(bb)(2)(A), agents approved by the Food and Drug Administra-
tion under the over-the-counter monograph process for purposes 
of promoting, and when used to promote, tobacco cessation’’. 
Definition. 
42 USC 1396d 
note. 
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124 STAT. 561 
PUBLIC LAW 111–148—MAR. 23, 2010 
(c) 
REMOVAL
OF
COST-SHARING
FOR
COUNSELING
AND 
PHARMACOTHERAPY FOR CESSATION OF TOBACCO USE BY PREGNANT 
WOMEN.— 
(1) GENERAL COST-SHARING LIMITATIONS.—Section 1916 of 
the Social Security Act (42 U.S.C. 1396o) is amended in each 
of subsections (a)(2)(B) and (b)(2)(B) by inserting ‘‘, and coun-
seling and pharmacotherapy for cessation of tobacco use by 
pregnant women (as defined in section 1905(bb)) and covered 
outpatient drugs (as defined in subsection (k)(2) of section 
1927 and including nonprescription drugs described in sub-
section (d)(2) of such section) that are prescribed for purposes 
of promoting, and when used to promote, tobacco cessation 
by pregnant women in accordance with the Guideline referred 
to in section 1905(bb)(2)(A)’’ after ‘‘complicate the pregnancy’’. 
(2) APPLICATION TO ALTERNATIVE COST-SHARING.—Section 
1916A(b)(3)(B)(iii) of such Act (42 U.S.C. 1396o–1(b)(3)(B)(iii)) 
is amended by inserting ‘‘, and counseling and pharmacotherapy 
for cessation of tobacco use by pregnant women (as defined 
in section 1905(bb))’’ after ‘‘complicate the pregnancy’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall take effect on October 1, 2010. 
SEC. 4108. INCENTIVES FOR PREVENTION OF CHRONIC DISEASES IN 
MEDICAID. 
(a) INITIATIVES.— 
(1) ESTABLISHMENT.— 
(A) IN GENERAL.—The Secretary shall award grants 
to States to carry out initiatives to provide incentives to 
Medicaid beneficiaries who— 
(i) successfully participate in a program described 
in paragraph (3); and 
(ii) upon completion of such participation, dem-
onstrate changes in health risk and outcomes, 
including the adoption and maintenance of healthy 
behaviors by meeting specific targets (as described in 
subsection (c)(2)). 
(B) PURPOSE.—The purpose of the initiatives under 
this section is to test approaches that may encourage 
behavior modification and determine scalable solutions. 
(2) DURATION.— 
(A) INITIATION
OF
PROGRAM; RESOURCES.—The Sec-
retary shall awards grants to States beginning on January 
1, 2011, or beginning on the date on which the Secretary 
develops program criteria, whichever is earlier. The Sec-
retary shall develop program criteria for initiatives under 
this section using relevant evidence-based research and 
resources, including the Guide to Community Preventive 
Services, the Guide to Clinical Preventive Services, and 
the National Registry of Evidence-Based Programs and 
Practices. 
(B) DURATION OF PROGRAM.—A State awarded a grant 
to carry out initiatives under this section shall carry out 
such initiatives within the 5-year period beginning on 
January 1, 2011, or beginning on the date on which the 
Secretary develops program criteria, whichever is earlier. 
Initiatives under this section shall be carried out by a 
State for a period of not less than 3 years. 
Deadline. 
Criteria. 
Effective date. 
Grants. 
42 USC 1396a 
note. 
42 USC 1396d 
note. 
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124 STAT. 562 
PUBLIC LAW 111–148—MAR. 23, 2010 
(3) PROGRAM DESCRIBED.— 
(A) IN GENERAL.—A program described in this para-
graph is a comprehensive, evidence-based, widely available, 
and easily accessible program, proposed by the State and 
approved by the Secretary, that is designed and uniquely 
suited to address the needs of Medicaid beneficiaries and 
has demonstrated success in helping individuals achieve 
one or more of the following: 
(i) Ceasing use of tobacco products. 
(ii) Controlling or reducing their weight. 
(iii) Lowering their cholesterol. 
(iv) Lowering their blood pressure. 
(v) Avoiding the onset of diabetes or, in the case 
of a diabetic, improving the management of that condi-
tion. 
(B) CO-MORBIDITIES.—A program under this section 
may also address co-morbidities (including depression) that 
are related to any of the conditions described in subpara-
graph (A). 
(C) WAIVER AUTHORITY.—The Secretary may waive the 
requirements 
of 
section 
1902(a)(1) 
(relating 
to 
statewideness) of the Social Security Act for a State 
awarded a grant to conduct an initiative under this section 
and shall ensure that a State makes any program described 
in subparagraph (A) available and accessible to Medicaid 
beneficiaries. 
(D) FLEXIBILITY
IN
IMPLEMENTATION.—A State may 
enter into arrangements with providers participating in 
Medicaid, 
community-based 
organizations, 
faith-based 
organizations, public-private partnerships, Indian tribes, 
or similar entities or organizations to carry out programs 
described in subparagraph (A). 
(4) APPLICATION.—Following the development of program 
criteria by the Secretary, a State may submit an application, 
in such manner and containing such information as the Sec-
retary may require, that shall include a proposal for programs 
described in paragraph (3)(A) and a plan to make Medicaid 
beneficiaries and providers participating in Medicaid who reside 
in the State aware and informed about such programs. 
(b) EDUCATION AND OUTREACH CAMPAIGN.— 
(1) STATE
AWARENESS.—The Secretary shall conduct an 
outreach and education campaign to make States aware of 
the grants under this section. 
(2) PROVIDER
AND
BENEFICIARY
EDUCATION.—A State 
awarded a grant to conduct an initiative under this section 
shall conduct an outreach and education campaign to make 
Medicaid beneficiaries and providers participating in Medicaid 
who reside in the State aware of the programs described in 
subsection (a)(3) that are to be carried out by the State under 
the grant. 
(c) IMPACT.—A State awarded a grant to conduct an initiative 
under this section shall develop and implement a system to— 
(1) track Medicaid beneficiary participation in the program 
and validate changes in health risk and outcomes with clinical 
data, including the adoption and maintenance of health behav-
iors by such beneficiaries; 
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124 STAT. 563 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) to the extent practicable, establish standards and health 
status targets for Medicaid beneficiaries participating in the 
program and measure the degree to which such standards 
and targets are met; 
(3) evaluate the effectiveness of the program and provide 
the Secretary with such evaluations; 
(4) report to the Secretary on processes that have been 
developed and lessons learned from the program; and 
(5) report on preventive services as part of reporting on 
quality measures for Medicaid managed care programs. 
(d) EVALUATIONS AND REPORTS.— 
(1) INDEPENDENT ASSESSMENT.—The Secretary shall enter 
into a contract with an independent entity or organization 
to conduct an evaluation and assessment of the initiatives 
carried out by States under this section, for the purpose of 
determining— 
(A) the effect of such initiatives on the use of health 
care services by Medicaid beneficiaries participating in the 
program; 
(B) the extent to which special populations (including 
adults with disabilities, adults with chronic illnesses, and 
children with special health care needs) are able to partici-
pate in the program; 
(C) the level of satisfaction of Medicaid beneficiaries 
with respect to the accessibility and quality of health care 
services provided through the program; and 
(D) the administrative costs incurred by State agencies 
that are responsible for administration of the program. 
(2) STATE REPORTING.—A State awarded a grant to carry 
out initiatives under this section shall submit reports to the 
Secretary, on a semi-annual basis, regarding the programs 
that are supported by the grant funds. Such report shall include 
information, as specified by the Secretary, regarding— 
(A) the specific uses of the grant funds; 
(B) an assessment of program implementation and les-
sons learned from the programs; 
(C) an assessment of quality improvements and clinical 
outcomes under such programs; and 
(D) estimates of cost savings resulting from such pro-
grams. 
(3) INITIAL REPORT.—Not later than January 1, 2014, the 
Secretary shall submit to Congress an initial report on such 
initiatives based on information provided by States through 
reports required under paragraph (2). The initial report shall 
include an interim evaluation of the effectiveness of the initia-
tives carried out with grants awarded under this section and 
a recommendation regarding whether funding for expanding 
or extending the initiatives should be extended beyond January 
1, 2016. 
(4) FINAL REPORT.—Not later than July 1, 2016, the Sec-
retary shall submit to Congress a final report on the program 
that includes the results of the independent assessment 
required under paragraph (1), together with recommendations 
for such legislation and administrative action as the Secretary 
determines appropriate. 
Contracts. 
Reports. 
Reports. 
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124 STAT. 564 
PUBLIC LAW 111–148—MAR. 23, 2010 
(e) NO EFFECT ON ELIGIBILITY FOR, OR AMOUNT OF, MEDICAID 
OR OTHER BENEFITS.—Any incentives provided to a Medicaid bene-
ficiary participating in a program described in subsection (a)(3) 
shall not be taken into account for purposes of determining the 
beneficiary’s eligibility for, or amount of, benefits under the Med-
icaid program or any program funded in whole or in part with 
Federal funds. 
(f) FUNDING.—Out of any funds in the Treasury not otherwise 
appropriated, there are appropriated for the 5-year period beginning 
on January 1, 2011, $100,000,000 to the Secretary to carry out 
this section. Amounts appropriated under this subsection shall 
remain available until expended. 
(g) DEFINITIONS.—In this section: 
(1) MEDICAID
BENEFICIARY.—The term ‘‘Medicaid bene-
ficiary’’ means an individual who is eligible for medical assist-
ance under a State plan or waiver under title XIX of the 
Social Security Act (42 U.S.C. 1396 et seq.) and is enrolled 
in such plan or waiver. 
(2) STATE.—The term ‘‘State’’ has the meaning given that 
term for purposes of title XIX of the Social Security Act (42 
U.S.C. 1396 et seq.). 
Subtitle C—Creating Healthier 
Communities 
SEC. 4201. COMMUNITY TRANSFORMATION GRANTS. 
(a) IN GENERAL.—The Secretary of Health and Human Services 
(referred to in this section as the ‘‘Secretary’’), acting through the 
Director of the Centers for Disease Control and Prevention (referred 
to in this section as the ‘‘Director’’), shall award competitive grants 
to State and local governmental agencies and community-based 
organizations for the implementation, evaluation, and dissemination 
of evidence-based community preventive health activities in order 
to reduce chronic disease rates, prevent the development of sec-
ondary conditions, address health disparities, and develop a 
stronger evidence-base of effective prevention programming. 
(b) ELIGIBILITY.—To be eligible to receive a grant under sub-
section (a), an entity shall— 
(1) be— 
(A) a State governmental agency; 
(B) a local governmental agency; 
(C) a national network of community-based organiza-
tions; 
(D) a State or local non-profit organization; or 
(E) an Indian tribe; and 
(2) submit to the Director an application at such time, 
in such a manner, and containing such information as the 
Director may require, including a description of the program 
to be carried out under the grant; and 
(3) demonstrate a history or capacity, if funded, to develop 
relationships necessary to engage key stakeholders from mul-
tiple sectors within and beyond health care and across a 
community, such as healthy futures corps and health care 
providers. 
(c) USE OF FUNDS.— 
42 USC 300u–13. 
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124 STAT. 565 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) IN
GENERAL.—An eligible entity shall use amounts 
received under a grant under this section to carry out programs 
described in this subsection. 
(2) COMMUNITY TRANSFORMATION PLAN.— 
(A) IN GENERAL.—An eligible entity that receives a 
grant under this section shall submit to the Director (for 
approval) a detailed plan that includes the policy, environ-
mental, programmatic, and as appropriate infrastructure 
changes needed to promote healthy living and reduce 
disparities. 
(B) ACTIVITIES.—Activities within the plan may focus 
on (but not be limited to)— 
(i) 
creating 
healthier 
school 
environments, 
including increasing healthy food options, physical 
activity opportunities, promotion of healthy lifestyle, 
emotional wellness, and prevention curricula, and 
activities to prevent chronic diseases; 
(ii) creating the infrastructure to support active 
living and access to nutritious foods in a safe environ-
ment; 
(iii) developing and promoting programs targeting 
a variety of age levels to increase access to nutrition, 
physical activity and smoking cessation, improve social 
and emotional wellness, enhance safety in a commu-
nity, or address any other chronic disease priority area 
identified by the grantee; 
(iv) assessing and implementing worksite wellness 
programming and incentives; 
(v) working to highlight healthy options at res-
taurants and other food venues; 
(vi) prioritizing strategies to reduce racial and 
ethnic disparities, including social, economic, and 
geographic determinants of health; and 
(vii) 
addressing 
special 
populations 
needs, 
including all age groups and individuals with disabil-
ities, and individuals in both urban and rural areas. 
(3) COMMUNITY-BASED PREVENTION HEALTH ACTIVITIES.— 
(A) IN GENERAL.—An eligible entity shall use amounts 
received under a grant under this section to implement 
a variety of programs, policies, and infrastructure improve-
ments to promote healthier lifestyles. 
(B) ACTIVITIES.—An eligible entity shall implement 
activities detailed in the community transformation plan 
under paragraph (2). 
(C) IN-KIND SUPPORT.—An eligible entity may provide 
in-kind resources such as staff, equipment, or office space 
in carrying out activities under this section. 
(4) EVALUATION.— 
(A) IN GENERAL.—An eligible entity shall use amounts 
provided under a grant under this section to conduct activi-
ties to measure changes in the prevalence of chronic disease 
risk factors among community members participating in 
preventive health activities 
(B) TYPES
OF
MEASURES.—In carrying out subpara-
graph (A), the eligible entity shall, with respect to residents 
in the community, measure— 
(i) changes in weight; 
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124 STAT. 566 
PUBLIC LAW 111–148—MAR. 23, 2010 
(ii) changes in proper nutrition; 
(iii) changes in physical activity; 
(iv) changes in tobacco use prevalence; 
(v) changes in emotional well-being and overall 
mental health; 
(vi) other factors using community-specific data 
from the Behavioral Risk Factor Surveillance Survey; 
and 
(vii) other factors as determined by the Secretary. 
(C) REPORTING.—An eligible entity shall annually 
submit to the Director a report containing an evaluation 
of activities carried out under the grant. 
(5) DISSEMINATION.—A grantee under this section shall— 
(A) meet at least annually in regional or national 
meetings to discuss challenges, best practices, and lessons 
learned with respect to activities carried out under the 
grant; and 
(B) develop models for the replication of successful 
programs and activities and the mentoring of other eligible 
entities. 
(d) TRAINING.— 
(1) IN GENERAL.—The Director shall develop a program 
to provide training for eligible entities on effective strategies 
for the prevention and control of chronic disease and the link 
between physical, emotional, and social well-being. 
(2) COMMUNITY TRANSFORMATION PLAN.—The Director shall 
provide appropriate feedback and technical assistance to 
grantees to establish community transformation plans 
(3) EVALUATION.—The Director shall provide a literature 
review and framework for the evaluation of programs conducted 
as part of the grant program under this section, in addition 
to working with academic institutions or other entities with 
expertise in outcome evaluation. 
(e) PROHIBITION.—A grantee shall not use funds provided under 
a grant under this section to create video games or to carry out 
any other activities that may lead to higher rates of obesity or 
inactivity. 
(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated to carry out this section, such sums as may 
be necessary for each fiscal years 2010 through 2014. 
SEC. 4202. HEALTHY AGING, LIVING WELL; EVALUATION OF COMMU-
NITY-BASED PREVENTION AND WELLNESS PROGRAMS 
FOR MEDICARE BENEFICIARIES. 
(a) HEALTHY AGING, LIVING WELL.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services (referred to in this section as the ‘‘Secretary’’), acting 
through the Director of the Centers for Disease Control and 
Prevention, shall award grants to State or local health depart-
ments and Indian tribes to carry out 5-year pilot programs 
to provide public health community interventions, screenings, 
and where necessary, clinical referrals for individuals who are 
between 55 and 64 years of age. 
(2) ELIGIBILITY.—To be eligible to receive a grant under 
paragraph (1), an entity shall— 
(A) be— 
(i) a State health department; 
42 USC 300u–14. 
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124 STAT. 567 
PUBLIC LAW 111–148—MAR. 23, 2010 
(ii) a local health department; or 
(iii) an Indian tribe; 
(B) submit to the Secretary an application at such 
time, in such manner, and containing such information 
as the Secretary may require including a description of 
the program to be carried out under the grant; 
(C) design a strategy for improving the health of the 
55-to-64 year-old population through community-based 
public health interventions; and 
(D) demonstrate the capacity, if funded, to develop 
the relationships necessary with relevant health agencies, 
health care providers, community-based organizations, and 
insurers to carry out the activities described in paragraph 
(3), such relationships to include the identification of a 
community-based clinical partner, such as a community 
health center or rural health clinic. 
(3) USE OF FUNDS.— 
(A) IN GENERAL.—A State or local health department 
shall use amounts received under a grant under this sub-
section to carry out a program to provide the services 
described in this paragraph to individuals who are between 
55 and 64 years of age. 
(B) PUBLIC HEALTH INTERVENTIONS.— 
(i) IN GENERAL.—In developing and implementing 
such activities, a grantee shall collaborate with the 
Centers for Disease Control and Prevention and the 
Administration on Aging, and relevant local agencies 
and organizations. 
(ii) TYPES OF INTERVENTION ACTIVITIES.—Interven-
tion activities conducted under this subparagraph may 
include efforts to improve nutrition, increase physical 
activity, reduce tobacco use and substance abuse, 
improve mental health, and promote healthy lifestyles 
among the target population. 
(C) COMMUNITY PREVENTIVE SCREENINGS.— 
(i) IN GENERAL.—In addition to community-wide 
public health interventions, a State or local health 
department shall use amounts received under a grant 
under this subsection to conduct ongoing health 
screening to identify risk factors for cardiovascular 
disease, cancer, stroke, and diabetes among individuals 
in both urban and rural areas who are between 55 
and 64 years of age. 
(ii) TYPES
OF
SCREENING
ACTIVITIES.—Screening 
activities conducted under this subparagraph may 
include— 
(I) mental health/behavioral health and sub-
stance use disorders; 
(II) physical activity, smoking, and nutrition; 
and 
(III) any other measures deemed appropriate 
by the Secretary. 
(iii) MONITORING.—Grantees under this section 
shall maintain records of screening results under this 
subparagraph to establish the baseline data for moni-
toring the targeted population 
Records. 
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124 STAT. 568 
PUBLIC LAW 111–148—MAR. 23, 2010 
(D) CLINICAL REFERRAL/TREATMENT FOR CHRONIC DIS-
EASES.— 
(i) IN GENERAL.—A State or local health depart-
ment shall use amounts received under a grant under 
this subsection to ensure that individuals between 55 
and 64 years of age who are found to have chronic 
disease risk factors through the screening activities 
described in subparagraph (C)(ii), receive clinical 
referral/treatment for follow-up services to reduce such 
risk. 
(ii) MECHANISM.— 
(I) IDENTIFICATION
AND
DETERMINATION
OF 
STATUS.—With respect to each individual with risk 
factors for or having heart disease, stroke, 
diabetes, or any other condition for which such 
individual was screened under subparagraph (C), 
a grantee under this section shall determine 
whether or not such individual is covered under 
any public or private health insurance program. 
(II) 
INSURED
INDIVIDUALS.—An 
individual 
determined to be covered under a health insurance 
program under subclause (I) shall be referred by 
the grantee to the existing providers under such 
program or, if such individual does not have a 
current provider, to a provider who is in-network 
with respect to the program involved. 
(III) UNINSURED
INDIVIDUALS.—With respect 
to an individual determined to be uninsured under 
subclause (I), the grantee’s community-based clin-
ical partner described in paragraph (4)(D) shall 
assist the individual in determining eligibility for 
available public coverage options and identify other 
appropriate community health care resources and 
assistance programs. 
(iii) PUBLIC HEALTH INTERVENTION PROGRAM.—A 
State or local health department shall use amounts 
received under a grant under this subsection to enter 
into contracts with community health centers or rural 
health clinics and mental health and substance use 
disorder service providers to assist in the referral/treat-
ment of at risk patients to community resources for 
clinical follow-up and help determine eligibility for 
other public programs. 
(E) GRANTEE EVALUATION.—An eligible entity shall use 
amounts provided under a grant under this subsection 
to conduct activities to measure changes in the prevalence 
of chronic disease risk factors among participants. 
(4) PILOT PROGRAM EVALUATION.—The Secretary shall con-
duct an annual evaluation of the effectiveness of the pilot 
program under this subsection. In determining such effective-
ness, the Secretary shall consider changes in the prevalence 
of uncontrolled chronic disease risk factors among new Medicare 
enrollees (or individuals nearing enrollment, including those 
who are 63 and 64 years of age) who reside in States or 
localities receiving grants under this section as compared with 
national and historical data for those States and localities 
for the same population. 
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124 STAT. 569 
PUBLIC LAW 111–148—MAR. 23, 2010 
(5) AUTHORIZATION OF APPROPRIATIONS.—There are author-
ized to be appropriated to carry out this subsection, such sums 
as may be necessary for each of fiscal years 2010 through 
2014. 
(b) EVALUATION AND PLAN FOR COMMUNITY-BASED PREVENTION 
AND WELLNESS PROGRAMS FOR MEDICARE BENEFICIARIES.— 
(1) IN GENERAL.—The Secretary shall conduct an evaluation 
of community-based prevention and wellness programs and 
develop a plan for promoting healthy lifestyles and chronic 
disease self-management for Medicare beneficiaries. 
(2) MEDICARE EVALUATION OF PREVENTION AND WELLNESS 
PROGRAMS.— 
(A) IN GENERAL.—The Secretary shall evaluate commu-
nity prevention and wellness programs including those that 
are sponsored by the Administration on Aging, are evi-
dence-based, and have demonstrated potential to help 
Medicare beneficiaries (particularly beneficiaries that have 
attained 65 years of age) reduce their risk of disease, 
disability, and injury by making healthy lifestyle choices, 
including exercise, diet, and self-management of chronic 
diseases. 
(B) EVALUATION.—The evaluation under subparagraph 
(A) shall consist of the following: 
(i) EVIDENCE REVIEW.—The Secretary shall review 
available evidence, literature, best practices, and 
resources that are relevant to programs that promote 
healthy lifestyles and reduce risk factors for the Medi-
care population. The Secretary may determine the 
scope of the evidence review and such issues to be 
considered, which shall include, at a minimum— 
(I) physical activity, nutrition, and obesity; 
(II) falls; 
(III) chronic disease self-management; and 
(IV) mental health. 
(ii) INDEPENDENT EVALUATION OF EVIDENCE-BASED 
COMMUNITY PREVENTION AND WELLNESS PROGRAMS.— 
The Administrator of the Centers for Medicare & Med-
icaid Services, in consultation with the Assistant Sec-
retary for Aging, shall, to the extent feasible and prac-
ticable, conduct an evaluation of existing community 
prevention and wellness programs that are sponsored 
by the Administration on Aging to assess the extent 
to which Medicare beneficiaries who participate in such 
programs— 
(I) reduce their health risks, improve their 
health outcomes, and adopt and maintain healthy 
behaviors; 
(II) improve their ability to manage their 
chronic conditions; and 
(III) reduce their utilization of health services 
and associated costs under the Medicare program 
for conditions that are amenable to improvement 
under such programs. 
(3) REPORT.—Not later than September 30, 2013, the Sec-
retary shall submit to Congress a report that includes— 
(A) recommendations for such legislation and adminis-
trative action as the Secretary determines appropriate to 
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124 STAT. 570 
PUBLIC LAW 111–148—MAR. 23, 2010 
promote healthy lifestyles and chronic disease self-manage-
ment for Medicare beneficiaries; 
(B) any relevant findings relating to the evidence 
review under paragraph (2)(B)(i); and 
(C) the results of the evaluation under paragraph 
(2)(B)(ii). 
(4) FUNDING.—For purposes of carrying out this subsection, 
the Secretary shall provide 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 Supplemental 
Medical Insurance Trust Fund under section 1841 of such Act 
(42 U.S.C. 1395t), in such proportion as the Secretary deter-
mines appropriate, of $50,000,000 to the Centers for Medicare 
& Medicaid Services Program Management Account. Amounts 
transferred under the preceding sentence shall remain available 
until expended. 
(5) ADMINISTRATION.—Chapter 35 of title 44, United States 
Code shall not apply to the this subsection. 
(6) MEDICARE BENEFICIARY.—In this subsection, the term 
‘‘Medicare beneficiary’’ means an individual who is entitled 
to benefits under part A of title XVIII of the Social Security 
Act and enrolled under part B of such title. 
SEC. 4203. REMOVING BARRIERS AND IMPROVING ACCESS TO 
WELLNESS FOR INDIVIDUALS WITH DISABILITIES. 
Title V of the Rehabilitation Act of 1973 (29 U.S.C. 791 et 
seq.) is amended by adding at the end of the following: 
‘‘SEC. 510. ESTABLISHMENT OF STANDARDS FOR ACCESSIBLE MED-
ICAL DIAGNOSTIC EQUIPMENT. 
‘‘(a) STANDARDS.—Not later than 24 months after the date 
of enactment of the Affordable Health Choices Act, the Architectural 
and Transportation Barriers Compliance Board shall, in consulta-
tion with the Commissioner of the Food and Drug Administration, 
promulgate regulatory standards in accordance with the Adminis-
trative Procedure Act (2 U.S.C. 551 et seq.) setting forth the min-
imum technical criteria for medical diagnostic equipment used in 
(or in conjunction with) physician’s offices, clinics, emergency rooms, 
hospitals, and other medical settings. The standards shall ensure 
that such equipment is accessible to, and usable by, individuals 
with accessibility needs, and shall allow independent entry to, use 
of, and exit from the equipment by such individuals to the maximum 
extent possible. 
‘‘(b) MEDICAL DIAGNOSTIC EQUIPMENT COVERED.—The stand-
ards issued under subsection (a) for medical diagnostic equipment 
shall apply to equipment that includes examination tables, examina-
tion chairs (including chairs used for eye examinations or proce-
dures, and dental examinations or procedures), weight scales, 
mammography equipment, x-ray machines, and other radiological 
equipment commonly used for diagnostic purposes by health profes-
sionals. 
‘‘(c) 
REVIEW
AND
AMENDMENT.—The 
Architectural 
and 
Transportation Barriers Compliance Board, in consultation with 
the Commissioner of the Food and Drug Administration, shall 
periodically review and, as appropriate, amend the standards in 
accordance with the Administrative Procedure Act (2 U.S.C. 551 
et seq.).’’. 
Deadline. 
29 USC 794f. 
Definition. 
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124 STAT. 571 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 4204. IMMUNIZATIONS. 
(a) STATE AUTHORITY TO PURCHASE RECOMMENDED VACCINES 
FOR ADULTS.—Section 317 of the Public Health Service Act (42 
U.S.C. 247b) is amended by adding at the end the following: 
‘‘(l) AUTHORITY
TO PURCHASE RECOMMENDED VACCINES
FOR 
ADULTS.— 
‘‘(1) IN GENERAL.—The Secretary may negotiate and enter 
into contracts with manufacturers of vaccines for the purchase 
and delivery of vaccines for adults as provided for under sub-
section (e). 
‘‘(2) STATE
PURCHASE.—A State may obtain additional 
quantities of such adult vaccines (subject to amounts specified 
to the Secretary by the State in advance of negotiations) 
through the purchase of vaccines from manufacturers at the 
applicable price negotiated by the Secretary under this sub-
section.’’. 
(b) DEMONSTRATION PROGRAM TO IMPROVE IMMUNIZATION COV-
ERAGE.—Section 317 of the Public Health Service Act (42 U.S.C. 
247b), as amended by subsection (a), is further amended by adding 
at the end the following: 
‘‘(m) DEMONSTRATION PROGRAM TO IMPROVE IMMUNIZATION 
COVERAGE.— 
‘‘(1) IN
GENERAL.—The Secretary, acting through the 
Director of the Centers for Disease Control and Prevention, 
shall establish a demonstration program to award grants to 
States to improve the provision of recommended immunizations 
for children, adolescents, and adults through the use of evi-
dence-based, population-based interventions for high-risk popu-
lations. 
‘‘(2) STATE PLAN.—To be eligible for a grant under para-
graph (1), a State shall submit to the Secretary an application 
at such time, in such manner, and containing such information 
as the Secretary may require, including a State plan that 
describes the interventions to be implemented under the grant 
and how such interventions match with local needs and 
capabilities, as determined through consultation with local 
authorities. 
‘‘(3) USE OF FUNDS.—Funds received under a grant under 
this subsection shall be used to implement interventions that 
are recommended by the Task Force on Community Preventive 
Services (as established by the Secretary, acting through the 
Director of the Centers for Disease Control and Prevention) 
or other evidence-based interventions, including— 
‘‘(A) providing immunization reminders or recalls for 
target populations of clients, patients, and consumers; 
‘‘(B) educating targeted populations and health care 
providers concerning immunizations in combination with 
one or more other interventions; 
‘‘(C) reducing out-of-pocket costs for families for vac-
cines and their administration; 
‘‘(D) carrying out immunization-promoting strategies 
for participants or clients of public programs, including 
assessments of immunization status, referrals to health 
care providers, education, provision of on-site immuniza-
tions, or incentives for immunization; 
Grants. 
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124 STAT. 572 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(E) providing for home visits that promote immuniza-
tion through education, assessments of need, referrals, 
provision of immunizations, or other services; 
‘‘(F) providing reminders or recalls for immunization 
providers; 
‘‘(G) conducting assessments of, and providing feedback 
to, immunization providers; 
‘‘(H) any combination of one or more interventions 
described in this paragraph; or 
‘‘(I) immunization information systems to allow all 
States to have electronic databases for immunization 
records. 
‘‘(4) CONSIDERATION.—In awarding grants under this sub-
section, the Secretary shall consider any reviews or rec-
ommendations of the Task Force on Community Preventive 
Services. 
‘‘(5) EVALUATION.—Not later than 3 years after the date 
on which a State receives a grant under this subsection, the 
State shall submit to the Secretary an evaluation of progress 
made toward improving immunization coverage rates among 
high-risk populations within the State. 
‘‘(6) REPORT TO CONGRESS.—Not later than 4 years after 
the date of enactment of the Affordable Health Choices Act, 
the Secretary shall submit to Congress a report concerning 
the effectiveness of the demonstration program established 
under this subsection together with recommendations on 
whether to continue and expand such program. 
‘‘(7) AUTHORIZATION OF APPROPRIATIONS.—There is author-
ized to be appropriated to carry out this subsection, such sums 
as may be necessary for each of fiscal years 2010 through 
2014.’’. 
(c) REAUTHORIZATION
OF
IMMUNIZATION
PROGRAM.—Section 
317(j) of the Public Health Service Act (42 U.S.C. 247b(j)) is 
amended— 
(1) in paragraph (1), by striking ‘‘for each of the fiscal 
years 1998 through 2005’’; and 
(2) in paragraph (2), by striking ‘‘after October 1, 1997,’’. 
(d) RULE OF CONSTRUCTION REGARDING ACCESS TO IMMUNIZA-
TIONS.—Nothing in this section (including the amendments made 
by this section), or any other provision of this Act (including any 
amendments made by this Act) shall be construed to decrease 
children’s access to immunizations. 
(e) GAO STUDY AND REPORT ON MEDICARE BENEFICIARY ACCESS 
TO VACCINES.— 
(1) STUDY.—The Comptroller General of the United States 
(in this section referred to as the ‘‘Comptroller General’’) shall 
conduct a study on the ability of Medicare beneficiaries who 
were 65 years of age or older to access routinely recommended 
vaccines covered under the prescription drug program under 
part D of title XVIII of the Social Security Act over the period 
since the establishment of such program. Such study shall 
include the following: 
(A) An analysis and determination of— 
(i) the number of Medicare beneficiaries who were 
65 years of age or older and were eligible for a routinely 
recommended vaccination that was covered under part 
D; 
42 USC 247b 
note. 
Deadline. 
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124 STAT. 573 
PUBLIC LAW 111–148—MAR. 23, 2010 
(ii) the number of such beneficiaries who actually 
received a routinely recommended vaccination that was 
covered under part D; and 
(iii) any barriers to access by such beneficiaries 
to routinely recommended vaccinations that were cov-
ered under part D. 
(B) A summary of the findings and recommendations 
by government agencies, departments, and advisory bodies 
(as well as relevant professional organizations) on the 
impact of coverage under part D of routinely recommended 
adult immunizations for access to such immunizations by 
Medicare beneficiaries. 
(2) REPORT.—Not later than June 1, 2011, the Comptroller 
General shall submit to the appropriate committees of jurisdic-
tion of the House of Representatives and the Senate a report 
containing the results of the study conducted under paragraph 
(1), together with recommendations for such legislation and 
administrative action as the Comptroller General determines 
appropriate. 
(3) FUNDING.—Out of any funds in the Treasury not other-
wise appropriated, there are appropriated $1,000,000 for fiscal 
year 2010 to carry out this subsection. 
SEC. 4205. NUTRITION LABELING OF STANDARD MENU ITEMS AT 
CHAIN RESTAURANTS. 
(a) TECHNICAL AMENDMENTS.—Section 403(q)(5)(A) of the Fed-
eral Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)(A)) is 
amended— 
(1) in subitem (i), by inserting at the beginning ‘‘except 
as provided in clause (H)(ii)(III),’’; and 
(2) in subitem (ii), by inserting at the beginning ‘‘except 
as provided in clause (H)(ii)(III),’’. 
(b) LABELING REQUIREMENTS.—Section 403(q)(5) of the Federal 
Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)) is amended 
by adding at the end the following: 
‘‘(H) RESTAURANTS, RETAIL
FOOD
ESTABLISHMENTS, 
AND 
VENDING MACHINES.— 
‘‘(i) GENERAL REQUIREMENTS FOR RESTAURANTS AND SIMILAR 
RETAIL FOOD ESTABLISHMENTS.—Except for food described in 
subclause (vii), in the case of food that is a standard menu 
item that is offered for sale in a restaurant or similar retail 
food establishment that is part of a chain with 20 or more 
locations doing business under the same name (regardless of 
the type of ownership of the locations) and offering for sale 
substantially the same menu items, the restaurant or similar 
retail food establishment shall disclose the information 
described in subclauses (ii) and (iii). 
‘‘(ii) INFORMATION
REQUIRED
TO
BE
DISCLOSED
BY
RES-
TAURANTS AND RETAIL FOOD ESTABLISHMENTS.—Except as pro-
vided in subclause (vii), the restaurant or similar retail food 
establishment shall disclose in a clear and conspicuous 
manner— 
‘‘(I)(aa) in a nutrient content disclosure statement adja-
cent to the name of the standard menu item, so as to 
be clearly associated with the standard menu item, on 
the menu listing the item for sale, the number of calories 
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124 STAT. 574 
PUBLIC LAW 111–148—MAR. 23, 2010 
contained in the standard menu item, as usually prepared 
and offered for sale; and 
‘‘(bb) a succinct statement concerning suggested daily 
caloric intake, as specified by the Secretary by regulation 
and posted prominently on the menu and designed to 
enable the public to understand, in the context of a total 
daily diet, the significance of the caloric information that 
is provided on the menu; 
‘‘(II)(aa) in a nutrient content disclosure statement 
adjacent to the name of the standard menu item, so as 
to be clearly associated with the standard menu item, 
on the menu board, including a drive-through menu board, 
the number of calories contained in the standard menu 
item, as usually prepared and offered for sale; and 
‘‘(bb) a succinct statement concerning suggested daily 
caloric intake, as specified by the Secretary by regulation 
and posted prominently on the menu board, designed to 
enable the public to understand, in the context of a total 
daily diet, the significance of the nutrition information 
that is provided on the menu board; 
‘‘(III) in a written form, available on the premises of the 
restaurant or similar retail establishment and to the consumer 
upon request, the nutrition information required under clauses 
(C) and (D) of subparagraph (1); and 
‘‘(IV) on the menu or menu board, a prominent, clear, 
and conspicuous statement regarding the availability of the 
information described in item (III). 
‘‘(iii) SELF-SERVICE FOOD AND FOOD ON DISPLAY.—Except 
as provided in subclause (vii), in the case of food sold at a 
salad bar, buffet line, cafeteria line, or similar self-service 
facility, and for self-service beverages or food that is on display 
and that is visible to customers, a restaurant or similar retail 
food establishment shall place adjacent to each food offered 
a sign that lists calories per displayed food item or per serving. 
‘‘(iv) REASONABLE BASIS.—For the purposes of this clause, 
a restaurant or similar retail food establishment shall have 
a reasonable basis for its nutrient content disclosures, including 
nutrient databases, cookbooks, laboratory analyses, and other 
reasonable means, as described in section 101.10 of title 21, 
Code of Federal Regulations (or any successor regulation) or 
in a related guidance of the Food and Drug Administration. 
‘‘(v) MENU VARIABILITY AND COMBINATION MEALS.—The Sec-
retary shall establish by regulation standards for determining 
and disclosing the nutrient content for standard menu items 
that come in different flavors, varieties, or combinations, but 
which are listed as a single menu item, such as soft drinks, 
ice cream, pizza, doughnuts, or children’s combination meals, 
through means determined by the Secretary, including ranges, 
averages, or other methods. 
‘‘(vi) ADDITIONAL
INFORMATION.—If the Secretary deter-
mines that a nutrient, other than a nutrient required under 
subclause (ii)(III), should be disclosed for the purpose of pro-
viding information to assist consumers in maintaining healthy 
dietary practices, the Secretary may require, by regulation, 
disclosure of such nutrient in the written form required under 
subclause (ii)(III). 
‘‘(vii) NONAPPLICABILITY TO CERTAIN FOOD.— 
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124 STAT. 575 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(I) IN GENERAL.—Subclauses (i) through (vi) do not 
apply to— 
‘‘(aa) items that are not listed on a menu or menu 
board (such as condiments and other items placed on 
the table or counter for general use); 
‘‘(bb) 
daily 
specials, 
temporary 
menu 
items 
appearing on the menu for less than 60 days per cal-
endar year, or custom orders; or 
‘‘(cc) such other food that is part of a customary 
market test appearing on the menu for less than 90 
days, under terms and conditions established by the 
Secretary. 
‘‘(II) WRITTEN FORMS.—Subparagraph (5)(C) shall apply 
to any regulations promulgated under subclauses (ii)(III) 
and (vi). 
‘‘(viii) VENDING MACHINES.— 
‘‘(I) IN
GENERAL.—In the case of an article of food 
sold from a vending machine that— 
‘‘(aa) does not permit a prospective purchaser to 
examine the Nutrition Facts Panel before purchasing 
the article or does not otherwise provide visible nutri-
tion information at the point of purchase; and 
‘‘(bb) is operated by a person who is engaged in 
the business of owning or operating 20 or more vending 
machines, 
the vending machine operator shall provide a sign in close 
proximity to each article of food or the selection button 
that includes a clear and conspicuous statement disclosing 
the number of calories contained in the article. 
‘‘(ix) VOLUNTARY PROVISION OF NUTRITION INFORMATION.— 
‘‘(I) IN GENERAL.—An authorized official of any res-
taurant or similar retail food establishment or vending 
machine operator not subject to the requirements of this 
clause may elect to be subject to the requirements of such 
clause, by registering biannually the name and address 
of such restaurant or similar retail food establishment or 
vending machine operator with the Secretary, as specified 
by the Secretary by regulation. 
‘‘(II) REGISTRATION.—Within 120 days of enactment of 
this clause, the Secretary shall publish a notice in the 
Federal Register specifying the terms and conditions for 
implementation of item (I), pending promulgation of regula-
tions. 
‘‘(III) RULE OF CONSTRUCTION.—Nothing in this sub-
clause shall be construed to authorize the Secretary to 
require an application, review, or licensing process for any 
entity to register with the Secretary, as described in such 
item. 
‘‘(x) REGULATIONS.— 
‘‘(I) PROPOSED
REGULATION.—Not later than 1 year 
after the date of enactment of this clause, the Secretary 
shall promulgate proposed regulations to carry out this 
clause. 
‘‘(II) CONTENTS.—In promulgating regulations, the Sec-
retary shall— 
‘‘(aa) consider standardization of recipes and 
methods of preparation, reasonable variation in serving 
Deadline. 
Deadline. 
Notice. 
Federal Register, 
publication. 
Applicability. 
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124 STAT. 576 
PUBLIC LAW 111–148—MAR. 23, 2010 
size and formulation of menu items, space on menus 
and menu boards, inadvertent human error, training 
of food service workers, variations in ingredients, and 
other factors, as the Secretary determines; and 
‘‘(bb) specify the format and manner of the nutrient 
content disclosure requirements under this subclause. 
‘‘(III) REPORTING.—The Secretary shall submit to the 
Committee on Health, Education, Labor, and Pensions of 
the Senate and the Committee on Energy and Commerce 
of the House of Representatives a quarterly report that 
describes the Secretary’s progress toward promulgating 
final regulations under this subparagraph. 
‘‘(xi) DEFINITION.—In this clause, the term ‘menu’ or ‘menu 
board’ means the primary writing of the restaurant or other 
similar retail food establishment from which a consumer makes 
an order selection.’’ 
(c) NATIONAL UNIFORMITY.—Section 403A(a)(4) of the Federal 
Food, Drug, and Cosmetic Act (21 U.S.C. 343–1(a)(4)) is amended 
by striking ‘‘except a requirement for nutrition labeling of food 
which is exempt under subclause (i) or (ii) of section 403(q)(5)(A)’’ 
and inserting ‘‘except that this paragraph does not apply to food 
that is offered for sale in a restaurant or similar retail food 
establishment that is not part of a chain with 20 or more locations 
doing business under the same name (regardless of the type of 
ownership of the locations) and offering for sale substantially the 
same menu items unless such restaurant or similar retail food 
establishment complies with the voluntary provision of nutrition 
information requirements under section 403(q)(5)(H)(ix)’’. 
(d) RULE OF CONSTRUCTION.—Nothing in the amendments made 
by this section shall be construed— 
(1) to preempt any provision of State or local law, unless 
such provision establishes or continues into effect nutrient con-
tent disclosures of the type required under section 403(q)(5)(H) 
of the Federal Food, Drug, and Cosmetic Act (as added by 
subsection (b)) and is expressly preempted under subsection 
(a)(4) of such section; 
(2) to apply to any State or local requirement respecting 
a statement in the labeling of food that provides for a warning 
concerning the safety of the food or component of the food; 
or 
(3) except as provided in section 403(q)(5)(H)(ix) of the 
Federal Food, Drug, and Cosmetic Act (as added by subsection 
(b)), to apply to any restaurant or similar retail food establish-
ment other than a restaurant or similar retail food establish-
ment described in section 403(q)(5)(H)(i) of such Act. 
SEC. 4206. DEMONSTRATION PROJECT CONCERNING INDIVIDUALIZED 
WELLNESS PLAN. 
Section 330 of the Public Health Service Act (42 U.S.C. 245b) 
is amended by adding at the end the following: 
‘‘(s) DEMONSTRATION PROGRAM FOR INDIVIDUALIZED WELLNESS 
PLANS.— 
‘‘(1) IN
GENERAL.—The Secretary shall establish a pilot 
program to test the impact of providing at-risk populations 
who utilize community health centers funded under this section 
an individualized wellness plan that is designed to reduce risk 
21 USC 343 note. 
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124 STAT. 577 
PUBLIC LAW 111–148—MAR. 23, 2010 
factors for preventable conditions as identified by a comprehen-
sive risk-factor assessment. 
‘‘(2) AGREEMENTS.—The Secretary shall enter into agree-
ments with not more than 10 community health centers funded 
under this section to conduct activities under the pilot program 
under paragraph (1). 
‘‘(3) WELLNESS PLANS.— 
‘‘(A) IN GENERAL.—An individualized wellness plan pre-
pared under the pilot program under this subsection may 
include one or more of the following as appropriate to 
the individual’s identified risk factors: 
‘‘(i) Nutritional counseling. 
‘‘(ii) A physical activity plan. 
‘‘(iii) Alcohol and smoking cessation counseling and 
services. 
‘‘(iv) Stress management. 
‘‘(v) Dietary supplements that have health claims 
approved by the Secretary. 
‘‘(vi) Compliance assistance provided by a commu-
nity health center employee. 
‘‘(B) RISK FACTORS.—Wellness plan risk factors shall 
include— 
‘‘(i) weight; 
‘‘(ii) tobacco and alcohol use; 
‘‘(iii) exercise rates; 
‘‘(iv) nutritional status; and 
‘‘(v) blood pressure. 
‘‘(C) COMPARISONS.—Individualized wellness plans 
shall make comparisons between the individual involved 
and a control group of individuals with respect to the 
risk factors described in subparagraph (B). 
‘‘(4) AUTHORIZATION OF APPROPRIATIONS.—There is author-
ized to be appropriated to carry out this subsection, such sums 
as may be necessary.’’. 
SEC. 4207. REASONABLE BREAK TIME FOR NURSING MOTHERS. 
Section 7 of the Fair Labor Standards Act of 1938 (29 U.S.C. 
207) is amended by adding at the end the following: 
‘‘(r)(1) An employer shall provide— 
‘‘(A) a reasonable break time for an employee to express 
breast milk for her nursing child for 1 year after the child’s 
birth each time such employee has need to express the milk; 
and 
‘‘(B) a place, other than a bathroom, that is shielded from 
view and free from intrusion from coworkers and the public, 
which may be used by an employee to express breast milk. 
‘‘(2) An employer shall not be required to compensate an 
employee receiving reasonable break time under paragraph (1) for 
any work time spent for such purpose. 
‘‘(3) An employer that employs less than 50 employees shall 
not be subject to the requirements of this subsection, if such require-
ments would impose an undue hardship by causing the employer 
significant difficulty or expense when considered in relation to 
the size, financial resources, nature, or structure of the employer’s 
business. 
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124 STAT. 578 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(4) Nothing in this subsection shall preempt a State law that 
provides greater protections to employees than the protections pro-
vided for under this subsection.’’. 
Subtitle D—Support for Prevention and 
Public Health Innovation 
SEC. 4301. RESEARCH ON OPTIMIZING THE DELIVERY OF PUBLIC 
HEALTH SERVICES. 
(a) IN GENERAL.—The Secretary of Health and Human Services 
(referred to in this section as the ‘‘Secretary’’), acting through the 
Director of the Centers for Disease Control and Prevention, shall 
provide funding for research in the area of public health services 
and systems. 
(b) REQUIREMENTS OF RESEARCH.—Research supported under 
this section shall include— 
(1) examining evidence-based practices relating to preven-
tion, with a particular focus on high priority areas as identified 
by the Secretary in the National Prevention Strategy or Healthy 
People 2020, and including comparing community-based public 
health interventions in terms of effectiveness and cost; 
(2) analyzing the translation of interventions from academic 
settings to real world settings; and 
(3) identifying effective strategies for organizing, financing, 
or delivering public health services in real world community 
settings, including comparing State and local health depart-
ment structures and systems in terms of effectiveness and 
cost. 
(c) EXISTING PARTNERSHIPS.—Research supported under this 
section shall be coordinated with the Community Preventive Serv-
ices Task Force and carried out by building on existing partnerships 
within the Federal Government while also considering initiatives 
at the State and local levels and in the private sector. 
(d) ANNUAL REPORT.—The Secretary shall, on an annual basis, 
submit to Congress a report concerning the activities and findings 
with respect to research supported under this section. 
SEC. 4302. UNDERSTANDING HEALTH DISPARITIES: DATA COLLECTION 
AND ANALYSIS. 
(a) UNIFORM CATEGORIES AND COLLECTION REQUIREMENTS.— 
The Public Health Service Act (42 U.S.C. 201 et seq.) is amended 
by adding at the end the following: 
‘‘TITLE XXXI—DATA COLLECTION, 
ANALYSIS, AND QUALITY 
‘‘SEC. 3101. DATA COLLECTION, ANALYSIS, AND QUALITY. 
‘‘(a) DATA COLLECTION.— 
‘‘(1) IN GENERAL.—The Secretary shall ensure that, by not 
later than 2 years after the date of enactment of this title, 
any federally conducted or supported health care or public 
health program, activity or survey (including Current Popu-
lation Surveys and American Community Surveys conducted 
Deadline. 
42 USC 300kk. 
42 USC 300u–15. 
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124 STAT. 579 
PUBLIC LAW 111–148—MAR. 23, 2010 
by the Bureau of Labor Statistics and the Bureau of the Census) 
collects and reports, to the extent practicable— 
‘‘(A) data on race, ethnicity, sex, primary language, 
and disability status for applicants, recipients, or partici-
pants; 
‘‘(B) data at the smallest geographic level such as 
State, local, or institutional levels if such data can be 
aggregated; 
‘‘(C) sufficient data to generate statistically reliable 
estimates by racial, ethnic, sex, primary language, and 
disability status subgroups for applicants, recipients or 
participants using, if needed, statistical oversamples of 
these subpopulations; and 
‘‘(D) any other demographic data as deemed appro-
priate by the Secretary regarding health disparities. 
‘‘(2) COLLECTION STANDARDS.—In collecting data described 
in paragraph (1), the Secretary or designee shall— 
‘‘(A) use Office of Management and Budget standards, 
at a minimum, for race and ethnicity measures; 
‘‘(B) develop standards for the measurement of sex, 
primary language, and disability status; 
‘‘(C) develop standards for the collection of data 
described in paragraph (1) that, at a minimum— 
‘‘(i) collects self-reported data by the applicant, 
recipient, or participant; and 
‘‘(ii) collects data from a parent or legal guardian 
if the applicant, recipient, or participant is a minor 
or legally incapacitated; 
‘‘(D) survey health care providers and establish other 
procedures in order to assess access to care and treatment 
for individuals with disabilities and to identify— 
‘‘(i) locations where individuals with disabilities 
access primary, acute (including intensive), and long- 
term care; 
‘‘(ii) the number of providers with accessible facili-
ties and equipment to meet the needs of the individuals 
with disabilities, including medical diagnostic equip-
ment that meets the minimum technical criteria set 
forth in section 510 of the Rehabilitation Act of 1973; 
and 
‘‘(iii) the number of employees of health care pro-
viders trained in disability awareness and patient care 
of individuals with disabilities; and 
‘‘(E) require that any reporting requirement imposed 
for purposes of measuring quality under any ongoing or 
federally conducted or supported health care or public 
health program, activity, or survey includes requirements 
for the collection of data on individuals receiving health 
care items or services under such programs activities by 
race, ethnicity, sex, primary language, and disability status. 
‘‘(3) DATA MANAGEMENT.—In collecting data described in 
paragraph (1), the Secretary, acting through the National 
Coordinator for Health Information Technology shall— 
‘‘(A) develop national standards for the management 
of data collected; and 
‘‘(B) develop interoperability and security systems for 
data management. 
Standards. 
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124 STAT. 580 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(b) DATA ANALYSIS.— 
‘‘(1) IN GENERAL.—For each federally conducted or sup-
ported health care or public health program or activity, the 
Secretary shall analyze data collected under paragraph (a) to 
detect and monitor trends in health disparities (as defined 
for purposes of section 485E) at the Federal and State levels. 
‘‘(c) DATA REPORTING AND DISSEMINATION.— 
‘‘(1) IN GENERAL.—The Secretary shall make the analyses 
described in (b) available to— 
‘‘(A) the Office of Minority Health; 
‘‘(B) the National Center on Minority Health and 
Health Disparities; 
‘‘(C) the Agency for Healthcare Research and Quality; 
‘‘(D) the Centers for Disease Control and Prevention; 
‘‘(E) the Centers for Medicare & Medicaid Services; 
‘‘(F) the Indian Health Service and epidemiology cen-
ters funded under the Indian Health Care Improvement 
Act; 
‘‘(G) the Office of Rural health; 
‘‘(H) other agencies within the Department of Health 
and Human Services; and 
‘‘(I) other entities as determined appropriate by the 
Secretary. 
‘‘(2) REPORTING OF DATA.—The Secretary shall report data 
and analyses described in (a) and (b) through— 
‘‘(A) public postings on the Internet websites of the 
Department of Health and Human Services; and 
‘‘(B) any other reporting or dissemination mechanisms 
determined appropriate by the Secretary. 
‘‘(3) AVAILABILITY OF DATA.—The Secretary may make data 
described in (a) and (b) available for additional research, anal-
yses, and dissemination to other Federal agencies, non-govern-
mental entities, and the public, in accordance with any Federal 
agency’s data user agreements. 
‘‘(d) LIMITATIONS ON USE OF DATA.—Nothing in this section 
shall be construed to permit the use of information collected under 
this section in a manner that would adversely affect any individual. 
‘‘(e) PROTECTION AND SHARING OF DATA.— 
‘‘(1) PRIVACY AND OTHER SAFEGUARDS.—The Secretary shall 
ensure (through the promulgation of regulations or otherwise) 
that— 
‘‘(A) all data collected pursuant to subsection (a) is 
protected— 
‘‘(i) under privacy protections that are at least 
as broad as those that the Secretary applies to other 
health data under the regulations promulgated under 
section 264(c) of the Health Insurance Portability and 
Accountability Act of 1996 (Public Law 104–191; 110 
Stat. 2033); and 
‘‘(ii) from all inappropriate internal use by any 
entity that collects, stores, or receives the data, 
including use of such data in determinations of eligi-
bility (or continued eligibility) in health plans, and 
from other inappropriate uses, as defined by the Sec-
retary; and 
Public 
information. 
Web sites. 
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124 STAT. 581 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) all appropriate information security safeguards 
are used in the collection, analysis, and sharing of data 
collected pursuant to subsection (a). 
‘‘(2) DATA SHARING.—The Secretary shall establish proce-
dures for sharing data collected pursuant to subsection (a), 
measures relating to such data, and analyses of such data, 
with other relevant Federal and State agencies including the 
agencies, centers, and entities within the Department of Health 
and Human Services specified in subsection (c)(1).. 
‘‘(f) DATA ON RURAL UNDERSERVED POPULATIONS.—The Sec-
retary shall ensure that any data collected in accordance with 
this section regarding racial and ethnic minority groups are also 
collected regarding underserved rural and frontier populations. 
‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of 
carrying out this section, there are authorized to be appropriated 
such sums as may be necessary for each of fiscal years 2010 through 
2014. 
‘‘(h) REQUIREMENT
FOR
IMPLEMENTATION.—Notwithstanding 
any other provision of this section, data may not be collected under 
this section unless funds are directly appropriated for such purpose 
in an appropriations Act. 
‘‘(i) CONSULTATION.—The Secretary shall consult with the 
Director of the Office of Personnel Management, the Secretary 
of Defense, the Secretary of Veterans Affairs, the Director of the 
Bureau of the Census, the Commissioner of Social Security, and 
the head of other appropriate Federal agencies in carrying out 
this section.’’. 
(b) ADDRESSING HEALTH CARE DISPARITIES IN MEDICAID AND 
CHIP.— 
(1) STANDARDIZED COLLECTION REQUIREMENTS INCLUDED IN 
STATE PLANS.— 
(A) MEDICAID.—Section 1902(a) of the Social Security 
Act (42 U.S.C. 1396a(a)), as amended by section 2001(d), 
is amended— 
(i) in paragraph 4), by striking ‘‘and’’ at the end; 
(ii) in paragraph (75), by striking the period at 
the end and inserting ‘‘; and’’; and 
(iii) by inserting after paragraph (75) the following 
new paragraph: 
‘‘(76) provide that any data collected under the State plan 
meets the requirements of section 3101 of the Public Health 
Service Act.’’. 
(B) CHIP.—Section 2108(e) of the Social Security Act 
(42 U.S.C. 1397hh(e)) is amended by adding at the end 
the following new paragraph: 
‘‘(7) Data collected and reported in accordance with section 
3101 of the Public Health Service Act, with respect to individ-
uals enrolled in the State child health plan (and, in the case 
of enrollees under 19 years of age, their parents or legal guard-
ians), including data regarding the primary language of such 
individuals, parents, and legal guardians.’’. 
(2) EXTENDING
MEDICARE
REQUIREMENT
TO
ADDRESS 
HEALTH DISPARITIES DATA COLLECTION TO MEDICAID AND CHIP.— 
Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), 
as amended by section 2703 is amended by adding at the 
end the following new section: 
Procedures. 
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124 STAT. 582 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 1946. ADDRESSING HEALTH CARE DISPARITIES. 
‘‘(a) EVALUATING DATA COLLECTION APPROACHES.—The Sec-
retary shall evaluate approaches for the collection of data under 
this title and title XXI, to be performed in conjunction with existing 
quality reporting requirements and programs under this title and 
title XXI, that allow for the ongoing, accurate, and timely collection 
and evaluation of data on disparities in health care services and 
performance on the basis of race, ethnicity, sex, primary language, 
and disability status. In conducting such evaluation, the Secretary 
shall consider the following objectives: 
‘‘(1) Protecting patient privacy. 
‘‘(2) Minimizing the administrative burdens of data collec-
tion and reporting on States, providers, and health plans 
participating under this title or title XXI. 
‘‘(3) Improving program data under this title and title 
XXI on race, ethnicity, sex, primary language, and disability 
status. 
‘‘(b) REPORTS TO CONGRESS.— 
‘‘(1) REPORT ON EVALUATION.—Not later than 18 months 
after the date of the enactment of this section, the Secretary 
shall submit to Congress a report on the evaluation conducted 
under subsection (a). Such report shall, taking into consider-
ation the results of such evaluation— 
‘‘(A) identify approaches (including defining methodolo-
gies) for identifying and collecting and evaluating data 
on health care disparities on the basis of race, ethnicity, 
sex, primary language, and disability status for the pro-
grams under this title and title XXI; and 
‘‘(B) include recommendations on the most effective 
strategies and approaches to reporting HEDIS quality 
measures as required under section 1852(e)(3) and other 
nationally recognized quality performance measures, as 
appropriate, on such bases. 
‘‘(2) REPORTS ON DATA ANALYSES.—Not later than 4 years 
after the date of the enactment of this section, and 4 years 
thereafter, the Secretary shall submit to Congress a report 
that includes recommendations for improving the identification 
of health care disparities for beneficiaries under this title and 
under title XXI based on analyses of the data collected under 
subsection (c). 
‘‘(c) IMPLEMENTING EFFECTIVE APPROACHES.—Not later than 
24 months after the date of the enactment of this section, the 
Secretary shall implement the approaches identified in the report 
submitted under subsection (b)(1) for the ongoing, accurate, and 
timely collection and evaluation of data on health care disparities 
on the basis of race, ethnicity, sex, primary language, and disability 
status.’’. 
SEC. 4303. CDC AND EMPLOYER-BASED WELLNESS PROGRAMS. 
Title III of the Public Health Service Act (42 U.S.C. 241 et 
seq.), by section 4102, is further amended by adding at the end 
the following: 
Deadline. 
42 USC 1396w–5. 
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124 STAT. 583 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘PART U—EMPLOYER-BASED WELLNESS 
PROGRAM 
‘‘SEC. 
399MM. 
TECHNICAL 
ASSISTANCE 
FOR 
EMPLOYER-BASED 
WELLNESS PROGRAMS. 
‘‘In order to expand the utilization of evidence-based prevention 
and health promotion approaches in the workplace, the Director 
shall— 
‘‘(1) provide employers (including small, medium, and large 
employers, as determined by the Director) with technical assist-
ance, consultation, tools, and other resources in evaluating 
such employers’ employer-based wellness programs, including— 
‘‘(A) measuring the participation and methods to 
increase participation of employees in such programs; 
‘‘(B) developing standardized measures that assess 
policy, environmental and systems changes necessary to 
have a positive health impact on employees’ health behav-
iors, health outcomes, and health care expenditures; and 
‘‘(C) evaluating such programs as they relate to 
changes in the health status of employees, the absenteeism 
of employees, the productivity of employees, the rate of 
workplace injury, and the medical costs incurred by 
employees; and 
‘‘(2) build evaluation capacity among workplace staff by 
training employers on how to evaluate employer-based wellness 
programs by ensuring evaluation resources, technical assist-
ance, and consultation are available to workplace staff as 
needed through such mechanisms as web portals, call centers, 
or other means. 
‘‘SEC. 399MM–1. NATIONAL WORKSITE HEALTH POLICIES AND PRO-
GRAMS STUDY. 
‘‘(a) IN GENERAL.—In order to assess, analyze, and monitor 
over time data about workplace policies and programs, and to 
develop instruments to assess and evaluate comprehensive work-
place chronic disease prevention and health promotion programs, 
policies and practices, not later than 2 years after the date of 
enactment of this part, and at regular intervals (to be determined 
by the Director) thereafter, the Director shall conduct a national 
worksite health policies and programs survey to assess employer- 
based health policies and programs. 
‘‘(b) REPORT.—Upon the completion of each study under sub-
section (a), the Director shall submit to Congress a report that 
includes the recommendations of the Director for the implementa-
tion of effective employer-based health policies and programs. 
‘‘SEC. 399MM–2. PRIORITIZATION OF EVALUATION BY SECRETARY. 
‘‘The Secretary shall evaluate, in accordance with this part, 
all programs funded through the Centers for Disease Control and 
Prevention before conducting such an evaluation of privately funded 
programs unless an entity with a privately funded wellness program 
requests such an evaluation. 
‘‘SEC. 399MM–3. PROHIBITION OF FEDERAL WORKPLACE WELLNESS 
REQUIREMENTS. 
‘‘Notwithstanding any other provision of this part, any rec-
ommendations, data, or assessments carried out under this part 
42 USC 280l–3. 
42 USC 280l–2. 
Deadline. 
Determination. 
42 USC 280l–1. 
42 USC 280l. 
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124 STAT. 584 
PUBLIC LAW 111–148—MAR. 23, 2010 
shall not be used to mandate requirements for workplace wellness 
programs.’’. 
SEC. 4304. EPIDEMIOLOGY-LABORATORY CAPACITY GRANTS. 
Title XXVIII of the Public Health Service Act (42 U.S.C. 300hh 
et seq.) is amended by adding at the end the following: 
‘‘Subtitle C—Strengthening Public Health 
Surveillance Systems 
‘‘SEC. 2821. EPIDEMIOLOGY-LABORATORY CAPACITY GRANTS. 
‘‘(a) IN GENERAL.—Subject to the availability of appropriations, 
the Secretary, acting through the Director of the Centers for Disease 
Control and Prevention, shall establish an Epidemiology and Lab-
oratory Capacity Grant Program to award grants to State health 
departments as well as local health departments and tribal jurisdic-
tions that meet such criteria as the Director determines appropriate. 
Academic centers that assist State and eligible local and tribal 
health departments may also be eligible for funding under this 
section as the Director determines appropriate. Grants shall be 
awarded under this section to assist public health agencies in 
improving surveillance for, and response to, infectious diseases and 
other conditions of public health importance by— 
‘‘(1) strengthening epidemiologic capacity to identify and 
monitor the occurrence of infectious diseases and other condi-
tions of public health importance; 
‘‘(2) enhancing laboratory practice as well as systems to 
report test orders and results electronically; 
‘‘(3) improving information systems including developing 
and maintaining an information exchange using national guide-
lines and complying with capacities and functions determined 
by an advisory council established and appointed by the 
Director; and 
‘‘(4) developing and implementing prevention and control 
strategies. 
‘‘(b) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated to carry out this section $190,000,000 for each 
of fiscal years 2010 through 2013, of which— 
‘‘(1) not less than $95,000,000 shall be made available 
each such fiscal year for activities under paragraphs (1) and 
(4) of subsection (a); 
‘‘(2) not less than $60,000,000 shall be made available 
each such fiscal year for activities under subsection (a)(3); and 
‘‘(3) not less than $32,000,000 shall be made available 
each such fiscal year for activities under subsection (a)(2).’’. 
SEC. 4305. ADVANCING RESEARCH AND TREATMENT FOR PAIN CARE 
MANAGEMENT. 
(a) INSTITUTE OF MEDICINE CONFERENCE ON PAIN.— 
(1) CONVENING.—Not later than 1 year after funds are 
appropriated to carry out this subsection, the Secretary of 
Health and Human Services shall seek to enter into an agree-
ment with the Institute of Medicine of the National Academies 
to convene a Conference on Pain (in this subsection referred 
to as ‘‘the Conference’’). 
Deadline. 
Contracts. 
42 USC 
300hh–31. 
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124 STAT. 585 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) PURPOSES.—The purposes of the Conference shall be 
to— 
(A) increase the recognition of pain as a significant 
public health problem in the United States; 
(B) evaluate the adequacy of assessment, diagnosis, 
treatment, and management of acute and chronic pain 
in the general population, and in identified racial, ethnic, 
gender, age, and other demographic groups that may be 
disproportionately affected by inadequacies in the assess-
ment, diagnosis, treatment, and management of pain; 
(C) identify barriers to appropriate pain care; 
(D) establish an agenda for action in both the public 
and private sectors that will reduce such barriers and 
significantly improve the state of pain care research, edu-
cation, and clinical care in the United States. 
(3) OTHER APPROPRIATE ENTITY.—If the Institute of Medi-
cine declines to enter into an agreement under paragraph (1), 
the Secretary of Health and Human Services may enter into 
such agreement with another appropriate entity. 
(4) REPORT.—A report summarizing the Conference’s 
findings and recommendations shall be submitted to the Con-
gress not later than June 30, 2011. 
(5) AUTHORIZATION OF APPROPRIATIONS.—For the purpose 
of carrying out this subsection, there is authorized to be appro-
priated such sums as may be necessary for each of fiscal years 
2010 and 2011. 
(b) PAIN RESEARCH
AT NATIONAL INSTITUTES
OF HEALTH.— 
Part B of title IV of the Public Health Service Act (42 U.S.C. 
284 et seq.) is amended by adding at the end the following: 
‘‘SEC. 409J. PAIN RESEARCH. 
‘‘(a) RESEARCH INITIATIVES.— 
‘‘(1) IN GENERAL.—The Director of NIH is encouraged to 
continue and expand, through the Pain Consortium, an aggres-
sive program of basic and clinical research on the causes of 
and potential treatments for pain. 
‘‘(2) ANNUAL RECOMMENDATIONS.—Not less than annually, 
the Pain Consortium, in consultation with the Division of Pro-
gram Coordination, Planning, and Strategic Initiatives, shall 
develop and submit to the Director of NIH recommendations 
on appropriate pain research initiatives that could be under-
taken with funds reserved under section 402A(c)(1) for the 
Common Fund or otherwise available for such initiatives. 
‘‘(3) DEFINITION.—In this subsection, the term ‘Pain Consor-
tium’ means the Pain Consortium of the National Institutes 
of Health or a similar trans-National Institutes of Health 
coordinating entity designated by the Secretary for purposes 
of this subsection. 
‘‘(b) 
INTERAGENCY
PAIN
RESEARCH
COORDINATING
COM-
MITTEE.— 
‘‘(1) ESTABLISHMENT.—The Secretary shall establish not 
later than 1 year after the date of the enactment of this section 
and as necessary maintain a committee, to be known as the 
Interagency Pain Research Coordinating Committee (in this 
section referred to as the ‘Committee’), to coordinate all efforts 
within the Department of Health and Human Services and 
other Federal agencies that relate to pain research. 
Deadline. 
42 USC 284q. 
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124 STAT. 586 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) MEMBERSHIP.— 
‘‘(A) IN GENERAL.—The Committee shall be composed 
of the following voting members: 
‘‘(i) Not more than 7 voting Federal representatives 
appoint by the Secretary from agencies that conduct 
pain care research and treatment. 
‘‘(ii) 12 additional voting members appointed under 
subparagraph (B). 
‘‘(B) ADDITIONAL
MEMBERS.—The Committee shall 
include additional voting members appointed by the Sec-
retary as follows: 
‘‘(i) 6 non-Federal members shall be appointed from 
among scientists, physicians, and other health profes-
sionals. 
‘‘(ii) 6 members shall be appointed from members 
of the general public, who are representatives of 
leading research, advocacy, and service organizations 
for individuals with pain-related conditions. 
‘‘(C) NONVOTING
MEMBERS.—The Committee shall 
include such nonvoting members as the Secretary deter-
mines to be appropriate. 
‘‘(3) CHAIRPERSON.—The voting members of the Committee 
shall select a chairperson from among such members. The 
selection of a chairperson shall be subject to the approval 
of the Director of NIH. 
‘‘(4) MEETINGS.—The Committee shall meet at the call of 
the chairperson of the Committee or upon the request of the 
Director of NIH, but in no case less often than once each 
year. 
‘‘(5) DUTIES.—The Committee shall— 
‘‘(A) develop a summary of advances in pain care 
research supported or conducted by the Federal agencies 
relevant to the diagnosis, prevention, and treatment of 
pain and diseases and disorders associated with pain; 
‘‘(B) identify critical gaps in basic and clinical research 
on the symptoms and causes of pain; 
‘‘(C) make recommendations to ensure that the activi-
ties of the National Institutes of Health and other Federal 
agencies are free of unnecessary duplication of effort; 
‘‘(D) make recommendations on how best to dissemi-
nate information on pain care; and 
‘‘(E) make recommendations on how to expand partner-
ships between public entities and private entities to expand 
collaborative, cross-cutting research. 
‘‘(6) REVIEW.—The Secretary shall review the necessity of 
the Committee at least once every 2 years.’’. 
(c) PAIN CARE EDUCATION AND TRAINING.—Part D of title VII 
of the Public Health Service Act (42 U.S.C. 294 et seq.) is amended 
by adding at the end the following new section: 
‘‘SEC. 759. PROGRAM FOR EDUCATION AND TRAINING IN PAIN CARE. 
‘‘(a) IN GENERAL.—The Secretary may make awards of grants, 
cooperative agreements, and contracts to health professions schools, 
hospices, and other public and private entities for the development 
and implementation of programs to provide education and training 
to health care professionals in pain care. 
42 USC 294i. 
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124 STAT. 587 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(b) CERTAIN TOPICS.—An award may be made under subsection 
(a) only if the applicant for the award agrees that the program 
carried out with the award will include information and education 
on— 
‘‘(1) recognized means for assessing, diagnosing, treating, 
and managing pain and related signs and symptoms, including 
the medically appropriate use of controlled substances; 
‘‘(2) applicable laws, regulations, rules, and policies on con-
trolled substances, including the degree to which misconcep-
tions and concerns regarding such laws, regulations, rules, 
and policies, or the enforcement thereof, may create barriers 
to patient access to appropriate and effective pain care; 
‘‘(3) interdisciplinary approaches to the delivery of pain 
care, including delivery through specialized centers providing 
comprehensive pain care treatment expertise; 
‘‘(4) cultural, linguistic, literacy, geographic, and other bar-
riers to care in underserved populations; and 
‘‘(5) recent findings, developments, and improvements in 
the provision of pain care. 
‘‘(c) EVALUATION OF PROGRAMS.—The Secretary shall (directly 
or through grants or contracts) provide for the evaluation of pro-
grams implemented under subsection (a) in order to determine 
the effect of such programs on knowledge and practice of pain 
care. 
‘‘(d) PAIN CARE DEFINED.—For purposes of this section the 
term ‘pain care’ means the assessment, diagnosis, treatment, or 
management of acute or chronic pain regardless of causation or 
body location. 
‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 
to be appropriated to carry out this section, such sums as may 
be necessary for each of the fiscal years 2010 through 2012. 
Amounts appropriated under this subsection shall remain available 
until expended.’’. 
SEC. 4306. FUNDING FOR CHILDHOOD OBESITY DEMONSTRATION 
PROJECT. 
Section 1139A(e)(8) of the Social Security Act (42 U.S.C. 1320b– 
9a(e)(8)) is amended to read as follows: 
‘‘(8) APPROPRIATION.—Out of any funds in the Treasury 
not otherwise appropriated, there is appropriated to carry out 
this subsection, $25,000,000 for the period of fiscal years 2010 
through 2014.’’. 
Subtitle E—Miscellaneous Provisions 
SEC. 4401. SENSE OF THE SENATE CONCERNING CBO SCORING. 
(a) FINDING.—The Senate finds that the costs of prevention 
programs are difficult to estimate due in part because prevention 
initiatives are hard to measure and results may occur outside 
the 5 and 10 year budget windows. 
(b) SENSE OF CONGRESS.—It is the sense of the Senate that 
Congress should work with the Congressional Budget Office to 
develop better methodologies for scoring progress to be made in 
prevention and wellness programs. 
Grants. 
Contracts. 
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124 STAT. 588 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 4402. EFFECTIVENESS OF FEDERAL HEALTH AND WELLNESS INI-
TIATIVES. 
To determine whether existing Federal health and wellness 
initiatives are effective in achieving their stated goals, the Secretary 
of Health and Human Services shall— 
(1) conduct an evaluation of such programs as they relate 
to changes in health status of the American public and specifi-
cally on the health status of the Federal workforce, including 
absenteeism of employees, the productivity of employees, the 
rate of workplace injury, and the medical costs incurred by 
employees, and health conditions, including workplace fitness, 
healthy food and beverages, and incentives in the Federal 
Employee Health Benefits Program; and 
(2) submit to Congress a report concerning such evaluation, 
which shall include conclusions concerning the reasons that 
such existing programs have proven successful or not successful 
and what factors contributed to such conclusions. 
TITLE V—HEALTH CARE WORKFORCE 
Subtitle A—Purpose and Definitions 
SEC. 5001. PURPOSE. 
The purpose of this title is to improve access to and the delivery 
of health care services for all individuals, particularly low income, 
underserved, uninsured, minority, health disparity, and rural popu-
lations by— 
(1) gathering and assessing comprehensive data in order 
for the health care workforce to meet the health care needs 
of individuals, including research on the supply, demand, dis-
tribution, diversity, and skills needs of the health care 
workforce; 
(2) increasing the supply of a qualified health care 
workforce to improve access to and the delivery of health care 
services for all individuals; 
(3) enhancing health care workforce education and training 
to improve access to and the delivery of health care services 
for all individuals; and 
(4) providing support to the existing health care workforce 
to improve access to and the delivery of health care services 
for all individuals. 
SEC. 5002. DEFINITIONS. 
(a) THIS TITLE.—In this title: 
(1) ALLIED HEALTH PROFESSIONAL.—The term ‘‘allied health 
professional’’ means an allied health professional as defined 
in section 799B(5) of the Public Heath Service Act (42 U.S.C. 
295p(5)) who— 
(A) has graduated and received an allied health profes-
sions degree or certificate from an institution of higher 
education; and 
(B) is employed with a Federal, State, local or tribal 
public health agency, or in a setting where patients might 
require health care services, including acute care facilities, 
ambulatory care facilities, personal residences, and other 
42 USC 294q 
note. 
42 USC 294q 
note. 
Reports. 
Evaluation. 
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124 STAT. 589 
PUBLIC LAW 111–148—MAR. 23, 2010 
settings located in health professional shortage areas, medi-
cally underserved areas, or medically underserved popu-
lations, as recognized by the Secretary of Health and 
Human Services. 
(2) HEALTH CARE CAREER PATHWAY.—The term ‘‘healthcare 
career pathway’’ means a rigorous, engaging, and high quality 
set of courses and services that— 
(A) includes an articulated sequence of academic and 
career courses, including 21st century skills; 
(B) is aligned with the needs of healthcare industries 
in a region or State; 
(C) prepares students for entry into the full range 
of postsecondary education options, including registered 
apprenticeships, and careers; 
(D) provides academic and career counseling in stu-
dent-to-counselor ratios that allow students to make 
informed decisions about academic and career options; 
(E) meets State academic standards, State require-
ments for secondary school graduation and is aligned with 
requirements for entry into postsecondary education, and 
applicable industry standards; and 
(F) leads to 2 or more credentials, including— 
(i) a secondary school diploma; and 
(ii) a postsecondary degree, an apprenticeship or 
other occupational certification, a certificate, or a 
license. 
(3) INSTITUTION OF HIGHER EDUCATION.—The term ‘‘institu-
tion of higher education’’ has the meaning given the term 
in sections 101 and 102 of the Higher Education Act of 1965 
(20 U.S.C. 1001 and 1002). 
(4) LOW
INCOME
INDIVIDUAL, STATE
WORKFORCE
INVEST-
MENT
BOARD, AND
LOCAL
WORKFORCE
INVESTMENT
BOARD.— 
(A) LOW-INCOME INDIVIDUAL.—The term ‘‘low-income 
individual’’ has the meaning given that term in section 
101 of the Workforce investment Act of 1998 (29 U.S.C. 
2801). 
(B) STATE
WORKFORCE
INVESTMENT
BOARD; LOCAL 
WORKFORCE
INVESTMENT
BOARD.—The 
terms 
‘‘State 
workforce investment board’’ and ‘‘local workforce invest-
ment board’’, refer to a State workforce investment board 
established under section 111 of the Workforce Investment 
Act of 1998 (29 U.S.C. 2821) and a local workforce invest-
ment board established under section 117 of such Act (29 
U.S.C. 2832), respectively. 
(5) POSTSECONDARY EDUCATION.—The term ‘‘postsecondary 
education’’ means— 
(A) a 4-year program of instruction, or not less than 
a 1-year program of instruction that is acceptable for credit 
toward an associate or a baccalaureate degree, offered by 
an institution of higher education; or 
(B) a certificate or registered apprenticeship program 
at the postsecondary level offered by an institution of 
higher education or a non-profit educational institution. 
(6) REGISTERED APPRENTICESHIP PROGRAM.—The term ‘‘reg-
istered apprenticeship program’’ means an industry skills 
training program at the postsecondary level that combines tech-
nical and theoretical training through structure on the job 
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124 STAT. 590 
PUBLIC LAW 111–148—MAR. 23, 2010 
learning with related instruction (in a classroom or through 
distance learning) while an individual is employed, working 
under the direction of qualified personnel or a mentor, and 
earning incremental wage increases aligned to enhance job 
proficiency, resulting in the acquisition of a nationally recog-
nized and portable certificate, under a plan approved by the 
Office of Apprenticeship or a State agency recognized by the 
Department of Labor. 
(b) TITLE VII OF THE PUBLIC HEALTH SERVICE ACT.—Section 
799B of the Public Health Service Act (42 U.S.C. 295p) is amended— 
(1) by striking paragraph (3) and inserting the following: 
‘‘(3) PHYSICIAN ASSISTANT EDUCATION PROGRAM.—The term 
‘physician assistant education program’ means an educational 
program in a public or private institution in a State that— 
‘‘(A) has as its objective the education of individuals 
who, upon completion of their studies in the program, 
be qualified to provide primary care medical services with 
the supervision of a physician; and 
‘‘(B) is accredited by the Accreditation Review Commis-
sion on Education for the Physician Assistant.’’; and 
(2) by adding at the end the following: 
‘‘(12) AREA HEALTH EDUCATION CENTER.—The term ‘area 
health education center’ means a public or nonprofit private 
organization that has a cooperative agreement or contract in 
effect with an entity that has received an award under sub-
section (a)(1) or (a)(2) of section 751, satisfies the requirements 
in section 751(d)(1), and has as one of its principal functions 
the operation of an area health education center. Appropriate 
organizations may include hospitals, health organizations with 
accredited primary care training programs, accredited physician 
assistant educational programs associated with a college or 
university, and universities or colleges not operating a school 
of medicine or osteopathic medicine. 
‘‘(13) AREA
HEALTH
EDUCATION
CENTER
PROGRAM.—The 
term ‘area health education center program’ means cooperative 
program consisting of an entity that has received an award 
under subsection (a)(1) or (a)(2) of section 751 for the purpose 
of planning, developing, operating, and evaluating an area 
health education center program and one or more area health 
education centers, which carries out the required activities 
described in section 751(c), satisfies the program requirements 
in such section, has as one of its principal functions identifying 
and implementing strategies and activities that address health 
care workforce needs in its service area, in coordination with 
the local workforce investment boards. 
‘‘(14) CLINICAL SOCIAL WORKER.—The term ‘clinical social 
worker’ has the meaning given the term in section 1861(hh)(1) 
of the Social Security Act (42 U.S.C. 1395x(hh)(1)). 
‘‘(15) CULTURAL
COMPETENCY.—The term ‘cultural com-
petency’ shall be defined by the Secretary in a manner con-
sistent with section 1707(d)(3). 
‘‘(16) DIRECT CARE WORKER.—The term ‘direct care worker’ 
has the meaning given that term in the 2010 Standard Occupa-
tional Classifications of the Department of Labor for Home 
Health Aides [31–1011], Psychiatric Aides [31–1013], Nursing 
Assistants [31–1014], and Personal Care Aides [39–9021]. 
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124 STAT. 591 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(17) FEDERALLY
QUALIFIED
HEALTH
CENTER.—The term 
‘Federally qualified health center’ has the meaning given that 
term in section 1861(aa) of the Social Security Act (42 U.S.C. 
1395x(aa)). 
‘‘(18) FRONTIER HEALTH PROFESSIONAL SHORTAGE AREA.— 
The term ‘frontier health professional shortage area’ means 
an area— 
‘‘(A) with a population density less than 6 persons 
per square mile within the service area; and 
‘‘(B) with respect to which the distance or time for 
the population to access care is excessive. 
‘‘(19) GRADUATE
PSYCHOLOGY.—The term ‘graduate psy-
chology’ means an accredited program in professional psy-
chology. 
‘‘(20) HEALTH
DISPARITY
POPULATION.—The term ‘health 
disparity population’ has the meaning given such term in sec-
tion 903(d)(1). 
‘‘(21) HEALTH LITERACY.—The term ‘health literacy’ means 
the degree to which an individual has the capacity to obtain, 
communicate, process, and understand health information and 
services in order to make appropriate health decisions. 
‘‘(22) MENTAL HEALTH SERVICE PROFESSIONAL.—The term 
‘mental health service professional’ means an individual with 
a graduate or postgraduate degree from an accredited institu-
tion of higher education in psychiatry, psychology, school psy-
chology, behavioral pediatrics, psychiatric nursing, social work, 
school social work, substance abuse disorder prevention and 
treatment, marriage and family counseling, school counseling, 
or professional counseling. 
‘‘(23) ONE-STOP DELIVERY SYSTEM CENTER.—The term ‘one- 
stop delivery system’ means a one-stop delivery system 
described in section 134(c) of the Workforce Investment Act 
of 1998 (29 U.S.C. 2864(c)). 
‘‘(24) PARAPROFESSIONAL CHILD AND ADOLESCENT MENTAL 
HEALTH WORKER.—The term ‘paraprofessional child and adoles-
cent mental health worker’ means an individual who is not 
a mental or behavioral health service professional, but who 
works at the first stage of contact with children and families 
who are seeking mental or behavioral health services, including 
substance abuse prevention and treatment services. 
‘‘(25) RACIAL
AND
ETHNIC
MINORITY
GROUP; RACIAL
AND 
ETHNIC MINORITY POPULATION.—The terms ‘racial and ethnic 
minority group’ and ‘racial and ethnic minority population’ 
have the meaning given the term ‘racial and ethnic minority 
group’ in section 1707. 
‘‘(26) RURAL HEALTH CLINIC.—The term ‘rural health clinic’ 
has the meaning given that term in section 1861(aa) of the 
Social Security Act (42 U.S.C. 1395x(aa)).’’. 
(c) TITLE VIII OF THE PUBLIC HEALTH SERVICE ACT.—Section 
801 of the Public Health Service Act (42 U.S.C. 296) is amended— 
(1) in paragraph (2)— 
(A) by striking ‘‘means a’’ and inserting ‘‘means an 
accredited (as defined in paragraph 6)’’; and 
(B) by striking the period as inserting the following: 
‘‘where graduates are— 
‘‘(A) authorized to sit for the National Council Licen-
sure EXamination-Registered Nurse (NCLEX–RN); or 
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124 STAT. 592 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) licensed registered nurses who will receive a grad-
uate or equivalent degree or training to become an 
advanced education nurse as defined by section 811(b).’’; 
and 
(2) by adding at the end the following: 
‘‘(16) ACCELERATED NURSING DEGREE PROGRAM.—The term 
‘accelerated nursing degree program’ means a program of edu-
cation in professional nursing offered by an accredited school 
of nursing in which an individual holding a bachelors degree 
in another discipline receives a BSN or MSN degree in an 
accelerated time frame as determined by the accredited school 
of nursing. 
‘‘(17) BRIDGE OR DEGREE COMPLETION PROGRAM.—The term 
‘bridge or degree completion program’ means a program of 
education in professional nursing offered by an accredited school 
of nursing, as defined in paragraph (2), that leads to a bacca-
laureate degree in nursing. Such programs may include, Reg-
istered Nurse (RN) to Bachelor’s of Science of Nursing (BSN) 
programs, RN to MSN (Master of Science of Nursing) programs, 
or BSN to Doctoral programs.’’. 
Subtitle B—Innovations in the Health Care 
Workforce 
SEC. 5101. NATIONAL HEALTH CARE WORKFORCE COMMISSION. 
(a) PURPOSE.—It is the purpose of this section to establish 
a National Health Care Workforce Commission that— 
(1) serves as a national resource for Congress, the Presi-
dent, States, and localities; 
(2) communicates and coordinates with the Departments 
of Health and Human Services, Labor, Veterans Affairs, Home-
land Security, and Education on related activities administered 
by one or more of such Departments; 
(3) develops and commissions evaluations of education and 
training activities to determine whether the demand for health 
care workers is being met; 
(4) identifies barriers to improved coordination at the Fed-
eral, State, and local levels and recommend ways to address 
such barriers; and 
(5) encourages innovations to address population needs, 
constant changes in technology, and other environmental fac-
tors. 
(b) ESTABLISHMENT.—There is hereby established the National 
Health Care Workforce Commission (in this section referred to 
as the ‘‘Commission’’). 
(c) MEMBERSHIP.— 
(1) NUMBER AND APPOINTMENT.—The Commission shall be 
composed of 15 members to be appointed by the Comptroller 
General, without regard to section 5 of the Federal Advisory 
Committee Act (5 U.S.C. App.). 
(2) QUALIFICATIONS.— 
(A) IN GENERAL.—The membership of the Commission 
shall include individuals— 
(i) with national recognition for their expertise 
in health care labor market analysis, including health 
care workforce analysis; health care finance and 
42 USC 294q. 
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124 STAT. 593 
PUBLIC LAW 111–148—MAR. 23, 2010 
economics; health care facility management; health 
care plans and integrated delivery systems; health care 
workforce education and training; health care philan-
thropy; providers of health care services; and other 
related fields; and 
(ii) who will provide a combination of professional 
perspectives, broad geographic representation, and a 
balance between urban, suburban, rural, and frontier 
representatives. 
(B) INCLUSION.— 
(i) IN GENERAL.—The membership of the Commis-
sion shall include no less than one representative of— 
(I) the health care workforce and health 
professionals; 
(II) employers; 
(III) third-party payers; 
(IV) individuals skilled in the conduct and 
interpretation of health care services and health 
economics research; 
(V) representatives of consumers; 
(VI) labor unions; 
(VII) State or local workforce investment 
boards; and 
(VIII) educational institutions (which may 
include elementary and secondary institutions, 
institutions of higher education, including 2 and 
4 year institutions, or registered apprenticeship 
programs). 
(ii) ADDITIONAL MEMBERS.—The remaining mem-
bership may include additional representatives from 
clause (i) and other individuals as determined appro-
priate by the Comptroller General of the United States. 
(C) MAJORITY
NON-PROVIDERS.—Individuals who are 
directly involved in health professions education or practice 
shall not constitute a majority of the membership of the 
Commission. 
(D) ETHICAL
DISCLOSURE.—The Comptroller General 
shall establish a system for public disclosure by members 
of the Commission of financial and other potential conflicts 
of interest relating to such members. Members of the 
Commission shall be treated as employees of Congress 
for purposes of applying title I of the Ethics in Government 
Act of 1978. Members of the Commission shall not be 
treated as special government employees under title 18, 
United States Code. 
(3) TERMS.— 
(A) IN
GENERAL.—The terms of members of the 
Commission shall be for 3 years except that the Comptroller 
General shall designate staggered terms for the members 
first appointed. 
(B) VACANCIES.—Any member appointed to fill a 
vacancy occurring before the expiration of the term for 
which the member’s predecessor was appointed shall be 
appointed only for the remainder of that term. A member 
may serve after the expiration of that member’s term until 
a successor has taken office. A vacancy in the Commission 
Public 
information. 
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124 STAT. 594 
PUBLIC LAW 111–148—MAR. 23, 2010 
shall be filled in the manner in which the original appoint-
ment was made. 
(C) INITIAL APPOINTMENTS.—The Comptroller General 
shall make initial appointments of members to the Commis-
sion not later than September 30, 2010. 
(4) COMPENSATION.—While serving on the business of the 
Commission (including travel time), a member of the Commis-
sion shall be entitled to compensation at the per diem equiva-
lent of the rate provided for level IV of the Executive Schedule 
under section 5315 of tile 5, United States Code, and while 
so serving away from home and the member’s regular place 
of business, a member may be allowed travel expenses, as 
authorized by the Chairman of the Commission. Physicians 
serving as personnel of the Commission may be provided a 
physician comparability allowance by the Commission in the 
same manner as Government physicians may be provided such 
an allowance by an agency under section 5948 of title 5, United 
States Code, and for such purpose subsection (i) of such section 
shall apply to the Commission in the same manner as it applies 
to the Tennessee Valley Authority. For purposes of pay (other 
than pay of members of the Commission) and employment 
benefits, rights, and privileges, all personnel of the Commission 
shall be treated as if they were employees of the United States 
Senate. Personnel of the Commission shall not be treated as 
employees of the Government Accountability Office for any 
purpose. 
(5) CHAIRMAN, VICE CHAIRMAN.—The Comptroller General 
shall designate a member of the Commission, at the time of 
appointment of the member, as Chairman and a member as 
Vice Chairman for that term of appointment, except that in 
the case of vacancy of the chairmanship or vice chairmanship, 
the Comptroller General may designate another member for 
the remainder of that member’s term. 
(6) MEETINGS.—The Commission shall meet at the call 
of the chairman, but no less frequently than on a quarterly 
basis. 
(d) DUTIES.— 
(1) RECOGNITION, DISSEMINATION, AND COMMUNICATION.— 
The Commission shall— 
(A) recognize efforts of Federal, State, and local part-
nerships to develop and offer health care career pathways 
of proven effectiveness; 
(B) disseminate information on promising retention 
practices for health care professionals; and 
(C) communicate information on important policies and 
practices that affect the recruitment, education and 
training, and retention of the health care workforce. 
(2) REVIEW
OF
HEALTH
CARE
WORKFORCE
AND
ANNUAL 
REPORTS.—In order to develop a fiscally sustainable integrated 
workforce that supports a high-quality, readily accessible health 
care delivery system that meets the needs of patients and 
populations, the Commission, in consultation with relevant Fed-
eral, State, and local agencies, shall— 
(A) review current and projected health care workforce 
supply and demand, including the topics described in para-
graph (3); 
Designation. 
Applicability. 
Deadline. 
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124 STAT. 595 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) make recommendations to Congress and the 
Administration concerning national health care workforce 
priorities, goals, and policies; 
(C) by not later than October 1 of each year (beginning 
with 2011), submit a report to Congress and the Adminis-
tration containing the results of such reviews and rec-
ommendations concerning related policies; and 
(D) by not later than April 1 of each year (beginning 
with 2011), submit a report to Congress and the Adminis-
tration containing a review of, and recommendations on, 
at a minimum one high priority area as described in para-
graph (4). 
(3) SPECIFIC TOPICS TO BE REVIEWED.—The topics described 
in this paragraph include— 
(A) current health care workforce supply and distribu-
tion, including demographics, skill sets, and demands, with 
projected demands during the subsequent 10 and 25 year 
periods; 
(B) health care workforce education and training 
capacity, including the number of students who have com-
pleted 
education 
and 
training, 
including 
registered 
apprenticeships; the number of qualified faculty; the edu-
cation and training infrastructure; and the education and 
training demands, with projected demands during the sub-
sequent 10 and 25 year periods; 
(C) the education loan and grant programs in titles 
VII and VIII of the Public Health Service Act (42 U.S.C. 
292 et seq. and 296 et seq.), with recommendations on 
whether such programs should become part of the Higher 
Education Act of 1965 (20 U.S.C. 1001 et seq); 
(D) the implications of new and existing Federal poli-
cies which affect the health care workforce, including Medi-
care and Medicaid graduate medical education policies, 
titles VII and VIII of the Public Health Service Act (42 
U.S.C. 292 et seq. and 296 et seq.), the National Health 
Service Corps (with recommendations for aligning such 
programs with national health workforce priorities and 
goals), and other health care workforce programs, including 
those supported through the Workforce Investment Act 
of 1998 (29 U.S.C. 2801 et seq.), the Carl D. Perkins 
Career and Technical Education Act of 2006 (20 U.S.C. 
2301 et seq.), the Higher Education Act of 1965 (20 U.S.C. 
1001 et seq.), and any other Federal health care workforce 
programs; 
(E) the health care workforce needs of special popu-
lations, such as minorities, rural populations, medically 
underserved populations, gender specific needs, individuals 
with disabilities, and geriatric and pediatric populations 
with recommendations for new and existing Federal policies 
to meet the needs of these special populations; and 
(F) recommendations creating or revising national loan 
repayment programs and scholarship programs to require 
low-income, minority medical students to serve in their 
home communities, if designated as medical underserved 
community. 
(4) HIGH PRIORITY AREAS.— 
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124 STAT. 596 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) IN
GENERAL.—The initial high priority topics 
described in this paragraph include each of the following: 
(i) Integrated health care workforce planning that 
identifies health care professional skills needed and 
maximizes the skill sets of health care professionals 
across disciplines. 
(ii) An analysis of the nature, scopes of practice, 
and demands for health care workers in the enhanced 
information technology and management workplace. 
(iii) An analysis of how to align Medicare and 
Medicaid graduate medical education policies with 
national workforce goals. 
(iv) The education and training capacity, projected 
demands, and integration with the health care delivery 
system of each of the following: 
(I) Nursing workforce capacity at all levels. 
(II) Oral health care workforce capacity at all 
levels. 
(III) Mental and behavioral health care 
workforce capacity at all levels. 
(IV) Allied health and public health care 
workforce capacity at all levels. 
(V) Emergency medical service workforce 
capacity, including the retention and recruitment 
of the volunteer workforce, at all levels. 
(VI) The geographic distribution of health care 
providers as compared to the identified health care 
workforce needs of States and regions. 
(B) FUTURE DETERMINATIONS.—The Commission may 
require that additional topics be included under subpara-
graph (A). The appropriate committees of Congress may 
recommend to the Commission the inclusion of other topics 
for health care workforce development areas that require 
special attention. 
(5) GRANT PROGRAM.—The Commission shall— 
(A) review implementation progress reports on, and 
report to Congress about, the State Health Care Workforce 
Development Grant program established in section 5102; 
(B) in collaboration with the Department of Labor and 
in coordination with the Department of Education and 
other relevant Federal agencies, make recommendations 
to the fiscal and administrative agent under section 5102(b) 
for grant recipients under section 5102; 
(C) assess the implementation of the grants under 
such section; and 
(D) collect performance and report information, 
including identified models and best practices, on grants 
from the fiscal and administrative agent under such section 
and distribute this information to Congress, relevant Fed-
eral agencies, and to the public. 
(6) STUDY.—The Commission shall study effective mecha-
nisms for financing education and training for careers in health 
care, including public health and allied health. 
(7) RECOMMENDATIONS.—The Commission shall submit rec-
ommendations to Congress, the Department of Labor, and the 
Department of Health and Human Services about improving 
Review. 
Reports. 
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124 STAT. 597 
PUBLIC LAW 111–148—MAR. 23, 2010 
safety, health, and worker protections in the workplace for 
the health care workforce. 
(8) ASSESSMENT.—The Commission shall assess and receive 
reports from the National Center for Health Care Workforce 
Analysis established under section 761(b) of the Public Service 
Health Act (as amended by section 5103). 
(e) CONSULTATION WITH FEDERAL, STATE, AND LOCAL AGENCIES, 
CONGRESS, AND OTHER ORGANIZATIONS.— 
(1) IN GENERAL.—The Commission shall consult with Fed-
eral agencies (including the Departments of Health and Human 
Services, Labor, Education, Commerce, Agriculture, Defense, 
and Veterans Affairs and the Environmental Protection 
Agency), Congress, the Medicare Payment Advisory Commis-
sion, the Medicaid and CHIP Payment and Access Commission, 
and, to the extent practicable, with State and local agencies, 
Indian tribes, voluntary health care organizations, professional 
societies, and other relevant public-private health care partner-
ships. 
(2) OBTAINING OFFICIAL DATA.—The Commission, consistent 
with established privacy rules, may secure directly from any 
department or agency of the Executive Branch information 
necessary to enable the Commission to carry out this section. 
(3) DETAIL
OF
FEDERAL
GOVERNMENT
EMPLOYEES.—An 
employee of the Federal Government may be detailed to the 
Commission without reimbursement. The detail of such an 
employee shall be without interruption or loss of civil service 
status. 
(f) DIRECTOR AND STAFF; EXPERTS AND CONSULTANTS.—Subject 
to such review as the Comptroller General of the United States 
determines to be necessary to ensure the efficient administration 
of the Commission, the Commission may— 
(1) employ and fix the compensation of an executive director 
that shall not exceed the rate of basic pay payable for level 
V of the Executive Schedule and such other personnel as may 
be necessary to carry out its duties (without regard to the 
provisions of title 5, United States Code, governing appoint-
ments in the competitive service); 
(2) seek such assistance and support as may be required 
in the performance of its duties from appropriate Federal 
departments and agencies; 
(3) enter into contracts or make other arrangements, as 
may be necessary for the conduct of the work of the Commission 
(without regard to section 3709 of the Revised Statutes (41 
U.S.C. 5)); 
(4) make advance, progress, and other payments which 
relate to the work of the Commission; 
(5) provide transportation and subsistence for persons 
serving without compensation; and 
(6) prescribe such rules and regulations as the Commission 
determines to be necessary with respect to the internal 
organization and operation of the Commission. 
(g) POWERS.— 
(1) DATA COLLECTION.—In order to carry out its functions 
under this section, the Commission shall— 
(A) utilize existing information, both published and 
unpublished, where possible, collected and assessed either 
by its own staff or under other arrangements made in 
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124 STAT. 598 
PUBLIC LAW 111–148—MAR. 23, 2010 
accordance with this section, including coordination with 
the Bureau of Labor Statistics; 
(B) carry out, or award grants or contracts for the 
carrying out of, original research and development, where 
existing information is inadequate, and 
(C) adopt procedures allowing interested parties to 
submit information for the Commission’s use in making 
reports and recommendations. 
(2) ACCESS OF THE GOVERNMENT ACCOUNTABILITY OFFICE 
TO
INFORMATION.—The Comptroller General of the United 
States shall have unrestricted access to all deliberations, 
records, and data of the Commission, immediately upon request. 
(3) PERIODIC AUDIT.—The Commission shall be subject to 
periodic audit by an independent public accountant under con-
tract to the Commission. 
(h) AUTHORIZATION OF APPROPRIATIONS.— 
(1) REQUEST FOR APPROPRIATIONS.—The Commission shall 
submit requests for appropriations in the same manner as 
the Comptroller General of the United States submits requests 
for appropriations. Amounts so appropriated for the Commis-
sion shall be separate from amounts appropriated for the Comp-
troller General. 
(2) AUTHORIZATION.—There are authorized to be appro-
priated such sums as may be necessary to carry out this section. 
(3) GIFTS AND SERVICES.—The Commission may not accept 
gifts, bequeaths, or donations of property, but may accept and 
use donations of services for purposes of carrying out this 
section. 
(i) DEFINITIONS.—In this section: 
(1) HEALTH
CARE
WORKFORCE.—The term ‘‘health care 
workforce’’ includes all health care providers with direct patient 
care and support responsibilities, such as physicians, nurses, 
nurse practitioners, primary care providers, preventive medi-
cine physicians, optometrists, ophthalmologists, physician 
assistants, pharmacists, dentists, dental hygienists, and other 
oral healthcare professionals, allied health professionals, doc-
tors of chiropractic, community health workers, health care 
paraprofessionals, direct care workers, psychologists and other 
behavioral and mental health professionals (including sub-
stance abuse prevention and treatment providers), social 
workers, physical and occupational therapists, certified nurse 
midwives, podiatrists, the EMS workforce (including profes-
sional and volunteer ambulance personnel and firefighters who 
perform emergency medical services), licensed complementary 
and alternative medicine providers, integrative health practi-
tioners, public health professionals, and any other health 
professional that the Comptroller General of the United States 
determines appropriate. 
(2) HEALTH
PROFESSIONALS.—The term ‘‘health profes-
sionals’’ includes— 
(A) dentists, dental hygienists, primary care providers, 
specialty physicians, nurses, nurse practitioners, physician 
assistants, psychologists and other behavioral and mental 
health professionals (including substance abuse prevention 
and treatment providers), social workers, physical and 
occupational therapists, public health professionals, clinical 
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124 STAT. 599 
PUBLIC LAW 111–148—MAR. 23, 2010 
pharmacists, allied health professionals, doctors of chiro-
practic, community health workers, school nurses, certified 
nurse midwives, podiatrists, licensed complementary and 
alternative 
medicine 
providers, 
the 
EMS 
workforce 
(including professional and volunteer ambulance personnel 
and firefighters who perform emergency medical services), 
and integrative health practitioners; 
(B) national representatives of health professionals; 
(C) representatives of schools of medicine, osteopathy, 
nursing, dentistry, optometry, pharmacy, chiropractic, 
allied health, educational programs for public health profes-
sionals, behavioral and mental health professionals (as so 
defined), social workers, pharmacists, physical and occupa-
tional therapists, oral health care industry dentistry and 
dental hygiene, and physician assistants; 
(D) representatives of public and private teaching hos-
pitals, and ambulatory health facilities, including Federal 
medical facilities; and 
(E) any other health professional the Comptroller Gen-
eral of the United States determines appropriate. 
SEC. 5102. STATE HEALTH CARE WORKFORCE DEVELOPMENT GRANTS. 
(a) ESTABLISHMENT.—There is established a competitive health 
care workforce development grant program (referred to in this sec-
tion as the ‘‘program’’) for the purpose of enabling State partner-
ships to complete comprehensive planning and to carry out activities 
leading to coherent and comprehensive health care workforce 
development strategies at the State and local levels. 
(b) FISCAL AND ADMINISTRATIVE AGENT.—The Health Resources 
and Services Administration of the Department of Health and 
Human Services (referred to in this section as the ‘‘Administration’’) 
shall be the fiscal and administrative agent for the grants awarded 
under this section. The Administration is authorized to carry out 
the program, in consultation with the National Health Care 
Workforce Commission (referred to in this section as the ‘‘Commis-
sion’’), which shall review reports on the development, implementa-
tion, and evaluation activities of the grant program, including— 
(1) administering the grants; 
(2) providing technical assistance to grantees; and 
(3) reporting performance information to the Commission. 
(c) PLANNING GRANTS.— 
(1) AMOUNT AND DURATION.—A planning grant shall be 
awarded under this subsection for a period of not more than 
one year and the maximum award may not be more than 
$150,000. 
(2) ELIGIBILITY.—To be eligible to receive a planning grant, 
an entity shall be an eligible partnership. An eligible partner-
ship shall be a State workforce investment board, if it includes 
or modifies the members to include at least one representative 
from each of the following: health care employer, labor organiza-
tion, a public 2-year institution of higher education, a public 
4-year institution of higher education, the recognized State 
federation of labor, the State public secondary education agency, 
the State P–16 or P–20 Council if such a council exists, and 
a philanthropic organization that is actively engaged in pro-
viding learning, mentoring, and work opportunities to recruit, 
Review. 
42 USC 294r. 
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124 STAT. 600 
PUBLIC LAW 111–148—MAR. 23, 2010 
educate, and train individuals for, and retain individuals in, 
careers in health care and related industries. 
(3) FISCAL AND ADMINISTRATIVE AGENT.—The Governor of 
the State receiving a planning grant has the authority to 
appoint a fiscal and an administrative agency for the partner-
ship. 
(4) APPLICATION.—Each State partnership desiring a plan-
ning grant shall submit an application to the Administrator 
of the Administration at such time and in such manner, and 
accompanied by such information as the Administrator may 
reasonable require. Each application submitted for a planning 
grant shall describe the members of the State partnership, 
the activities for which assistance is sought, the proposed 
performance benchmarks to be used to measure progress under 
the planning grant, a budget for use of the funds to complete 
the required activities described in paragraph (5), and such 
additional assurance and information as the Administrator 
determines to be essential to ensure compliance with the grant 
program requirements. 
(5) REQUIRED ACTIVITIES.—A State partnership receiving 
a planning grant shall carry out the following: 
(A) Analyze State labor market information in order 
to create health care career pathways for students and 
adults, including dislocated workers. 
(B) Identify current and projected high demand State 
or regional health care sectors for purposes of planning 
career pathways. 
(C) Identify existing Federal, State, and private 
resources to recruit, educate or train, and retain a skilled 
health care workforce and strengthen partnerships. 
(D) Describe the academic and health care industry 
skill standards for high school graduation, for entry into 
postsecondary education, and for various credentials and 
licensure. 
(E) Describe State secondary and postsecondary edu-
cation and training policies, models, or practices for the 
health care sector, including career information and guid-
ance counseling. 
(F) Identify Federal or State policies or rules to devel-
oping a coherent and comprehensive health care workforce 
development strategy and barriers and a plan to resolve 
these barriers. 
(G) Participate in the Administration’s evaluation and 
reporting activities. 
(6) PERFORMANCE AND EVALUATION.—Before the State part-
nership receives a planning grant, such partnership and the 
Administrator of the Administration shall jointly determine 
the performance benchmarks that will be established for the 
purposes of the planning grant. 
(7) MATCH.—Each State partnership receiving a planning 
grant shall provide an amount, in cash or in kind, that is 
not less that 15 percent of the amount of the grant, to carry 
out the activities supported by the grant. The matching require-
ment may be provided from funds available under other Fed-
eral, State, local or private sources to carry out the activities. 
(8) REPORT.— 
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124 STAT. 601 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) REPORT TO ADMINISTRATION.—Not later than 1 year 
after a State partnership receives a planning grant, the 
partnership shall submit a report to the Administration 
on the State’s performance of the activities under the grant, 
including the use of funds, including matching funds, to 
carry out required activities, and a description of the 
progress of the State workforce investment board in 
meeting the performance benchmarks. 
(B) REPORT TO CONGRESS.—The Administration shall 
submit a report to Congress analyzing the planning activi-
ties, performance, and fund utilization of each State grant 
recipient, including an identification of promising practices 
and a profile of the activities of each State grant recipient. 
(d) IMPLEMENTATION GRANTS.— 
(1) IN GENERAL.—The Administration shall— 
(A) competitively award implementation grants to 
State partnerships to enable such partnerships to imple-
ment activities that will result in a coherent and com-
prehensive plan for health workforce development that will 
address current and projected workforce demands within 
the State; and 
(B) inform the Commission and Congress about the 
awards made. 
(2) DURATION.—An implementation grant shall be awarded 
for a period of no more than 2 years, except in those cases 
where the Administration determines that the grantee is high 
performing and the activities supported by the grant warrant 
up to 1 additional year of funding. 
(3) ELIGIBILITY.—To be eligible for an implementation 
grant, a State partnership shall have— 
(A) received a planning grant under subsection (c) and 
completed all requirements of such grant; or 
(B) completed a satisfactory application, including a 
plan to coordinate with required partners and complete 
the required activities during the 2 year period of the 
implementation grant. 
(4) FISCAL AND ADMINISTRATIVE AGENT.—A State partner-
ship receiving an implementation grant shall appoint a fiscal 
and an administration agent for the implementation of such 
grant. 
(5) APPLICATION.—Each eligible State partnership desiring 
an implementation grant shall submit an application to the 
Administration at such time, in such manner, and accompanied 
by such information as the Administration may reasonably 
require. Each application submitted shall include— 
(A) a description of the members of the State partner-
ship; 
(B) a description of how the State partnership com-
pleted the required activities under the planning grant, 
if applicable; 
(C) a description of the activities for which implementa-
tion grant funds are sought, including grants to regions 
by the State partnership to advance coherent and com-
prehensive regional health care workforce planning activi-
ties; 
(D) a description of how the State partnership will 
coordinate with required partners and complete the 
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124 STAT. 602 
PUBLIC LAW 111–148—MAR. 23, 2010 
required partnership activities during the duration of an 
implementation grant; 
(E) a budget proposal of the cost of the activities sup-
ported by the implementation grant and a timeline for 
the provision of matching funds required; 
(F) proposed performance benchmarks to be used to 
assess and evaluate the progress of the partnership activi-
ties; 
(G) a description of how the State partnership will 
collect data to report progress in grant activities; and 
(H) such additional assurances as the Administration 
determines to be essential to ensure compliance with grant 
requirements. 
(6) REQUIRED ACTIVITIES.— 
(A) IN GENERAL.—A State partnership that receives 
an implementation grant may reserve not less than 60 
percent of the grant funds to make grants to be competi-
tively awarded by the State partnership, consistent with 
State procurement rules, to encourage regional partner-
ships to address health care workforce development needs 
and to promote innovative health care workforce career 
pathway activities, including career counseling, learning, 
and employment. 
(B) ELIGIBLE PARTNERSHIP DUTIES.—An eligible State 
partnership receiving an implementation grant shall— 
(i) identify and convene regional leadership to dis-
cuss opportunities to engage in statewide health care 
workforce development planning, including the poten-
tial use of competitive grants to improve the develop-
ment, distribution, and diversity of the regional health 
care workforce; the alignment of curricula for health 
care careers; and the access to quality career informa-
tion and guidance and education and training 
opportunities; 
(ii) in consultation with key stakeholders and 
regional leaders, take appropriate steps to reduce Fed-
eral, State, or local barriers to a comprehensive and 
coherent strategy, including changes in State or local 
policies to foster coherent and comprehensive health 
care workforce development activities, including health 
care career pathways at the regional and State levels, 
career planning information, retraining for dislocated 
workers, and as appropriate, requests for Federal pro-
gram or administrative waivers; 
(iii) develop, disseminate, and review with key 
stakeholders a preliminary statewide strategy that 
addresses short- and long-term health care workforce 
development supply versus demand; 
(iv) convene State partnership members on a reg-
ular basis, and at least on a semiannual basis; 
(v) assist leaders at the regional level to form 
partnerships, 
including 
technical 
assistance 
and 
capacity building activities; 
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124 STAT. 603 
PUBLIC LAW 111–148—MAR. 23, 2010 
(vi) collect and assess data on and report on the 
performance benchmarks selected by the State partner-
ship and the Administration for implementation activi-
ties carried out by regional and State partnerships; 
and 
(vii) participate in the Administration’s evaluation 
and reporting activities. 
(7) PERFORMANCE AND EVALUATION.—Before the State part-
nership receives an implementation grant, it and the Adminis-
trator shall jointly determine the performance benchmarks that 
shall be established for the purposes of the implementation 
grant. 
(8) 
MATCH.—Each 
State 
partnership 
receiving 
an 
implementation grant shall provide an amount, in cash or 
in kind that is not less than 25 percent of the amount of 
the grant, to carry out the activities supported by the grant. 
The matching funds may be provided from funds available 
from other Federal, State, local, or private sources to carry 
out such activities. 
(9) REPORTS.— 
(A) REPORT TO ADMINISTRATION.—For each year of the 
implementation grant, the State partnership receiving the 
implementation grant shall submit a report to the Adminis-
tration on the performance of the State of the grant activi-
ties, including a description of the use of the funds, 
including matched funds, to complete activities, and a 
description of the performance of the State partnership 
in meeting the performance benchmarks. 
(B) REPORT TO CONGRESS.—The Administration shall 
submit a report to Congress analyzing implementation 
activities, performance, and fund utilization of the State 
grantees, including an identification of promising practices 
and a profile of the activities of each State grantee. 
(e) AUTHORIZATION FOR APPROPRIATIONS.— 
(1) PLANNING GRANTS.—There are authorized to be appro-
priated to award planning grants under subsection (c) 
$8,000,000 for fiscal year 2010, and such sums as may be 
necessary for each subsequent fiscal year. 
(2) IMPLEMENTATION GRANTS.—There are authorized to be 
appropriated to award implementation grants under subsection 
(d), $150,000,000 for fiscal year 2010, and such sums as may 
be necessary for each subsequent fiscal year. 
SEC. 5103. HEALTH CARE WORKFORCE ASSESSMENT. 
(a) IN GENERAL.—Section 761 of the Public Health Service 
Act (42 U.S.C. 294m) is amended— 
(1) by redesignating subsection (c) as subsection (e); 
(2) by striking subsection (b) and inserting the following: 
‘‘(b) NATIONAL CENTER FOR HEALTH CARE WORKFORCE ANAL-
YSIS.— 
‘‘(1) ESTABLISHMENT.—The Secretary shall establish the 
National Center for Health Workforce Analysis (referred to 
in this section as the ‘National Center’). 
‘‘(2) PURPOSES.—The National Center, in coordination to 
the extent practicable with the National Health Care Workforce 
42 USC 294n. 
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124 STAT. 604 
PUBLIC LAW 111–148—MAR. 23, 2010 
Commission (established in section 5101 of the Patient Protec-
tion and Affordable Care Act), and relevant regional and State 
centers and agencies, shall— 
‘‘(A) provide for the development of information 
describing and analyzing the health care workforce and 
workforce related issues; 
‘‘(B) carry out the activities under section 792(a); 
‘‘(C) annually evaluate programs under this title; 
‘‘(D) develop and publish performance measures and 
benchmarks for programs under this title; and 
‘‘(E) establish, maintain, and publicize a national Inter-
net registry of each grant awarded under this title and 
a database to collect data from longitudinal evaluations 
(as described in subsection (d)(2)) on performance measures 
(as developed under sections 749(d)(3), 757(d)(3), and 
762(a)(3)). 
‘‘(3) COLLABORATION AND DATA SHARING.— 
‘‘(A) IN GENERAL.—The National Center shall collabo-
rate with Federal agencies and relevant professional and 
educational organizations or societies for the purpose of 
linking data regarding grants awarded under this title. 
‘‘(B) CONTRACTS FOR HEALTH WORKFORCE ANALYSIS.— 
For the purpose of carrying out the activities described 
in subparagraph (A), the National Center may enter into 
contracts with relevant professional and educational 
organizations or societies. 
‘‘(c) STATE AND REGIONAL CENTERS FOR HEALTH WORKFORCE 
ANALYSIS.— 
‘‘(1) IN GENERAL.—The Secretary shall award grants to, 
or enter into contracts with, eligible entities for purposes of— 
‘‘(A) collecting, analyzing, and reporting data regarding 
programs under this title to the National Center and to 
the public; and 
‘‘(B) providing technical assistance to local and regional 
entities on the collection, analysis, and reporting of data. 
‘‘(2) ELIGIBLE ENTITIES.—To be eligible for a grant or con-
tract under this subsection, an entity shall— 
‘‘(A) be a State, a State workforce investment board, 
a public health or health professions school, an academic 
health center, or an appropriate public or private nonprofit 
entity; and 
‘‘(B) submit to the Secretary an application at such 
time, in such manner, and containing such information 
as the Secretary may require. 
‘‘(d) INCREASE IN GRANTS FOR LONGITUDINAL EVALUATIONS.— 
‘‘(1) IN GENERAL.—The Secretary shall increase the amount 
awarded to an eligible entity under this title for a longitudinal 
evaluation of individuals who have received education, training, 
or financial assistance from programs under this title. 
‘‘(2) CAPABILITY.—A longitudinal evaluation shall be 
capable of— 
‘‘(A) studying practice patterns; and 
‘‘(B) collecting and reporting data on performance 
measures developed under sections 749(d)(3), 757(d)(3), and 
762(a)(3). 
Grants. 
Contracts. 
Internet registry. 
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124 STAT. 605 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(3) GUIDELINES.—A longitudinal evaluation shall comply 
with guidelines issued under sections 749(d)(4), 757(d)(4), and 
762(a)(4). 
‘‘(4) ELIGIBLE ENTITIES.—To be eligible to obtain an increase 
under this section, an entity shall be a recipient of a grant 
or contract under this title.’’; and 
(3) in subsection (e), as so redesignated— 
(A) by striking paragraph (1) and inserting the fol-
lowing: 
‘‘(1) IN GENERAL.— 
‘‘(A) NATIONAL CENTER.—To carry out subsection (b), 
there are authorized to be appropriated $7,500,000 for each 
of fiscal years 2010 through 2014. 
‘‘(B) STATE AND REGIONAL CENTERS.—To carry out sub-
section (c), there are authorized to be appropriated 
$4,500,000 for each of fiscal years 2010 through 2014. 
‘‘(C) GRANTS
FOR
LONGITUDINAL
EVALUATIONS.—To 
carry out subsection (d), there are authorized to be appro-
priated such sums as may be necessary for fiscal years 
2010 through 2014.’’; and 
(4) in paragraph (2), by striking ‘‘subsection (a)’’ and 
inserting ‘‘paragraph (1)’’. 
(b) TRANSFERS.—Not later than 180 days after the date of 
enactment of this Act, the responsibilities and resources of the 
National Center for Health Workforce Analysis, as in effect on 
the date before the date of enactment of this Act, shall be trans-
ferred to the National Center for Health Care Workforce Analysis 
established under section 761 of the Public Health Service Act, 
as amended by subsection (a). 
(c) USE OF LONGITUDINAL EVALUATIONS.—Section 791(a)(1) of 
the Public Health Service Act (42 U.S.C. 295j(a)(1)) is amended— 
(1) in subparagraph (A), by striking ‘‘or’’ at the end; 
(2) in subparagraph (B), by striking the period and 
inserting ‘‘; or’’; and 
(3) by adding at the end the following: 
‘‘(C) utilizes a longitudinal evaluation (as described 
in section 761(d)(2)) and reports data from such system 
to the national workforce database (as established under 
section 761(b)(2)(E)).’’. 
(d) PERFORMANCE MEASURES; GUIDELINES FOR LONGITUDINAL 
EVALUATIONS.— 
(1) ADVISORY COMMITTEE ON TRAINING IN PRIMARY CARE 
MEDICINE AND DENTISTRY.—Section 748(d) of the Public Health 
Service Act is amended— 
(A) in paragraph (1), by striking ‘‘and’’ at the end; 
(B) in paragraph (2), by striking the period and 
inserting a semicolon; and 
(C) by adding at the end the following: 
‘‘(3) develop, publish, and implement performance measures 
for programs under this part; 
‘‘(4) develop and publish guidelines for longitudinal evalua-
tions (as described in section 761(d)(2)) for programs under 
this part; and 
‘‘(5) recommend appropriation levels for programs under 
this part.’’. 
42 USC 293l. 
Deadline. 
42 USC 294n 
note. 
Appropriation 
authorization. 
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124 STAT. 606 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) ADVISORY COMMITTEE ON INTERDISCIPLINARY, COMMU-
NITY-BASED
LINKAGES.—Section 756(d) of the Public Health 
Service Act is amended— 
(A) in paragraph (1), by striking ‘‘and’’ at the end; 
(B) in paragraph (2), by striking the period and 
inserting a semicolon; and 
(C) by adding at the end the following: 
‘‘(3) develop, publish, and implement performance measures 
for programs under this part; 
‘‘(4) develop and publish guidelines for longitudinal evalua-
tions (as described in section 761(d)(2)) for programs under 
this part; and 
‘‘(5) recommend appropriation levels for programs under 
this part.’’. 
(3) ADVISORY COUNCIL ON GRADUATE MEDICAL EDUCATION.— 
Section 762(a) of the Public Health Service Act (42 U.S.C. 
294o(a)) is amended— 
(A) in paragraph (1), by striking ‘‘and’’ at the end; 
(B) in paragraph (2), by striking the period and 
inserting a semicolon; and 
(C) by adding at the end the following: 
‘‘(3) develop, publish, and implement performance measures 
for programs under this title, except for programs under part 
C or D; 
‘‘(4) develop and publish guidelines for longitudinal evalua-
tions (as described in section 761(d)(2)) for programs under 
this title, except for programs under part C or D; and 
‘‘(5) recommend appropriation levels for programs under 
this title, except for programs under part C or D.’’. 
Subtitle C—Increasing the Supply of the 
Health Care Workforce 
SEC. 5201. FEDERALLY SUPPORTED STUDENT LOAN FUNDS. 
(a) MEDICAL SCHOOLS AND PRIMARY HEALTH CARE.—Section 
723 of the Public Health Service Act (42 U.S.C. 292s) is amended— 
(1) in subsection (a)— 
(A) in paragraph (1), by striking subparagraph (B) 
and inserting the following: 
‘‘(B) to practice in such care for 10 years (including 
residency training in primary health care) or through the 
date on which the loan is repaid in full, whichever occurs 
first.’’; and 
(B) by striking paragraph (3) and inserting the fol-
lowing: 
‘‘(3) 
NONCOMPLIANCE
BY
STUDENT.—Each 
agreement 
entered into with a student pursuant to paragraph (1) shall 
provide that, if the student fails to comply with such agreement, 
the loan involved will begin to accrue interest at a rate of 
2 percent per year greater than the rate at which the student 
would pay if compliant in such year.’’; and 
(2) by adding at the end the following: 
‘‘(d) SENSE OF CONGRESS.—It is the sense of Congress that 
funds repaid under the loan program under this section should 
not be transferred to the Treasury of the United States or otherwise 
used for any other purpose other than to carry out this section.’’. 
42 USC 294f. 
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124 STAT. 607 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b) STUDENT LOAN GUIDELINES.—The Secretary of Health and 
Human Services shall not require parental financial information 
for an independent student to determine financial need under sec-
tion 723 of the Public Health Service Act (42 U.S.C. 292s) and 
the determination of need for such information shall be at the 
discretion of applicable school loan officer. The Secretary shall 
amend guidelines issued by the Health Resources and Services 
Administration in accordance with the preceding sentence. 
SEC. 5202. NURSING STUDENT LOAN PROGRAM. 
(a) LOAN AGREEMENTS.—Section 836(a) of the Public Health 
Service Act (42 U.S.C. 297b(a)) is amended— 
(1) by striking ‘‘$2,500’’ and inserting ‘‘$3,300’’; 
(2) by striking ‘‘$4,000’’ and inserting ‘‘$5,200’’; and 
(3) by striking ‘‘$13,000’’ and all that follows through the 
period and inserting ‘‘$17,000 in the case of any student during 
fiscal years 2010 and 2011. After fiscal year 2011, such amounts 
shall be adjusted to provide for a cost-of-attendance increase 
for the yearly loan rate and the aggregate of the loans.’’. 
(b) LOAN PROVISIONS.—Section 836(b) of the Public Health 
Service Act (42 U.S.C. 297b(b)) is amended— 
(1) in paragraph (1)(C), by striking ‘‘1986’’ and inserting 
‘‘2000’’; and 
(2) in paragraph (3), by striking ‘‘the date of enactment 
of the Nurse Training Amendments of 1979’’ and inserting 
‘‘September 29, 1995’’. 
SEC. 5203. HEALTH CARE WORKFORCE LOAN REPAYMENT PROGRAMS. 
Part E of title VII of the Public Health Service Act (42 U.S.C. 
294n et seq.) is amended by adding at the end the following: 
‘‘Subpart 3—Recruitment and Retention Programs 
‘‘SEC. 775. INVESTMENT IN TOMORROW’S PEDIATRIC HEALTH CARE 
WORKFORCE. 
‘‘(a) ESTABLISHMENT.—The Secretary shall establish and carry 
out a pediatric specialty loan repayment program under which 
the eligible individual agrees to be employed full-time for a specified 
period (which shall not be less than 2 years) in providing pediatric 
medical subspecialty, pediatric surgical specialty, or child and 
adolescent mental and behavioral health care, including substance 
abuse prevention and treatment services. 
‘‘(b) PROGRAM ADMINISTRATION.—Through the program estab-
lished under this section, the Secretary shall enter into contracts 
with qualified health professionals under which— 
‘‘(1) such qualified health professionals will agree to provide 
pediatric medical subspecialty, pediatric surgical specialty, or 
child and adolescent mental and behavioral health care in 
an area with a shortage of the specified pediatric subspecialty 
that has a sufficient pediatric population to support such pedi-
atric subspecialty, as determined by the Secretary; and 
‘‘(2) the Secretary agrees to make payments on the principal 
and interest of undergraduate, graduate, or graduate medical 
education loans of professionals described in paragraph (1) 
of not more than $35,000 a year for each year of agreed upon 
service under such paragraph for a period of not more than 
3 years during the qualified health professional’s— 
Contracts. 
42 USC 295f. 
42 USC 292s 
note. 
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124 STAT. 608 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) participation in an accredited pediatric medical 
subspecialty, pediatric surgical specialty, or child and 
adolescent mental health subspecialty residency or fellow-
ship; or 
‘‘(B) employment as a pediatric medical subspecialist, 
pediatric surgical specialist, or child and adolescent mental 
health professional serving an area or population described 
in such paragraph. 
‘‘(c) IN GENERAL.— 
‘‘(1) ELIGIBLE INDIVIDUALS.— 
‘‘(A) PEDIATRIC
MEDICAL
SPECIALISTS
AND
PEDIATRIC 
SURGICAL
SPECIALISTS.—For purposes of contracts with 
respect to pediatric medical specialists and pediatric sur-
gical specialists, the term ‘qualified health professional’ 
means a licensed physician who— 
‘‘(i) is entering or receiving training in an accred-
ited pediatric medical subspecialty or pediatric surgical 
specialty residency or fellowship; or 
‘‘(ii) has completed (but not prior to the end of 
the calendar year in which this section is enacted) 
the training described in subparagraph (B). 
‘‘(B) CHILD AND ADOLESCENT MENTAL AND BEHAVIORAL 
HEALTH.—For purposes of contracts with respect to child 
and adolescent mental and behavioral health care, the 
term ‘qualified health professional’ means a health care 
professional who— 
‘‘(i) has received specialized training or clinical 
experience in child and adolescent mental health in 
psychiatry, psychology, school psychology, behavioral 
pediatrics, psychiatric nursing, social work, school 
social work, substance abuse disorder prevention and 
treatment, marriage and family therapy, school coun-
seling, or professional counseling; 
‘‘(ii) has a license or certification in a State to 
practice allopathic medicine, osteopathic medicine, psy-
chology, school psychology, psychiatric nursing, social 
work, school social work, marriage and family therapy, 
school counseling, or professional counseling; or 
‘‘(iii) is a mental health service professional who 
completed (but not before the end of the calendar year 
in which this section is enacted) specialized training 
or clinical experience in child and adolescent mental 
health described in clause (i). 
‘‘(2) ADDITIONAL
ELIGIBILITY
REQUIREMENTS.—The Sec-
retary may not enter into a contract under this subsection 
with an eligible individual unless— 
‘‘(A) the individual agrees to work in, or for a provider 
serving, a health professional shortage area or medically 
underserved area, or to serve a medically underserved 
population; 
‘‘(B) the individual is a United States citizen or a 
permanent legal United States resident; and 
‘‘(C) if the individual is enrolled in a graduate program, 
the program is accredited, and the individual has an accept-
able level of academic standing (as determined by the Sec-
retary). 
Definitions. 
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124 STAT. 609 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(d) PRIORITY.—In entering into contracts under this subsection, 
the Secretary shall give priority to applicants who— 
‘‘(1) are or will be working in a school or other pre-kinder-
garten, elementary, or secondary education setting; 
‘‘(2) have familiarity with evidence-based methods and cul-
tural and linguistic competence health care services; and 
‘‘(3) demonstrate financial need. 
‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 
to be appropriated $30,000,000 for each of fiscal years 2010 through 
2014 to carry out subsection (c)(1)(A) and $20,000,000 for each 
of fiscal years 2010 through 2013 to carry out subsection (c)(1)(B).’’. 
SEC. 5204. PUBLIC HEALTH WORKFORCE RECRUITMENT AND RETEN-
TION PROGRAMS. 
Part E of title VII of the Public Health Service Act (42 U.S.C. 
294n et seq.), as amended by section 5203, is further amended 
by adding at the end the following: 
‘‘SEC. 776. PUBLIC HEALTH WORKFORCE LOAN REPAYMENT PROGRAM. 
‘‘(a) ESTABLISHMENT.—The Secretary shall establish the Public 
Health Workforce Loan Repayment Program (referred to in this 
section as the ‘Program’) to assure an adequate supply of public 
health professionals to eliminate critical public health workforce 
shortages in Federal, State, local, and tribal public health agencies. 
‘‘(b) ELIGIBILITY.—To be eligible to participate in the Program, 
an individual shall— 
‘‘(1)(A) be accepted for enrollment, or be enrolled, as a 
student in an accredited academic educational institution in 
a State or territory in the final year of a course of study 
or program leading to a public health or health professions 
degree or certificate; and have accepted employment with a 
Federal, State, local, or tribal public health agency, or a related 
training fellowship, as recognized by the Secretary, to com-
mence upon graduation; 
‘‘(B)(i) have graduated, during the preceding 10-year period, 
from an accredited educational institution in a State or territory 
and received a public health or health professions degree or 
certificate; and 
‘‘(ii) be employed by, or have accepted employment with, 
a Federal, State, local, or tribal public health agency or a 
related training fellowship, as recognized by the Secretary; 
‘‘(2) be a United States citizen; and 
‘‘(3)(A) submit an application to the Secretary to participate 
in the Program; 
‘‘(B) execute a written contract as required in subsection 
(c); and 
‘‘(4) not have received, for the same service, a reduction 
of loan obligations under section 455(m), 428J, 428K, 428L, 
or 460 of the Higher Education Act of 1965. 
‘‘(c) CONTRACT.—The written contract (referred to in this section 
as the ‘written contract’) between the Secretary and an individual 
shall contain— 
‘‘(1) an agreement on the part of the Secretary that the 
Secretary will repay on behalf of the individual loans incurred 
by the individual in the pursuit of the relevant degree or 
certificate in accordance with the terms of the contract; 
‘‘(2) an agreement on the part of the individual that the 
individual will serve in the full-time employment of a Federal, 
42 USC 295f–1. 
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124 STAT. 610 
PUBLIC LAW 111–148—MAR. 23, 2010 
State, local, or tribal public health agency or a related fellow-
ship program in a position related to the course of study or 
program for which the contract was awarded for a period of 
time (referred to in this section as the ‘period of obligated 
service’) equal to the greater of— 
‘‘(A) 3 years; or 
‘‘(B) such longer period of time as determined appro-
priate by the Secretary and the individual; 
‘‘(3) an agreement, as appropriate, on the part of the indi-
vidual to relocate to a priority service area (as determined 
by the Secretary) in exchange for an additional loan repayment 
incentive amount to be determined by the Secretary; 
‘‘(4) a provision that any financial obligation of the United 
States arising out of a contract entered into under this section 
and any obligation of the individual that is conditioned thereon, 
is contingent on funds being appropriated for loan repayments 
under this section; 
‘‘(5) a statement of the damages to which the United States 
is entitled, under this section for the individual’s breach of 
the contract; and 
‘‘(6) such other statements of the rights and liabilities 
of the Secretary and of the individual, not inconsistent with 
this section. 
‘‘(d) PAYMENTS.— 
‘‘(1) IN GENERAL.—A loan repayment provided for an indi-
vidual under a written contract under the Program shall consist 
of payment, in accordance with paragraph (2), on behalf of 
the individual of the principal, interest, and related expenses 
on government and commercial loans received by the individual 
regarding the undergraduate or graduate education of the indi-
vidual (or both), which loans were made for tuition expenses 
incurred by the individual. 
‘‘(2) PAYMENTS FOR YEARS SERVED.—For each year of obli-
gated service that an individual contracts to serve under sub-
section (c) the Secretary may pay up to $35,000 on behalf 
of the individual for loans described in paragraph (1). With 
respect to participants under the Program whose total eligible 
loans are less than $105,000, the Secretary shall pay an amount 
that does not exceed 1⁄3 of the eligible loan balance for each 
year of obligated service of the individual. 
‘‘(3) 
TAX
LIABILITY.—For 
the 
purpose 
of 
providing 
reimbursements for tax liability resulting from payments under 
paragraph (2) on behalf of an individual, the Secretary shall, 
in addition to such payments, make payments to the individual 
in an amount not to exceed 39 percent of the total amount 
of loan repayments made for the taxable year involved. 
‘‘(e) POSTPONING OBLIGATED SERVICE.—With respect to an indi-
vidual receiving a degree or certificate from a health professions 
or other related school, the date of the initiation of the period 
of obligated service may be postponed as approved by the Secretary. 
‘‘(f) BREACH OF CONTRACT.—An individual who fails to comply 
with the contract entered into under subsection (c) shall be subject 
to the same financial penalties as provided for under section 338E 
for breaches of loan repayment contracts under section 338B. 
‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 
to be appropriated to carry out this section $195,000,000 for fiscal 
Penalty. 
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124 STAT. 611 
PUBLIC LAW 111–148—MAR. 23, 2010 
year 2010, and such sums as may be necessary for each of fiscal 
years 2011 through 2015.’’. 
SEC. 5205. ALLIED HEALTH WORKFORCE RECRUITMENT AND RETEN-
TION PROGRAMS. 
(a) PURPOSE.—The purpose of this section is to assure an ade-
quate supply of allied health professionals to eliminate critical 
allied health workforce shortages in Federal, State, local, and tribal 
public health agencies or in settings where patients might require 
health care services, including acute care facilities, ambulatory 
care facilities, personal residences and other settings, as recognized 
by the Secretary of Health and Human Services by authorizing 
an Allied Health Loan Forgiveness Program. 
(b) ALLIED HEALTH WORKFORCE RECRUITMENT AND RETENTION 
PROGRAM.—Section 428K of the Higher Education Act of 1965 (20 
U.S.C. 1078–11) is amended— 
(1) in subsection (b), by adding at the end the following: 
‘‘(18) ALLIED HEALTH PROFESSIONALS.—The individual is 
employed full-time as an allied health professional— 
‘‘(A) in a Federal, State, local, or tribal public health 
agency; or 
‘‘(B) in a setting where patients might require health 
care services, including acute care facilities, ambulatory 
care facilities, personal residences and other settings 
located in health professional shortage areas, medically 
underserved areas, or medically underserved populations, 
as recognized by the Secretary of Health and Human Serv-
ices.’’; and 
(2) in subsection (g)— 
(A) by redesignating paragraphs (1) through (9) as 
paragraphs (2) through (10), respectively; and 
(B) by inserting before paragraph (2) (as redesignated 
by subparagraph (A)) the following: 
‘‘(1) ALLIED HEALTH PROFESSIONAL.—The term ‘allied health 
professional’ means an allied health professional as defined 
in section 799B(5) of the Public Heath Service Act (42 U.S.C. 
295p(5)) who— 
‘‘(A) has graduated and received an allied health profes-
sions degree or certificate from an institution of higher 
education; and 
‘‘(B) is employed with a Federal, State, local or tribal 
public health agency, or in a setting where patients might 
require health care services, including acute care facilities, 
ambulatory care facilities, personal residences and other 
settings located in health professional shortage areas, medi-
cally underserved areas, or medically underserved popu-
lations, as recognized by the Secretary of Health and 
Human Services.’’. 
SEC. 5206. GRANTS FOR STATE AND LOCAL PROGRAMS. 
(a) IN GENERAL.—Section 765(d) of the Public Health Service 
Act (42 U.S.C. 295(d)) is amended— 
(1) in paragraph (7), by striking ‘‘; or’’ and inserting a 
semicolon; 
(2) by redesignating paragraph (8) as paragraph (9); and 
(3) by inserting after paragraph (7) the following: 
‘‘(8) public health workforce loan repayment programs; or’’. 
Definition. 
20 USC 1078–11 
note. 
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124 STAT. 612 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b) TRAINING
FOR
MID-CAREER
PUBLIC
HEALTH
PROFES-
SIONALS.—Part E of title VII of the Public Health Service Act 
(42 U.S.C. 294n et seq.), as amended by section 5204, is further 
amended by adding at the end the following: 
‘‘SEC. 777. TRAINING FOR MID-CAREER PUBLIC AND ALLIED HEALTH 
PROFESSIONALS. 
‘‘(a) IN GENERAL.—The Secretary may make grants to, or enter 
into contracts with, any eligible entity to award scholarships to 
eligible individuals to enroll in degree or professional training pro-
grams for the purpose of enabling mid-career professionals in the 
public health and allied health workforce to receive additional 
training in the field of public health and allied health. 
‘‘(b) ELIGIBILITY.— 
‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible entity’ indicates 
an accredited educational institution that offers a course of 
study, certificate program, or professional training program 
in public or allied health or a related discipline, as determined 
by the Secretary 
‘‘(2) ELIGIBLE INDIVIDUALS.—The term ‘eligible individuals’ 
includes those individuals employed in public and allied health 
positions at the Federal, State, tribal, or local level who are 
interested in retaining or upgrading their education. 
‘‘(c) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 
to be appropriated to carry out this section, $60,000,000 for fiscal 
year 2010 and such sums as may be necessary for each of fiscal 
years 2011 through 2015. Fifty percent of appropriated funds shall 
be allotted to public health mid-career professionals and 50 percent 
shall be allotted to allied health mid-career professionals.’’. 
SEC. 5207. FUNDING FOR NATIONAL HEALTH SERVICE CORPS. 
Section 338H(a) of the Public Health Service Act (42 U.S.C. 
254q(a)) is amended to read as follows: 
‘‘(a) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of 
carrying out this section, there is authorized to be appropriated, 
out of any funds in the Treasury not otherwise appropriated, the 
following: 
‘‘(1) For fiscal year 2010, $320,461,632. 
‘‘(2) For fiscal year 2011, $414,095,394. 
‘‘(3) For fiscal year 2012, $535,087,442. 
‘‘(4) For fiscal year 2013, $691,431,432. 
‘‘(5) For fiscal year 2014, $893,456,433. 
‘‘(6) For fiscal year 2015, $1,154,510,336. 
‘‘(7) For fiscal year 2016, and each subsequent fiscal year, 
the amount appropriated for the preceding fiscal year adjusted 
by the product of— 
‘‘(A) one plus the average percentage increase in the 
costs of health professions education during the prior fiscal 
year; and 
‘‘(B) one plus the average percentage change in the 
number of individuals residing in health professions short-
age areas designated under section 333 during the prior 
fiscal year, relative to the number of individuals residing 
in such areas during the previous fiscal year.’’. 
SEC. 5208. NURSE-MANAGED HEALTH CLINICS. 
(a) PURPOSE.—The purpose of this section is to fund the develop-
ment and operation of nurse-managed health clinics. 
42 USC 254c–1a 
note. 
Definitions. 
42 USC 295f–2. 
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124 STAT. 613 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b) GRANTS.—Subpart 1 of part D of title III of the Public 
Health Service Act (42 U.S.C. 254b et seq.) is amended by inserting 
after section 330A the following: 
‘‘SEC. 330A–1. GRANTS TO NURSE–MANAGED HEALTH CLINICS. 
‘‘(a) DEFINITIONS.— 
‘‘(1) COMPREHENSIVE
PRIMARY
HEALTH
CARE
SERVICES.— 
In this section, the term ‘comprehensive primary health care 
services’ means the primary health services described in section 
330(b)(1). 
‘‘(2) NURSE-MANAGED
HEALTH
CLINIC.—The term ‘nurse- 
managed health clinic’ means a nurse-practice arrangement, 
managed by advanced practice nurses, that provides primary 
care or wellness services to underserved or vulnerable popu-
lations and that is associated with a school, college, university 
or department of nursing, federally qualified health center, 
or independent nonprofit health or social services agency. 
‘‘(b) AUTHORITY TO AWARD GRANTS.—The Secretary shall award 
grants for the cost of the operation of nurse-managed health clinics 
that meet the requirements of this section. 
‘‘(c) APPLICATIONS.—To be eligible to receive a grant under 
this section, an entity shall— 
‘‘(1) be an NMHC; and 
‘‘(2) submit to the Secretary an application at such time, 
in such manner, and containing— 
‘‘(A) assurances that nurses are the major providers 
of services at the NMHC and that at least 1 advanced 
practice nurse holds an executive management position 
within the organizational structure of the NMHC; 
‘‘(B) an assurance that the NMHC will continue pro-
viding comprehensive primary health care services or 
wellness services without regard to income or insurance 
status of the patient for the duration of the grant period; 
and 
‘‘(C) an assurance that, not later than 90 days of 
receiving a grant under this section, the NMHC will estab-
lish a community advisory committee, for which a majority 
of the members shall be individuals who are served by 
the NMHC. 
‘‘(d) GRANT AMOUNT.—The amount of any grant made under 
this section for any fiscal year shall be determined by the Secretary, 
taking into account— 
‘‘(1) the financial need of the NMHC, considering State, 
local, and other operational funding provided to the NMHC; 
and 
‘‘(2) other factors, as the Secretary determines appropriate. 
‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—For the purposes of 
carrying out this section, there are authorized to be appropriated 
$50,000,000 for the fiscal year 2010 and such sums as may be 
necessary for each of the fiscal years 2011 through 2014.’’. 
SEC. 5209. ELIMINATION OF CAP ON COMMISSIONED CORPS. 
Section 202 of the Department of Health and Human Services 
Appropriations Act, 1993 (Public Law 102–394) is amended by 
striking ‘‘not to exceed 2,800’’. 
42 USC 238f 
note. 
Determination. 
42 USC 254c–1a. 
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124 STAT. 614 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 5210. ESTABLISHING A READY RESERVE CORPS. 
Section 203 of the Public Health Service Act (42 U.S.C. 204) 
is amended to read as follows: 
‘‘SEC. 203. COMMISSIONED CORPS AND READY RESERVE CORPS. 
‘‘(a) ESTABLISHMENT.— 
‘‘(1) IN GENERAL.—There shall be in the Service a commis-
sioned Regular Corps and a Ready Reserve Corps for service 
in time of national emergency. 
‘‘(2) REQUIREMENT.—All commissioned officers shall be citi-
zens of the United States and shall be appointed without regard 
to the civil-service laws and compensated without regard to 
the Classification Act of 1923, as amended. 
‘‘(3) APPOINTMENT.—Commissioned officers of the Ready 
Reserve Corps shall be appointed by the President and commis-
sioned officers of the Regular Corps shall be appointed by 
the President with the advice and consent of the Senate. 
‘‘(4) ACTIVE
DUTY.—Commissioned officers of the Ready 
Reserve Corps shall at all times be subject to call to active 
duty by the Surgeon General, including active duty for the 
purpose of training. 
‘‘(5) 
WARRANT
OFFICERS.—Warrant 
officers 
may 
be 
appointed to the Service for the purpose of providing support 
to the health and delivery systems maintained by the Service 
and any warrant officer appointed to the Service shall be consid-
ered for purposes of this Act and title 37, United States Code, 
to be a commissioned officer within the Commissioned Corps 
of the Service. 
‘‘(b) ASSIMILATING RESERVE CORP OFFICERS INTO THE REGULAR 
CORPS.—Effective on the date of enactment of the Patient Protection 
and Affordable Care Act, all individuals classified as officers in 
the Reserve Corps under this section (as such section existed on 
the day before the date of enactment of such Act) and serving 
on active duty shall be deemed to be commissioned officers of 
the Regular Corps. 
‘‘(c) PURPOSE AND USE OF READY RESEARCH.— 
‘‘(1) PURPOSE.—The purpose of the Ready Reserve Corps 
is to fulfill the need to have additional Commissioned Corps 
personnel available on short notice (similar to the uniformed 
service’s reserve program) to assist regular Commissioned 
Corps personnel to meet both routine public health and emer-
gency response missions. 
‘‘(2) USES.—The Ready Reserve Corps shall— 
‘‘(A) participate in routine training to meet the general 
and specific needs of the Commissioned Corps; 
‘‘(B) be available and ready for involuntary calls to 
active duty during national emergencies and public health 
crises, similar to the uniformed service reserve personnel; 
‘‘(C) be available for backfilling critical positions left 
vacant during deployment of active duty Commissioned 
Corps members, as well as for deployment to respond to 
public health emergencies, both foreign and domestic; and 
‘‘(D) be available for service assignment in isolated, 
hardship, and medically underserved communities (as 
defined in section 799B) to improve access to health serv-
ices. 
Effective date. 
President. 
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124 STAT. 615 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(d) FUNDING.—For the purpose of carrying out the duties and 
responsibilities of the Commissioned Corps under this section, there 
are authorized to be appropriated $5,000,000 for each of fiscal 
years 2010 through 2014 for recruitment and training and 
$12,500,000 for each of fiscal years 2010 through 2014 for the 
Ready Reserve Corps.’’. 
Subtitle D—Enhancing Health Care 
Workforce Education and Training 
SEC. 5301. TRAINING IN FAMILY MEDICINE, GENERAL INTERNAL MEDI-
CINE, 
GENERAL 
PEDIATRICS, 
AND 
PHYSICIAN 
ASSISTANTSHIP. 
Part C of title VII (42 U.S.C. 293k et seq.) is amended by 
striking section 747 and inserting the following: 
‘‘SEC. 747. PRIMARY CARE TRAINING AND ENHANCEMENT. 
‘‘(a) SUPPORT AND DEVELOPMENT OF PRIMARY CARE TRAINING 
PROGRAMS.— 
‘‘(1) IN GENERAL.—The Secretary may make grants to, or 
enter into contracts with, an accredited public or nonprofit 
private hospital, school of medicine or osteopathic medicine, 
academically affiliated physician assistant training program, 
or a public or private nonprofit entity which the Secretary 
has determined is capable of carrying out such grant or con-
tract— 
‘‘(A) to plan, develop, operate, or participate in an 
accredited professional training program, including an 
accredited residency or internship program in the field 
of family medicine, general internal medicine, or general 
pediatrics for medical students, interns, residents, or prac-
ticing physicians as defined by the Secretary; 
‘‘(B) to provide need-based financial assistance in the 
form of traineeships and fellowships to medical students, 
interns, residents, practicing physicians, or other medical 
personnel, who are participants in any such program, and 
who plan to specialize or work in the practice of the fields 
defined in subparagraph (A); 
‘‘(C) to plan, develop, and operate a program for the 
training of physicians who plan to teach in family medicine, 
general internal medicine, or general pediatrics training 
programs; 
‘‘(D) to plan, develop, and operate a program for the 
training of physicians teaching in community-based set-
tings; 
‘‘(E) to provide financial assistance in the form of 
traineeships and fellowships to physicians who are partici-
pants in any such programs and who plan to teach or 
conduct research in a family medicine, general internal 
medicine, or general pediatrics training program; 
‘‘(F) to plan, develop, and operate a physician assistant 
education program, and for the training of individuals who 
will teach in programs to provide such training; 
‘‘(G) to plan, develop, and operate a demonstration 
program that provides training in new competencies, as 
recommended by the Advisory Committee on Training in 
42 USC 293k. 
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124 STAT. 616 
PUBLIC LAW 111–148—MAR. 23, 2010 
Primary Care Medicine and Dentistry and the National 
Health Care Workforce Commission established in section 
5101 of the Patient Protection and Affordable Care Act, 
which may include— 
‘‘(i) providing training to primary care physicians 
relevant to providing care through patient-centered 
medical homes (as defined by the Secretary for pur-
poses of this section); 
‘‘(ii) developing tools and curricula relevant to 
patient-centered medical homes; and 
‘‘(iii) providing continuing education to primary 
care physicians relevant to patient-centered medical 
homes; and 
‘‘(H) to plan, develop, and operate joint degree pro-
grams to provide interdisciplinary and interprofessional 
graduate training in public health and other health profes-
sions to provide training in environmental health, infec-
tious disease control, disease prevention and health pro-
motion, epidemiological studies and injury control. 
‘‘(2) DURATION OF AWARDS.—The period during which pay-
ments are made to an entity from an award of a grant or 
contract under this subsection shall be 5 years. 
‘‘(b) CAPACITY BUILDING IN PRIMARY CARE.— 
‘‘(1) IN GENERAL.—The Secretary may make grants to or 
enter into contracts with accredited schools of medicine or 
osteopathic medicine to establish, maintain, or improve— 
‘‘(A) academic units or programs that improve clinical 
teaching and research in fields defined in subsection 
(a)(1)(A); or 
‘‘(B) programs that integrate academic administrative 
units in fields defined in subsection (a)(1)(A) to enhance 
interdisciplinary recruitment, training, and faculty develop-
ment. 
‘‘(2) PREFERENCE
IN
MAKING
AWARDS
UNDER
THIS
SUB-
SECTION.—In making awards of grants and contracts under 
paragraph (1), the Secretary shall give preference to any quali-
fied applicant for such an award that agrees to expend the 
award for the purpose of— 
‘‘(A) establishing academic units or programs in fields 
defined in subsection (a)(1)(A); or 
‘‘(B) substantially expanding such units or programs. 
‘‘(3) PRIORITIES IN MAKING AWARDS.—In awarding grants 
or contracts under paragraph (1), the Secretary shall give pri-
ority to qualified applicants that— 
‘‘(A) proposes a collaborative project between academic 
administrative units of primary care; 
‘‘(B) proposes innovative approaches to clinical teaching 
using models of primary care, such as the patient centered 
medical home, team management of chronic disease, and 
interprofessional integrated models of health care that 
incorporate transitions in health care settings and integra-
tion physical and mental health provision; 
‘‘(C) have a record of training the greatest percentage 
of providers, or that have demonstrated significant 
improvements in the percentage of providers trained, who 
enter and remain in primary care practice; 
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124 STAT. 617 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(D) have a record of training individuals who are 
from underrepresented minority groups or from a rural 
or disadvantaged background; 
‘‘(E) provide training in the care of vulnerable popu-
lations such as children, older adults, homeless individuals, 
victims of abuse or trauma, individuals with mental health 
or substance-related disorders, individuals with HIV/AIDS, 
and individuals with disabilities; 
‘‘(F) establish formal relationships and submit joint 
applications with federally qualified health centers, rural 
health clinics, area health education centers, or clinics 
located in underserved areas or that serve underserved 
populations; 
‘‘(G) teach trainees the skills to provide interprofes-
sional, integrated care through collaboration among health 
professionals; 
‘‘(H) provide training in enhanced communication with 
patients, evidence-based practice, chronic disease manage-
ment, preventive care, health information technology, or 
other competencies as recommended by the Advisory Com-
mittee on Training in Primary Care Medicine and Dentistry 
and the National Health Care Workforce Commission 
established in section 5101 of the Patient Protection and 
Affordable Care Act; or 
‘‘(I) provide training in cultural competency and health 
literacy. 
‘‘(4) DURATION OF AWARDS.—The period during which pay-
ments are made to an entity from an award of a grant or 
contract under this subsection shall be 5 years. 
‘‘(c) AUTHORIZATION OF APPROPRIATIONS.— 
‘‘(1) IN GENERAL.—For purposes of carrying out this section 
(other than subsection (b)(1)(B)), there are authorized to be 
appropriated $125,000,000 for fiscal year 2010, and such sums 
as may be necessary for each of fiscal years 2011 through 
2014. 
‘‘(2) TRAINING PROGRAMS.—Fifteen percent of the amount 
appropriated pursuant to paragraph (1) in each such fiscal 
year shall be allocated to the physician assistant training pro-
grams described in subsection (a)(1)(F), which prepare students 
for practice in primary care. 
‘‘(3) INTEGRATING ACADEMIC ADMINISTRATIVE UNITS.—For 
purposes of carrying out subsection (b)(1)(B), there are author-
ized to be appropriated $750,000 for each of fiscal years 2010 
through 2014.’’. 
SEC. 5302. TRAINING OPPORTUNITIES FOR DIRECT CARE WORKERS. 
Part C of title VII of the Public Health Service Act (42 U.S.C. 
293k et seq.) is amended by inserting after section 747, as amended 
by section 5301, the following: 
‘‘SEC. 747A. TRAINING OPPORTUNITIES FOR DIRECT CARE WORKERS. 
‘‘(a) IN GENERAL.—The Secretary shall award grants to eligible 
entities to enable such entities to provide new training opportunities 
for direct care workers who are employed in long-term care settings 
such as nursing homes (as defined in section 1908(e)(1) of the 
Social Security Act (42 U.S.C. 1396g(e)(1)), assisted living facilities 
Grants. 
42 USC 293k–1. 
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124 STAT. 618 
PUBLIC LAW 111–148—MAR. 23, 2010 
and skilled nursing facilities, intermediate care facilities for individ-
uals with mental retardation, home and community based settings, 
and any other setting the Secretary determines to be appropriate. 
‘‘(b) ELIGIBILITY.—To be eligible to receive a grant under this 
section, an entity shall— 
‘‘(1) be an institution of higher education (as defined in 
section 102 of the Higher Education Act of 1965 (20 U.S.C. 
1002)) that— 
‘‘(A) is accredited by a nationally recognized accrediting 
agency or association listed under section 101(c) of the 
Higher Education Act of 1965 (20 U.S.C. 1001(c)); and 
‘‘(B) has established a public-private educational part-
nership with a nursing home or skilled nursing facility, 
agency or entity providing home and community based 
services to individuals with disabilities, or other long-term 
care provider; and 
‘‘(2) submit to the Secretary an application at such time, 
in such manner, and containing such information as the Sec-
retary may require. 
‘‘(c) USE
OF FUNDS.—An eligible entity shall use amounts 
awarded under a grant under this section to provide assistance 
to eligible individuals to offset the cost of tuition and required 
fees for enrollment in academic programs provided by such entity. 
‘‘(d) ELIGIBLE INDIVIDUAL.— 
‘‘(1) ELIGIBILITY.—To be eligible for assistance under this 
section, an individual shall be enrolled in courses provided 
by a grantee under this subsection and maintain satisfactory 
academic progress in such courses. 
‘‘(2) CONDITION OF ASSISTANCE.—As a condition of receiving 
assistance under this section, an individual shall agree that, 
following completion of the assistance period, the individual 
will work in the field of geriatrics, disability services, long 
term services and supports, or chronic care management for 
a minimum of 2 years under guidelines set by the Secretary. 
‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 
to be appropriated to carry out this section, $10,000,000 for the 
period of fiscal years 2011 through 2013.’’. 
SEC. 5303. TRAINING IN GENERAL, PEDIATRIC, AND PUBLIC HEALTH 
DENTISTRY. 
Part C of Title VII of the Public Health Service Act (42 U.S.C. 
293k et seq.) is amended by— 
(1) redesignating section 748, as amended by section 5103 
of this Act, as section 749; and 
(2) inserting after section 747A, as added by section 5302, 
the following: 
‘‘SEC. 748. TRAINING IN GENERAL, PEDIATRIC, AND PUBLIC HEALTH 
DENTISTRY. 
‘‘(a) SUPPORT AND DEVELOPMENT OF DENTAL TRAINING PRO-
GRAMS.— 
‘‘(1) IN GENERAL.—The Secretary may make grants to, or 
enter into contracts with, a school of dentistry, public or non-
profit private hospital, or a public or private nonprofit entity 
which the Secretary has determined is capable of carrying 
out such grant or contract— 
‘‘(A) to plan, develop, and operate, or participate in, 
an approved professional training program in the field 
42 USC 293k–2. 
42 USC 293l. 
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124 STAT. 619 
PUBLIC LAW 111–148—MAR. 23, 2010 
of general dentistry, pediatric dentistry, or public health 
dentistry for dental students, residents, practicing dentists, 
dental hygienists, or other approved primary care dental 
trainees, that emphasizes training for general, pediatric, 
or public health dentistry; 
‘‘(B) to provide financial assistance to dental students, 
residents, practicing dentists, and dental hygiene students 
who are in need thereof, who are participants in any such 
program, and who plan to work in the practice of general, 
pediatric, public heath dentistry, or dental hygiene; 
‘‘(C) to plan, develop, and operate a program for the 
training of oral health care providers who plan to teach 
in general, pediatric, public health dentistry, or dental 
hygiene; 
‘‘(D) to provide financial assistance in the form of 
traineeships and fellowships to dentists who plan to teach 
or are teaching in general, pediatric, or public health den-
tistry; 
‘‘(E) to meet the costs of projects to establish, maintain, 
or improve dental faculty development programs in primary 
care (which may be departments, divisions or other units); 
‘‘(F) to meet the costs of projects to establish, maintain, 
or improve predoctoral and postdoctoral training in primary 
care programs; 
‘‘(G) to create a loan repayment program for faculty 
in dental programs; and 
‘‘(H) to provide technical assistance to pediatric 
training programs in developing and implementing instruc-
tion regarding the oral health status, dental care needs, 
and risk-based clinical disease management of all pediatric 
populations with an emphasis on underserved children. 
‘‘(2) FACULTY LOAN REPAYMENT.— 
‘‘(A) IN GENERAL.—A grant or contract under subsection 
(a)(1)(G) may be awarded to a program of general, pediatric, 
or public health dentistry described in such subsection 
to plan, develop, and operate a loan repayment program 
under which— 
‘‘(i) individuals agree to serve full-time as faculty 
members; and 
‘‘(ii) the program of general, pediatric or public 
health dentistry agrees to pay the principal and 
interest on the outstanding student loans of the 
individuals. 
‘‘(B) MANNER OF PAYMENTS.—With respect to the pay-
ments described in subparagraph (A)(ii), upon completion 
by an individual of each of the first, second, third, fourth, 
and fifth years of service, the program shall pay an amount 
equal to 10, 15, 20, 25, and 30 percent, respectively, of 
the individual’s student loan balance as calculated based 
on principal and interest owed at the initiation of the 
agreement. 
‘‘(b) ELIGIBLE ENTITY.—For purposes of this subsection, entities 
eligible for such grants or contracts in general, pediatric, or public 
health dentistry shall include entities that have programs in dental 
or dental hygiene schools, or approved residency or advanced edu-
cation programs in the practice of general, pediatric, or public 
health dentistry. Eligible entities may partner with schools of public 
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124 STAT. 620 
PUBLIC LAW 111–148—MAR. 23, 2010 
health to permit the education of dental students, residents, and 
dental hygiene students for a master’s year in public health at 
a school of public health. 
‘‘(c) PRIORITIES IN MAKING AWARDS.—With respect to training 
provided for under this section, the Secretary shall give priority 
in awarding grants or contracts to the following: 
‘‘(1) Qualified applicants that propose collaborative projects 
between departments of primary care medicine and depart-
ments of general, pediatric, or public health dentistry. 
‘‘(2) Qualified applicants that have a record of training 
the greatest percentage of providers, or that have demonstrated 
significant improvements in the percentage of providers, who 
enter and remain in general, pediatric, or public health den-
tistry. 
‘‘(3) Qualified applicants that have a record of training 
individuals who are from a rural or disadvantaged background, 
or from underrepresented minorities. 
‘‘(4) Qualified applicants that establish formal relationships 
with Federally qualified health centers, rural health centers, 
or accredited teaching facilities and that conduct training of 
students, residents, fellows, or faculty at the center or facility. 
‘‘(5) Qualified applicants that conduct teaching programs 
targeting vulnerable populations such as older adults, homeless 
individuals, victims of abuse or trauma, individuals with mental 
health or substance-related disorders, individuals with disabil-
ities, and individuals with HIV/AIDS, and in the risk-based 
clinical disease management of all populations. 
‘‘(6) Qualified applicants that include educational activities 
in cultural competency and health literacy. 
‘‘(7) Qualified applicants that have a high rate for placing 
graduates in practice settings that serve underserved areas 
or health disparity populations, or who achieve a significant 
increase in the rate of placing graduates in such settings. 
‘‘(8) Qualified applicants that intend to establish a special 
populations oral health care education center or training pro-
gram for the didactic and clinical education of dentists, dental 
health professionals, and dental hygienists who plan to teach 
oral health care for people with developmental disabilities, 
cognitive impairment, complex medical problems, significant 
physical limitations, and vulnerable elderly. 
‘‘(d) APPLICATION.—An eligible entity desiring a grant under 
this section shall submit to the Secretary an application at such 
time, in such manner, and containing such information as the 
Secretary may require. 
‘‘(e) DURATION OF AWARD.—The period during which payments 
are made to an entity from an award of a grant or contract under 
subsection (a) shall be 5 years. The provision of such payments 
shall be subject to annual approval by the Secretary and subject 
to the availability of appropriations for the fiscal year involved 
to make the payments. 
‘‘(f) AUTHORIZATIONS OF APPROPRIATIONS.—For the purpose of 
carrying out subsections (a) and (b), there is authorized to be 
appropriated $30,000,000 for fiscal year 2010 and such sums as 
may be necessary for each of fiscal years 2011 through 2015. 
‘‘(g) CARRYOVER FUNDS.—An entity that receives an award 
under this section may carry over funds from 1 fiscal year to 
another without obtaining approval from the Secretary. In no case 
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124 STAT. 621 
PUBLIC LAW 111–148—MAR. 23, 2010 
may any funds be carried over pursuant to the preceding sentence 
for more than 3 years.’’. 
SEC. 5304. ALTERNATIVE DENTAL HEALTH CARE PROVIDERS DEM-
ONSTRATION PROJECT. 
Subpart X of part D of title III of the Public Health Service 
Act (42 U.S.C. 256f et seq.) is amended by adding at the end 
the following: 
‘‘SEC. 340G–1. DEMONSTRATION PROGRAM. 
‘‘(a) IN GENERAL.— 
‘‘(1) AUTHORIZATION.—The Secretary is authorized to award 
grants to 15 eligible entities to enable such entities to establish 
a demonstration program to establish training programs to 
train, or to employ, alternative dental health care providers 
in order to increase access to dental health care services in 
rural and other underserved communities. 
‘‘(2) DEFINITION.—The term ‘alternative dental health care 
providers’ includes community dental health coordinators, 
advance practice dental hygienists, independent dental hygien-
ists, supervised dental hygienists, primary care physicians, 
dental therapists, dental health aides, and any other health 
professional that the Secretary determines appropriate. 
‘‘(b) TIMEFRAME.—The demonstration projects funded under this 
section shall begin not later than 2 years after the date of enactment 
of this section, and shall conclude not later than 7 years after 
such date of enactment. 
‘‘(c) ELIGIBLE ENTITIES.—To be eligible to receive a grant under 
subsection (a), an entity shall— 
‘‘(1) be— 
‘‘(A) an institution of higher education, including a 
community college; 
‘‘(B) a public-private partnership; 
‘‘(C) a federally qualified health center; 
‘‘(D) an Indian Health Service facility or a tribe or 
tribal organization (as such terms are defined in section 
4 of the Indian Self-Determination and Education Assist-
ance Act); 
‘‘(E) a State or county public health clinic, a health 
facility operated by an Indian tribe or tribal organization, 
or urban Indian organization providing dental services; 
or 
‘‘(F) a public hospital or health system; 
‘‘(2) be within a program accredited by the Commission 
on Dental Accreditation or within a dental education program 
in an accredited institution; and 
‘‘(3) shall submit an application to the Secretary at such 
time, in such manner, and containing such information as 
the Secretary may require. 
‘‘(d) ADMINISTRATIVE PROVISIONS.— 
‘‘(1) AMOUNT OF GRANT.—Each grant under this section 
shall be in an amount that is not less than $4,000,000 for 
the 5-year period during which the demonstration project being 
conducted. 
‘‘(2) DISBURSEMENT OF FUNDS.— 
‘‘(A) PRELIMINARY DISBURSEMENTS.—Beginning 1 year 
after the enactment of this section, the Secretary may 
disperse to any entity receiving a grant under this section 
Effective date. 
Grants. 
42 USC 256g–1. 
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124 STAT. 622 
PUBLIC LAW 111–148—MAR. 23, 2010 
not more than 20 percent of the total funding awarded 
to such entity under such grant, for the purpose of enabling 
the entity to plan the demonstration project to be conducted 
under such grant. 
‘‘(B) SUBSEQUENT
DISBURSEMENTS.—The remaining 
amount of grant funds not dispersed under subparagraph 
(A) shall be dispersed such that not less than 15 percent 
of such remaining amount is dispersed each subsequent 
year. 
‘‘(e) COMPLIANCE WITH STATE REQUIREMENTS.—Each entity 
receiving a grant under this section shall certify that it is in 
compliance with all applicable State licensing requirements. 
‘‘(f) EVALUATION.—The Secretary shall contract with the 
Director of the Institute of Medicine to conduct a study of the 
demonstration programs conducted under this section that shall 
provide analysis, based upon quantitative and qualitative data, 
regarding access to dental health care in the United States. 
‘‘(g) CLARIFICATION REGARDING DENTAL HEALTH AIDE PRO-
GRAM.—Nothing in this section shall prohibit a dental health aide 
training program approved by the Indian Health Service from being 
eligible for a grant under this section. 
‘‘(h) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 
to be appropriated such sums as may be necessary to carry out 
this section.’’. 
SEC. 5305. GERIATRIC EDUCATION AND TRAINING; CAREER AWARDS; 
COMPREHENSIVE GERIATRIC EDUCATION. 
(a) WORKFORCE DEVELOPMENT; CAREER AWARDS.—Section 753 
of the Public Health Service Act (42 U.S.C. 294c) is amended 
by adding at the end the following: 
‘‘(d) GERIATRIC WORKFORCE DEVELOPMENT.— 
‘‘(1) IN GENERAL.—The Secretary shall award grants or 
contracts under this subsection to entities that operate a geri-
atric education center pursuant to subsection (a)(1). 
‘‘(2) APPLICATION.—To be eligible for an award under para-
graph (1), an entity described in such paragraph shall submit 
to the Secretary an application at such time, in such manner, 
and containing such information as the Secretary may require. 
‘‘(3) USE OF FUNDS.—Amounts awarded under a grant or 
contract under paragraph (1) shall be used to— 
‘‘(A) carry out the fellowship program described in 
paragraph (4); and 
‘‘(B) carry out 1 of the 2 activities described in para-
graph (5). 
‘‘(4) FELLOWSHIP PROGRAM.— 
‘‘(A) IN GENERAL.—Pursuant to paragraph (3), a geri-
atric education center that receives an award under this 
subsection shall use such funds to offer short-term intensive 
courses (referred to in this subsection as a ‘fellowship’) 
that focus on geriatrics, chronic care management, and 
long-term care that provide supplemental training for fac-
ulty members in medical schools and other health profes-
sions schools with programs in psychology, pharmacy, 
nursing, social work, dentistry, public health, allied health, 
or other health disciplines, as approved by the Secretary. 
Such a fellowship shall be open to current faculty, and 
Grants. 
Contracts. 
Contracts. 
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124 STAT. 623 
PUBLIC LAW 111–148—MAR. 23, 2010 
appropriately credentialed volunteer faculty and practi-
tioners, who do not have formal training in geriatrics, 
to upgrade their knowledge and clinical skills for the care 
of older adults and adults with functional limitations and 
to enhance their interdisciplinary teaching skills. 
‘‘(B) LOCATION.—A fellowship shall be offered either 
at the geriatric education center that is sponsoring the 
course, in collaboration with other geriatric education cen-
ters, or at medical schools, schools of dentistry, schools 
of nursing, schools of pharmacy, schools of social work, 
graduate programs in psychology, or allied health and other 
health professions schools approved by the Secretary with 
which the geriatric education centers are affiliated. 
‘‘(C) CME CREDIT.—Participation in a fellowship under 
this paragraph shall be accepted with respect to complying 
with continuing health profession education requirements. 
As a condition of such acceptance, the recipient shall agree 
to subsequently provide a minimum of 18 hours of vol-
untary instructional support through a geriatric education 
center that is providing clinical training to students or 
trainees in long-term care settings. 
‘‘(5) ADDITIONAL REQUIRED ACTIVITIES DESCRIBED.—Pursu-
ant to paragraph (3), a geriatric education center that receives 
an award under this subsection shall use such funds to carry 
out 1 of the following 2 activities. 
‘‘(A) FAMILY
CAREGIVER
AND
DIRECT
CARE
PROVIDER 
TRAINING.—A geriatric education center that receives an 
award under this subsection shall offer at least 2 courses 
each year, at no charge or nominal cost, to family caregivers 
and direct care providers that are designed to provide 
practical training for supporting frail elders and individuals 
with disabilities. The Secretary shall require such Centers 
to work with appropriate community partners to develop 
training program content and to publicize the availability 
of training courses in their service areas. All family care-
giver and direct care provider training programs shall 
include instruction on the management of psychological 
and behavioral aspects of dementia, communication tech-
niques for working with individuals who have dementia, 
and the appropriate, safe, and effective use of medications 
for older adults. 
‘‘(B) INCORPORATION OF BEST PRACTICES.—A geriatric 
education center that receives an award under this sub-
section shall develop and include material on depression 
and other mental disorders common among older adults, 
medication safety issues for older adults, and management 
of the psychological and behavioral aspects of dementia 
and communication techniques with individuals who have 
dementia in all training courses, where appropriate. 
‘‘(6) TARGETS.—A geriatric education center that receives 
an award under this subsection shall meet targets approved 
by the Secretary for providing geriatric training to a certain 
number of faculty or practitioners during the term of the award, 
as well as other parameters established by the Secretary. 
‘‘(7) AMOUNT OF AWARD.—An award under this subsection 
shall be in an amount of $150,000. Not more than 24 geriatric 
education centers may receive an award under this subsection. 
Requirements. 
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124 STAT. 624 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(8) MAINTENANCE OF EFFORT.—A geriatric education center 
that receives an award under this subsection shall provide 
assurances to the Secretary that funds provided to the geriatric 
education center under this subsection will be used only to 
supplement, not to supplant, the amount of Federal, State, 
and local funds otherwise expended by the geriatric education 
center. 
‘‘(9) AUTHORIZATION
OF
APPROPRIATIONS.—In addition to 
any other funding available to carry out this section, there 
is authorized to be appropriated to carry out this subsection, 
$10,800,000 for the period of fiscal year 2011 through 2014. 
‘‘(e) GERIATRIC CAREER INCENTIVE AWARDS.— 
‘‘(1) IN GENERAL.—The Secretary shall award grants or 
contracts under this section to individuals described in para-
graph (2) to foster greater interest among a variety of health 
professionals in entering the field of geriatrics, long-term care, 
and chronic care management. 
‘‘(2) ELIGIBLE INDIVIDUALS.—To be eligible to received an 
award under paragraph (1), an individual shall— 
‘‘(A) be an advanced practice nurse, a clinical social 
worker, a pharmacist, or student of psychology who is 
pursuing a doctorate or other advanced degree in geriatrics 
or related fields in an accredited health professions school; 
and 
‘‘(B) submit to the Secretary an application at such 
time, in such manner, and containing such information 
as the Secretary may require. 
‘‘(3) CONDITION
OF
AWARD.—As a condition of receiving 
an award under this subsection, an individual shall agree that, 
following completion of the award period, the individual will 
teach or practice in the field of geriatrics, long-term care, or 
chronic care management for a minimum of 5 years under 
guidelines set by the Secretary. 
‘‘(4) AUTHORIZATION OF APPROPRIATIONS.—There is author-
ized to be appropriated to carry out this subsection, $10,000,000 
for the period of fiscal years 2011 through 2013.’’. 
(b) EXPANSION OF ELIGIBILITY FOR GERIATRIC ACADEMIC CAREER 
AWARDS; PAYMENT TO INSTITUTION.—Section 753(c) of the Public 
Health Service Act 294(c)) is amended— 
(1) by redesignating paragraphs (4) and (5) as paragraphs 
(5) and (6), respectively; 
(2) by striking paragraph (2) through paragraph (3) and 
inserting the following: 
‘‘(2) ELIGIBLE INDIVIDUALS.—To be eligible to receive an 
Award under paragraph (1), an individual shall— 
‘‘(A) be board certified or board eligible in internal 
medicine, family practice, psychiatry, or licensed dentistry, 
or have completed any required training in a discipline 
and employed in an accredited health professions school 
that is approved by the Secretary; 
‘‘(B) have completed an approved fellowship program 
in geriatrics or have completed specialty training in geri-
atrics as required by the discipline and any addition geri-
atrics training as required by the Secretary; and 
‘‘(C) have a junior (non-tenured) faculty appointment 
at an accredited (as determined by the Secretary) school 
of medicine, osteopathic medicine, nursing, social work, 
42 USC 294c. 
Grants. 
Contracts. 
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124 STAT. 625 
PUBLIC LAW 111–148—MAR. 23, 2010 
psychology, dentistry, pharmacy, or other allied health dis-
ciplines in an accredited health professions school that 
is approved by the Secretary. 
‘‘(3) LIMITATIONS.—No Award under paragraph (1) may 
be made to an eligible individual unless the individual— 
‘‘(A) has submitted to the Secretary an application, 
at such time, in such manner, and containing such informa-
tion as the Secretary may require, and the Secretary has 
approved such application; 
‘‘(B) provides, in such form and manner as the Sec-
retary may require, assurances that the individual will 
meet the service requirement described in paragraph (6); 
and 
‘‘(C) provides, in such form and manner as the Sec-
retary may require, assurances that the individual has 
a full-time faculty appointment in a health professions 
institution and documented commitment from such institu-
tion to spend 75 percent of the total time of such individual 
on teaching and developing skills in interdisciplinary edu-
cation in geriatrics. 
‘‘(4) MAINTENANCE OF EFFORT.—An eligible individual that 
receives an Award under paragraph (1) shall provide assurances 
to the Secretary that funds provided to the eligible individual 
under this subsection will be used only to supplement, not 
to supplant, the amount of Federal, State, and local funds 
otherwise expended by the eligible individual.’’; and 
(3) in paragraph (5), as so designated— 
(A) in subparagraph (A)— 
(i) by inserting ‘‘for individuals who are physicians’’ 
after ‘‘this section’’; and 
(ii) by inserting after the period at the end the 
following: ‘‘The Secretary shall determine the amount 
of an Award under this section for individuals who 
are not physicians.’’; and 
(B) by adding at the end the following: 
‘‘(C) PAYMENT TO INSTITUTION.—The Secretary shall 
make payments to institutions which include schools of 
medicine, osteopathic medicine, nursing, social work, psy-
chology, dentistry, and pharmacy, or other allied health 
discipline in an accredited health professions school that 
is approved by the Secretary.’’. 
(c) COMPREHENSIVE GERIATRIC EDUCATION.—Section 855 of the 
Public Health Service Act (42 U.S.C. 298) is amended— 
(1) in subsection (b)— 
(A) in paragraph (3), by striking ‘‘or’’ at the end; 
(B) in paragraph (4), by striking the period and 
inserting ‘‘; or’’; and 
(C) by adding at the end the following: 
‘‘(5) establish traineeships for individuals who are pre-
paring for advanced education nursing degrees in geriatric 
nursing, long-term care, gero-psychiatric nursing or other 
nursing areas that specialize in the care of the elderly popu-
lation.’’; and 
(2) in subsection (e), by striking ‘‘2003 through 2007’’ and 
inserting ‘‘2010 through 2014’’. 
Determination. 
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124 STAT. 626 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 5306. MENTAL AND BEHAVIORAL HEALTH EDUCATION AND 
TRAINING GRANTS. 
(a) IN GENERAL.—Part D of title VII (42 U.S.C. 294 et seq.) 
is amended by— 
(1) striking section 757; 
(2) redesignating section 756 (as amended by section 5103) 
as section 757; and 
(3) inserting after section 755 the following: 
‘‘SEC. 756. MENTAL AND BEHAVIORAL HEALTH EDUCATION AND 
TRAINING GRANTS. 
‘‘(a) GRANTS AUTHORIZED.—The Secretary may award grants 
to eligible institutions of higher education to support the recruit-
ment of students for, and education and clinical experience of the 
students in— 
‘‘(1) baccalaureate, master’s, and doctoral degree programs 
of social work, as well as the development of faculty in social 
work; 
‘‘(2) accredited master’s, doctoral, internship, and post-doc-
toral residency programs of psychology for the development 
and implementation of interdisciplinary training of psychology 
graduate students for providing behavioral and mental health 
services, including substance abuse prevention and treatment 
services; 
‘‘(3) accredited institutions of higher education or accredited 
professional training programs that are establishing or 
expanding internships or other field placement programs in 
child and adolescent mental health in psychiatry, psychology, 
school psychology, behavioral pediatrics, psychiatric nursing, 
social work, school social work, substance abuse prevention 
and treatment, marriage and family therapy, school counseling, 
or professional counseling; and 
‘‘(4) State-licensed mental health nonprofit and for-profit 
organizations to enable such organizations to pay for programs 
for preservice or in-service training of paraprofessional child 
and adolescent mental health workers. 
‘‘(b) ELIGIBILITY REQUIREMENTS.—To be eligible for a grant 
under this section, an institution shall demonstrate— 
‘‘(1) participation in the institutions’ programs of individ-
uals and groups from different racial, ethnic, cultural, 
geographic, religious, linguistic, and class backgrounds, and 
different genders and sexual orientations; 
‘‘(2) knowledge and understanding of the concerns of the 
individuals and groups described in subsection (a); 
‘‘(3) any internship or other field placement program 
assisted under the grant will prioritize cultural and linguistic 
competency; 
‘‘(4) the institution will provide to the Secretary such data, 
assurances, and information as the Secretary may require; 
and 
‘‘(5) with respect to any violation of the agreement between 
the Secretary and the institution, the institution will pay such 
liquidated damages as prescribed by the Secretary by regula-
tion. 
‘‘(c) INSTITUTIONAL
REQUIREMENT.—For grants authorized 
under subsection (a)(1), at least 4 of the grant recipients shall 
42 USC 294e–1. 
42 USC 294f. 
42 USC 294g. 
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124 STAT. 627 
PUBLIC LAW 111–148—MAR. 23, 2010 
be historically black colleges or universities or other minority- 
serving institutions. 
‘‘(d) PRIORITY.— 
‘‘(1) In selecting the grant recipients in social work under 
subsection (a)(1), the Secretary shall give priority to applicants 
that— 
‘‘(A) are accredited by the Council on Social Work 
Education; 
‘‘(B) have a graduation rate of not less than 80 percent 
for social work students; and 
‘‘(C) exhibit an ability to recruit social workers from 
and place social workers in areas with a high need and 
high demand population. 
‘‘(2) In selecting the grant recipients in graduate psychology 
under subsection (a)(2), the Secretary shall give priority to 
institutions in which training focuses on the needs of vulnerable 
groups such as older adults and children, individuals with 
mental health or substance-related disorders, victims of abuse 
or trauma and of combat stress disorders such as posttraumatic 
stress disorder and traumatic brain injuries, homeless individ-
uals, chronically ill persons, and their families. 
‘‘(3) In selecting the grant recipients in training programs 
in child and adolescent mental health under subsections (a)(3) 
and (a)(4), the Secretary shall give priority to applicants that— 
‘‘(A) have demonstrated the ability to collect data on 
the number of students trained in child and adolescent 
mental health and the populations served by such students 
after graduation or completion of preservice or in-service 
training; 
‘‘(B) have demonstrated familiarity with evidence-based 
methods in child and adolescent mental health services, 
including substance abuse prevention and treatment serv-
ices; 
‘‘(C) have programs designed to increase the number 
of professionals and paraprofessionals serving high-priority 
populations and to applicants who come from high-priority 
communities and plan to serve medically underserved popu-
lations, in health professional shortage areas, or in medi-
cally underserved areas; 
‘‘(D) offer curriculum taught collaboratively with a 
family on the consumer and family lived experience or 
the importance of family-professional or family-paraprofes-
sional partnerships; and 
‘‘(E) provide services through a community mental 
health program described in section 1913(b)(1). 
‘‘(e) AUTHORIZATION OF APPROPRIATION.—For the fiscal years 
2010 through 2013, there is authorized to be appropriated to carry 
out this section— 
‘‘(1) $8,000,000 for training in social work in subsection 
(a)(1); 
‘‘(2) $12,000,000 for training in graduate psychology in 
subsection (a)(2), of which not less than $10,000,000 shall be 
allocated for doctoral, postdoctoral, and internship level 
training; 
‘‘(3) $10,000,000 for training in professional child and 
adolescent mental health in subsection (a)(3); and 
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124 STAT. 628 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(4) $5,000,000 for training in paraprofessional child and 
adolescent work in subsection (a)(4).’’. 
(b) CONFORMING AMENDMENTS.—Section 757(b)(2) of the Public 
Health Service Act, as redesignated by subsection (a), is amended 
by striking ‘‘sections 751(a)(1)(A), 751(a)(1)(B), 753(b), 754(3)(A), 
and 755(b)’’ and inserting ‘‘sections 751(b)(1)(A), 753(b), and 755(b)’’. 
SEC. 5307. CULTURAL COMPETENCY, PREVENTION, AND PUBLIC 
HEALTH 
AND 
INDIVIDUALS 
WITH 
DISABILITIES 
TRAINING. 
(a) TITLE VII.—Section 741 of the Public Health Service Act 
(42 U.S.C. 293e) is amended— 
(1) in subsection (a)— 
(A) by striking the subsection heading and inserting 
‘‘CULTURAL
COMPETENCY, 
PREVENTION, 
AND
PUBLIC 
HEALTH AND INDIVIDUALS WITH DISABILITY GRANTS’’; and 
(B) in paragraph (1), by striking ‘‘for the purpose of’’ 
and all that follows through the period at the end and 
inserting ‘‘for the development, evaluation, and dissemina-
tion of research, demonstration projects, and model cur-
ricula for cultural competency, prevention, public health 
proficiency, reducing health disparities, and aptitude for 
working with individuals with disabilities training for use 
in health professions schools and continuing education pro-
grams, and for other purposes determined as appropriate 
by the Secretary.’’; and 
(2) by striking subsection (b) and inserting the following: 
‘‘(b) COLLABORATION.—In carrying out subsection (a), the Sec-
retary shall collaborate with health professional societies, licensing 
and accreditation entities, health professions schools, and experts 
in minority health and cultural competency, prevention, and public 
health and disability groups, community-based organizations, and 
other organizations as determined appropriate by the Secretary. 
The Secretary shall coordinate with curricula and research and 
demonstration projects developed under section 807. 
‘‘(c) DISSEMINATION.— 
‘‘(1) IN GENERAL.—Model curricula developed under this 
section shall be disseminated through the Internet Clearing-
house under section 270 and such other means as determined 
appropriate by the Secretary. 
‘‘(2) EVALUATION.—The Secretary shall evaluate the adop-
tion and the implementation of cultural competency, prevention, 
and public health, and working with individuals with a dis-
ability training curricula, and the facilitate inclusion of these 
competency measures in quality measurement systems as 
appropriate. 
‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 
to be appropriated to carry out this section such sums as may 
be necessary for each of fiscal years 2010 through 2015.’’. 
(b) TITLE VIII.—Section 807 of the Public Health Service Act 
(42 U.S.C. 296e–1) is amended— 
(1) in subsection (a)— 
(A) by striking the subsection heading and inserting 
‘‘CULTURAL
COMPETENCY, 
PREVENTION, 
AND
PUBLIC 
HEALTH AND INDIVIDUALS WITH DISABILITY GRANTS’’; and 
(B) by striking ‘‘for the purpose of’’ and all that follows 
through ‘‘health care.’’ and inserting ‘‘for the development, 
42 USC 294f. 
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124 STAT. 629 
PUBLIC LAW 111–148—MAR. 23, 2010 
evaluation, and dissemination of research, demonstration 
projects, and model curricula for cultural competency, 
prevention, public health proficiency, reducing health 
disparities, and aptitude for working with individuals with 
disabilities training for use in health professions schools 
and continuing education programs, and for other purposes 
determined as appropriate by the Secretary.’’; and 
(2) by redesignating subsection (b) as subsection (d); 
(3) by inserting after subsection (a) the following: 
‘‘(b) COLLABORATION.—In carrying out subsection (a), the Sec-
retary shall collaborate with the entities described in section 741(b). 
The Secretary shall coordinate with curricula and research and 
demonstration projects developed under such section 741. 
‘‘(c) DISSEMINATION.—Model curricula developed under this sec-
tion shall be disseminated and evaluated in the same manner 
as model curricula developed under section 741, as described in 
subsection (c) of such section.’’; and 
(4) in subsection (d), as so redesignated— 
(A) by striking ‘‘subsection (a)’’ and inserting ‘‘this sec-
tion’’; and 
(B) by striking ‘‘2001 through 2004’’ and inserting 
‘‘2010 through 2015’’. 
SEC. 5308. ADVANCED NURSING EDUCATION GRANTS. 
Section 811 of the Public Health Service Act (42 U.S.C. 296j) 
is amended— 
(1) in subsection (c)— 
(A) in the subsection heading, by striking ‘‘AND NURSE 
MIDWIFERY PROGRAMS’’; and 
(B) by striking ‘‘and nurse midwifery’’; 
(2) in subsection (f)— 
(A) by striking paragraph (2); and 
(B) by redesignating paragraph (3) as paragraph (2); 
and 
(3) by redesignating subsections (d), (e), and (f) as sub-
sections (e), (f), and (g), respectively; and 
(4) by inserting after subsection (c), the following: 
‘‘(d) AUTHORIZED
NURSE-MIDWIFERY
PROGRAMS.—Midwifery 
programs that are eligible for support under this section are edu-
cational programs that— 
‘‘(1) have as their objective the education of midwives; 
and 
‘‘(2) are accredited by the American College of Nurse-Mid-
wives Accreditation Commission for Midwifery Education.’’. 
SEC. 5309. NURSE EDUCATION, PRACTICE, AND RETENTION GRANTS. 
(a) IN GENERAL.—Section 831 of the Public Health Service 
Act (42 U.S.C. 296p) is amended— 
(1) in the section heading, by striking ‘‘RETENTION’’ and 
inserting ‘‘QUALITY’’; 
(2) in subsection (a)— 
(A) in paragraph (1), by adding ‘‘or’’ after the semicolon; 
(B) by striking paragraph (2); and 
(C) by redesignating paragraph (3) as paragraph (2); 
(3) in subsection (b)(3), by striking ‘‘managed care, quality 
improvement’’ and inserting ‘‘coordinated care’’; 
(4) in subsection (g), by inserting ‘‘, as defined in section 
801(2),’’ after ‘‘school of nursing’’; and 
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124 STAT. 630 
PUBLIC LAW 111–148—MAR. 23, 2010 
(5) in subsection (h), by striking ‘‘2003 through 2007’’ and 
inserting ‘‘2010 through 2014’’. 
(b) NURSE RETENTION GRANTS.—Title VIII of the Public Health 
Service Act is amended by inserting after section 831 (42 U.S.C. 
296b) the following: 
‘‘SEC. 831A. NURSE RETENTION GRANTS. 
‘‘(a) RETENTION PRIORITY AREAS.—The Secretary may award 
grants to, and enter into contracts with, eligible entities to enhance 
the nursing workforce by initiating and maintaining nurse retention 
programs pursuant to subsection (b) or (c). 
‘‘(b) GRANTS FOR CAREER LADDER PROGRAM.—The Secretary 
may award grants to, and enter into contracts with, eligible entities 
for programs— 
‘‘(1) to promote career advancement for individuals 
including licensed practical nurses, licensed vocational nurses, 
certified nurse assistants, home health aides, diploma degree 
or associate degree nurses, to become baccalaureate prepared 
registered nurses or advanced education nurses in order to 
meet the needs of the registered nurse workforce; 
‘‘(2) developing and implementing internships and resi-
dency programs in collaboration with an accredited school of 
nursing, as defined by section 801(2), to encourage mentoring 
and the development of specialties; or 
‘‘(3) to assist individuals in obtaining education and 
training required to enter the nursing profession and advance 
within such profession. 
‘‘(c) ENHANCING PATIENT CARE DELIVERY SYSTEMS.— 
‘‘(1) GRANTS.—The Secretary may award grants to eligible 
entities to improve the retention of nurses and enhance patient 
care that is directly related to nursing activities by enhancing 
collaboration and communication among nurses and other 
health care professionals, and by promoting nurse involvement 
in the organizational and clinical decision-making processes 
of a health care facility. 
‘‘(2) PRIORITY.—In making awards of grants under this 
subsection, the Secretary shall give preference to applicants 
that have not previously received an award under this sub-
section (or section 831(c) as such section existed on the day 
before the date of enactment of this section). 
‘‘(3) CONTINUATION
OF
AN
AWARD.—The Secretary shall 
make continuation of any award under this subsection beyond 
the second year of such award contingent on the recipient 
of such award having demonstrated to the Secretary measur-
able and substantive improvement in nurse retention or patient 
care. 
‘‘(d) OTHER PRIORITY AREAS.—The Secretary may award grants 
to, or enter into contracts with, eligible entities to address other 
areas that are of high priority to nurse retention, as determined 
by the Secretary. 
‘‘(e) REPORT.—The Secretary shall submit to the Congress before 
the end of each fiscal year a report on the grants awarded and 
the contracts entered into under this section. Each such report 
shall identify the overall number of such grants and contracts 
and provide an explanation of why each such grant or contract 
will meet the priority need of the nursing workforce. 
42 USC 296p–1. 
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124 STAT. 631 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(f) ELIGIBLE ENTITY.—For purposes of this section, the term 
‘eligible entity’ includes an accredited school of nursing, as defined 
by section 801(2), a health care facility, or a partnership of such 
a school and facility. 
‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated to carry out this section such sums as may 
be necessary for each of fiscal years 2010 through 2012.’’. 
SEC. 5310. LOAN REPAYMENT AND SCHOLARSHIP PROGRAM. 
(a) LOAN REPAYMENTS AND SCHOLARSHIPS.—Section 846(a)(3) 
of the Public Health Service Act (42 U.S.C. 297n(a)(3)) is amended 
by inserting before the semicolon the following: ‘‘, or in a accredited 
school of nursing, as defined by section 801(2), as nurse faculty’’. 
(b) TECHNICAL AND CONFORMING AMENDMENTS.—Title VIII (42 
U.S.C. 296 et seq.) is amended— 
(1) by redesignating section 810 (relating to prohibition 
against discrimination by schools on the basis of sex) as section 
809 and moving such section so that it follows section 808; 
(2) in sections 835, 836, 838, 840, and 842, by striking 
the term ‘‘this subpart’’ each place it appears and inserting 
‘‘this part’’; 
(3) in section 836(h), by striking the last sentence; 
(4) in section 836, by redesignating subsection (l) as sub-
section (k); 
(5) in section 839, by striking ‘‘839’’ and all that follows 
through ‘‘(a)’’ and inserting ‘‘839. (a)’’; 
(6) in section 835(b), by striking ‘‘841’’ each place it appears 
and inserting ‘‘871’’; 
(7) by redesignating section 841 as section 871, moving 
part F to the end of the title, and redesignating such part 
as part I; 
(8) in part G— 
(A) by redesignating section 845 as section 851; and 
(B) by redesignating part G as part F; 
(9) in part H— 
(A) by redesignating sections 851 and 852 as sections 
861 and 862, respectively; and 
(B) by redesignating part H as part G; and 
(10) in part I— 
(A) by redesignating section 855, as amended by section 
5305, as section 865; and 
(B) by redesignating part I as part H. 
SEC. 5311. NURSE FACULTY LOAN PROGRAM. 
(a) IN GENERAL.—Section 846A of the Public Health Service 
Act (42 U.S.C. 297n–1) is amended— 
(1) in subsection (a)— 
(A) in the subsection heading, by striking ‘‘ESTABLISH-
MENT’’ and inserting ‘‘SCHOOL OF NURSING STUDENT LOAN 
FUND’’; and 
(B) by inserting ‘‘accredited’’ after ‘‘agreement with 
any’’; 
(2) in subsection (c)— 
(A) in paragraph (2), by striking ‘‘$30,000’’ and all 
that follows through the semicolon and inserting ‘‘$35,500, 
during fiscal years 2010 and 2011 fiscal years (after fiscal 
year 2011, such amounts shall be adjusted to provide for 
42 USC 298. 
42 USC 297w, 
297x. 
42 USC 297t. 
42 USC 298d. 
42 USC 297a. 
42 USC 297e. 
42 USC 297b. 
42 USC 297a, 
297b, 297d, 
297g, 297i. 
42 USC 296g. 
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124 STAT. 632 
PUBLIC LAW 111–148—MAR. 23, 2010 
a cost-of-attendance increase for the yearly loan rate and 
the aggregate loan;’’; and 
(B) in paragraph (3)(A), by inserting ‘‘an accredited’’ 
after ‘‘faculty member in’’; 
(3) in subsection (e), by striking ‘‘a school’’ and inserting 
‘‘an accredited school’’; and 
(4) in subsection (f), by striking ‘‘2003 through 2007’’ and 
inserting ‘‘2010 through 2014’’. 
(b) ELIGIBLE INDIVIDUAL STUDENT LOAN REPAYMENT.—Title 
VIII of the Public Health Service Act is amended by inserting 
after section 846A (42 U.S.C. 297n–1) the following: 
‘‘SEC. 847. ELIGIBLE INDIVIDUAL STUDENT LOAN REPAYMENT. 
‘‘(a) IN GENERAL.—The Secretary, acting through the Adminis-
trator of the Health Resources and Services Administration, may 
enter into an agreement with eligible individuals for the repayment 
of education loans, in accordance with this section, to increase 
the number of qualified nursing faculty. 
‘‘(b) AGREEMENTS.—Each agreement entered into under this 
subsection shall require that the eligible individual shall serve 
as a full-time member of the faculty of an accredited school of 
nursing, for a total period, in the aggregate, of at least 4 years 
during the 6-year period beginning on the later of— 
‘‘(1) the date on which the individual receives a master’s 
or doctorate nursing degree from an accredited school of 
nursing; or 
‘‘(2) the date on which the individual enters into an agree-
ment under this subsection. 
‘‘(c) AGREEMENT PROVISIONS.—Agreements entered into pursu-
ant to subsection (b) shall be entered into on such terms and 
conditions as the Secretary may determine, except that— 
‘‘(1) not more than 10 months after the date on which 
the 6-year period described under subsection (b) begins, but 
in no case before the individual starts as a full-time member 
of the faculty of an accredited school of nursing the Secretary 
shall begin making payments, for and on behalf of that indi-
vidual, on the outstanding principal of, and interest on, any 
loan of that individual obtained to pay for such degree; 
‘‘(2) for an individual who has completed a master’s in 
nursing or equivalent degree in nursing— 
‘‘(A) payments may not exceed $10,000 per calendar 
year; and 
‘‘(B) total payments may not exceed $40,000 during 
the 2010 and 2011 fiscal years (after fiscal year 2011, 
such amounts shall be adjusted to provide for a cost-of- 
attendance increase for the yearly loan rate and the aggre-
gate loan); and 
‘‘(3) for an individual who has completed a doctorate or 
equivalent degree in nursing— 
‘‘(A) payments may not exceed $20,000 per calendar 
year; and 
‘‘(B) total payments may not exceed $80,000 during 
the 2010 and 2011 fiscal years (adjusted for subsequent 
fiscal years as provided for in the same manner as in 
paragraph (2)(B)). 
‘‘(d) BREACH OF AGREEMENT.— 
Deadline. 
42 USC 297o. 
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124 STAT. 633 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) IN
GENERAL.—In the case of any agreement made 
under subsection (b), the individual is liable to the Federal 
Government for the total amount paid by the Secretary under 
such agreement, and for interest on such amount at the max-
imum legal prevailing rate, if the individual fails to meet the 
agreement terms required under such subsection. 
‘‘(2) WAIVER
OR
SUSPENSION
OF
LIABILITY.—In the case 
of an individual making an agreement for purposes of para-
graph (1), the Secretary shall provide for the waiver or suspen-
sion of liability under such paragraph if compliance by the 
individual with the agreement involved is impossible or would 
involve extreme hardship to the individual or if enforcement 
of the agreement with respect to the individual would be uncon-
scionable. 
‘‘(3) DATE CERTAIN FOR RECOVERY.—Subject to paragraph 
(2), any amount that the Federal Government is entitled to 
recover under paragraph (1) shall be paid to the United States 
not later than the expiration of the 3-year period beginning 
on the date the United States becomes so entitled. 
‘‘(4) AVAILABILITY.—Amounts recovered under paragraph 
(1) shall be available to the Secretary for making loan repay-
ments under this section and shall remain available for such 
purpose until expended. 
‘‘(e) ELIGIBLE INDIVIDUAL DEFINED.—For purposes of this sec-
tion, the term ‘eligible individual’ means an individual who— 
‘‘(1) is a United States citizen, national, or lawful perma-
nent resident; 
‘‘(2) holds an unencumbered license as a registered nurse; 
and 
‘‘(3) has either already completed a master’s or doctorate 
nursing program at an accredited school of nursing or is cur-
rently enrolled on a full-time or part-time basis in such a 
program. 
‘‘(f) PRIORITY.—For the purposes of this section and section 
846A, funding priority will be awarded to School of Nursing Student 
Loans that support doctoral nursing students or Individual Student 
Loan Repayment that support doctoral nursing students. 
‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated to carry out this section such sums as may 
be necessary for each of fiscal years 2010 through 2014.’’. 
SEC. 5312. AUTHORIZATION OF APPROPRIATIONS FOR PARTS B 
THROUGH D OF TITLE VIII. 
Section 871 of the Public Health Service Act, as redesignated 
and moved by section 5310, is amended to read as follows: 
‘‘SEC. 871. AUTHORIZATION OF APPROPRIATIONS. 
‘‘For the purpose of carrying out parts B, C, and D (subject 
to section 851(g)), there are authorized to be appropriated 
$338,000,000 for fiscal year 2010, and such sums as may be nec-
essary for each of the fiscal years 2011 through 2016.’’. 
SEC. 
5313. 
GRANTS 
TO 
PROMOTE 
THE 
COMMUNITY 
HEALTH 
WORKFORCE. 
(a) IN GENERAL.—Part P of title III of the Public Health Service 
Act (42 U.S.C. 280g et seq.) is amended by adding at the end 
the following: 
42 USC 298d. 
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124 STAT. 634 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 399V. GRANTS TO PROMOTE POSITIVE HEALTH BEHAVIORS AND 
OUTCOMES. 
‘‘(a) GRANTS AUTHORIZED.—The Director of the Centers for Dis-
ease Control and Prevention, in collaboration with the Secretary, 
shall award grants to eligible entities to promote positive health 
behaviors and outcomes for populations in medically underserved 
communities through the use of community health workers. 
‘‘(b) USE OF FUNDS.—Grants awarded under subsection (a) shall 
be used to support community health workers— 
‘‘(1) to educate, guide, and provide outreach in a community 
setting regarding health problems prevalent in medically under-
served communities, particularly racial and ethnic minority 
populations; 
‘‘(2) to educate and provide guidance regarding effective 
strategies to promote positive health behaviors and discourage 
risky health behaviors; 
‘‘(3) to educate and provide outreach regarding enrollment 
in health insurance including the Children’s Health Insurance 
Program under title XXI of the Social Security Act, Medicare 
under title XVIII of such Act and Medicaid under title XIX 
of such Act; 
‘‘(4) to identify, educate, refer, and enroll underserved popu-
lations to appropriate healthcare agencies and community- 
based programs and organizations in order to increase access 
to quality healthcare services and to eliminate duplicative care; 
or 
‘‘(5) to educate, guide, and provide home visitation services 
regarding maternal health and prenatal care. 
‘‘(c) APPLICATION.—Each eligible entity that desires to receive 
a grant under subsection (a) shall submit an application to the 
Secretary, at such time, in such manner, and accompanied by 
such information as the Secretary may require. 
‘‘(d) PRIORITY.—In awarding grants under subsection (a), the 
Secretary shall give priority to applicants that— 
‘‘(1) propose to target geographic areas— 
‘‘(A) with a high percentage of residents who are 
eligible for health insurance but are uninsured or under-
insured; 
‘‘(B) with a high percentage of residents who suffer 
from chronic diseases; or 
‘‘(C) with a high infant mortality rate; 
‘‘(2) have experience in providing health or health-related 
social services to individuals who are underserved with respect 
to such services; and 
‘‘(3) have documented community activity and experience 
with community health workers. 
‘‘(e) COLLABORATION WITH ACADEMIC INSTITUTIONS AND THE 
ONE-STOP
DELIVERY
SYSTEM.—The Secretary shall encourage 
community health worker programs receiving funds under this sec-
tion to collaborate with academic institutions and one-stop delivery 
systems under section 134(c) of the Workforce Investment Act of 
1998. Nothing in this section shall be construed to require such 
collaboration. 
‘‘(f) EVIDENCE-BASED
INTERVENTIONS.—The Secretary shall 
encourage community health worker programs receiving funding 
under this section to implement a process or an outcome-based 
42 USC 280g–11. 
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124 STAT. 635 
PUBLIC LAW 111–148—MAR. 23, 2010 
payment system that rewards community health workers for con-
necting underserved populations with the most appropriate services 
at the most appropriate time. Nothing in this section shall be 
construed to require such a payment. 
‘‘(g) QUALITY ASSURANCE AND COST EFFECTIVENESS.—The Sec-
retary shall establish guidelines for assuring the quality of the 
training and supervision of community health workers under the 
programs funded under this section and for assuring the cost- 
effectiveness of such programs. 
‘‘(h) MONITORING.—The Secretary shall monitor community 
health worker programs identified in approved applications under 
this section and shall determine whether such programs are in 
compliance with the guidelines established under subsection (g). 
‘‘(i) TECHNICAL ASSISTANCE.—The Secretary may provide tech-
nical assistance to community health worker programs identified 
in approved applications under this section with respect to planning, 
developing, and operating programs under the grant. 
‘‘(j) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated, such sums as may be necessary to carry out 
this section for each of fiscal years 2010 through 2014. 
‘‘(k) DEFINITIONS.—In this section: 
‘‘(1) COMMUNITY HEALTH WORKER.—The term ‘community 
health worker’, as defined by the Department of Labor as 
Standard Occupational Classification [21–1094] means an indi-
vidual who promotes health or nutrition within the community 
in which the individual resides— 
‘‘(A) by serving as a liaison between communities and 
healthcare agencies; 
‘‘(B) by providing guidance and social assistance to 
community residents; 
‘‘(C) by enhancing community residents’ ability to effec-
tively communicate with healthcare providers; 
‘‘(D) by providing culturally and linguistically appro-
priate health or nutrition education; 
‘‘(E) by advocating for individual and community 
health; 
‘‘(F) by providing referral and follow-up services or 
otherwise coordinating care; and 
‘‘(G) by proactively identifying and enrolling eligible 
individuals in Federal, State, local, private or nonprofit 
health and human services programs. 
‘‘(2) COMMUNITY SETTING.—The term ‘community setting’ 
means a home or a community organization located in the 
neighborhood in which a participant in the program under 
this section resides. 
‘‘(3) ELIGIBLE ENTITY.—The term ‘eligible entity’ means a 
public or nonprofit private entity (including a State or public 
subdivision of a State, a public health department, a free health 
clinic, a hospital, or a Federally-qualified health center (as 
defined in section 1861(aa) of the Social Security Act)), or 
a consortium of any such entities. 
‘‘(4) MEDICALLY
UNDERSERVED
COMMUNITY.—The term 
‘medically underserved community’ means a community identi-
fied by a State— 
‘‘(A) that has a substantial number of individuals who 
are members of a medically underserved population, as 
defined by section 330(b)(3); and 
Guidelines. 
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124 STAT. 636 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) a significant portion of which is a health profes-
sional shortage area as designated under section 332.’’. 
SEC. 5314. FELLOWSHIP TRAINING IN PUBLIC HEALTH. 
Part E of title VII of the Public Health Service Act (42 U.S.C. 
294n et seq.), as amended by section 5206, is further amended 
by adding at the end the following: 
‘‘SEC. 778. FELLOWSHIP TRAINING IN APPLIED PUBLIC HEALTH EPIDE-
MIOLOGY, 
PUBLIC 
HEALTH 
LABORATORY 
SCIENCE, 
PUBLIC HEALTH INFORMATICS, AND EXPANSION OF THE 
EPIDEMIC INTELLIGENCE SERVICE. 
‘‘(a) IN GENERAL.—The Secretary may carry out activities to 
address documented workforce shortages in State and local health 
departments in the critical areas of applied public health epidemi-
ology and public health laboratory science and informatics and 
may expand the Epidemic Intelligence Service. 
‘‘(b) SPECIFIC USES.—In carrying out subsection (a), the Sec-
retary shall provide for the expansion of existing fellowship pro-
grams operated through the Centers for Disease Control and 
Prevention in a manner that is designed to alleviate shortages 
of the type described in subsection (a). 
‘‘(c) OTHER PROGRAMS.—The Secretary may provide for the 
expansion of other applied epidemiology training programs that 
meet objectives similar to the objectives of the programs described 
in subsection (b). 
‘‘(d) WORK OBLIGATION.—Participation in fellowship training 
programs under this section shall be deemed to be service for 
purposes of satisfying work obligations stipulated in contracts under 
section 338I(j). 
‘‘(e) GENERAL SUPPORT.—Amounts may be used from grants 
awarded under this section to expand the Public Health Informatics 
Fellowship Program at the Centers for Disease Control and Preven-
tion to better support all public health systems at all levels of 
government. 
‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated to carry out this section $39,500,000 for each 
of fiscal years 2010 through 2013, of which— 
‘‘(1) $5,000,000 shall be made available in each such fiscal 
year for epidemiology fellowship training program activities 
under subsections (b) and (c); 
‘‘(2) $5,000,000 shall be made available in each such fiscal 
year for laboratory fellowship training programs under sub-
section (b); 
‘‘(3) $5,000,000 shall be made available in each such fiscal 
year for the Public Health Informatics Fellowship Program 
under subsection (e); and 
‘‘(4) $24,500,000 shall be made available for expanding 
the Epidemic Intelligence Service under subsection (a).’’. 
SEC. 5315. UNITED STATES PUBLIC HEALTH SCIENCES TRACK. 
Title II of the Public Health Service Act (42 U.S.C. 202 et 
seq.) is amended by adding at the end the following: 
42 USC 295f–3. 
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124 STAT. 637 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘PART D—UNITED STATES PUBLIC HEALTH 
SCIENCES TRACK 
‘‘SEC. 271. ESTABLISHMENT. 
‘‘(a) UNITED STATES PUBLIC HEALTH SERVICES TRACK.— 
‘‘(1) IN GENERAL.—There is hereby authorized to be estab-
lished a United States Public Health Sciences Track (referred 
to in this part as the ‘Track’), at sites to be selected by the 
Secretary, with authority to grant appropriate advanced 
degrees in a manner that uniquely emphasizes team-based 
service, public health, epidemiology, and emergency prepared-
ness and response. It shall be so organized as to graduate 
not less than— 
‘‘(A) 150 medical students annually, 10 of whom shall 
be awarded studentships to the Uniformed Services Univer-
sity of Health Sciences; 
‘‘(B) 100 dental students annually; 
‘‘(C) 250 nursing students annually; 
‘‘(D) 100 public health students annually; 
‘‘(E) 100 behavioral and mental health professional 
students annually; 
‘‘(F) 100 physician assistant or nurse practitioner stu-
dents annually; and 
‘‘(G) 50 pharmacy students annually. 
‘‘(2) LOCATIONS.—The Track shall be located at existing 
and accredited, affiliated health professions education training 
programs at academic health centers located in regions of the 
United States determined appropriate by the Surgeon General, 
in consultation with the National Health Care Workforce 
Commission established in section 5101 of the Patient Protec-
tion and Affordable Care Act. 
‘‘(b) NUMBER OF GRADUATES.—Except as provided in subsection 
(a), the number of persons to be graduated from the Track shall 
be prescribed by the Secretary. In so prescribing the number of 
persons to be graduated from the Track, the Secretary shall 
institute actions necessary to ensure the maximum number of first- 
year enrollments in the Track consistent with the academic capacity 
of the affiliated sites and the needs of the United States for medical, 
dental, and nursing personnel. 
‘‘(c) DEVELOPMENT.—The development of the Track may be 
by such phases as the Secretary may prescribe subject to the 
requirements of subsection (a). 
‘‘(d) INTEGRATED LONGITUDINAL PLAN.—The Surgeon General 
shall develop an integrated longitudinal plan for health professions 
continuing education throughout the continuum of health-related 
education, training, and practice. Training under such plan shall 
emphasize patient-centered, interdisciplinary, and care coordination 
skills. Experience with deployment of emergency response teams 
shall be included during the clinical experiences. 
‘‘(e) FACULTY
DEVELOPMENT.—The Surgeon General shall 
develop faculty development programs and curricula in decentral-
ized venues of health care, to balance urban, tertiary, and inpatient 
venues. 
‘‘SEC. 272. ADMINISTRATION. 
‘‘(a) IN GENERAL.—The business of the Track shall be conducted 
by the Surgeon General with funds appropriated for and provided 
42 USC 239l–1. 
42 USC 239l. 
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124 STAT. 638 
PUBLIC LAW 111–148—MAR. 23, 2010 
by the Department of Health and Human Services. The National 
Health Care Workforce Commission shall assist the Surgeon Gen-
eral in an advisory capacity. 
‘‘(b) FACULTY.— 
‘‘(1) IN GENERAL.—The Surgeon General, after considering 
the recommendations of the National Health Care Workforce 
Commission, shall obtain the services of such professors, 
instructors, and administrative and other employees as may 
be necessary to operate the Track, but utilize when possible, 
existing affiliated health professions training institutions. Mem-
bers of the faculty and staff shall be employed under salary 
schedules and granted retirement and other related benefits 
prescribed by the Secretary so as to place the employees of 
the Track faculty on a comparable basis with the employees 
of fully accredited schools of the health professions within the 
United States. 
‘‘(2) TITLES.—The Surgeon General may confer academic 
titles, as appropriate, upon the members of the faculty. 
‘‘(3) NONAPPLICATION OF PROVISIONS.—The limitations in 
section 5373 of title 5, United States Code, shall not apply 
to the authority of the Surgeon General under paragraph (1) 
to prescribe salary schedules and other related benefits. 
‘‘(c) AGREEMENTS.—The Surgeon General may negotiate agree-
ments with agencies of the Federal Government to utilize on a 
reimbursable basis appropriate existing Federal medical resources 
located in the United States (or locations selected in accordance 
with section 271(a)(2)). Under such agreements the facilities con-
cerned will retain their identities and basic missions. The Surgeon 
General may negotiate affiliation agreements with accredited 
universities and health professions training institutions in the 
United States. Such agreements may include provisions for pay-
ments for educational services provided students participating in 
Department of Health and Human Services educational programs. 
‘‘(d) PROGRAMS.—The Surgeon General may establish the fol-
lowing educational programs for Track students: 
‘‘(1) Postdoctoral, postgraduate, and technological pro-
grams. 
‘‘(2) A cooperative program for medical, dental, physician 
assistant, pharmacy, behavioral and mental health, public 
health, and nursing students. 
‘‘(3) Other programs that the Surgeon General determines 
necessary in order to operate the Track in a cost-effective 
manner. 
‘‘(e) CONTINUING MEDICAL EDUCATION.—The Surgeon General 
shall establish programs in continuing medical education for mem-
bers of the health professions to the end that high standards of 
health care may be maintained within the United States. 
‘‘(f) AUTHORITY OF THE SURGEON GENERAL.— 
‘‘(1) IN GENERAL.—The Surgeon General is authorized— 
‘‘(A) to enter into contracts with, accept grants from, 
and make grants to any nonprofit entity for the purpose 
of carrying out cooperative enterprises in medical, dental, 
physician assistant, pharmacy, behavioral and mental 
health, public health, and nursing research, consultation, 
and education; 
‘‘(B) to enter into contracts with entities under which 
the Surgeon General may furnish the services of such 
Contracts. 
Grants. 
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124 STAT. 639 
PUBLIC LAW 111–148—MAR. 23, 2010 
professional, technical, or clerical personnel as may be nec-
essary to fulfill cooperative enterprises undertaken by the 
Track; 
‘‘(C) to accept, hold, administer, invest, and spend any 
gift, devise, or bequest of personal property made to the 
Track, including any gift, devise, or bequest for the support 
of an academic chair, teaching, research, or demonstration 
project; 
‘‘(D) to enter into agreements with entities that may 
be utilized by the Track for the purpose of enhancing 
the activities of the Track in education, research, and 
technological applications of knowledge; and 
‘‘(E) to accept the voluntary services of guest scholars 
and other persons. 
‘‘(2) LIMITATION.—The Surgeon General may not enter into 
any contract with an entity if the contract would obligate the 
Track to make outlays in advance of the enactment of budget 
authority for such outlays. 
‘‘(3) SCIENTISTS.—Scientists or other medical, dental, or 
nursing personnel utilized by the Track under an agreement 
described in paragraph (1) may be appointed to any position 
within the Track and may be permitted to perform such duties 
within the Track as the Surgeon General may approve. 
‘‘(4) VOLUNTEER
SERVICES.—A person who provides vol-
untary services under the authority of subparagraph (E) of 
paragraph (1) shall be considered to be an employee of the 
Federal Government for the purposes of chapter 81 of title 
5, relating to compensation for work-related injuries, and to 
be an employee of the Federal Government for the purposes 
of chapter 171 of title 28, relating to tort claims. Such a person 
who is not otherwise employed by the Federal Government 
shall not be considered to be a Federal employee for any other 
purpose by reason of the provision of such services. 
‘‘SEC. 273. STUDENTS; SELECTION; OBLIGATION. 
‘‘(a) STUDENT SELECTION.— 
‘‘(1) IN
GENERAL.—Medical, dental, physician assistant, 
pharmacy, behavioral and mental health, public health, and 
nursing students at the Track shall be selected under proce-
dures prescribed by the Surgeon General. In so prescribing, 
the Surgeon General shall consider the recommendations of 
the National Health Care Workforce Commission. 
‘‘(2) PRIORITY.—In developing admissions procedures under 
paragraph (1), the Surgeon General shall ensure that such 
procedures give priority to applicant medical, dental, physician 
assistant, pharmacy, behavioral and mental health, public 
health, and nursing students from rural communities and 
underrepresented minorities. 
‘‘(b) CONTRACT AND SERVICE OBLIGATION.— 
‘‘(1) CONTRACT.—Upon being admitted to the Track, a med-
ical, dental, physician assistant, pharmacy, behavioral and 
mental health, public health, or nursing student shall enter 
into a written contract with the Surgeon General that shall 
contain— 
‘‘(A) an agreement under which— 
‘‘(i) subject to subparagraph (B), the Surgeon Gen-
eral agrees to provide the student with tuition (or 
42 USC 239l–2. 
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124 STAT. 640 
PUBLIC LAW 111–148—MAR. 23, 2010 
tuition remission) and a student stipend (described 
in paragraph (2)) in each school year for a period 
of years (not to exceed 4 school years) determined 
by the student, during which period the student is 
enrolled in the Track at an affiliated or other partici-
pating health professions institution pursuant to an 
agreement between the Track and such institution; 
and 
‘‘(ii) subject to subparagraph (B), the student 
agrees— 
‘‘(I) to accept the provision of such tuition and 
student stipend to the student; 
‘‘(II) to maintain enrollment at the Track until 
the student completes the course of study involved; 
‘‘(III) while enrolled in such course of study, 
to maintain an acceptable level of academic 
standing (as determined by the Surgeon General); 
‘‘(IV) if pursuing a degree from a school of 
medicine or osteopathic medicine, dental, public 
health, or nursing school or a physician assistant, 
pharmacy, or behavioral and mental health profes-
sional program, to complete a residency or intern-
ship in a specialty that the Surgeon General deter-
mines is appropriate; and 
‘‘(V) to serve for a period of time (referred 
to in this part as the ‘period of obligated service’) 
within the Commissioned Corps of the Public 
Health Service equal to 2 years for each school 
year during which such individual was enrolled 
at the College, reduced as provided for in para-
graph (3); 
‘‘(B) a provision that any financial obligation of the 
United States arising out of a contract entered into under 
this part and any obligation of the student which is condi-
tioned thereon, is contingent upon funds being appropriated 
to carry out this part; 
‘‘(C) a statement of the damages to which the United 
States is entitled for the student’s breach of the contract; 
and 
‘‘(D) such other statements of the rights and liabilities 
of the Secretary and of the individual, not inconsistent 
with the provisions of this part. 
‘‘(2) TUITION AND STUDENT STIPEND.— 
‘‘(A) TUITION REMISSION RATES.—The Surgeon General, 
based on the recommendations of the National Health Care 
Workforce Commission, shall establish Federal tuition 
remission rates to be used by the Track to provide 
reimbursement to affiliated and other participating health 
professions institutions for the cost of educational services 
provided by such institutions to Track students. The agree-
ment entered into by such participating institutions under 
paragraph (1)(A)(i) shall contain an agreement to accept 
as payment in full the established remission rate under 
this subparagraph. 
‘‘(B) STIPEND.—The Surgeon General, based on the rec-
ommendations of the National Health Care Workforce 
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124 STAT. 641 
PUBLIC LAW 111–148—MAR. 23, 2010 
Commission, shall establish and update Federal stipend 
rates for payment to students under this part. 
‘‘(3) REDUCTIONS IN THE PERIOD OF OBLIGATED SERVICE.— 
The period of obligated service under paragraph (1)(A)(ii)(V) 
shall be reduced— 
‘‘(A) in the case of a student who elects to participate 
in a high-needs speciality residency (as determined by the 
National Health Care Workforce Commission), by 3 months 
for each year of such participation (not to exceed a total 
of 12 months); and 
‘‘(B) in the case of a student who, upon completion 
of their residency, elects to practice in a Federal medical 
facility (as defined in section 781(e)) that is located in 
a health professional shortage area (as defined in section 
332), by 3 months for year of full-time practice in such 
a facility (not to exceed a total of 12 months). 
‘‘(c) SECOND 2 YEARS OF SERVICE.—During the third and fourth 
years in which a medical, dental, physician assistant, pharmacy, 
behavioral and mental health, public health, or nursing student 
is enrolled in the Track, training should be designed to prioritize 
clinical rotations in Federal medical facilities in health professional 
shortage areas, and emphasize a balance of hospital and community- 
based experiences, and training within interdisciplinary teams. 
‘‘(d) DENTIST, PHYSICIAN ASSISTANT, PHARMACIST, BEHAVIORAL 
AND MENTAL HEALTH PROFESSIONAL, PUBLIC HEALTH PROFES-
SIONAL, AND NURSE TRAINING.—The Surgeon General shall estab-
lish provisions applicable with respect to dental, physician assistant, 
pharmacy, behavioral and mental health, public health, and nursing 
students that are comparable to those for medical students under 
this section, including service obligations, tuition support, and sti-
pend support. The Surgeon General shall give priority to health 
professions training institutions that train medical, dental, physi-
cian assistant, pharmacy, behavioral and mental health, public 
health, and nursing students for some significant period of time 
together, but at a minimum have a discrete and shared core cur-
riculum. 
‘‘(e) ELITE FEDERAL DISASTER TEAMS.—The Surgeon General, 
in consultation with the Secretary, the Director of the Centers 
for Disease Control and Prevention, and other appropriate military 
and Federal government agencies, shall develop criteria for the 
appointment of highly qualified Track faculty, medical, dental, 
physician assistant, pharmacy, behavioral and mental health, public 
health, and nursing students, and graduates to elite Federal dis-
aster preparedness teams to train and to respond to public health 
emergencies, natural disasters, bioterrorism events, and other emer-
gencies. 
‘‘(f) STUDENT DROPPED FROM TRACK IN AFFILIATE SCHOOL.— 
A medical, dental, physician assistant, pharmacy, behavioral and 
mental health, public health, or nursing student who, under regula-
tions prescribed by the Surgeon General, is dropped from the Track 
in an affiliated school for deficiency in conduct or studies, or for 
other reasons, shall be liable to the United States for all tuition 
and stipend support provided to the student. 
Regulations. 
Criteria. 
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124 STAT. 642 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 274. FUNDING. 
‘‘Beginning with fiscal year 2010, the Secretary shall transfer 
from the Public Health and Social Services Emergency Fund such 
sums as may be necessary to carry out this part.’’. 
Subtitle E—Supporting the Existing Health 
Care Workforce 
SEC. 5401. CENTERS OF EXCELLENCE. 
Section 736 of the Public Health Service Act (42 U.S.C. 293) 
is amended by striking subsection (h) and inserting the following: 
‘‘(h) FORMULA FOR ALLOCATIONS.— 
‘‘(1) ALLOCATIONS.—Based on the amount appropriated 
under subsection (i) for a fiscal year, the following subpara-
graphs shall apply as appropriate: 
‘‘(A) IN GENERAL.—If the amounts appropriated under 
subsection (i) for a fiscal year are $24,000,000 or less— 
‘‘(i) the Secretary shall make available $12,000,000 
for grants under subsection (a) to health professions 
schools that meet the conditions described in sub-
section (c)(2)(A); and 
‘‘(ii) and available after grants are made with funds 
under clause (i), the Secretary shall make available— 
‘‘(I) 60 percent of such amount for grants under 
subsection (a) to health professions schools that 
meet the conditions described in paragraph (3) 
or (4) of subsection (c) (including meeting the 
conditions under subsection (e)); and 
‘‘(II) 40 percent of such amount for grants 
under subsection (a) to health professions schools 
that meet the conditions described in subsection 
(c)(5). 
‘‘(B) FUNDING
IN
EXCESS
OF
$24,000,000.—If amounts 
appropriated under subsection (i) for a fiscal year exceed 
$24,000,000 but are less than $30,000,000— 
‘‘(i) 80 percent of such excess amounts shall be 
made available for grants under subsection (a) to 
health professions schools that meet the requirements 
described in paragraph (3) or (4) of subsection (c) 
(including meeting conditions pursuant to subsection 
(e)); and 
‘‘(ii) 20 percent of such excess amount shall be 
made available for grants under subsection (a) to 
health professions schools that meet the conditions 
described in subsection (c)(5). 
‘‘(C) FUNDING
IN
EXCESS
OF
$30,000,000.—If amounts 
appropriated under subsection (i) for a fiscal year exceed 
$30,000,000 but are less than $40,000,000, the Secretary 
shall make available— 
‘‘(i) not less than $12,000,000 for grants under 
subsection (a) to health professions schools that meet 
the conditions described in subsection (c)(2)(A); 
‘‘(ii) not less than $12,000,000 for grants under 
subsection (a) to health professions schools that meet 
the conditions described in paragraph (3) or (4) of 
Applicability. 
Grants. 
Effective date. 
42 USC 239l–3. 
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124 STAT. 643 
PUBLIC LAW 111–148—MAR. 23, 2010 
subsection (c) (including meeting conditions pursuant 
to subsection (e)); 
‘‘(iii) not less than $6,000,000 for grants under 
subsection (a) to health professions schools that meet 
the conditions described in subsection (c)(5); and 
‘‘(iv) after grants are made with funds under 
clauses (i) through (iii), any remaining excess amount 
for grants under subsection (a) to health professions 
schools that meet the conditions described in para-
graph (2)(A), (3), (4), or (5) of subsection (c). 
‘‘(D) FUNDING IN EXCESS OF $40,000,000.—If amounts 
appropriated under subsection (i) for a fiscal year are 
$40,000,000 or more, the Secretary shall make available— 
‘‘(i) not less than $16,000,000 for grants under 
subsection (a) to health professions schools that meet 
the conditions described in subsection (c)(2)(A); 
‘‘(ii) not less than $16,000,000 for grants under 
subsection (a) to health professions schools that meet 
the conditions described in paragraph (3) or (4) of 
subsection (c) (including meeting conditions pursuant 
to subsection (e)); 
‘‘(iii) not less than $8,000,000 for grants under 
subsection (a) to health professions schools that meet 
the conditions described in subsection (c)(5); and 
‘‘(iv) after grants are made with funds under 
clauses (i) through (iii), any remaining funds for grants 
under subsection (a) to health professions schools that 
meet the conditions described in paragraph (2)(A), (3), 
(4), or (5) of subsection (c). 
‘‘(2) NO LIMITATION.—Nothing in this subsection shall be 
construed as limiting the centers of excellence referred to in 
this section to the designated amount, or to preclude such 
entities from competing for grants under this section. 
‘‘(3) MAINTENANCE OF EFFORT.— 
‘‘(A) IN GENERAL.—With respect to activities for which 
a grant made under this part are authorized to be 
expended, the Secretary may not make such a grant to 
a center of excellence for any fiscal year unless the center 
agrees to maintain expenditures of non-Federal amounts 
for such activities at a level that is not less than the 
level of such expenditures maintained by the center for 
the fiscal year preceding the fiscal year for which the 
school receives such a grant. 
‘‘(B) USE
OF
FEDERAL
FUNDS.—With respect to any 
Federal amounts received by a center of excellence and 
available for carrying out activities for which a grant under 
this part is authorized to be expended, the center shall, 
before expending the grant, expend the Federal amounts 
obtained from sources other than the grant, unless given 
prior approval from the Secretary. 
‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated to carry out this section— 
‘‘(1) $50,000,000 for each of the fiscal years 2010 through 
2015; and 
‘‘(2) and such sums as are necessary for each subsequent 
fiscal year.’’. 
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124 STAT. 644 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 5402. HEALTH CARE PROFESSIONALS TRAINING FOR DIVERSITY. 
(a) LOAN REPAYMENTS AND FELLOWSHIPS REGARDING FACULTY 
POSITIONS.—Section 738(a)(1) of the Public Health Service Act (42 
U.S.C. 293b(a)(1)) is amended by striking ‘‘$20,000 of the principal 
and interest of the educational loans of such individuals.’’ and 
inserting ‘‘$30,000 of the principal and interest of the educational 
loans of such individuals.’’. 
(b) SCHOLARSHIPS
FOR DISADVANTAGED STUDENTS.—Section 
740(a) of such Act (42 U.S.C. 293d(a)) is amended by striking 
‘‘$37,000,000’’ and all that follows through ‘‘2002’’ and inserting 
‘‘$51,000,000 for fiscal year 2010, and such sums as may be nec-
essary for each of the fiscal years 2011 through 2014’’. 
(c) REAUTHORIZATION FOR LOAN REPAYMENTS AND FELLOWSHIPS 
REGARDING FACULTY POSITIONS.—Section 740(b) of such Act (42 
U.S.C. 293d(b)) is amended by striking ‘‘appropriated’’ and all that 
follows through the period at the end and inserting ‘‘appropriated, 
$5,000,000 for each of the fiscal years 2010 through 2014.’’. 
(d) REAUTHORIZATION FOR EDUCATIONAL ASSISTANCE IN THE 
HEALTH PROFESSIONS REGARDING INDIVIDUALS FROM A DISADVAN-
TAGED BACKGROUND.—Section 740(c) of such Act (42 U.S.C. 293d(c)) 
is amended by striking the first sentence and inserting the fol-
lowing: ‘‘For the purpose of grants and contracts under section 
739(a)(1), there is authorized to be appropriated $60,000,000 for 
fiscal year 2010 and such sums as may be necessary for each 
of the fiscal years 2011 through 2014.’’ 
SEC. 5403. INTERDISCIPLINARY, COMMUNITY-BASED LINKAGES. 
(a) AREA HEALTH EDUCATION CENTERS.—Section 751 of the 
Public Health Service Act (42 U.S.C. 294a) is amended to read 
as follows: 
‘‘SEC. 751. AREA HEALTH EDUCATION CENTERS. 
‘‘(a) ESTABLISHMENT OF AWARDS.—The Secretary shall make 
the following 2 types of awards in accordance with this section: 
‘‘(1) INFRASTRUCTURE
DEVELOPMENT
AWARD.—The Sec-
retary shall make awards to eligible entities to enable such 
entities to initiate health care workforce educational programs 
or to continue to carry out comparable programs that are oper-
ating at the time the award is made by planning, developing, 
operating, and evaluating an area health education center pro-
gram. 
‘‘(2) POINT OF SERVICE MAINTENANCE AND ENHANCEMENT 
AWARD.—The Secretary shall make awards to eligible entities 
to maintain and improve the effectiveness and capabilities of 
an existing area health education center program, and make 
other modifications to the program that are appropriate due 
to changes in demographics, needs of the populations served, 
or other similar issues affecting the area health education 
center program. For the purposes of this section, the term 
‘Program’ refers to the area health education center program. 
‘‘(b) ELIGIBLE ENTITIES; APPLICATION.— 
‘‘(1) ELIGIBLE ENTITIES.— 
‘‘(A) INFRASTRUCTURE DEVELOPMENT.—For purposes of 
subsection (a)(1), the term ‘eligible entity’ means a school 
of medicine or osteopathic medicine, an incorporated 
consortium of such schools, or the parent institutions of 
such a school. With respect to a State in which no area 
Definitions. 
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124 STAT. 645 
PUBLIC LAW 111–148—MAR. 23, 2010 
health education center program is in operation, the Sec-
retary may award a grant or contract under subsection 
(a)(1) to a school of nursing. 
‘‘(B) POINT OF SERVICE MAINTENANCE AND ENHANCE-
MENT.—For purposes of subsection (a)(2), the term ‘eligible 
entity’ means an entity that has received funds under 
this section, is operating an area health education center 
program, including an area health education center or cen-
ters, and has a center or centers that are no longer eligible 
to receive financial assistance under subsection (a)(1). 
‘‘(2) APPLICATION.—An eligible entity desiring to receive 
an award under this section shall submit to the Secretary 
an application at such time, in such manner, and containing 
such information as the Secretary may require. 
‘‘(c) USE OF FUNDS.— 
‘‘(1) REQUIRED
ACTIVITIES.—An eligible entity shall use 
amounts awarded under a grant under subsection (a)(1) or 
(a)(2) to carry out the following activities: 
‘‘(A) Develop and implement strategies, in coordination 
with the applicable one-stop delivery system under section 
134(c) of the Workforce Investment Act of 1998, to recruit 
individuals from underrepresented minority populations or 
from disadvantaged or rural backgrounds into health 
professions, and support such individuals in attaining such 
careers. 
‘‘(B) Develop and implement strategies to foster and 
provide community-based training and education to individ-
uals seeking careers in health professions within under-
served areas for the purpose of developing and maintaining 
a diverse health care workforce that is prepared to deliver 
high-quality care, with an emphasis on primary care, in 
underserved areas or for health disparity populations, in 
collaboration with other Federal and State health care 
workforce development programs, the State workforce 
agency, and local workforce investment boards, and in 
health care safety net sites. 
‘‘(C) Prepare individuals to more effectively provide 
health services to underserved areas and health disparity 
populations through field placements or preceptorships in 
conjunction with community-based organizations, accred-
ited primary care residency training programs, Federally 
qualified health centers, rural health clinics, public health 
departments, or other appropriate facilities. 
‘‘(D) Conduct and participate in interdisciplinary 
training that involves physicians, physician assistants, 
nurse practitioners, nurse midwives, dentists, psycholo-
gists, 
pharmacists, 
optometrists, 
community 
health 
workers, public and allied health professionals, or other 
health professionals, as practicable. 
‘‘(E) Deliver or facilitate continuing education and 
information dissemination programs for health care profes-
sionals, with an emphasis on individuals providing care 
in underserved areas and for health disparity populations. 
‘‘(F) Propose and implement effective program and out-
comes measurement and evaluation strategies. 
Grants. 
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124 STAT. 646 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(G) Establish a youth public health program to expose 
and recruit high school students into health careers, with 
a focus on careers in public health. 
‘‘(2) INNOVATIVE OPPORTUNITIES.—An eligible entity may 
use amounts awarded under a grant under subsection (a)(1) 
or subsection (a)(2) to carry out any of the following activities: 
‘‘(A) Develop and implement innovative curricula in 
collaboration with community-based accredited primary 
care residency training programs, Federally qualified 
health centers, rural health clinics, behavioral and mental 
health facilities, public health departments, or other appro-
priate facilities, with the goal of increasing the number 
of primary care physicians and other primary care pro-
viders prepared to serve in underserved areas and health 
disparity populations. 
‘‘(B) 
Coordinate 
community-based 
participatory 
research with academic health centers, and facilitate rapid 
flow and dissemination of evidence-based health care 
information, research results, and best practices to improve 
quality, efficiency, and effectiveness of health care and 
health care systems within community settings. 
‘‘(C) Develop and implement other strategies to address 
identified workforce needs and increase and enhance the 
health care workforce in the area served by the area health 
education center program. 
‘‘(d) REQUIREMENTS.— 
‘‘(1) AREA HEALTH EDUCATION CENTER PROGRAM.—In car-
rying out this section, the Secretary shall ensure the following: 
‘‘(A) An entity that receives an award under this section 
shall conduct at least 10 percent of clinical education 
required for medical students in community settings that 
are removed from the primary teaching facility of the con-
tracting institution for grantees that operate a school of 
medicine or osteopathic medicine. In States in which an 
entity that receives an award under this section is a 
nursing school or its parent institution, the Secretary shall 
alternatively ensure that— 
‘‘(i) the nursing school conducts at least 10 percent 
of clinical education required for nursing students in 
community settings that are remote from the primary 
teaching facility of the school; and 
‘‘(ii) the entity receiving the award maintains a 
written agreement with a school of medicine or osteo-
pathic medicine to place students from that school 
in training sites in the area health education center 
program area. 
‘‘(B) An entity receiving funds under subsection (a)(2) 
does not distribute such funding to a center that is eligible 
to receive funding under subsection (a)(1). 
‘‘(2) AREA HEALTH EDUCATION CENTER.—The Secretary shall 
ensure that each area health education center program includes 
at least 1 area health education center, and that each such 
center— 
‘‘(A) is a public or private organization whose structure, 
governance, and operation is independent from the awardee 
and the parent institution of the awardee; 
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124 STAT. 647 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) is not a school of medicine or osteopathic medicine, 
the parent institution of such a school, or a branch campus 
or other subunit of a school of medicine or osteopathic 
medicine or its parent institution, or a consortium of such 
entities; 
‘‘(C) designates an underserved area or population to 
be served by the center which is in a location removed 
from the main location of the teaching facilities of the 
schools participating in the program with such center and 
does not duplicate, in whole or in part, the geographic 
area or population served by any other center; 
‘‘(D) fosters networking and collaboration among 
communities and between academic health centers and 
community-based centers; 
‘‘(E) serves communities with a demonstrated need 
of health professionals in partnership with academic med-
ical centers; 
‘‘(F) addresses the health care workforce needs of the 
communities served in coordination with the public 
workforce investment system; and 
‘‘(G) has a community-based governing or advisory 
board that reflects the diversity of the communities 
involved. 
‘‘(e) MATCHING FUNDS.—With respect to the costs of operating 
a program through a grant under this section, to be eligible for 
financial assistance under this section, an entity shall make avail-
able (directly or through contributions from State, county or munic-
ipal governments, or the private sector) recurring non-Federal con-
tributions in cash or in kind, toward such costs in an amount 
that is equal to not less than 50 percent of such costs. At least 
25 percent of the total required non-Federal contributions shall 
be in cash. An entity may apply to the Secretary for a waiver 
of not more than 75 percent of the matching fund amount required 
by the entity for each of the first 3 years the entity is funded 
through a grant under subsection (a)(1). 
‘‘(f) LIMITATION.—Not less than 75 percent of the total amount 
provided to an area health education center program under sub-
section (a)(1) or (a)(2) shall be allocated to the area health education 
centers participating in the program under this section. To provide 
needed flexibility to newly funded area health education center 
programs, the Secretary may waive the requirement in the sentence 
for the first 2 years of a new area health education center program 
funded under subsection (a)(1). 
‘‘(g) AWARD.—An award to an entity under this section shall 
be not less than $250,000 annually per area health education center 
included in the program involved. If amounts appropriated to carry 
out this section are not sufficient to comply with the preceding 
sentence, the Secretary may reduce the per center amount provided 
for in such sentence as necessary, provided the distribution estab-
lished in subsection (j)(2) is maintained. 
‘‘(h) PROJECT TERMS.— 
‘‘(1) IN GENERAL.—Except as provided in paragraph (2), 
the period during which payments may be made under an 
award under subsection (a)(1) may not exceed— 
‘‘(A) in the case of a program, 12 years; or 
‘‘(B) in the case of a center within a program, 6 years. 
Waiver authority. 
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124 STAT. 648 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) EXCEPTION.—The periods described in paragraph (1) 
shall not apply to programs receiving point of service mainte-
nance and enhancement awards under subsection (a)(2) to 
maintain existing centers and activities. 
‘‘(i) INAPPLICABILITY OF PROVISION.—Notwithstanding any other 
provision of this title, section 791(a) shall not apply to an area 
health education center funded under this section. 
‘‘(j) AUTHORIZATION OF APPROPRIATIONS.— 
‘‘(1) IN GENERAL.—There is authorized to be appropriated 
to carry out this section $125,000,000 for each of the fiscal 
years 2010 through 2014. 
‘‘(2) REQUIREMENTS.—Of the amounts appropriated for a 
fiscal year under paragraph (1)— 
‘‘(A) not more than 35 percent shall be used for awards 
under subsection (a)(1); 
‘‘(B) not less than 60 percent shall be used for awards 
under subsection (a)(2); 
‘‘(C) not more than 1 percent shall be used for grants 
and contracts to implement outcomes evaluation for the 
area health education centers; and 
‘‘(D) not more than 4 percent shall be used for grants 
and contracts to provide technical assistance to entities 
receiving awards under this section. 
‘‘(3) CARRYOVER FUNDS.—An entity that receives an award 
under this section may carry over funds from 1 fiscal year 
to another without obtaining approval from the Secretary. In 
no case may any funds be carried over pursuant to the pre-
ceding sentence for more than 3 years. 
‘‘(k) SENSE
OF CONGRESS.—It is the sense of the Congress 
that every State have an area health education center program 
in effect under this section.’’. 
(b) CONTINUING EDUCATIONAL SUPPORT FOR HEALTH PROFES-
SIONALS SERVING IN UNDERSERVED COMMUNITIES.—Part D of title 
VII of the Public Health Service Act (42 U.S.C. 294 et seq.) is 
amended by striking section 752 and inserting the following: 
‘‘SEC. 
752. 
CONTINUING 
EDUCATIONAL 
SUPPORT 
FOR 
HEALTH 
PROFESSIONALS SERVING IN UNDERSERVED COMMU-
NITIES. 
‘‘(a) IN GENERAL.—The Secretary shall make grants to, and 
enter into contracts with, eligible entities to improve health care, 
increase retention, increase representation of minority faculty mem-
bers, enhance the practice environment, and provide information 
dissemination and educational support to reduce professional isola-
tion through the timely dissemination of research findings using 
relevant resources. 
‘‘(b) ELIGIBLE ENTITIES.—For purposes of this section, the term 
‘eligible entity’ means an entity described in section 799(b). 
‘‘(c) APPLICATION.—An eligible entity desiring to receive an 
award under this section shall submit to the Secretary an applica-
tion at such time, in such manner, and containing such information 
as the Secretary may require. 
‘‘(d) USE
OF FUNDS.—An eligible entity shall use amounts 
awarded under a grant or contract under this section to provide 
Definition. 
Grants. 
Contracts. 
42 USC 294b. 
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124 STAT. 649 
PUBLIC LAW 111–148—MAR. 23, 2010 
innovative supportive activities to enhance education through dis-
tance learning, continuing educational activities, collaborative con-
ferences, and electronic and telelearning activities, with priority 
for primary care. 
‘‘(e) AUTHORIZATION.—There is authorized to be appropriated 
to carry out this section $5,000,000 for each of the fiscal years 
2010 through 2014, and such sums as may be necessary for each 
subsequent fiscal year.’’. 
SEC. 5404. WORKFORCE DIVERSITY GRANTS. 
Section 821 of the Public Health Service Act (42 U.S.C. 296m) 
is amended— 
(1) in subsection (a)— 
(A) by striking ‘‘The Secretary may’’ and inserting the 
following: 
‘‘(1) AUTHORITY.—The Secretary may’’; 
(B) by striking ‘‘pre-entry preparation, and retention 
activities’’ and inserting the following: ‘‘stipends for diploma 
or associate degree nurses to enter a bridge or degree 
completion program, student scholarships or stipends for 
accelerated nursing degree programs, pre-entry prepara-
tion, advanced education preparation, and retention activi-
ties’’; and 
(2) in subsection (b)— 
(A) by striking ‘‘First’’ and all that follows through 
‘‘including the’’ and inserting ‘‘National Advisory Council 
on Nurse Education and Practice and consult with nursing 
associations including the National Coalition of Ethnic 
Minority Nurse Associations,’’; and 
(B) by inserting before the period the following: ‘‘, 
and other organizations determined appropriate by the Sec-
retary’’. 
SEC. 5405. PRIMARY CARE EXTENSION PROGRAM. 
Part P of title III of the Public Health Service Act (42 U.S.C. 
280g et seq.), as amended by section 5313, is further amended 
by adding at the end the following: 
‘‘SEC. 399W. PRIMARY CARE EXTENSION PROGRAM. 
‘‘(a) ESTABLISHMENT, PURPOSE AND DEFINITION.— 
‘‘(1) IN
GENERAL.—The Secretary, acting through the 
Director of the Agency for Healthcare Research and Quality, 
shall establish a Primary Care Extension Program. 
‘‘(2) PURPOSE.—The Primary Care Extension Program shall 
provide support and assistance to primary care providers to 
educate providers about preventive medicine, health promotion, 
chronic disease management, mental and behavioral health 
services (including substance abuse prevention and treatment 
services), and evidence-based and evidence-informed therapies 
and techniques, in order to enable providers to incorporate 
such matters into their practice and to improve community 
health by working with community-based health connectors 
(referred to in this section as ‘Health Extension Agents’). 
‘‘(3) DEFINITIONS.—In this section: 
‘‘(A) HEALTH
EXTENSION
AGENT.—The term ‘Health 
Extension Agent’ means any local, community-based health 
worker who facilitates and provides assistance to primary 
care practices by implementing quality improvement or 
42 USC 280g–12. 
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124 STAT. 650 
PUBLIC LAW 111–148—MAR. 23, 2010 
system redesign, incorporating the principles of the patient- 
centered medical home to provide high-quality, effective, 
efficient, and safe primary care and to provide guidance 
to patients in culturally and linguistically appropriate 
ways, and linking practices to diverse health system 
resources. 
‘‘(B) PRIMARY CARE PROVIDER.—The term ‘primary care 
provider’ means a clinician who provides integrated, acces-
sible health care services and who is accountable for 
addressing a large majority of personal health care needs, 
including providing preventive and health promotion serv-
ices for men, women, and children of all ages, developing 
a sustained partnership with patients, and practicing in 
the context of family and community, as recognized by 
a State licensing or regulatory authority, unless otherwise 
specified in this section. 
‘‘(b) GRANTS TO ESTABLISH STATE HUBS AND LOCAL PRIMARY 
CARE EXTENSION AGENCIES.— 
‘‘(1) GRANTS.—The Secretary shall award competitive 
grants to States for the establishment of State- or multistate- 
level primary care Primary Care Extension Program State Hubs 
(referred to in this section as ‘Hubs’). 
‘‘(2) COMPOSITION OF HUBS.—A Hub established by a State 
pursuant to paragraph (1)— 
‘‘(A) shall consist of, at a minimum, the State health 
department, the entity responsible for administering the 
State Medicaid program (if other than the State health 
department), the State-level entity administering the Medi-
care program, and the departments of 1 or more health 
professions schools in the State that train providers in 
primary care; and 
‘‘(B) may include entities such as hospital associations, 
primary care practice-based research networks, health 
professional societies, State primary care associations, 
State licensing boards, organizations with a contract with 
the Secretary under section 1153 of the Social Security 
Act, consumer groups, and other appropriate entities. 
‘‘(c) STATE AND LOCAL ACTIVITIES.— 
‘‘(1) HUB
ACTIVITIES.—Hubs established under a grant 
under subsection (b) shall— 
‘‘(A) submit to the Secretary a plan to coordinate func-
tions with quality improvement organizations and area 
health education centers if such entities are members of 
the Hub not described in subsection (b)(2)(A); 
‘‘(B) contract with a county- or local-level entity that 
shall serve as the Primary Care Extension Agency to 
administer the services described in paragraph (2); 
‘‘(C) organize and administer grant funds to county- 
or local-level Primary Care Extension Agencies that serve 
a catchment area, as determined by the State; and 
‘‘(D) organize State-wide or multistate networks of 
local-level Primary Care Extension Agencies to share and 
disseminate information and practices. 
‘‘(2) LOCAL PRIMARY CARE EXTENSION AGENCY ACTIVITIES.— 
‘‘(A) REQUIRED ACTIVITIES.—Primary Care Extension 
Agencies established by a Hub under paragraph (1) shall— 
Contracts. 
Plans. 
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124 STAT. 651 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) assist primary care providers to implement 
a patient-centered medical home to improve the acces-
sibility, quality, and efficiency of primary care services, 
including health homes; 
‘‘(ii) develop and support primary care learning 
communities to enhance the dissemination of research 
findings 
for 
evidence-based 
practice, 
assess 
implementation of practice improvement, share best 
practices, and involve community clinicians in the 
generation of new knowledge and identification of 
important questions for research; 
‘‘(iii) participate in a national network of Primary 
Care Extension Hubs and propose how the Primary 
Care Extension Agency will share and disseminate les-
sons learned and best practices; and 
‘‘(iv) develop a plan for financial sustainability 
involving State, local, and private contributions, to pro-
vide for the reduction in Federal funds that is expected 
after an initial 6-year period of program establishment, 
infrastructure development, and planning. 
‘‘(B) DISCRETIONARY ACTIVITIES.—Primary Care Exten-
sion Agencies established by a Hub under paragraph (1) 
may— 
‘‘(i) provide technical assistance, training, and 
organizational support for community health teams 
established under section 3602 of the Patient Protec-
tion and Affordable Care Act; 
‘‘(ii) collect data and provision of primary care 
provider feedback from standardized measurements of 
processes and outcomes to aid in continuous perform-
ance improvement; 
‘‘(iii) collaborate with local health departments, 
community health centers, tribes and tribal entities, 
and other community agencies to identify community 
health priorities and local health workforce needs, and 
participate in community-based efforts to address the 
social and primary determinants of health, strengthen 
the local primary care workforce, and eliminate health 
disparities; 
‘‘(iv) develop measures to monitor the impact of 
the proposed program on the health of practice 
enrollees and of the wider community served; and 
‘‘(v) participate in other activities, as determined 
appropriate by the Secretary. 
‘‘(d) FEDERAL PROGRAM ADMINISTRATION.— 
‘‘(1) GRANTS; TYPES.—Grants awarded under subsection (b) 
shall be— 
‘‘(A) program grants, that are awarded to State or 
multistate entities that submit fully-developed plans for 
the implementation of a Hub, for a period of 6 years; 
or 
‘‘(B) planning grants, that are awarded to State or 
multistate entities with the goal of developing a plan for 
a Hub, for a period of 2 years. 
‘‘(2) APPLICATIONS.—To be eligible for a grant under sub-
section (b), a State or multistate entity shall submit to the 
Plans. 
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124 STAT. 652 
PUBLIC LAW 111–148—MAR. 23, 2010 
Secretary an application, at such time, in such manner, and 
containing such information as the Secretary may require. 
‘‘(3) EVALUATION.—A State that receives a grant under 
subsection (b) shall be evaluated at the end of the grant period 
by an evaluation panel appointed by the Secretary. 
‘‘(4) CONTINUING SUPPORT.—After the sixth year in which 
assistance is provided to a State under a grant awarded under 
subsection (b), the State may receive additional support under 
this section if the State program has received satisfactory 
evaluations with respect to program performance and the 
merits of the State sustainability plan, as determined by the 
Secretary. 
‘‘(5) LIMITATION.—A State shall not use in excess of 10 
percent of the amount received under a grant to carry out 
administrative activities under this section. Funds awarded 
pursuant to this section shall not be used for funding direct 
patient care. 
‘‘(e) REQUIREMENTS ON THE SECRETARY.—In carrying out this 
section, the Secretary shall consult with the heads of other Federal 
agencies with demonstrated experience and expertise in health 
care and preventive medicine, such as the Centers for Disease 
Control and Prevention, the Substance Abuse and Mental Health 
Administration, the Health Resources and Services Administration, 
the National Institutes of Health, the Office of the National Coordi-
nator for Health Information Technology, the Indian Health Service, 
the Agricultural Cooperative Extension Service of the Department 
of Agriculture, and other entities, as the Secretary determines 
appropriate. 
‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—To awards grants as 
provided in subsection (d), there are authorized to be appropriated 
$120,000,000 for each of fiscal years 2011 and 2012, and such 
sums as may be necessary to carry out this section for each of 
fiscal years 2013 through 2014.’’. 
Subtitle F—Strengthening Primary Care 
and Other Workforce Improvements 
SEC. 5501. EXPANDING ACCESS TO PRIMARY CARE SERVICES AND GEN-
ERAL SURGERY SERVICES. 
(a) INCENTIVE PAYMENT PROGRAM FOR PRIMARY CARE SERV-
ICES.— 
(1) IN GENERAL.—Section 1833 of the Social Security Act 
(42 U.S.C. 1395l) is amended by adding at the end the following 
new subsection: 
‘‘(x) INCENTIVE PAYMENTS FOR PRIMARY CARE SERVICES.— 
‘‘(1) IN
GENERAL.—In the case of primary care services 
furnished on or after January 1, 2011, and before January 
1, 2016, by a primary care practitioner, in addition to the 
amount of payment that would otherwise be made for such 
services under this part, there also shall be paid (on a monthly 
or quarterly basis) an amount equal to 10 percent of the pay-
ment amount for the service under this part. 
‘‘(2) DEFINITIONS.—In this subsection: 
‘‘(A) PRIMARY CARE PRACTITIONER.—The term ‘primary 
care practitioner’ means an individual— 
‘‘(i) who— 
Time period. 
Consultation. 
Appointment. 
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124 STAT. 653 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(I) is a physician (as described in section 
1861(r)(1)) who has a primary specialty designa-
tion of family medicine, internal medicine, geriatric 
medicine, or pediatric medicine; or 
‘‘(II) is a nurse practitioner, clinical nurse spe-
cialist, or physician assistant (as those terms are 
defined in section 1861(aa)(5)); and 
‘‘(ii) for whom primary care services accounted for 
at least 60 percent of the allowed charges under this 
part for such physician or practitioner in a prior period 
as determined appropriate by the Secretary. 
‘‘(B) PRIMARY CARE SERVICES.—The term ‘primary care 
services’ means services identified, as of January 1, 2009, 
by the following HCPCS codes (and as subsequently modi-
fied by the Secretary): 
‘‘(i) 99201 through 99215. 
‘‘(ii) 99304 through 99340. 
‘‘(iii) 99341 through 99350. 
‘‘(3) COORDINATION WITH OTHER PAYMENTS.—The amount 
of the additional payment for a service under this subsection 
and subsection (m) shall be determined without regard to any 
additional payment for the service under subsection (m) and 
this subsection, respectively. 
‘‘(4) LIMITATION ON REVIEW.—There shall be no administra-
tive or judicial review under section 1869, 1878, or otherwise, 
respecting the identification of primary care practitioners under 
this subsection.’’. 
(2) CONFORMING AMENDMENT.—Section 1834(g)(2)(B) of the 
Social Security Act (42 U.S.C. 1395m(g)(2)(B)) is amended by 
adding at the end the following sentence: ‘‘Section 1833(x) shall 
not be taken into account in determining the amounts that 
would otherwise be paid pursuant to the preceding sentence.’’. 
(b) INCENTIVE PAYMENT PROGRAM FOR MAJOR SURGICAL PROCE-
DURES FURNISHED IN HEALTH PROFESSIONAL SHORTAGE AREAS.— 
(1) IN GENERAL.—Section 1833 of the Social Security Act 
(42 U.S.C. 1395l), as amended by subsection (a)(1), is amended 
by adding at the end the following new subsection: 
‘‘(y) INCENTIVE PAYMENTS FOR MAJOR SURGICAL PROCEDURES 
FURNISHED IN HEALTH PROFESSIONAL SHORTAGE AREAS.— 
‘‘(1) IN GENERAL.—In the case of major surgical procedures 
furnished on or after January 1, 2011, and before January 
1, 2016, by a general surgeon in an area that is designated 
(under section 332(a)(1)(A) of the Public Health Service Act) 
as a health professional shortage area as identified by the 
Secretary prior to the beginning of the year involved, in addition 
to the amount of payment that would otherwise be made for 
such services under this part, there also shall be paid (on 
a monthly or quarterly basis) an amount equal to 10 percent 
of the payment amount for the service under this part. 
‘‘(2) DEFINITIONS.—In this subsection: 
‘‘(A) GENERAL SURGEON.—In this subsection, the term 
‘general surgeon’ means a physician (as described in section 
1861(r)(1)) who has designated CMS specialty code 02– 
General Surgery as their primary specialty code in the 
physician’s enrollment under section 1866(j). 
‘‘(B) MAJOR SURGICAL PROCEDURES.—The term ‘major 
surgical procedures’ means physicians’ services which are 
Time period. 
Determination. 
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124 STAT. 654 
PUBLIC LAW 111–148—MAR. 23, 2010 
surgical procedures for which a 10-day or 90-day global 
period is used for payment under the fee schedule under 
section 1848(b). 
‘‘(3) COORDINATION WITH OTHER PAYMENTS.—The amount 
of the additional payment for a service under this subsection 
and subsection (m) shall be determined without regard to any 
additional payment for the service under subsection (m) and 
this subsection, respectively. 
‘‘(4) APPLICATION.—The provisions of paragraph (2) and 
(4) of subsection (m) shall apply to the determination of addi-
tional payments under this subsection in the same manner 
as such provisions apply to the determination of additional 
payments under subsection (m).’’. 
(2) CONFORMING AMENDMENT.—Section 1834(g)(2)(B) of the 
Social Security Act (42 U.S.C. 1395m(g)(2)(B)), as amended 
by subsection (a)(2), is amended by striking ‘‘Section 1833(x)’’ 
and inserting ‘‘Subsections (x) and (y) of section 1833’’ in the 
last sentence. 
(c) BUDGET-NEUTRALITY ADJUSTMENT.—Section 1848(c)(2)(B) of 
the Social Security Act (42 U.S.C. 1395w–4(c)(2)(B)) is amended 
by adding at the end the following new clause: 
‘‘(vii) ADJUSTMENT FOR CERTAIN PHYSICIAN INCEN-
TIVE
PAYMENTS.—Fifty percent of the additional 
expenditures under this part attributable to sub-
sections (x) and (y) of section 1833 for a year (as 
estimated by the Secretary) shall be taken into account 
in applying clause (ii)(II) for 2011 and subsequent 
years. In lieu of applying the budget-neutrality adjust-
ments required under clause (ii)(II) to relative value 
units to account for such costs for the year, the Sec-
retary shall apply such budget-neutrality adjustments 
to the conversion factor otherwise determined for the 
year. For 2011 and subsequent years, the Secretary 
shall 
increase 
the 
incentive 
payment 
otherwise 
applicable under section 1833(m) by a percent esti-
mated to be equal to the additional expenditures esti-
mated under the first sentence of this clause for such 
year that is applicable to physicians who primarily 
furnish services in areas designated (under section 
332(a)(1)(A) of the Public Health Service Act) as health 
professional shortage areas.’’. 
SEC. 5502. MEDICARE FEDERALLY QUALIFIED HEALTH CENTER 
IMPROVEMENTS. 
(a) EXPANSION OF MEDICARE-COVERED PREVENTIVE SERVICES 
AT FEDERALLY QUALIFIED HEALTH CENTERS.— 
(1) IN GENERAL.—Section 1861(aa)(3)(A) of the Social Secu-
rity Act (42 U.S.C. 1395w (aa)(3)(A)) is amended to read as 
follows: 
‘‘(A) services of the type described subparagraphs (A) 
through (C) of paragraph (1) and preventive services (as 
defined in section 1861(ddd)(3)); and’’. 
(2) EFFECTIVE DATE.—The amendment made by paragraph 
(1) shall apply to services furnished on or after January 1, 
2011. 
(b) PROSPECTIVE PAYMENT SYSTEM FOR FEDERALLY QUALIFIED 
HEALTH CENTERS.—Section 1834 of the Social Security Act (42 
Applicability. 
42 USC 1395x 
note. 
42 USC 1395x. 
Applicability. 
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124 STAT. 655 
PUBLIC LAW 111–148—MAR. 23, 2010 
U.S.C. 1395m) is amended by adding at the end the following 
new subsection: 
‘‘(n) DEVELOPMENT AND IMPLEMENTATION OF PROSPECTIVE PAY-
MENT SYSTEM.— 
‘‘(1) DEVELOPMENT.— 
‘‘(A) IN
GENERAL.—The Secretary shall develop a 
prospective payment system for payment for Federally 
qualified health services furnished by Federally qualified 
health centers under this title. Such system shall include 
a process for appropriately describing the services fur-
nished by Federally qualified health centers. 
‘‘(B) COLLECTION OF DATA AND EVALUATION.—The Sec-
retary shall require Federally qualified health centers to 
submit to the Secretary such information as the Secretary 
may require in order to develop and implement the prospec-
tive payment system under this paragraph and paragraph 
(2), respectively, including the reporting of services using 
HCPCS codes. 
‘‘(2) IMPLEMENTATION.— 
‘‘(A) 
IN
GENERAL.—Notwithstanding 
section 
1833(a)(3)(B), the Secretary shall provide, for cost reporting 
periods beginning on or after October 1, 2014, for payments 
for Federally qualified health services furnished by Feder-
ally qualified health centers under this title in accordance 
with the prospective payment system developed by the 
Secretary under paragraph (1). 
‘‘(B) PAYMENTS.— 
‘‘(i) INITIAL PAYMENTS.—The Secretary shall imple-
ment such prospective payment system so that the 
estimated amount of expenditures under this title for 
Federally qualified health services in the first year 
that the prospective payment system is implemented 
is equal to 103 percent of the estimated amount of 
expenditures under this title that would have occurred 
for such services in such year if the system had not 
been implemented. 
‘‘(ii) PAYMENTS IN SUBSEQUENT YEARS.—In the year 
after the first year of implementation of such system, 
and in each subsequent year, the payment rate for 
Federally qualified health services furnished in the 
year shall be equal to the payment rate established 
for such services furnished in the preceding year under 
this subparagraph increased by the percentage increase 
in the MEI (as defined in 1842(i)(3)) for the year 
involved.’’. 
SEC. 5503. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS. 
(a) IN GENERAL.—Section 1886(h) of the Social Security Act 
(42 U.S.C. 1395ww(h)) is amended— 
(1) in paragraph (4)(F)(i), by striking ‘‘paragraph (7)’’ and 
inserting ‘‘paragraphs (7) and (8)’’; 
(2) in paragraph (4)(H)(i), by striking ‘‘paragraph (7)’’ and 
inserting ‘‘paragraphs (7) and (8)’’; 
(3) in paragraph (7)(E), by inserting ‘‘or paragraph (8)’’ 
before the period at the end; and 
(4) by adding at the end the following new paragraph: 
‘‘(8) DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS.— 
Effective date. 
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124 STAT. 656 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) REDUCTIONS
IN
LIMIT
BASED
ON
UNUSED
POSI-
TIONS.— 
‘‘(i) IN
GENERAL.—Except as provided in clause 
(ii), if a hospital’s reference resident level (as defined 
in subparagraph (H)(i)) is less than the otherwise 
applicable resident limit (as defined in subparagraph 
(H)(iii)), effective for portions of cost reporting periods 
occurring on or after July 1, 2011, the otherwise 
applicable resident limit shall be reduced by 65 percent 
of the difference between such otherwise applicable 
resident limit and such reference resident level. 
‘‘(ii) EXCEPTIONS.—This subparagraph shall not 
apply to— 
‘‘(I) a hospital located in a rural area (as 
defined in subsection (d)(2)(D)(ii)) with fewer than 
250 acute care inpatient beds; 
‘‘(II) a hospital that was part of a qualifying 
entity which had a voluntary residency reduction 
plan approved under paragraph (6)(B) or under 
the authority of section 402 of Public Law 90– 
248, if the hospital demonstrates to the Secretary 
that it has a specified plan in place for filling 
the unused positions by not later than 2 years 
after the date of enactment of this paragraph; 
or 
‘‘(III) a hospital described in paragraph 
(4)(H)(v). 
‘‘(B) DISTRIBUTION.— 
‘‘(i) IN GENERAL.—The Secretary shall increase the 
otherwise applicable resident limit for each qualifying 
hospital that submits an application under this 
subparagraph by such number as the Secretary may 
approve for portions of cost reporting periods occurring 
on or after July 1, 2011. The aggregate number of 
increases in the otherwise applicable resident limit 
under this subparagraph shall be equal to the aggre-
gate reduction in such limits attributable to subpara-
graph (A) (as estimated by the Secretary). 
‘‘(ii) REQUIREMENTS.—Subject to clause (iii), a hos-
pital that receives an increase in the otherwise 
applicable resident limit under this subparagraph shall 
ensure, during the 5-year period beginning on the date 
of such increase, that— 
‘‘(I) the number of full-time equivalent primary 
care residents, as defined in paragraph (5)(H) (as 
determined by the Secretary), excluding any addi-
tional positions under subclause (II), is not less 
than the average number of full-time equivalent 
primary care residents (as so determined) during 
the 3 most recent cost reporting periods ending 
prior to the date of enactment of this paragraph; 
and 
‘‘(II) not less than 75 percent of the positions 
attributable to such increase are in a primary care 
or general surgery residency (as determined by 
the Secretary). 
Deadline. 
Effective date. 
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124 STAT. 657 
PUBLIC LAW 111–148—MAR. 23, 2010 
The Secretary may determine whether a hospital has 
met the requirements under this clause during such 
5-year period in such manner and at such time as 
the Secretary determines appropriate, including at the 
end of such 5-year period. 
‘‘(iii) REDISTRIBUTION
OF
POSITIONS
IF
HOSPITAL 
NO
LONGER
MEETS
CERTAIN
REQUIREMENTS.—In the 
case where the Secretary determines that a hospital 
described in clause (ii) does not meet either of the 
requirements under subclause (I) or (II) of such clause, 
the Secretary shall— 
‘‘(I) reduce the otherwise applicable resident 
limit of the hospital by the amount by which such 
limit was increased under this paragraph; and 
‘‘(II) provide for the distribution of positions 
attributable to such reduction in accordance with 
the requirements of this paragraph. 
‘‘(C) CONSIDERATIONS
IN
REDISTRIBUTION.—In deter-
mining for which hospitals the increase in the otherwise 
applicable resident limit is provided under subparagraph 
(B), the Secretary shall take into account— 
‘‘(i) the demonstration likelihood of the hospital 
filling the positions made available under this para-
graph within the first 3 cost reporting periods begin-
ning on or after July 1, 2011, as determined by the 
Secretary; and 
‘‘(ii) whether the hospital has an accredited rural 
training track (as described in paragraph (4)(H)(iv)). 
‘‘(D) PRIORITY FOR CERTAIN AREAS.—In determining for 
which hospitals the increase in the otherwise applicable 
resident limit is provided under subparagraph (B), subject 
to subparagraph (E), the Secretary shall distribute the 
increase to hospitals based on the following factors: 
‘‘(i) Whether the hospital is located in a State 
with a resident-to-population ratio in the lowest quar-
tile (as determined by the Secretary). 
‘‘(ii) Whether the hospital is located in a State, 
a territory of the United States, or the District of 
Columbia that is among the top 10 States, territories, 
or Districts in terms of the ratio of— 
‘‘(I) the total population of the State, territory, 
or District living in an area designated (under 
such section 332(a)(1)(A)) as a health professional 
shortage area (as of the date of enactment of this 
paragraph); to 
‘‘(II) the total population of the State, territory, 
or District (as determined by the Secretary based 
on the most recent available population data pub-
lished by the Bureau of the Census). 
‘‘(iii) Whether the hospital is located in a rural 
area (as defined in subsection (d)(2)(D)(ii)). 
‘‘(E) RESERVATION
OF
POSITIONS
FOR
CERTAIN
HOS-
PITALS.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), the Sec-
retary shall reserve the positions available for distribu-
tion under this paragraph as follows: 
Effective date. 
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124 STAT. 658 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(I) 70 percent of such positions for distribu-
tion to hospitals described in clause (i) of subpara-
graph (D). 
‘‘(II) 30 percent of such positions for distribu-
tion to hospitals described in clause (ii) and (iii) 
of such subparagraph. 
‘‘(ii) EXCEPTION IF POSITIONS NOT REDISTRIBUTED 
BY JULY 1, 2011.—In the case where the Secretary does 
not distribute positions to hospitals in accordance with 
clause (i) by July 1, 2011, the Secretary shall distribute 
such positions to other hospitals in accordance with 
the considerations described in subparagraph (C) and 
the priority described in subparagraph (D). 
‘‘(F) LIMITATION.—A hospital may not receive more 
than 75 full-time equivalent additional residency positions 
under this paragraph. 
‘‘(G) APPLICATION OF PER RESIDENT AMOUNTS FOR PRI-
MARY CARE AND NONPRIMARY CARE.—With respect to addi-
tional residency positions in a hospital attributable to the 
increase provided under this paragraph, the approved FTE 
per resident amounts are deemed to be equal to the hospital 
per resident amounts for primary care and nonprimary 
care computed under paragraph (2)(D) for that hospital. 
‘‘(H) DEFINITIONS.—In this paragraph: 
‘‘(i) REFERENCE RESIDENT LEVEL.—The term ‘ref-
erence resident level’ means, with respect to a hospital, 
the highest resident level for any of the 3 most recent 
cost reporting periods (ending before the date of the 
enactment of this paragraph) of the hospital for which 
a cost report has been settled (or, if not, submitted 
(subject to audit)), as determined by the Secretary. 
‘‘(ii) RESIDENT
LEVEL.—The term ‘resident level’ 
has the meaning given such term in paragraph 
(7)(C)(i). 
‘‘(iii) OTHERWISE APPLICABLE RESIDENT LIMIT.—The 
term ‘otherwise applicable resident limit’ means, with 
respect to a hospital, the limit otherwise applicable 
under subparagraphs (F)(i) and (H) of paragraph (4) 
on the resident level for the hospital determined with-
out regard to this paragraph but taking into account 
paragraph (7)(A).’’. 
(b) IME.— 
(1) IN
GENERAL.—Section 1886(d)(5)(B)(v) of the Social 
Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sen-
tence, is amended— 
(A) by striking ‘‘subsection (h)(7)’’ and inserting ‘‘sub-
sections (h)(7) and (h)(8)’’; and 
(B) by striking ‘‘it applies’’ and inserting ‘‘they apply’’. 
(2) CONFORMING AMENDMENT.—Section 1886(d)(5)(B) of the 
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended 
by adding at the end the following clause: 
‘‘(x) For discharges occurring on or after July 1, 2011, 
insofar as an additional payment amount under this subpara-
graph is attributable to resident positions distributed to a hos-
pital under subsection (h)(8)(B), the indirect teaching adjust-
ment factor shall be computed in the same manner as provided 
under clause (ii) with respect to such resident positions.’’. 
Effective date. 
Deadline. 
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124 STAT. 659 
PUBLIC LAW 111–148—MAR. 23, 2010 
(c) CONFORMING AMENDMENT.—Section 422(b)(2) of the Medi-
care Prescription Drug, Improvement, and Modernization Act of 
2003 (Public Law 108–173) is amended by striking ‘‘section 
1886(h)(7)’’ and all that follows and inserting ‘‘paragraphs (7) and 
(8) of subsection (h) of section 1886 of the Social Security Act’’. 
SEC. 5504. COUNTING RESIDENT TIME IN NONPROVIDER SETTINGS. 
(a) GME.—Section 1886(h)(4)(E) of the Social Security Act (42 
U.S.C. 1395ww(h)(4)(E)) is amended— 
(1) by striking ‘‘shall be counted and that all the time’’ 
and inserting ‘‘shall be counted and that— 
‘‘(i) effective for cost reporting periods beginning 
before July 1, 2010, all the time;’’; 
(2) in clause (i), as inserted by paragraph (1), by striking 
the period at the end and inserting ‘‘; and’’; 
(3) by inserting after clause (i), as so inserted, the following 
new clause: 
‘‘(ii) effective for cost reporting periods beginning 
on or after July 1, 2010, all the time so spent by 
a resident shall be counted towards the determination 
of full-time equivalency, without regard to the setting 
in which the activities are performed, if a hospital 
incurs the costs of the stipends and fringe benefits 
of the resident during the time the resident spends 
in that setting. If more than one hospital incurs these 
costs, either directly or through a third party, such 
hospitals shall count a proportional share of the time, 
as determined by written agreement between the hos-
pitals, that a resident spends training in that setting.’’; 
and 
(4) by adding at the end the following flush sentence: 
‘‘Any hospital claiming under this subparagraph for time 
spent in a nonprovider setting shall maintain and make 
available to the Secretary records regarding the amount 
of such time and such amount in comparison with amounts 
of such time in such base year as the Secretary shall 
specify.’’. 
(b) IME.—Section 1886(d)(5)(B)(iv) of the Social Security Act 
(42 U.S.C. 1395ww(d)(5)) is amended— 
(1) by striking ‘‘(iv) Effective for discharges occurring on 
or after October 1, 1997’’ and inserting ‘‘(iv)(I) Effective for 
discharges occurring on or after October 1, 1997, and before 
July 1, 2010’’; and 
(2) by inserting after clause (I), as inserted by paragraph 
(1), the following new subparagraph: 
‘‘(II) Effective for discharges occurring on or after July 
1, 2010, all the time spent by an intern or resident in patient 
care activities in a nonprovider setting shall be counted towards 
the determination of full-time equivalency if a hospital incurs 
the costs of the stipends and fringe benefits of the intern 
or resident during the time the intern or resident spends in 
that setting. If more than one hospital incurs these costs, 
either directly or through a third party, such hospitals shall 
count a proportional share of the time, as determined by written 
agreement between the hospitals, that a resident spends 
training in that setting.’’. 
Time period. 
Records. 
Effective dates. 
42 USC 1395ww 
note. 
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124 STAT. 660 
PUBLIC LAW 111–148—MAR. 23, 2010 
(c) APPLICATION.—The amendments made by this section shall 
not be applied in a manner that requires reopening of any settled 
hospital cost reports as to which there is not a jurisdictionally 
proper appeal pending as of the date of the enactment of this 
Act on the issue of payment for indirect costs of medical education 
under section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(B)) or for direct graduate medical education costs 
under section 1886(h) of such Act (42 U.S.C. 1395ww(h)). 
SEC. 5505. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND 
SCHOLARLY ACTIVITIES AND OTHER ACTIVITIES. 
(a) GME.—Section 1886(h) of the Social Security Act (42 U.S.C. 
1395ww(h)), as amended by section 5504, is amended— 
(1) in paragraph (4)— 
(A) in subparagraph (E), by striking ‘‘Such rules’’ and 
inserting ‘‘Subject to subparagraphs (J) and (K), such 
rules’’; and 
(B) by adding at the end the following new subpara-
graphs: 
‘‘(J) 
TREATMENT
OF
CERTAIN
NONPROVIDER
AND 
DIDACTIC ACTIVITIES.—Such rules shall provide that all time 
spent by an intern or resident in an approved medical 
residency training program in a nonprovider setting that 
is primarily engaged in furnishing patient care (as defined 
in paragraph (5)(K)) in non-patient care activities, such 
as didactic conferences and seminars, but not including 
research not associated with the treatment or diagnosis 
of a particular patient, as such time and activities are 
defined by the Secretary, shall be counted toward the deter-
mination of full-time equivalency. 
‘‘(K) TREATMENT
OF
CERTAIN
OTHER
ACTIVITIES.—In 
determining the hospital’s number of full-time equivalent 
residents for purposes of this subsection, all the time that 
is spent by an intern or resident in an approved medical 
residency training program on vacation, sick leave, or other 
approved leave, as such time is defined by the Secretary, 
and that does not prolong the total time the resident is 
participating in the approved program beyond the normal 
duration of the program shall be counted toward the deter-
mination of full-time equivalency.’’; and 
(2) in paragraph (5), by adding at the end the following 
new subparagraph: 
‘‘(K) 
NONPROVIDER
SETTING
THAT
IS
PRIMARILY 
ENGAGED IN FURNISHING PATIENT CARE.—The term ‘nonpro-
vider setting that is primarily engaged in furnishing patient 
care’ means a nonprovider setting in which the primary 
activity is the care and treatment of patients, as defined 
by the Secretary.’’. 
(b) IME DETERMINATIONS.—Section 1886(d)(5)(B) of such Act 
(42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the 
following new clause: 
‘‘(x)(I) The provisions of subparagraph (K) of sub-
section (h)(4) shall apply under this subparagraph in 
the same manner as they apply under such subsection. 
‘‘(II) In determining the hospital’s number of full- 
time equivalent residents for purposes of this subpara-
graph, all the time spent by an intern or resident 
Applicability. 
Definition. 
42 USC 1395ww 
note. 
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124 STAT. 661 
PUBLIC LAW 111–148—MAR. 23, 2010 
in an approved medical residency training program 
in non-patient care activities, such as didactic con-
ferences and seminars, as such time and activities 
are defined by the Secretary, that occurs in the hospital 
shall be counted toward the determination of full-time 
equivalency if the hospital— 
‘‘(aa) is recognized as a subsection (d) hospital; 
‘‘(bb) is recognized as a subsection (d) Puerto 
Rico hospital; 
‘‘(cc) is reimbursed under a reimbursement 
system authorized under section 1814(b)(3); or 
‘‘(dd) is a provider-based hospital outpatient 
department. 
‘‘(III) In determining the hospital’s number of full- 
time equivalent residents for purposes of this subpara-
graph, all the time spent by an intern or resident 
in an approved medical residency training program 
in research activities that are not associated with the 
treatment or diagnosis of a particular patient, as such 
time and activities are defined by the Secretary, shall 
not be counted toward the determination of full-time 
equivalency.’’. 
(c) EFFECTIVE DATES.— 
(1) IN GENERAL.—Except as otherwise provided, the Sec-
retary of Health and Human Services shall implement the 
amendments made by this section in a manner so as to apply 
to cost reporting periods beginning on or after January 1, 
1983. 
(2) GME.—Section 1886(h)(4)(J) of the Social Security Act, 
as added by subsection (a)(1)(B), shall apply to cost reporting 
periods beginning on or after July 1, 2009. 
(3) IME.—Section 1886(d)(5)(B)(x)(III) of the Social Security 
Act, as added by subsection (b), shall apply to cost reporting 
periods beginning on or after October 1, 2001. Such section, 
as so added, shall not give rise to any inference as to how 
the law in effect prior to such date should be interpreted. 
SEC. 5506. PRESERVATION OF RESIDENT CAP POSITIONS FROM 
CLOSED HOSPITALS. 
(a) GME.—Section 1886(h)(4)(H) of the Social Security Act (42 
U.S.C. Section 1395ww(h)(4)(H)) is amended by adding at the end 
the following new clause: 
‘‘(vi) REDISTRIBUTION OF RESIDENCY SLOTS AFTER 
A HOSPITAL CLOSES.— 
‘‘(I) IN GENERAL.—Subject to the succeeding 
provisions of this clause, the Secretary shall, by 
regulation, establish a process under which, in 
the case where a hospital (other than a hospital 
described in clause (v)) with an approved medical 
residency program closes on or after a date that 
is 2 years before the date of enactment of this 
clause, the Secretary shall increase the otherwise 
applicable resident limit under this paragraph for 
other hospitals in accordance with this clause. 
‘‘(II) PRIORITY
FOR
HOSPITALS
IN
CERTAIN 
AREAS.—Subject to the succeeding provisions of 
this clause, in determining for which hospitals the 
Regulations. 
Applicability. 
42 USC 1395ww 
note. 
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124 STAT. 662 
PUBLIC LAW 111–148—MAR. 23, 2010 
increase in the otherwise applicable resident limit 
is provided under such process, the Secretary shall 
distribute the increase to hospitals in the following 
priority order (with preference given within each 
category to hospitals that are members of the same 
affiliated group (as defined by the Secretary under 
clause (ii)) as the closed hospital): 
‘‘(aa) First, to hospitals located in the 
same core-based statistical area as, or a core- 
based statistical area contiguous to, the hos-
pital that closed. 
‘‘(bb) Second, to hospitals located in the 
same State as the hospital that closed. 
‘‘(cc) Third, to hospitals located in the 
same region of the country as the hospital 
that closed. 
‘‘(dd) Fourth, only if the Secretary is not 
able to distribute the increase to hospitals 
described in item (cc), to qualifying hospitals 
in accordance with the provisions of paragraph 
(8). 
‘‘(III) REQUIREMENT HOSPITAL LIKELY TO FILL 
POSITION WITHIN CERTAIN TIME PERIOD.—The Sec-
retary may only increase the otherwise applicable 
resident limit of a hospital under such process 
if the Secretary determines the hospital has dem-
onstrated a likelihood of filling the positions made 
available under this clause within 3 years. 
‘‘(IV) LIMITATION.—The aggregate number of 
increases in the otherwise applicable resident 
limits for hospitals under this clause shall be equal 
to the number of resident positions in the approved 
medical residency programs that closed on or after 
the date described in subclause (I). 
‘‘(V) ADMINISTRATION.—Chapter 35 of title 44, 
United States Code, shall not apply to the 
implementation of this clause.’’. 
(b) IME.—Section 1886(d)(5)(B)(v) of the Social Security Act 
(42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, as amended 
by section 5503, is amended by striking ‘‘subsections (h)(7) and 
(h)(8)’’ and inserting ‘‘subsections (h)(4)(H)(vi), (h)(7), and (h)(8)’’. 
(c) APPLICATION.—The amendments made by this section shall 
not be applied in a manner that requires reopening of any settled 
hospital cost reports as to which there is not a jurisdictionally 
proper appeal pending as of the date of the enactment of this 
Act on the issue of payment for indirect costs of medical education 
under section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(B)) or for direct graduate medical education costs 
under section 1886(h) of such Act (42 U.S.C. Section 1395ww(h)). 
(d) EFFECT ON TEMPORARY FTE CAP ADJUSTMENTS.—The Sec-
retary of Health and Human Services shall give consideration to 
the effect of the amendments made by this section on any temporary 
adjustment to a hospital’s FTE cap under section 413.79(h) of 
title 42, Code of Federal Regulations (as in effect on the date 
of enactment of this Act) in order to ensure that there is no 
duplication of FTE slots. Such amendments shall not affect the 
42 USC 1395ww 
note. 
42 USC 1395ww 
note. 
Determination. 
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124 STAT. 663 
PUBLIC LAW 111–148—MAR. 23, 2010 
application of section 1886(h)(4)(H)(v) of the Social Security Act 
(42 U.S.C. 1395ww(h)(4)(H)(v)). 
(e) CONFORMING AMENDMENT.—Section 1886(h)(7)(E) of the 
Social Security Act (42 U.S.C. 1395ww(h)(7)(E)), as amended by 
section 5503(a), is amended by striking ‘‘paragraph or paragraph 
(8)’’ and inserting ‘‘this paragraph, paragraph (8), or paragraph 
(4)(H)(vi)’’. 
SEC. 5507. DEMONSTRATION PROJECTS TO ADDRESS HEALTH PROFES-
SIONS WORKFORCE NEEDS; EXTENSION OF FAMILY-TO- 
FAMILY HEALTH INFORMATION CENTERS. 
(a) AUTHORITY TO CONDUCT DEMONSTRATION PROJECTS.—Title 
XX of the Social Security Act (42 U.S.C. 1397 et seq.) is amended 
by adding at the end the following: 
‘‘SEC. 
2008. 
DEMONSTRATION 
PROJECTS 
TO 
ADDRESS 
HEALTH 
PROFESSIONS WORKFORCE NEEDS. 
‘‘(a) DEMONSTRATION
PROJECTS
TO
PROVIDE
LOW-INCOME 
INDIVIDUALS WITH OPPORTUNITIES FOR EDUCATION, TRAINING, AND 
CAREER
ADVANCEMENT
TO
ADDRESS
HEALTH
PROFESSIONS 
WORKFORCE NEEDS.— 
‘‘(1) AUTHORITY TO AWARD GRANTS.—The Secretary, in con-
sultation with the Secretary of Labor, shall award grants to 
eligible entities to conduct demonstration projects that are 
designed to provide eligible individuals with the opportunity 
to obtain education and training for occupations in the health 
care field that pay well and are expected to either experience 
labor shortages or be in high demand. 
‘‘(2) REQUIREMENTS.— 
‘‘(A) AID AND SUPPORTIVE SERVICES.— 
‘‘(i) IN
GENERAL.—A demonstration project con-
ducted by an eligible entity awarded a grant under 
this section shall, if appropriate, provide eligible 
individuals participating in the project with financial 
aid, child care, case management, and other supportive 
services. 
‘‘(ii) TREATMENT.—Any aid, services, or incentives 
provided to an eligible beneficiary participating in a 
demonstration project under this section shall not be 
considered income, and shall not be taken into account 
for purposes of determining the individual’s eligibility 
for, or amount of, benefits under any means-tested 
program. 
‘‘(B) CONSULTATION
AND
COORDINATION.—An eligible 
entity applying for a grant to carry out a demonstration 
project under this section shall demonstrate in the applica-
tion that the entity has consulted with the State agency 
responsible for administering the State TANF program, 
the local workforce investment board in the area in which 
the project is to be conducted (unless the applicant is 
such board), the State workforce investment board estab-
lished under section 111 of the Workforce Investment Act 
of 1998, and the State Apprenticeship Agency recognized 
under the Act of August 16, 1937 (commonly known as 
the ‘National Apprenticeship Act’) (or if no agency has 
been recognized in the State, the Office of Apprenticeship 
of the Department of Labor) and that the project will 
be carried out in coordination with such entities. 
42 USC 1397g. 
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124 STAT. 664 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(C) ASSURANCE OF OPPORTUNITIES FOR INDIAN POPU-
LATIONS.—The Secretary shall award at least 3 grants 
under this subsection to an eligible entity that is an Indian 
tribe, tribal organization, or Tribal College or University. 
‘‘(3) REPORTS AND EVALUATION.— 
‘‘(A) ELIGIBLE ENTITIES.—An eligible entity awarded 
a grant to conduct a demonstration project under this sub-
section shall submit interim reports to the Secretary on 
the activities carried out under the project and a final 
report on such activities upon the conclusion of the entities’ 
participation in the project. Such reports shall include 
assessments of the effectiveness of such activities with 
respect to improving outcomes for the eligible individuals 
participating in the project and with respect to addressing 
health professions workforce needs in the areas in which 
the project is conducted. 
‘‘(B) EVALUATION.—The Secretary shall, by grant, con-
tract, or interagency agreement, evaluate the demonstra-
tion projects conducted under this subsection. Such evalua-
tion shall include identification of successful activities for 
creating opportunities for developing and sustaining, 
particularly with respect to low-income individuals and 
other entry-level workers, a health professions workforce 
that has accessible entry points, that meets high standards 
for education, training, certification, and professional 
development, and that provides increased wages and afford-
able benefits, including health care coverage, that are 
responsive to the workforce’s needs. 
‘‘(C) REPORT TO CONGRESS.—The Secretary shall submit 
interim reports and, based on the evaluation conducted 
under subparagraph (B), a final report to Congress on 
the demonstration projects conducted under this subsection. 
‘‘(4) DEFINITIONS.—In this subsection: 
‘‘(A) ELIGIBLE ENTITY.—The term ‘eligible entity’ means 
a State, an Indian tribe or tribal organization, an institu-
tion of higher education, a local workforce investment board 
established under section 117 of the Workforce Investment 
Act of 1998, a sponsor of an apprenticeship program reg-
istered under the National Apprenticeship Act or a commu-
nity-based organization. 
‘‘(B) ELIGIBLE INDIVIDUAL.— 
‘‘(i) IN
GENERAL.—The term ‘eligible individual’ 
means a individual receiving assistance under the 
State TANF program. 
‘‘(ii) OTHER LOW-INCOME INDIVIDUALS.—Such term 
may include other low-income individuals described 
by the eligible entity in its application for a grant 
under this section. 
‘‘(C) INDIAN TRIBE; TRIBAL ORGANIZATION.—The terms 
‘Indian tribe’ and ‘tribal organization’ have the meaning 
given such terms in section 4 of the Indian Self-Determina-
tion and Education Assistance Act (25 U.S.C. 450b). 
‘‘(D) INSTITUTION
OF
HIGHER
EDUCATION.—The term 
‘institution of higher education’ has the meaning given 
that term in section 101 of the Higher Education Act of 
1965 (20 U.S.C. 1001). 
Grants. 
Contracts. 
Grants. 
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124 STAT. 665 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(E) STATE.—The term ‘State’ means each of the 50 
States, the District of Columbia, the Commonwealth of 
Puerto Rico, the United States Virgin Islands, Guam, and 
American Samoa. 
‘‘(F) STATE
TANF
PROGRAM.—The term ‘State TANF 
program’ means the temporary assistance for needy fami-
lies program funded under part A of title IV. 
‘‘(G) TRIBAL COLLEGE OR UNIVERSITY.—The term ‘Tribal 
College or University’ has the meaning given that term 
in section 316(b) of the Higher Education Act of 1965 
(20 U.S.C. 1059c(b)). 
‘‘(b) DEMONSTRATION PROJECT TO DEVELOP TRAINING AND CER-
TIFICATION PROGRAMS FOR PERSONAL OR HOME CARE AIDES.— 
‘‘(1) AUTHORITY
TO
AWARD
GRANTS.—Not later than 18 
months after the date of enactment of this section, the Secretary 
shall award grants to eligible entities that are States to conduct 
demonstration projects for purposes of developing core training 
competencies and certification programs for personal or home 
care aides. The Secretary shall— 
‘‘(A) evaluate the efficacy of the core training com-
petencies described in paragraph (3)(A) for newly hired 
personal or home care aides and the methods used by 
States to implement such core training competencies in 
accordance with the issues specified in paragraph (3)(B); 
and 
‘‘(B) ensure that the number of hours of training pro-
vided by States under the demonstration project with 
respect to such core training competencies are not less 
than the number of hours of training required under any 
applicable State or Federal law or regulation. 
‘‘(2) DURATION.—A demonstration project shall be con-
ducted under this subsection for not less than 3 years. 
‘‘(3) CORE TRAINING COMPETENCIES FOR PERSONAL OR HOME 
CARE AIDES.— 
‘‘(A) IN GENERAL.—The core training competencies for 
personal or home care aides described in this subparagraph 
include competencies with respect to the following areas: 
‘‘(i) The role of the personal or home care aide 
(including differences between a personal or home care 
aide employed by an agency and a personal or home 
care aide employed directly by the health care con-
sumer or an independent provider). 
‘‘(ii) Consumer rights, ethics, and confidentiality 
(including the role of proxy decision-makers in the 
case where a health care consumer has impaired deci-
sion-making capacity). 
‘‘(iii) Communication, cultural and linguistic com-
petence and sensitivity, problem solving, behavior 
management, and relationship skills. 
‘‘(iv) Personal care skills. 
‘‘(v) Health care support. 
‘‘(vi) Nutritional support. 
‘‘(vii) Infection control. 
‘‘(viii) Safety and emergency training. 
‘‘(ix) Training specific to an individual consumer’s 
needs (including older individuals, younger individuals 
with 
disabilities, 
individuals 
with 
developmental 
Evaluation. 
Deadline. 
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124 STAT. 666 
PUBLIC LAW 111–148—MAR. 23, 2010 
disabilities, individuals with dementia, and individuals 
with mental and behavioral health needs). 
‘‘(x) Self-Care. 
‘‘(B) IMPLEMENTATION.—The implementation issues 
specified in this subparagraph include the following: 
‘‘(i) The length of the training. 
‘‘(ii) The appropriate trainer to student ratio. 
‘‘(iii) The amount of instruction time spent in the 
classroom as compared to on-site in the home or a 
facility. 
‘‘(iv) Trainer qualifications. 
‘‘(v) Content for a ‘hands-on’ and written certifi-
cation exam. 
‘‘(vi) Continuing education requirements. 
‘‘(4) APPLICATION AND SELECTION CRITERIA.— 
‘‘(A) IN GENERAL.— 
‘‘(i) NUMBER OF STATES.—The Secretary shall enter 
into agreements with not more than 6 States to conduct 
demonstration projects under this subsection. 
‘‘(ii) REQUIREMENTS
FOR
STATES.—An agreement 
entered into under clause (i) shall require that a 
participating State— 
‘‘(I) implement the core training competencies 
described in paragraph (3)(A); and 
‘‘(II) develop written materials and protocols 
for such core training competencies, including the 
development of a certification test for personal or 
home care aides who have completed such training 
competencies. 
‘‘(iii) CONSULTATION
AND
COLLABORATION
WITH 
COMMUNITY
AND
VOCATIONAL
COLLEGES.—The Sec-
retary shall encourage participating States to consult 
with community and vocational colleges regarding the 
development of curricula to implement the project with 
respect to activities, as applicable, which may include 
consideration of such colleges as partners in such 
implementation. 
‘‘(B) APPLICATION AND ELIGIBILITY.—A State seeking 
to participate in the project shall— 
‘‘(i) submit an application to the Secretary con-
taining such information and at such time as the Sec-
retary may specify; 
‘‘(ii) meet the selection criteria established under 
subparagraph (C); and 
‘‘(iii) meet such additional criteria as the Secretary 
may specify. 
‘‘(C) SELECTION
CRITERIA.—In selecting States to 
participate in the program, the Secretary shall establish 
criteria to ensure (if applicable with respect to the activities 
involved)— 
‘‘(i) geographic and demographic diversity; 
‘‘(ii) that participating States offer medical assist-
ance for personal care services under the State Med-
icaid plan; 
‘‘(iii) that the existing training standards for per-
sonal or home care aides in each participating State— 
Contracts. 
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124 STAT. 667 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(I) are different from such standards in the 
other participating States; and 
‘‘(II) are different from the core training com-
petencies described in paragraph (3)(A); 
‘‘(iv) that participating States do not reduce the 
number of hours of training required under applicable 
State law or regulation after being selected to partici-
pate in the project; and 
‘‘(v) that participating States recruit a minimum 
number of eligible health and long-term care providers 
to participate in the project. 
‘‘(D) TECHNICAL ASSISTANCE.—The Secretary shall pro-
vide technical assistance to States in developing written 
materials and protocols for such core training competencies. 
‘‘(5) EVALUATION AND REPORT.— 
‘‘(A) EVALUATION.—The Secretary shall develop an 
experimental or control group testing protocol in consulta-
tion with an independent evaluation contractor selected 
by the Secretary. Such contractor shall evaluate— 
‘‘(i) the impact of core training competencies 
described in paragraph (3)(A), including curricula 
developed to implement such core training com-
petencies, for personal or home care aides within each 
participating State on job satisfaction, mastery of job 
skills, beneficiary and family caregiver satisfaction 
with services, and additional measures determined by 
the Secretary in consultation with the expert panel; 
‘‘(ii) the impact of providing such core training 
competencies on the existing training infrastructure 
and resources of States; and 
‘‘(iii) whether a minimum number of hours of ini-
tial training should be required for personal or home 
care aides and, if so, what minimum number of hours 
should be required. 
‘‘(B) REPORTS.— 
‘‘(i) REPORT
ON
INITIAL
IMPLEMENTATION.—Not 
later than 2 years after the date of enactment of this 
section, the Secretary shall submit to Congress a report 
on the initial implementation of activities conducted 
under the demonstration project, including any avail-
able results of the evaluation conducted under subpara-
graph (A) with respect to such activities, together with 
such recommendations for legislation or administrative 
action as the Secretary determines appropriate. 
‘‘(ii) FINAL REPORT.—Not later than 1 year after 
the completion of the demonstration project, the Sec-
retary shall submit to Congress a report containing 
the results of the evaluation conducted under subpara-
graph (A), together with such recommendations for 
legislation or administrative action as the Secretary 
determines appropriate. 
‘‘(6) DEFINITIONS.—In this subsection: 
‘‘(A) ELIGIBLE
HEALTH
AND
LONG-TERM
CARE
PRO-
VIDER.—The term ‘eligible health and long-term care pro-
vider’ means a personal or home care agency (including 
personal or home care public authorities), a nursing home, 
a home health agency (as defined in section 1861(o)), or 
Contracts. 
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124 STAT. 668 
PUBLIC LAW 111–148—MAR. 23, 2010 
any other health care provider the Secretary determines 
appropriate which— 
‘‘(i) is licensed or authorized to provide services 
in a participating State; and 
‘‘(ii) receives payment for services under title XIX. 
‘‘(B) PERSONAL
CARE
SERVICES.—The term ‘personal 
care services’ has the meaning given such term for purposes 
of title XIX. 
‘‘(C) PERSONAL OR HOME CARE AIDE.—The term ‘per-
sonal or home care aide’ means an individual who helps 
individuals who are elderly, disabled, ill, or mentally dis-
abled (including an individual with Alzheimer’s disease 
or other dementia) to live in their own home or a residential 
care facility (such as a nursing home, assisted living 
facility, or any other facility the Secretary determines 
appropriate) by providing routine personal care services 
and other appropriate services to the individual. 
‘‘(D) STATE.—The term ‘State’ has the meaning given 
that term for purposes of title XIX. 
‘‘(c) FUNDING.— 
‘‘(1) IN
GENERAL.—Subject to paragraph (2), out of any 
funds in the Treasury not otherwise appropriated, there are 
appropriated to the Secretary to carry out subsections (a) and 
(b), $85,000,000 for each of fiscal years 2010 through 2014. 
‘‘(2) TRAINING AND CERTIFICATION PROGRAMS FOR PERSONAL 
AND
HOME
CARE
AIDES.—With respect to the demonstration 
projects under subsection (b), the Secretary shall use $5,000,000 
of the amount appropriated under paragraph (1) for each of 
fiscal years 2010 through 2012 to carry out such projects. 
No funds appropriated under paragraph (1) shall be used to 
carry out demonstration projects under subsection (b) after 
fiscal year 2012. 
‘‘(d) NONAPPLICATION.— 
‘‘(1) IN GENERAL.—Except as provided in paragraph (2), 
the preceding sections of this title shall not apply to grant 
awarded under this section. 
‘‘(2) LIMITATIONS
ON
USE
OF
GRANTS.—Section 2005(a) 
(other than paragraph (6)) shall apply to a grant awarded 
under this section to the same extent and in the same manner 
as such section applies to payments to States under this title.’’. 
(b) EXTENSION
OF FAMILY-TO-FAMILY HEALTH INFORMATION 
CENTERS.—Section 501(c)(1)(A)(iii) of the Social Security Act (42 
U.S.C. 701(c)(1)(A)(iii)) is amended by striking ‘‘fiscal year 2009’’ 
and inserting ‘‘each of fiscal years 2009 through 2012’’. 
SEC. 5508. INCREASING TEACHING CAPACITY. 
(a) TEACHING
HEALTH
CENTERS
TRAINING
AND
ENHANCE-
MENT.—Part C of title VII of the Public Health Service Act (42 
U.S.C. 293k et. seq.), as amended by section 5303, is further 
amended by inserting after section 749 the following: 
‘‘SEC. 749A. TEACHING HEALTH CENTERS DEVELOPMENT GRANTS. 
‘‘(a) PROGRAM AUTHORIZED.—The Secretary may award grants 
under this section to teaching health centers for the purpose of 
establishing new accredited or expanded primary care residency 
programs. 
42 USC 239l–1. 
Applicability. 
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124 STAT. 669 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(b) AMOUNT AND DURATION.—Grants awarded under this sec-
tion shall be for a term of not more than 3 years and the maximum 
award may not be more than $500,000. 
‘‘(c) USE OF FUNDS.—Amounts provided under a grant under 
this section shall be used to cover the costs of— 
‘‘(1) establishing or expanding a primary care residency 
training program described in subsection (a), including costs 
associated with— 
‘‘(A) curriculum development; 
‘‘(B) recruitment, training and retention of residents 
and faculty: 
‘‘(C) accreditation by the Accreditation Council for 
Graduate Medical Education (ACGME), the American 
Dental Association (ADA), or the American Osteopathic 
Association (AOA); and 
‘‘(D) faculty salaries during the development phase; 
and 
‘‘(2) technical assistance provided by an eligible entity. 
‘‘(d) APPLICATION.—A teaching health center seeking a grant 
under this section shall submit an application to the Secretary 
at such time, in such manner, and containing such information 
as the Secretary may require. 
‘‘(e) PREFERENCE
FOR CERTAIN APPLICATIONS.—In selecting 
recipients for grants under this section, the Secretary shall give 
preference to any such application that documents an existing affili-
ation agreement with an area health education center program 
as defined in sections 751 and 799B. 
‘‘(f) DEFINITIONS.—In this section: 
‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible entity’ means an 
organization capable of providing technical assistance including 
an area health education center program as defined in sections 
751 and 799B. 
‘‘(2) PRIMARY CARE RESIDENCY PROGRAM.—The term ‘pri-
mary care residency program’ means an approved graduate 
medical residency training program (as defined in section 340H) 
in family medicine, internal medicine, pediatrics, internal medi-
cine-pediatrics, obstetrics and gynecology, psychiatry, general 
dentistry, pediatric dentistry, and geriatrics. 
‘‘(3) TEACHING HEALTH CENTER.— 
‘‘(A) IN GENERAL.—The term ‘teaching health center’ 
means an entity that— 
‘‘(i) is a community based, ambulatory patient care 
center; and 
‘‘(ii) operates a primary care residency program. 
‘‘(B) INCLUSION
OF
CERTAIN
ENTITIES.—Such term 
includes the following: 
‘‘(i) A Federally qualified health center (as defined 
in section 1905(l)(2)(B), of the Social Security Act). 
‘‘(ii) A community mental health center (as defined 
in section 1861(ff)(3)(B) of the Social Security Act). 
‘‘(iii) A rural health clinic, as defined in section 
1861(aa) of the Social Security Act. 
‘‘(iv) A health center operated by the Indian Health 
Service, an Indian tribe or tribal organization, or an 
urban Indian organization (as defined in section 4 of 
the Indian Health Care Improvement Act). 
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124 STAT. 670 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(v) An entity receiving funds under title X of 
the Public Health Service Act. 
‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 
to be appropriated, $25,000,000 for fiscal year 2010, $50,000,000 
for fiscal year 2011, $50,000,000 for fiscal year 2012, and such 
sums as may be necessary for each fiscal year thereafter to carry 
out this section. Not to exceed $5,000,000 annually may be used 
for technical assistance program grants.’’. 
(b) NATIONAL HEALTH SERVICE CORPS TEACHING CAPACITY.— 
Section 338C(a) of the Public Health Service Act (42 U.S.C. 254m(a)) 
is amended to read as follows: 
‘‘(a) SERVICE IN FULL-TIME CLINICAL PRACTICE.—Except as pro-
vided in section 338D, each individual who has entered into a 
written contract with the Secretary under section 338A or 338B 
shall provide service in the full-time clinical practice of such individ-
ual’s profession as a member of the Corps for the period of obligated 
service provided in such contract. For the purpose of calculating 
time spent in full-time clinical practice under this subsection, up 
to 50 percent of time spent teaching by a member of the Corps 
may be counted toward his or her service obligation.’’. 
(c) PAYMENTS TO QUALIFIED TEACHING HEALTH CENTERS.—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: 
‘‘Subpart XI—Support of Graduate Medical 
Education in Qualified Teaching Health Centers 
‘‘SEC. 340H. PROGRAM OF PAYMENTS TO TEACHING HEALTH CENTERS 
THAT OPERATE GRADUATE MEDICAL EDUCATION PRO-
GRAMS. 
‘‘(a) PAYMENTS.—Subject to subsection (h)(2), the Secretary 
shall make payments under this section for direct expenses and 
for indirect expenses to qualified teaching health centers that are 
listed as sponsoring institutions by the relevant accrediting body 
for expansion of existing or establishment of new approved graduate 
medical residency training programs. 
‘‘(b) AMOUNT OF PAYMENTS.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), the amounts 
payable under this section to qualified teaching health centers 
for an approved graduate medical residency training program 
for a fiscal year are each of the following amounts: 
‘‘(A) DIRECT
EXPENSE
AMOUNT.—The amount deter-
mined under subsection (c) for direct expenses associated 
with sponsoring approved graduate medical residency 
training programs. 
‘‘(B) INDIRECT EXPENSE AMOUNT.—The amount deter-
mined under subsection (d) for indirect expenses associated 
with the additional costs relating to teaching residents 
in such programs. 
‘‘(2) CAPPED AMOUNT.— 
‘‘(A) IN GENERAL.—The total of the payments made 
to qualified teaching health centers under paragraph (1)(A) 
or paragraph (1)(B) in a fiscal year shall not exceed the 
amount of funds appropriated under subsection (g) for such 
payments for that fiscal year. 
‘‘(B) LIMITATION.—The Secretary shall limit the 
funding of full-time equivalent residents in order to ensure 
42 USC 256h. 
Contracts. 
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124 STAT. 671 
PUBLIC LAW 111–148—MAR. 23, 2010 
the direct and indirect payments as determined under sub-
section (c) and (d) do not exceed the total amount of funds 
appropriated in a fiscal year under subsection (g). 
‘‘(c) AMOUNT OF PAYMENT FOR DIRECT GRADUATE MEDICAL EDU-
CATION.— 
‘‘(1) IN GENERAL.—The amount determined under this sub-
section for payments to qualified teaching health centers for 
direct graduate expenses relating to approved graduate medical 
residency training programs for a fiscal year is equal to the 
product of— 
‘‘(A) the updated national per resident amount for 
direct graduate medical education, as determined under 
paragraph (2); and 
‘‘(B) the average number of full-time equivalent resi-
dents in the teaching health center’s graduate approved 
medical residency training programs as determined under 
section 1886(h)(4) of the Social Security Act (without regard 
to the limitation under subparagraph (F) of such section) 
during the fiscal year. 
‘‘(2) UPDATED NATIONAL PER RESIDENT AMOUNT FOR DIRECT 
GRADUATE
MEDICAL
EDUCATION.—The updated per resident 
amount for direct graduate medical education for a qualified 
teaching health center for a fiscal year is an amount determined 
as follows: 
‘‘(A) DETERMINATION OF QUALIFIED TEACHING HEALTH 
CENTER PER RESIDENT AMOUNT.—The Secretary shall com-
pute for each individual qualified teaching health center 
a per resident amount— 
‘‘(i) by dividing the national average per resident 
amount computed under section 340E(c)(2)(D) into a 
wage-related portion and a non-wage related portion 
by applying the proportion determined under subpara-
graph (B); 
‘‘(ii) by multiplying the wage-related portion by 
the factor applied under section 1886(d)(3)(E) of the 
Social Security Act (but without application of section 
4410 of the Balanced Budget Act of 1997 (42 U.S.C. 
1395ww note)) during the preceding fiscal year for 
the teaching health center’s area; and 
‘‘(iii) by adding the non-wage-related portion to 
the amount computed under clause (ii). 
‘‘(B) UPDATING RATE.—The Secretary shall update such 
per resident amount for each such qualified teaching health 
center as determined appropriate by the Secretary. 
‘‘(d) AMOUNT OF PAYMENT FOR INDIRECT MEDICAL EDUCATION.— 
‘‘(1) IN GENERAL.—The amount determined under this sub-
section for payments to qualified teaching health centers for 
indirect expenses associated with the additional costs of 
teaching residents for a fiscal year is equal to an amount 
determined appropriate by the Secretary. 
‘‘(2) FACTORS.—In determining the amount under para-
graph (1), the Secretary shall— 
‘‘(A) evaluate indirect training costs relative to sup-
porting a primary care residency program in qualified 
teaching health centers; and 
‘‘(B) based on this evaluation, assure that the aggregate 
of the payments for indirect expenses under this section 
Determination. 
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124 STAT. 672 
PUBLIC LAW 111–148—MAR. 23, 2010 
and the payments for direct graduate medical education 
as determined under subsection (c) in a fiscal year do 
not exceed the amount appropriated for such expenses as 
determined in subsection (g). 
‘‘(3) INTERIM PAYMENT.—Before the Secretary makes a pay-
ment under this subsection pursuant to a determination of 
indirect expenses under paragraph (1), the Secretary may pro-
vide to qualified teaching health centers a payment, in addition 
to any payment made under subsection (c), for expected indirect 
expenses associated with the additional costs of teaching resi-
dents for a fiscal year, based on an estimate by the Secretary. 
‘‘(e) CLARIFICATION REGARDING RELATIONSHIP TO OTHER PAY-
MENTS FOR GRADUATE MEDICAL EDUCATION.—Payments under this 
section— 
‘‘(1) shall be in addition to any payments— 
‘‘(A) for the indirect costs of medical education under 
section 1886(d)(5)(B) of the Social Security Act; 
‘‘(B) for direct graduate medical education costs under 
section 1886(h) of such Act; and 
‘‘(C) for direct costs of medical education under section 
1886(k) of such Act; 
‘‘(2) shall not be taken into account in applying the limita-
tion on the number of total full-time equivalent residents under 
subparagraphs (F) and (G) of section 1886(h)(4) of such Act 
and clauses (v), (vi)(I), and (vi)(II) of section 1886(d)(5)(B) of 
such Act for the portion of time that a resident rotates to 
a hospital; and 
‘‘(3) shall not include the time in which a resident is 
counted toward full-time equivalency by a hospital under para-
graph (2) or under section 1886(d)(5)(B)(iv) of the Social Secu-
rity Act, section 1886(h)(4)(E) of such Act, or section 340E 
of this Act. 
‘‘(f) RECONCILIATION.—The Secretary shall determine any 
changes to the number of residents reported by a hospital in the 
application of the hospital for the current fiscal year to determine 
the final amount payable to the hospital for the current fiscal 
year for both direct expense and indirect expense amounts. Based 
on such determination, the Secretary shall recoup any overpayments 
made to pay any balance due to the extent possible. The final 
amount so determined shall be considered a final intermediary 
determination for the purposes of section 1878 of the Social Security 
Act and shall be subject to administrative and judicial review under 
that section in the same manner as the amount of payment under 
section 1186(d) of such Act is subject to review under such section. 
‘‘(g) FUNDING.—To carry out this section, there are appropriated 
such sums as may be necessary, not to exceed $230,000,000, for 
the period of fiscal years 2011 through 2015. 
‘‘(h) ANNUAL REPORTING REQUIRED.— 
‘‘(1) ANNUAL REPORT.—The report required under this para-
graph for a qualified teaching health center for a fiscal year 
is a report that includes (in a form and manner specified 
by the Secretary) the following information for the residency 
academic year completed immediately prior to such fiscal year: 
‘‘(A) The types of primary care resident approved 
training programs that the qualified teaching health center 
provided for residents. 
Determination. 
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124 STAT. 673 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) The number of approved training positions for 
residents described in paragraph (4). 
‘‘(C) The number of residents described in paragraph 
(4) who completed their residency training at the end of 
such residency academic year and care for vulnerable popu-
lations living in underserved areas. 
‘‘(D) Other information as deemed appropriate by the 
Secretary. 
‘‘(2) AUDIT AUTHORITY; LIMITATION ON PAYMENT.— 
‘‘(A) AUDIT AUTHORITY.—The Secretary may audit a 
qualified teaching health center to ensure the accuracy 
and completeness of the information submitted in a report 
under paragraph (1). 
‘‘(B) LIMITATION
ON
PAYMENT.—A teaching health 
center may only receive payment in a cost reporting period 
for a number of such resident positions that is greater 
than the base level of primary care resident positions, 
as determined by the Secretary. For purposes of this 
subparagraph, the ‘base level of primary care residents’ 
for a teaching health center is the level of such residents 
as of a base period. 
‘‘(3) REDUCTION IN PAYMENT FOR FAILURE TO REPORT.— 
‘‘(A) IN GENERAL.—The amount payable under this sec-
tion to a qualified teaching health center for a fiscal year 
shall be reduced by at least 25 percent if the Secretary 
determines that— 
‘‘(i) the qualified teaching health center has failed 
to provide the Secretary, as an addendum to the quali-
fied teaching health center’s application under this 
section for such fiscal year, the report required under 
paragraph (1) for the previous fiscal year; or 
‘‘(ii) such report fails to provide complete and 
accurate information required under any subparagraph 
of such paragraph. 
‘‘(B) NOTICE AND OPPORTUNITY TO PROVIDE ACCURATE 
AND MISSING INFORMATION.—Before imposing a reduction 
under subparagraph (A) on the basis of a qualified teaching 
health center’s failure to provide complete and accurate 
information described in subparagraph (A)(ii), the Secretary 
shall provide notice to the teaching health center of such 
failure and the Secretary’s intention to impose such reduc-
tion and shall provide the teaching health center with 
the opportunity to provide the required information within 
the period of 30 days beginning on the date of such notice. 
If the teaching health center provides such information 
within such period, no reduction shall be made under 
subparagraph (A) on the basis of the previous failure to 
provide such information. 
‘‘(4) RESIDENTS.—The residents described in this paragraph 
are those who are in part-time or full-time equivalent resident 
training positions at a qualified teaching health center in any 
approved graduate medical residency training program. 
‘‘(i) REGULATIONS.—The Secretary shall promulgate regulations 
to carry out this section. 
‘‘(j) DEFINITIONS.—In this section: 
‘‘(1) APPROVED
GRADUATE
MEDICAL
RESIDENCY
TRAINING 
PROGRAM.—The term ‘approved graduate medical residency 
Deadline. 
Determination. 
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124 STAT. 674 
PUBLIC LAW 111–148—MAR. 23, 2010 
training program’ means a residency or other postgraduate 
medical training program— 
‘‘(A) participation in which may be counted toward 
certification in a specialty or subspecialty and includes 
formal postgraduate training programs in geriatric medi-
cine approved by the Secretary; and 
‘‘(B) that meets criteria for accreditation (as established 
by the Accreditation Council for Graduate Medical Edu-
cation, the American Osteopathic Association, or the Amer-
ican Dental Association). 
‘‘(2) PRIMARY CARE RESIDENCY PROGRAM.—The term ‘pri-
mary care residency program’ has the meaning given that term 
in section 749A. 
‘‘(3) QUALIFIED
TEACHING
HEALTH
CENTER.—The term 
‘qualified teaching health center’ has the meaning given the 
term ‘teaching health center’ in section 749A.’’. 
SEC. 5509. GRADUATE NURSE EDUCATION DEMONSTRATION. 
(a) IN GENERAL.— 
(1) ESTABLISHMENT.— 
(A) IN GENERAL.—The Secretary shall establish a grad-
uate nurse education demonstration under title XVIII of 
the Social Security Act (42 U.S.C. 1395 et seq.) under 
which an eligible hospital may receive payment for the 
hospital’s reasonable costs (described in paragraph (2)) for 
the provision of qualified clinical training to advance prac-
tice nurses. 
(B) NUMBER.—The demonstration shall include up to 
5 eligible hospitals. 
(C) WRITTEN AGREEMENTS.—Eligible hospitals selected 
to participate in the demonstration shall enter into written 
agreements pursuant to subsection (b) in order to reimburse 
the eligible partners of the hospital the share of the costs 
attributable to each partner. 
(2) COSTS DESCRIBED.— 
(A) IN GENERAL.—Subject to subparagraph (B) and sub-
section (d), the costs described in this paragraph are the 
reasonable costs (as described in section 1861(v) of the 
Social Security Act (42 U.S.C. 1395x(v))) of each eligible 
hospital for the clinical training costs (as determined by 
the Secretary) that are attributable to providing advanced 
practice registered nurses with qualified training. 
(B) LIMITATION.—With respect to a year, the amount 
reimbursed under subparagraph (A) may not exceed the 
amount of costs described in subparagraph (A) that are 
attributable to an increase in the number of advanced 
practice registered nurses enrolled in a program that pro-
vides qualified training during the year and for which 
the hospital is being reimbursed under the demonstration, 
as compared to the average number of advanced practice 
registered nurses who graduated in each year during the 
period beginning on January 1, 2006, and ending on 
December 31, 2010 (as determined by the Secretary) from 
the graduate nursing education program operated by the 
applicable school of nursing that is an eligible partner 
of the hospital for purposes of the demonstration. 
Time period. 
42 USC 1395ww 
note. 
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124 STAT. 675 
PUBLIC LAW 111–148—MAR. 23, 2010 
(3) WAIVER AUTHORITY.—The Secretary may waive such 
requirements of titles XI and XVIII of the Social Security 
Act as may be necessary to carry out the demonstration. 
(4) ADMINISTRATION.—Chapter 35 of title 44, United States 
Code, shall not apply to the implementation of this section. 
(b) WRITTEN AGREEMENTS WITH ELIGIBLE PARTNERS.—No pay-
ment shall be made under this section to an eligible hospital unless 
such hospital has in effect a written agreement with the eligible 
partners of the hospital. Such written agreement shall describe, 
at a minimum— 
(1) the obligations of the eligible partners with respect 
to the provision of qualified training; and 
(2) the obligation of the eligible hospital to reimburse such 
eligible partners applicable (in a timely manner) for the costs 
of such qualified training attributable to partner. 
(c) EVALUATION.—Not later than October 17, 2017, the Sec-
retary shall submit to Congress a report on the demonstration. 
Such report shall include an analysis of the following: 
(1) The growth in the number of advanced practice reg-
istered nurses with respect to a specific base year as a result 
of the demonstration. 
(2) The growth for each of the specialties described in 
subparagraphs (A) through (D) of subsection (e)(1). 
(3) The costs to the Medicare program under title XVIII 
of the Social Security Act as a result of the demonstration. 
(4) Other items the Secretary determines appropriate and 
relevant. 
(d) FUNDING.— 
(1) IN GENERAL.—There is hereby appropriated to the Sec-
retary, out of any funds in the Treasury not otherwise appro-
priated, $50,000,000 for each of fiscal years 2012 through 2015 
to carry out this section, including the design, implementation, 
monitoring, and evaluation of the demonstration. 
(2) PRORATION.—If the aggregate payments to eligible hos-
pitals under the demonstration exceed $50,000,000 for a fiscal 
year described in paragraph (1), the Secretary shall prorate 
the payment amounts to each eligible hospital in order to 
ensure that the aggregate payments do not exceed such amount. 
(3) WITHOUT
FISCAL
YEAR
LIMITATION.—Amounts appro-
priated under this subsection shall remain available without 
fiscal year limitation. 
(e) DEFINITIONS.—In this section: 
(1) ADVANCED
PRACTICE
REGISTERED
NURSE.—The term 
‘‘advanced practice registered nurse’’ includes the following: 
(A) A clinical nurse specialist (as defined in subsection 
(aa)(5) of section 1861 of the Social Security Act (42 U.S.C. 
1395x)). 
(B) A nurse practitioner (as defined in such subsection). 
(C) A certified registered nurse anesthetist (as defined 
in subsection (bb)(2) of such section). 
(D) A certified nurse-midwife (as defined in subsection 
(gg)(2) of such section). 
(2) APPLICABLE NON-HOSPITAL COMMUNITY-BASED CARE SET-
TING.—The term ‘‘applicable non-hospital community-based care 
setting’’ means a non-hospital community-based care setting 
which has entered into a written agreement (as described in 
subsection (b)) with the eligible hospital participating in the 
Deadline. 
Reports. 
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124 STAT. 676 
PUBLIC LAW 111–148—MAR. 23, 2010 
demonstration. Such settings include Federally qualified health 
centers, rural health clinics, and other non-hospital settings 
as determined appropriate by the Secretary. 
(3) APPLICABLE SCHOOL OF NURSING.—The term ‘‘applicable 
school of nursing’’ means an accredited school of nursing (as 
defined in section 801 of the Public Health Service Act) which 
has entered into a written agreement (as described in sub-
section (b)) with the eligible hospital participating in the dem-
onstration. 
(4) DEMONSTRATION.—The term ‘‘demonstration’’ means the 
graduate nurse education demonstration established under sub-
section (a). 
(5) ELIGIBLE HOSPITAL.—The term ‘‘eligible hospital’’ means 
a hospital (as defined in subsection (e) of section 1861 of the 
Social Security Act (42 U.S.C. 1395x)) or a critical access hos-
pital (as defined in subsection (mm)(1) of such section) that 
has a written agreement in place with— 
(A) 1 or more applicable schools of nursing; and 
(B) 2 or more applicable non-hospital community-based 
care settings. 
(6) ELIGIBLE
PARTNERS.—The term ‘‘eligible partners’’ 
includes the following: 
(A) An applicable non-hospital community-based care 
setting. 
(B) An applicable school of nursing. 
(7) QUALIFIED TRAINING.— 
(A) IN GENERAL.—The term ‘‘qualified training’’ means 
training— 
(i) that provides an advanced practice registered 
nurse with the clinical skills necessary to provide pri-
mary care, preventive care, transitional care, chronic 
care management, and other services appropriate for 
individuals entitled to, or enrolled for, benefits under 
part A of title XVIII of the Social Security Act, or 
enrolled under part B of such title; and 
(ii) subject to subparagraph (B), at least half of 
which is provided in a non-hospital community-based 
care setting. 
(B) WAIVER OF REQUIREMENT HALF OF TRAINING BE 
PROVIDED IN NON-HOSPITAL COMMUNITY-BASED CARE SET-
TING IN CERTAIN AREAS.—The Secretary may waive the 
requirement under subparagraph (A)(ii) with respect to 
eligible hospitals located in rural or medically underserved 
areas. 
(8) SECRETARY.—The term ‘‘Secretary’’ means the Secretary 
of Health and Human Services. 
Subtitle G—Improving Access to Health 
Care Services 
SEC. 5601. SPENDING FOR FEDERALLY QUALIFIED HEALTH CENTERS 
(FQHCS). 
(a) IN GENERAL.—Section 330(r) of the Public Health Service 
Act (42 U.S.C. 254b(r)) is amended by striking paragraph (1) and 
inserting the following: 
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124 STAT. 677 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) GENERAL AMOUNTS FOR GRANTS.—For the purpose of 
carrying out this section, in addition to the amounts authorized 
to be appropriated under subsection (d), there is authorized 
to be appropriated the following: 
‘‘(A) For fiscal year 2010, $2,988,821,592. 
‘‘(B) For fiscal year 2011, $3,862,107,440. 
‘‘(C) For fiscal year 2012, $4,990,553,440. 
‘‘(D) For fiscal year 2013, $6,448,713,307. 
‘‘(E) For fiscal year 2014, $7,332,924,155. 
‘‘(F) For fiscal year 2015, $8,332,924,155. 
‘‘(G) For fiscal year 2016, and each subsequent fiscal 
year, the amount appropriated for the preceding fiscal year 
adjusted by the product of— 
‘‘(i) one plus the average percentage increase in 
costs incurred per patient served; and 
‘‘(ii) one plus the average percentage increase in 
the total number of patients served.’’. 
(b) RULE
OF CONSTRUCTION.—Section 330(r) of the Public 
Health Service Act (42 U.S.C. 254b(r)) is amended by adding at 
the end the following: 
‘‘(4) RULE
OF
CONSTRUCTION
WITH
RESPECT
TO
RURAL 
HEALTH CLINICS.— 
‘‘(A) IN
GENERAL.—Nothing in this section shall be 
construed to prevent a community health center from con-
tracting with a Federally certified rural health clinic (as 
defined in section 1861(aa)(2) of the Social Security Act), 
a low-volume hospital (as defined for purposes of section 
1886 of such Act), a critical access hospital, a sole commu-
nity 
hospital 
(as 
defined 
for 
purposes 
of 
section 
1886(d)(5)(D)(iii) of such Act), or a medicare-dependent 
share hospital (as defined for purposes of section 
1886(d)(5)(G)(iv) of such Act) for the delivery of primary 
health care services that are available at the clinic or 
hospital to individuals who would otherwise be eligible 
for free or reduced cost care if that individual were able 
to obtain that care at the community health center. Such 
services may be limited in scope to those primary health 
care services available in that clinic or hospitals. 
‘‘(B) ASSURANCES.—In order for a clinic or hospital 
to receive funds under this section through a contract with 
a community health center under subparagraph (A), such 
clinic or hospital shall establish policies to ensure— 
‘‘(i) nondiscrimination based on the ability of a 
patient to pay; and 
‘‘(ii) the establishment of a sliding fee scale for 
low-income patients.’’. 
SEC. 5602. NEGOTIATED RULEMAKING FOR DEVELOPMENT OF METH-
ODOLOGY AND CRITERIA FOR DESIGNATING MEDICALLY 
UNDERSERVED POPULATIONS AND HEALTH PROFES-
SIONS SHORTAGE AREAS. 
(a) ESTABLISHMENT.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services (in this section referred to as the ‘‘Secretary’’) shall 
establish, through a negotiated rulemaking process under sub-
chapter 3 of chapter 5 of title 5, United States Code, a com-
prehensive methodology and criteria for designation of— 
Deadlines. 
42 USC 254b 
note. 
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124 STAT. 678 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) medically underserved populations in accordance 
with section 330(b)(3) of the Public Health Service Act 
(42 U.S.C. 254b(b)(3)); 
(B) health professions shortage areas under section 
332 of the Public Health Service Act (42 U.S.C. 254e). 
(2) FACTORS TO CONSIDER.—In establishing the method-
ology and criteria under paragraph (1), the Secretary— 
(A) shall consult with relevant stakeholders who will 
be significantly affected by a rule (such as national, State 
and regional organizations representing affected entities), 
State health offices, community organizations, health cen-
ters and other affected entities, and other interested par-
ties; and 
(B) shall take into account— 
(i) the timely availability and appropriateness of 
data used to determine a designation to potential 
applicants for such designations; 
(ii) the impact of the methodology and criteria 
on communities of various types and on health centers 
and other safety net providers; 
(iii) the degree of ease or difficulty that will face 
potential applicants for such designations in securing 
the necessary data; and 
(iv) the extent to which the methodology accurately 
measures various barriers that confront individuals 
and population groups in seeking health care services. 
(b) PUBLICATION OF NOTICE.—In carrying out the rulemaking 
process under this subsection, the Secretary shall publish the notice 
provided for under section 564(a) of title 5, United States Code, 
by not later than 45 days after the date of the enactment of 
this Act. 
(c) TARGET DATE FOR PUBLICATION OF RULE.—As part of the 
notice under subsection (b), and for purposes of this subsection, 
the ‘‘target date for publication’’, as referred to in section 564(a)(5) 
of title 5, United Sates Code, shall be July 1, 2010. 
(d) APPOINTMENT OF NEGOTIATED RULEMAKING COMMITTEE AND 
FACILITATOR.—The Secretary shall provide for— 
(1) the appointment of a negotiated rulemaking committee 
under section 565(a) of title 5, United States Code, by not 
later than 30 days after the end of the comment period provided 
for under section 564(c) of such title; and 
(2) the nomination of a facilitator under section 566(c) 
of such title 5 by not later than 10 days after the date of 
appointment of the committee. 
(e) PRELIMINARY COMMITTEE REPORT.—The negotiated rule-
making committee appointed under subsection (d) shall report to 
the Secretary, by not later than April 1, 2010, regarding the commit-
tee’s progress on achieving a consensus with regard to the rule-
making proceeding and whether such consensus is likely to occur 
before one month before the target date for publication of the 
rule. If the committee reports that the committee has failed to 
make significant progress toward such consensus or is unlikely 
to reach such consensus by the target date, the Secretary may 
terminate such process and provide for the publication of a rule 
under this section through such other methods as the Secretary 
may provide. 
Deadlines. 
Deadline. 
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124 STAT. 679 
PUBLIC LAW 111–148—MAR. 23, 2010 
(f) FINAL COMMITTEE REPORT.—If the committee is not termi-
nated under subsection (e), the rulemaking committee shall submit 
a report containing a proposed rule by not later than one month 
before the target publication date. 
(g) INTERIM FINAL EFFECT.—The Secretary shall publish a rule 
under this section in the Federal Register by not later than the 
target publication date. Such rule shall be effective and final imme-
diately on an interim basis, but is subject to change and revision 
after public notice and opportunity for a period (of not less than 
90 days) for public comment. In connection with such rule, the 
Secretary shall specify the process for the timely review and 
approval of applications for such designations pursuant to such 
rules and consistent with this section. 
(h) PUBLICATION OF RULE AFTER PUBLIC COMMENT.—The Sec-
retary shall provide for consideration of such comments and 
republication of such rule by not later than 1 year after the target 
publication date. 
SEC. 5603. REAUTHORIZATION OF THE WAKEFIELD EMERGENCY MED-
ICAL SERVICES FOR CHILDREN PROGRAM. 
Section 1910 of the Public Health Service Act (42 U.S.C. 300w– 
9) is amended— 
(1) in subsection (a), by striking ‘‘3-year period (with an 
optional 4th year’’ and inserting ‘‘4-year period (with an optional 
5th year’’; and 
(2) in subsection (d)— 
(A) by striking ‘‘and such sums’’ and inserting ‘‘such 
sums’’; and 
(B) by inserting before the period the following: ‘‘, 
$25,000,000 for fiscal year 2010, $26,250,000 for fiscal year 
2011, $27,562,500 for fiscal year 2012, $28,940,625 for fiscal 
year 2013, and $30,387,656 for fiscal year 2014’’. 
SEC. 5604. CO-LOCATING PRIMARY AND SPECIALTY CARE IN COMMU-
NITY-BASED MENTAL HEALTH SETTINGS. 
Subpart 3 of part B of title V of the Public Health Service 
Act (42 U.S.C. 290bb–31 et seq.) is amended by adding at the 
end the following: 
‘‘SEC. 520K. AWARDS FOR CO-LOCATING PRIMARY AND SPECIALTY 
CARE IN COMMUNITY-BASED MENTAL HEALTH SET-
TINGS. 
‘‘(a) DEFINITIONS.—In this section: 
‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible entity’ means a 
qualified community mental health program defined under sec-
tion 1913(b)(1). 
‘‘(2) SPECIAL POPULATIONS.—The term ‘special populations’ 
means adults with mental illnesses who have co-occurring pri-
mary care conditions and chronic diseases. 
‘‘(b) PROGRAM AUTHORIZED.—The Secretary, acting through the 
Administrator shall award grants and cooperative agreements to 
eligible entities to establish demonstration projects for the provision 
of coordinated and integrated services to special populations 
through the co-location of primary and specialty care services in 
community-based mental and behavioral health settings. 
‘‘(c) APPLICATION.—To be eligible to receive a grant or coopera-
tive agreement under this section, an eligible entity shall submit 
an application to the Administrator at such time, in such manner, 
Grants. 
Contracts. 
42 USC 
290bb–42. 
Effective date. 
Public 
information. 
Regulations. 
Federal Register, 
publication. 
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124 STAT. 680 
PUBLIC LAW 111–148—MAR. 23, 2010 
and accompanied by such information as the Administrator may 
require, including a description of partnerships, or other arrange-
ments with local primary care providers, including community 
health centers, to provide services to special populations. 
‘‘(d) USE OF FUNDS.— 
‘‘(1) IN GENERAL.—For the benefit of special populations, 
an eligible entity shall use funds awarded under this section 
for— 
‘‘(A) the provision, by qualified primary care profes-
sionals, of on site primary care services; 
‘‘(B) reasonable costs associated with medically nec-
essary referrals to qualified specialty care professionals, 
other coordinators of care or, if permitted by the terms 
of the grant or cooperative agreement, by qualified specialty 
care professionals on a reasonable cost basis on site at 
the eligible entity; 
‘‘(C) information technology required to accommodate 
the clinical needs of primary and specialty care profes-
sionals; or 
‘‘(D) facility modifications needed to bring primary and 
specialty care professionals on site at the eligible entity. 
‘‘(2) LIMITATION.—Not to exceed 15 percent of grant or 
cooperative agreement funds may be used for activities 
described in subparagraphs (C) and (D) of paragraph (1). 
‘‘(e) EVALUATION.—Not later than 90 days after a grant or 
cooperative agreement awarded under this section expires, an 
eligible entity shall submit to the Secretary the results of an evalua-
tion to be conducted by the entity concerning the effectiveness 
of the activities carried out under the grant or agreement. 
‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated to carry out this section, $50,000,000 for fiscal 
year 2010 and such sums as may be necessary for each of fiscal 
years 2011 through 2014.’’. 
SEC. 5605. KEY NATIONAL INDICATORS. 
(a) DEFINITIONS.—In this section: 
(1) ACADEMY.—The term ‘‘Academy’’ means the National 
Academy of Sciences. 
(2) COMMISSION.—The term ‘‘Commission’’ means the 
Commission on Key National Indicators established under sub-
section (b). 
(3) INSTITUTE.—The term ‘‘Institute’’ means a Key National 
Indicators Institute as designated under subsection (c)(3). 
(b) COMMISSION ON KEY NATIONAL INDICATORS.— 
(1) ESTABLISHMENT.—There is established a ‘‘Commission 
on Key National Indicators’’. 
(2) MEMBERSHIP.— 
(A) NUMBER
AND
APPOINTMENT.—The Commission 
shall be composed of 8 members, to be appointed equally 
by the majority and minority leaders of the Senate and 
the Speaker and minority leader of the House of Represent-
atives. 
(B) PROHIBITED
APPOINTMENTS.—Members of the 
Commission shall not include Members of Congress or other 
elected Federal, State, or local government officials. 
(C) QUALIFICATIONS.—In making appointments under 
subparagraph (A), the majority and minority leaders of 
36 USC 150303 
note. 
Deadline. 
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124 STAT. 681 
PUBLIC LAW 111–148—MAR. 23, 2010 
the Senate and the Speaker and minority leader of the 
House of Representatives shall appoint individuals who 
have shown a dedication to improving civic dialogue and 
decision-making through the wide use of scientific evidence 
and factual information. 
(D) PERIOD
OF
APPOINTMENT.—Each member of the 
Commission shall be appointed for a 2-year term, except 
that 1 initial appointment shall be for 3 years. Any vacan-
cies shall not affect the power and duties of the Commission 
but shall be filled in the same manner as the original 
appointment and shall last only for the remainder of that 
term. 
(E) DATE.—Members of the Commission shall be 
appointed by not later than 30 days after the date of 
enactment of this Act. 
(F) INITIAL ORGANIZING PERIOD.—–Not later than 60 
days after the date of enactment of this Act, the Commis-
sion shall develop and implement a schedule for completion 
of the review and reports required under subsection (d). 
(G) CO-CHAIRPERSONS.—The Commission shall select 
2 Co-Chairpersons from among its members. 
(c) DUTIES OF THE COMMISSION.— 
(1) IN GENERAL.—The Commission shall— 
(A) conduct comprehensive oversight of a newly estab-
lished key national indicators system consistent with the 
purpose described in this subsection; 
(B) make recommendations on how to improve the 
key national indicators system; 
(C) coordinate with Federal Government users and 
information providers to assure access to relevant and 
quality data; and 
(D) enter into contracts with the Academy. 
(2) REPORTS.— 
(A) ANNUAL REPORT TO CONGRESS.—Not later than 1 
year after the selection of the 2 Co-Chairpersons of the 
Commission, and each subsequent year thereafter, the 
Commission shall prepare and submit to the appropriate 
Committees of Congress and the President a report that 
contains a detailed statement of the recommendations, 
findings, and conclusions of the Commission on the activi-
ties of the Academy and a designated Institute related 
to the establishment of a Key National Indicator System. 
(B) ANNUAL REPORT TO THE ACADEMY.— 
(i) IN GENERAL.—Not later than 6 months after 
the selection of the 2 Co-Chairpersons of the Commis-
sion, and each subsequent year thereafter, the Commis-
sion shall prepare and submit to the Academy and 
a designated Institute a report making recommenda-
tions concerning potential issue areas and key indica-
tors to be included in the Key National Indicators. 
(ii) LIMITATION.—The Commission shall not have 
the authority to direct the Academy or, if established, 
the Institute, to adopt, modify, or delete any key indica-
tors. 
(3) CONTRACT WITH THE NATIONAL ACADEMY OF SCIENCES.— 
(A) IN GENERAL.—–As soon as practicable after the 
selection of the 2 Co-Chairpersons of the Commission, the 
Contracts. 
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124 STAT. 682 
PUBLIC LAW 111–148—MAR. 23, 2010 
Co-Chairpersons shall enter into an arrangement with the 
National Academy of Sciences under which the Academy 
shall— 
(i) review available public and private sector 
research on the selection of a set of key national indica-
tors; 
(ii) determine how best to establish a key national 
indicator system for the United States, by either cre-
ating its own institutional capability or designating 
an independent private nonprofit organization as an 
Institute to implement a key national indicator system; 
(iii) if the Academy designates an independent 
Institute under clause (ii), provide scientific and tech-
nical advice to the Institute and create an appropriate 
governance mechanism that balances Academy involve-
ment and the independence of the Institute; and 
(iv) provide an annual report to the Commission 
addressing scientific and technical issues related to 
the key national indicator system and, if established, 
the Institute, and governance of the Institute’s budget 
and operations. 
(B) PARTICIPATION.—In executing the arrangement 
under subparagraph (A), the National Academy of Sciences 
shall convene a multi-sector, multi-disciplinary process to 
define major scientific and technical issues associated with 
developing, maintaining, and evolving a Key National Indi-
cator System and, if an Institute is established, to provide 
it with scientific and technical advice. 
(C) ESTABLISHMENT
OF
A
KEY
NATIONAL
INDICATOR 
SYSTEM.— 
(i) IN
GENERAL.—In executing the arrangement 
under subparagraph (A), the National Academy of 
Sciences shall enable the establishment of a key 
national indicator system by— 
(I) creating its own institutional capability; 
or 
(II) partnering with an independent private 
nonprofit organization as an Institute to imple-
ment a key national indicator system. 
(ii) INSTITUTE.—If the Academy designates an 
Institute under clause (i)(II), such Institute shall be 
a non-profit entity (as defined for purposes of section 
501(c)(3) of the Internal Revenue Code of 1986) with 
an educational mission, a governance structure that 
emphasizes independence, and characteristics that 
make such entity appropriate for establishing a key 
national indicator system. 
(iii) RESPONSIBILITIES.—Either the Academy or the 
Institute designated under clause (i)(II) shall be 
responsible for the following: 
(I) Identifying and selecting issue areas to be 
represented by the key national indicators. 
(II) Identifying and selecting the measures 
used for key national indicators within the issue 
areas under subclause (I). 
Reports. 
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124 STAT. 683 
PUBLIC LAW 111–148—MAR. 23, 2010 
(III) Identifying and selecting data to populate 
the key national indicators described under sub-
clause (II). 
(IV) Designing, publishing, and maintaining 
a public website that contains a freely accessible 
database allowing public access to the key national 
indicators. 
(V) Developing a quality assurance framework 
to ensure rigorous and independent processes and 
the selection of quality data. 
(VI) Developing a budget for the construction 
and management of a sustainable, adaptable, and 
evolving key national indicator system that reflects 
all Commission funding of Academy and, if an 
Institute is established, Institute activities. 
(VII) Reporting annually to the Commission 
regarding its selection of issue areas, key indica-
tors, data, and progress toward establishing a web- 
accessible database. 
(VIII) Responding directly to the Commission 
in response to any Commission recommendations 
and to the Academy regarding any inquiries by 
the Academy. 
(iv) GOVERNANCE.—Upon the establishment of a 
key national indicator system, the Academy shall 
create an appropriate governance mechanism that 
incorporates advisory and control functions. If an 
Institute is designated under clause (i)(II), the govern-
ance mechanism shall balance appropriate Academy 
involvement and the independence of the Institute. 
(v) MODIFICATION
AND
CHANGES.—The Academy 
shall retain the sole discretion, at any time, to alter 
its approach to the establishment of a key national 
indicator system or, if an Institute is designated under 
clause (i)(II), to alter any aspect of its relationship 
with the Institute or to designate a different non- 
profit entity to serve as the Institute. 
(vi) CONSTRUCTION.—Nothing in this section shall 
be construed to limit the ability of the Academy or 
the Institute designated under clause (i)(II) to receive 
private funding for activities related to the establish-
ment of a key national indicator system. 
(D) ANNUAL
REPORT.—As part of the arrangement 
under subparagraph (A), the National Academy of Sciences 
shall, not later than 270 days after the date of enactment 
of this Act, and annually thereafter, submit to the Co- 
Chairpersons of the Commission a report that contains 
the findings and recommendations of the Academy. 
(d) 
GOVERNMENT
ACCOUNTABILITY
OFFICE
STUDY
AND 
REPORT.— 
(1) GAO STUDY.—The Comptroller General of the United 
States shall conduct a study of previous work conducted by 
all public agencies, private organizations, or foreign countries 
with respect to best practices for a key national indicator 
system. The study shall be submitted to the appropriate author-
izing committees of Congress. 
Reports. 
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124 STAT. 684 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) GAO FINANCIAL AUDIT.—If an Institute is established 
under this section, the Comptroller General shall conduct an 
annual audit of the financial statements of the Institute, in 
accordance with generally accepted government auditing stand-
ards and submit a report on such audit to the Commission 
and the appropriate authorizing committees of Congress. 
(3) GAO PROGRAMMATIC REVIEW.—The Comptroller General 
of the United States shall conduct programmatic assessments 
of the Institute established under this section as determined 
necessary by the Comptroller General and report the findings 
to the Commission and to the appropriate authorizing commit-
tees of Congress. 
(e) AUTHORIZATION OF APPROPRIATIONS.— 
(1) IN GENERAL.—–There are authorized to be appropriated 
to carry out the purposes of this section, $10,000,000 for fiscal 
year 2010, and $7,500,000 for each of fiscal year 2011 through 
2018. 
(2) AVAILABILITY.—–Amounts appropriated under para-
graph (1) shall remain available until expended. 
Subtitle H—General Provisions 
SEC. 5701. REPORTS. 
(a) REPORTS BY SECRETARY OF HEALTH AND HUMAN SERVICES.— 
On an annual basis, the Secretary of Health and Human Services 
shall submit to the appropriate Committees of Congress a report 
on the activities carried out under the amendments made by this 
title, and the effectiveness of such activities. 
(b) REPORTS BY RECIPIENTS OF FUNDS.—The Secretary of Health 
and Human Services may require, as a condition of receiving funds 
under the amendments made by this title, that the entity receiving 
such award submit to such Secretary such reports as the such 
Secretary may require on activities carried out with such award, 
and the effectiveness of such activities. 
TITLE VI—TRANSPARENCY AND 
PROGRAM INTEGRITY 
Subtitle A—Physician Ownership and 
Other Transparency 
SEC. 6001. LIMITATION ON MEDICARE EXCEPTION TO THE PROHIBI-
TION ON CERTAIN PHYSICIAN REFERRALS FOR HOS-
PITALS. 
(a) IN GENERAL.—Section 1877 of the Social Security Act (42 
U.S.C. 1395nn) is amended— 
(1) in subsection (d)(2)— 
(A) in subparagraph (A), by striking ‘‘and’’ at the end; 
(B) in subparagraph (B), by striking the period at 
the end and inserting ‘‘; and’’; and 
(C) by adding at the end the following new subpara-
graph: 
‘‘(C) in the case where the entity is a hospital, the 
hospital meets the requirements of paragraph (3)(D).’’; 
42 USC 204 note. 
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124 STAT. 685 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) in subsection (d)(3)— 
(A) in subparagraph (B), by striking ‘‘and’’ at the end; 
(B) in subparagraph (C), by striking the period at 
the end and inserting ‘‘; and’’; and 
(C) by adding at the end the following new subpara-
graph: 
‘‘(D) the hospital meets the requirements described 
in subsection (i)(1) not later than 18 months after the 
date of the enactment of this subparagraph.’’; and 
(3) by adding at the end the following new subsection: 
‘‘(i) REQUIREMENTS
FOR HOSPITALS TO QUALIFY
FOR RURAL 
PROVIDER AND HOSPITAL EXCEPTION TO OWNERSHIP OR INVESTMENT 
PROHIBITION.— 
‘‘(1) REQUIREMENTS DESCRIBED.—For purposes of subsection 
(d)(3)(D), the requirements described in this paragraph for a 
hospital are as follows: 
‘‘(A) PROVIDER AGREEMENT.—The hospital had— 
‘‘(i) physician ownership or investment on Feb-
ruary 1, 2010; and 
‘‘(ii) a provider agreement under section 1866 in 
effect on such date. 
‘‘(B) LIMITATION ON EXPANSION OF FACILITY CAPACITY.— 
Except as provided in paragraph (3), the number of oper-
ating rooms, procedure rooms, and beds for which the hos-
pital is licensed at any time on or after the date of the 
enactment of this subsection is no greater than the number 
of operating rooms, procedure rooms, and beds for which 
the hospital is licensed as of such date. 
‘‘(C) PREVENTING CONFLICTS OF INTEREST.— 
‘‘(i) The hospital submits to the Secretary an 
annual report containing a detailed description of— 
‘‘(I) the identity of each physician owner or 
investor and any other owners or investors of the 
hospital; and 
‘‘(II) the nature and extent of all ownership 
and investment interests in the hospital. 
‘‘(ii) The hospital has procedures in place to require 
that any referring physician owner or investor discloses 
to the patient being referred, by a time that permits 
the patient to make a meaningful decision regarding 
the receipt of care, as determined by the Secretary— 
‘‘(I) the ownership or investment interest, as 
applicable, of such referring physician in the hos-
pital; and 
‘‘(II) if applicable, any such ownership or 
investment interest of the treating physician. 
‘‘(iii) The hospital does not condition any physician 
ownership or investment interests either directly or 
indirectly on the physician owner or investor making 
or influencing referrals to the hospital or otherwise 
generating business for the hospital. 
‘‘(iv) The hospital discloses the fact that the hos-
pital is partially owned or invested in by physicians— 
‘‘(I) on any public website for the hospital; 
and 
‘‘(II) in any public advertising for the hospital. 
‘‘(D) ENSURING BONA FIDE INVESTMENT.— 
Reports. 
Deadline. 
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124 STAT. 686 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) The percentage of the total value of the owner-
ship or investment interests held in the hospital, or 
in an entity whose assets include the hospital, by physi-
cian owners or investors in the aggregate does not 
exceed such percentage as of the date of enactment 
of this subsection. 
‘‘(ii) Any ownership or investment interests that 
the hospital offers to a physician owner or investor 
are not offered on more favorable terms than the terms 
offered to a person who is not a physician owner or 
investor. 
‘‘(iii) The hospital (or any owner or investor in 
the hospital) does not directly or indirectly provide 
loans or financing for any investment in the hospital 
by a physician owner or investor. 
‘‘(iv) The hospital (or any owner or investor in 
the hospital) does not directly or indirectly guarantee 
a loan, make a payment toward a loan, or otherwise 
subsidize a loan, for any individual physician owner 
or investor or group of physician owners or investors 
that is related to acquiring any ownership or invest-
ment interest in the hospital. 
‘‘(v) Ownership or investment returns are distrib-
uted to each owner or investor in the hospital in an 
amount that is directly proportional to the ownership 
or investment interest of such owner or investor in 
the hospital. 
‘‘(vi) Physician owners and investors do not receive, 
directly or indirectly, any guaranteed receipt of or right 
to purchase other business interests related to the 
hospital, including the purchase or lease of any prop-
erty under the control of other owners or investors 
in the hospital or located near the premises of the 
hospital. 
‘‘(vii) The hospital does not offer a physician owner 
or investor the opportunity to purchase or lease any 
property under the control of the hospital or any other 
owner or investor in the hospital on more favorable 
terms than the terms offered to an individual who 
is not a physician owner or investor. 
‘‘(E) PATIENT SAFETY.— 
‘‘(i) Insofar as the hospital admits a patient and 
does not have any physician available on the premises 
to provide services during all hours in which the hos-
pital is providing services to such patient, before admit-
ting the patient— 
‘‘(I) the hospital discloses such fact to a 
patient; and 
‘‘(II) following such disclosure, the hospital 
receives from the patient a signed acknowledgment 
that the patient understands such fact. 
‘‘(ii) The hospital has the capacity to— 
‘‘(I) provide assessment and initial treatment 
for patients; and 
‘‘(II) refer and transfer patients to hospitals 
with the capability to treat the needs of the patient 
involved. 
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124 STAT. 687 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(F) LIMITATION
ON
APPLICATION
TO
CERTAIN
CON-
VERTED FACILITIES.—The hospital was not converted from 
an ambulatory surgical center to a hospital on or after 
the date of enactment of this subsection. 
‘‘(2) PUBLICATION
OF
INFORMATION
REPORTED.—The Sec-
retary shall publish, and update on an annual basis, the 
information submitted by hospitals under paragraph (1)(C)(i) 
on the public Internet website of the Centers for Medicare 
& Medicaid Services. 
‘‘(3) EXCEPTION TO PROHIBITION ON EXPANSION OF FACILITY 
CAPACITY.— 
‘‘(A) PROCESS.— 
‘‘(i) ESTABLISHMENT.—The Secretary shall estab-
lish and implement a process under which an 
applicable hospital (as defined in subparagraph (E)) 
may apply for an exception from the requirement under 
paragraph (1)(B). 
‘‘(ii) OPPORTUNITY
FOR
COMMUNITY
INPUT.—The 
process under clause (i) shall provide individuals and 
entities in the community in which the applicable hos-
pital applying for an exception is located with the 
opportunity to provide input with respect to the 
application. 
‘‘(iii) TIMING FOR IMPLEMENTATION.—The Secretary 
shall implement the process under clause (i) on August 
1, 2011. 
‘‘(iv) REGULATIONS.—Not later than July 1, 2011, 
the Secretary shall promulgate regulations to carry 
out the process under clause (i). 
‘‘(B) FREQUENCY.—The process described in subpara-
graph (A) shall permit an applicable hospital to apply for 
an exception up to once every 2 years. 
‘‘(C) PERMITTED INCREASE.— 
‘‘(i) IN
GENERAL.—Subject to clause (ii) and 
subparagraph (D), an applicable hospital granted an 
exception under the process described in subparagraph 
(A) may increase the number of operating rooms, proce-
dure rooms, and beds for which the applicable hospital 
is licensed above the baseline number of operating 
rooms, procedure rooms, and beds of the applicable 
hospital (or, if the applicable hospital has been granted 
a previous exception under this paragraph, above the 
number of operating rooms, procedure rooms, and beds 
for which the hospital is licensed after the application 
of the most recent increase under such an exception). 
‘‘(ii) 100 PERCENT INCREASE LIMITATION.—The Sec-
retary shall not permit an increase in the number 
of operating rooms, procedure rooms, and beds for 
which an applicable hospital is licensed under clause 
(i) to the extent such increase would result in the 
number of operating rooms, procedure rooms, and beds 
for which the applicable hospital is licensed exceeding 
200 percent of the baseline number of operating rooms, 
procedure rooms, and beds of the applicable hospital. 
‘‘(iii) BASELINE
NUMBER
OF
OPERATING
ROOMS, 
PROCEDURE ROOMS, AND BEDS.—In this paragraph, the 
term ‘baseline number of operating rooms, procedure 
Deadline. 
Deadline. 
Web posting. 
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124 STAT. 688 
PUBLIC LAW 111–148—MAR. 23, 2010 
rooms, and beds’ means the number of operating rooms, 
procedure rooms, and beds for which the applicable 
hospital is licensed as of the date of enactment of 
this subsection. 
‘‘(D) INCREASE
LIMITED
TO
FACILITIES
ON
THE
MAIN 
CAMPUS OF THE HOSPITAL.—Any increase in the number 
of operating rooms, procedure rooms, and beds for which 
an applicable hospital is licensed pursuant to this para-
graph may only occur in facilities on the main campus 
of the applicable hospital. 
‘‘(E) APPLICABLE
HOSPITAL.—In this paragraph, the 
term ‘applicable hospital’ means a hospital— 
‘‘(i) that is located in a county in which the percent-
age increase in the population during the most recent 
5-year period (as of the date of the application under 
subparagraph (A)) is at least 150 percent of the 
percentage increase in the population growth of the 
State in which the hospital is located during that 
period, as estimated by Bureau of the Census; 
‘‘(ii) whose annual percent of total inpatient admis-
sions that represent inpatient admissions under the 
program under title XIX is equal to or greater than 
the average percent with respect to such admissions 
for all hospitals located in the county in which the 
hospital is located; 
‘‘(iii) that does not discriminate against bene-
ficiaries of Federal health care programs and does 
not permit physicians practicing at the hospital to 
discriminate against such beneficiaries; 
‘‘(iv) that is located in a State in which the average 
bed capacity in the State is less than the national 
average bed capacity; and 
‘‘(v) that has an average bed occupancy rate that 
is greater than the average bed occupancy rate in 
the State in which the hospital is located. 
‘‘(F) PROCEDURE ROOMS.—In this subsection, the term 
‘procedure rooms’ includes rooms in which catheterizations, 
angiographies, angiograms, and endoscopies are performed, 
except such term shall not include emergency rooms or 
departments (exclusive of rooms in which catheterizations, 
angiographies, angiograms, and endoscopies are per-
formed). 
‘‘(G) PUBLICATION OF FINAL DECISIONS.—Not later than 
60 days after receiving a complete application under this 
paragraph, the Secretary shall publish in the Federal Reg-
ister the final decision with respect to such application. 
‘‘(H) LIMITATION
ON
REVIEW.—There shall be no 
administrative or judicial review under section 1869, sec-
tion 1878, or otherwise of the process under this paragraph 
(including the establishment of such process). 
‘‘(4) COLLECTION OF OWNERSHIP AND INVESTMENT INFORMA-
TION.—For purposes of subparagraphs (A)(i) and (D)(i) of para-
graph (1), the Secretary shall collect physician ownership and 
investment information for each hospital. 
‘‘(5) PHYSICIAN
OWNER
OR
INVESTOR
DEFINED.—For pur-
poses of this subsection, the term ‘physician owner or investor’ 
means a physician (or an immediate family member of such 
Deadline. 
Federal Register, 
publication. 
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124 STAT. 689 
PUBLIC LAW 111–148—MAR. 23, 2010 
physician) with a direct or an indirect ownership or investment 
interest in the hospital. 
‘‘(6) CLARIFICATION.—Nothing in this subsection shall be 
construed as preventing the Secretary from revoking a hos-
pital’s provider agreement if not in compliance with regulations 
implementing section 1866.’’. 
(b) ENFORCEMENT.— 
(1) ENSURING COMPLIANCE.—The Secretary of Health and 
Human Services shall establish policies and procedures to 
ensure compliance with the requirements described in sub-
section (i)(1) of section 1877 of the Social Security Act, as 
added by subsection (a)(3), beginning on the date such require-
ments first apply. Such policies and procedures may include 
unannounced site reviews of hospitals. 
(2) AUDITS.—Beginning not later than November 1, 2011, 
the Secretary of Health and Human Services shall conduct 
audits to determine if hospitals violate the requirements 
referred to in paragraph (1). 
SEC. 6002. TRANSPARENCY REPORTS AND REPORTING OF PHYSICIAN 
OWNERSHIP OR INVESTMENT INTERESTS. 
Part A of title XI of the Social Security Act (42 U.S.C. 1301 
et seq.) is amended by inserting after section 1128F the following 
new section: 
‘‘SEC. 1128G. TRANSPARENCY REPORTS AND REPORTING OF PHYSI-
CIAN OWNERSHIP OR INVESTMENT INTERESTS. 
‘‘(a) TRANSPARENCY REPORTS.— 
‘‘(1) PAYMENTS OR OTHER TRANSFERS OF VALUE.— 
‘‘(A) IN GENERAL.—On March 31, 2013, and on the 
90th day of each calendar year beginning thereafter, any 
applicable manufacturer that provides a payment or other 
transfer of value to a covered recipient (or to an entity 
or individual at the request of or designated on behalf 
of a covered recipient), shall submit to the Secretary, in 
such electronic form as the Secretary shall require, the 
following information with respect to the preceding cal-
endar year: 
‘‘(i) The name of the covered recipient. 
‘‘(ii) The business address of the covered recipient 
and, in the case of a covered recipient who is a physi-
cian, the specialty and National Provider Identifier 
of the covered recipient. 
‘‘(iii) The amount of the payment or other transfer 
of value. 
‘‘(iv) The dates on which the payment or other 
transfer of value was provided to the covered recipient. 
‘‘(v) A description of the form of the payment or 
other transfer of value, indicated (as appropriate for 
all that apply) as— 
‘‘(I) cash or a cash equivalent; 
‘‘(II) in-kind items or services; 
‘‘(III) stock, a stock option, or any other owner-
ship interest, dividend, profit, or other return on 
investment; or 
‘‘(IV) any other form of payment or other 
transfer of value (as defined by the Secretary). 
Electronic 
format. 
42 USC 
1320a–7h. 
Deadline. 
Procedures. 
42 USC 1395nn 
note. 
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124 STAT. 690 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(vi) A description of the nature of the payment 
or other transfer of value, indicated (as appropriate 
for all that apply) as— 
‘‘(I) consulting fees; 
‘‘(II) compensation for services other than con-
sulting; 
‘‘(III) honoraria; 
‘‘(IV) gift; 
‘‘(V) entertainment; 
‘‘(VI) food; 
‘‘(VII) travel (including the specified destina-
tions); 
‘‘(VIII) education; 
‘‘(IX) research; 
‘‘(X) charitable contribution; 
‘‘(XI) royalty or license; 
‘‘(XII) current or prospective ownership or 
investment interest; 
‘‘(XIII) direct compensation for serving as fac-
ulty or as a speaker for a medical education pro-
gram; 
‘‘(XIV) grant; or 
‘‘(XV) any other nature of the payment or other 
transfer of value (as defined by the Secretary). 
‘‘(vii) If the payment or other transfer of value 
is related to marketing, education, or research specific 
to a covered drug, device, biological, or medical supply, 
the name of that covered drug, device, biological, or 
medical supply. 
‘‘(viii) 
Any 
other 
categories 
of 
information 
regarding the payment or other transfer of value the 
Secretary determines appropriate. 
‘‘(B) SPECIAL RULE FOR CERTAIN PAYMENTS OR OTHER 
TRANSFERS OF VALUE.—In the case where an applicable 
manufacturer provides a payment or other transfer of value 
to an entity or individual at the request of or designated 
on behalf of a covered recipient, the applicable manufac-
turer shall disclose that payment or other transfer of value 
under the name of the covered recipient. 
‘‘(2) PHYSICIAN OWNERSHIP.—In addition to the requirement 
under paragraph (1)(A), on March 31, 2013, and on the 90th 
day of each calendar year beginning thereafter, any applicable 
manufacturer or applicable group purchasing organization shall 
submit to the Secretary, in such electronic form as the Secretary 
shall require, the following information regarding any owner-
ship or investment interest (other than an ownership or invest-
ment interest in a publicly traded security and mutual fund, 
as described in section 1877(c)) held by a physician (or an 
immediate family member of such physician (as defined for 
purposes of section 1877(a))) in the applicable manufacturer 
or applicable group purchasing organization during the pre-
ceding year: 
‘‘(A) The dollar amount invested by each physician 
holding such an ownership or investment interest. 
‘‘(B) The value and terms of each such ownership or 
investment interest. 
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124 STAT. 691 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(C) Any payment or other transfer of value provided 
to a physician holding such an ownership or investment 
interest (or to an entity or individual at the request of 
or designated on behalf of a physician holding such an 
ownership or investment interest), including the informa-
tion described in clauses (i) through (viii) of paragraph 
(1)(A), except that in applying such clauses, ‘physician’ 
shall be substituted for ‘covered recipient’ each place it 
appears. 
‘‘(D) Any other information regarding the ownership 
or investment interest the Secretary determines appro-
priate. 
‘‘(b) PENALTIES FOR NONCOMPLIANCE.— 
‘‘(1) FAILURE TO REPORT.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B) except 
as provided in paragraph (2), any applicable manufacturer 
or applicable group purchasing organization that fails to 
submit information required under subsection (a) in a 
timely manner in accordance with rules or regulations 
promulgated to carry out such subsection, shall be subject 
to a civil money penalty of not less than $1,000, but not 
more than $10,000, for each payment or other transfer 
of value or ownership or investment interest not reported 
as required under such subsection. Such penalty shall be 
imposed and collected in the same manner as civil money 
penalties under subsection (a) of section 1128A are imposed 
and collected under that section. 
‘‘(B) LIMITATION.—The total amount of civil money pen-
alties imposed under subparagraph (A) with respect to 
each annual submission of information under subsection 
(a) by an applicable manufacturer or applicable group pur-
chasing organization shall not exceed $150,000. 
‘‘(2) KNOWING FAILURE TO REPORT.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), any 
applicable manufacturer or applicable group purchasing 
organization that knowingly fails to submit information 
required under subsection (a) in a timely manner in accord-
ance with rules or regulations promulgated to carry out 
such subsection, shall be subject to a civil money penalty 
of not less than $10,000, but not more than $100,000, 
for each payment or other transfer of value or ownership 
or investment interest not reported as required under such 
subsection. Such penalty shall be imposed and collected 
in the same manner as civil money penalties under sub-
section (a) of section 1128A are imposed and collected under 
that section. 
‘‘(B) LIMITATION.—The total amount of civil money pen-
alties imposed under subparagraph (A) with respect to 
each annual submission of information under subsection 
(a) by an applicable manufacturer or applicable group pur-
chasing organization shall not exceed $1,000,000. 
‘‘(3) USE OF FUNDS.—Funds collected by the Secretary as 
a result of the imposition of a civil money penalty under this 
subsection shall be used to carry out this section. 
‘‘(c) PROCEDURES FOR SUBMISSION OF INFORMATION AND PUBLIC 
AVAILABILITY.— 
‘‘(1) IN GENERAL.— 
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124 STAT. 692 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) ESTABLISHMENT.—Not later than October 1, 2011, 
the Secretary shall establish procedures— 
‘‘(i) for applicable manufacturers and applicable 
group purchasing organizations to submit information 
to the Secretary under subsection (a); and 
‘‘(ii) for the Secretary to make such information 
submitted available to the public. 
‘‘(B) DEFINITION
OF
TERMS.—The procedures estab-
lished under subparagraph (A) shall provide for the defini-
tion of terms (other than those terms defined in subsection 
(e)), as appropriate, for purposes of this section. 
‘‘(C) PUBLIC
AVAILABILITY.—Except as provided in 
subparagraph (E), the procedures established under 
subparagraph (A)(ii) shall ensure that, not later than Sep-
tember 30, 2013, and on June 30 of each calendar year 
beginning thereafter, the information submitted under sub-
section (a) with respect to the preceding calendar year 
is made available through an Internet website that— 
‘‘(i) is searchable and is in a format that is clear 
and understandable; 
‘‘(ii) contains information that is presented by the 
name of the applicable manufacturer or applicable 
group purchasing organization, the name of the covered 
recipient, the business address of the covered recipient, 
the specialty of the covered recipient, the value of 
the payment or other transfer of value, the date on 
which the payment or other transfer of value was 
provided to the covered recipient, the form of the pay-
ment or other transfer of value, indicated (as appro-
priate) under subsection (a)(1)(A)(v), the nature of the 
payment or other transfer of value, indicated (as appro-
priate) under subsection (a)(1)(A)(vi), and the name 
of the covered drug, device, biological, or medical 
supply, as applicable; 
‘‘(iii) contains information that is able to be easily 
aggregated and downloaded; 
‘‘(iv) contains a description of any enforcement 
actions taken to carry out this section, including any 
penalties imposed under subsection (b), during the pre-
ceding year; 
‘‘(v) contains background information on industry- 
physician relationships; 
‘‘(vi) in the case of information submitted with 
respect to a payment or other transfer of value 
described in subparagraph (E)(i), lists such information 
separately from the other information submitted under 
subsection (a) and designates such separately listed 
information as funding for clinical research; 
‘‘(vii) contains any other information the Secretary 
determines would be helpful to the average consumer; 
‘‘(viii) does not contain the National Provider 
Identifier of the covered recipient, and 
‘‘(ix) subject to subparagraph (D), provides the 
applicable manufacturer, applicable group purchasing 
organization, or covered recipient an opportunity to 
review and submit corrections to the information sub-
mitted with respect to the applicable manufacturer, 
Deadlines. 
Web posting. 
Deadline. 
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124 STAT. 693 
PUBLIC LAW 111–148—MAR. 23, 2010 
applicable group purchasing organization, or covered 
recipient, respectively, for a period of not less than 
45 days prior to such information being made available 
to the public. 
‘‘(D) CLARIFICATION OF TIME PERIOD FOR REVIEW AND 
CORRECTIONS.—In no case may the 45-day period for review 
and submission of corrections to information under 
subparagraph (C)(ix) prevent such information from being 
made available to the public in accordance with the dates 
described in the matter preceding clause (i) in subpara-
graph (C). 
‘‘(E) DELAYED PUBLICATION FOR PAYMENTS MADE PURSU-
ANT TO PRODUCT RESEARCH OR DEVELOPMENT AGREEMENTS 
AND CLINICAL INVESTIGATIONS.— 
‘‘(i) IN GENERAL.—In the case of information sub-
mitted under subsection (a) with respect to a payment 
or other transfer of value made to a covered recipient 
by an applicable manufacturer pursuant to a product 
research or development agreement for services fur-
nished in connection with research on a potential new 
medical technology or a new application of an existing 
medical technology or the development of a new drug, 
device, biological, or medical supply, or by an applicable 
manufacturer in connection with a clinical investiga-
tion regarding a new drug, device, biological, or medical 
supply, the procedures established under subparagraph 
(A)(ii) shall provide that such information is made 
available to the public on the first date described in 
the matter preceding clause (i) in subparagraph (C) 
after the earlier of the following: 
‘‘(I) The date of the approval or clearance of 
the covered drug, device, biological, or medical 
supply by the Food and Drug Administration. 
‘‘(II) Four calendar years after the date such 
payment or other transfer of value was made. 
‘‘(ii) CONFIDENTIALITY OF INFORMATION PRIOR TO 
PUBLICATION.—Information described in clause (i) shall 
be considered confidential and shall not be subject 
to disclosure under section 552 of title 5, United States 
Code, or any other similar Federal, State, or local 
law, until on or after the date on which the information 
is made available to the public under such clause. 
‘‘(2) CONSULTATION.—In establishing the procedures under 
paragraph (1), the Secretary shall consult with the Inspector 
General of the Department of Health and Human Services, 
affected industry, consumers, consumer advocates, and other 
interested parties in order to ensure that the information made 
available to the public under such paragraph is presented in 
the appropriate overall context. 
‘‘(d) ANNUAL REPORTS AND RELATION TO STATE LAWS.— 
‘‘(1) ANNUAL REPORT TO CONGRESS.—Not later than April 
1 of each year beginning with 2013, the Secretary shall submit 
to Congress a report that includes the following: 
‘‘(A) The information submitted under subsection (a) 
during the preceding year, aggregated for each applicable 
manufacturer and applicable group purchasing organiza-
tion that submitted such information during such year 
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124 STAT. 694 
PUBLIC LAW 111–148—MAR. 23, 2010 
(except, in the case of information submitted with respect 
to a payment or other transfer of value described in sub-
section (c)(1)(E)(i), such information shall be included in 
the first report submitted to Congress after the date on 
which such information is made available to the public 
under such subsection). 
‘‘(B) A description of any enforcement actions taken 
to carry out this section, including any penalties imposed 
under subsection (b), during the preceding year. 
‘‘(2) ANNUAL
REPORTS
TO
STATES.—Not later than Sep-
tember 30, 2013 and on June 30 of each calendar year there-
after, the Secretary shall submit to States a report that includes 
a summary of the information submitted under subsection (a) 
during the preceding year with respect to covered recipients 
in the State (except, in the case of information submitted with 
respect to a payment or other transfer of value described in 
subsection (c)(1)(E)(i), such information shall be included in 
the first report submitted to States after the date on which 
such information is made available to the public under such 
subsection). 
‘‘(3) RELATION TO STATE LAWS.— 
‘‘(A) IN GENERAL.—In the case of a payment or other 
transfer of value provided by an applicable manufacturer 
that is received by a covered recipient (as defined in sub-
section (e)) on or after January 1, 2012, subject to subpara-
graph (B), the provisions of this section shall preempt 
any statute or regulation of a State or of a political subdivi-
sion of a State that requires an applicable manufacturer 
(as so defined) to disclose or report, in any format, the 
type of information (as described in subsection (a)) 
regarding such payment or other transfer of value. 
‘‘(B) NO PREEMPTION OF ADDITIONAL REQUIREMENTS.— 
Subparagraph (A) shall not preempt any statute or regula-
tion of a State or of a political subdivision of a State 
that requires the disclosure or reporting of information— 
‘‘(i) not of the type required to be disclosed or 
reported under this section; 
‘‘(ii) described in subsection (e)(10)(B), except in 
the case of information described in clause (i) of such 
subsection; 
‘‘(iii) by any person or entity other than an 
applicable manufacturer (as so defined) or a covered 
recipient (as defined in subsection (e)); or 
‘‘(iv) to a Federal, State, or local governmental 
agency for public health surveillance, investigation, or 
other public health purposes or health oversight pur-
poses. 
‘‘(C) Nothing in subparagraph (A) shall be construed 
to limit the discovery or admissibility of information 
described in such subparagraph in a criminal, civil, or 
administrative proceeding. 
‘‘(4) CONSULTATION.—The Secretary shall consult with the 
Inspector General of the Department of Health and Human 
Services on the implementation of this section. 
‘‘(e) DEFINITIONS.—In this section: 
‘‘(1) APPLICABLE GROUP PURCHASING ORGANIZATION.—The 
term ‘applicable group purchasing organization’ means a group 
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124 STAT. 695 
PUBLIC LAW 111–148—MAR. 23, 2010 
purchasing organization (as defined by the Secretary) that pur-
chases, arranges for, or negotiates the purchase of a covered 
drug, device, biological, or medical supply which is operating 
in the United States, or in a territory, possession, or common-
wealth of the United States. 
‘‘(2) APPLICABLE
MANUFACTURER.—The term ‘applicable 
manufacturer’ means a manufacturer of a covered drug, device, 
biological, or medical supply which is operating in the United 
States, or in a territory, possession, or commonwealth of the 
United States. 
‘‘(3) CLINICAL INVESTIGATION.—The term ‘clinical investiga-
tion’ means any experiment involving 1 or more human sub-
jects, or materials derived from human subjects, in which a 
drug or device is administered, dispensed, or used. 
‘‘(4) COVERED DEVICE.—The term ‘covered device’ means 
any device for which payment is available under title XVIII 
or a State plan under title XIX or XXI (or a waiver of such 
a plan). 
‘‘(5) COVERED
DRUG, DEVICE, BIOLOGICAL, OR
MEDICAL 
SUPPLY.—The term ‘covered drug, device, biological, or medical 
supply’ means any drug, biological product, device, or medical 
supply for which payment is available under title XVIII or 
a State plan under title XIX or XXI (or a waiver of such 
a plan). 
‘‘(6) COVERED RECIPIENT.— 
‘‘(A) IN GENERAL.—Except as provided in subparagraph 
(B), the term ‘covered recipient’ means the following: 
‘‘(i) A physician. 
‘‘(ii) A teaching hospital. 
‘‘(B) EXCLUSION.—Such term does not include a physi-
cian who is an employee of the applicable manufacturer 
that is required to submit information under subsection 
(a). 
‘‘(7) EMPLOYEE.—The term ‘employee’ has the meaning 
given such term in section 1877(h)(2). 
‘‘(8) KNOWINGLY.—The term ‘knowingly’ has the meaning 
given such term in section 3729(b) of title 31, United States 
Code. 
‘‘(9) 
MANUFACTURER
OF
A
COVERED
DRUG, 
DEVICE, 
BIOLOGICAL, OR MEDICAL SUPPLY.—The term ‘manufacturer of 
a covered drug, device, biological, or medical supply’ means 
any entity which is engaged in the production, preparation, 
propagation, compounding, or conversion of a covered drug, 
device, biological, or medical supply (or any entity under 
common ownership with such entity which provides assistance 
or support to such entity with respect to the production, 
preparation, propagation, compounding, conversion, marketing, 
promotion, sale, or distribution of a covered drug, device, 
biological, or medical supply). 
‘‘(10) PAYMENT OR OTHER TRANSFER OF VALUE.— 
‘‘(A) IN GENERAL.—The term ‘payment or other transfer 
of value’ means a transfer of anything of value. Such term 
does not include a transfer of anything of value that is 
made indirectly to a covered recipient through a third 
party in connection with an activity or service in the case 
where the applicable manufacturer is unaware of the 
identity of the covered recipient. 
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124 STAT. 696 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) EXCLUSIONS.—An applicable manufacturer shall 
not be required to submit information under subsection 
(a) with respect to the following: 
‘‘(i) A transfer of anything the value of which is 
less than $10, unless the aggregate amount transferred 
to, requested by, or designated on behalf of the covered 
recipient by the applicable manufacturer during the 
calendar year exceeds $100. For calendar years after 
2012, the dollar amounts specified in the preceding 
sentence shall be increased by the same percentage 
as the percentage increase in the consumer price index 
for all urban consumers (all items; U.S. city average) 
for the 12-month period ending with June of the pre-
vious year. 
‘‘(ii) Product samples that are not intended to be 
sold and are intended for patient use. 
‘‘(iii) Educational materials that directly benefit 
patients or are intended for patient use. 
‘‘(iv) The loan of a covered device for a short- 
term trial period, not to exceed 90 days, to permit 
evaluation of the covered device by the covered 
recipient. 
‘‘(v) Items or services provided under a contractual 
warranty, including the replacement of a covered 
device, where the terms of the warranty are set forth 
in the purchase or lease agreement for the covered 
device. 
‘‘(vi) A transfer of anything of value to a covered 
recipient when the covered recipient is a patient and 
not acting in the professional capacity of a covered 
recipient. 
‘‘(vii) Discounts (including rebates). 
‘‘(viii) In-kind items used for the provision of 
charity care. 
‘‘(ix) A dividend or other profit distribution from, 
or ownership or investment interest in, a publicly 
traded security and mutual fund (as described in sec-
tion 1877(c)). 
‘‘(x) In the case of an applicable manufacturer 
who offers a self-insured plan, payments for the provi-
sion of health care to employees under the plan. 
‘‘(xi) In the case of a covered recipient who is 
a licensed non-medical professional, a transfer of any-
thing of value to the covered recipient if the transfer 
is payment solely for the non-medical professional serv-
ices of such licensed non-medical professional. 
‘‘(xii) In the case of a covered recipient who is 
a physician, a transfer of anything of value to the 
covered recipient if the transfer is payment solely for 
the services of the covered recipient with respect to 
a civil or criminal action or an administrative pro-
ceeding. 
‘‘(11) PHYSICIAN.—The term ‘physician’ has the meaning 
given that term in section 1861(r).’’. 
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124 STAT. 697 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 6003. DISCLOSURE REQUIREMENTS FOR IN-OFFICE ANCILLARY 
SERVICES EXCEPTION TO THE PROHIBITION ON PHYSI-
CIAN SELF-REFERRAL FOR CERTAIN IMAGING SERVICES. 
(a) IN GENERAL.—Section 1877(b)(2) of the Social Security Act 
(42 U.S.C. 1395nn(b)(2)) is amended by adding at the end the 
following new sentence: ‘‘Such requirements shall, with respect 
to magnetic resonance imaging, computed tomography, positron 
emission tomography, and any other designated health services 
specified under subsection (h)(6)(D) that the Secretary determines 
appropriate, include a requirement that the referring physician 
inform the individual in writing at the time of the referral that 
the individual may obtain the services for which the individual 
is being referred from a person other than a person described 
in subparagraph (A)(i) and provide such individual with a written 
list of suppliers (as defined in section 1861(d)) who furnish such 
services in the area in which such individual resides.’’. 
(b) EFFECTIVE DATE.—The amendment made by this section 
shall apply to services furnished on or after January 1, 2010. 
SEC. 6004. PRESCRIPTION DRUG SAMPLE TRANSPARENCY. 
Part A of title XI of the Social Security Act (42 U.S.C. 1301 
et seq.), as amended by section 6002, is amended by inserting 
after section 1128G the following new section: 
‘‘SEC. 1128H. REPORTING OF INFORMATION RELATING TO DRUG SAM-
PLES. 
‘‘(a) IN GENERAL.—Not later than April 1 of each year (begin-
ning with 2012), each manufacturer and authorized distributor 
of record of an applicable drug shall submit to the Secretary (in 
a form and manner specified by the Secretary) the following 
information with respect to the preceding year: 
‘‘(1) In the case of a manufacturer or authorized distributor 
of record which makes distributions by mail or common carrier 
under subsection (d)(2) of section 503 of the Federal Food, 
Drug, and Cosmetic Act (21 U.S.C. 353), the identity and 
quantity of drug samples requested and the identity and 
quantity of drug samples distributed under such subsection 
during that year, aggregated by— 
‘‘(A) the name, address, professional designation, and 
signature of the practitioner making the request under 
subparagraph (A)(i) of such subsection, or of any individual 
who makes or signs for the request on behalf of the practi-
tioner; and 
‘‘(B) any other category of information determined 
appropriate by the Secretary. 
‘‘(2) In the case of a manufacturer or authorized distributor 
of record which makes distributions by means other than mail 
or common carrier under subsection (d)(3) of such section 503, 
the identity and quantity of drug samples requested and the 
identity and quantity of drug samples distributed under such 
subsection during that year, aggregated by— 
‘‘(A) the name, address, professional designation, and 
signature of the practitioner making the request under 
subparagraph (A)(i) of such subsection, or of any individual 
who makes or signs for the request on behalf of the practi-
tioner; and 
42 USC 
1320a–7i. 
42 USC 1395nn 
note. 
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124 STAT. 698 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) any other category of information determined 
appropriate by the Secretary. 
‘‘(b) DEFINITIONS.—In this section: 
‘‘(1) APPLICABLE DRUG.—The term ‘applicable drug’ means 
a drug— 
‘‘(A) which is subject to subsection (b) of such section 
503; and 
‘‘(B) for which payment is available under title XVIII 
or a State plan under title XIX or XXI (or a waiver of 
such a plan). 
‘‘(2) AUTHORIZED
DISTRIBUTOR
OF
RECORD.—The term 
‘authorized distributor of record’ has the meaning given that 
term in subsection (e)(3)(A) of such section. 
‘‘(3) MANUFACTURER.—The term ‘manufacturer’ has the 
meaning given that term for purposes of subsection (d) of such 
section.’’. 
SEC. 6005. PHARMACY BENEFIT MANAGERS TRANSPARENCY REQUIRE-
MENTS. 
Part A of title XI of the Social Security Act (42 U.S.C. 1301 
et seq.) is amended by inserting after section 1150 the following 
new section: 
‘‘SEC. 
1150A. 
PHARMACY 
BENEFIT 
MANAGERS 
TRANSPARENCY 
REQUIREMENTS. 
‘‘(a) PROVISION OF INFORMATION.—A health benefits plan or 
any entity that provides pharmacy benefits management services 
on behalf of a health benefits plan (in this section referred to 
as a ‘PBM’) that manages prescription drug coverage under a con-
tract with— 
‘‘(1) a PDP sponsor of a prescription drug plan or an MA 
organization offering an MA–PD plan under part D of title 
XVIII; or 
‘‘(2) a qualified health benefits plan offered through an 
exchange established by a State under section 1311 of the 
Patient Protection and Affordable Care Act, 
shall provide the information described in subsection (b) to the 
Secretary and, in the case of a PBM, to the plan with which 
the PBM is under contract with, at such times, and in such form 
and manner, as the Secretary shall specify. 
‘‘(b) INFORMATION DESCRIBED.—The information described in 
this subsection is the following with respect to services provided 
by a health benefits plan or PBM for a contract year: 
‘‘(1) The percentage of all prescriptions that were provided 
through retail pharmacies compared to mail order pharmacies, 
and the percentage of prescriptions for which a generic drug 
was available and dispensed (generic dispensing rate), by phar-
macy type (which includes an independent pharmacy, chain 
pharmacy, supermarket pharmacy, or mass merchandiser phar-
macy that is licensed as a pharmacy by the State and that 
dispenses medication to the general public), that is paid by 
the health benefits plan or PBM under the contract. 
‘‘(2) The aggregate amount, and the type of rebates, dis-
counts, or price concessions (excluding bona fide service fees, 
which include but are not limited to distribution service fees, 
inventory management fees, product stocking allowances, and 
fees associated with administrative services agreements and 
patient care programs (such as medication compliance programs 
42 USC 
1320b–23. 
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124 STAT. 699 
PUBLIC LAW 111–148—MAR. 23, 2010 
and patient education programs)) that the PBM negotiates 
that are attributable to patient utilization under the plan, 
and the aggregate amount of the rebates, discounts, or price 
concessions that are passed through to the plan sponsor, and 
the total number of prescriptions that were dispensed. 
‘‘(3) The aggregate amount of the difference between the 
amount the health benefits plan pays the PBM and the amount 
that the PBM pays retail pharmacies, and mail order phar-
macies, and the total number of prescriptions that were dis-
pensed. 
‘‘(c) CONFIDENTIALITY.—Information disclosed by a health bene-
fits plan or PBM under this section is confidential and shall not 
be disclosed by the Secretary or by a plan receiving the information, 
except that the Secretary may disclose the information in a form 
which does not disclose the identity of a specific PBM, plan, or 
prices charged for drugs, for the following purposes: 
‘‘(1) As the Secretary determines to be necessary to carry 
out this section or part D of title XVIII. 
‘‘(2) To permit the Comptroller General to review the 
information provided. 
‘‘(3) To permit the Director of the Congressional Budget 
Office to review the information provided. 
‘‘(4) To States to carry out section 1311 of the Patient 
Protection and Affordable Care Act. 
‘‘(d) PENALTIES.—The provisions of subsection (b)(3)(C) of sec-
tion 1927 shall apply to a health benefits plan or PBM that fails 
to provide information required under subsection (a) on a timely 
basis or that knowingly provides false information in the same 
manner as such provisions apply to a manufacturer with an agree-
ment under that section.’’. 
Subtitle B—Nursing Home Transparency 
and Improvement 
PART I—IMPROVING TRANSPARENCY OF 
INFORMATION 
SEC. 6101. REQUIRED DISCLOSURE OF OWNERSHIP AND ADDITIONAL 
DISCLOSABLE PARTIES INFORMATION. 
(a) IN GENERAL.—Section 1124 of the Social Security Act (42 
U.S.C. 1320a–3) is amended by adding at the end the following 
new subsection: 
‘‘(c) REQUIRED DISCLOSURE
OF OWNERSHIP
AND ADDITIONAL 
DISCLOSABLE PARTIES INFORMATION.— 
‘‘(1) DISCLOSURE.—A facility shall have the information 
described in paragraph (2) available— 
‘‘(A) during the period beginning on the date of the 
enactment of this subsection and ending on the date such 
information is made available to the public under section 
6101(b) of the Patient Protection and Affordable Care Act 
for submission to the Secretary, the Inspector General of 
the Department of Health and Human Services, the State 
in which the facility is located, and the State long-term 
care ombudsman in the case where the Secretary, the 
Time period. 
Applicability. 
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124 STAT. 700 
PUBLIC LAW 111–148—MAR. 23, 2010 
Inspector General, the State, or the State long-term care 
ombudsman requests such information; and 
‘‘(B) beginning on the effective date of the final regula-
tions promulgated under paragraph (3)(A), for reporting 
such information in accordance with such final regulations. 
Nothing in subparagraph (A) shall be construed as authorizing 
a facility to dispose of or delete information described in such 
subparagraph after the effective date of the final regulations 
promulgated under paragraph (3)(A). 
‘‘(2) INFORMATION DESCRIBED.— 
‘‘(A) IN
GENERAL.—The following information is 
described in this paragraph: 
‘‘(i) The information described in subsections (a) 
and (b), subject to subparagraph (C). 
‘‘(ii) The identity of and information on— 
‘‘(I) each member of the governing body of 
the facility, including the name, title, and period 
of service of each such member; 
‘‘(II) each person or entity who is an officer, 
director, member, partner, trustee, or managing 
employee of the facility, including the name, title, 
and period of service of each such person or entity; 
and 
‘‘(III) each person or entity who is an addi-
tional disclosable party of the facility. 
‘‘(iii) The organizational structure of each addi-
tional disclosable party of the facility and a description 
of the relationship of each such additional disclosable 
party to the facility and to one another. 
‘‘(B) SPECIAL RULE WHERE INFORMATION IS ALREADY 
REPORTED OR SUBMITTED.—To the extent that information 
reported by a facility to the Internal Revenue Service on 
Form 990, information submitted by a facility to the Securi-
ties and Exchange Commission, or information otherwise 
submitted to the Secretary or any other Federal agency 
contains the information described in clauses (i), (ii), or 
(iii) of subparagraph (A), the facility may provide such 
Form or such information submitted to meet the require-
ments of paragraph (1). 
‘‘(C) SPECIAL RULE.—In applying subparagraph (A)(i)— 
‘‘(i) with respect to subsections (a) and (b), ‘owner-
ship or control interest’ shall include direct or indirect 
interests, including such interests in intermediate enti-
ties; and 
‘‘(ii) subsection (a)(3)(A)(ii) shall include the owner 
of a whole or part interest in any mortgage, deed 
of trust, note, or other obligation secured, in whole 
or in part, by the entity or any of the property or 
assets thereof, if the interest is equal to or exceeds 
5 percent of the total property or assets of the entirety. 
‘‘(3) REPORTING.— 
‘‘(A) IN
GENERAL.—Not later than the date that is 
2 years after the date of the enactment of this subsection, 
the Secretary shall promulgate final regulations requiring, 
effective on the date that is 90 days after the date on 
which such final regulations are published in the Federal 
Register, a facility to report the information described in 
Regulations. 
Effective date. 
Federal Register, 
publication. 
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124 STAT. 701 
PUBLIC LAW 111–148—MAR. 23, 2010 
paragraph (2) to the Secretary in a standardized format, 
and such other regulations as are necessary to carry out 
this subsection. Such final regulations shall ensure that 
the facility certifies, as a condition of participation and 
payment under the program under title XVIII or XIX, 
that the information reported by the facility in accordance 
with such final regulations is, to the best of the facility’s 
knowledge, accurate and current. 
‘‘(B) GUIDANCE.—The Secretary shall provide guidance 
and technical assistance to States on how to adopt the 
standardized format under subparagraph (A). 
‘‘(4) NO EFFECT ON EXISTING REPORTING REQUIREMENTS.— 
Nothing in this subsection shall reduce, diminish, or alter any 
reporting requirement for a facility that is in effect as of the 
date of the enactment of this subsection. 
‘‘(5) DEFINITIONS.—In this subsection: 
‘‘(A) ADDITIONAL DISCLOSABLE PARTY.—The term ‘addi-
tional disclosable party’ means, with respect to a facility, 
any person or entity who— 
‘‘(i) exercises operational, financial, or managerial 
control over the facility or a part thereof, or provides 
policies or procedures for any of the operations of the 
facility, or provides financial or cash management serv-
ices to the facility; 
‘‘(ii) leases or subleases real property to the facility, 
or owns a whole or part interest equal to or exceeding 
5 percent of the total value of such real property; 
or 
‘‘(iii) provides management or administrative serv-
ices, management or clinical consulting services, or 
accounting or financial services to the facility. 
‘‘(B) FACILITY.—The term ‘facility’ means a disclosing 
entity which is— 
‘‘(i) a skilled nursing facility (as defined in section 
1819(a)); or 
‘‘(ii) a nursing facility (as defined in section 
1919(a)). 
‘‘(C) MANAGING
EMPLOYEE.—The term ‘managing 
employee’ means, with respect to a facility, an individual 
(including a general manager, business manager, adminis-
trator, director, or consultant) who directly or indirectly 
manages, advises, or supervises any element of the prac-
tices, finances, or operations of the facility. 
‘‘(D) ORGANIZATIONAL STRUCTURE.—The term ‘organiza-
tional structure’ means, in the case of— 
‘‘(i) a corporation, the officers, directors, and share-
holders of the corporation who have an ownership 
interest in the corporation which is equal to or exceeds 
5 percent; 
‘‘(ii) a limited liability company, the members and 
managers of the limited liability company (including, 
as applicable, what percentage each member and man-
ager has of the ownership interest in the limited 
liability company); 
‘‘(iii) a general partnership, the partners of the 
general partnership; 
Certification. 
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124 STAT. 702 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(iv) a limited partnership, the general partners 
and any limited partners of the limited partnership 
who have an ownership interest in the limited partner-
ship which is equal to or exceeds 10 percent; 
‘‘(v) a trust, the trustees of the trust; 
‘‘(vi) an individual, contact information for the indi-
vidual; and 
‘‘(vii) any other person or entity, such information 
as the Secretary determines appropriate.’’. 
(b) PUBLIC AVAILABILITY OF INFORMATION.—Not later than the 
date that is 1 year after the date on which the final regulations 
promulgated under section 1124(c)(3)(A) of the Social Security Act, 
as added by subsection (a), are published in the Federal Register, 
the Secretary of Health and Human Services shall make the 
information reported in accordance with such final regulations avail-
able to the public in accordance with procedures established by 
the Secretary. 
(c) CONFORMING AMENDMENTS.— 
(1) IN GENERAL.— 
(A) SKILLED NURSING FACILITIES.—Section 1819(d)(1) 
of the Social Security Act (42 U.S.C. 1395i–3(d)(1)) is 
amended by striking subparagraph (B) and redesignating 
subparagraph (C) as subparagraph (B). 
(B) NURSING
FACILITIES.—Section 1919(d)(1) of the 
Social Security Act (42 U.S.C. 1396r(d)(1)) is amended by 
striking subparagraph (B) and redesignating subparagraph 
(C) as subparagraph (B). 
(2) EFFECTIVE DATE.—The amendments made by paragraph 
(1) shall take effect on the date on which the Secretary makes 
the information described in subsection (b)(1) available to the 
public under such subsection. 
SEC. 6102. ACCOUNTABILITY REQUIREMENTS FOR SKILLED NURSING 
FACILITIES AND NURSING FACILITIES. 
Part A of title XI of the Social Security Act (42 U.S.C. 1301 
et seq.), as amended by sections 6002 and 6004, is amended by 
inserting after section 1128H the following new section: 
‘‘SEC. 1128I. ACCOUNTABILITY REQUIREMENTS FOR FACILITIES. 
‘‘(a) DEFINITION OF FACILITY.—In this section, the term ‘facility’ 
means— 
‘‘(1) a skilled nursing facility (as defined in section 1819(a)); 
or 
‘‘(2) a nursing facility (as defined in section 1919(a)). 
‘‘(b) EFFECTIVE COMPLIANCE AND ETHICS PROGRAMS.— 
‘‘(1) REQUIREMENT.—On or after the date that is 36 months 
after the date of the enactment of this section, a facility shall, 
with respect to the entity that operates the facility (in this 
subparagraph referred to as the ‘operating organization’ or 
‘organization’), have in operation a compliance and ethics pro-
gram that is effective in preventing and detecting criminal, 
civil, and administrative violations under this Act and in pro-
moting quality of care consistent with regulations developed 
under paragraph (2). 
‘‘(2) DEVELOPMENT OF REGULATIONS.— 
‘‘(A) IN
GENERAL.—Not later than the date that is 
2 years after such date of the enactment, the Secretary, 
Deadlines. 
Effective date. 
42 USC 
1320a–7j. 
42 USC 
1395i–3 note. 
Deadline. 
Procedures. 
42 USC 
1320a–3 note. 
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124 STAT. 703 
PUBLIC LAW 111–148—MAR. 23, 2010 
working jointly with the Inspector General of the Depart-
ment of Health and Human Services, shall promulgate 
regulations for an effective compliance and ethics program 
for operating organizations, which may include a model 
compliance program. 
‘‘(B) DESIGN OF REGULATIONS.—Such regulations with 
respect to specific elements or formality of a program shall, 
in the case of an organization that operates 5 or more 
facilities, vary with the size of the organization, such that 
larger organizations should have a more formal program 
and include established written policies defining the stand-
ards and procedures to be followed by its employees. Such 
requirements may specifically apply to the corporate level 
management of multi unit nursing home chains. 
‘‘(C) EVALUATION.—Not later than 3 years after the 
date of the promulgation of regulations under this para-
graph, the Secretary shall complete an evaluation of the 
compliance and ethics programs required to be established 
under this subsection. Such evaluation shall determine if 
such programs led to changes in deficiency citations, 
changes in quality performance, or changes in other metrics 
of patient quality of care. The Secretary shall submit to 
Congress a report on such evaluation and shall include 
in such report such recommendations regarding changes 
in the requirements for such programs as the Secretary 
determines appropriate. 
‘‘(3) REQUIREMENTS
FOR
COMPLIANCE
AND
ETHICS
PRO-
GRAMS.—In this subsection, the term ‘compliance and ethics 
program’ means, with respect to a facility, a program of the 
operating organization that— 
‘‘(A) has been reasonably designed, implemented, and 
enforced so that it generally will be effective in preventing 
and detecting criminal, civil, and administrative violations 
under this Act and in promoting quality of care; and 
‘‘(B) includes at least the required components specified 
in paragraph (4). 
‘‘(4) REQUIRED COMPONENTS OF PROGRAM.—The required 
components of a compliance and ethics program of an operating 
organization are the following: 
‘‘(A) The organization must have established compli-
ance standards and procedures to be followed by its 
employees and other agents that are reasonably capable 
of reducing the prospect of criminal, civil, and administra-
tive violations under this Act. 
‘‘(B) Specific individuals within high-level personnel 
of the organization must have been assigned overall respon-
sibility to oversee compliance with such standards and 
procedures and have sufficient resources and authority to 
assure such compliance. 
‘‘(C) The organization must have used due care not 
to delegate substantial discretionary authority to individ-
uals whom the organization knew, or should have known 
through the exercise of due diligence, had a propensity 
to engage in criminal, civil, and administrative violations 
under this Act. 
‘‘(D) The organization must have taken steps to commu-
nicate effectively its standards and procedures to all 
Definition. 
Reports. 
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124 STAT. 704 
PUBLIC LAW 111–148—MAR. 23, 2010 
employees and other agents, such as by requiring participa-
tion in training programs or by disseminating publications 
that explain in a practical manner what is required. 
‘‘(E) The organization must have taken reasonable 
steps to achieve compliance with its standards, such as 
by utilizing monitoring and auditing systems reasonably 
designed to detect criminal, civil, and administrative viola-
tions under this Act by its employees and other agents 
and by having in place and publicizing a reporting system 
whereby employees and other agents could report violations 
by others within the organization without fear of retribu-
tion. 
‘‘(F) The standards must have been consistently 
enforced through appropriate disciplinary mechanisms, 
including, as appropriate, discipline of individuals respon-
sible for the failure to detect an offense. 
‘‘(G) After an offense has been detected, the organiza-
tion must have taken all reasonable steps to respond appro-
priately to the offense and to prevent further similar 
offenses, including any necessary modification to its pro-
gram to prevent and detect criminal, civil, and administra-
tive violations under this Act. 
‘‘(H) The organization must periodically undertake 
reassessment of its compliance program to identify changes 
necessary to reflect changes within the organization and 
its facilities. 
‘‘(c) QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT PRO-
GRAM.— 
‘‘(1) IN GENERAL.—Not later than December 31, 2011, the 
Secretary shall establish and implement a quality assurance 
and performance improvement program (in this subparagraph 
referred to as the ‘QAPI program’) for facilities, including multi 
unit chains of facilities. Under the QAPI program, the Secretary 
shall establish standards relating to quality assurance and 
performance improvement with respect to facilities and provide 
technical assistance to facilities on the development of best 
practices in order to meet such standards. Not later than 1 
year after the date on which the regulations are promulgated 
under paragraph (2), a facility must submit to the Secretary 
a plan for the facility to meet such standards and implement 
such 
best 
practices, 
including 
how 
to 
coordinate 
the 
implementation of such plan with quality assessment and 
assurance activities conducted under sections 1819(b)(1)(B) and 
1919(b)(1)(B), as applicable. 
‘‘(2) REGULATIONS.—The Secretary shall promulgate regula-
tions to carry out this subsection.’’. 
SEC. 6103. NURSING HOME COMPARE MEDICARE WEBSITE. 
(a) SKILLED NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1819 of the Social Security Act 
(42 U.S.C. 1395i–3) is amended— 
(A) by redesignating subsection (i) as subsection (j); 
and 
(B) by inserting after subsection (h) the following new 
subsection: 
‘‘(i) NURSING HOME COMPARE WEBSITE.— 
‘‘(1) INCLUSION OF ADDITIONAL INFORMATION.— 
Plans. 
Standards. 
Deadlines. 
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124 STAT. 705 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) IN GENERAL.—The Secretary shall ensure that the 
Department of Health and Human Services includes, as 
part of the information provided for comparison of nursing 
homes on the official Internet website of the Federal 
Government for Medicare beneficiaries (commonly referred 
to as the ‘Nursing Home Compare’ Medicare website) (or 
a successor website), the following information in a manner 
that is prominent, updated on a timely basis, easily acces-
sible, readily understandable to consumers of long-term 
care services, and searchable: 
‘‘(i) Staffing data for each facility (including resi-
dent census data and data on the hours of care pro-
vided per resident per day) based on data submitted 
under section 1128I(g), including information on 
staffing turnover and tenure, in a format that is clearly 
understandable to consumers of long-term care services 
and allows such consumers to compare differences in 
staffing between facilities and State and national aver-
ages for the facilities. Such format shall include— 
‘‘(I) concise explanations of how to interpret 
the data (such as a plain English explanation of 
data reflecting ‘nursing home staff hours per resi-
dent day’); 
‘‘(II) differences in types of staff (such as 
training associated with different categories of 
staff); 
‘‘(III) the relationship between nurse staffing 
levels and quality of care; and 
‘‘(IV) an explanation that appropriate staffing 
levels vary based on patient case mix. 
‘‘(ii) Links to State Internet websites with informa-
tion regarding State survey and certification programs, 
links to Form 2567 State inspection reports (or a suc-
cessor form) on such websites, information to guide 
consumers in how to interpret and understand such 
reports, and the facility plan of correction or other 
response to such report. Any such links shall be posted 
on a timely basis. 
‘‘(iii) The standardized complaint form developed 
under section 1128I(f), including explanatory material 
on what complaint forms are, how they are used, and 
how to file a complaint with the State survey and 
certification program and the State long-term care 
ombudsman program. 
‘‘(iv) Summary information on the number, type, 
severity, and outcome of substantiated complaints. 
‘‘(v) The number of adjudicated instances of 
criminal violations by a facility or the employees of 
a facility— 
‘‘(I) that were committed inside the facility; 
‘‘(II) with respect to such instances of viola-
tions or crimes committed inside of the facility 
that were the violations or crimes of abuse, neglect, 
and exploitation, criminal sexual abuse, or other 
violations or crimes that resulted in serious bodily 
injury; and 
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124 STAT. 706 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(III) the number of civil monetary penalties 
levied against the facility, employees, contractors, 
and other agents. 
‘‘(B) DEADLINE FOR PROVISION OF INFORMATION.— 
‘‘(i) IN
GENERAL.—Except as provided in clause 
(ii), the Secretary shall ensure that the information 
described in subparagraph (A) is included on such 
website (or a successor website) not later than 1 year 
after the date of the enactment of this subsection. 
‘‘(ii) EXCEPTION.—The Secretary shall ensure that 
the information described in subparagraph (A)(i) is 
included on such website (or a successor website) not 
later than the date on which the requirements under 
section 1128I(g) are implemented. 
‘‘(2) REVIEW AND MODIFICATION OF WEBSITE.— 
‘‘(A) IN
GENERAL.—The Secretary shall establish a 
process— 
‘‘(i) to review the accuracy, clarity of presentation, 
timeliness, and comprehensiveness of information 
reported on such website as of the day before the 
date of the enactment of this subsection; and 
‘‘(ii) not later than 1 year after the date of the 
enactment of this subsection, to modify or revamp such 
website in accordance with the review conducted under 
clause (i). 
‘‘(B) CONSULTATION.—In conducting the review under 
subparagraph (A)(i), the Secretary shall consult with— 
‘‘(i) State long-term care ombudsman programs; 
‘‘(ii) consumer advocacy groups; 
‘‘(iii) provider stakeholder groups; and 
‘‘(iv) any other representatives of programs or 
groups the Secretary determines appropriate.’’. 
(2) TIMELINESS OF SUBMISSION OF SURVEY AND CERTIFI-
CATION INFORMATION.— 
(A) IN GENERAL.—Section 1819(g)(5) of the Social Secu-
rity Act (42 U.S.C. 1395i–3(g)(5)) is amended by adding 
at the end the following new subparagraph: 
‘‘(E) SUBMISSION
OF
SURVEY
AND
CERTIFICATION 
INFORMATION TO THE SECRETARY.—In order to improve the 
timeliness of information made available to the public 
under subparagraph (A) and provided on the Nursing Home 
Compare Medicare website under subsection (i), each State 
shall submit information respecting any survey or certifi-
cation made respecting a skilled nursing facility (including 
any enforcement actions taken by the State) to the Sec-
retary not later than the date on which the State sends 
such information to the facility. The Secretary shall use 
the information submitted under the preceding sentence 
to update the information provided on the Nursing Home 
Compare Medicare website as expeditiously as practicable 
but not less frequently than quarterly.’’. 
(B) EFFECTIVE DATE.—The amendment made by this 
paragraph shall take effect 1 year after the date of the 
enactment of this Act. 
(3) SPECIAL FOCUS FACILITY PROGRAM.—Section 1819(f) of 
the Social Security Act (42 U.S.C. 1395i–3(f)) is amended by 
adding at the end the following new paragraph: 
42 USC 
1395i–3 note. 
Deadline. 
Procedures. 
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124 STAT. 707 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(8) SPECIAL FOCUS FACILITY PROGRAM.— 
‘‘(A) IN GENERAL.—The Secretary shall conduct a spe-
cial focus facility program for enforcement of requirements 
for skilled nursing facilities that the Secretary has identi-
fied as having substantially failed to meet applicable 
requirement of this Act. 
‘‘(B) PERIODIC SURVEYS.—Under such program the Sec-
retary shall conduct surveys of each facility in the program 
not less than once every 6 months.’’. 
(b) NURSING FACILITIES.— 
(1) IN GENERAL.—Section 1919 of the Social Security Act 
(42 U.S.C. 1396r) is amended— 
(A) by redesignating subsection (i) as subsection (j); 
and 
(B) by inserting after subsection (h) the following new 
subsection: 
‘‘(i) NURSING HOME COMPARE WEBSITE.— 
‘‘(1) INCLUSION OF ADDITIONAL INFORMATION.— 
‘‘(A) IN GENERAL.—The Secretary shall ensure that the 
Department of Health and Human Services includes, as 
part of the information provided for comparison of nursing 
homes on the official Internet website of the Federal 
Government for Medicare beneficiaries (commonly referred 
to as the ‘Nursing Home Compare’ Medicare website) (or 
a successor website), the following information in a manner 
that is prominent, updated on a timely basis, easily acces-
sible, readily understandable to consumers of long-term 
care services, and searchable: 
‘‘(i) Staffing data for each facility (including resi-
dent census data and data on the hours of care pro-
vided per resident per day) based on data submitted 
under section 1128I(g), including information on 
staffing turnover and tenure, in a format that is clearly 
understandable to consumers of long-term care services 
and allows such consumers to compare differences in 
staffing between facilities and State and national aver-
ages for the facilities. Such format shall include— 
‘‘(I) concise explanations of how to interpret 
the data (such as plain English explanation of 
data reflecting ‘nursing home staff hours per resi-
dent day’); 
‘‘(II) differences in types of staff (such as 
training associated with different categories of 
staff); 
‘‘(III) the relationship between nurse staffing 
levels and quality of care; and 
‘‘(IV) an explanation that appropriate staffing 
levels vary based on patient case mix. 
‘‘(ii) Links to State Internet websites with informa-
tion regarding State survey and certification programs, 
links to Form 2567 State inspection reports (or a suc-
cessor form) on such websites, information to guide 
consumers in how to interpret and understand such 
reports, and the facility plan of correction or other 
response to such report. Any such links shall be posted 
on a timely basis. 
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124 STAT. 708 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(iii) The standardized complaint form developed 
under section 1128I(f), including explanatory material 
on what complaint forms are, how they are used, and 
how to file a complaint with the State survey and 
certification program and the State long-term care 
ombudsman program. 
‘‘(iv) Summary information on the number, type, 
severity, and outcome of substantiated complaints. 
‘‘(v) The number of adjudicated instances of 
criminal violations by a facility or the employees of 
a facility— 
‘‘(I) that were committed inside of the facility; 
and 
‘‘(II) with respect to such instances of viola-
tions or crimes committed outside of the facility, 
that were violations or crimes that resulted in 
the serious bodily injury of an elder. 
‘‘(B) DEADLINE FOR PROVISION OF INFORMATION.— 
‘‘(i) IN
GENERAL.—Except as provided in clause 
(ii), the Secretary shall ensure that the information 
described in subparagraph (A) is included on such 
website (or a successor website) not later than 1 year 
after the date of the enactment of this subsection. 
‘‘(ii) EXCEPTION.—The Secretary shall ensure that 
the information described in subparagraph (A)(i) is 
included on such website (or a successor website) not 
later than the date on which the requirements under 
section 1128I(g) are implemented. 
‘‘(2) REVIEW AND MODIFICATION OF WEBSITE.— 
‘‘(A) IN
GENERAL.—The Secretary shall establish a 
process— 
‘‘(i) to review the accuracy, clarity of presentation, 
timeliness, and comprehensiveness of information 
reported on such website as of the day before the 
date of the enactment of this subsection; and 
‘‘(ii) not later than 1 year after the date of the 
enactment of this subsection, to modify or revamp such 
website in accordance with the review conducted under 
clause (i). 
‘‘(B) CONSULTATION.—In conducting the review under 
subparagraph (A)(i), the Secretary shall consult with— 
‘‘(i) State long-term care ombudsman programs; 
‘‘(ii) consumer advocacy groups; 
‘‘(iii) provider stakeholder groups; 
‘‘(iv) skilled nursing facility employees and their 
representatives; and 
‘‘(v) any other representatives of programs or 
groups the Secretary determines appropriate.’’. 
(2) TIMELINESS OF SUBMISSION OF SURVEY AND CERTIFI-
CATION INFORMATION.— 
(A) IN GENERAL.—Section 1919(g)(5) of the Social Secu-
rity Act (42 U.S.C. 1396r(g)(5)) is amended by adding at 
the end the following new subparagraph: 
‘‘(E) SUBMISSION
OF
SURVEY
AND
CERTIFICATION 
INFORMATION TO THE SECRETARY.—In order to improve the 
timeliness of information made available to the public 
under subparagraph (A) and provided on the Nursing Home 
Deadline. 
Deadline. 
Procedures. 
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124 STAT. 709 
PUBLIC LAW 111–148—MAR. 23, 2010 
Compare Medicare website under subsection (i), each State 
shall submit information respecting any survey or certifi-
cation made respecting a nursing facility (including any 
enforcement actions taken by the State) to the Secretary 
not later than the date on which the State sends such 
information to the facility. The Secretary shall use the 
information submitted under the preceding sentence to 
update the information provided on the Nursing Home 
Compare Medicare website as expeditiously as practicable 
but not less frequently than quarterly.’’. 
(B) EFFECTIVE DATE.—The amendment made by this 
paragraph shall take effect 1 year after the date of the 
enactment of this Act. 
(3) SPECIAL FOCUS FACILITY PROGRAM.—Section 1919(f) of 
the Social Security Act (42 U.S.C. 1396r(f)) is amended by 
adding at the end of the following new paragraph: 
‘‘(10) SPECIAL FOCUS FACILITY PROGRAM.— 
‘‘(A) IN GENERAL.—The Secretary shall conduct a spe-
cial focus facility program for enforcement of requirements 
for nursing facilities that the Secretary has identified as 
having substantially failed to meet applicable requirements 
of this Act. 
‘‘(B) PERIODIC SURVEYS.—Under such program the Sec-
retary shall conduct surveys of each facility in the program 
not less often than once every 6 months.’’. 
(c) AVAILABILITY OF REPORTS ON SURVEYS, CERTIFICATIONS, AND 
COMPLAINT INVESTIGATIONS.— 
(1) SKILLED NURSING FACILITIES.—Section 1819(d)(1) of the 
Social Security Act (42 U.S.C. 1395i–3(d)(1)), as amended by 
section 6101, is amended by adding at the end the following 
new subparagraph: 
‘‘(C) AVAILABILITY OF SURVEY, CERTIFICATION, AND COM-
PLAINT INVESTIGATION REPORTS.—A skilled nursing facility 
must— 
‘‘(i) have reports with respect to any surveys, cer-
tifications, 
and 
complaint 
investigations 
made 
respecting the facility during the 3 preceding years 
available for any individual to review upon request; 
and 
‘‘(ii) post notice of the availability of such reports 
in areas of the facility that are prominent and acces-
sible to the public. 
The facility shall not make available under clause (i) identi-
fying information about complainants or residents.’’. 
(2) NURSING FACILITIES.—Section 1919(d)(1) of the Social 
Security Act (42 U.S.C. 1396r(d)(1)), as amended by section 
6101, is amended by adding at the end the following new 
subparagraph: 
‘‘(V) AVAILABILITY OF SURVEY, CERTIFICATION, AND COM-
PLAINT INVESTIGATION REPORTS.—A nursing facility must— 
‘‘(i) have reports with respect to any surveys, cer-
tifications, 
and 
complaint 
investigations 
made 
respecting the facility during the 3 preceding years 
available for any individual to review upon request; 
and 
Public 
information. 
42 USC 
1396r note. 
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124 STAT. 710 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(ii) post notice of the availability of such reports 
in areas of the facility that are prominent and acces-
sible to the public. 
The facility shall not make available under clause (i) identi-
fying information about complainants or residents.’’. 
(3) EFFECTIVE DATE.—The amendments made by this sub-
section shall take effect 1 year after the date of the enactment 
of this Act. 
(d) GUIDANCE TO STATES ON FORM 2567 STATE INSPECTION 
REPORTS AND COMPLAINT INVESTIGATION REPORTS.— 
(1) GUIDANCE.—The Secretary of Health and Human Serv-
ices (in this subtitle referred to as the ‘‘Secretary’’) shall provide 
guidance to States on how States can establish electronic links 
to Form 2567 State inspection reports (or a successor form), 
complaint investigation reports, and a facility’s plan of correc-
tion or other response to such Form 2567 State inspection 
reports (or a successor form) on the Internet website of the 
State that provides information on skilled nursing facilities 
and nursing facilities and the Secretary shall, if possible, 
include such information on Nursing Home Compare. 
(2) REQUIREMENT.—Section 1902(a)(9) of the Social Security 
Act (42 U.S.C. 1396a(a)(9)) is amended— 
(A) by striking ‘‘and’’ at the end of subparagraph (B); 
(B) by striking the semicolon at the end of subpara-
graph (C) and inserting ‘‘, and’’; and 
(C) by adding at the end the following new subpara-
graph: 
‘‘(D) that the State maintain a consumer-oriented 
website 
providing 
useful 
information 
to 
consumers 
regarding all skilled nursing facilities and all nursing facili-
ties in the State, including for each facility, Form 2567 
State inspection reports (or a successor form), complaint 
investigation reports, the facility’s plan of correction, and 
such other information that the State or the Secretary 
considers useful in assisting the public to assess the quality 
of long term care options and the quality of care provided 
by individual facilities;’’. 
(3) DEFINITIONS.—In this subsection: 
(A) NURSING FACILITY.—The term ‘‘nursing facility’’ has 
the meaning given such term in section 1919(a) of the 
Social Security Act (42 U.S.C. 1396r(a)). 
(B) SECRETARY.—The term ‘‘Secretary’’ means the Sec-
retary of Health and Human Services. 
(C) SKILLED
NURSING
FACILITY.—The term ‘‘skilled 
nursing facility’’ has the meaning given such term in sec-
tion 1819(a) of the Social Security Act (42 U.S.C. 1395i– 
3(a)). 
(e) DEVELOPMENT OF CONSUMER RIGHTS INFORMATION PAGE 
ON NURSING HOME COMPARE WEBSITE.—Not later than 1 year 
after the date of enactment of this Act, the Secretary shall ensure 
that the Department of Health and Human Services, as part of 
the information provided for comparison of nursing facilities on 
the Nursing Home Compare Medicare website develops and includes 
a consumer rights information page that contains links to descrip-
tions of, and information with respect to, the following: 
(1) The documentation on nursing facilities that is available 
to the public. 
42 USC 
1395i–3 note. 
Deadline. 
42 USC 
1395i–3 note. 
42 USC 
1395i–3 note. 
Web posting. 
42 USC 
1395i–3 note. 
Public 
information. 
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124 STAT. 711 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) General information and tips on choosing a nursing 
facility that meets the needs of the individual. 
(3) General information on consumer rights with respect 
to nursing facilities. 
(4) The nursing facility survey process (on a national and 
State-specific basis). 
(5) On a State-specific basis, the services available through 
the State long-term care ombudsman for such State. 
SEC. 6104. REPORTING OF EXPENDITURES. 
Section 1888 of the Social Security Act (42 U.S.C. 1395yy) 
is amended by adding at the end the following new subsection: 
‘‘(f) REPORTING OF DIRECT CARE EXPENDITURES.— 
‘‘(1) IN GENERAL.—For cost reports submitted under this 
title for cost reporting periods beginning on or after the date 
that is 2 years after the date of the enactment of this subsection, 
skilled nursing facilities shall separately report expenditures 
for wages and benefits for direct care staff (breaking out (at 
a minimum) registered nurses, licensed professional nurses, 
certified nurse assistants, and other medical and therapy staff). 
‘‘(2) MODIFICATION OF FORM.—The Secretary, in consulta-
tion with private sector accountants experienced with Medicare 
and Medicaid nursing facility home cost reports, shall redesign 
such reports to meet the requirement of paragraph (1) not 
later than 1 year after the date of the enactment of this sub-
section. 
‘‘(3) CATEGORIZATION BY FUNCTIONAL ACCOUNTS.—Not later 
than 30 months after the date of the enactment of this sub-
section, the Secretary, working in consultation with the Medi-
care Payment Advisory Commission, the Medicaid and CHIP 
Payment and Access Commission, the Inspector General of 
the Department of Health and Human Services, and other 
expert parties the Secretary determines appropriate, shall take 
the expenditures listed on cost reports, as modified under para-
graph (1), submitted by skilled nursing facilities and categorize 
such expenditures, regardless of any source of payment for 
such expenditures, for each skilled nursing facility into the 
following functional accounts on an annual basis: 
‘‘(A) Spending on direct care services (including 
nursing, therapy, and medical services). 
‘‘(B) Spending on indirect care (including housekeeping 
and dietary services). 
‘‘(C) Capital assets (including building and land costs). 
‘‘(D) Administrative services costs. 
‘‘(4) AVAILABILITY OF INFORMATION SUBMITTED.—The Sec-
retary shall establish procedures to make information on 
expenditures submitted under this subsection readily available 
to interested parties upon request, subject to such requirements 
as the Secretary may specify under the procedures established 
under this paragraph.’’. 
SEC. 6105. STANDARDIZED COMPLAINT FORM. 
(a) IN GENERAL.—Section 1128I of the Social Security Act, 
as added and amended by this Act, is amended by adding at 
the end the following new subsection: 
‘‘(f) STANDARDIZED COMPLAINT FORM.— 
‘‘(1) DEVELOPMENT BY THE SECRETARY.—The Secretary shall 
develop a standardized complaint form for use by a resident 
42 USC 
1320a–7j. 
Procedures. 
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124 STAT. 712 
PUBLIC LAW 111–148—MAR. 23, 2010 
(or a person acting on the resident’s behalf) in filing a complaint 
with a State survey and certification agency and a State long- 
term care ombudsman program with respect to a facility. 
‘‘(2) COMPLAINT FORMS AND RESOLUTION PROCESSES.— 
‘‘(A) COMPLAINT
FORMS.—The State must make the 
standardized complaint form developed under paragraph 
(1) available upon request to— 
‘‘(i) a resident of a facility; and 
‘‘(ii) any person acting on the resident’s behalf. 
‘‘(B) COMPLAINT RESOLUTION PROCESS.—The State must 
establish a complaint resolution process in order to ensure 
that the legal representative of a resident of a facility 
or other responsible party is not denied access to such 
resident or otherwise retaliated against if they have com-
plained about the quality of care provided by the facility 
or other issues relating to the facility. Such complaint 
resolution process shall include— 
‘‘(i) procedures to assure accurate tracking of com-
plaints received, including notification to the complain-
ant that a complaint has been received; 
‘‘(ii) procedures to determine the likely severity 
of a complaint and for the investigation of the com-
plaint; and 
‘‘(iii) deadlines for responding to a complaint and 
for notifying the complainant of the outcome of the 
investigation. 
‘‘(3) RULE OF CONSTRUCTION.—Nothing in this subsection 
shall be construed as preventing a resident of a facility (or 
a person acting on the resident’s behalf) from submitting a 
complaint in a manner or format other than by using the 
standardized complaint form developed under paragraph (1) 
(including submitting a complaint orally).’’. 
(b) EFFECTIVE DATE.—The amendment made by this section 
shall take effect 1 year after the date of the enactment of this 
Act. 
SEC. 6106. ENSURING STAFFING ACCOUNTABILITY. 
Section 1128I of the Social Security Act, as added and amended 
by this Act, is amended by adding at the end the following new 
subsection: 
‘‘(g) SUBMISSION OF STAFFING INFORMATION BASED ON PAYROLL 
DATA IN A UNIFORM FORMAT.—Beginning not later than 2 years 
after the date of the enactment of this subsection, and after con-
sulting with State long-term care ombudsman programs, consumer 
advocacy groups, provider stakeholder groups, employees and their 
representatives, and other parties the Secretary deems appropriate, 
the Secretary shall require a facility to electronically submit to 
the Secretary direct care staffing information (including information 
with respect to agency and contract staff) based on payroll and 
other verifiable and auditable data in a uniform format (according 
to specifications established by the Secretary in consultation with 
such programs, groups, and parties). Such specifications shall 
require that the information submitted under the preceding sen-
tence— 
‘‘(1) specify the category of work a certified employee per-
forms (such as whether the employee is a registered nurse, 
Deadline. 
42 USC 
1320a–7j. 
42 USC 
1320a–7j note. 
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124 STAT. 713 
PUBLIC LAW 111–148—MAR. 23, 2010 
licensed practical nurse, licensed vocational nurse, certified 
nursing assistant, therapist, or other medical personnel); 
‘‘(2) include resident census data and information on resi-
dent case mix; 
‘‘(3) include a regular reporting schedule; and 
‘‘(4) include information on employee turnover and tenure 
and on the hours of care provided by each category of certified 
employees referenced in paragraph (1) per resident per day. 
Nothing in this subsection shall be construed as preventing the 
Secretary from requiring submission of such information with 
respect to specific categories, such as nursing staff, before other 
categories of certified employees. Information under this subsection 
with respect to agency and contract staff shall be kept separate 
from information on employee staffing.’’. 
SEC. 6107. GAO STUDY AND REPORT ON FIVE-STAR QUALITY RATING 
SYSTEM. 
(a) STUDY.—The Comptroller General of the United States (in 
this section referred to as the ‘‘Comptroller General’’) shall conduct 
a study on the Five-Star Quality Rating System for nursing homes 
of the Centers for Medicare & Medicaid Services. Such study shall 
include an analysis of— 
(1) how such system is being implemented; 
(2) any problems associated with such system or its 
implementation; and 
(3) how such system could be improved. 
(b) REPORT.—Not later than 2 years after the date of enactment 
of this Act, the Comptroller General shall submit to Congress a 
report containing the results of the study conducted under sub-
section (a), together with recommendations for such legislation and 
administrative action as the Comptroller General determines appro-
priate. 
PART II—TARGETING ENFORCEMENT 
SEC. 6111. CIVIL MONEY PENALTIES. 
(a) SKILLED NURSING FACILITIES.— 
(1) IN
GENERAL.—Section 1819(h)(2)(B)(ii) of the Social 
Security Act (42 U.S.C. 1395i–3(h)(2)(B)(ii)) is amended— 
(A) by striking ‘‘PENALTIES.—The Secretary’’ and 
inserting ‘‘PENALTIES.— 
‘‘(I) IN
GENERAL.—Subject to subclause (II), 
the Secretary’’; and 
(B) by adding at the end the following new subclauses: 
‘‘(II) REDUCTION
OF
CIVIL
MONEY
PENALTIES 
IN CERTAIN CIRCUMSTANCES.—Subject to subclause 
(III), in the case where a facility self-reports and 
promptly corrects a deficiency for which a penalty 
was imposed under this clause not later than 10 
calendar days after the date of such imposition, 
the Secretary may reduce the amount of the pen-
alty imposed by not more than 50 percent. 
‘‘(III) PROHIBITIONS ON REDUCTION FOR CER-
TAIN DEFICIENCIES.— 
‘‘(aa) REPEAT
DEFICIENCIES.—The Sec-
retary may not reduce the amount of a penalty 
under subclause (II) if the Secretary had 
Deadline. 
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124 STAT. 714 
PUBLIC LAW 111–148—MAR. 23, 2010 
reduced a penalty imposed on the facility in 
the preceding year under such subclause with 
respect to a repeat deficiency. 
‘‘(bb) CERTAIN OTHER DEFICIENCIES.—The 
Secretary may not reduce the amount of a 
penalty under subclause (II) if the penalty 
is imposed on the facility for a deficiency that 
is found to result in a pattern of harm or 
widespread harm, immediately jeopardizes the 
health or safety of a resident or residents of 
the facility, or results in the death of a resi-
dent of the facility. 
‘‘(IV) COLLECTION
OF
CIVIL
MONEY
PEN-
ALTIES.—In the case of a civil money penalty 
imposed under this clause, the Secretary shall 
issue regulations that— 
‘‘(aa) subject to item (cc), not later than 
30 days after the imposition of the penalty, 
provide for the facility to have the opportunity 
to participate in an independent informal dis-
pute resolution process which generates a 
written record prior to the collection of such 
penalty; 
‘‘(bb) in the case where the penalty is 
imposed for each day of noncompliance, pro-
vide that a penalty may not be imposed for 
any day during the period beginning on the 
initial day of the imposition of the penalty 
and ending on the day on which the informal 
dispute resolution process under item (aa) is 
completed; 
‘‘(cc) may provide for the collection of such 
civil money penalty and the placement of such 
amounts collected in an escrow account under 
the direction of the Secretary on the earlier 
of the date on which the informal dispute reso-
lution process under item (aa) is completed 
or the date that is 90 days after the date 
of the imposition of the penalty; 
‘‘(dd) may provide that such amounts col-
lected are kept in such account pending the 
resolution of any subsequent appeals; 
‘‘(ee) in the case where the facility success-
fully appeals the penalty, may provide for the 
return 
of 
such 
amounts 
collected 
(plus 
interest) to the facility; and 
‘‘(ff) in the case where all such appeals 
are unsuccessful, may provide that some por-
tion of such amounts collected may be used 
to support activities that benefit residents, 
including assistance to support and protect 
residents of a facility that closes (voluntarily 
or involuntarily) or is decertified (including 
offsetting costs of relocating residents to home 
and community-based settings or another 
facility), projects that support resident and 
Time period. 
Deadline. 
Regulations. 
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124 STAT. 715 
PUBLIC LAW 111–148—MAR. 23, 2010 
family councils and other consumer involve-
ment in assuring quality care in facilities, and 
facility improvement initiatives approved by 
the Secretary (including joint training of 
facility staff and surveyors, technical assist-
ance for facilities implementing quality assur-
ance programs, the appointment of temporary 
management 
firms, 
and 
other 
activities 
approved by the Secretary).’’. 
(2) CONFORMING AMENDMENT.—The second sentence of sec-
tion 1819(h)(5) of the Social Security Act (42 U.S.C. 1395i– 
3(h)(5)) is amended by inserting ‘‘(ii)(IV),’’ after ‘‘(i),’’. 
(b) NURSING FACILITIES.— 
(1) IN
GENERAL.—Section 1919(h)(3)(C)(ii) of the Social 
Security Act (42 U.S.C. 1396r(h)(3)(C)) is amended— 
(A) by striking ‘‘PENALTIES.—The Secretary’’ and 
inserting ‘‘PENALTIES.— 
‘‘(I) IN
GENERAL.—Subject to subclause (II), 
the Secretary’’; and 
(B) by adding at the end the following new subclauses: 
‘‘(II) REDUCTION
OF
CIVIL
MONEY
PENALTIES 
IN CERTAIN CIRCUMSTANCES.—Subject to subclause 
(III), in the case where a facility self-reports and 
promptly corrects a deficiency for which a penalty 
was imposed under this clause not later than 10 
calendar days after the date of such imposition, 
the Secretary may reduce the amount of the pen-
alty imposed by not more than 50 percent. 
‘‘(III) PROHIBITIONS ON REDUCTION FOR CER-
TAIN DEFICIENCIES.— 
‘‘(aa) REPEAT
DEFICIENCIES.—The Sec-
retary may not reduce the amount of a penalty 
under subclause (II) if the Secretary had 
reduced a penalty imposed on the facility in 
the preceding year under such subclause with 
respect to a repeat deficiency. 
‘‘(bb) CERTAIN OTHER DEFICIENCIES.—The 
Secretary may not reduce the amount of a 
penalty under subclause (II) if the penalty 
is imposed on the facility for a deficiency that 
is found to result in a pattern of harm or 
widespread harm, immediately jeopardizes the 
health or safety of a resident or residents of 
the facility, or results in the death of a resi-
dent of the facility. 
‘‘(IV) COLLECTION
OF
CIVIL
MONEY
PEN-
ALTIES.—In the case of a civil money penalty 
imposed under this clause, the Secretary shall 
issue regulations that— 
‘‘(aa) subject to item (cc), not later than 
30 days after the imposition of the penalty, 
provide for the facility to have the opportunity 
to participate in an independent informal dis-
pute resolution process which generates a 
written record prior to the collection of such 
penalty; 
Deadline. 
Regulations. 
Deadline. 
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124 STAT. 716 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(bb) in the case where the penalty is 
imposed for each day of noncompliance, pro-
vide that a penalty may not be imposed for 
any day during the period beginning on the 
initial day of the imposition of the penalty 
and ending on the day on which the informal 
dispute resolution process under item (aa) is 
completed; 
‘‘(cc) may provide for the collection of such 
civil money penalty and the placement of such 
amounts collected in an escrow account under 
the direction of the Secretary on the earlier 
of the date on which the informal dispute reso-
lution process under item (aa) is completed 
or the date that is 90 days after the date 
of the imposition of the penalty; 
‘‘(dd) may provide that such amounts col-
lected are kept in such account pending the 
resolution of any subsequent appeals; 
‘‘(ee) in the case where the facility success-
fully appeals the penalty, may provide for the 
return 
of 
such 
amounts 
collected 
(plus 
interest) to the facility; and 
‘‘(ff) in the case where all such appeals 
are unsuccessful, may provide that some por-
tion of such amounts collected may be used 
to support activities that benefit residents, 
including assistance to support and protect 
residents of a facility that closes (voluntarily 
or involuntarily) or is decertified (including 
offsetting costs of relocating residents to home 
and community-based settings or another 
facility), projects that support resident and 
family councils and other consumer involve-
ment in assuring quality care in facilities, and 
facility improvement initiatives approved by 
the Secretary (including joint training of 
facility staff and surveyors, technical assist-
ance for facilities implementing quality assur-
ance programs, the appointment of temporary 
management 
firms, 
and 
other 
activities 
approved by the Secretary).’’. 
(2) CONFORMING AMENDMENT.—Section 1919(h)(5)(8) of the 
Social Security Act (42 U.S.C. 1396r(h)(5)(8)) is amended by 
inserting ‘‘(ii)(IV),’’ after ‘‘(i),’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall take effect 1 year after the date of the enactment of this 
Act. 
SEC. 6112. NATIONAL INDEPENDENT MONITOR DEMONSTRATION 
PROJECT. 
(a) ESTABLISHMENT.— 
(1) IN GENERAL.—The Secretary, in consultation with the 
Inspector General of the Department of Health and Human 
Services, shall conduct a demonstration project to develop, test, 
and implement an independent monitor program to oversee 
42 USC 
1320a–7j note. 
42 USC 
1395i–3 note. 
Time period. 
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124 STAT. 717 
PUBLIC LAW 111–148—MAR. 23, 2010 
interstate and large intrastate chains of skilled nursing facili-
ties and nursing facilities. 
(2) SELECTION.—The Secretary shall select chains of skilled 
nursing facilities and nursing facilities described in paragraph 
(1) to participate in the demonstration project under this section 
from among those chains that submit an application to the 
Secretary at such time, in such manner, and containing such 
information as the Secretary may require. 
(3) DURATION.—The Secretary shall conduct the demonstra-
tion project under this section for a 2-year period. 
(4) IMPLEMENTATION.—The Secretary shall implement the 
demonstration project under this section not later than 1 year 
after the date of the enactment of this Act. 
(b) REQUIREMENTS.—The Secretary shall evaluate chains 
selected to participate in the demonstration project under this sec-
tion based on criteria selected by the Secretary, including where 
evidence suggests that a number of the facilities of the chain are 
experiencing serious safety and quality of care problems. Such 
criteria may include the evaluation of a chain that includes a 
number of facilities participating in the ‘‘Special Focus Facility’’ 
program (or a successor program) or multiple facilities with a record 
of repeated serious safety and quality of care deficiencies. 
(c) RESPONSIBILITIES.—An independent monitor that enters into 
a contract with the Secretary to participate in the conduct of the 
demonstration project under this section shall— 
(1) conduct periodic reviews and prepare root-cause quality 
and deficiency analyses of a chain to assess if facilities of 
the chain are in compliance with State and Federal laws and 
regulations applicable to the facilities; 
(2) conduct sustained oversight of the efforts of the chain, 
whether publicly or privately held, to achieve compliance by 
facilities of the chain with State and Federal laws and regula-
tions applicable to the facilities; 
(3) analyze the management structure, distribution of 
expenditures, and nurse staffing levels of facilities of the chain 
in relation to resident census, staff turnover rates, and tenure; 
(4) report findings and recommendations with respect to 
such reviews, analyses, and oversight to the chain and facilities 
of the chain, to the Secretary, and to relevant States; and 
(5) publish the results of such reviews, analyses, and over-
sight. 
(d) IMPLEMENTATION OF RECOMMENDATIONS.— 
(1) RECEIPT OF FINDING BY CHAIN.—Not later than 10 days 
after receipt of a finding of an independent monitor under 
subsection (c)(4), a chain participating in the demonstration 
project shall submit to the independent monitor a report— 
(A) outlining corrective actions the chain will take 
to implement the recommendations in such report; or 
(B) indicating that the chain will not implement such 
recommendations, and why it will not do so. 
(2) RECEIPT OF REPORT BY INDEPENDENT MONITOR.—Not 
later than 10 days after receipt of a report submitted by a 
chain under paragraph (1), an independent monitor shall 
finalize its recommendations and submit a report to the chain 
and facilities of the chain, the Secretary, and the State or 
States, as appropriate, containing such final recommendations. 
Reports. 
Deadline. 
Publication. 
Reports. 
Review. 
Contracts. 
Evaluation. 
Deadline. 
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124 STAT. 718 
PUBLIC LAW 111–148—MAR. 23, 2010 
(e) COST OF APPOINTMENT.—A chain shall be responsible for 
a portion of the costs associated with the appointment of inde-
pendent monitors under the demonstration project under this sec-
tion. The chain shall pay such portion to the Secretary (in an 
amount and in accordance with procedures established by the Sec-
retary). 
(f) WAIVER AUTHORITY.—The Secretary may waive such require-
ments of titles XVIII and XIX of the Social Security Act (42 U.S.C. 
1395 et seq.; 1396 et seq.) as may be necessary for the purpose 
of carrying out the demonstration project under this section. 
(g) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated such sums as may be necessary to carry out 
this section. 
(h) DEFINITIONS.—In this section: 
(1) ADDITIONAL DISCLOSABLE PARTY.—The term ‘‘additional 
disclosable party’’ has the meaning given such term in section 
1124(c)(5)(A) of the Social Security Act, as added by section 
4201(a). 
(2) FACILITY.—The term ‘‘facility’’ means a skilled nursing 
facility or a nursing facility. 
(3) NURSING
FACILITY.—The term ‘‘nursing facility’’ has 
the meaning given such term in section 1919(a) of the Social 
Security Act (42 U.S.C. 1396r(a)). 
(4) SECRETARY.—The term ‘‘Secretary’’ means the Secretary 
of Health and Human Services, acting through the Assistant 
Secretary for Planning and Evaluation. 
(5) SKILLED NURSING FACILITY.—The term ‘‘skilled nursing 
facility’’ has the meaning given such term in section 1819(a) 
of the Social Security Act (42 U.S.C. 1395(a)). 
(i) EVALUATION AND REPORT.— 
(1) EVALUATION.—The Secretary, in consultation with the 
Inspector General of the Department of Health and Human 
Services, shall evaluate the demonstration project conducted 
under this section. 
(2) REPORT.—Not later than 180 days after the completion 
of the demonstration project under this section, the Secretary 
shall submit to Congress a report containing the results of 
the evaluation conducted under paragraph (1), together with 
recommendations— 
(A) as to whether the independent monitor program 
should be established on a permanent basis; 
(B) if the Secretary recommends that such program 
be so established, on appropriate procedures and mecha-
nisms for such establishment; and 
(C) for such legislation and administrative action as 
the Secretary determines appropriate. 
SEC. 6113. NOTIFICATION OF FACILITY CLOSURE. 
(a) IN GENERAL.—Section 1128I of the Social Security Act, 
as added and amended by this Act, is amended by adding at 
the end the following new subsection: 
‘‘(h) NOTIFICATION OF FACILITY CLOSURE.— 
‘‘(1) IN GENERAL.—Any individual who is the administrator 
of a facility must— 
42 USC 
1320a–7j. 
Payment. 
Procedures. 
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124 STAT. 719 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) submit to the Secretary, the State long-term care 
ombudsman, residents of the facility, and the legal rep-
resentatives of such residents or other responsible parties, 
written notification of an impending closure— 
‘‘(i) subject to clause (ii), not later than the date 
that is 60 days prior to the date of such closure; and 
‘‘(ii) in the case of a facility where the Secretary 
terminates the facility’s participation under this title, 
not later than the date that the Secretary determines 
appropriate; 
‘‘(B) ensure that the facility does not admit any new 
residents on or after the date on which such written 
notification is submitted; and 
‘‘(C) include in the notice a plan for the transfer and 
adequate relocation of the residents of the facility by a 
specified date prior to closure that has been approved by 
the State, including assurances that the residents will be 
transferred to the most appropriate facility or other setting 
in terms of quality, services, and location, taking into 
consideration the needs, choice, and best interests of each 
resident. 
‘‘(2) RELOCATION.— 
‘‘(A) IN GENERAL.—The State shall ensure that, before 
a facility closes, all residents of the facility have been 
successfully relocated to another facility or an alternative 
home and community-based setting. 
‘‘(B) CONTINUATION
OF
PAYMENTS
UNTIL
RESIDENTS 
RELOCATED.—The Secretary may, as the Secretary deter-
mines appropriate, continue to make payments under this 
title with respect to residents of a facility that has sub-
mitted a notification under paragraph (1) during the period 
beginning on the date such notification is submitted and 
ending on the date on which the resident is successfully 
relocated. 
‘‘(3) SANCTIONS.—Any individual who is the administrator 
of a facility that fails to comply with the requirements of 
paragraph (1)— 
‘‘(A) shall be subject to a civil monetary penalty of 
up to $100,000; 
‘‘(B) may be subject to exclusion from participation 
in any Federal health care program (as defined in section 
1128B(f)); and 
‘‘(C) shall be subject to any other penalties that may 
be prescribed by law. 
‘‘(4) PROCEDURE.—The provisions of section 1128A (other 
than subsections (a) and (b) and the second sentence of sub-
section (f)) shall apply to a civil money penalty or exclusion 
under paragraph (3) in the same manner as such provisions 
apply to a penalty or proceeding under section 1128A(a).’’. 
(b) CONFORMING AMENDMENTS.—Section 1819(h)(4) of the Social 
Security Act (42 U.S.C. 1395i–3(h)(4)) is amended— 
(1) in the first sentence, by striking ‘‘the Secretary shall 
terminate’’ and inserting ‘‘the Secretary, subject to section 
1128I(h), shall terminate’’; and 
(2) in the second sentence, by striking ‘‘subsection (c)(2)’’ 
and inserting ‘‘subsection (c)(2) and section 1128I(h)’’. 
Applicability. 
Time period. 
Plans. 
Notification. 
Deadlines. 
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124 STAT. 720 
PUBLIC LAW 111–148—MAR. 23, 2010 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall take effect 1 year after the date of the enactment of this 
Act. 
SEC. 6114. NATIONAL DEMONSTRATION PROJECTS ON CULTURE 
CHANGE AND USE OF INFORMATION TECHNOLOGY IN 
NURSING HOMES. 
(a) IN GENERAL.—The Secretary shall conduct 2 demonstration 
projects, 1 for the development of best practices in skilled nursing 
facilities and nursing facilities that are involved in the culture 
change movement (including the development of resources for facili-
ties to find and access funding in order to undertake culture change) 
and 1 for the development of best practices in skilled nursing 
facilities and nursing facilities for the use of information technology 
to improve resident care. 
(b) CONDUCT OF DEMONSTRATION PROJECTS.— 
(1) GRANT AWARD.—Under each demonstration project con-
ducted under this section, the Secretary shall award 1 or more 
grants to facility-based settings for the development of best 
practices described in subsection (a) with respect to the dem-
onstration project involved. Such award shall be made on a 
competitive basis and may be allocated in 1 lump-sum payment. 
(2) CONSIDERATION OF SPECIAL NEEDS OF RESIDENTS.—Each 
demonstration project conducted under this section shall take 
into consideration the special needs of residents of skilled 
nursing facilities and nursing facilities who have cognitive 
impairment, including dementia. 
(c) DURATION AND IMPLEMENTATION.— 
(1) DURATION.—The demonstration projects shall each be 
conducted for a period not to exceed 3 years. 
(2) IMPLEMENTATION.—The demonstration projects shall 
each be implemented not later than 1 year after the date 
of the enactment of this Act. 
(d) DEFINITIONS.—In this section: 
(1) NURSING
FACILITY.—The term ‘‘nursing facility’’ has 
the meaning given such term in section 1919(a) of the Social 
Security Act (42 U.S.C. 1396r(a)). 
(2) SECRETARY.—The term ‘‘Secretary’’ means the Secretary 
of Health and Human Services. 
(3) SKILLED NURSING FACILITY.—The term ‘‘skilled nursing 
facility’’ has the meaning given such term in section 1819(a) 
of the Social Security Act (42 U.S.C. 1395(a)). 
(e) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated such sums as may be necessary to carry out 
this section. 
(f) REPORT.—Not later than 9 months after the completion 
of the demonstration project, the Secretary shall submit to Congress 
a report on such project, together with recommendations for such 
legislation and administrative action as the Secretary determines 
appropriate. 
PART III—IMPROVING STAFF TRAINING 
SEC. 6121. DEMENTIA AND ABUSE PREVENTION TRAINING. 
(a) SKILLED NURSING FACILITIES.— 
(1) IN
GENERAL.—Section 1819(f)(2)(A)(i)(I) of the Social 
Security Act (42 U.S.C. 1395i–3(f)(2)(A)(i)(I)) is amended by 
Recommenda- 
tions. 
Deadline. 
42 USC 1395i–3 
note. 
42 USC 1320a–7j 
note. 
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124 STAT. 721 
PUBLIC LAW 111–148—MAR. 23, 2010 
inserting ‘‘(including, in the case of initial training and, if 
the Secretary determines appropriate, in the case of ongoing 
training, dementia management training, and patient abuse 
prevention training’’ before ‘‘, (II)’’. 
(2) CLARIFICATION OF DEFINITION OF NURSE AIDE.—Section 
1819(b)(5)(F) of the Social Security Act (42 U.S.C. 1395i– 
3(b)(5)(F)) is amended by adding at the end the following flush 
sentence: 
‘‘Such term includes an individual who provides such serv-
ices through an agency or under a contract with the 
facility.’’. 
(b) NURSING FACILITIES.— 
(1) IN
GENERAL.—Section 1919(f)(2)(A)(i)(I) of the Social 
Security Act (42 U.S.C. 1396r(f)(2)(A)(i)(I)) is amended by 
inserting ‘‘(including, in the case of initial training and, if 
the Secretary determines appropriate, in the case of ongoing 
training, dementia management training, and patient abuse 
prevention training’’ before ‘‘, (II)’’. 
(2) CLARIFICATION OF DEFINITION OF NURSE AIDE.—Section 
1919(b)(5)(F) 
of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1396r(b)(5)(F)) is amended by adding at the end the following 
flush sentence: 
‘‘Such term includes an individual who provides such serv-
ices through an agency or under a contract with the 
facility.’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall take effect 1 year after the date of the enactment of this 
Act. 
Subtitle C—Nationwide Program for Na-
tional and State Background Checks on 
Direct 
Patient 
Access 
Employees 
of 
Long-term Care Facilities and Providers 
SEC. 6201. NATIONWIDE PROGRAM FOR NATIONAL AND STATE BACK-
GROUND 
CHECKS 
ON 
DIRECT 
PATIENT 
ACCESS 
EMPLOYEES OF LONG-TERM CARE FACILITIES AND PRO-
VIDERS. 
(a) IN GENERAL.—The Secretary of Health and Human Services 
(in this section referred to as the ‘‘Secretary’’), shall establish a 
program to identify efficient, effective, and economical procedures 
for long term care facilities or providers to conduct background 
checks on prospective direct patient access employees on a nation-
wide basis (in this subsection, such program shall be referred to 
as the ‘‘nationwide program’’). Except for the following modifica-
tions, the Secretary shall carry out the nationwide program under 
similar terms and conditions as the pilot program under section 
307 of the Medicare Prescription Drug, Improvement, and Mod-
ernization Act of 2003 (Public Law 108–173; 117 Stat. 2257), 
including the prohibition on hiring abusive workers and the 
authorization of the imposition of penalties by a participating State 
under subsection (b)(3)(A) and (b)(6), respectively, of such section 
307: 
(1) AGREEMENTS.— 
42 USC 
1320a–7l. 
42 USC 1395i–3 
note. 
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124 STAT. 722 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) NEWLY PARTICIPATING STATES.—The Secretary shall 
enter into agreements with each State— 
(i) that the Secretary has not entered into an 
agreement with under subsection (c)(1) of such section 
307; 
(ii) that agrees to conduct background checks 
under the nationwide program on a Statewide basis; 
and 
(iii) that submits an application to the Secretary 
containing such information and at such time as the 
Secretary may specify. 
(B) CERTAIN PREVIOUSLY PARTICIPATING STATES.—The 
Secretary shall enter into agreements with each State— 
(i) that the Secretary has entered into an agree-
ment with under such subsection (c)(1), but only in 
the case where such agreement did not require the 
State to conduct background checks under the program 
established under subsection (a) of such section 307 
on a Statewide basis; 
(ii) that agrees to conduct background checks 
under the nationwide program on a Statewide basis; 
and 
(iii) that submits an application to the Secretary 
containing such information and at such time as the 
Secretary may specify. 
(2) NONAPPLICATION OF SELECTION CRITERIA.—The selection 
criteria required under subsection (c)(3)(B) of such section 307 
shall not apply. 
(3) REQUIRED FINGERPRINT CHECK AS PART OF CRIMINAL 
HISTORY
BACKGROUND
CHECK.—The procedures established 
under subsection (b)(1) of such section 307 shall— 
(A) require that the long-term care facility or provider 
(or the designated agent of the long-term care facility or 
provider) obtain State and national criminal history back-
ground checks on the prospective employee through such 
means as the Secretary determines appropriate, efficient, 
and effective that utilize a search of State-based abuse 
and neglect registries and databases, including the abuse 
and neglect registries of another State in the case where 
a prospective employee previously resided in that State, 
State criminal history records, the records of any pro-
ceedings in the State that may contain disqualifying 
information about prospective employees (such as pro-
ceedings conducted by State professional licensing and dis-
ciplinary boards and State Medicaid Fraud Control Units), 
and Federal criminal history records, including a finger-
print check using the Integrated Automated Fingerprint 
Identification System of the Federal Bureau of Investiga-
tion; 
(B) require States to describe and test methods that 
reduce duplicative fingerprinting, including providing for 
the development of ‘‘rap back’’ capability by the State such 
that, if a direct patient access employee of a long-term 
care facility or provider is convicted of a crime following 
the initial criminal history background check conducted 
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124 STAT. 723 
PUBLIC LAW 111–148—MAR. 23, 2010 
with respect to such employee, and the employee’s finger-
prints match the prints on file with the State law enforce-
ment department, the department will immediately inform 
the State and the State will immediately inform the long- 
term care facility or provider which employs the direct 
patient access employee of such conviction; and 
(C) require that criminal history background checks 
conducted under the nationwide program remain valid for 
a period of time specified by the Secretary. 
(4) STATE
REQUIREMENTS.—An agreement entered into 
under paragraph (1) shall require that a participating State— 
(A) be responsible for monitoring compliance with the 
requirements of the nationwide program; 
(B) have procedures in place to— 
(i) conduct screening and criminal history back-
ground checks under the nationwide program in accord-
ance with the requirements of this section; 
(ii) monitor compliance by long-term care facilities 
and providers with the procedures and requirements 
of the nationwide program; 
(iii) as appropriate, provide for a provisional period 
of employment by a long-term care facility or provider 
of a direct patient access employee, not to exceed 60 
days, pending completion of the required criminal his-
tory background check and, in the case where the 
employee has appealed the results of such background 
check, pending completion of the appeals process, 
during which the employee shall be subject to direct 
on-site supervision (in accordance with procedures 
established by the State to ensure that a long-term 
care facility or provider furnishes such direct on-site 
supervision); 
(iv) provide an independent process by which a 
provisional employee or an employee may appeal or 
dispute the accuracy of the information obtained in 
a background check performed under the nationwide 
program, including the specification of criteria for 
appeals for direct patient access employees found to 
have disqualifying information which shall include 
consideration of the passage of time, extenuating cir-
cumstances, demonstration of rehabilitation, and rel-
evancy of the particular disqualifying information with 
respect to the current employment of the individual; 
(v) provide for the designation of a single State 
agency as responsible for— 
(I) overseeing the coordination of any State 
and national criminal history background checks 
requested by a long-term care facility or provider 
(or the designated agent of the long-term care 
facility or provider) utilizing a search of State and 
Federal criminal history records, including a 
fingerprint check of such records; 
(II) overseeing the design of appropriate pri-
vacy and security safeguards for use in the review 
of the results of any State or national criminal 
history background checks conducted regarding a 
Procedures. 
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124 STAT. 724 
PUBLIC LAW 111–148—MAR. 23, 2010 
prospective direct patient access employee to deter-
mine whether the employee has any conviction 
for a relevant crime; 
(III) immediately reporting to the long-term 
care facility or provider that requested the criminal 
history background check the results of such 
review; and 
(IV) in the case of an employee with a convic-
tion for a relevant crime that is subject to reporting 
under section 1128E of the Social Security Act 
(42 U.S.C. 1320a–7e), reporting the existence of 
such conviction to the database established under 
that section; 
(vi) determine which individuals are direct patient 
access employees (as defined in paragraph (6)(B)) for 
purposes of the nationwide program; 
(vii) as appropriate, specify offenses, including 
convictions for violent crimes, for purposes of the 
nationwide program; and 
(viii) describe and test methods that reduce 
duplicative fingerprinting, including providing for the 
development of ‘‘rap back’’ capability such that, if a 
direct patient access employee of a long-term care 
facility or provider is convicted of a crime following 
the initial criminal history background check conducted 
with respect to such employee, and the employee’s 
fingerprints match the prints on file with the State 
law enforcement department— 
(I) the department will immediately inform 
the State agency designated under clause (v) and 
such agency will immediately inform the facility 
or provider which employs the direct patient access 
employee of such conviction; and 
(II) the State will provide, or will require the 
facility to provide, to the employee a copy of the 
results of the criminal history background check 
conducted with respect to the employee at no 
charge in the case where the individual requests 
such a copy. 
(5) PAYMENTS.— 
(A) NEWLY PARTICIPATING STATES.— 
(i) IN GENERAL.—As part of the application sub-
mitted by a State under paragraph (1)(A)(iii), the State 
shall guarantee, with respect to the costs to be incurred 
by the State in carrying out the nationwide program, 
that the State will make available (directly or through 
donations from public or private entities) a particular 
amount of non-Federal contributions, as a condition 
of receiving the Federal match under clause (ii). 
(ii) FEDERAL
MATCH.—The payment amount to 
each State that the Secretary enters into an agreement 
with under paragraph (1)(A) shall be 3 times the 
amount that the State guarantees to make available 
under clause (i), except that in no case may the pay-
ment amount exceed $3,000,000. 
(B) PREVIOUSLY PARTICIPATING STATES.— 
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124 STAT. 725 
PUBLIC LAW 111–148—MAR. 23, 2010 
(i) IN GENERAL.—As part of the application sub-
mitted by a State under paragraph (1)(B)(iii), the State 
shall guarantee, with respect to the costs to be incurred 
by the State in carrying out the nationwide program, 
that the State will make available (directly or through 
donations from public or private entities) a particular 
amount of non-Federal contributions, as a condition 
of receiving the Federal match under clause (ii). 
(ii) FEDERAL
MATCH.—The payment amount to 
each State that the Secretary enters into an agreement 
with under paragraph (1)(B) shall be 3 times the 
amount that the State guarantees to make available 
under clause (i), except that in no case may the pay-
ment amount exceed $1,500,000. 
(6) DEFINITIONS.—Under the nationwide program: 
(A) CONVICTION
FOR
A
RELEVANT
CRIME.—The term 
‘‘conviction for a relevant crime’’ means any Federal or 
State criminal conviction for— 
(i) any offense described in section 1128(a) of the 
Social Security Act (42 U.S.C. 1320a–7); or 
(ii) such other types of offenses as a participating 
State may specify for purposes of conducting the pro-
gram in such State. 
(B) DISQUALIFYING INFORMATION.—The term ‘‘disquali-
fying information’’ means a conviction for a relevant crime 
or a finding of patient or resident abuse. 
(C) FINDING
OF
PATIENT
OR
RESIDENT
ABUSE.—The 
term ‘‘finding of patient or resident abuse’’ means any 
substantiated finding by a State agency under section 
1819(g)(1)(C) or 1919(g)(1)(C) of the Social Security Act 
(42 U.S.C. 1395i–3(g)(1)(C), 1396r(g)(1)(C)) or a Federal 
agency that a direct patient access employee has com-
mitted— 
(i) an act of patient or resident abuse or neglect 
or a misappropriation of patient or resident property; 
or 
(ii) such other types of acts as a participating 
State may specify for purposes of conducting the pro-
gram in such State. 
(D) DIRECT
PATIENT
ACCESS
EMPLOYEE.—The term 
‘‘direct patient access employee’’ means any individual who 
has access to a patient or resident of a long-term care 
facility or provider through employment or through a con-
tract with such facility or provider and has duties that 
involve (or may involve) one-on-one contact with a patient 
or resident of the facility or provider, as determined by 
the State for purposes of the nationwide program. Such 
term does not include a volunteer unless the volunteer 
has duties that are equivalent to the duties of a direct 
patient access employee and those duties involve (or may 
involve) one-on-one contact with a patient or resident of 
the long-term care facility or provider. 
(E) LONG-TERM CARE FACILITY OR PROVIDER.—The term 
‘‘long-term care facility or provider’’ means the following 
facilities or providers which receive payment for services 
under title XVIII or XIX of the Social Security Act: 
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124 STAT. 726 
PUBLIC LAW 111–148—MAR. 23, 2010 
(i) A skilled nursing facility (as defined in section 
1819(a) of the Social Security Act (42 U.S.C. 1395i– 
3(a))). 
(ii) A nursing facility (as defined in section 1919(a) 
of such Act (42 U.S.C. 1396r(a))). 
(iii) A home health agency. 
(iv) A provider of hospice care (as defined in section 
1861(dd)(1) of such Act (42 U.S.C. 1395x(dd)(1))). 
(v) A long-term care hospital (as described in sec-
tion 
1886(d)(1)(B)(iv) 
of 
such 
Act 
(42 
U.S.C. 
1395ww(d)(1)(B)(iv))). 
(vi) A provider of personal care services. 
(vii) A provider of adult day care. 
(viii) A residential care provider that arranges for, 
or directly provides, long-term care services, including 
an assisted living facility that provides a level of care 
established by the Secretary. 
(ix) An intermediate care facility for the mentally 
retarded (as defined in section 1905(d) of such Act 
(42 U.S.C. 1396d(d))). 
(x) Any other facility or provider of long-term care 
services under such titles as the participating State 
determines appropriate. 
(7) EVALUATION AND REPORT.— 
(A) EVALUATION.— 
(i) IN
GENERAL.—The Inspector General of the 
Department of Health and Human Services shall con-
duct an evaluation of the nationwide program. 
(ii) INCLUSION OF SPECIFIC TOPICS.—The evaluation 
conducted under clause (i) shall include the following: 
(I) A review of the various procedures imple-
mented by participating States for long-term care 
facilities or providers, including staffing agencies, 
to conduct background checks of direct patient 
access employees under the nationwide program 
and identification of the most appropriate, effi-
cient, and effective procedures for conducting such 
background checks. 
(II) An assessment of the costs of conducting 
such background checks (including start up and 
administrative costs). 
(III) A determination of the extent to which 
conducting such background checks leads to any 
unintended consequences, including a reduction in 
the available workforce for long-term care facilities 
or providers. 
(IV) An assessment of the impact of the nation-
wide program on reducing the number of incidents 
of neglect, abuse, and misappropriation of resident 
property to the extent practicable. 
(V) An evaluation of other aspects of the 
nationwide program, as determined appropriate by 
the Secretary. 
(B) REPORT.—Not later than 180 days after the comple-
tion of the nationwide program, the Inspector General of 
the Department of Health and Human Services shall 
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124 STAT. 727 
PUBLIC LAW 111–148—MAR. 23, 2010 
submit a report to Congress containing the results of the 
evaluation conducted under subparagraph (A). 
(b) FUNDING.— 
(1) NOTIFICATION.—The Secretary of Health and Human 
Services shall notify the Secretary of the Treasury of the 
amount necessary to carry out the nationwide program under 
this section for the period of fiscal years 2010 through 2012, 
except that in no case shall such amount exceed $160,000,000. 
(2) TRANSFER OF FUNDS.— 
(A) IN GENERAL.—Out of any funds in the Treasury 
not otherwise appropriated, the Secretary of the Treasury 
shall provide for the transfer to the Secretary of Health 
and Human Services of the amount specified as necessary 
to carry out the nationwide program under paragraph (1). 
Such amount shall remain available until expended. 
(B) RESERVATION OF FUNDS FOR CONDUCT OF EVALUA-
TION.—The 
Secretary 
may 
reserve 
not 
more 
than 
$3,000,000 of the amount transferred under subparagraph 
(A) to provide for the conduct of the evaluation under 
subsection (a)(7)(A). 
Subtitle D—Patient-Centered Outcomes 
Research 
SEC. 6301. PATIENT-CENTERED OUTCOMES RESEARCH. 
(a) IN GENERAL.—Title XI of the Social Security Act (42 U.S.C. 
1301 et seq.) is amended by adding at the end the following new 
part: 
‘‘PART D—COMPARATIVE CLINICAL EFFECTIVENESS RESEARCH 
‘‘COMPARATIVE CLINICAL EFFECTIVENESS RESEARCH 
‘‘SEC. 1181. (a) DEFINITIONS.—In this section: 
‘‘(1) BOARD.—The term ‘Board’ means the Board of Gov-
ernors established under subsection (f). 
‘‘(2) COMPARATIVE
CLINICAL
EFFECTIVENESS
RESEARCH; 
RESEARCH.— 
‘‘(A) IN
GENERAL.—The terms ‘comparative clinical 
effectiveness research’ and ‘research’ mean research evalu-
ating and comparing health outcomes and the clinical 
effectiveness, risks, and benefits of 2 or more medical treat-
ments, services, and items described in subparagraph (B). 
‘‘(B) MEDICAL
TREATMENTS, 
SERVICES, 
AND
ITEMS 
DESCRIBED.—The medical treatments, services, and items 
described in this subparagraph are health care interven-
tions, protocols for treatment, care management, and 
delivery, procedures, medical devices, diagnostic tools, 
pharmaceuticals (including drugs and biologicals), integra-
tive health practices, and any other strategies or items 
being used in the treatment, management, and diagnosis 
of, or prevention of illness or injury in, individuals. 
‘‘(3) CONFLICT OF INTEREST.—The term ‘conflict of interest’ 
means an association, including a financial or personal associa-
tion, that have the potential to bias or have the appearance 
42 USC 1320e. 
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124 STAT. 728 
PUBLIC LAW 111–148—MAR. 23, 2010 
of biasing an individual’s decisions in matters related to the 
Institute or the conduct of activities under this section. 
‘‘(4) REAL CONFLICT OF INTEREST.—The term ‘real conflict 
of interest’ means any instance where a member of the Board, 
the methodology committee established under subsection (d)(6), 
or an advisory panel appointed under subsection (d)(4), or a 
close relative of such member, has received or could receive 
either of the following: 
‘‘(A) A direct financial benefit of any amount deriving 
from the result or findings of a study conducted under 
this section. 
‘‘(B) A financial benefit from individuals or companies 
that own or manufacture medical treatments, services, or 
items to be studied under this section that in the aggregate 
exceeds $10,000 per year. For purposes of the preceding 
sentence, a financial benefit includes honoraria, fees, stock, 
or other financial benefit and the current value of the 
member or close relative’s already existing stock holdings, 
in addition to any direct financial benefit deriving from 
the results or findings of a study conducted under this 
section. 
‘‘(b) PATIENT-CENTERED OUTCOMES RESEARCH INSTITUTE.— 
‘‘(1) ESTABLISHMENT.—There is authorized to be established 
a nonprofit corporation, to be known as the ‘Patient-Centered 
Outcomes Research Institute’ (referred to in this section as 
the ‘Institute’) which is neither an agency nor establishment 
of the United States Government. 
‘‘(2) APPLICATION OF PROVISIONS.—The Institute shall be 
subject to the provisions of this section, and, to the extent 
consistent with this section, to the District of Columbia Non-
profit Corporation Act. 
‘‘(3) FUNDING
OF
COMPARATIVE
CLINICAL
EFFECTIVENESS 
RESEARCH.—For fiscal year 2010 and each subsequent fiscal 
year, amounts in 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 shall be 
available, without further appropriation, to the Institute to 
carry out this section. 
‘‘(c) PURPOSE.—The purpose of the Institute is to assist patients, 
clinicians, purchasers, and policy-makers in making informed health 
decisions by advancing the quality and relevance of evidence con-
cerning the manner in which diseases, disorders, and other health 
conditions 
can 
effectively 
and 
appropriately 
be 
prevented, 
diagnosed, treated, monitored, and managed through research and 
evidence synthesis that considers variations in patient subpopula-
tions, and the dissemination of research findings with respect to 
the relative health outcomes, clinical effectiveness, and appropriate-
ness of the medical treatments, services, and items described in 
subsection (a)(2)(B). 
‘‘(d) DUTIES.— 
‘‘(1) IDENTIFYING RESEARCH PRIORITIES AND ESTABLISHING 
RESEARCH PROJECT AGENDA.— 
‘‘(A) IDENTIFYING RESEARCH PRIORITIES.—The Institute 
shall identify national priorities for research, taking into 
account factors of disease incidence, prevalence, and burden 
in the United States (with emphasis on chronic conditions), 
gaps in evidence in terms of clinical outcomes, practice 
District of 
Columbia. 
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124 STAT. 729 
PUBLIC LAW 111–148—MAR. 23, 2010 
variations and health disparities in terms of delivery and 
outcomes of care, the potential for new evidence to improve 
patient health, well-being, and the quality of care, the 
effect on national expenditures associated with a health 
care treatment, strategy, or health conditions, as well as 
patient needs, outcomes, and preferences, the relevance 
to patients and clinicians in making informed health 
decisions, and priorities in the National Strategy for quality 
care established under section 399H of the Public Health 
Service Act that are consistent with this section. 
‘‘(B) ESTABLISHING RESEARCH PROJECT AGENDA.—The 
Institute shall establish and update a research project 
agenda for research to address the priorities identified 
under subparagraph (A), taking into consideration the 
types of research that might address each priority and 
the relative value (determined based on the cost of con-
ducting research compared to the potential usefulness of 
the information produced by research) associated with the 
different types of research, and such other factors as the 
Institute determines appropriate. 
‘‘(2) CARRYING OUT RESEARCH PROJECT AGENDA.— 
‘‘(A) RESEARCH.—The Institute shall carry out the 
research project agenda established under paragraph (1)(B) 
in accordance with the methodological standards adopted 
under paragraph (9) using methods, including the following: 
‘‘(i) Systematic reviews and assessments of existing 
and future research and evidence including original 
research conducted subsequent to the date of the enact-
ment of this section. 
‘‘(ii) Primary research, such as randomized clinical 
trials, molecularly informed trials, and observational 
studies. 
‘‘(iii) Any other methodologies recommended by the 
methodology committee established under paragraph 
(6) that are adopted by the Board under paragraph 
(9). 
‘‘(B) CONTRACTS FOR THE MANAGEMENT OF FUNDING 
AND CONDUCT OF RESEARCH.— 
‘‘(i) CONTRACTS.— 
‘‘(I) IN
GENERAL.—In accordance with the 
research project agenda established under para-
graph (1)(B), the Institute shall enter into con-
tracts for the management of funding and conduct 
of research in accordance with the following: 
‘‘(aa) Appropriate agencies and instrumen-
talities of the Federal Government. 
‘‘(bb) Appropriate academic research, pri-
vate sector research, or study-conducting enti-
ties. 
‘‘(II) PREFERENCE.—In entering into contracts 
under subclause (I), the Institute shall give pref-
erence to the Agency for Healthcare Research and 
Quality and the National Institutes of Health, but 
only if the research to be conducted or managed 
under such contract is authorized by the governing 
statutes of such Agency or Institutes. 
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124 STAT. 730 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(ii) CONDITIONS
FOR
CONTRACTS.—A contract 
entered into under this subparagraph shall require 
that the agency, instrumentality, or other entity— 
‘‘(I) abide by the transparency and conflicts 
of interest requirements under subsection (h) that 
apply to the Institute with respect to the research 
managed or conducted under such contract; 
‘‘(II) comply with the methodological standards 
adopted under paragraph (9) with respect to such 
research; 
‘‘(III) consult with the expert advisory panels 
for clinical trials and rare disease appointed under 
clauses (ii) and (iii), respectively, of paragraph 
(4)(A); 
‘‘(IV) subject to clause (iv), permit a researcher 
who conducts original research under the contract 
for the agency, instrumentality, or other entity 
to have such research published in a peer-reviewed 
journal or other publication; 
‘‘(V) have appropriate processes in place to 
manage data privacy and meet ethical standards 
for the research; 
‘‘(VI) comply with the requirements of the 
Institute for making the information available to 
the public under paragraph (8); and 
‘‘(VII) comply with other terms and conditions 
determined necessary by the Institute to carry out 
the research agenda adopted under paragraph (2). 
‘‘(iii) COVERAGE
OF
COPAYMENTS
OR
COINSUR-
ANCE.—A contract entered into under this subpara-
graph may allow for the coverage of copayments or 
coinsurance, or allow for other appropriate measures, 
to the extent that such coverage or other measures 
are necessary to preserve the validity of a research 
project, such as in the case where the research project 
must be blinded. 
‘‘(iv) 
REQUIREMENTS
FOR
PUBLICATION
OF 
RESEARCH.—Any research published under clause 
(ii)(IV) shall be within the bounds of and entirely con-
sistent with the evidence and findings produced under 
the contract with the Institute under this subpara-
graph. If the Institute determines that those require-
ments are not met, the Institute shall not enter into 
another contract with the agency, instrumentality, or 
entity which managed or conducted such research for 
a period determined appropriate by the Institute (but 
not less than 5 years). 
‘‘(C) REVIEW AND UPDATE OF EVIDENCE.—The Institute 
shall review and update evidence on a periodic basis as 
appropriate. 
‘‘(D) TAKING INTO ACCOUNT POTENTIAL DIFFERENCES.— 
Research shall be designed, as appropriate, to take into 
account the potential for differences in the effectiveness 
of health care treatments, services, and items as used 
with various subpopulations, such as racial and ethnic 
minorities, women, age, and groups of individuals with 
different comorbidities, genetic and molecular sub-types, 
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124 STAT. 731 
PUBLIC LAW 111–148—MAR. 23, 2010 
or quality of life preferences and include members of such 
subpopulations as subjects in the research as feasible and 
appropriate. 
‘‘(E) 
DIFFERENCES
IN
TREATMENT
MODALITIES.— 
Research shall be designed, as appropriate, to take into 
account different characteristics of treatment modalities 
that may affect research outcomes, such as the phase of 
the treatment modality in the innovation cycle and the 
impact of the skill of the operator of the treatment 
modality. 
‘‘(3) DATA COLLECTION.— 
‘‘(A) IN GENERAL.—The Secretary shall, with appro-
priate safeguards for privacy, make available to the 
Institute such data collected by the Centers for Medicare 
& Medicaid Services under the programs under titles XVIII, 
XIX, and XXI, as well as provide access to the data net-
works developed under section 937(f) of the Public Health 
Service Act, as the Institute and its contractors may require 
to carry out this section. The Institute may also request 
and obtain data from Federal, State, or private entities, 
including data from clinical databases and registries. 
‘‘(B) USE OF DATA.—The Institute shall only use data 
provided to the Institute under subparagraph (A) in accord-
ance with laws and regulations governing the release and 
use of such data, including applicable confidentiality and 
privacy standards. 
‘‘(4) APPOINTING EXPERT ADVISORY PANELS.— 
‘‘(A) APPOINTMENT.— 
‘‘(i) IN
GENERAL.—The Institute may appoint 
permanent or ad hoc expert advisory panels as deter-
mined appropriate to assist in identifying research 
priorities and establishing the research project agenda 
under paragraph (1) and for other purposes. 
‘‘(ii) EXPERT
ADVISORY
PANELS
FOR
CLINICAL 
TRIALS.—The Institute shall appoint expert advisory 
panels in carrying out randomized clinical trials under 
the research project agenda under paragraph (2)(A)(ii). 
Such expert advisory panels shall advise the Institute 
and the agency, instrumentality, or entity conducting 
the research on the research question involved and 
the research design or protocol, including important 
patient subgroups and other parameters of the 
research. Such panels shall be available as a resource 
for technical questions that may arise during the con-
duct of such research. 
‘‘(iii) EXPERT ADVISORY PANEL FOR RARE DISEASE.— 
In the case of a research study for rare disease, the 
Institute shall appoint an expert advisory panel for 
purposes of assisting in the design of the research 
study and determining the relative value and feasi-
bility of conducting the research study. 
‘‘(B) 
COMPOSITION.—An 
expert 
advisory 
panel 
appointed under subparagraph (A) shall include representa-
tives of practicing and research clinicians, patients, and 
experts in scientific and health services research, health 
services delivery, and evidence-based medicine who have 
experience in the relevant topic, and as appropriate, experts 
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124 STAT. 732 
PUBLIC LAW 111–148—MAR. 23, 2010 
in integrative health and primary prevention strategies. 
The Institute may include a technical expert of each manu-
facturer or each medical technology that is included under 
the relevant topic, project, or category for which the panel 
is established. 
‘‘(5) SUPPORTING
PATIENT
AND
CONSUMER
REPRESENTA-
TIVES.—The Institute shall provide support and resources to 
help patient and consumer representatives effectively partici-
pate on the Board and expert advisory panels appointed by 
the Institute under paragraph (4). 
‘‘(6) ESTABLISHING METHODOLOGY COMMITTEE.— 
‘‘(A) IN
GENERAL.—The Institute shall establish a 
standing methodology committee to carry out the functions 
described in subparagraph (C). 
‘‘(B) APPOINTMENT
AND
COMPOSITION.—The method-
ology committee established under subparagraph (A) shall 
be composed of not more than 15 members appointed by 
the Comptroller General of the United States. Members 
appointed to the methodology committee shall be experts 
in their scientific field, such as health services research, 
clinical 
research, 
comparative 
clinical 
effectiveness 
research, biostatistics, genomics, and research methodolo-
gies. Stakeholders with such expertise may be appointed 
to the methodology committee. In addition to the members 
appointed under the first sentence, the Directors of the 
National Institutes of Health and the Agency for 
Healthcare Research and Quality (or their designees) shall 
each be included as members of the methodology com-
mittee. 
‘‘(C) FUNCTIONS.—Subject to subparagraph (D), the 
methodology committee shall work to develop and improve 
the science and methods of comparative clinical effective-
ness research by, not later than 18 months after the 
establishment of the Institute, directly or through sub-
contract, developing and periodically updating the fol-
lowing: 
‘‘(i) Methodological standards for research. Such 
methodological standards shall provide specific criteria 
for internal validity, generalizability, feasibility, and 
timeliness of research and for health outcomes meas-
ures, risk adjustment, and other relevant aspects of 
research and assessment with respect to the design 
of research. Any methodological standards developed 
and updated under this subclause shall be scientifically 
based and include methods by which new information, 
data, or advances in technology are considered and 
incorporated into ongoing research projects by the 
Institute, as appropriate. The process for developing 
and updating such standards shall include input from 
relevant experts, stakeholders, and decisionmakers, 
and shall provide opportunities for public comment. 
Such standards shall also include methods by which 
patient subpopulations can be accounted for and evalu-
ated in different types of research. As appropriate, 
such standards shall build on existing work on meth-
odological standards for defined categories of health 
interventions and for each of the major categories of 
Deadline. 
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124 STAT. 733 
PUBLIC LAW 111–148—MAR. 23, 2010 
comparative clinical effectiveness research methods 
(determined as of the date of enactment of the Patient 
Protection and Affordable Care Act). 
‘‘(ii) A translation table that is designed to provide 
guidance and act as a reference for the Board to deter-
mine research methods that are most likely to address 
each specific research question. 
‘‘(D) CONSULTATION AND CONDUCT OF EXAMINATIONS.— 
The methodology committee may consult and contract with 
the Institute of Medicine of the National Academies and 
academic, nonprofit, or other private and governmental 
entities with relevant expertise to carry out activities 
described in subparagraph (C) and may consult with rel-
evant stakeholders to carry out such activities. 
‘‘(E) REPORTS.—The methodology committee shall 
submit reports to the Board on the committee’s performance 
of the functions described in subparagraph (C). Reports 
shall contain recommendations for the Institute to adopt 
methodological standards developed and updated by the 
methodology committee as well as other actions deemed 
necessary to comply with such methodological standards. 
‘‘(7) PROVIDING FOR A PEER-REVIEW PROCESS FOR PRIMARY 
RESEARCH.— 
‘‘(A) IN GENERAL.—The Institute shall ensure that there 
is a process for peer review of primary research described 
in subparagraph (A)(ii) of paragraph (2) that is conducted 
under such paragraph. Under such process— 
‘‘(i) evidence from such primary research shall be 
reviewed to assess scientific integrity and adherence 
to methodological standards adopted under paragraph 
(9); and 
‘‘(ii) a list of the names of individuals contributing 
to any peer-review process during the preceding year 
or years shall be made public and included in annual 
reports in accordance with paragraph (10)(D). 
‘‘(B) COMPOSITION.—Such peer-review process shall be 
designed in a manner so as to avoid bias and conflicts 
of interest on the part of the reviewers and shall be com-
posed of experts in the scientific field relevant to the 
research under review. 
‘‘(C) USE OF EXISTING PROCESSES.— 
‘‘(i) PROCESSES OF ANOTHER ENTITY.—In the case 
where the Institute enters into a contract or other 
agreement with another entity for the conduct or 
management of research under this section, the 
Institute may utilize the peer-review process of such 
entity if such process meets the requirements under 
subparagraphs (A) and (B). 
‘‘(ii) PROCESSES
OF
APPROPRIATE
MEDICAL
JOUR-
NALS.—The Institute may utilize the peer-review 
process of appropriate medical journals if such process 
meets the requirements under subparagraphs (A) and 
(B). 
‘‘(8) RELEASE OF RESEARCH FINDINGS.— 
‘‘(A) IN GENERAL.—The Institute shall, not later than 
90 days after the conduct or receipt of research findings 
under this part, make such research findings available 
Deadline. 
Lists. 
Public 
information. 
Recommenda- 
tions. 
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124 STAT. 734 
PUBLIC LAW 111–148—MAR. 23, 2010 
to clinicians, patients, and the general public. The Institute 
shall ensure that the research findings— 
‘‘(i) convey the findings of research in a manner 
that is comprehensible and useful to patients and pro-
viders in making health care decisions; 
‘‘(ii) fully convey findings and discuss consider-
ations specific to certain subpopulations, risk factors, 
and comorbidities, as appropriate; 
‘‘(iii) include limitations of the research and what 
further research may be needed as appropriate; 
‘‘(iv) not be construed as mandates for practice 
guidelines, coverage recommendations, payment, or 
policy recommendations; and 
‘‘(v) not include any data which would violate the 
privacy of research participants or any confidentiality 
agreements made with respect to the use of data under 
this section. 
‘‘(B) DEFINITION OF RESEARCH FINDINGS.—In this para-
graph, the term ‘research findings’ means the results of 
a study or assessment. 
‘‘(9) ADOPTION.—Subject to subsection (h)(1), the Institute 
shall adopt the national priorities identified under paragraph 
(1)(A), the research project agenda established under paragraph 
(1)(B), the methodological standards developed and updated 
by the methodology committee under paragraph (6)(C)(i), and 
any peer-review process provided under paragraph (7) by 
majority vote. In the case where the Institute does not adopt 
such processes in accordance with the preceding sentence, the 
processes shall be referred to the appropriate staff or entity 
within the Institute (or, in the case of the methodological stand-
ards, the methodology committee) for further review. 
‘‘(10) ANNUAL
REPORTS.—The Institute shall submit an 
annual report to Congress and the President, and shall make 
the annual report available to the public. Such report shall 
contain— 
‘‘(A) a description of the activities conducted under 
this section, research priorities identified under paragraph 
(1)(A) and methodological standards developed and updated 
by the methodology committee under paragraph (6)(C)(i) 
that are adopted under paragraph (9) during the preceding 
year; 
‘‘(B) the research project agenda and budget of the 
Institute for the following year; 
‘‘(C) any administrative activities conducted by the 
Institute during the preceding year; 
‘‘(D) the names of individuals contributing to any peer- 
review process under paragraph (7), without identifying 
them with a particular research project; and 
‘‘(E) any other relevant information (including informa-
tion on the membership of the Board, expert advisory 
panels, methodology committee, and the executive staff 
of the Institute, any conflicts of interest with respect to 
these individuals, and any bylaws adopted by the Board 
during the preceding year). 
‘‘(e) ADMINISTRATION.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), the Board shall 
carry out the duties of the Institute. 
Public 
information. 
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124 STAT. 735 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) NONDELEGABLE DUTIES.—The activities described in 
subsections (d)(1) and (d)(9) are nondelegable. 
‘‘(f) BOARD OF GOVERNORS.— 
‘‘(1) IN
GENERAL.—The Institute shall have a Board of 
Governors, which shall consist of the following members: 
‘‘(A) The Director of Agency for Healthcare Research 
and Quality (or the Director’s designee). 
‘‘(B) The Director of the National Institutes of Health 
(or the Director’s designee). 
‘‘(C) Seventeen members appointed, not later than 6 
months after the date of enactment of this section, by 
the Comptroller General of the United States as follows: 
‘‘(i) 3 members representing patients and health 
care consumers. 
‘‘(ii) 5 members representing physicians and pro-
viders, including at least 1 surgeon, nurse, State- 
licensed integrative health care practitioner, and rep-
resentative of a hospital. 
‘‘(iii) 3 members representing private payers, of 
whom at least 1 member shall represent health insur-
ance issuers and at least 1 member shall represent 
employers who self-insure employee benefits. 
‘‘(iv) 3 members representing pharmaceutical, 
device, and diagnostic manufacturers or developers. 
‘‘(v) 1 member representing quality improvement 
or independent health service researchers. 
‘‘(vi) 2 members representing the Federal Govern-
ment or the States, including at least 1 member rep-
resenting a Federal health program or agency. 
‘‘(2) QUALIFICATIONS.—The Board shall represent a broad 
range of perspectives and collectively have scientific expertise 
in clinical health sciences research, including epidemiology, 
decisions sciences, health economics, and statistics. In 
appointing the Board, the Comptroller General of the United 
States shall consider and disclose any conflicts of interest in 
accordance with subsection (h)(4)(B). Members of the Board 
shall be recused from relevant Institute activities in the case 
where the member (or an immediate family member of such 
member) has a real conflict of interest directly related to the 
research project or the matter that could affect or be affected 
by such participation. 
‘‘(3) TERMS; VACANCIES.—A member of the Board shall be 
appointed for a term of 6 years, except with respect to the 
members first appointed, whose terms of appointment shall 
be staggered evenly over 2-year increments. No individual shall 
be appointed to the Board for more than 2 terms. Vacancies 
shall be filled in the same manner as the original appointment 
was made. 
‘‘(4) CHAIRPERSON
AND
VICE-CHAIRPERSON.—The Comp-
troller General of the United States shall designate a Chair-
person and Vice Chairperson of the Board from among the 
members of the Board. Such members shall serve as Chair-
person or Vice Chairperson for a period of 3 years. 
‘‘(5) COMPENSATION.—Each member of the Board who is 
not an officer or employee of the Federal Government shall 
be entitled to compensation (equivalent to the rate provided 
for level IV of the Executive Schedule under section 5315 of 
Designation. 
Deadline. 
Establishment. 
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124 STAT. 736 
PUBLIC LAW 111–148—MAR. 23, 2010 
title 5, United States Code) and expenses incurred while per-
forming the duties of the Board. An officer or employee of 
the Federal government who is a member of the Board shall 
be exempt from compensation. 
‘‘(6) DIRECTOR AND STAFF; EXPERTS AND CONSULTANTS.— 
The Board may employ and fix the compensation of an Execu-
tive Director and such other personnel as may be necessary 
to carry out the duties of the Institute and may seek such 
assistance and support of, or contract with, experts and consult-
ants that may be necessary for the performance of the duties 
of the Institute. 
‘‘(7) MEETINGS AND HEARINGS.—The Board shall meet and 
hold hearings at the call of the Chairperson or a majority 
of its members. Meetings not solely concerning matters of per-
sonnel shall be advertised at least 7 days in advance and 
open to the public. A majority of the Board members shall 
constitute a quorum, but a lesser number of members may 
meet and hold hearings. 
‘‘(g) FINANCIAL AND GOVERNMENTAL OVERSIGHT.— 
‘‘(1) CONTRACT FOR AUDIT.—The Institute shall provide for 
the conduct of financial audits of the Institute on an annual 
basis by a private entity with expertise in conducting financial 
audits. 
‘‘(2) REVIEW AND ANNUAL REPORTS.— 
‘‘(A) REVIEW.—The Comptroller General of the United 
States shall review the following: 
‘‘(i) Not less frequently than on an annual basis, 
the financial audits conducted under paragraph (1). 
‘‘(ii) Not less frequently than every 5 years, the 
processes established by the Institute, including the 
research priorities and the conduct of research projects, 
in order to determine whether information produced 
by such research projects is objective and credible, 
is produced in a manner consistent with the require-
ments under this section, and is developed through 
a transparent process. 
‘‘(iii) Not less frequently than every 5 years, the 
dissemination and training activities and data net-
works established under section 937 of the Public 
Health Service Act, including the methods and prod-
ucts used to disseminate research, the types of training 
conducted and supported, and the types and functions 
of the data networks established, in order to determine 
whether the activities and data are produced in a 
manner consistent with the requirements under such 
section. 
‘‘(iv) Not less frequently than every 5 years, the 
overall effectiveness of activities conducted under this 
section and the dissemination, training, and capacity 
building activities conducted under section 937 of the 
Public Health Service Act. Such review shall include 
an analysis of the extent to which research findings 
are used by health care decision-makers, the effect 
of the dissemination of such findings on reducing prac-
tice variation and disparities in health care, and the 
effect of the research conducted and disseminated on 
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124 STAT. 737 
PUBLIC LAW 111–148—MAR. 23, 2010 
innovation and the health care economy of the United 
States. 
‘‘(v) Not later than 8 years after the date of enact-
ment of this section, the adequacy and use of the 
funding for the Institute and the activities conducted 
under section 937 of the Public Health Service Act, 
including a determination as to whether, based on 
the utilization of research findings by public and pri-
vate payers, funding sources for the Patient-Centered 
Outcomes Research Trust Fund under section 9511 
of the Internal Revenue Code of 1986 are appropriate 
and whether such sources of funding should be contin-
ued or adjusted. 
‘‘(B) ANNUAL REPORTS.—Not later than April 1 of each 
year, the Comptroller General of the United States shall 
submit to Congress a report containing the results of the 
review conducted under subparagraph (A) with respect to 
the preceding year (or years, if applicable), together with 
recommendations for such legislation and administrative 
action as the Comptroller General determines appropriate. 
‘‘(h) ENSURING TRANSPARENCY, CREDIBILITY, AND ACCESS.—The 
Institute shall establish procedures to ensure that the following 
requirements for ensuring transparency, credibility, and access are 
met: 
‘‘(1) PUBLIC COMMENT PERIODS.—The Institute shall provide 
for a public comment period of not less than 45 days and 
not more than 60 days prior to the adoption under subsection 
(d)(9) of the national priorities identified under subsection 
(d)(1)(A), the research project agenda established under sub-
section (d)(1)(B), the methodological standards developed and 
updated by the methodology committee under subsection 
(d)(6)(C)(i), and the peer-review process provided under para-
graph (7), and after the release of draft findings with respect 
to systematic reviews of existing research and evidence. 
‘‘(2) ADDITIONAL
FORUMS.—The Institute shall support 
forums to increase public awareness and obtain and incorporate 
public input and feedback through media (such as an Internet 
website) on research priorities, research findings, and other 
duties, activities, or processes the Institute determines appro-
priate. 
‘‘(3) PUBLIC AVAILABILITY.—The Institute shall make avail-
able to the public and disclose through the official public Inter-
net website of the Institute the following: 
‘‘(A) Information contained in research findings as 
specified in subsection (d)(9). 
‘‘(B) The process and methods for the conduct of 
research, including the identity of the entity and the inves-
tigators conducing such research and any conflicts of 
interests of such parties, any direct or indirect links the 
entity has to industry, and research protocols, including 
measures taken, methods of research and analysis, research 
results, and such other information the Institute deter-
mines appropriate) concurrent with the release of research 
findings. 
‘‘(C) Notice of public comment periods under paragraph 
(1), including deadlines for public comments. 
Notice. 
Web posting. 
Procedures. 
Recommenda- 
tions. 
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124 STAT. 738 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(D) Subsequent comments received during each of the 
public comment periods. 
‘‘(E) In accordance with applicable laws and processes 
and as the Institute determines appropriate, proceedings 
of the Institute. 
‘‘(4) DISCLOSURE OF CONFLICTS OF INTEREST.— 
‘‘(A) IN GENERAL.—A conflict of interest shall be dis-
closed in the following manner: 
‘‘(i) By the Institute in appointing members to 
an expert advisory panel under subsection (d)(4), in 
selecting individuals to contribute to any peer-review 
process under subsection (d)(7), and for employment 
as executive staff of the Institute. 
‘‘(ii) By the Comptroller General in appointing 
members of the methodology committee under sub-
section (d)(6); 
‘‘(iii) By the Institute in the annual report under 
subsection (d)(10), except that, in the case of individ-
uals contributing to any such peer review process, such 
description shall be in a manner such that those 
individuals cannot be identified with a particular 
research project. 
‘‘(B) MANNER
OF
DISCLOSURE.—Conflicts of interest 
shall be disclosed as described in subparagraph (A) as 
soon as practicable on the Internet web site of the Institute 
and of the Government Accountability Office. The informa-
tion disclosed under the preceding sentence shall include 
the type, nature, and magnitude of the interests of the 
individual involved, except to the extent that the individual 
recuses himself or herself from participating in the consid-
eration of or any other activity with respect to the study 
as to which the potential conflict exists. 
‘‘(i) RULES.—The Institute, its Board or staff, shall be prohibited 
from accepting gifts, bequeaths, or donations of services or property. 
In addition, the Institute shall be prohibited from establishing 
a corporation or generating revenues from activities other than 
as provided under this section. 
‘‘(j) RULES OF CONSTRUCTION.— 
‘‘(1) COVERAGE.—Nothing in this section shall be con-
strued— 
‘‘(A) to permit the Institute to mandate coverage, 
reimbursement, or other policies for any public or private 
payer; or 
‘‘(B) as preventing the Secretary from covering the 
routine costs of clinical care received by an individual enti-
tled to, or enrolled for, benefits under title XVIII, XIX, 
or XXI in the case where such individual is participating 
in a clinical trial and such costs would otherwise be covered 
under such title with respect to the beneficiary.’’. 
(b) DISSEMINATION AND BUILDING CAPACITY FOR RESEARCH.— 
Title IX of the Public Health Service Act (42 U.S.C. 299 et seq.), 
as amended by section 3606, is further amended by inserting after 
section 936 the following: 
‘‘SEC. 937. DISSEMINATION AND BUILDING CAPACITY FOR RESEARCH. 
‘‘(a) IN GENERAL.— 
42 USC 299b–37. 
Web posting. 
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124 STAT. 739 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) DISSEMINATION.—The Office of Communication and 
Knowledge Transfer (referred to in this section as the ‘Office’) 
at the Agency for Healthcare Research and Quality (or any 
other relevant office designated by Agency for Healthcare 
Research and Quality), in consultation with the National 
Institutes of Health, shall broadly disseminate the research 
findings that are published by the Patient Centered Outcomes 
Research Institute established under section 1181(b) of the 
Social Security Act (referred to in this section as the ‘Institute’) 
and other government-funded research relevant to comparative 
clinical effectiveness research. The Office shall create informa-
tional tools that organize and disseminate research findings 
for physicians, health care providers, patients, payers, and 
policy makers. The Office shall also develop a publicly available 
resource database that collects and contains government-funded 
evidence and research from public, private, not-for profit, and 
academic sources. 
‘‘(2) REQUIREMENTS.—The Office shall provide for the 
dissemination of the Institute’s research findings and govern-
ment-funded research relevant to comparative clinical effective-
ness research to physicians, health care providers, patients, 
vendors of health information technology focused on clinical 
decision support, appropriate professional associations, and 
Federal and private health plans. Materials, forums, and media 
used to disseminate the findings, informational tools, and 
resource databases shall— 
‘‘(A) include a description of considerations for specific 
subpopulations, the research methodology, and the limita-
tions of the research, and the names of the entities, agen-
cies, instrumentalities, and individuals who conducted any 
research which was published by the Institute; and 
‘‘(B) not be construed as mandates, guidelines, or rec-
ommendations for payment, coverage, or treatment. 
‘‘(b) INCORPORATION OF RESEARCH FINDINGS.—The Office, in 
consultation with relevant medical and clinical associations, shall 
assist users of health information technology focused on clinical 
decision support to promote the timely incorporation of research 
findings disseminated under subsection (a) into clinical practices 
and to promote the ease of use of such incorporation. 
‘‘(c) FEEDBACK.—The Office shall establish a process to receive 
feedback from physicians, health care providers, patients, and ven-
dors of health information technology focused on clinical decision 
support, appropriate professional associations, and Federal and pri-
vate health plans about the value of the information disseminated 
and the assistance provided under this section. 
‘‘(d) RULE OF CONSTRUCTION.—Nothing in this section shall 
preclude the Institute from making its research findings publicly 
available as required under section 1181(d)(8) of the Social Security 
Act. 
‘‘(e) TRAINING OF RESEARCHERS.—The Agency for Health Care 
Research and Quality, in consultation with the National Institutes 
of Health, shall build capacity for comparative clinical effectiveness 
research by establishing a grant program that provides for the 
training of researchers in the methods used to conduct such 
research, including systematic reviews of existing research and 
primary research such as clinical trials. At a minimum, such 
Public 
information. 
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124 STAT. 740 
PUBLIC LAW 111–148—MAR. 23, 2010 
training shall be in methods that meet the methodological standards 
adopted under section 1181(d)(9) of the Social Security Act. 
‘‘(f) BUILDING DATA FOR RESEARCH.—The Secretary shall pro-
vide for the coordination of relevant Federal health programs to 
build data capacity for comparative clinical effectiveness research, 
including the development and use of clinical registries and health 
outcomes research data networks, in order to develop and maintain 
a comprehensive, interoperable data network to collect, link, and 
analyze data on outcomes and effectiveness from multiple sources, 
including electronic health records. 
‘‘(g) AUTHORITY TO CONTRACT WITH THE INSTITUTE.—Agencies 
and instrumentalities of the Federal Government may enter into 
agreements with the Institute, and accept and retain funds, for 
the conduct and support of research described in this part, provided 
that the research to be conducted or supported under such agree-
ments is authorized under the governing statutes of such agencies 
and instrumentalities.’’. 
(c) IN GENERAL.—Part D of title XI of the Social Security 
Act, as added by subsection (a), is amended by adding at the 
end the following new section: 
‘‘LIMITATIONS ON CERTAIN USES OF COMPARATIVE CLINICAL 
EFFECTIVENESS RESEARCH 
‘‘SEC. 1182. (a) The Secretary may only use evidence and 
findings from research conducted under section 1181 to make a 
determination regarding coverage under title XVIII if such use 
is through an iterative and transparent process which includes 
public comment and considers the effect on subpopulations. 
‘‘(b) Nothing in section 1181 shall be construed as— 
‘‘(1) superceding or modifying the coverage of items or 
services under title XVIII that the Secretary determines are 
reasonable and necessary under section 1862(l)(1); or 
‘‘(2) authorizing the Secretary to deny coverage of items 
or services under such title solely on the basis of comparative 
clinical effectiveness research. 
‘‘(c)(1) The Secretary shall not use evidence or findings from 
comparative clinical effectiveness research conducted under section 
1181 in determining coverage, reimbursement, or incentive pro-
grams under title XVIII in a manner that treats extending the 
life of an elderly, disabled, or terminally ill individual as of lower 
value than extending the life of an individual who is younger, 
nondisabled, or not terminally ill. 
‘‘(2) Paragraph (1) shall not be construed as preventing the 
Secretary from using evidence or findings from such comparative 
clinical effectiveness research in determining coverage, reimburse-
ment, or incentive programs under title XVIII based upon a 
comparison of the difference in the effectiveness of alternative treat-
ments in extending an individual’s life due to the individual’s age, 
disability, or terminal illness. 
‘‘(d)(1) The Secretary shall not use evidence or findings from 
comparative clinical effectiveness research conducted under section 
1181 in determining coverage, reimbursement, or incentive pro-
grams under title XVIII in a manner that precludes, or with the 
intent to discourage, an individual from choosing a health care 
treatment based on how the individual values the tradeoff between 
extending the length of their life and the risk of disability. 
‘‘(2)(A) Paragraph (1) shall not be construed to— 
42 USC 1320e–1. 
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124 STAT. 741 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(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.’’. 
42 USC 1320e–2. 
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124 STAT. 742 
PUBLIC LAW 111–148—MAR. 23, 2010 
(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. 
26 USC 9511. 
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124 STAT. 743 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(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 
26 USC 4375. 
Definition. 
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124 STAT. 744 
PUBLIC LAW 111–148—MAR. 23, 2010 
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— 
Definition. 
26 USC 4376. 
Definition. 
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124 STAT. 745 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(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. 
Definition. 
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124 STAT. 746 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 4377. DEFINITIONS AND SPECIAL RULES. 
‘‘(a) DEFINITIONS.—For purposes of this subchapter— 
‘‘(1) ACCIDENT AND HEALTH COVERAGE.—The term ‘accident 
and health coverage’ means any coverage which, if provided 
by an insurance policy, would cause such policy to be a specified 
health insurance policy (as defined in section 4375(c)). 
‘‘(2) INSURANCE POLICY.—The term ‘insurance policy’ means 
any policy or other instrument whereby a contract of insurance 
is issued, renewed, or extended. 
‘‘(3) UNITED
STATES.—The term ‘United States’ includes 
any possession of the United States. 
‘‘(b) TREATMENT OF GOVERNMENTAL ENTITIES.— 
‘‘(1) IN GENERAL.—For purposes of this subchapter— 
‘‘(A) the term ‘person’ includes any governmental 
entity, and 
‘‘(B) notwithstanding any other law or rule of law, 
governmental entities shall not be exempt from the fees 
imposed by this subchapter except as provided in paragraph 
(2). 
‘‘(2) TREATMENT OF EXEMPT GOVERNMENTAL PROGRAMS.— 
In the case of an exempt governmental program, no fee shall 
be imposed under section 4375 or section 4376 on any covered 
life under such program. 
‘‘(3) EXEMPT GOVERNMENTAL PROGRAM DEFINED.—For pur-
poses of this subchapter, the term ‘exempt governmental pro-
gram’ means— 
‘‘(A) any insurance program established under title 
XVIII of the Social Security Act, 
‘‘(B) the medical assistance program established by 
title XIX or XXI of the Social Security Act, 
‘‘(C) any program established by Federal law for pro-
viding medical care (other than through insurance policies) 
to individuals (or the spouses and dependents thereof) by 
reason of such individuals being members of the Armed 
Forces of the United States or veterans, and 
‘‘(D) any program established by Federal law for pro-
viding medical care (other than through insurance policies) 
to members of Indian tribes (as defined in section 4(d) 
of the Indian Health Care Improvement Act). 
‘‘(c) TREATMENT AS TAX.—For purposes of subtitle F, the fees 
imposed by this subchapter shall be treated as if they were taxes. 
‘‘(d) NO COVER OVER TO POSSESSIONS.—Notwithstanding any 
other provision of law, no amount collected under this subchapter 
shall be covered over to any possession of the United States.’’. 
(B) CLERICAL AMENDMENTS.— 
(i) Chapter 34 of such Code is amended by striking 
the chapter heading and inserting the following: 
26 USC 4377. 
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124 STAT. 747 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘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. 
Deadline. 
Termination 
date. 
42 USC 2996–8 
note. 
26 USC 501. 
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124 STAT. 748 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(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 
Determination. 
Determination. 
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124 STAT. 749 
PUBLIC LAW 111–148—MAR. 23, 2010 
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. 
Procedures. 
Effective date. 
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124 STAT. 750 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(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 
Determination. 
Determination. 
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124 STAT. 751 
PUBLIC LAW 111–148—MAR. 23, 2010 
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). 
Determination. 
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124 STAT. 752 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(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 
42 USC 1395cc 
note. 
Determination. 
Determination. 
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124 STAT. 753 
PUBLIC LAW 111–148—MAR. 23, 2010 
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 
42 USC 
1320a–7k. 
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124 STAT. 754 
PUBLIC LAW 111–148—MAR. 23, 2010 
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, 
Contracts. 
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124 STAT. 755 
PUBLIC LAW 111–148—MAR. 23, 2010 
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)), 
Notification. 
Definition. 
Penalty. 
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124 STAT. 756 
PUBLIC LAW 111–148—MAR. 23, 2010 
Medicare Advantage organization (as defined in section 
1859(a)(1)), or PDP sponsor (as defined in section 
1860D–41(a)(13)). 
‘‘(ii) EXCLUSION.—Such term does not include a 
beneficiary. 
‘‘(e) INCLUSION
OF NATIONAL PROVIDER IDENTIFIER
ON ALL 
APPLICATIONS AND CLAIMS.—The Secretary shall promulgate a regu-
lation that requires, not later than January 1, 2011, all providers 
of medical or other items or services and suppliers under the 
programs under titles XVIII and XIX that qualify for a national 
provider identifier to include their national provider identifier on 
all applications to enroll in such programs and on all claims for 
payment submitted under such programs.’’. 
(b) ACCESS TO DATA.— 
(1) MEDICARE PART D.—Section 1860D–15(f)(2) of the Social 
Security Act (42 U.S.C. 1395w–116(f)(2)) is amended by striking 
‘‘may be used by’’ and all that follows through the period 
at the end and inserting ‘‘may be used— 
‘‘(A) by officers, employees, and contractors of the 
Department of Health and Human Services for the pur-
poses of, and to the extent necessary in— 
‘‘(i) carrying out this section; and 
‘‘(ii) conducting oversight, evaluation, and enforce-
ment under this title; and 
‘‘(B) by the Attorney General and the Comptroller Gen-
eral of the United States for the purposes of, and to the 
extent necessary in, carrying out health oversight activi-
ties.’’. 
(2) DATA
MATCHING.—Section 552a(a)(8)(B) of title 5, 
United States Code, is amended— 
(A) in clause (vii), by striking ‘‘or’’ at the end; 
(B) in clause (viii), by inserting ‘‘or’’ after the semicolon; 
and 
(C) by adding at the end the following new clause: 
‘‘(ix) matches performed by the Secretary of Health 
and Human Services or the Inspector General of the 
Department of Health and Human Services with 
respect to potential fraud, waste, and abuse, including 
matches of a system of records with non-Federal 
records;’’. 
(3) MATCHING AGREEMENTS WITH THE COMMISSIONER OF 
SOCIAL
SECURITY.—Section 205(r) of the Social Security Act 
(42 U.S.C. 405(r)) is amended by adding at the end the following 
new paragraph: 
‘‘(9)(A) The Commissioner of Social Security shall, upon 
the request of the Secretary or the Inspector General of the 
Department of Health and Human Services— 
‘‘(i) enter into an agreement with the Secretary or 
such Inspector General for the purpose of matching data 
in the system of records of the Social Security Administra-
tion and the system of records of the Department of Health 
and Human Services; and 
‘‘(ii) include in such agreement safeguards to assure 
the maintenance of the confidentiality of any information 
disclosed. 
Contracts. 
42 USC 
1395w–115. 
Regulations. 
Deadline. 
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124 STAT. 757 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) For purposes 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.’’. 
(c) WITHHOLDING OF FEDERAL MATCHING PAYMENTS FOR STATES 
THAT FAIL TO REPORT ENROLLEE ENCOUNTER DATA IN THE MED-
ICAID STATISTICAL INFORMATION SYSTEM.—Section 1903(i) of the 
Social Security Act (42 U.S.C. 1396b(i)) is amended— 
(1) in paragraph (23), by striking ‘‘or’’ at the end; 
(2) in paragraph (24), by striking the period at the end 
and inserting ‘‘; or’’; and 
(3) by adding at the end the following new paragraph:. 
‘‘(25) with respect to any amounts expended for medical 
assistance for individuals for whom the State does not report 
enrollee encounter data (as defined by the Secretary) to the 
Medicaid Statistical Information System (MSIS) in a timely 
manner (as determined by the Secretary).’’. 
(d) PERMISSIVE EXCLUSIONS AND CIVIL MONETARY PENALTIES.— 
(1) PERMISSIVE EXCLUSIONS.—Section 1128(b) of the Social 
Security Act (42 U.S.C. 1320a–7(b)) is amended by adding 
at the end the following new paragraph: 
‘‘(16) MAKING FALSE STATEMENTS OR MISREPRESENTATION 
OF MATERIAL FACTS.—Any individual or entity that knowingly 
makes or causes to be made any false statement, omission, 
or misrepresentation of a material fact in any application, 
agreement, bid, or contract to participate or enroll as a provider 
of services or supplier under a Federal health care program 
(as defined in section 1128B(f)), including Medicare Advantage 
organizations under part C of title XVIII, prescription drug 
plan sponsors under part D of title XVIII, medicaid managed 
care organizations under title XIX, and entities that apply 
to participate as providers of services or suppliers in such 
managed care organizations and such plans.’’. 
(2) CIVIL MONETARY PENALTIES.— 
(A) IN GENERAL.—Section 1128A(a) of the Social Secu-
rity Act (42 U.S.C. 1320a–7a(a)) is amended— 
(i) in paragraph (1)(D), by striking ‘‘was excluded’’ 
and all that follows through the period at the end 
and inserting ‘‘was excluded from the Federal health 
care program (as defined in section 1128B(f)) under 
which the claim was made pursuant to Federal law.’’; 
(ii) in paragraph (6), by striking ‘‘or’’ at the end; 
(iii) by inserting after paragraph (7), the following 
new paragraphs: 
‘‘(8) orders or prescribes a medical or other item or service 
during a period in which the person was excluded from a 
Federal health care program (as so defined), in the case where 
the person knows or should know that a claim for such medical 
or other item or service will be made under such a program; 
‘‘(9) knowingly makes or causes to be made any false state-
ment, omission, or misrepresentation of a material fact in any 
application, bid, or contract to participate or enroll as a provider 
of services or a supplier under a Federal health care program 
(as so defined), including Medicare Advantage organizations 
under part C of title XVIII, prescription drug plan sponsors 
under part D of title XVIII, medicaid managed care organiza-
tions under title XIX, and entities that apply to participate 
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124 STAT. 758 
PUBLIC LAW 111–148—MAR. 23, 2010 
as providers of services or suppliers in such managed care 
organizations and such plans; 
‘‘(10) knows of an overpayment (as defined in paragraph 
(4) of section 1128J(d)) and does not report and return the 
overpayment in accordance with such section;’’; 
(iv) in the first sentence— 
(I) by striking the ‘‘or’’ after ‘‘prohibited rela-
tionship occurs;’’; and 
(II) by striking ‘‘act)’’ and inserting ‘‘act; or 
in cases under paragraph (9), $50,000 for each 
false statement or misrepresentation of a material 
fact)’’; and 
(v) in the second sentence, by striking ‘‘purpose)’’ 
and inserting ‘‘purpose; or in cases under paragraph 
(9), an assessment of not more than 3 times the total 
amount claimed for each item or service for which 
payment was made based upon the application con-
taining the false statement or misrepresentation of 
a material fact)’’. 
(B) CLARIFICATION OF TREATMENT OF CERTAIN CHARI-
TABLE
AND
OTHER
INNOCUOUS
PROGRAMS.—Section 
1128A(i)(6) of the Social Security Act (42 U.S.C. 1320a– 
7a(i)(6)) is amended— 
(i) in subparagraph (C), by striking ‘‘or’’ at the 
end; 
(ii) in subparagraph (D), as redesignated by section 
4331(e) of the Balanced Budget Act of 1997 (Public 
Law 105–33), by striking the period at the end and 
inserting a semicolon; 
(iii) by redesignating subparagraph (D), as added 
by section 4523(c) of such Act, as subparagraph (E) 
and striking the period at the end and inserting ‘‘; 
or’’; and 
(iv) by adding at the end the following new sub-
paragraphs: 
‘‘(F) any other remuneration which promotes access 
to care and poses a low risk of harm to patients and 
Federal health care programs (as defined in section 
1128B(f) and designated by the Secretary under regula-
tions); 
‘‘(G) the offer or transfer of items or services for free 
or less than fair market value by a person, if— 
‘‘(i) the items or services consist of coupons, 
rebates, or other rewards from a retailer; 
‘‘(ii) the items or services are offered or transferred 
on equal terms available to the general public, regard-
less of health insurance status; and 
‘‘(iii) the offer or transfer of the items or services 
is not tied to the provision of other items or services 
reimbursed in whole or in part by the program under 
title XVIII or a State health care program (as defined 
in section 1128(h)); 
‘‘(H) the offer or transfer of items or services for free 
or less than fair market value by a person, if— 
‘‘(i) the items or services are not offered as part 
of any advertisement or solicitation; 
Regulations. 
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124 STAT. 759 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(ii) the items or services are not tied to the provi-
sion of other services reimbursed in whole or in part 
by the program under title XVIII or a State health 
care program (as so defined); 
‘‘(iii) there is a reasonable connection between the 
items or services and the medical care of the individual; 
and 
‘‘(iv) the person provides the items or services after 
determining in good faith that the individual is in 
financial need; or 
‘‘(I) effective on a date specified by the Secretary (but 
not earlier than January 1, 2011), the waiver by a PDP 
sponsor of a prescription drug plan under part D of title 
XVIII or an MA organization offering an MA–PD plan 
under part C of such title of any copayment for the first 
fill of a covered part D drug (as defined in section 1860D– 
2(e)) that is a generic drug for individuals enrolled in 
the prescription drug plan or MA–PD plan, respectively.’’. 
(e) TESTIMONIAL SUBPOENA AUTHORITY
IN EXCLUSION-ONLY 
CASES.—Section 1128(f) of the Social Security Act (42 U.S.C. 1320a– 
7(f)) is amended by adding at the end the following new paragraph: 
‘‘(4) The provisions of subsections (d) and (e) of section 
205 shall apply with respect to this section to the same extent 
as they are applicable with respect to title II. The Secretary 
may delegate the authority granted by section 205(d) (as made 
applicable to this section) to the Inspector General of the 
Department of Health and Human Services for purposes of 
any investigation under this section.’’. 
(f) HEALTH CARE FRAUD.— 
(1) KICKBACKS.—Section 1128B of the Social Security Act 
(42 U.S.C. 1320a–7b) is amended by adding at the end the 
following new subsection: 
‘‘(g) In addition to the penalties provided for in this section 
or section 1128A, a claim that includes items or services resulting 
from a violation of this section constitutes a false or fraudulent 
claim for purposes of subchapter III of chapter 37 of title 31, 
United States Code.’’. 
(2) REVISING
THE
INTENT
REQUIREMENT.—Section 1128B 
of the Social Security Act (42 U.S.C. 1320a–7b), as amended 
by paragraph (1), is amended by adding at the end the following 
new subsection: 
‘‘(h) 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.’’. 
(g) SURETY BOND REQUIREMENTS.— 
(1) DURABLE MEDICAL EQUIPMENT.—Section 1834(a)(16)(B) 
of the Social Security Act (42 U.S.C. 1395m(a)(16)(B)) is 
amended by inserting ‘‘that the Secretary determines is 
commensurate with the volume of the billing of the supplier’’ 
before the period at the end. 
(2) HOME HEALTH AGENCIES.—Section 1861(o)(7)(C) of the 
Social Security Act (42 U.S.C. 1395x(o)(7)(C)) is amended by 
inserting ‘‘that the Secretary determines is commensurate with 
the volume of the billing of the home health agency’’ before 
the semicolon at the end. 
(3) REQUIREMENTS FOR CERTAIN OTHER PROVIDERS OF SERV-
ICES AND SUPPLIERS.—Section 1862 of the Social Security Act 
Applicability. 
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124 STAT. 760 
PUBLIC LAW 111–148—MAR. 23, 2010 
(42 U.S.C. 1395y) is amended by adding at the end the following 
new subsection: 
‘‘(n) REQUIREMENT OF A SURETY BOND FOR CERTAIN PROVIDERS 
OF SERVICES AND SUPPLIERS.— 
‘‘(1) IN GENERAL.—The Secretary may require a provider 
of services or supplier described in paragraph (2) to provide 
the Secretary on a continuing basis with a surety bond in 
a form specified by the Secretary in an amount (not less than 
$50,000) that the Secretary determines is commensurate with 
the volume of the billing of the provider of services or supplier. 
The Secretary may waive the requirement of a bond under 
the preceding sentence in the case of a provider of services 
or supplier that provides a comparable surety bond under State 
law. 
‘‘(2) PROVIDER
OF
SERVICES
OR
SUPPLIER
DESCRIBED.—A 
provider of services or supplier described in this paragraph 
is a provider of services or supplier the Secretary determines 
appropriate based on the level of risk involved with respect 
to the provider of services or supplier, and consistent with 
the surety bond requirements under sections 1834(a)(16)(B) 
and 1861(o)(7)(C).’’. 
(h) SUSPENSION
OF
MEDICARE
AND
MEDICAID
PAYMENTS 
PENDING INVESTIGATION OF CREDIBLE ALLEGATIONS OF FRAUD.— 
(1) MEDICARE.—Section 1862 of the Social Security Act 
(42 U.S.C. 1395y), as amended by subsection (g)(3), is amended 
by adding at the end the following new subsection: 
‘‘(o) SUSPENSION
OF PAYMENTS PENDING INVESTIGATION
OF 
CREDIBLE ALLEGATIONS OF FRAUD.— 
‘‘(1) IN GENERAL.—The Secretary may suspend payments 
to a provider of services or supplier under this title pending 
an investigation of a credible allegation of fraud against the 
provider of services or supplier, unless the Secretary determines 
there is good cause not to suspend such payments. 
‘‘(2) CONSULTATION.—The Secretary shall consult with the 
Inspector General of the Department of Health and Human 
Services in determining whether there is a credible allegation 
of fraud against a provider of services or supplier. 
‘‘(3) PROMULGATION OF REGULATIONS.—The Secretary shall 
promulgate regulations to carry out this subsection and section 
1903(i)(2)(C).’’. 
(2) MEDICAID.—Section 1903(i)(2) of such Act (42 U.S.C. 
1396b(i)(2)) is amended— 
(A) in subparagraph (A), by striking ‘‘or’’ at the end; 
and 
(B) by inserting after subparagraph (B), the following: 
‘‘(C) by any individual or entity to whom the State 
has failed to suspend payments under the plan during 
any period when there is pending an investigation of a 
credible allegation of fraud against the individual or entity, 
as determined by the State in accordance with regulations 
promulgated by the Secretary for purposes of section 
1862(o) and this subparagraph, unless the State determines 
in accordance with such regulations there is good cause 
not to suspend such payments; or’’. 
(i) INCREASED FUNDING TO FIGHT FRAUD AND ABUSE.— 
(1) IN GENERAL.—Section 1817(k) of the Social Security 
Act (42 U.S.C. 1395i(k)) is amended— 
Determination. 
Determination. 
Waiver authority. 
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124 STAT. 761 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) by adding at the end the following new paragraph: 
‘‘(7) ADDITIONAL FUNDING.—In addition to the funds other-
wise appropriated to the Account from the Trust Fund under 
paragraphs (3) and (4) and for purposes described in paragraphs 
(3)(C) and (4)(A), there are hereby appropriated an additional 
$10,000,000 to such Account from such Trust Fund for each 
of fiscal years 2011 through 2020. The funds appropriated 
under this paragraph shall be allocated in the same proportion 
as the total funding appropriated with respect to paragraphs 
(3)(A) and (4)(A) was allocated with respect to fiscal year 2010, 
and shall be available without further appropriation until 
expended.’’; and 
(B) in paragraph (4)(A), by inserting ‘‘until expended’’ 
after ‘‘appropriation’’. 
(2) INDEXING OF AMOUNTS APPROPRIATED.— 
(A) DEPARTMENTS OF HEALTH AND HUMAN SERVICES 
AND JUSTICE.—Section 1817(k)(3)(A)(i) of the Social Secu-
rity Act (42 U.S.C. 1395i(k)(3)(A)(i)) is amended— 
(i) in subclause (III), by inserting ‘‘and’’ at the 
end; 
(ii) in subclause (IV)— 
(I) by striking ‘‘for each of fiscal years 2007, 
2008, 2009, and 2010’’ and inserting ‘‘for each fiscal 
year after fiscal year 2006’’; and 
(II) by striking ‘‘; and’’ and inserting a period; 
and 
(iii) by striking subclause (V). 
(B) OFFICE OF THE INSPECTOR GENERAL OF THE DEPART-
MENT
OF
HEALTH
AND
HUMAN
SERVICES.—Section 
1817(k)(3)(A)(ii) of such Act (42 U.S.C. 1395i(k)(3)(A)(ii)) 
is amended— 
(i) in subclause (VIII), by inserting ‘‘and’’ at the 
end; 
(ii) in subclause (IX)— 
(I) by striking ‘‘for each of fiscal years 2008, 
2009, and 2010’’ and inserting ‘‘for each fiscal year 
after fiscal year 2007’’; and 
(II) by striking ‘‘; and’’ and inserting a period; 
and 
(iii) by striking subclause (X). 
(C) FEDERAL
BUREAU
OF
INVESTIGATION.—Section 
1817(k)(3)(B) of the Social Security Act (42 U.S.C. 
1395i(k)(3)(B)) is amended— 
(i) in clause (vii), by inserting ‘‘and’’ at the end; 
(ii) in clause (viii)— 
(I) by striking ‘‘for each of fiscal years 2007, 
2008, 2009, and 2010’’ and inserting ‘‘for each fiscal 
year after fiscal year 2006’’; and 
(II) by striking ‘‘; and’’ and inserting a period; 
and 
(iii) by striking clause (ix). 
(D) 
MEDICARE
INTEGRITY
PROGRAM.—Section 
1817(k)(4)(C) of the Social Security Act (42 U.S.C. 
1395i(k)(4)(C)) is amended by adding at the end the fol-
lowing new clause: 
‘‘(ii) For each fiscal year after 2010, by the percent-
age increase in the consumer price index for all urban 
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124 STAT. 762 
PUBLIC LAW 111–148—MAR. 23, 2010 
consumers (all items; United States city average) over 
the previous year.’’. 
(j) MEDICARE INTEGRITY PROGRAM AND MEDICAID INTEGRITY 
PROGRAM.— 
(1) MEDICARE INTEGRITY PROGRAM.— 
(A) REQUIREMENT TO PROVIDE PERFORMANCE STATIS-
TICS.—Section 1893(c) of the Social Security Act (42 U.S.C. 
1395ddd(c)) is amended— 
(i) in paragraph (3), by striking ‘‘and’’ at the end; 
(ii) by redesignating paragraph (4) as paragraph 
(5); and 
(iii) by inserting after paragraph (3) the following 
new paragraph: 
‘‘(4) the entity agrees to provide the Secretary and the 
Inspector General of the Department of Health and Human 
Services with such performance statistics (including the number 
and amount of overpayments recovered, the number of fraud 
referrals, and the return on investment of such activities by 
the entity) as the Secretary or the Inspector General may 
request; and’’. 
(B) EVALUATIONS AND ANNUAL REPORT.—Section 1893 
of the Social Security Act (42 U.S.C. 1395ddd) is amended 
by adding at the end the following new subsection: 
‘‘(i) EVALUATIONS AND ANNUAL REPORT.— 
‘‘(1) EVALUATIONS.—The Secretary shall conduct evalua-
tions of eligible entities which the Secretary contracts with 
under the Program not less frequently than every 3 years. 
‘‘(2) ANNUAL REPORT.—Not later than 180 days after the 
end of each fiscal year (beginning with fiscal year 2011), the 
Secretary shall submit a report to Congress which identifies— 
‘‘(A) the use of funds, including funds transferred from 
the Federal Hospital Insurance Trust Fund under section 
1817 and the Federal Supplementary Insurance Trust Fund 
under section 1841, to carry out this section; and 
‘‘(B) the effectiveness of the use of such funds.’’. 
(C) FLEXIBILITY IN PURSUING FRAUD AND ABUSE.—Sec-
tion 1893(a) of the Social Security Act (42 U.S.C. 
1395ddd(a)) is amended by inserting ‘‘, or otherwise,’’ after 
‘‘entities’’. 
(2) MEDICAID INTEGRITY PROGRAM.— 
(A) REQUIREMENT TO PROVIDE PERFORMANCE STATIS-
TICS.—Section 1936(c)(2) of the Social Security Act (42 
U.S.C. 1396u–6(c)(2)) is amended— 
(i) by redesignating subparagraph (D) as subpara-
graph (E); and 
(ii) by inserting after subparagraph (C) the fol-
lowing new subparagraph: 
‘‘(D) The entity agrees to provide the Secretary and 
the Inspector General of the Department of Health and 
Human 
Services 
with 
such 
performance 
statistics 
(including the number and amount of overpayments recov-
ered, the number of fraud referrals, and the return on 
investment of such activities by the entity) as the Secretary 
or the Inspector General may request.’’. 
(B) 
EVALUATIONS
AND
ANNUAL
REPORT.—Section 
1936(e) of the Social Security Act (42 U.S.C. 1396u–7(e)) 
is amended— 
42 USC 1396u–6. 
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124 STAT. 763 
PUBLIC LAW 111–148—MAR. 23, 2010 
(i) by redesignating paragraph (4) as paragraph 
(5); and 
(ii) by inserting after paragraph (3) the following 
new paragraph: 
‘‘(4) EVALUATIONS.—The Secretary shall conduct evalua-
tions of eligible entities which the Secretary contracts with 
under the Program not less frequently than every 3 years.’’. 
(k) EXPANDED APPLICATION OF HARDSHIP WAIVERS FOR EXCLU-
SIONS.—Section 1128(c)(3)(B) of the Social Security Act (42 U.S.C. 
1320a–7(c)(3)(B)) is amended by striking ‘‘individuals entitled to 
benefits under part A of title XVIII or enrolled under part B 
of such title, or both’’ and inserting ‘‘beneficiaries (as defined in 
section 1128A(i)(5)) of that program’’. 
SEC. 
6403. 
ELIMINATION 
OF 
DUPLICATION 
BETWEEN 
THE 
HEALTHCARE INTEGRITY AND PROTECTION DATA BANK 
AND THE NATIONAL PRACTITIONER DATA BANK. 
(a) INFORMATION REPORTED BY FEDERAL AGENCIES AND HEALTH 
PLANS.—Section 1128E of the Social Security Act (42 U.S.C. 1320a– 
7e) is amended— 
(1) by striking subsection (a) and inserting the following: 
‘‘(a) IN GENERAL.—The Secretary shall maintain a national 
health care fraud and abuse data collection program under this 
section for the reporting of certain final adverse actions (not 
including settlements in which no findings of liability have been 
made) against health care providers, suppliers, or practitioners 
as required by subsection (b), with access as set forth in subsection 
(d), and shall furnish the information collected under this section 
to the National Practitioner Data Bank established pursuant to 
the Health Care Quality Improvement Act of 1986 (42 U.S.C. 11101 
et seq.).’’; 
(2) by striking subsection (d) and inserting the following: 
‘‘(d) ACCESS TO REPORTED INFORMATION.— 
‘‘(1) AVAILABILITY.—The information collected under this 
section shall be available from the National Practitioner Data 
Bank to the agencies, authorities, and officials which are pro-
vided under section 1921(b) information reported under section 
1921(a). 
‘‘(2) FEES FOR DISCLOSURE.—The Secretary may establish 
or approve reasonable fees for the disclosure of information 
under this section. The amount of such a fee may not exceed 
the costs of processing the requests for disclosure and of pro-
viding such information. Such fees shall be available to the 
Secretary to cover such costs.’’; 
(3) by striking subsection (f) and inserting the following: 
‘‘(f) APPROPRIATE COORDINATION.—In implementing this section, 
the Secretary shall provide for the maximum appropriate coordina-
tion with part B of the Health Care Quality Improvement Act 
of 1986 (42 U.S.C. 11131 et seq.) and section 1921.’’; and 
(4) in subsection (g)— 
(A) in paragraph (1)(A)— 
(i) in clause (iii)— 
(I) by striking ‘‘or State’’ each place it appears; 
(II) by redesignating subclauses (II) and (III) 
as subclauses (III) and (IV), respectively; and 
(III) by inserting after subclause (I) the fol-
lowing new subclause: 
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124 STAT. 764 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(II) any dismissal or closure of the pro-
ceedings by reason of the provider, supplier, or 
practitioner surrendering their license or leaving 
the State or jurisdiction’’; and 
(ii) by striking clause (iv) and inserting the fol-
lowing: 
‘‘(iv) Exclusion from participation in a Federal 
health care program (as defined in section 1128B(f)).’’; 
(B) in paragraph (3)— 
(i) by striking subparagraphs (D) and (E); and 
(ii) by redesignating subparagraph (F) as subpara-
graph (D); and 
(C) in subparagraph (D) (as so redesignated), by 
striking ‘‘or State’’. 
(b) INFORMATION REPORTED BY STATE LAW OR FRAUD ENFORCE-
MENT AGENCIES.—Section 1921 of the Social Security Act (42 U.S.C. 
1396r–2) is amended— 
(1) in subsection (a)— 
(A) in paragraph (1)— 
(i) by striking ‘‘SYSTEM.—The State’’ and all that 
follows through the semicolon and inserting SYSTEM.— 
‘‘(A) LICENSING OR CERTIFICATION ACTIONS.—The State 
must have in effect a system of reporting the following 
information with respect to formal proceedings (as defined 
by the Secretary in regulations) concluded against a health 
care practitioner or entity by a State licensing or certifi-
cation agency:’’; 
(ii) by redesignating subparagraphs (A) through 
(D) as clauses (i) through (iv), respectively, and 
indenting appropriately; 
(iii) in subparagraph (A)(iii) (as so redesignated)— 
(I) by striking ‘‘the license of’’ and inserting 
‘‘license or the right to apply for, or renew, a 
license by’’; and 
(II) by inserting ‘‘nonrenewability,’’ after ‘‘vol-
untary surrender,’’; and 
(iv) by adding at the end the following new 
subparagraph: 
‘‘(B) OTHER FINAL ADVERSE ACTIONS.—The State must 
have in effect a system of reporting information with 
respect to any final adverse action (not including settle-
ments in which no findings of liability have been made) 
taken against a health care provider, supplier, or practi-
tioner by a State law or fraud enforcement agency.’’; and 
(B) in paragraph (2), by striking ‘‘the authority 
described in paragraph (1)’’ and inserting ‘‘a State licensing 
or certification agency or State law or fraud enforcement 
agency’’; 
(2) in subsection (b)— 
(A) by striking paragraph (2) and inserting the fol-
lowing: 
‘‘(2) to State licensing or certification agencies and Federal 
agencies responsible for the licensing and certification of health 
care providers, suppliers, and licensed health care practi-
tioners;’’; 
Reports. 
Reports. 
Regulations. 
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124 STAT. 765 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) in each of paragraphs (4) and (6), by inserting 
‘‘, but only with respect to information provided pursuant 
to subsection (a)(1)(A)’’ before the comma at the end; 
(C) by striking paragraph (5) and inserting the fol-
lowing: 
‘‘(5) to State law or fraud enforcement agencies,’’; 
(D) by redesignating paragraphs (7) and (8) as para-
graphs (8) and (9), respectively; and 
(E) by inserting after paragraph (6) the following new 
paragraph: 
‘‘(7) to health plans (as defined in section 1128C(c));’’; 
(3) by redesignating subsection (d) as subsection (h), and 
by inserting after subsection (c) the following new subsections: 
‘‘(d) DISCLOSURE AND CORRECTION OF INFORMATION.— 
‘‘(1) DISCLOSURE.—With respect to information reported 
pursuant to subsection (a)(1), the Secretary shall— 
‘‘(A) provide for disclosure of the information, upon 
request, to the health care practitioner who, or the entity 
that, is the subject of the information reported; and 
‘‘(B) establish procedures for the case where the health 
care practitioner or entity disputes the accuracy of the 
information reported. 
‘‘(2) CORRECTIONS.—Each State licensing or certification 
agency and State law or fraud enforcement agency shall report 
corrections of information already reported about any formal 
proceeding or final adverse action described in subsection (a), 
in such form and manner as the Secretary prescribes by regula-
tion. 
‘‘(e) FEES FOR DISCLOSURE.—The Secretary may establish or 
approve reasonable fees for the disclosure of information under 
this section. The amount of such a fee may not exceed the costs 
of processing the requests for disclosure and of providing such 
information. Such fees shall be available to the Secretary to cover 
such costs. 
‘‘(f) PROTECTION FROM LIABILITY FOR REPORTING.—No person 
or entity, including any agency designated by the Secretary in 
subsection (b), shall be held liable in any civil action with respect 
to any reporting of information as required under this section, 
without knowledge of the falsity of the information contained in 
the report. 
‘‘(g) REFERENCES.—For purposes of this section: 
‘‘(1) STATE LICENSING OR CERTIFICATION AGENCY.—The term 
‘State licensing or certification agency’ includes any authority 
of a State (or of a political subdivision thereof) responsible 
for the licensing of health care practitioners (or any peer review 
organization or private accreditation entity reviewing the serv-
ices provided by health care practitioners) or entities. 
‘‘(2) STATE
LAW
OR
FRAUD
ENFORCEMENT
AGENCY.—The 
term ‘State law or fraud enforcement agency’ includes— 
‘‘(A) a State law enforcement agency; and 
‘‘(B) a State medicaid fraud control unit (as defined 
in section 1903(q)). 
‘‘(3) FINAL ADVERSE ACTION.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 
term ‘final adverse action’ includes— 
Reports. 
Regulations. 
Procedures. 
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124 STAT. 766 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) civil judgments against a health care provider, 
supplier, or practitioner in State court related to the 
delivery of a health care item or service; 
‘‘(ii) State criminal convictions related to the 
delivery of a health care item or service; 
‘‘(iii) exclusion from participation in State health 
care programs (as defined in section 1128(h)); 
‘‘(iv) any licensing or certification action described 
in subsection (a)(1)(A) taken against a supplier by a 
State licensing or certification agency; and 
‘‘(v) any other adjudicated actions or decisions that 
the Secretary shall establish by regulation. 
‘‘(B) EXCEPTION.—Such term does not include any 
action with respect to a malpractice claim.’’; and 
(4) in subsection (h), as so redesignated, by striking ‘‘The 
Secretary’’ and all that follows through the period at the end 
and inserting ‘‘In implementing this section, the Secretary shall 
provide for the maximum appropriate coordination with part 
B of the Health Care Quality Improvement Act of 1986 (42 
U.S.C. 11131 et seq.) and section 1128E.’’. 
(c) CONFORMING
AMENDMENT.—Section 1128C(a)(1) of the 
Social Security Act (42 U.S.C. 1320a–7c(a)(1)) is amended— 
(1) in subparagraph (C), by adding ‘‘and’’ after the comma 
at the end; 
(2) in subparagraph (D), by striking ‘‘, and’’ and inserting 
a period; and 
(3) by striking subparagraph (E). 
(d) TRANSITION PROCESS; EFFECTIVE DATE.— 
(1) IN GENERAL.—Effective on the date of enactment of 
this Act, the Secretary of Health and Human Services (in 
this section referred to as the ‘‘Secretary’’) shall implement 
a transition process under which, by not later than the end 
of the transition period described in paragraph (5), the Sec-
retary shall cease operating the Healthcare Integrity and 
Protection Data Bank established under section 1128E of the 
Social Security Act (as in effect before the effective date speci-
fied in paragraph (6)) and shall transfer all data collected 
in the Healthcare Integrity and Protection Data Bank to the 
National Practitioner Data Bank established pursuant to the 
Health Care Quality Improvement Act of 1986 (42 U.S.C. 11101 
et seq.). During such transition process, the Secretary shall 
have in effect appropriate procedures to ensure that data collec-
tion and access to the Healthcare Integrity and Protection 
Data Bank and the National Practitioner Data Bank are not 
disrupted. 
(2) REGULATIONS.—The Secretary shall promulgate regula-
tions to carry out the amendments made by subsections (a) 
and (b). 
(3) FUNDING.— 
(A) AVAILABILITY
OF
FEES.—Fees collected pursuant 
to section 1128E(d)(2) of the Social Security Act prior to 
the effective date specified in paragraph (6) for the disclo-
sure of information in the Healthcare Integrity and Protec-
tion Data Bank shall be available to the Secretary, without 
fiscal year limitation, for payment of costs related to the 
transition process described in paragraph (1). Any such 
fees remaining after the transition period is complete shall 
Procedures. 
42 USC 1320a–7e 
note. 
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124 STAT. 767 
PUBLIC LAW 111–148—MAR. 23, 2010 
be available to the Secretary, without fiscal year limitation, 
for payment of the costs of operating the National Practi-
tioner Data Bank. 
(B) AVAILABILITY OF ADDITIONAL FUNDS.—In addition 
to the fees described in subparagraph (A), any funds avail-
able to the Secretary or to the Inspector General of the 
Department of Health and Human Services for a purpose 
related to combating health care fraud, waste, or abuse 
shall be available to the extent necessary for operating 
the Healthcare Integrity and Protection Data Bank during 
the transition period, including systems testing and other 
activities necessary to ensure that information formerly 
reported to the Healthcare Integrity and Protection Data 
Bank will be accessible through the National Practitioner 
Data Bank after the end of such transition period. 
(4) SPECIAL
PROVISION
FOR
ACCESS
TO
THE
NATIONAL 
PRACTITIONER DATA BANK BY THE DEPARTMENT OF VETERANS 
AFFAIRS.— 
(A) IN GENERAL.—Notwithstanding any other provision 
of law, during the 1-year period that begins on the effective 
date specified in paragraph (6), the information described 
in subparagraph (B) shall be available from the National 
Practitioner Data Bank to the Secretary of Veterans Affairs 
without charge. 
(B) 
INFORMATION
DESCRIBED.—For 
purposes 
of 
subparagraph (A), the information described in this 
subparagraph is the information that would, but for the 
amendments made by this section, have been available 
to the Secretary of Veterans Affairs from the Healthcare 
Integrity and Protection Data Bank. 
(5) TRANSITION PERIOD DEFINED.—For purposes of this sub-
section, the term ‘‘transition period’’ means the period that 
begins on the date of enactment of this Act and ends on the 
later of— 
(A) the date that is 1 year after such date of enactment; 
or 
(B) the effective date of the regulations promulgated 
under paragraph (2). 
(6) EFFECTIVE
DATE.—The amendments made by sub-
sections (a), (b), and (c) shall take effect on the first day 
after the final day of the transition period. 
SEC. 6404. MAXIMUM PERIOD FOR SUBMISSION OF MEDICARE CLAIMS 
REDUCED TO NOT MORE THAN 12 MONTHS. 
(a) REDUCING MAXIMUM PERIOD FOR SUBMISSION.— 
(1) PART
A.—Section 1814(a) of the Social Security Act 
(42 U.S.C. 1395f(a)(1)) is amended— 
(A) in paragraph (1), by striking ‘‘period of 3 calendar 
years’’ and all that follows through the semicolon and 
inserting ‘‘period ending 1 calendar year after the date 
of service;’’; and 
(B) by adding at the end the following new sentence: 
‘‘In applying paragraph (1), the Secretary may specify 
exceptions to the 1 calendar year period specified in such 
paragraph.’’ 
(2) PART B.— 
Time period. 
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124 STAT. 768 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) Section 1842(b)(3) of such Act (42 U.S.C. 
1395u(b)(3)(B)) is amended— 
(i) in subparagraph (B), in the flush language fol-
lowing clause (ii), by striking ‘‘close of the calendar 
year following the year in which such service is fur-
nished (deeming any service furnished in the last 3 
months of any calendar year to have been furnished 
in the succeeding calendar year)’’ and inserting ‘‘period 
ending 1 calendar year after the date of service’’; and 
(ii) by adding at the end the following new sen-
tence: ‘‘In applying subparagraph (B), the Secretary 
may specify exceptions to the 1 calendar year period 
specified in such subparagraph.’’ 
(B) Section 1835(a) of such Act (42 U.S.C. 1395n(a)) 
is amended— 
(i) in paragraph (1), by striking ‘‘period of 3 cal-
endar years’’ and all that follows through the semicolon 
and inserting ‘‘period ending 1 calendar year after 
the date of service;’’; and 
(ii) by adding at the end the following new sen-
tence: ‘‘In applying paragraph (1), the Secretary may 
specify exceptions to the 1 calendar year period speci-
fied in such paragraph.’’ 
(b) EFFECTIVE DATE.— 
(1) IN
GENERAL.—The amendments made by subsection 
(a) shall apply to services furnished on or after January 1, 
2010. 
(2) SERVICES FURNISHED BEFORE 2010.—In the case of serv-
ices furnished before January 1, 2010, a bill or request for 
payment under section 1814(a)(1), 1842(b)(3)(B), or 1835(a) 
shall be filed not later that December 31, 2010. 
SEC. 6405. PHYSICIANS WHO ORDER ITEMS OR SERVICES REQUIRED 
TO BE MEDICARE ENROLLED PHYSICIANS OR ELIGIBLE 
PROFESSIONALS. 
(a) DME.—Section 1834(a)(11)(B) of the Social Security Act 
(42 U.S.C. 1395m(a)(11)(B)) is amended by striking ‘‘physician’’ 
and inserting ‘‘physician enrolled under section 1866(j) or an eligible 
professional under section 1848(k)(3)(B) that is enrolled under sec-
tion 1866(j)’’. 
(b) HOME HEALTH SERVICES.— 
(1) PART
A.—Section 1814(a)(2) of such Act (42 U.S.C. 
1395(a)(2)) is amended in the matter preceding subparagraph 
(A) by inserting ‘‘in the case of services described in subpara-
graph (C), a physician enrolled under section 1866(j) or an 
eligible professional under section 1848(k)(3)(B),’’ before ‘‘or, 
in the case of services’’. 
(2) PART
B.—Section 1835(a)(2) of such 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) 
or an eligible professional under section 1848(k)(3)(B),’’ after 
‘‘a physician’’. 
(c) APPLICATION TO OTHER ITEMS OR SERVICES.—The Secretary 
may extend the requirement applied by the amendments made 
by subsections (a) and (b) to durable medical equipment and home 
health services (relating to requiring certifications and written 
42 USC 1395f 
note. 
42 USC 1395f. 
Deadline. 
42 USC 1395f 
note. 
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124 STAT. 769 
PUBLIC LAW 111–148—MAR. 23, 2010 
orders to be made by enrolled physicians and health professions) 
to all other categories of items or services under title XVIII of 
the Social Security Act (42 U.S.C. 1395 et seq.), including covered 
part D drugs as defined in section 1860D–2(e) of such Act (42 
U.S.C. 1395w–102), that are ordered, prescribed, or referred by 
a physician enrolled under section 1866(j) of such Act (42 U.S.C. 
1395cc(j)) or an eligible professional under section 1848(k)(3)(B) 
of such Act (42 U.S.C. 1395w–4(k)(3)(B)). 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall apply to written orders and certifications made on or after 
July 1, 2010. 
SEC. 6406. REQUIREMENT FOR PHYSICIANS TO PROVIDE DOCUMENTA-
TION ON REFERRALS TO PROGRAMS AT HIGH RISK OF 
WASTE AND ABUSE. 
(a) PHYSICIANS AND OTHER SUPPLIERS.—Section 1842(h) of the 
Social Security Act (42 U.S.C. 1395u(h)) is amended by adding 
at the end the following new paragraph: 
‘‘(9) The Secretary may revoke enrollment, for a period of not 
more than one year for each act, for a physician or supplier under 
section 1866(j) if such physician or supplier fails to maintain and, 
upon request of the Secretary, provide access to documentation 
relating to written orders or requests for payment for durable 
medical equipment, certifications for home health services, or refer-
rals for other items or services written or ordered by such physician 
or supplier under this title, as specified by the Secretary.’’. 
(b) PROVIDERS OF SERVICES.—Section 1866(a)(1) of such Act 
(42 U.S.C. 1395cc) is further amended— 
(1) in subparagraph (U), by striking at the end ‘‘and’’; 
(2) in subparagraph (V), by striking the period at the 
end and adding ‘‘; and’’; and 
(3) by adding at the end the following new subparagraph: 
‘‘(W) maintain and, upon request of the Secretary, pro-
vide access to documentation relating to written orders 
or requests for payment for durable medical equipment, 
certifications for home health services, or referrals for other 
items or services written or ordered by the provider under 
this title, as specified by the Secretary.’’. 
(c) 
OIG 
PERMISSIVE
EXCLUSION
AUTHORITY.—Section 
1128(b)(11) of the Social Security Act (42 U.S.C. 1320a–7(b)(11)) 
is amended by inserting ‘‘, ordering, referring for furnishing, or 
certifying the need for’’ after ‘‘furnishing’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall apply to orders, certifications, and referrals made on or after 
January 1, 2010. 
SEC. 6407. FACE TO FACE ENCOUNTER WITH PATIENT REQUIRED 
BEFORE PHYSICIANS MAY CERTIFY ELIGIBILITY FOR 
HOME HEALTH SERVICES OR DURABLE MEDICAL EQUIP-
MENT UNDER MEDICARE. 
(a) CONDITION OF PAYMENT FOR HOME HEALTH SERVICES.— 
(1) PART A.—Section 1814(a)(2)(C) of such Act is amended— 
(A) by striking ‘‘and such services’’ and inserting ‘‘such 
services’’; and 
(B) by inserting after ‘‘care of a physician’’ the fol-
lowing: ‘‘, and, in the case of a certification made by a 
physician after January 1, 2010, prior to making such 
42 USC 1395f. 
42 USC 1320a–7 
note. 
42 USC 1395f 
note. 
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124 STAT. 770 
PUBLIC LAW 111–148—MAR. 23, 2010 
certification the physician must document that the physi-
cian himself or herself has had a face-to-face encounter 
(including through use of telehealth, subject to the require-
ments in section 1834(m), and other than with respect 
to encounters that are incident to services involved) with 
the individual within a reasonable timeframe as deter-
mined by the Secretary’’. 
(2) PART B.—Section 1835(a)(2)(A) of the Social Security 
Act is amended— 
(A) by striking ‘‘and’’ before ‘‘(iii)’’; and 
(B) by inserting after ‘‘care of a physician’’ the fol-
lowing: ‘‘, and (iv) in the case of a certification after January 
1, 2010, prior to making such certification the physician 
must document that the physician has had a face-to-face 
encounter (including through use of telehealth and other 
than with respect to encounters that are incident to services 
involved) with the individual during the 6-month period 
preceding such certification, or other reasonable timeframe 
as determined by the Secretary’’. 
(b) CONDITION
OF PAYMENT
FOR DURABLE MEDICAL EQUIP-
MENT.—Section 1834(a)(11)(B) of the Social Security Act (42 U.S.C. 
1395m(a)(11)(B)) is amended— 
(1) by striking ‘‘ORDER.—The Secretary’’ and inserting 
‘‘ORDER.— 
‘‘(i) IN GENERAL.—The Secretary’’; and 
(2) by adding at the end the following new clause: 
‘‘(ii) 
REQUIREMENT
FOR
FACE
TO
FACE 
ENCOUNTER.—The Secretary shall require that such 
an order be written pursuant to the physician docu-
menting that a physician, a physician assistant, a 
nurse practitioner, or a clinical nurse specialist (as 
those terms are defined in section 1861(aa)(5)) has 
had a face-to-face encounter (including through use 
of telehealth under subsection (m) and other than with 
respect to encounters that are incident to services 
involved) with the individual involved during the 6- 
month period preceding such written order, or other 
reasonable timeframe as determined by the Secretary.’’. 
(c) APPLICATION TO OTHER AREAS UNDER MEDICARE.—The Sec-
retary may apply the face-to-face encounter requirement described 
in the amendments made by subsections (a) and (b) to other items 
and services for which payment is provided under title XVIII of 
the Social Security Act based upon a finding that such an decision 
would reduce the risk of waste, fraud, or abuse. 
(d) APPLICATION TO MEDICAID.—The requirements pursuant to 
the amendments made by subsections (a) and (b) shall apply in 
the case of physicians making certifications for home health services 
under title XIX of the Social Security Act in the same manner 
and to the same extent as such requirements apply in the case 
of physicians making such certifications under title XVIII of such 
Act. 
SEC. 6408. ENHANCED PENALTIES. 
(a) CIVIL MONETARY PENALTIES
FOR FALSE STATEMENTS
OR 
DELAYING INSPECTIONS.—Section 1128A(a) of the Social Security 
Act (42 U.S.C. 1320a–7a(a)), as amended by section 5002(d)(2)(A), 
is amended— 
42 USC 1395f 
note. 
42 USC 1395f 
note. 
42 USC 1395n. 
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124 STAT. 771 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) in paragraph (6), by striking ‘‘or’’ at the end; and 
(2) by inserting after paragraph (7) the following new para-
graphs: 
‘‘(8) knowingly makes, uses, or causes to be made or used, 
a false record or statement material to a false or fraudulent 
claim for payment for items and services furnished under a 
Federal health care program; or 
‘‘(9) fails to grant timely access, upon reasonable request 
(as defined by the Secretary in regulations), to the Inspector 
General of the Department of Health and Human Services, 
for the purpose of audits, investigations, evaluations, or other 
statutory functions of the Inspector General of the Department 
of Health and Human Services;’’; and 
(3) in the first sentence— 
(A) by striking ‘‘or in cases under paragraph (7)’’ and 
inserting ‘‘in cases under paragraph (7)’’; and 
(B) by striking ‘‘act)’’ and inserting ‘‘act, in cases under 
paragraph (8), $50,000 for each false record or statement, 
or in cases under paragraph (9), $15,000 for each day 
of the failure described in such paragraph)’’. 
(b) MEDICARE ADVANTAGE AND PART D PLANS.— 
(1) ENSURING TIMELY INSPECTIONS RELATING TO CONTRACTS 
WITH MA ORGANIZATIONS.—Section 1857(d)(2) of such Act (42 
U.S.C. 1395w–27(d)(2)) is amended— 
(A) in subparagraph (A), by inserting ‘‘timely’’ before 
‘‘inspect’’; and 
(B) in subparagraph (B), by inserting ‘‘timely’’ before 
‘‘audit and inspect’’. 
(2) MARKETING
VIOLATIONS.—Section 1857(g)(1) of the 
Social Security Act (42 U.S.C. 1395w–27(g)(1)) is amended— 
(A) in subparagraph (F), by striking ‘‘or’’ at the end; 
(B) by inserting after subparagraph (G) the following 
new subparagraphs: 
‘‘(H) except as provided under subparagraph (C) or 
(D) of section 1860D–1(b)(1), enrolls an individual in any 
plan under this part without the prior consent of the indi-
vidual or the designee of the individual; 
‘‘(I) transfers an individual enrolled under this part 
from one plan to another without the prior consent of 
the individual or the designee of the individual or solely 
for the purpose of earning a commission; 
‘‘(J) fails to comply with marketing restrictions 
described in subsections (h) and (j) of section 1851 or 
applicable implementing regulations or guidance; or 
‘‘(K) employs or contracts with any individual or entity 
who engages in the conduct described in subparagraphs 
(A) through (J) of this paragraph;’’; and 
(C) by adding at the end the following new sentence: 
‘‘The Secretary may provide, in addition to any other rem-
edies authorized by law, for any of the remedies described 
in paragraph (2), if the Secretary determines that any 
employee or agent of such organization, or any provider 
or supplier who contracts with such organization, has 
engaged in any conduct described in subparagraphs (A) 
through (K) of this paragraph.’’. 
(3) 
PROVISION
OF
FALSE
INFORMATION.—Section 
1857(g)(2)(A) of the Social Security Act (42 U.S.C. 1395w– 
Determination. 
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124 STAT. 772 
PUBLIC LAW 111–148—MAR. 23, 2010 
27(g)(2)(A)) is amended by inserting ‘‘except with respect to 
a determination under subparagraph (E), an assessment of 
not more than the amount claimed by such plan or plan sponsor 
based upon the misrepresentation or falsified information 
involved,’’ after ‘‘for each such determination,’’. 
(c) OBSTRUCTION OF PROGRAM AUDITS.—Section 1128(b)(2) of 
the Social Security Act (42 U.S.C. 1320a–7(b)(2)) is amended— 
(1) in the heading, by inserting ‘‘OR AUDIT’’ after ‘‘INVESTIGA-
TION’’; and 
(2) by striking ‘‘investigation into’’ and all that follows 
through the period and inserting ‘‘investigation or audit related 
to—’’ 
‘‘(i) any offense described in paragraph (1) or in 
subsection (a); or 
‘‘(ii) the use of funds received, directly or indirectly, 
from any Federal health care program (as defined in 
section 1128B(f)).’’. 
(d) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as provided in paragraph (2), the 
amendments made by this section shall apply to acts committed 
on or after January 1, 2010. 
(2) EXCEPTION.—The amendments made by subsection 
(b)(1) take effect on the date of enactment of this Act. 
SEC. 6409. MEDICARE SELF-REFERRAL DISCLOSURE PROTOCOL. 
(a) DEVELOPMENT OF SELF-REFERRAL DISCLOSURE PROTOCOL.— 
(1) IN
GENERAL.—The Secretary of Health and Human 
Services, in cooperation with the Inspector General of the 
Department of Health and Human Services, shall establish, 
not later than 6 months after the date of the enactment of 
this Act, a protocol to enable health care providers of services 
and suppliers to disclose an actual or potential violation of 
section 1877 of the Social Security Act (42 U.S.C. 1395nn) 
pursuant to a self-referral disclosure protocol (in this section 
referred to as an ‘‘SRDP’’). The SRDP shall include direction 
to health care providers of services and suppliers on— 
(A) a specific person, official, or office to whom such 
disclosures shall be made; and 
(B) instruction on the implication of the SRDP on 
corporate integrity agreements and corporate compliance 
agreements. 
(2) PUBLICATION ON INTERNET WEBSITE OF SRDP INFORMA-
TION.—The Secretary of Health and Human Services shall post 
information on the public Internet website of the Centers for 
Medicare & Medicaid Services to inform relevant stakeholders 
of how to disclose actual or potential violations pursuant to 
an SRDP. 
(3) RELATION TO ADVISORY OPINIONS.—The SRDP shall be 
separate from the advisory opinion process set forth in regula-
tions implementing section 1877(g) of the Social Security Act. 
(b) REDUCTION IN AMOUNTS OWED.—The Secretary of Health 
and Human Services is authorized to reduce the amount due and 
owing for all violations under section 1877 of the Social Security 
Act to an amount less than that specified in subsection (g) of 
such section. In establishing such amount for a violation, the Sec-
retary may consider the following factors: 
Deadline. 
42 USC 1395nn 
note. 
42 USC 1320a–7 
note. 
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124 STAT. 773 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) The nature and extent of the improper or illegal prac-
tice. 
(2) The timeliness of such self-disclosure. 
(3) The cooperation in providing additional information 
related to the disclosure. 
(4) Such other factors as the Secretary considers appro-
priate. 
(c) REPORT.—Not later than 18 months after the date on which 
the SRDP protocol is established under subsection (a)(1), the Sec-
retary shall submit to Congress a report on the implementation 
of this section. Such report shall include— 
(1) the number of health care providers of services and 
suppliers making disclosures pursuant to the SRDP; 
(2) the amounts collected pursuant to the SRDP; 
(3) the types of violations reported under the SRDP; and 
(4) such other information as may be necessary to evaluate 
the impact of this section. 
SEC. 6410. ADJUSTMENTS TO THE MEDICARE DURABLE MEDICAL 
EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES 
COMPETITIVE ACQUISITION PROGRAM. 
(a) EXPANSION OF ROUND 2 OF THE DME COMPETITIVE BIDDING 
PROGRAM.—Section 1847(a)(1) of the Social Security Act (42 U.S.C. 
1395w–3(a)(1)) is amended— 
(1) in subparagraph (B)(i)(II), by striking ‘‘70’’ and inserting 
‘‘91’’; and 
(2) in subparagraph (D)(ii)— 
(A) in subclause (I), by striking ‘‘and’’ at the end; 
(B) by redesignating subclause (II) as subclause (III); 
and 
(C) by inserting after subclause (I) the following new 
subclause: 
‘‘(II) the Secretary shall include the next 21 
largest metropolitan statistical areas by total popu-
lation (after those selected under subclause (I)) 
for such round; and’’. 
(b) REQUIREMENT
TO EITHER COMPETITIVELY BID AREAS
OR 
USE COMPETITIVE BID PRICES BY 2016.—Section 1834(a)(1)(F) of 
the Social Security Act (42 U.S.C. 1395m(a)(1)(F)) is amended— 
(1) in clause (i), by striking ‘‘and’’ at the end; 
(2) in clause (ii)— 
(A) by inserting ‘‘(and, in the case of covered items 
furnished on or after January 1, 2016, subject to clause 
(iii), shall)’’ after ‘‘may’’; and 
(B) by striking the period at the end and inserting 
‘‘; and’’; and 
(3) by adding at the end the following new clause: 
‘‘(iii) in the case of covered items furnished on 
or after January 1, 2016, the Secretary shall continue 
to make such adjustments described in clause (ii) as, 
under such competitive acquisition programs, addi-
tional covered items are phased in or information is 
updated as contracts under section 1847 are recom-
peted in accordance with section 1847(b)(3)(B).’’. 
SEC. 6411. EXPANSION OF THE RECOVERY AUDIT CONTRACTOR (RAC) 
PROGRAM. 
(a) EXPANSION TO MEDICAID.— 
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124 STAT. 774 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) STATE PLAN AMENDMENT.—Section 1902(a)(42) of the 
Social Security Act (42 U.S.C. 1396a(a)(42)) is amended— 
(A) by striking ‘‘that the records’’ and inserting ‘‘that— 
‘‘(A) the records’’; 
(B) by inserting ‘‘and’’ after the semicolon; and 
(C) by adding at the end the following: 
‘‘(B) not later than December 31, 2010, the State 
shall— 
‘‘(i) establish a program under which the State 
contracts (consistent with State law and in the same 
manner as the Secretary enters into contracts with 
recovery audit contractors under section 1893(h), sub-
ject to such exceptions or requirements as the Secretary 
may require for purposes of this title or a particular 
State) with 1 or more recovery audit contractors for 
the purpose of identifying underpayments and overpay-
ments and recouping overpayments under the State 
plan and under any waiver of the State plan with 
respect to all services for which payment is made to 
any entity under such plan or waiver; and 
‘‘(ii) provide assurances satisfactory to the Sec-
retary that— 
‘‘(I) under such contracts, payment shall be 
made to such a contractor only from amounts 
recovered; 
‘‘(II) from such amounts recovered, payment— 
‘‘(aa) shall be made on a contingent basis 
for collecting overpayments; and 
‘‘(bb) may be made in such amounts as 
the State may specify for identifying under-
payments; 
‘‘(III) the State has an adequate process for 
entities to appeal any adverse determination made 
by such contractors; and 
‘‘(IV) such program is carried out in accordance 
with such requirements as the Secretary shall 
specify, including— 
‘‘(aa) for purposes of section 1903(a)(7), 
that amounts expended by the State to carry 
out the program shall be considered amounts 
expended as necessary for the proper and effi-
cient administration of the State plan or a 
waiver of the plan; 
‘‘(bb) that section 1903(d) shall apply to 
amounts recovered under the program; and 
‘‘(cc) that the State and any such contrac-
tors under contract with the State shall coordi-
nate such recovery audit efforts with other 
contractors or entities performing audits of 
entities receiving payments under the State 
plan or waiver in the State, including efforts 
with Federal and State law enforcement with 
respect to the Department of Justice, including 
the Federal Bureau of Investigations, the 
Inspector General of the Department of Health 
and Human Services, and the State medicaid 
fraud control unit; and’’. 
Deadline. 
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124 STAT. 775 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) COORDINATION; REGULATIONS.— 
(A) IN GENERAL.—The Secretary of Health and Human 
Services, acting through the Administrator of the Centers 
for Medicare & Medicaid Services, shall coordinate the 
expansion of the Recovery Audit Contractor program to 
Medicaid with States, particularly with respect to each 
State that enters into a contract with a recovery audit 
contractor for purposes of the State’s Medicaid program 
prior to December 31, 2010. 
(B) REGULATIONS.—The Secretary of Health and 
Human Services shall promulgate regulations to carry out 
this subsection and the amendments made by this sub-
section, including with respect to conditions of Federal 
financial participation, as specified by the Secretary. 
(b) EXPANSION TO MEDICARE PARTS C AND D.—Section 1893(h) 
of the Social Security Act (42 U.S.C. 1395ddd(h)) is amended— 
(1) in paragraph (1), in the matter preceding subparagraph 
(A), by striking ‘‘part A or B’’ and inserting ‘‘this title’’; 
(2) in paragraph (2), by striking ‘‘parts A and B’’ and 
inserting ‘‘this title’’; 
(3) in paragraph (3), by inserting ‘‘(not later than December 
31, 2010, in the case of contracts relating to payments made 
under part C or D)’’ after ‘‘2010’’; 
(4) in paragraph (4), in the matter preceding subparagraph 
(A), by striking ‘‘part A or B’’ and inserting ‘‘this title’’; and 
(5) by adding at the end the following: 
‘‘(9) SPECIAL
RULES
RELATING
TO
PARTS
C
AND
D.—The 
Secretary shall enter into contracts under paragraph (1) to 
require recovery audit contractors to— 
‘‘(A) ensure that each MA plan under part C has an 
anti-fraud plan in effect and to review the effectiveness 
of each such anti-fraud plan; 
‘‘(B) ensure that each prescription drug plan under 
part D has an anti-fraud plan in effect and to review 
the effectiveness of each such anti-fraud plan; 
‘‘(C) examine claims for reinsurance payments under 
section 1860D–15(b) to determine whether prescription 
drug plans submitting such claims incurred costs in excess 
of the allowable reinsurance costs permitted under para-
graph (2) of that section; and 
‘‘(D) review estimates submitted by prescription drug 
plans by private plans with respect to the enrollment of 
high cost beneficiaries (as defined by the Secretary) and 
to compare such estimates with the numbers of such bene-
ficiaries actually enrolled by such plans.’’. 
(c) ANNUAL REPORT.—The Secretary of Health and Human 
Services, acting through the Administrator of the Centers for Medi-
care & Medicaid Services, shall submit an annual report to Congress 
concerning the effectiveness of the Recovery Audit Contractor pro-
gram under Medicaid and Medicare and shall include such reports 
recommendations for expanding or improving the program. 
42 USC 1396a 
note. 
42 USC 1396a 
note. 
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124 STAT. 776 
PUBLIC LAW 111–148—MAR. 23, 2010 
Subtitle F—Additional Medicaid Program 
Integrity Provisions 
SEC. 6501. TERMINATION OF PROVIDER PARTICIPATION UNDER MED-
ICAID IF TERMINATED UNDER MEDICARE OR OTHER 
STATE PLAN. 
Section 1902(a)(39) of the Social Security Act (42 U.S.C. 42 
U.S.C. 1396a(a)) is amended by inserting after ‘‘1128A,’’ the fol-
lowing: ‘‘terminate the participation of any individual or entity 
in such program if (subject to such exceptions as are permitted 
with respect to exclusion under sections 1128(c)(3)(B) and 
1128(d)(3)(B)) participation of such individual or entity is termi-
nated under title XVIII or any other State plan under this title,’’. 
SEC. 6502. MEDICAID EXCLUSION FROM PARTICIPATION RELATING TO 
CERTAIN OWNERSHIP, CONTROL, AND MANAGEMENT 
AFFILIATIONS. 
Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), 
as amended by section 6401(b), is amended by inserting after para-
graph (77) the following: 
‘‘(78) provide that the State agency described in paragraph 
(9) exclude, with respect to a period, any individual or entity 
from participation in the program under the State plan if 
such individual or entity owns, controls, or manages an entity 
that (or if such entity is owned, controlled, or managed by 
an individual or entity that)— 
‘‘(A) has unpaid overpayments (as defined by the Sec-
retary) under this title during such period determined by 
the Secretary or the State agency to be delinquent; 
‘‘(B) is suspended or excluded from participation under 
or whose participation is terminated under this title during 
such period; or 
‘‘(C) is affiliated with an individual or entity that has 
been suspended or excluded from participation under this 
title or whose participation is terminated under this title 
during such period;’’. 
SEC. 6503. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTER-
NATE PAYEES REQUIRED TO REGISTER UNDER MED-
ICAID. 
(a) IN GENERAL.—Section 1902(a) of the Social Security Act 
(42 U.S.C. 42 U.S.C. 1396a(a)), as amended by section 6502(a), 
is amended by inserting after paragraph (78), the following: 
‘‘(79) provide that any agent, clearinghouse, or other alter-
nate payee (as defined by the Secretary) that submits claims 
on behalf of a health care provider must register with the 
State and the Secretary in a form and manner specified by 
the Secretary;’’. 
SEC. 6504. REQUIREMENT TO REPORT EXPANDED SET OF DATA ELE-
MENTS UNDER MMIS TO DETECT FRAUD AND ABUSE. 
(a) IN GENERAL.—Section 1903(r)(1)(F) of the Social Security 
Act (42 U.S.C. 1396b(r)(1)(F)) is amended by inserting after ‘‘nec-
essary’’ the following: ‘‘and including, for data submitted to the 
Secretary on or after January 1, 2010, data elements from the 
Determination. 
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124 STAT. 777 
PUBLIC LAW 111–148—MAR. 23, 2010 
automated data system that the Secretary determines to be nec-
essary for program integrity, program oversight, and administra-
tion, at such frequency as the Secretary shall determine’’. 
(b) MANAGED CARE ORGANIZATIONS.— 
(1) IN GENERAL.—Section 1903(m)(2)(A)(xi) of the Social 
Security Act (42 U.S.C. 1396b(m)(2)(A)(xi)) is amended by 
inserting ‘‘and for the provision of such data to the State 
at a frequency and level of detail to be specified by the Sec-
retary’’ after ‘‘patients’’. 
(2) EFFECTIVE DATE.—The amendment made by paragraph 
(1) shall apply with respect to contract years beginning on 
or after January 1, 2010. 
SEC. 6505. PROHIBITION ON PAYMENTS TO INSTITUTIONS OR ENTITIES 
LOCATED OUTSIDE OF THE UNITED STATES. 
Section 1902(a) of the Social Security Act (42 U.S.C. 1396b(a)), 
as amended by section 6503, is amended by inserting after para-
graph (79) the following new paragraph: 
‘‘(80) provide that the State shall not provide any payments 
for items or services provided under the State plan or under 
a waiver to any financial institution or entity located outside 
of the United States;’’. 
SEC. 6506. OVERPAYMENTS. 
(a) EXTENSION OF PERIOD FOR COLLECTION OF OVERPAYMENTS 
DUE TO FRAUD.— 
(1) IN GENERAL.—Section 1903(d)(2) of the Social Security 
Act (42 U.S.C. 1396b(d)(2)) is amended— 
(A) in subparagraph (C)— 
(i) in the first sentence, by striking ‘‘60 days’’ and 
inserting ‘‘1 year’’; and 
(ii) in the second sentence, by striking ‘‘60 days’’ 
and inserting ‘‘1-year period’’; and 
(B) in subparagraph (D)— 
(i) in inserting ‘‘(i)’’ after ‘‘(D)’’; and 
(ii) by adding at the end the following: 
‘‘(ii) In any case where the State is unable to recover a debt 
which represents an overpayment (or any portion thereof) made 
to a person or other entity due to fraud within 1 year of discovery 
because there is not a final determination of the amount of the 
overpayment under an administrative or judicial process (as 
applicable), including as a result of a judgment being under appeal, 
no adjustment shall be made in the Federal payment to such 
State on account of such overpayment (or portion thereof) before 
the date that is 30 days after the date on which a final judgment 
(including, if applicable, a final determination on an appeal) is 
made.’’. 
(2) EFFECTIVE DATE.—The amendments made by this sub-
section take effect on the date of enactment of this Act and 
apply to overpayments discovered on or after that date. 
(b) CORRECTIVE ACTION.—The Secretary shall promulgate regu-
lations that require States to correct Federally identified claims 
overpayments, of an ongoing or recurring nature, with new Medicaid 
Management Information System (MMIS) edits, audits, or other 
appropriate corrective action. 
Regulations. 
42 USC 1396b 
note. 
42 USC 1396b 
note. 
42 USC 1396a. 
42 USC 1396b 
note. 
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124 STAT. 778 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 6507. MANDATORY STATE USE OF NATIONAL CORRECT CODING 
INITIATIVE. 
Section 1903(r) of the Social Security Act (42 U.S.C. 1396b(r)) 
is amended— 
(1) in paragraph (1)(B)— 
(A) in clause (ii), by striking ‘‘and’’ at the end; 
(B) in clause (iii), by adding ‘‘and’’ after the semi- 
colon; and 
(C) by adding at the end the following new clause: 
‘‘(iv) effective for claims filed on or after October 
1, 2010, incorporate compatible methodologies of the 
National Correct Coding Initiative administered by the 
Secretary (or any successor initiative to promote correct 
coding and to control improper coding leading to 
inappropriate payment) and such other methodologies 
of that Initiative (or such other national correct coding 
methodologies) as the Secretary identifies in accord-
ance with paragraph (4);’’; and 
(2) by adding at the end the following new paragraph: 
‘‘(4) For purposes of paragraph (1)(B)(iv), the Secretary shall 
do the following: 
‘‘(A) Not later than September 1, 2010: 
‘‘(i) Identify those methodologies of the National Cor-
rect Coding Initiative administered by the Secretary (or 
any successor initiative to promote correct coding and to 
control improper coding leading to inappropriate payment) 
which are compatible to claims filed under this title. 
‘‘(ii) Identify those methodologies of such Initiative (or 
such other national correct coding methodologies) that 
should be incorporated into claims filed under this title 
with respect to items or services for which States provide 
medical assistance under this title and no national correct 
coding methodologies have been established under such 
Initiative with respect to title XVIII. 
‘‘(iii) Notify States of— 
‘‘(I) the methodologies identified under subpara-
graphs (A) and (B) (and of any other national correct 
coding methodologies identified under subparagraph 
(B)); and 
‘‘(II) how States are to incorporate such methodolo-
gies into claims filed under this title. 
‘‘(B) Not later than March 1, 2011, submit a report to 
Congress that includes the notice to States under clause (iii) 
of subparagraph (A) and an analysis supporting the identifica-
tion of the methodologies made under clauses (i) and (ii) of 
subparagraph (A).’’. 
SEC. 6508. GENERAL EFFECTIVE DATE. 
(a) IN GENERAL.—Except as otherwise provided in this subtitle, 
this subtitle and the amendments made by this subtitle take effect 
on January 1, 2011, without regard to whether final regulations 
to carry out such amendments and subtitle have been promulgated 
by that date. 
(b) DELAY IF STATE LEGISLATION REQUIRED.—In the case of 
a State plan for medical assistance under title XIX of the Social 
Security Act or a child health plan under title XXI of such Act 
which the Secretary of Health and Human Services determines 
Determination. 
Plans. 
42 USC 1396a 
note. 
Notification. 
Deadlines. 
Effective date. 
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124 STAT. 779 
PUBLIC LAW 111–148—MAR. 23, 2010 
requires State legislation (other than legislation appropriating 
funds) in order for the plan to meet the additional requirement 
imposed by the amendments made by this subtitle, the State plan 
or child health plan shall not be regarded as failing to comply 
with the requirements of such title solely on the basis of its failure 
to meet this additional requirement before the first day of the 
first calendar quarter beginning after the close of the first regular 
session of the State legislature that begins after the date of the 
enactment of this Act. For purposes of the previous sentence, in 
the case of a State that has a 2-year legislative session, each 
year of such session shall be deemed to be a separate regular 
session of the State legislature. 
Subtitle G—Additional Program Integrity 
Provisions 
SEC. 6601. PROHIBITION ON FALSE STATEMENTS AND REPRESENTA-
TIONS. 
(a) PROHIBITION.—Part 5 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.) 
is amended by adding at the end the following: 
‘‘SEC. 519. PROHIBITION ON FALSE STATEMENTS AND REPRESENTA-
TIONS. 
‘‘No person, in connection with a plan or other arrangement 
that is multiple employer welfare arrangement described in section 
3(40), shall make a false statement or false representation of fact, 
knowing it to be false, in connection with the marketing or sale 
of such plan or arrangement, to any employee, any member of 
an employee organization, any beneficiary, any employer, any 
employee organization, the Secretary, or any State, or the represent-
ative or agent of any such person, State, or the Secretary, con-
cerning— 
‘‘(1) the financial condition or solvency of such plan or 
arrangement; 
‘‘(2) the benefits provided by such plan or arrangement; 
‘‘(3) the regulatory status of such plan or other arrangement 
under any Federal or State law governing collective bargaining, 
labor management relations, or intern union affairs; or 
‘‘(4) the regulatory status of such plan or other arrangement 
regarding exemption from state regulatory authority under this 
Act. 
This section shall not apply to any plan or arrangement that does 
not fall within the meaning of the term ‘multiple employer welfare 
arrangement’ under section 3(40)(A).’’. 
(b) CRIMINAL PENALTIES.—Section 501 of the Employee Retire-
ment Income Security Act of 1974 (29 U.S.C. 1131) is amended— 
(1) by inserting ‘‘(a)’’ before ‘‘Any person’’; and 
(2) by adding at the end the following: 
‘‘(b) Any person that violates section 519 shall upon conviction 
be imprisoned not more than 10 years or fined under title 18, 
United States Code, or both.’’. 
(c) CONFORMING AMENDMENT.—The table of sections for part 
5 of subtitle B of title I of the Employee Retirement Income Security 
Act of 1974 is amended by adding at the end the following: 
‘‘Sec. 519. Prohibition on false statement and representations.’’. 
29 USC 1149. 
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124 STAT. 780 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 6602. CLARIFYING DEFINITION. 
Section 24(a)(2) of title 18, United States Code, is amended 
by inserting ‘‘or section 411, 518, or 511 of the Employee Retirement 
Income Security Act of 1974,’’ after ‘‘1954 of this title’’. 
SEC. 6603. DEVELOPMENT OF MODEL UNIFORM REPORT FORM. 
Part C of title XXVII of the Public Health Service Act (42 
U.S.C. 300gg–91 et seq.) is amended by adding at the end the 
following: 
‘‘SEC. 2794. UNIFORM FRAUD AND ABUSE REFERRAL FORMAT. 
‘‘The Secretary shall request the National Association of Insur-
ance Commissioners to develop a model uniform report form for 
private health insurance issuer seeking to refer suspected fraud 
and abuse to State insurance departments or other responsible 
State agencies for investigation. The Secretary shall request that 
the National Association of Insurance Commissioners develop rec-
ommendations for uniform reporting standards for such referrals.’’. 
SEC. 6604. APPLICABILITY OF STATE LAW TO COMBAT FRAUD AND 
ABUSE. 
(a) IN GENERAL.—Part 5 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.), 
as amended by section 6601, is further amended by adding at 
the end the following: 
‘‘SEC. 520. APPLICABILITY OF STATE LAW TO COMBAT FRAUD AND 
ABUSE. 
‘‘The Secretary may, for the purpose of identifying, preventing, 
or prosecuting fraud and abuse, adopt regulatory standards estab-
lishing, or issue an order relating to a specific person establishing, 
that a person engaged in the business of providing insurance 
through a multiple employer welfare arrangement described in 
section 3(40) is subject to the laws of the States in which such 
person operates which regulate insurance in such State, notwith-
standing section 514(b)(6) of this Act or the Liability Risk Retention 
Act of 1986, and regardless of whether the law of the State is 
otherwise preempted under any of such provisions. This section 
shall not apply to any plan or arrangement that does not fall 
within the meaning of the term ‘multiple employer welfare arrange-
ment’ under section 3(40)(A).’’. 
(b) CONFORMING AMENDMENT.—The table of sections for part 
5 of subtitle B of title I of the Employee Retirement Income Security 
Act of 1974, as amended by section 6601, is further amended 
by adding at the end the following: 
‘‘Sec. 520. Applicability of State law to combat fraud and abuse.’’. 
SEC. 6605. ENABLING THE DEPARTMENT OF LABOR TO ISSUE ADMINIS-
TRATIVE SUMMARY CEASE AND DESIST ORDERS AND 
SUMMARY SEIZURES ORDERS AGAINST PLANS THAT ARE 
IN FINANCIALLY HAZARDOUS CONDITION. 
(a) IN GENERAL.—Part 5 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.), 
as amended by section 6604, is further amended by adding at 
the end the following: 
29 USC 1150. 
42 USC 
300gg–95. 
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124 STAT. 781 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 521. ADMINISTRATIVE SUMMARY CEASE AND DESIST ORDERS 
AND SUMMARY SEIZURE ORDERS AGAINST MULTIPLE 
EMPLOYER WELFARE ARRANGEMENTS IN FINANCIALLY 
HAZARDOUS CONDITION. 
‘‘(a) IN GENERAL.—The Secretary may issue a cease and desist 
(ex parte) order under this title if it appears to the Secretary 
that the alleged conduct of a multiple employer welfare arrangement 
described in section 3(40), other than a plan or arrangement 
described in subsection (g), is fraudulent, or creates an immediate 
danger to the public safety or welfare, or is causing or can be 
reasonably expected to cause significant, imminent, and irreparable 
public injury. 
‘‘(b) HEARING.—A person that is adversely affected by the 
issuance of a cease and desist order under subsection (a) may 
request a hearing by the Secretary regarding such order. The Sec-
retary may require that a proceeding under this section, including 
all related information and evidence, be conducted in a confidential 
manner. 
‘‘(c) BURDEN OF PROOF.—The burden of proof in any hearing 
conducted under subsection (b) shall be on the party requesting 
the hearing to show cause why the cease and desist order should 
be set aside. 
‘‘(d) DETERMINATION.—Based upon the evidence presented at 
a hearing under subsection (b), the cease and desist order involved 
may be affirmed, modified, or set aside by the Secretary in whole 
or in part. 
‘‘(e) SEIZURE.—The Secretary may issue a summary seizure 
order under this title if it appears that a multiple employer welfare 
arrangement is in a financially hazardous condition. 
‘‘(f) REGULATIONS.—The Secretary may promulgate such regula-
tions or other guidance as may be necessary or appropriate to 
carry out this section. 
‘‘(g) EXCEPTION.—This section shall not apply to any plan or 
arrangement that does not fall within the meaning of the term 
‘multiple employer welfare arrangement’ under section 3(40)(A).’’. 
(b) CONFORMING AMENDMENT.—The table of sections for part 
5 of subtitle B of title I of the Employee Retirement Income Security 
Act of 1974, as amended by section 6604, is further amended 
by adding at the end the following: 
‘‘Sec. 521. Administrative summary cease and desist orders and summary seizure 
orders against health plans in financially hazardous condition.’’. 
SEC. 6606. MEWA PLAN REGISTRATION WITH DEPARTMENT OF LABOR. 
Section 101(g) of the Employee Retirement Income Security 
Act of 1974 (29 U.S.C. 1021(g)) is amended— 
(1) by striking ‘‘Secretary may’’ and inserting ‘‘Secretary 
shall’’; and 
(2) by inserting ‘‘to register with the Secretary prior to 
operating in a State and may, by regulation, require such 
multiple employer welfare arrangements’’ after ‘‘not group 
health plans’’. 
SEC. 6607. PERMITTING EVIDENTIARY PRIVILEGE AND CONFIDENTIAL 
COMMUNICATIONS. 
Section 504 of the Employee Retirement Income Security Act 
of 1974 (29 U.S.C. 1134) is amended by adding at the end the 
following: 
29 USC 1151. 
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124 STAT. 782 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(d) The Secretary may promulgate a regulation that provides 
an evidentiary privilege for, and provides for the confidentiality 
of communications between or among, any of the following entities 
or their agents, consultants, or employees: 
‘‘(1) A State insurance department. 
‘‘(2) A State attorney general. 
‘‘(3) The National Association of Insurance Commissioners. 
‘‘(4) The Department of Labor. 
‘‘(5) The Department of the Treasury. 
‘‘(6) The Department of Justice. 
‘‘(7) The Department of Health and Human Services. 
‘‘(8) Any other Federal or State authority that the Secretary 
determines is appropriate for the purposes of enforcing the 
provisions of this title. 
‘‘(e) The privilege established under subsection (d) shall apply 
to communications related to any investigation, audit, examination, 
or inquiry conducted or coordinated by any of the agencies. A 
communication that is privileged under subsection (d) shall not 
waive any privilege otherwise available to the communicating 
agency or to any person who provided the information that is 
communicated.’’. 
Subtitle H—Elder Justice Act 
SEC. 6701. SHORT TITLE OF SUBTITLE. 
This subtitle may be cited as the ‘‘Elder Justice Act of 2009’’. 
SEC. 6702. DEFINITIONS. 
Except as otherwise specifically provided, any term that is 
defined in section 2011 of the Social Security Act (as added by 
section 6703(a)) and is used in this subtitle has the meaning given 
such term by such section. 
SEC. 6703. ELDER JUSTICE. 
(a) ELDER JUSTICE.— 
(1) IN GENERAL.—Title XX of the Social Security Act (42 
U.S.C. 1397 et seq.) is amended— 
(A) in the heading, by inserting ‘‘AND ELDER JUS-
TICE’’ after ‘‘SOCIAL SERVICES’’; 
(B) by inserting before section 2001 the following: 
‘‘Subtitle A—Block Grants to States for 
Social Services’’; 
and 
(C) by adding at the end the following: 
‘‘Subtitle B—Elder Justice 
‘‘SEC. 2011. DEFINITIONS. 
‘‘In this subtitle: 
‘‘(1) ABUSE.—The term ‘abuse’ means the knowing infliction 
of physical or psychological harm or the knowing deprivation 
of goods or services that are necessary to meet essential needs 
or to avoid physical or psychological harm. 
42 USC 1397j. 
42 USC 1395i–3a 
note. 
42 USC 1305 
note. 
Elder Justice Act 
of 2009. 
Applicability. 
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124 STAT. 783 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) ADULT PROTECTIVE SERVICES.—The term ‘adult protec-
tive services’ means such services provided to adults as the 
Secretary may specify and includes services such as— 
‘‘(A) receiving reports of adult abuse, neglect, or exploi-
tation; 
‘‘(B) investigating the reports described in subpara-
graph (A); 
‘‘(C) case planning, monitoring, evaluation, and other 
case work and services; and 
‘‘(D) providing, arranging for, or facilitating the provi-
sion of medical, social service, economic, legal, housing, 
law enforcement, or other protective, emergency, or support 
services. 
‘‘(3) CAREGIVER.—The term ‘caregiver’ means an individual 
who has the responsibility for the care of an elder, either 
voluntarily, by contract, by receipt of payment for care, or 
as a result of the operation of law, and means a family member 
or other individual who provides (on behalf of such individual 
or of a public or private agency, organization, or institution) 
compensated or uncompensated care to an elder who needs 
supportive services in any setting. 
‘‘(4) DIRECT CARE.—The term ‘direct care’ means care by 
an employee or contractor who provides assistance or long- 
term care services to a recipient. 
‘‘(5) ELDER.—The term ‘elder’ means an individual age 
60 or older. 
‘‘(6) ELDER JUSTICE.—The term ‘elder justice’ means— 
‘‘(A) from a societal perspective, efforts to— 
‘‘(i) prevent, detect, treat, intervene in, and pros-
ecute elder abuse, neglect, and exploitation; and 
‘‘(ii) protect elders with diminished capacity while 
maximizing their autonomy; and 
‘‘(B) from an individual perspective, the recognition 
of an elder’s rights, including the right to be free of abuse, 
neglect, and exploitation. 
‘‘(7) ELIGIBLE ENTITY.—The term ‘eligible entity’ means a 
State or local government agency, Indian tribe or tribal 
organization, or any other public or private entity that is 
engaged in and has expertise in issues relating to elder justice 
or in a field necessary to promote elder justice efforts. 
‘‘(8) EXPLOITATION.—The term ‘exploitation’ means the 
fraudulent or otherwise illegal, unauthorized, or improper act 
or process of an individual, including a caregiver or fiduciary, 
that uses the resources of an elder for monetary or personal 
benefit, profit, or gain, or that results in depriving an elder 
of rightful access to, or use of, benefits, resources, belongings, 
or assets. 
‘‘(9) FIDUCIARY.—The term ‘fiduciary’— 
‘‘(A) means a person or entity with the legal responsi-
bility— 
‘‘(i) to make decisions on behalf of and for the 
benefit of another person; and 
‘‘(ii) to act in good faith and with fairness; and 
‘‘(B) includes a trustee, a guardian, a conservator, an 
executor, an agent under a financial power of attorney 
or health care power of attorney, or a representative payee. 
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124 STAT. 784 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(10) GRANT.—The term ‘grant’ includes a contract, coopera-
tive agreement, or other mechanism for providing financial 
assistance. 
‘‘(11) GUARDIANSHIP.—The term ‘guardianship’ means— 
‘‘(A) the process by which a State court determines 
that an adult individual lacks capacity to make decisions 
about self-care or property, and appoints another individual 
or entity known as a guardian, as a conservator, or by 
a similar term, as a surrogate decisionmaker; 
‘‘(B) the manner in which the court-appointed surrogate 
decisionmaker carries out duties to the individual and the 
court; or 
‘‘(C) the manner in which the court exercises oversight 
of the surrogate decisionmaker. 
‘‘(12) INDIAN TRIBE.— 
‘‘(A) IN
GENERAL.—The term ‘Indian tribe’ has the 
meaning given such term in section 4 of the Indian Self- 
Determination and Education Assistance Act (25 U.S.C. 
450b). 
‘‘(B) INCLUSION OF PUEBLO AND RANCHERIA.—The term 
‘Indian tribe’ includes any Pueblo or Rancheria. 
‘‘(13) LAW
ENFORCEMENT.—The term ‘law enforcement’ 
means the full range of potential responders to elder abuse, 
neglect, and exploitation including— 
‘‘(A) police, sheriffs, detectives, public safety officers, 
and corrections personnel; 
‘‘(B) prosecutors; 
‘‘(C) medical examiners; 
‘‘(D) investigators; and 
‘‘(E) coroners. 
‘‘(14) LONG-TERM CARE.— 
‘‘(A) IN GENERAL.—The term ‘long-term care’ means 
supportive and health services specified by the Secretary 
for individuals who need assistance because the individuals 
have a loss of capacity for self-care due to illness, disability, 
or vulnerability. 
‘‘(B) LOSS OF CAPACITY FOR SELF-CARE.—For purposes 
of subparagraph (A), the term ‘loss of capacity for self- 
care’ means an inability to engage in 1 or more activities 
of daily living, including eating, dressing, bathing, manage-
ment of one’s financial affairs, and other activities the 
Secretary determines appropriate. 
‘‘(15) LONG-TERM CARE FACILITY.—The term ‘long-term care 
facility’ means a residential care provider that arranges for, 
or directly provides, long-term care. 
‘‘(16) NEGLECT.—The term ‘neglect’ means— 
‘‘(A) the failure of a caregiver or fiduciary to provide 
the goods or services that are necessary to maintain the 
health or safety of an elder; or 
‘‘(B) self-neglect. 
‘‘(17) NURSING FACILITY.— 
‘‘(A) IN GENERAL.—The term ‘nursing facility’ has the 
meaning given such term under section 1919(a). 
‘‘(B) INCLUSION
OF
SKILLED
NURSING
FACILITY.—The 
term ‘nursing facility’ includes a skilled nursing facility 
(as defined in section 1819(a)). 
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124 STAT. 785 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(18) SELF-NEGLECT.—The term ‘self-neglect’ means an 
adult’s inability, due to physical or mental impairment or 
diminished capacity, to perform essential self-care tasks 
including— 
‘‘(A) obtaining essential food, clothing, shelter, and 
medical care; 
‘‘(B) obtaining goods and services necessary to maintain 
physical health, mental health, or general safety; or 
‘‘(C) managing one’s own financial affairs. 
‘‘(19) SERIOUS BODILY INJURY.— 
‘‘(A) IN
GENERAL.—The term ‘serious bodily injury’ 
means an injury— 
‘‘(i) involving extreme physical pain; 
‘‘(ii) involving substantial risk of death; 
‘‘(iii) involving protracted loss or impairment of 
the function of a bodily member, organ, or mental 
faculty; or 
‘‘(iv) requiring medical intervention such as sur-
gery, hospitalization, or physical rehabilitation. 
‘‘(B) CRIMINAL SEXUAL ABUSE.—Serious bodily injury 
shall be considered to have occurred if the conduct causing 
the injury is conduct described in section 2241 (relating 
to aggravated sexual abuse) or 2242 (relating to sexual 
abuse) of title 18, United States Code, or any similar offense 
under State law. 
‘‘(20) SOCIAL.—The term ‘social’, when used with respect 
to a service, includes adult protective services. 
‘‘(21) STATE
LEGAL
ASSISTANCE
DEVELOPER.—The term 
‘State legal assistance developer’ means an individual described 
in section 731 of the Older Americans Act of 1965. 
‘‘(22) STATE
LONG-TERM
CARE
OMBUDSMAN.—The term 
‘State Long-Term Care Ombudsman’ means the State Long- 
Term Care Ombudsman described in section 712(a)(2) of the 
Older Americans Act of 1965. 
‘‘SEC. 2012. GENERAL PROVISIONS. 
‘‘(a) PROTECTION OF PRIVACY.—In pursuing activities under this 
subtitle, the Secretary shall ensure the protection of individual 
health privacy consistent with the regulations promulgated under 
section 264(c) of the Health Insurance Portability and Accountability 
Act of 1996 and applicable State and local privacy regulations. 
‘‘(b) RULE OF CONSTRUCTION.—Nothing in this subtitle shall 
be construed to interfere with or abridge an elder’s right to practice 
his or her religion through reliance on prayer alone for healing 
when this choice— 
‘‘(1) is contemporaneously expressed, either orally or in 
writing, with respect to a specific illness or injury which the 
elder has at the time of the decision by an elder who is com-
petent at the time of the decision; 
‘‘(2) is previously set forth in a living will, health care 
proxy, or other advance directive document that is validly 
executed and applied under State law; or 
‘‘(3) may be unambiguously deduced from the elder’s life 
history. 
42 USC 
1397j–1. 
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124 STAT. 786 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘PART I—NATIONAL COORDINATION OF 
ELDER JUSTICE ACTIVITIES AND RESEARCH 
‘‘Subpart A—Elder Justice Coordinating Council 
and Advisory Board on Elder Abuse, Neglect, 
and Exploitation 
‘‘SEC. 2021. ELDER JUSTICE COORDINATING COUNCIL. 
‘‘(a) ESTABLISHMENT.—There is established within the Office 
of the Secretary an Elder Justice Coordinating Council (in this 
section referred to as the ‘Council’). 
‘‘(b) MEMBERSHIP.— 
‘‘(1) IN GENERAL.—The Council shall be composed of the 
following members: 
‘‘(A) The Secretary (or the Secretary’s designee). 
‘‘(B) The Attorney General (or the Attorney General’s 
designee). 
‘‘(C) The head of each Federal department or agency 
or other governmental entity identified by the Chair 
referred to in subsection (d) as having responsibilities, or 
administering programs, relating to elder abuse, neglect, 
and exploitation. 
‘‘(2) REQUIREMENT.—Each member of the Council shall be 
an officer or employee of the Federal Government. 
‘‘(c) VACANCIES.—Any vacancy in the Council shall not affect 
its powers, but shall be filled in the same manner as the original 
appointment was made. 
‘‘(d) CHAIR.—The member described in subsection (b)(1)(A) shall 
be Chair of the Council. 
‘‘(e) MEETINGS.—The Council shall meet at least 2 times per 
year, as determined by the Chair. 
‘‘(f) DUTIES.— 
‘‘(1) IN GENERAL.—The Council shall make recommenda-
tions to the Secretary for the coordination of activities of the 
Department of Health and Human Services, the Department 
of Justice, and other relevant Federal, State, local, and private 
agencies and entities, relating to elder abuse, neglect, and 
exploitation and other crimes against elders. 
‘‘(2) REPORT.—Not later than the date that is 2 years after 
the date of enactment of the Elder Justice Act of 2009 and 
every 2 years thereafter, the Council shall submit to the Com-
mittee on Finance of the Senate and the Committee on Ways 
and Means and the Committee on Energy and Commerce of 
the House of Representatives a report that— 
‘‘(A) describes the activities and accomplishments of, 
and challenges faced by— 
‘‘(i) the Council; and 
‘‘(ii) the entities represented on the Council; and 
‘‘(B) makes such recommendations for legislation, 
model laws, or other action as the Council determines 
to be appropriate. 
‘‘(g) POWERS OF THE COUNCIL.— 
‘‘(1) INFORMATION FROM FEDERAL AGENCIES.—Subject to the 
requirements of section 2012(a), the Council may secure directly 
from any Federal department or agency such information as 
the Council considers necessary to carry out this section. Upon 
Recommenda- 
tions. 
42 USC 1397k. 
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124 STAT. 787 
PUBLIC LAW 111–148—MAR. 23, 2010 
request of the Chair of the Council, the head of such department 
or agency shall furnish such information to the Council. 
‘‘(2) POSTAL SERVICES.—The Council may use the United 
States mails in the same manner and under the same conditions 
as other departments and agencies of the Federal Government. 
‘‘(h) TRAVEL EXPENSES.—The members of the Council shall 
not receive compensation for the performance of services for the 
Council. The members shall be allowed travel expenses, including 
per diem in lieu of subsistence, at rates authorized for employees 
of agencies under subchapter I of chapter 57 of title 5, United 
States Code, while away from their homes or regular places of 
business in the performance of services for the Council. Notwith-
standing section 1342 of title 31, United States Code, the Secretary 
may accept the voluntary and uncompensated services of the mem-
bers of the Council. 
‘‘(i) DETAIL OF GOVERNMENT EMPLOYEES.—Any Federal Govern-
ment employee may be detailed to the Council without reimburse-
ment, and such detail shall be without interruption or loss of 
civil service status or privilege. 
‘‘(j) STATUS AS PERMANENT COUNCIL.—Section 14 of the Federal 
Advisory Committee Act (5 U.S.C. App.) shall not apply to the 
Council. 
‘‘(k) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated such sums as are necessary to carry out this 
section. 
‘‘SEC. 2022. ADVISORY BOARD ON ELDER ABUSE, NEGLECT, AND 
EXPLOITATION. 
‘‘(a) ESTABLISHMENT.—There is established a board to be known 
as the ‘Advisory Board on Elder Abuse, Neglect, and Exploitation’ 
(in this section referred to as the ‘Advisory Board’) to create short- 
and long-term multidisciplinary strategic plans for the development 
of the field of elder justice and to make recommendations to the 
Elder Justice Coordinating Council established under section 2021. 
‘‘(b) COMPOSITION.—The Advisory Board shall be composed of 
27 members appointed by the Secretary from among members of 
the general public who are individuals with experience and expertise 
in elder abuse, neglect, and exploitation prevention, detection, treat-
ment, intervention, or prosecution. 
‘‘(c) SOLICITATION OF NOMINATIONS.—The Secretary shall pub-
lish a notice in the Federal Register soliciting nominations for 
the appointment of members of the Advisory Board under subsection 
(b). 
‘‘(d) TERMS.— 
‘‘(1) IN
GENERAL.—Each member of the Advisory Board 
shall be appointed for a term of 3 years, except that, of the 
members first appointed— 
‘‘(A) 9 shall be appointed for a term of 3 years; 
‘‘(B) 9 shall be appointed for a term of 2 years; and 
‘‘(C) 9 shall be appointed for a term of 1 year. 
‘‘(2) VACANCIES.— 
‘‘(A) IN GENERAL.—Any vacancy on the Advisory Board 
shall not affect its powers, but shall be filled in the same 
manner as the original appointment was made. 
‘‘(B) FILLING UNEXPIRED TERM.—An individual chosen 
to fill a vacancy shall be appointed for the unexpired term 
of the member replaced. 
Notice. 
Federal Register, 
publication. 
42 USC 1397k–1. 
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124 STAT. 788 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(3) EXPIRATION OF TERMS.—The term of any member shall 
not expire before the date on which the member’s successor 
takes office. 
‘‘(e) ELECTION OF OFFICERS.—The Advisory Board shall elect 
a Chair and Vice Chair from among its members. The Advisory 
Board shall elect its initial Chair and Vice Chair at its initial 
meeting. 
‘‘(f) DUTIES.— 
‘‘(1) ENHANCE COMMUNICATION ON PROMOTING QUALITY OF, 
AND PREVENTING ABUSE, NEGLECT, AND EXPLOITATION IN, LONG- 
TERM CARE.—The Advisory Board shall develop collaborative 
and innovative approaches to improve the quality of, including 
preventing abuse, neglect, and exploitation in, long-term care. 
‘‘(2) COLLABORATIVE
EFFORTS
TO
DEVELOP
CONSENSUS 
AROUND THE MANAGEMENT OF CERTAIN QUALITY-RELATED FAC-
TORS.— 
‘‘(A) IN GENERAL.—The Advisory Board shall establish 
multidisciplinary panels to address, and develop consensus 
on, subjects relating to improving the quality of long-term 
care. At least 1 such panel shall address, and develop 
consensus on, methods for managing resident-to-resident 
abuse in long-term care. 
‘‘(B) ACTIVITIES
CONDUCTED.—The multidisciplinary 
panels established under subparagraph (A) shall examine 
relevant research and data, identify best practices with 
respect to the subject of the panel, determine the best 
way to carry out those best practices in a practical and 
feasible manner, and determine an effective manner of 
distributing information on such subject. 
‘‘(3) REPORT.—Not later than the date that is 18 months 
after the date of enactment of the Elder Justice Act of 2009, 
and annually thereafter, the Advisory Board shall prepare and 
submit to the Elder Justice Coordinating Council, the Com-
mittee on Finance of the Senate, and the Committee on Ways 
and Means and the Committee on Energy and Commerce of 
the House of Representatives a report containing— 
‘‘(A) information on the status of Federal, State, and 
local public and private elder justice activities; 
‘‘(B) recommendations (including recommended prior-
ities) regarding— 
‘‘(i) elder justice programs, research, training, serv-
ices, practice, enforcement, and coordination; 
‘‘(ii) coordination between entities pursuing elder 
justice efforts and those involved in related areas that 
may inform or overlap with elder justice efforts, such 
as activities to combat violence against women and 
child abuse and neglect; and 
‘‘(iii) activities relating to adult fiduciary systems, 
including guardianship and other fiduciary arrange-
ments; 
‘‘(C) recommendations for specific modifications needed 
in Federal and State laws (including regulations) or for 
programs, research, and training to enhance prevention, 
detection, and treatment (including diagnosis) of, interven-
tion in (including investigation of), and prosecution of elder 
abuse, neglect, and exploitation; 
Panels. 
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124 STAT. 789 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(D) recommendations on methods for the most effec-
tive coordinated national data collection with respect to 
elder justice, and elder abuse, neglect, and exploitation; 
and 
‘‘(E) recommendations for a multidisciplinary strategic 
plan to guide the effective and efficient development of 
the field of elder justice. 
‘‘(g) POWERS OF THE ADVISORY BOARD.— 
‘‘(1) INFORMATION FROM FEDERAL AGENCIES.—Subject to the 
requirements of section 2012(a), the Advisory Board may secure 
directly from any Federal department or agency such informa-
tion as the Advisory Board considers necessary to carry out 
this section. Upon request of the Chair of the Advisory Board, 
the head of such department or agency shall furnish such 
information to the Advisory Board. 
‘‘(2) SHARING OF DATA AND REPORTS.—The Advisory Board 
may request from any entity pursuing elder justice activities 
under the Elder Justice Act of 2009 or an amendment made 
by that Act, any data, reports, or recommendations generated 
in connection with such activities. 
‘‘(3) POSTAL SERVICES.—The Advisory Board may use the 
United States mails in the same manner and under the same 
conditions as other departments and agencies of the Federal 
Government. 
‘‘(h) TRAVEL EXPENSES.—The members of the Advisory Board 
shall not receive compensation for the performance of services for 
the Advisory Board. The members shall be allowed travel expenses 
for up to 4 meetings per year, including per diem in lieu of subsist-
ence, at rates authorized for employees of agencies under subchapter 
I of chapter 57 of title 5, United States Code, while away from 
their homes or regular places of business in the performance of 
services for the Advisory Board. Notwithstanding section 1342 of 
title 31, United States Code, the Secretary may accept the voluntary 
and uncompensated services of the members of the Advisory Board. 
‘‘(i) DETAIL OF GOVERNMENT EMPLOYEES.—Any Federal Govern-
ment employee may be detailed to the Advisory Board without 
reimbursement, and such detail shall be without interruption or 
loss of civil service status or privilege. 
‘‘(j) STATUS AS PERMANENT ADVISORY COMMITTEE.—Section 14 
of the Federal Advisory Committee Act (5 U.S.C. App.) shall not 
apply to the advisory board. 
‘‘(k) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated such sums as are necessary to carry out this 
section. 
‘‘SEC. 2023. RESEARCH PROTECTIONS. 
‘‘(a) GUIDELINES.—The Secretary shall promulgate guidelines 
to assist researchers working in the area of elder abuse, neglect, 
and exploitation, with issues relating to human subject protections. 
‘‘(b) DEFINITION OF LEGALLY AUTHORIZED REPRESENTATIVE FOR 
APPLICATION
OF REGULATIONS.—For purposes of the application 
of subpart A of part 46 of title 45, Code of Federal Regulations, 
to research conducted under this subpart, the term ‘legally author-
ized representative’ means, unless otherwise provided by law, the 
individual or judicial or other body authorized under the applicable 
law to consent to medical treatment on behalf of another person. 
42 USC 1397k–2. 
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124 STAT. 790 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 2024. AUTHORIZATION OF APPROPRIATIONS. 
‘‘There are authorized to be appropriated to carry out this 
subpart— 
‘‘(1) for fiscal year 2011, $6,500,000; and 
‘‘(2) for each of fiscal years 2012 through 2014, $7,000,000. 
‘‘Subpart B—Elder Abuse, Neglect, and 
Exploitation Forensic Centers 
‘‘SEC. 2031. ESTABLISHMENT AND SUPPORT OF ELDER ABUSE, 
NEGLECT, AND EXPLOITATION FORENSIC CENTERS. 
‘‘(a) IN GENERAL.—The Secretary, in consultation with the 
Attorney General, shall make grants to eligible entities to establish 
and operate stationary and mobile forensic centers, to develop 
forensic expertise regarding, and provide services relating to, elder 
abuse, neglect, and exploitation. 
‘‘(b) STATIONARY
FORENSIC
CENTERS.—The Secretary shall 
make 4 of the grants described in subsection (a) to institutions 
of higher education with demonstrated expertise in forensics or 
commitment to preventing or treating elder abuse, neglect, or exploi-
tation, to establish and operate stationary forensic centers. 
‘‘(c) MOBILE CENTERS.—The Secretary shall make 6 of the 
grants described in subsection (a) to appropriate entities to establish 
and operate mobile forensic centers. 
‘‘(d) AUTHORIZED ACTIVITIES.— 
‘‘(1) DEVELOPMENT OF FORENSIC MARKERS AND METHODOLO-
GIES.—An eligible entity that receives a grant under this section 
shall use funds made available through the grant to assist 
in determining whether abuse, neglect, or exploitation occurred 
and whether a crime was committed and to conduct research 
to describe and disseminate information on— 
‘‘(A) forensic markers that indicate a case in which 
elder abuse, neglect, or exploitation may have occurred; 
and 
‘‘(B) methodologies for determining, in such a case, 
when and how health care, emergency service, social and 
protective services, and legal service providers should inter-
vene and when the providers should report the case to 
law enforcement authorities. 
‘‘(2) DEVELOPMENT
OF
FORENSIC
EXPERTISE.—An eligible 
entity that receives a grant under this section shall use funds 
made available through the grant to develop forensic expertise 
regarding elder abuse, neglect, and exploitation in order to 
provide medical and forensic evaluation, therapeutic interven-
tion, victim support and advocacy, case review, and case 
tracking. 
‘‘(3) COLLECTION OF EVIDENCE.—The Secretary, in coordina-
tion with the Attorney General, shall use data made available 
by grant recipients under this section to develop the capacity 
of geriatric health care professionals and law enforcement to 
collect forensic evidence, including collecting forensic evidence 
relating to a potential determination of elder abuse, neglect, 
or exploitation. 
‘‘(e) APPLICATION.—To be eligible to receive a grant under this 
section, an entity shall submit an application to the Secretary 
Grants. 
42 USC 1397l. 
42 USC 1397k–3. 
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124 STAT. 791 
PUBLIC LAW 111–148—MAR. 23, 2010 
at such time, in such manner, and containing such information 
as the Secretary may require. 
‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated to carry out this section— 
‘‘(1) for fiscal year 2011, $4,000,000; 
‘‘(2) for fiscal year 2012, $6,000,000; and 
‘‘(3) for each of fiscal years 2013 and 2014, $8,000,000. 
‘‘PART II—PROGRAMS TO PROMOTE ELDER 
JUSTICE 
‘‘SEC. 2041. ENHANCEMENT OF LONG-TERM CARE. 
‘‘(a) GRANTS AND INCENTIVES FOR LONG-TERM CARE STAFFING.— 
‘‘(1) IN GENERAL.—The Secretary shall carry out activities, 
including activities described in paragraphs (2) and (3), to pro-
vide incentives for individuals to train for, seek, and maintain 
employment providing direct care in long-term care. 
‘‘(2) SPECIFIC PROGRAMS TO ENHANCE TRAINING, RECRUIT-
MENT, AND RETENTION OF STAFF.— 
‘‘(A) COORDINATION
WITH
SECRETARY
OF
LABOR
TO 
RECRUIT AND TRAIN LONG-TERM CARE STAFF.—The Secretary 
shall coordinate activities under this subsection with the 
Secretary of Labor in order to provide incentives for individ-
uals to train for and seek employment providing direct 
care in long-term care. 
‘‘(B) CAREER LADDERS AND WAGE OR BENEFIT INCREASES 
TO INCREASE STAFFING IN LONG-TERM CARE.— 
‘‘(i) IN GENERAL.—The Secretary shall make grants 
to eligible entities to carry out programs through which 
the entities— 
‘‘(I) offer, to employees who provide direct care 
to residents of an eligible entity or individuals 
receiving community-based long-term care from an 
eligible entity, continuing training and varying 
levels of certification, based on observed clinical 
care practices and the amount of time the 
employees spend providing direct care; and 
‘‘(II) provide, or make arrangements to pro-
vide, bonuses or other increased compensation or 
benefits to employees who achieve certification 
under such a program. 
‘‘(ii) APPLICATION.—To be eligible to receive a grant 
under this subparagraph, an eligible entity shall 
submit an application to the Secretary at such time, 
in such manner, and containing such information as 
the Secretary may require (which may include evidence 
of consultation with the State in which the eligible 
entity is located with respect to carrying out activities 
funded under the grant). 
‘‘(iii) 
AUTHORITY
TO
LIMIT
NUMBER
OF 
APPLICANTS.—Nothing in this subparagraph shall be 
construed as prohibiting the Secretary from limiting 
the number of applicants for a grant under this 
subparagraph. 
‘‘(3) SPECIFIC PROGRAMS TO IMPROVE MANAGEMENT PRAC-
TICES.— 
Grants. 
Grants. 
42 USC 1397m. 
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124 STAT. 792 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) IN GENERAL.—The Secretary shall make grants 
to eligible entities to enable the entities to provide training 
and technical assistance. 
‘‘(B) AUTHORIZED ACTIVITIES.—An eligible entity that 
receives a grant under subparagraph (A) shall use funds 
made available through the grant to provide training and 
technical assistance regarding management practices using 
methods that are demonstrated to promote retention of 
individuals who provide direct care, such as— 
‘‘(i) the establishment of standard human resource 
policies that reward high performance, including poli-
cies that provide for improved wages and benefits on 
the basis of job reviews; 
‘‘(ii) 
the 
establishment 
of 
motivational 
and 
thoughtful work organization practices; 
‘‘(iii) the creation of a workplace culture that 
respects and values caregivers and their needs; 
‘‘(iv) the promotion of a workplace culture that 
respects the rights of residents of an eligible entity 
or individuals receiving community-based long-term 
care from an eligible entity and results in improved 
care for the residents or the individuals; and 
‘‘(v) the establishment of other programs that pro-
mote the provision of high quality care, such as a 
continuing education program that provides additional 
hours of training, including on-the-job training, for 
employees who are certified nurse aides. 
‘‘(C) APPLICATION.—To be eligible to receive a grant 
under this paragraph, an eligible entity shall submit an 
application to the Secretary at such time, in such manner, 
and containing such information as the Secretary may 
require (which may include evidence of consultation with 
the State in which the eligible entity is located with respect 
to carrying out activities funded under the grant). 
‘‘(D) AUTHORITY TO LIMIT NUMBER OF APPLICANTS.— 
Nothing in this paragraph shall be construed as prohibiting 
the Secretary from limiting the number of applicants for 
a grant under this paragraph. 
‘‘(4) ACCOUNTABILITY
MEASURES.—The Secretary shall 
develop accountability measures to ensure that the activities 
conducted using funds made available under this subsection 
benefit individuals who provide direct care and increase the 
stability of the long-term care workforce. 
‘‘(5) DEFINITIONS.—In this subsection: 
‘‘(A) COMMUNITY-BASED LONG-TERM CARE.—The term 
‘community-based long-term care’ has the meaning given 
such term by the Secretary. 
‘‘(B) ELIGIBLE ENTITY.—The term ‘eligible entity’ means 
the following: 
‘‘(i) A long-term care facility. 
‘‘(ii) A community-based long-term care entity (as 
defined by the Secretary). 
‘‘(b) CERTIFIED EHR TECHNOLOGY GRANT PROGRAM.— 
‘‘(1) GRANTS AUTHORIZED.—The Secretary is authorized to 
make grants to long-term care facilities for the purpose of 
assisting such entities in offsetting the costs related to pur-
chasing, leasing, developing, and implementing certified EHR 
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124 STAT. 793 
PUBLIC LAW 111–148—MAR. 23, 2010 
technology (as defined in section 1848(o)(4)) designed to improve 
patient safety and reduce adverse events and health care com-
plications resulting from medication errors. 
‘‘(2) USE OF GRANT FUNDS.—Funds provided under grants 
under this subsection may be used for any of the following: 
‘‘(A) Purchasing, leasing, and installing computer soft-
ware and hardware, including handheld computer tech-
nologies. 
‘‘(B) Making improvements to existing computer soft-
ware and hardware. 
‘‘(C) Making upgrades and other improvements to 
existing computer software and hardware to enable e-pre-
scribing. 
‘‘(D) Providing education and training to eligible long- 
term care facility staff on the use of such technology to 
implement the electronic transmission of prescription and 
patient information. 
‘‘(3) APPLICATION.— 
‘‘(A) IN GENERAL.—To be eligible to receive a grant 
under this subsection, a long-term care facility shall submit 
an application to the Secretary at such time, in such 
manner, and containing such information as the Secretary 
may require (which may include evidence of consultation 
with the State in which the long-term care facility is located 
with respect to carrying out activities funded under the 
grant). 
‘‘(B) AUTHORITY TO LIMIT NUMBER OF APPLICANTS.— 
Nothing in this subsection shall be construed as prohibiting 
the Secretary from limiting the number of applicants for 
a grant under this subsection. 
‘‘(4) PARTICIPATION IN STATE HEALTH EXCHANGES.—A long- 
term care facility that receives a grant under this subsection 
shall, where available, participate in activities conducted by 
a State or a qualified State-designated entity (as defined in 
section 3013(f) of the Public Health Service Act) under a grant 
under section 3013 of the Public Health Service Act to coordi-
nate care and for other purposes determined appropriate by 
the Secretary. 
‘‘(5) ACCOUNTABILITY
MEASURES.—The Secretary shall 
develop accountability measures to ensure that the activities 
conducted using funds made available under this subsection 
help improve patient safety and reduce adverse events and 
health care complications resulting from medication errors. 
‘‘(c) ADOPTION OF STANDARDS FOR TRANSACTIONS INVOLVING 
CLINICAL DATA BY LONG-TERM CARE FACILITIES.— 
‘‘(1) STANDARDS AND COMPATIBILITY.—The Secretary shall 
adopt electronic standards for the exchange of clinical data 
by long-term care facilities, including, where available, stand-
ards for messaging and nomenclature. Standards adopted by 
the Secretary under the preceding sentence shall be compatible 
with standards established under part C of title XI, standards 
established under subsections (b)(2)(B)(i) and (e)(4) of section 
1860D–4, standards adopted under section 3004 of the Public 
Health Service Act, and general health information technology 
standards. 
‘‘(2) ELECTRONIC SUBMISSION OF DATA TO THE SECRETARY.— 
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124 STAT. 794 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) IN GENERAL.—Not later than 10 years after the 
date of enactment of the Elder Justice Act of 2009, the 
Secretary shall have procedures in place to accept the 
optional electronic submission of clinical data by long-term 
care facilities pursuant to the standards adopted under 
paragraph (1). 
‘‘(B) RULE
OF
CONSTRUCTION.—Nothing in this sub-
section shall be construed to require a long-term care 
facility to submit clinical data electronically to the Sec-
retary. 
‘‘(3) REGULATIONS.—The Secretary shall promulgate regula-
tions to carry out this subsection. Such regulations shall require 
a State, as a condition of the receipt of funds under this 
part, to conduct such data collection and reporting as the Sec-
retary determines are necessary to satisfy the requirements 
of this subsection. 
‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated to carry out this section— 
‘‘(1) for fiscal year 2011, $20,000,000; 
‘‘(2) for fiscal year 2012, $17,500,000; and 
‘‘(3) for each of fiscal years 2013 and 2014, $15,000,000. 
‘‘SEC. 2042. ADULT PROTECTIVE SERVICES FUNCTIONS AND GRANT 
PROGRAMS. 
‘‘(a) SECRETARIAL RESPONSIBILITIES.— 
‘‘(1) IN
GENERAL.—The Secretary shall ensure that the 
Department of Health and Human Services— 
‘‘(A) provides funding authorized by this part to State 
and local adult protective services offices that investigate 
reports of the abuse, neglect, and exploitation of elders; 
‘‘(B) collects and disseminates data annually relating 
to the abuse, exploitation, and neglect of elders in coordina-
tion with the Department of Justice; 
‘‘(C) develops and disseminates information on best 
practices regarding, and provides training on, carrying out 
adult protective services; 
‘‘(D) conducts research related to the provision of adult 
protective services; and 
‘‘(E) provides technical assistance to States and other 
entities that provide or fund the provision of adult protec-
tive services, including through grants made under sub-
sections (b) and (c). 
‘‘(2) 
AUTHORIZATION
OF
APPROPRIATIONS.—There 
are 
authorized to be appropriated to carry out this subsection, 
$3,000,000 for fiscal year 2011 and $4,000,000 for each of 
fiscal years 2012 through 2014. 
‘‘(b) GRANTS TO ENHANCE THE PROVISION OF ADULT PROTECTIVE 
SERVICES.— 
‘‘(1) ESTABLISHMENT.—There is established an adult protec-
tive services grant program under which the Secretary shall 
annually award grants to States in the amounts calculated 
under paragraph (2) for the purposes of enhancing adult protec-
tive services provided by States and local units of government. 
‘‘(2) AMOUNT OF PAYMENT.— 
‘‘(A) IN GENERAL.—Subject to the availability of appro-
priations and subparagraphs (B) and (C), the amount paid 
to a State for a fiscal year under the program under this 
42 USC 
1397m–1. 
Deadline. 
Procedures. 
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124 STAT. 795 
PUBLIC LAW 111–148—MAR. 23, 2010 
subsection shall equal the amount appropriated for that 
year to carry out this subsection multiplied by the percent-
age of the total number of elders who reside in the United 
States who reside in that State. 
‘‘(B) GUARANTEED MINIMUM PAYMENT AMOUNT.— 
‘‘(i) 50 STATES.—Subject to clause (ii), if the amount 
determined under subparagraph (A) for a State for 
a fiscal year is less than 0.75 percent of the amount 
appropriated for such year, the Secretary shall increase 
such determined amount so that the total amount paid 
under this subsection to the State for the year is equal 
to 0.75 percent of the amount so appropriated. 
‘‘(ii) TERRITORIES.—In the case of a State other 
than 1 of the 50 States, clause (i) shall be applied 
as if each reference to ‘0.75’ were a reference to ‘0.1’. 
‘‘(C) PRO RATA REDUCTIONS.—The Secretary shall make 
such pro rata reductions to the amounts described in 
subparagraph (A) as are necessary to comply with the 
requirements of subparagraph (B). 
‘‘(3) AUTHORIZED ACTIVITIES.— 
‘‘(A) ADULT PROTECTIVE SERVICES.—Funds made avail-
able pursuant to this subsection may only be used by 
States and local units of government to provide adult 
protective services and may not be used for any other 
purpose. 
‘‘(B) USE
BY
AGENCY.—Each State receiving funds 
pursuant to this subsection shall provide such funds to 
the agency or unit of State government having legal respon-
sibility for providing adult protective services within the 
State. 
‘‘(C) SUPPLEMENT NOT SUPPLANT.—Each State or local 
unit of government shall use funds made available pursu-
ant to this subsection to supplement and not supplant 
other Federal, State, and local public funds expended to 
provide adult protective services in the State. 
‘‘(4) STATE
REPORTS.—Each State receiving funds under 
this subsection shall submit to the Secretary, at such time 
and in such manner as the Secretary may require, a report 
on the number of elders served by the grants awarded under 
this subsection. 
‘‘(5) 
AUTHORIZATION
OF
APPROPRIATIONS.—There 
are 
authorized to be appropriated to carry out this subsection, 
$100,000,000 for each of fiscal years 2011 through 2014. 
‘‘(c) STATE DEMONSTRATION PROGRAMS.— 
‘‘(1) ESTABLISHMENT.—The Secretary shall award grants 
to States for the purposes of conducting demonstration pro-
grams in accordance with paragraph (2). 
‘‘(2) DEMONSTRATION
PROGRAMS.—Funds made available 
pursuant to this subsection may be used by States and local 
units of government to conduct demonstration programs that 
test— 
‘‘(A) training modules developed for the purpose of 
detecting or preventing elder abuse; 
‘‘(B) methods to detect or prevent financial exploitation 
of elders; 
‘‘(C) methods to detect elder abuse; 
Applicability. 
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124 STAT. 796 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(D) whether training on elder abuse forensics 
enhances the detection of elder abuse by employees of 
the State or local unit of government; or 
‘‘(E) other matters relating to the detection or preven-
tion of elder abuse. 
‘‘(3) APPLICATION.—To be eligible to receive a grant under 
this subsection, a State shall submit an application to the 
Secretary at such time, in such manner, and containing such 
information as the Secretary may require. 
‘‘(4) STATE REPORTS.—Each State that receives funds under 
this subsection shall submit to the Secretary a report at such 
time, in such manner, and containing such information as 
the Secretary may require on the results of the demonstration 
program conducted by the State using funds made available 
under this subsection. 
‘‘(5) 
AUTHORIZATION
OF
APPROPRIATIONS.—There 
are 
authorized to be appropriated to carry out this subsection, 
$25,000,000 for each of fiscal years 2011 through 2014. 
‘‘SEC. 2043. LONG-TERM CARE OMBUDSMAN PROGRAM GRANTS AND 
TRAINING. 
‘‘(a) GRANTS TO SUPPORT THE LONG-TERM CARE OMBUDSMAN 
PROGRAM.— 
‘‘(1) IN
GENERAL.—The Secretary shall make grants to 
eligible entities with relevant expertise and experience in abuse 
and neglect in long-term care facilities or long-term care 
ombudsman programs and responsibilities, for the purpose of— 
‘‘(A) improving the capacity of State long-term care 
ombudsman programs to respond to and resolve complaints 
about abuse and neglect; 
‘‘(B) conducting pilot programs with State long-term 
care ombudsman offices or local ombudsman entities; and 
‘‘(C) providing support for such State long-term care 
ombudsman programs and such pilot programs (such as 
through the establishment of a national long-term care 
ombudsman resource center). 
‘‘(2) 
AUTHORIZATION
OF
APPROPRIATIONS.—There 
are 
authorized to be appropriated to carry out this subsection— 
‘‘(A) for fiscal year 2011, $5,000,000; 
‘‘(B) for fiscal year 2012, $7,500,000; and 
‘‘(C) for each of fiscal years 2013 and 2014, $10,000,000. 
‘‘(b) OMBUDSMAN TRAINING PROGRAMS.— 
‘‘(1) IN GENERAL.—The Secretary shall establish programs 
to provide and improve ombudsman training with respect to 
elder abuse, neglect, and exploitation for national organizations 
and State long-term care ombudsman programs. 
‘‘(2) 
AUTHORIZATION
OF
APPROPRIATIONS.—There 
are 
authorized to be appropriated to carry out this subsection, 
for each of fiscal years 2011 through 2014, $10,000,000. 
‘‘SEC. 2044. PROVISION OF INFORMATION REGARDING, AND EVALUA-
TIONS OF, ELDER JUSTICE PROGRAMS. 
‘‘(a) PROVISION OF INFORMATION.—To be eligible to receive a 
grant under this part, an applicant shall agree— 
‘‘(1) except as provided in paragraph (2), to provide the 
eligible entity conducting an evaluation under subsection (b) 
of the activities funded through the grant with such information 
42 USC 
1397m–3. 
42 USC 
1397m–2. 
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124 STAT. 797 
PUBLIC LAW 111–148—MAR. 23, 2010 
as the eligible entity may require in order to conduct such 
evaluation; or 
‘‘(2) in the case of an applicant for a grant under section 
2041(b), to provide the Secretary with such information as 
the Secretary may require to conduct an evaluation or audit 
under subsection (c). 
‘‘(b) USE OF ELIGIBLE ENTITIES TO CONDUCT EVALUATIONS.— 
‘‘(1) EVALUATIONS REQUIRED.—Except as provided in para-
graph (2), the Secretary shall— 
‘‘(A) reserve a portion (not less than 2 percent) of 
the funds appropriated with respect to each program car-
ried out under this part; and 
‘‘(B) use the funds reserved under subparagraph (A) 
to provide assistance to eligible entities to conduct evalua-
tions of the activities funded under each program carried 
out under this part. 
‘‘(2) CERTIFIED
EHR
TECHNOLOGY
GRANT
PROGRAM
NOT 
INCLUDED.—The provisions of this subsection shall not apply 
to the certified EHR technology grant program under section 
2041(b). 
‘‘(3) AUTHORIZED
ACTIVITIES.—A recipient of assistance 
described in paragraph (1)(B) shall use the funds made avail-
able through the assistance to conduct a validated evaluation 
of the effectiveness of the activities funded under a program 
carried out under this part. 
‘‘(4) APPLICATIONS.—To be eligible to receive assistance 
under paragraph (1)(B), an entity shall submit an application 
to the Secretary at such time, in such manner, and containing 
such information as the Secretary may require, including a 
proposal for the evaluation. 
‘‘(5) REPORTS.—Not later than a date specified by the Sec-
retary, an eligible entity receiving assistance under paragraph 
(1)(B) shall submit to the Secretary, the Committee on Ways 
and Means and the Committee on Energy and Commerce of 
the House of Representatives, and the Committee on Finance 
of the Senate a report containing the results of the evaluation 
conducted using such assistance together with such rec-
ommendations as the entity determines to be appropriate. 
‘‘(c) EVALUATIONS AND AUDITS OF CERTIFIED EHR TECHNOLOGY 
GRANT PROGRAM BY THE SECRETARY.— 
‘‘(1) EVALUATIONS.—The Secretary shall conduct an evalua-
tion of the activities funded under the certified EHR technology 
grant program under section 2041(b). Such evaluation shall 
include an evaluation of whether the funding provided under 
the grant is expended only for the purposes for which it is 
made. 
‘‘(2) AUDITS.—The Secretary shall conduct appropriate 
audits of grants made under section 2041(b). 
‘‘SEC. 2045. REPORT. 
‘‘Not later than October 1, 2014, the Secretary shall submit 
to the Elder Justice Coordinating Council established under section 
2021, the Committee on Ways and Means and the Committee 
on Energy and Commerce of the House of Representatives, and 
the Committee on Finance of the Senate a report— 
42 USC 
1397m–4. 
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124 STAT. 798 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) compiling, summarizing, and analyzing the information 
contained in the State reports submitted under subsections 
(b)(4) and (c)(4) of section 2042; and 
‘‘(2) containing such recommendations for legislative or 
administrative action as the Secretary determines to be appro-
priate. 
‘‘SEC. 2046. RULE OF CONSTRUCTION. 
‘‘Nothing in this subtitle shall be construed as— 
‘‘(1) limiting any cause of action or other relief related 
to obligations under this subtitle that is available under the 
law of any State, or political subdivision thereof; or 
‘‘(2) creating a private cause of action for a violation of 
this subtitle.’’. 
(2) OPTION
FOR
STATE
PLAN
UNDER
PROGRAM
FOR
TEM-
PORARY ASSISTANCE FOR NEEDY FAMILIES.— 
(A) IN
GENERAL.—Section 402(a)(1)(B) of the Social 
Security Act (42 U.S.C. 602(a)(1)(B)) is amended by adding 
at the end the following new clause: 
‘‘(v) The document shall indicate whether the State 
intends to assist individuals to train for, seek, and 
maintain employment— 
‘‘(I) providing direct care in a long-term care 
facility (as such terms are defined under section 
2011); or 
‘‘(II) in other occupations related to elder care 
determined appropriate by the State for which the 
State identifies an unmet need for service per-
sonnel, 
and, if so, shall include an overview of such assist-
ance.’’. 
(B) EFFECTIVE
DATE.—The amendment made by 
subparagraph (A) shall take effect on January 1, 2011. 
(b) PROTECTING RESIDENTS OF LONG-TERM CARE FACILITIES.— 
(1) NATIONAL TRAINING INSTITUTE FOR SURVEYORS.— 
(A) IN GENERAL.—The Secretary of Health and Human 
Services shall enter into a contract with an entity for 
the purpose of establishing and operating a National 
Training Institute for Federal and State surveyors. Such 
Institute shall provide and improve the training of sur-
veyors with respect to investigating allegations of abuse, 
neglect, and misappropriation of property in programs and 
long-term care facilities that receive payments under title 
XVIII or XIX of the Social Security Act. 
(B) ACTIVITIES CARRIED OUT BY THE INSTITUTE.—The 
contract entered into under subparagraph (A) shall require 
the Institute established and operated under such contract 
to carry out the following activities: 
(i) Assess the extent to which State agencies use 
specialized surveyors for the investigation of reported 
allegations of abuse, neglect, and misappropriation of 
property in such programs and long-term care facilities. 
(ii) Evaluate how the competencies of surveyors 
may be improved to more effectively investigate 
reported allegations of such abuse, neglect, and mis-
appropriation of property, and provide feedback to Fed-
eral and State agencies on the evaluations conducted. 
Contracts. 
42 USC 
1395i–3a. 
42 USC 602 note. 
42 USC 
1397m–5. 
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124 STAT. 799 
PUBLIC LAW 111–148—MAR. 23, 2010 
(iii) Provide a national program of training, tools, 
and technical assistance to Federal and State surveyors 
on investigating reports of such abuse, neglect, and 
misappropriation of property. 
(iv) Develop and disseminate information on best 
practices for the investigation of such abuse, neglect, 
and misappropriation of property. 
(v) Assess the performance of State complaint 
intake systems, in order to ensure that the intake 
of complaints occurs 24 hours per day, 7 days a week 
(including holidays). 
(vi) To the extent approved by the Secretary of 
Health and Human Services, provide a national 24 
hours per day, 7 days a week (including holidays), 
back-up system to State complaint intake systems in 
order to ensure optimum national responsiveness to 
complaints of such abuse, neglect, and misappropria-
tion of property. 
(vii) Analyze and report annually on the following: 
(I) The total number and sources of complaints 
of such abuse, neglect, and misappropriation of 
property. 
(II) The extent to which such complaints are 
referred to law enforcement agencies. 
(III) General results of Federal and State 
investigations of such complaints. 
(viii) Conduct a national study of the cost to State 
agencies of conducting complaint investigations of 
skilled nursing facilities and nursing facilities under 
sections 1819 and 1919, respectively, of the Social Secu-
rity Act (42 U.S.C. 1395i–3; 1396r), and making rec-
ommendations to the Secretary of Health and Human 
Services with respect to options to increase the effi-
ciency and cost-effectiveness of such investigations. 
(C) AUTHORIZATION.—There are authorized to be appro-
priated to carry out this paragraph, for the period of fiscal 
years 2011 through 2014, $12,000,000. 
(2) GRANTS TO STATE SURVEY AGENCIES.— 
(A) IN GENERAL.—The Secretary of Health and Human 
Services shall make grants to State agencies that perform 
surveys of skilled nursing facilities or nursing facilities 
under sections 1819 or 1919, respectively, of the Social 
Security Act (42 U.S.C. 1395i–3; 1395r). 
(B) USE OF FUNDS.—A grant awarded under subpara-
graph (A) shall be used for the purpose of designing and 
implementing complaint investigations systems that— 
(i) promptly prioritize complaints in order to 
ensure a rapid response to the most serious and urgent 
complaints; 
(ii) respond to complaints with optimum effective-
ness and timeliness; and 
(iii) optimize the collaboration between local 
authorities, consumers, and providers, including— 
(I) such State agency; 
(II) the State Long-Term Care Ombudsman; 
(III) local law enforcement agencies; 
(IV) advocacy and consumer organizations; 
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124 STAT. 800 
PUBLIC LAW 111–148—MAR. 23, 2010 
(V) State aging units; 
(VI) Area Agencies on Aging; and 
(VII) other appropriate entities. 
(C) AUTHORIZATION.—There are authorized to be appro-
priated to carry out this paragraph, for each of fiscal years 
2011 through 2014, $5,000,000. 
(3) REPORTING
OF
CRIMES
IN
FEDERALLY
FUNDED
LONG- 
TERM CARE FACILITIES.—Part A of title XI of the Social Security 
Act (42 U.S.C. 1301 et seq.), as amended by section 6005, 
is amended by inserting after section 1150A the following new 
section: 
‘‘REPORTING TO LAW ENFORCEMENT OF CRIMES OCCURRING IN 
FEDERALLY FUNDED LONG-TERM CARE FACILITIES 
‘‘SEC. 1150B. (a) DETERMINATION AND NOTIFICATION.— 
‘‘(1) DETERMINATION.—The owner or operator of each long- 
term care facility that receives Federal funds under this Act 
shall annually determine whether the facility received at least 
$10,000 in such Federal funds during the preceding year. 
‘‘(2) NOTIFICATION.—If the owner or operator determines 
under paragraph (1) that the facility received at least $10,000 
in such Federal funds during the preceding year, such owner 
or operator shall annually notify each covered individual (as 
defined in paragraph (3)) of that individual’s obligation to 
comply with the reporting requirements described in subsection 
(b). 
‘‘(3) COVERED INDIVIDUAL DEFINED.—In this section, the 
term ‘covered individual’ means each individual who is an 
owner, operator, employee, manager, agent, or contractor of 
a long-term care facility that is the subject of a determination 
described in paragraph (1). 
‘‘(b) REPORTING REQUIREMENTS.— 
‘‘(1) IN GENERAL.—Each covered individual shall report to 
the Secretary and 1 or more law enforcement entities for the 
political subdivision in which the facility is located any reason-
able suspicion of a crime (as defined by the law of the applicable 
political subdivision) against any individual who is a resident 
of, or is receiving care from, the facility. 
‘‘(2) TIMING.—If the events that cause the suspicion— 
‘‘(A) result in serious bodily injury, the individual shall 
report the suspicion immediately, but not later than 2 
hours after forming the suspicion; and 
‘‘(B) do not result in serious bodily injury, the indi-
vidual shall report the suspicion not later than 24 hours 
after forming the suspicion. 
‘‘(c) PENALTIES.— 
‘‘(1) IN
GENERAL.—If a covered individual violates sub-
section (b)— 
‘‘(A) the covered individual shall be subject to a civil 
money penalty of not more than $200,000; and 
‘‘(B) the Secretary may make a determination in the 
same proceeding to exclude the covered individual from 
participation in any Federal health care program (as 
defined in section 1128B(f)). 
‘‘(2) INCREASED HARM.—If a covered individual violates sub-
section (b) and the violation exacerbates the harm to the victim 
of the crime or results in harm to another individual— 
42 USC 
1320b–25. 
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124 STAT. 801 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) the covered individual shall be subject to a civil 
money penalty of not more than $300,000; and 
‘‘(B) the Secretary may make a determination in the 
same proceeding to exclude the covered individual from 
participation in any Federal health care program (as 
defined in section 1128B(f)). 
‘‘(3) EXCLUDED INDIVIDUAL.—During any period for which 
a covered individual is classified as an excluded individual 
under paragraph (1)(B) or (2)(B), a long-term care facility that 
employs such individual shall be ineligible to receive Federal 
funds under this Act. 
‘‘(4) EXTENUATING CIRCUMSTANCES.— 
‘‘(A) IN GENERAL.—The Secretary may take into account 
the financial burden on providers with underserved popu-
lations in determining any penalty to be imposed under 
this subsection. 
‘‘(B) UNDERSERVED
POPULATION
DEFINED.—In this 
paragraph, the term ‘underserved population’ means the 
population of an area designated by the Secretary as an 
area with a shortage of elder justice programs or a popu-
lation group designated by the Secretary as having a short-
age of such programs. Such areas or groups designated 
by the Secretary may include— 
‘‘(i) areas or groups that are geographically isolated 
(such as isolated in a rural area); 
‘‘(ii) racial and ethnic minority populations; and 
‘‘(iii) populations underserved because of special 
needs (such as language barriers, disabilities, alien 
status, or age). 
‘‘(d) ADDITIONAL PENALTIES FOR RETALIATION.— 
‘‘(1) IN GENERAL.—A long-term care facility may not— 
‘‘(A) discharge, demote, suspend, threaten, harass, or 
deny a promotion or other employment-related benefit to 
an employee, or in any other manner discriminate against 
an employee in the terms and conditions of employment 
because of lawful acts done by the employee; or 
‘‘(B) file a complaint or a report against a nurse or 
other employee with the appropriate State professional dis-
ciplinary agency because of lawful acts done by the nurse 
or employee, 
for making a report, causing a report to be made, or for taking 
steps in furtherance of making a report pursuant to subsection 
(b)(1). 
‘‘(2) PENALTIES
FOR
RETALIATION.—If a long-term care 
facility violates subparagraph (A) or (B) of paragraph (1) the 
facility shall be subject to a civil money penalty of not more 
than $200,000 or the Secretary may classify the entity as 
an excluded entity for a period of 2 years pursuant to section 
1128(b), or both. 
‘‘(3) REQUIREMENT TO POST NOTICE.—Each long-term care 
facility shall post conspicuously in an appropriate location a 
sign (in a form specified by the Secretary) specifying the rights 
of employees under this section. Such sign shall include a 
statement that an employee may file a complaint with the 
Secretary against a long-term care facility that violates the 
provisions of this subsection and information with respect to 
the manner of filing such a complaint. 
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124 STAT. 802 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(e) PROCEDURE.—The provisions of section 1128A (other than 
subsections (a) and (b) and the second sentence of subsection (f)) 
shall apply to a civil money penalty or exclusion under this section 
in the same manner as such provisions apply to a penalty or 
proceeding under section 1128A(a). 
‘‘(f) DEFINITIONS.—In this section, the terms ‘elder justice’, ‘long- 
term care facility’, and ‘law enforcement’ have the meanings given 
those terms in section 2011.’’. 
(c) NATIONAL NURSE AIDE REGISTRY.— 
(1) DEFINITION OF NURSE AIDE.—In this subsection, the 
term ‘‘nurse aide’’ has the meaning given that term in sections 
1819(b)(5)(F) and 1919(b)(5)(F) of the Social Security Act (42 
U.S.C. 1395i–3(b)(5)(F); 1396r(b)(5)(F)). 
(2) STUDY AND REPORT.— 
(A) IN GENERAL.—The Secretary, in consultation with 
appropriate government agencies and private sector 
organizations, shall conduct a study on establishing a 
national nurse aide registry. 
(B) AREAS
EVALUATED.—The study conducted under 
this subsection shall include an evaluation of— 
(i) who should be included in the registry; 
(ii) how such a registry would comply with Federal 
and State privacy laws and regulations; 
(iii) how data would be collected for the registry; 
(iv) what entities and individuals would have 
access to the data collected; 
(v) how the registry would provide appropriate 
information regarding violations of Federal and State 
law by individuals included in the registry; 
(vi) how the functions of a national nurse aide 
registry would be coordinated with the nationwide pro-
gram for national and State background checks on 
direct patient access employees of long-term care facili-
ties and providers under section 4301; and 
(vii) how the information included in State nurse 
aide registries developed and maintained under sec-
tions 1819(e)(2) and 1919(e)(2) of the Social Security 
Act (42 U.S.C. 1395i–3(e)(2); 1396r(e)(2)(2)) would be 
provided as part of a national nurse aide registry. 
(C) CONSIDERATIONS.—In conducting the study and 
preparing the report required under this subsection, the 
Secretary shall take into consideration the findings and 
conclusions 
of 
relevant 
reports 
and 
other 
relevant 
resources, including the following: 
(i) The Department of Health and Human Services 
Office of Inspector General Report, Nurse Aide Reg-
istries: State Compliance and Practices (February 
2005). 
(ii) The General Accounting Office (now known 
as the Government Accountability Office) Report, 
Nursing Homes: More Can Be Done to Protect Resi-
dents from Abuse (March 2002). 
(iii) The Department of Health and Human Serv-
ices Office of the Inspector General Report, Nurse Aide 
Registries: Long-Term Care Facility Compliance and 
Practices (July 2005). 
Applicability. 
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124 STAT. 803 
PUBLIC LAW 111–148—MAR. 23, 2010 
(iv) The Department of Health and Human Serv-
ices Health Resources and Services Administration 
Report, Nursing Aides, Home Health Aides, and 
Related Health Care Occupations—National and Local 
Workforce Shortages and Associated Data Needs (2004) 
(in particular with respect to chapter 7 and appendix 
F). 
(v) The 2001 Report to CMS from the School of 
Rural Public Health, Texas A&M University, Pre-
venting Abuse and Neglect in Nursing Homes: The 
Role of Nurse Aide Registries. 
(vi) Information included in State nurse aide reg-
istries developed and maintained under sections 
1819(e)(2) and 1919(e)(2) of the Social Security Act 
(42 U.S.C. 1395i–3(e)(2); 1396r(e)(2)(2)). 
(D) REPORT.—Not later than 18 months after the date 
of enactment of this Act, the Secretary shall submit to 
the Elder Justice Coordinating Council established under 
section 2021 of the Social Security Act, as added by section 
1805(a), the Committee on Finance of the Senate, and 
the Committee on Ways and Means and the Committee 
on Energy and Commerce of the House of Representatives 
a report containing the findings and recommendations of 
the study conducted under this paragraph. 
(E) FUNDING LIMITATION.—Funding for the study con-
ducted under this subsection shall not exceed $500,000. 
(3) CONGRESSIONAL
ACTION.—After receiving the report 
submitted by the Secretary under paragraph (2)(D), the Com-
mittee on Finance of the Senate and the Committee on Ways 
and Means and the Committee on Energy and Commerce of 
the House of Representatives shall, as they deem appropriate, 
take action based on the recommendations contained in the 
report. 
(4) AUTHORIZATION OF APPROPRIATIONS.—There are author-
ized to be appropriated such sums as are necessary for the 
purpose of carrying out this subsection. 
(d) CONFORMING AMENDMENTS.— 
(1) TITLE XX.—Title XX of the Social Security Act (42 U.S.C. 
1397 et seq.), as amended by section 6703(a), is amended— 
(A) in the heading of section 2001, by striking ‘‘TITLE’’ 
and inserting ‘‘SUBTITLE’’; and 
(B) in subtitle 1, by striking ‘‘this title’’ each place 
it appears and inserting ‘‘this subtitle’’. 
(2) TITLE IV.—Title IV of the Social Security Act (42 U.S.C. 
601 et seq.) is amended— 
(A) in section 404(d)— 
(i) in paragraphs (1)(A), (2)(A), and (3)(B), by 
inserting ‘‘subtitle 1 of’’ before ‘‘title XX’’ each place 
it appears; 
(ii) in the heading of paragraph (2), by inserting 
‘‘SUBTITLE 1 OF’’ before ‘‘TITLE XX’’; and 
(iii) in the heading of paragraph (3)(B), by inserting 
‘‘SUBTITLE 1 OF’’ before ‘‘TITLE XX’’; and 
(B) in sections 422(b), 471(a)(4), 472(h)(1), and 
473(b)(2), by inserting ‘‘subtitle 1 of’’ before ‘‘title XX’’ each 
place it appears. 
42 USC 622, 
671–673. 
42 USC 604. 
42 USC 1397, 
1397a, 1397c– 
1397e, 1397g. 
42 USC 1397. 
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124 STAT. 804 
PUBLIC LAW 111–148—MAR. 23, 2010 
(3) TITLE XI.—Title XI of the Social Security Act (42 U.S.C. 
1301 et seq.) is amended— 
(A) in section 1128(h)(3)— 
(i) by inserting ‘‘subtitle 1 of’’ before ‘‘title XX’’; 
and 
(ii) by striking ‘‘such title’’ and inserting ‘‘such 
subtitle’’; and 
(B) in section 1128A(i)(1), by inserting ‘‘subtitle 1 of’’ 
before ‘‘title XX’’. 
Subtitle I—Sense of the Senate Regarding 
Medical Malpractice 
SEC. 6801. SENSE OF THE SENATE REGARDING MEDICAL MAL-
PRACTICE. 
It is the sense of the Senate that— 
(1) health care reform presents an opportunity to address 
issues related to medical malpractice and medical liability 
insurance; 
(2) States should be encouraged to develop and test alter-
natives to the existing civil litigation system as a way of 
improving patient safety, reducing medical errors, encouraging 
the efficient resolution of disputes, increasing the availability 
of prompt and fair resolution of disputes, and improving access 
to liability insurance, while preserving an individual’s right 
to seek redress in court; and 
(3) Congress should consider establishing a State dem-
onstration program to evaluate alternatives to the existing 
civil litigation system with respect to the resolution of medical 
malpractice claims. 
TITLE VII—IMPROVING ACCESS TO 
INNOVATIVE MEDICAL THERAPIES 
Subtitle A—Biologics Price Competition 
and Innovation 
SEC. 7001. SHORT TITLE. 
(a) IN GENERAL.—This subtitle may be cited as the ‘‘Biologics 
Price Competition and Innovation Act of 2009’’. 
(b) SENSE OF THE SENATE.—It is the sense of the Senate that 
a biosimilars pathway balancing innovation and consumer interests 
should be established. 
SEC. 7002. APPROVAL PATHWAY FOR BIOSIMILAR BIOLOGICAL PROD-
UCTS. 
(a) LICENSURE
OF BIOLOGICAL PRODUCTS
AS BIOSIMILAR
OR 
INTERCHANGEABLE.—Section 351 of the Public Health Service Act 
(42 U.S.C. 262) is amended— 
(1) in subsection (a)(1)(A), by inserting ‘‘under this sub-
section or subsection (k)’’ after ‘‘biologics license’’; and 
(2) by adding at the end the following: 
42 USC 201 note. 
Biologics Price 
Competition and 
Innovation Act of 
2009. 
42 USC 
1320a–7a. 
42 USC 1320a–7. 
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124 STAT. 805 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(k) LICENSURE OF BIOLOGICAL PRODUCTS AS BIOSIMILAR OR 
INTERCHANGEABLE.— 
‘‘(1) IN GENERAL.—Any person may submit an application 
for licensure of a biological product under this subsection. 
‘‘(2) CONTENT.— 
‘‘(A) IN GENERAL.— 
‘‘(i) REQUIRED INFORMATION.—An application sub-
mitted under this subsection shall include information 
demonstrating that— 
‘‘(I) the biological product is biosimilar to a 
reference product based upon data derived from— 
‘‘(aa) analytical studies that demonstrate 
that the biological product is highly similar 
to the reference product notwithstanding 
minor differences in clinically inactive compo-
nents; 
‘‘(bb) animal studies (including the assess-
ment of toxicity); and 
‘‘(cc) a clinical study or studies (including 
the 
assessment 
of 
immunogenicity 
and 
pharmacokinetics or pharmacodynamics) that 
are sufficient to demonstrate safety, purity, 
and potency in 1 or more appropriate condi-
tions of use for which the reference product 
is licensed and intended to be used and for 
which licensure is sought for the biological 
product; 
‘‘(II) the biological product and reference 
product utilize the same mechanism or mecha-
nisms of action for the condition or conditions of 
use prescribed, recommended, or suggested in the 
proposed labeling, but only to the extent the 
mechanism or mechanisms of action are known 
for the reference product; 
‘‘(III) the condition or conditions of use pre-
scribed, recommended, or suggested in the labeling 
proposed for the biological product have been pre-
viously approved for the reference product; 
‘‘(IV) the route of administration, the dosage 
form, and the strength of the biological product 
are the same as those of the reference product; 
and 
‘‘(V) the facility in which the biological product 
is manufactured, processed, packed, or held meets 
standards designed to assure that the biological 
product continues to be safe, pure, and potent. 
‘‘(ii) DETERMINATION
BY
SECRETARY.—The Sec-
retary may determine, in the Secretary’s discretion, 
that an element described in clause (i)(I) is unnecessary 
in an application submitted under this subsection. 
‘‘(iii) ADDITIONAL
INFORMATION.—An application 
submitted under this subsection— 
‘‘(I) shall include publicly-available informa-
tion regarding the Secretary’s previous determina-
tion that the reference product is safe, pure, and 
potent; and 
Public 
information. 
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124 STAT. 806 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(II) may include any additional information 
in support of the application, including publicly- 
available information with respect to the reference 
product or another biological product. 
‘‘(B) 
INTERCHANGEABILITY.—An 
application 
(or 
a 
supplement to an application) submitted under this sub-
section may include information demonstrating that the 
biological product meets the standards described in para-
graph (4). 
‘‘(3) EVALUATION
BY
SECRETARY.—Upon review of an 
application (or a supplement to an application) submitted under 
this subsection, the Secretary shall license the biological 
product under this subsection if— 
‘‘(A) the Secretary determines that the information sub-
mitted in the application (or the supplement) is sufficient 
to show that the biological product— 
‘‘(i) is biosimilar to the reference product; or 
‘‘(ii) meets the standards described in paragraph 
(4), and therefore is interchangeable with the reference 
product; and 
‘‘(B) the applicant (or other appropriate person) con-
sents to the inspection of the facility that is the subject 
of the application, in accordance with subsection (c). 
‘‘(4) SAFETY STANDARDS FOR DETERMINING INTERCHANGE-
ABILITY.—Upon review of an application submitted under this 
subsection or any supplement to such application, the Secretary 
shall determine the biological product to be interchangeable 
with the reference product if the Secretary determines that 
the information submitted in the application (or a supplement 
to such application) is sufficient to show that— 
‘‘(A) the biological product— 
‘‘(i) is biosimilar to the reference product; and 
‘‘(ii) can be expected to produce the same clinical 
result as the reference product in any given patient; 
and 
‘‘(B) for a biological product that is administered more 
than once to an individual, the risk in terms of safety 
or diminished efficacy of alternating or switching between 
use of the biological product and the reference product 
is not greater than the risk of using the reference product 
without such alternation or switch. 
‘‘(5) GENERAL RULES.— 
‘‘(A) ONE
REFERENCE
PRODUCT
PER
APPLICATION.—A 
biological product, in an application submitted under this 
subsection, may not be evaluated against more than 1 
reference product. 
‘‘(B) REVIEW.—An application submitted under this 
subsection shall be reviewed by the division within the 
Food and Drug Administration that is responsible for the 
review and approval of the application under which the 
reference product is licensed. 
‘‘(C) RISK EVALUATION AND MITIGATION STRATEGIES.— 
The authority of the Secretary with respect to risk evalua-
tion and mitigation strategies under the Federal Food, 
Drug, and Cosmetic Act shall apply to biological products 
licensed under this subsection in the same manner as 
Applicability. 
Determination. 
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124 STAT. 807 
PUBLIC LAW 111–148—MAR. 23, 2010 
such authority applies to biological products licensed under 
subsection (a). 
‘‘(6) EXCLUSIVITY FOR FIRST INTERCHANGEABLE BIOLOGICAL 
PRODUCT.—Upon review of an application submitted under this 
subsection relying on the same reference product for which 
a prior biological product has received a determination of inter-
changeability for any condition of use, the Secretary shall not 
make a determination under paragraph (4) that the second 
or subsequent biological product is interchangeable for any 
condition of use until the earlier of— 
‘‘(A) 1 year after the first commercial marketing of 
the first interchangeable biosimilar biological product to 
be approved as interchangeable for that reference product; 
‘‘(B) 18 months after— 
‘‘(i) a final court decision on all patents in suit 
in an action instituted under subsection (l)(6) against 
the applicant that submitted the application for the 
first approved interchangeable biosimilar biological 
product; or 
‘‘(ii) the dismissal with or without prejudice of 
an action instituted under subsection (l)(6) against the 
applicant that submitted the application for the first 
approved interchangeable biosimilar biological product; 
or 
‘‘(C)(i) 42 months after approval of the first inter-
changeable biosimilar biological product if the applicant 
that submitted such application has been sued under sub-
section (l)(6) and such litigation is still ongoing within 
such 42-month period; or 
‘‘(ii) 18 months after approval of the first interchange-
able biosimilar biological product if the applicant that sub-
mitted such application has not been sued under subsection 
(l)(6). 
For purposes of this paragraph, the term ‘final court decision’ 
means a final decision of a court from which no appeal (other 
than a petition to the United States Supreme Court for a 
writ of certiorari) has been or can be taken. 
‘‘(7) EXCLUSIVITY FOR REFERENCE PRODUCT.— 
‘‘(A) EFFECTIVE
DATE
OF
BIOSIMILAR
APPLICATION 
APPROVAL.—Approval of an application under this sub-
section may not be made effective by the Secretary until 
the date that is 12 years after the date on which the 
reference product was first licensed under subsection (a). 
‘‘(B) FILING PERIOD.—An application under this sub-
section may not be submitted to the Secretary until the 
date that is 4 years after the date on which the reference 
product was first licensed under subsection (a). 
‘‘(C) FIRST
LICENSURE.—Subparagraphs (A) and (B) 
shall not apply to a license for or approval of— 
‘‘(i) a supplement for the biological product that 
is the reference product; or 
‘‘(ii) a subsequent application filed by the same 
sponsor or manufacturer of the biological product that 
is the reference product (or a licensor, predecessor 
in interest, or other related entity) for— 
‘‘(I) a change (not including a modification to 
the structure of the biological product) that results 
Definition. 
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124 STAT. 808 
PUBLIC LAW 111–148—MAR. 23, 2010 
in a new indication, route of administration, dosing 
schedule, dosage form, delivery system, delivery 
device, or strength; or 
‘‘(II) a modification to the structure of the 
biological product that does not result in a change 
in safety, purity, or potency. 
‘‘(8) GUIDANCE DOCUMENTS.— 
‘‘(A) IN
GENERAL.—The Secretary may, after oppor-
tunity for public comment, issue guidance in accordance, 
except as provided in subparagraph (B)(i), with section 
701(h) of the Federal Food, Drug, and Cosmetic Act with 
respect to the licensure of a biological product under this 
subsection. Any such guidance may be general or specific. 
‘‘(B) PUBLIC COMMENT.— 
‘‘(i) IN GENERAL.—The Secretary shall provide the 
public an opportunity to comment on any proposed 
guidance issued under subparagraph (A) before issuing 
final guidance. 
‘‘(ii) INPUT
REGARDING
MOST
VALUABLE
GUID-
ANCE.—The Secretary shall establish a process through 
which the public may provide the Secretary with input 
regarding priorities for issuing guidance. 
‘‘(C) NO
REQUIREMENT
FOR
APPLICATION
CONSIDER-
ATION.—The issuance (or non-issuance) of guidance under 
subparagraph (A) shall not preclude the review of, or action 
on, an application submitted under this subsection. 
‘‘(D) REQUIREMENT FOR PRODUCT CLASS-SPECIFIC GUID-
ANCE.—If the Secretary issues product class-specific guid-
ance under subparagraph (A), such guidance shall include 
a description of— 
‘‘(i) the criteria that the Secretary will use to deter-
mine whether a biological product is highly similar 
to a reference product in such product class; and 
‘‘(ii) the criteria, if available, that the Secretary 
will use to determine whether a biological product 
meets the standards described in paragraph (4). 
‘‘(E) CERTAIN PRODUCT CLASSES.— 
‘‘(i) GUIDANCE.—The Secretary may indicate in a 
guidance document that the science and experience, 
as of the date of such guidance, with respect to a 
product or product class (not including any recom-
binant protein) does not allow approval of an applica-
tion for a license as provided under this subsection 
for such product or product class. 
‘‘(ii) MODIFICATION OR REVERSAL.—The Secretary 
may issue a subsequent guidance document under 
subparagraph (A) to modify or reverse a guidance docu-
ment under clause (i). 
‘‘(iii) NO EFFECT ON ABILITY TO DENY LICENSE.— 
Clause (i) shall not be construed to require the Sec-
retary to approve a product with respect to which 
the Secretary has not indicated in a guidance document 
that the science and experience, as described in clause 
(i), does not allow approval of such an application. 
‘‘(l) PATENTS.— 
‘‘(1) CONFIDENTIAL
ACCESS
TO
SUBSECTION (k) APPLICA-
TION.— 
Criteria. 
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124 STAT. 809 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) APPLICATION
OF
PARAGRAPH.—Unless otherwise 
agreed to by a person that submits an application under 
subsection (k) (referred to in this subsection as the ‘sub-
section (k) applicant’) and the sponsor of the application 
for the reference product (referred to in this subsection 
as the ‘reference product sponsor’), the provisions of this 
paragraph shall apply to the exchange of information 
described in this subsection. 
‘‘(B) IN GENERAL.— 
‘‘(i) PROVISION OF CONFIDENTIAL INFORMATION.— 
When a subsection (k) applicant submits an application 
under subsection (k), such applicant shall provide to 
the persons described in clause (ii), subject to the terms 
of this paragraph, confidential access to the informa-
tion required to be produced pursuant to paragraph 
(2) and any other information that the subsection (k) 
applicant determines, in its sole discretion, to be appro-
priate (referred to in this subsection as the ‘confidential 
information’). 
‘‘(ii) RECIPIENTS
OF
INFORMATION.—The persons 
described in this clause are the following: 
‘‘(I) OUTSIDE COUNSEL.—One or more attorneys 
designated by the reference product sponsor who 
are employees of an entity other than the reference 
product sponsor (referred to in this paragraph as 
the ‘outside counsel’), provided that such attorneys 
do not engage, formally or informally, in patent 
prosecution relevant or related to the reference 
product. 
‘‘(II) IN-HOUSE COUNSEL.—One attorney that 
represents the reference product sponsor who is 
an employee of the reference product sponsor, pro-
vided that such attorney does not engage, formally 
or informally, in patent prosecution relevant or 
related to the reference product. 
‘‘(iii) PATENT OWNER ACCESS.—A representative of 
the owner of a patent exclusively licensed to a reference 
product sponsor with respect to the reference product 
and who has retained a right to assert the patent 
or participate in litigation concerning the patent may 
be provided the confidential information, provided that 
the representative informs the reference product 
sponsor and the subsection (k) applicant of his or her 
agreement to be subject to the confidentiality provi-
sions set forth in this paragraph, including those under 
clause (ii). 
‘‘(C) LIMITATION
ON
DISCLOSURE.—No person that 
receives confidential information pursuant to subparagraph 
(B) shall disclose any confidential information to any other 
person or entity, including the reference product sponsor 
employees, outside scientific consultants, or other outside 
counsel retained by the reference product sponsor, without 
the prior written consent of the subsection (k) applicant, 
which shall not be unreasonably withheld. 
‘‘(D) USE OF CONFIDENTIAL INFORMATION.—Confidential 
information shall be used for the sole and exclusive purpose 
of determining, with respect to each patent assigned to 
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124 STAT. 810 
PUBLIC LAW 111–148—MAR. 23, 2010 
or exclusively licensed by the reference product sponsor, 
whether a claim of patent infringement could reasonably 
be asserted if the subsection (k) applicant engaged in the 
manufacture, use, offering for sale, sale, or importation 
into the United States of the biological product that is 
the subject of the application under subsection (k). 
‘‘(E) OWNERSHIP OF CONFIDENTIAL INFORMATION.—The 
confidential information disclosed under this paragraph is, 
and shall remain, the property of the subsection (k) 
applicant. By providing the confidential information pursu-
ant to this paragraph, the subsection (k) applicant does 
not provide the reference product sponsor or the outside 
counsel any interest in or license to use the confidential 
information, for purposes other than those specified in 
subparagraph (D). 
‘‘(F) EFFECT OF INFRINGEMENT ACTION.—In the event 
that the reference product sponsor files a patent infringe-
ment suit, the use of confidential information shall continue 
to be governed by the terms of this paragraph until such 
time as a court enters a protective order regarding the 
information. Upon entry of such order, the subsection (k) 
applicant may redesignate confidential information in 
accordance with the terms of that order. No confidential 
information shall be included in any publicly-available com-
plaint or other pleading. In the event that the reference 
product sponsor does not file an infringement action by 
the date specified in paragraph (6), the reference product 
sponsor shall return or destroy all confidential information 
received under this paragraph, provided that if the ref-
erence product sponsor opts to destroy such information, 
it will confirm destruction in writing to the subsection 
(k) applicant. 
‘‘(G) RULE OF CONSTRUCTION.—Nothing in this para-
graph shall be construed— 
‘‘(i) as an admission by the subsection (k) applicant 
regarding the validity, enforceability, or infringement 
of any patent; or 
‘‘(ii) as an agreement or admission by the sub-
section (k) applicant with respect to the competency, 
relevance, or materiality of any confidential informa-
tion. 
‘‘(H) EFFECT OF VIOLATION.—The disclosure of any con-
fidential information in violation of this paragraph shall 
be deemed to cause the subsection (k) applicant to suffer 
irreparable harm for which there is no adequate legal 
remedy and the court shall consider immediate injunctive 
relief to be an appropriate and necessary remedy for any 
violation or threatened violation of this paragraph. 
‘‘(2) SUBSECTION (k) APPLICATION INFORMATION.—Not later 
than 20 days after the Secretary notifies the subsection (k) 
applicant that the application has been accepted for review, 
the subsection (k) applicant— 
‘‘(A) shall provide to the reference product sponsor 
a copy of the application submitted to the Secretary under 
subsection (k), and such other information that describes 
the process or processes used to manufacture the biological 
product that is the subject of such application; and 
Deadline. 
Notification. 
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124 STAT. 811 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) may provide to the reference product sponsor addi-
tional information requested by or on behalf of the reference 
product sponsor. 
‘‘(3) LIST AND DESCRIPTION OF PATENTS.— 
‘‘(A) LIST BY REFERENCE PRODUCT SPONSOR.—Not later 
than 60 days after the receipt of the application and 
information under paragraph (2), the reference product 
sponsor shall provide to the subsection (k) applicant— 
‘‘(i) a list of patents for which the reference product 
sponsor believes a claim of patent infringement could 
reasonably be asserted by the reference product 
sponsor, or by a patent owner that has granted an 
exclusive license to the reference product sponsor with 
respect to the reference product, if a person not licensed 
by the reference product sponsor engaged in the 
making, using, offering to sell, selling, or importing 
into the United States of the biological product that 
is the subject of the subsection (k) application; and 
‘‘(ii) an identification of the patents on such list 
that the reference product sponsor would be prepared 
to license to the subsection (k) applicant. 
‘‘(B) LIST
AND
DESCRIPTION
BY
SUBSECTION
(k) 
APPLICANT.—Not later than 60 days after receipt of the 
list under subparagraph (A), the subsection (k) applicant— 
‘‘(i) may provide to the reference product sponsor 
a list of patents to which the subsection (k) applicant 
believes a claim of patent infringement could reason-
ably be asserted by the reference product sponsor if 
a person not licensed by the reference product sponsor 
engaged in the making, using, offering to sell, selling, 
or importing into the United States of the biological 
product that is the subject of the subsection (k) applica-
tion; 
‘‘(ii) shall provide to the reference product sponsor, 
with respect to each patent listed by the reference 
product sponsor under subparagraph (A) or listed by 
the subsection (k) applicant under clause (i)— 
‘‘(I) a detailed statement that describes, on 
a claim by claim basis, the factual and legal basis 
of the opinion of the subsection (k) applicant that 
such patent is invalid, unenforceable, or will not 
be infringed by the commercial marketing of the 
biological product that is the subject of the sub-
section (k) application; or 
‘‘(II) a statement that the subsection (k) 
applicant does not intend to begin commercial mar-
keting of the biological product before the date 
that such patent expires; and 
‘‘(iii) shall provide to the reference product sponsor 
a response regarding each patent identified by the 
reference product sponsor under subparagraph (A)(ii). 
‘‘(C) DESCRIPTION BY REFERENCE PRODUCT SPONSOR.— 
Not later than 60 days after receipt of the list and state-
ment under subparagraph (B), the reference product 
sponsor shall provide to the subsection (k) applicant a 
detailed statement that describes, with respect to each 
patent described in subparagraph (B)(ii)(I), on a claim by 
Deadlines. 
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124 STAT. 812 
PUBLIC LAW 111–148—MAR. 23, 2010 
claim basis, the factual and legal basis of the opinion 
of the reference product sponsor that such patent will be 
infringed by the commercial marketing of the biological 
product that is the subject of the subsection (k) application 
and a response to the statement concerning validity and 
enforceability provided under subparagraph (B)(ii)(I). 
‘‘(4) PATENT RESOLUTION NEGOTIATIONS.— 
‘‘(A) IN GENERAL.—After receipt by the subsection (k) 
applicant of the statement under paragraph (3)(C), the 
reference product sponsor and the subsection (k) applicant 
shall engage in good faith negotiations to agree on which, 
if any, patents listed under paragraph (3) by the subsection 
(k) applicant or the reference product sponsor shall be 
the subject of an action for patent infringement under 
paragraph (6). 
‘‘(B) FAILURE TO REACH AGREEMENT.—If, within 15 days 
of beginning negotiations under subparagraph (A), the sub-
section (k) applicant and the reference product sponsor 
fail to agree on a final and complete list of which, if 
any, patents listed under paragraph (3) by the subsection 
(k) applicant or the reference product sponsor shall be 
the subject of an action for patent infringement under 
paragraph (6), the provisions of paragraph (5) shall apply 
to the parties. 
‘‘(5) PATENT RESOLUTION IF NO AGREEMENT.— 
‘‘(A) 
NUMBER
OF
PATENTS.—The 
subsection 
(k) 
applicant shall notify the reference product sponsor of the 
number of patents that such applicant will provide to the 
reference product sponsor under subparagraph (B)(i)(I). 
‘‘(B) EXCHANGE OF PATENT LISTS.— 
‘‘(i) IN GENERAL.—On a date agreed to by the sub-
section (k) applicant and the reference product sponsor, 
but in no case later than 5 days after the subsection 
(k) applicant notifies the reference product sponsor 
under subparagraph (A), the subsection (k) applicant 
and the reference product sponsor shall simultaneously 
exchange— 
‘‘(I) the list of patents that the subsection (k) 
applicant believes should be the subject of an 
action for patent infringement under paragraph 
(6); and 
‘‘(II) the list of patents, in accordance with 
clause (ii), that the reference product sponsor 
believes should be the subject of an action for 
patent infringement under paragraph (6). 
‘‘(ii) NUMBER OF PATENTS LISTED BY REFERENCE 
PRODUCT SPONSOR.— 
‘‘(I) IN
GENERAL.—Subject to subclause (II), 
the number of patents listed by the reference 
product sponsor under clause (i)(II) may not exceed 
the number of patents listed by the subsection 
(k) applicant under clause (i)(I). 
‘‘(II) EXCEPTION.—If a subsection (k) applicant 
does not list any patent under clause (i)(I), the 
reference product sponsor may list 1 patent under 
clause (i)(II). 
‘‘(6) IMMEDIATE PATENT INFRINGEMENT ACTION.— 
Deadlines. 
Deadline. 
Notification. 
Time period. 
Applicability. 
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124 STAT. 813 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) ACTION IF AGREEMENT ON PATENT LIST.—If the 
subsection (k) applicant and the reference product sponsor 
agree on patents as described in paragraph (4), not later 
than 30 days after such agreement, the reference product 
sponsor shall bring an action for patent infringement with 
respect to each such patent. 
‘‘(B) ACTION
IF
NO
AGREEMENT
ON
PATENT
LIST.—If 
the provisions of paragraph (5) apply to the parties as 
described in paragraph (4)(B), not later than 30 days after 
the exchange of lists under paragraph (5)(B), the reference 
product sponsor shall bring an action for patent infringe-
ment with respect to each patent that is included on such 
lists. 
‘‘(C) NOTIFICATION AND PUBLICATION OF COMPLAINT.— 
‘‘(i) NOTIFICATION TO SECRETARY.—Not later than 
30 days after a complaint is served to a subsection 
(k) applicant in an action for patent infringement 
described under this paragraph, the subsection (k) 
applicant shall provide the Secretary with notice and 
a copy of such complaint. 
‘‘(ii) PUBLICATION BY SECRETARY.—The Secretary 
shall publish in the Federal Register notice of a com-
plaint received under clause (i). 
‘‘(7) NEWLY
ISSUED
OR
LICENSED
PATENTS.—In the case 
of a patent that— 
‘‘(A) is issued to, or exclusively licensed by, the ref-
erence product sponsor after the date that the reference 
product sponsor provided the list to the subsection (k) 
applicant under paragraph (3)(A); and 
‘‘(B) the reference product sponsor reasonably believes 
that, due to the issuance of such patent, a claim of patent 
infringement could reasonably be asserted by the reference 
product sponsor if a person not licensed by the reference 
product sponsor engaged in the making, using, offering 
to sell, selling, or importing into the United States of 
the biological product that is the subject of the subsection 
(k) application, 
not later than 30 days after such issuance or licensing, the 
reference product sponsor shall provide to the subsection (k) 
applicant a supplement to the list provided by the reference 
product sponsor under paragraph (3)(A) that includes such 
patent, not later than 30 days after such supplement is pro-
vided, the subsection (k) applicant shall provide a statement 
to the reference product sponsor in accordance with paragraph 
(3)(B), and such patent shall be subject to paragraph (8). 
‘‘(8) NOTICE OF COMMERCIAL MARKETING AND PRELIMINARY 
INJUNCTION.— 
‘‘(A) NOTICE
OF
COMMERCIAL
MARKETING.—The sub-
section (k) applicant shall provide notice to the reference 
product sponsor not later than 180 days before the date 
of the first commercial marketing of the biological product 
licensed under subsection (k). 
‘‘(B) PRELIMINARY
INJUNCTION.—After receiving the 
notice under subparagraph (A) and before such date of 
the first commercial marketing of such biological product, 
the reference product sponsor may seek a preliminary 
injunction prohibiting the subsection (k) applicant from 
Deadline. 
Deadlines. 
Federal Register, 
publication. 
Notice. 
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124 STAT. 814 
PUBLIC LAW 111–148—MAR. 23, 2010 
engaging in the commercial manufacture or sale of such 
biological product until the court decides the issue of patent 
validity, enforcement, and infringement with respect to 
any patent that is— 
‘‘(i) included in the list provided by the reference 
product sponsor under paragraph (3)(A) or in the list 
provided by the subsection (k) applicant under para-
graph (3)(B); and 
‘‘(ii) not included, as applicable, on— 
‘‘(I) the list of patents described in paragraph 
(4); or 
‘‘(II) the lists of patents described in paragraph 
(5)(B). 
‘‘(C) REASONABLE
COOPERATION.—If the reference 
product sponsor has sought a preliminary injunction under 
subparagraph (B), the reference product sponsor and the 
subsection (k) applicant shall reasonably cooperate to expe-
dite such further discovery as is needed in connection with 
the preliminary injunction motion. 
‘‘(9) LIMITATION ON DECLARATORY JUDGMENT ACTION.— 
‘‘(A) SUBSECTION (k) APPLICATION PROVIDED.—If a sub-
section (k) applicant provides the application and informa-
tion required under paragraph (2)(A), neither the reference 
product sponsor nor the subsection (k) applicant may, prior 
to the date notice is received under paragraph (8)(A), bring 
any action under section 2201 of title 28, United States 
Code, for a declaration of infringement, validity, or enforce-
ability of any patent that is described in clauses (i) and 
(ii) of paragraph (8)(B). 
‘‘(B) SUBSEQUENT FAILURE TO ACT BY SUBSECTION (k) 
APPLICANT.—If a subsection (k) applicant fails to complete 
an action required of the subsection (k) applicant under 
paragraph (3)(B)(ii), paragraph (5), paragraph (6)(C)(i), 
paragraph (7), or paragraph (8)(A), the reference product 
sponsor, but not the subsection (k) applicant, may bring 
an action under section 2201 of title 28, United States 
Code, for a declaration of infringement, validity, or enforce-
ability of any patent included in the list described in para-
graph (3)(A), including as provided under paragraph (7). 
‘‘(C) SUBSECTION (k) APPLICATION NOT PROVIDED.—If 
a subsection (k) applicant fails to provide the application 
and information required under paragraph (2)(A), the ref-
erence product sponsor, but not the subsection (k) 
applicant, may bring an action under section 2201 of title 
28, United States Code, for a declaration of infringement, 
validity, or enforceability of any patent that claims the 
biological product or a use of the biological product.’’. 
(b) DEFINITIONS.—Section 351(i) of the Public Health Service 
Act (42 U.S.C. 262(i)) is amended— 
(1) by striking ‘‘In this section, the term ‘biological product’ 
means’’ and inserting the following: ‘‘In this section: 
‘‘(1) The term ‘biological product’ means’’; 
(2) in paragraph (1), as so designated, by inserting ‘‘protein 
(except any chemically synthesized polypeptide),’’ after ‘‘aller-
genic product,’’; and 
(3) by adding at the end the following: 
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124 STAT. 815 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) The term ‘biosimilar’ or ‘biosimilarity’, in reference 
to a biological product that is the subject of an application 
under subsection (k), means— 
‘‘(A) that the biological product is highly similar to 
the reference product notwithstanding minor differences 
in clinically inactive components; and 
‘‘(B) there are no clinically meaningful differences 
between the biological product and the reference product 
in terms of the safety, purity, and potency of the product. 
‘‘(3) The term ‘interchangeable’ or ‘interchangeability’, in 
reference to a biological product that is shown to meet the 
standards described in subsection (k)(4), means that the 
biological product may be substituted for the reference product 
without the intervention of the health care provider who pre-
scribed the reference product. 
‘‘(4) The term ‘reference product’ means the single biological 
product licensed under subsection (a) against which a biological 
product is evaluated in an application submitted under sub-
section (k).’’. 
(c) CONFORMING AMENDMENTS RELATING TO PATENTS.— 
(1) PATENTS.—Section 271(e) of title 35, United States Code, 
is amended— 
(A) in paragraph (2)— 
(i) in subparagraph (A), by striking ‘‘or’’ at the 
end; 
(ii) in subparagraph (B), by adding ‘‘or’’ at the 
end; and 
(iii) by inserting after subparagraph (B) the fol-
lowing: 
‘‘(C)(i) with respect to a patent that is identified in the 
list of patents described in section 351(l)(3) of the Public Health 
Service Act (including as provided under section 351(l)(7) of 
such Act), an application seeking approval of a biological 
product, or 
‘‘(ii) if the applicant for the application fails to provide 
the application and information required under section 
351(l)(2)(A) of such Act, an application seeking approval of 
a biological product for a patent that could be identified pursu-
ant to section 351(l)(3)(A)(i) of such Act,’’; and 
(iv) in the matter following subparagraph (C) (as 
added by clause (iii)), by striking ‘‘or veterinary 
biological product’’ and inserting ‘‘, veterinary biological 
product, or biological product’’; 
(B) in paragraph (4)— 
(i) in subparagraph (B), by— 
(I) striking ‘‘or veterinary biological product’’ 
and inserting ‘‘, veterinary biological product, or 
biological product’’; and 
(II) striking ‘‘and’’ at the end; 
(ii) in subparagraph (C), by— 
(I) striking ‘‘or veterinary biological product’’ 
and inserting ‘‘, veterinary biological product, or 
biological product’’; and 
(II) striking the period and inserting ‘‘, and’’; 
(iii) by inserting after subparagraph (C) the fol-
lowing: 
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124 STAT. 816 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(D) the court shall order a permanent injunction prohib-
iting any infringement of the patent by the biological product 
involved in the infringement until a date which is not earlier 
than the date of the expiration of the patent that has been 
infringed under paragraph (2)(C), provided the patent is the 
subject of a final court decision, as defined in section 351(k)(6) 
of the Public Health Service Act, in an action for infringement 
of the patent under section 351(l)(6) of such Act, and the 
biological product has not yet been approved because of section 
351(k)(7) of such Act.’’; and 
(iv) in the matter following subparagraph (D) (as 
added by clause (iii)), by striking ‘‘and (C)’’ and 
inserting ‘‘(C), and (D)’’; and 
(C) by adding at the end the following: 
‘‘(6)(A) Subparagraph (B) applies, in lieu of paragraph (4), in 
the case of a patent— 
‘‘(i) that is identified, as applicable, in the list of patents 
described in section 351(l)(4) of the Public Health Service Act 
or the lists of patents described in section 351(l)(5)(B) of such 
Act with respect to a biological product; and 
‘‘(ii) for which an action for infringement of the patent 
with respect to the biological product— 
‘‘(I) was brought after the expiration of the 30-day 
period described in subparagraph (A) or (B), as applicable, 
of section 351(l)(6) of such Act; or 
‘‘(II) was brought before the expiration of the 30-day 
period described in subclause (I), but which was dismissed 
without prejudice or was not prosecuted to judgment in 
good faith. 
‘‘(B) In an action for infringement of a patent described in 
subparagraph (A), the sole and exclusive remedy that may be 
granted by a court, upon a finding that the making, using, offering 
to sell, selling, or importation into the United States of the biological 
product that is the subject of the action infringed the patent, shall 
be a reasonable royalty. 
‘‘(C) The owner of a patent that should have been included 
in the list described in section 351(l)(3)(A) of the Public Health 
Service Act, including as provided under section 351(l)(7) of such 
Act for a biological product, but was not timely included in such 
list, may not bring an action under this section for infringement 
of the patent with respect to the biological product.’’. 
(2) CONFORMING
AMENDMENT
UNDER
TITLE 28.—Section 
2201(b) of title 28, United States Code, is amended by inserting 
before the period the following: ‘‘, or section 351 of the Public 
Health Service Act’’. 
(d) CONFORMING AMENDMENTS UNDER
THE FEDERAL FOOD, 
DRUG, AND COSMETIC ACT.— 
(1) CONTENT
AND
REVIEW
OF
APPLICATIONS.—Section 
505(b)(5)(B) of the Federal Food, Drug, and Cosmetic Act (21 
U.S.C. 355(b)(5)(B)) is amended by inserting before the period 
at the end of the first sentence the following: ‘‘or, with respect 
to an applicant for approval of a biological product under section 
351(k) of the Public Health Service Act, any necessary clinical 
study or studies’’. 
(2) NEW ACTIVE INGREDIENT.—Section 505B of the Federal 
Food, Drug, and Cosmetic Act (21 U.S.C. 355c) is amended 
by adding at the end the following: 
Applicability. 
Courts. 
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124 STAT. 817 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(n) NEW ACTIVE INGREDIENT.— 
‘‘(1) 
NON-INTERCHANGEABLE
BIOSIMILAR
BIOLOGICAL 
PRODUCT.—A biological product that is biosimilar to a reference 
product under section 351 of the Public Health Service Act, 
and that the Secretary has not determined to meet the stand-
ards described in subsection (k)(4) of such section for inter-
changeability with the reference product, shall be considered 
to have a new active ingredient under this section. 
‘‘(2) INTERCHANGEABLE BIOSIMILAR BIOLOGICAL PRODUCT.— 
A biological product that is interchangeable with a reference 
product under section 351 of the Public Health Service Act 
shall not be considered to have a new active ingredient under 
this section.’’. 
(e) PRODUCTS PREVIOUSLY APPROVED UNDER SECTION 505.— 
(1) REQUIREMENT TO FOLLOW SECTION 351.—Except as pro-
vided in paragraph (2), an application for a biological product 
shall be submitted under section 351 of the Public Health 
Service Act (42 U.S.C. 262) (as amended by this Act). 
(2) EXCEPTION.—An application for a biological product may 
be submitted under section 505 of the Federal Food, Drug, 
and Cosmetic Act (21 U.S.C. 355) if— 
(A) such biological product is in a product class for 
which a biological product in such product class is the 
subject of an application approved under such section 505 
not later than the date of enactment of this Act; and 
(B) such application— 
(i) has been submitted to the Secretary of Health 
and Human Services (referred to in this subtitle as 
the ‘‘Secretary’’) before the date of enactment of this 
Act; or 
(ii) is submitted to the Secretary not later than 
the date that is 10 years after the date of enactment 
of this Act. 
(3) 
LIMITATION.—Notwithstanding 
paragraph 
(2), 
an 
application for a biological product may not be submitted under 
section 505 of the Federal Food, Drug, and Cosmetic Act (21 
U.S.C. 355) if there is another biological product approved 
under subsection (a) of section 351 of the Public Health Service 
Act that could be a reference product with respect to such 
application (within the meaning of such section 351) if such 
application were submitted under subsection (k) of such section 
351. 
(4) DEEMED APPROVED UNDER SECTION 351.—An approved 
application for a biological product under section 505 of the 
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) shall 
be deemed to be a license for the biological product under 
such section 351 on the date that is 10 years after the date 
of enactment of this Act. 
(5) DEFINITIONS.—For purposes of this subsection, the term 
‘‘biological product’’ has the meaning given such term under 
section 351 of the Public Health Service Act (42 U.S.C. 262) 
(as amended by this Act). 
(f) FOLLOW-ON BIOLOGICS USER FEES.— 
(1) DEVELOPMENT OF USER FEES FOR BIOSIMILAR BIOLOGICAL 
PRODUCTS.— 
(A) IN GENERAL.—Beginning not later than October 
1, 2010, the Secretary shall develop recommendations to 
Deadline. 
Recommenda- 
tions. 
Effective date. 
Deadlines. 
42 USC 262 note. 
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124 STAT. 818 
PUBLIC LAW 111–148—MAR. 23, 2010 
present to Congress with respect to the goals, and plans 
for meeting the goals, for the process for the review of 
biosimilar biological product applications submitted under 
section 351(k) of the Public Health Service Act (as added 
by this Act) for the first 5 fiscal years after fiscal year 
2012. In developing such recommendations, the Secretary 
shall consult with— 
(i) the Committee on Health, Education, Labor, 
and Pensions of the Senate; 
(ii) the Committee on Energy and Commerce of 
the House of Representatives; 
(iii) scientific and academic experts; 
(iv) health care professionals; 
(v) representatives of patient and consumer 
advocacy groups; and 
(vi) the regulated industry. 
(B) PUBLIC REVIEW OF RECOMMENDATIONS.—After nego-
tiations with the regulated industry, the Secretary shall— 
(i) present the recommendations developed under 
subparagraph (A) to the Congressional committees 
specified in such subparagraph; 
(ii) publish such recommendations in the Federal 
Register; 
(iii) provide for a period of 30 days for the public 
to provide written comments on such recommendations; 
(iv) hold a meeting at which the public may present 
its views on such recommendations; and 
(v) after consideration of such public views and 
comments, revise such recommendations as necessary. 
(C) TRANSMITTAL
OF
RECOMMENDATIONS.—Not later 
than January 15, 2012, the Secretary shall transmit to 
Congress the revised recommendations under subpara-
graph (B), a summary of the views and comments received 
under such subparagraph, and any changes made to the 
recommendations in response to such views and comments. 
(2) ESTABLISHMENT OF USER FEE PROGRAM.—It is the sense 
of the Senate that, based on the recommendations transmitted 
to Congress by the Secretary pursuant to paragraph (1)(C), 
Congress should authorize a program, effective on October 1, 
2012, for the collection of user fees relating to the submission 
of biosimilar biological product applications under section 
351(k) of the Public Health Service Act (as added by this 
Act). 
(3) TRANSITIONAL
PROVISIONS
FOR
USER
FEES
FOR
BIO-
SIMILAR BIOLOGICAL PRODUCTS.— 
(A) APPLICATION OF THE PRESCRIPTION DRUG USER FEE 
PROVISIONS.—Section 735(1)(B) of the Federal Food, Drug, 
and Cosmetic Act (21 U.S.C. 379g(1)(B)) is amended by 
striking ‘‘section 351’’ and inserting ‘‘subsection (a) or (k) 
of section 351’’. 
(B) EVALUATION OF COSTS OF REVIEWING BIOSIMILAR 
BIOLOGICAL
PRODUCT
APPLICATIONS.—During the period 
beginning on the date of enactment of this Act and ending 
on October 1, 2010, the Secretary shall collect and evaluate 
data regarding the costs of reviewing applications for 
biological products submitted under section 351(k) of the 
Time period. 
42 USC 262 note. 
Effective date. 
Deadline. 
Time period. 
Federal Register, 
publication. 
Consultation. 
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124 STAT. 819 
PUBLIC LAW 111–148—MAR. 23, 2010 
Public Health Service Act (as added by this Act) during 
such period. 
(C) AUDIT.— 
(i) IN GENERAL.—On the date that is 2 years after 
first receiving a user fee applicable to an application 
for a biological product under section 351(k) of the 
Public Health Service Act (as added by this Act), and 
on a biennial basis thereafter until October 1, 2013, 
the Secretary shall perform an audit of the costs of 
reviewing such applications under such section 351(k). 
Such an audit shall compare— 
(I) the costs of reviewing such applications 
under such section 351(k) to the amount of the 
user fee applicable to such applications; and 
(II)(aa) such ratio determined under subclause 
(I); to 
(bb) the ratio of the costs of reviewing applica-
tions for biological products under section 351(a) 
of such Act (as amended by this Act) to the amount 
of the user fee applicable to such applications 
under such section 351(a). 
(ii) ALTERATION OF USER FEE.—If the audit per-
formed under clause (i) indicates that the ratios com-
pared under subclause (II) of such clause differ by 
more than 5 percent, then the Secretary shall alter 
the user fee applicable to applications submitted under 
such section 351(k) to more appropriately account for 
the costs of reviewing such applications. 
(iii) ACCOUNTING STANDARDS.—The Secretary shall 
perform an audit under clause (i) in conformance with 
the accounting principles, standards, and requirements 
prescribed by the Comptroller General of the United 
States under section 3511 of title 31, United State 
Code, to ensure the validity of any potential variability. 
(4) AUTHORIZATION OF APPROPRIATIONS.—There is author-
ized to be appropriated to carry out this subsection such sums 
as may be necessary for each of fiscal years 2010 through 
2012. 
(g) PEDIATRIC STUDIES OF BIOLOGICAL PRODUCTS.— 
(1) IN GENERAL.—Section 351 of the Public Health Service 
Act (42 U.S.C. 262) is amended by adding at the end the 
following: 
‘‘(m) PEDIATRIC STUDIES.— 
‘‘(1) APPLICATION OF CERTAIN PROVISIONS.—The provisions 
of subsections (a), (d), (e), (f), (i), (j), (k), (l), (p), and (q) of 
section 505A of the Federal Food, Drug, and Cosmetic Act 
shall apply with respect to the extension of a period under 
paragraphs (2) and (3) to the same extent and in the same 
manner as such provisions apply with respect to the extension 
of a period under subsection (b) or (c) of section 505A of the 
Federal Food, Drug, and Cosmetic Act. 
‘‘(2) MARKET
EXCLUSIVITY
FOR
NEW
BIOLOGICAL
PROD-
UCTS.—If, prior to approval of an application that is submitted 
under subsection (a), the Secretary determines that information 
relating to the use of a new biological product in the pediatric 
population may produce health benefits in that population, 
the Secretary makes a written request for pediatric studies 
Determination. 
Time period. 
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124 STAT. 820 
PUBLIC LAW 111–148—MAR. 23, 2010 
(which shall include a timeframe for completing such studies), 
the applicant agrees to the request, such studies are completed 
using appropriate formulations for each age group for which 
the study is requested within any such timeframe, and the 
reports thereof are submitted and accepted in accordance with 
section 505A(d)(3) of the Federal Food, Drug, and Cosmetic 
Act— 
‘‘(A) the periods for such biological product referred 
to in subsection (k)(7) are deemed to be 4 years and 6 
months rather than 4 years and 12 years and 6 months 
rather than 12 years; and 
‘‘(B) if the biological product is designated under section 
526 for a rare disease or condition, the period for such 
biological product referred to in section 527(a) is deemed 
to be 7 years and 6 months rather than 7 years. 
‘‘(3) 
MARKET
EXCLUSIVITY
FOR
ALREADY-MARKETED 
BIOLOGICAL
PRODUCTS.—If the Secretary determines that 
information relating to the use of a licensed biological product 
in the pediatric population may produce health benefits in 
that population and makes a written request to the holder 
of an approved application under subsection (a) for pediatric 
studies (which shall include a timeframe for completing such 
studies), the holder agrees to the request, such studies are 
completed using appropriate formulations for each age group 
for which the study is requested within any such timeframe, 
and the reports thereof are submitted and accepted in accord-
ance with section 505A(d)(3) of the Federal Food, Drug, and 
Cosmetic Act— 
‘‘(A) the periods for such biological product referred 
to in subsection (k)(7) are deemed to be 4 years and 6 
months rather than 4 years and 12 years and 6 months 
rather than 12 years; and 
‘‘(B) if the biological product is designated under section 
526 for a rare disease or condition, the period for such 
biological product referred to in section 527(a) is deemed 
to be 7 years and 6 months rather than 7 years. 
‘‘(4) EXCEPTION.—The Secretary shall not extend a period 
referred to in paragraph (2)(A), (2)(B), (3)(A), or (3)(B) if the 
determination under section 505A(d)(3) is made later than 9 
months prior to the expiration of such period.’’. 
(2) STUDIES REGARDING PEDIATRIC RESEARCH.— 
(A) PROGRAM FOR PEDIATRIC STUDY OF DRUGS.—Sub-
section (a)(1) of section 409I of the Public Health Service 
Act (42 U.S.C. 284m) is amended by inserting ‘‘, biological 
products,’’ after ‘‘including drugs’’. 
(B) INSTITUTE OF MEDICINE STUDY.—Section 505A(p) 
of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 
355b(p)) is amended by striking paragraphs (4) and (5) 
and inserting the following: 
‘‘(4) review and assess the number and importance of 
biological products for children that are being tested as a result 
of the amendments made by the Biologics Price Competition 
and Innovation Act of 2009 and the importance for children, 
health care providers, parents, and others of labeling changes 
made as a result of such testing; 
21 USC 355a. 
Determination. 
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124 STAT. 821 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(5) review and assess the number, importance, and 
prioritization of any biological products that are not being tested 
for pediatric use; and 
‘‘(6) offer recommendations for ensuring pediatric testing 
of biological products, including consideration of any incentives, 
such as those provided under this section or section 351(m) 
of the Public Health Service Act.’’. 
(h) ORPHAN PRODUCTS.—If a reference product, as defined in 
section 351 of the Public Health Service Act (42 U.S.C. 262) (as 
amended by this Act) has been designated under section 526 of 
the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360bb) for 
a rare disease or condition, a biological product seeking approval 
for such disease or condition under subsection (k) of such section 
351 as biosimilar to, or interchangeable with, such reference product 
may be licensed by the Secretary only after the expiration for 
such reference product of the later of— 
(1) the 7-year period described in section 527(a) of the 
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360cc(a)); 
and 
(2) the 12-year period described in subsection (k)(7) of 
such section 351. 
SEC. 7003. SAVINGS. 
(a) DETERMINATION.—The Secretary of the Treasury, in con-
sultation with the Secretary of Health and Human Services, shall 
for each fiscal year determine the amount of savings to the Federal 
Government as a result of the enactment of this subtitle. 
(b) USE.—Notwithstanding any other provision of this subtitle 
(or an amendment made by this subtitle), the savings to the Federal 
Government generated as a result of the enactment of this subtitle 
shall be used for deficit reduction. 
Subtitle B—More Affordable Medicines for 
Children and Underserved Communities 
SEC. 7101. EXPANDED PARTICIPATION IN 340B PROGRAM. 
(a) EXPANSION OF COVERED ENTITIES RECEIVING DISCOUNTED 
PRICES.—Section 340B(a)(4) of the Public Health Service Act (42 
U.S.C. 256b(a)(4)) is amended by adding at the end the following: 
‘‘(M) A children’s hospital excluded from the Medicare 
prospective 
payment 
system 
pursuant 
to 
section 
1886(d)(1)(B)(iii) of the Social Security Act, or a free- 
standing cancer hospital excluded from the Medicare 
prospective 
payment 
system 
pursuant 
to 
section 
1886(d)(1)(B)(v) of the Social Security Act, that would meet 
the requirements of subparagraph (L), including the dis-
proportionate share adjustment percentage requirement 
under clause (ii) of such subparagraph, if the hospital were 
a subsection (d) hospital as defined by section 1886(d)(1)(B) 
of the Social Security Act. 
‘‘(N) An entity that is a critical access hospital (as 
determined under section 1820(c)(2) of the Social Security 
Act), and that meets the requirements of subparagraph 
(L)(i). 
‘‘(O) An entity that is a rural referral center, as defined 
by section 1886(d)(5)(C)(i) of the Social Security Act, or 
42 USC 262 note. 
Time periods. 
42 USC 262 note. 
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124 STAT. 822 
PUBLIC LAW 111–148—MAR. 23, 2010 
a sole community hospital, as defined by section 
1886(d)(5)(C)(iii) of such Act, and that both meets the 
requirements of subparagraph (L)(i) and has a dispropor-
tionate share adjustment percentage equal to or greater 
than 8 percent.’’. 
(b) EXTENSION
OF DISCOUNT
TO INPATIENT DRUGS.—Section 
340B of the Public Health Service Act (42 U.S.C. 256b) is amended— 
(1) in paragraphs (2), (5), (7), and (9) of subsection (a), 
by striking ‘‘outpatient’’ each place it appears; and 
(2) in subsection (b)— 
(A) by striking ‘‘OTHER DEFINITION’’ and all that follows 
through ‘‘In this section’’ and inserting the following: 
‘‘OTHER DEFINITIONS.— 
‘‘(1) IN GENERAL.—In this section’’; and 
(B) by adding at the end the following new paragraph: 
‘‘(2) COVERED
DRUG.—In this section, the term ‘covered 
drug’— 
‘‘(A) means a covered outpatient drug (as defined in 
section 1927(k)(2) of the Social Security Act); and 
‘‘(B) includes, notwithstanding paragraph (3)(A) of sec-
tion 1927(k) of such Act, a drug used in connection with 
an inpatient or outpatient service provided by a hospital 
described in subparagraph (L), (M), (N), or (O) of subsection 
(a)(4) that is enrolled to participate in the drug discount 
program under this section.’’. 
(c) PROHIBITION ON GROUP PURCHASING ARRANGEMENTS.—Sec-
tion 340B(a) of the Public Health Service Act (42 U.S.C. 256b(a)) 
is amended— 
(1) in paragraph (4)(L)— 
(A) in clause (i), by adding ‘‘and’’ at the end; 
(B) in clause (ii), by striking ‘‘; and’’ and inserting 
a period; and 
(C) by striking clause (iii); and 
(2) in paragraph (5), as amended by subsection (b)— 
(A) by redesignating subparagraphs (C) and (D) as 
subparagraphs (D) and (E); respectively; and 
(B) by inserting after subparagraph (B), the following: 
‘‘(C) PROHIBITION
ON
GROUP
PURCHASING
ARRANGE-
MENTS.— 
‘‘(i) IN GENERAL.—A hospital described in subpara-
graph (L), (M), (N), or (O) of paragraph (4) shall not 
obtain covered outpatient drugs through a group pur-
chasing organization or other group purchasing 
arrangement, except as permitted or provided for 
pursuant to clauses (ii) or (iii). 
‘‘(ii) INPATIENT DRUGS.—Clause (i) shall not apply 
to drugs purchased for inpatient use. 
‘‘(iii) EXCEPTIONS.—The Secretary shall establish 
reasonable exceptions to clause (i)— 
‘‘(I) with respect to a covered outpatient drug 
that is unavailable to be purchased through the 
program under this section due to a drug shortage 
problem, manufacturer noncompliance, or any 
other circumstance beyond the hospital’s control; 
‘‘(II) to facilitate generic substitution when a 
generic covered outpatient drug is available at a 
lower price; or 
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124 STAT. 823 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(III) to reduce in other ways the administra-
tive burdens of managing both inventories of drugs 
subject to this section and inventories of drugs 
that are not subject to this section, so long as 
the exceptions do not create a duplicate discount 
problem in violation of subparagraph (A) or a 
diversion problem in violation of subparagraph (B). 
‘‘(iv) PURCHASING ARRANGEMENTS FOR INPATIENT 
DRUGS.—The Secretary shall ensure that a hospital 
described in subparagraph (L), (M), (N), or (O) of sub-
section (a)(4) that is enrolled to participate in the drug 
discount program under this section shall have mul-
tiple 
options 
for 
purchasing 
covered 
drugs 
for 
inpatients, including by utilizing a group purchasing 
organization or other group purchasing arrangement, 
establishing and utilizing its own group purchasing 
program, purchasing directly from a manufacturer, and 
any other purchasing arrangements that the Secretary 
determines is appropriate to ensure access to drug 
discount pricing under this section for inpatient drugs 
taking into account the particular needs of small and 
rural hospitals.’’. 
(d) MEDICAID CREDITS
ON INPATIENT DRUGS.—Section 340B 
of the Public Health Service Act (42 U.S.C. 256b) is amended 
by striking subsection (c) and inserting the following: 
‘‘(c) MEDICAID CREDIT.—Not later than 90 days after the date 
of filing of the hospital’s most recently filed Medicare cost report, 
the hospital shall issue a credit as determined by the Secretary 
to the State Medicaid program for inpatient covered drugs provided 
to Medicaid recipients.’’. 
(e) EFFECTIVE DATES.— 
(1) IN GENERAL.—The amendments made by this section 
and section 7102 shall take effect on January 1, 2010, and 
shall apply to drugs purchased on or after January 1, 2010. 
(2) EFFECTIVENESS.—The amendments made by this section 
and section 7102 shall be effective and shall be taken into 
account in determining whether a manufacturer is deemed 
to meet the requirements of section 340B(a) of the Public Health 
Service Act (42 U.S.C. 256b(a)), notwithstanding any other 
provision of law. 
SEC. 7102. IMPROVEMENTS TO 340B PROGRAM INTEGRITY. 
(a) INTEGRITY IMPROVEMENTS.—Subsection (d) of section 340B 
of the Public Health Service Act (42 U.S.C. 256b) is amended 
to read as follows: 
‘‘(d) IMPROVEMENTS IN PROGRAM INTEGRITY.— 
‘‘(1) MANUFACTURER COMPLIANCE.— 
‘‘(A) IN GENERAL.—From amounts appropriated under 
paragraph (4), the Secretary shall provide for improve-
ments in compliance by manufacturers with the require-
ments of this section in order to prevent overcharges and 
other violations of the discounted pricing requirements 
specified in this section. 
‘‘(B) IMPROVEMENTS.—The improvements described in 
subparagraph (A) shall include the following: 
42 USC 256b. 
Deadline. 
Determination. 
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124 STAT. 824 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) The development of a system to enable the 
Secretary to verify the accuracy of ceiling prices cal-
culated by manufacturers under subsection (a)(1) and 
charged to covered entities, which shall include the 
following: 
‘‘(I) Developing and publishing through an 
appropriate policy or regulatory issuance, precisely 
defined standards and methodology for the calcula-
tion of ceiling prices under such subsection. 
‘‘(II) Comparing regularly the ceiling prices 
calculated by the Secretary with the quarterly 
pricing data that is reported by manufacturers 
to the Secretary. 
‘‘(III) Performing spot checks of sales trans-
actions by covered entities. 
‘‘(IV) Inquiring into the cause of any pricing 
discrepancies that may be identified and either 
taking, or requiring manufacturers to take, such 
corrective action as is appropriate in response to 
such price discrepancies. 
‘‘(ii) The establishment of procedures for manufac-
turers to issue refunds to covered entities in the event 
that there is an overcharge by the manufacturers, 
including the following: 
‘‘(I) Providing the Secretary with an expla-
nation of why and how the overcharge occurred, 
how the refunds will be calculated, and to whom 
the refunds will be issued. 
‘‘(II) Oversight by the Secretary to ensure that 
the refunds are issued accurately and within a 
reasonable period of time, both in routine instances 
of retroactive adjustment to relevant pricing data 
and exceptional circumstances such as erroneous 
or intentional overcharging for covered drugs. 
‘‘(iii) The provision of access through the Internet 
website of the Department of Health and Human Serv-
ices to the applicable ceiling prices for covered drugs 
as calculated and verified by the Secretary in accord-
ance with this section, in a manner (such as through 
the use of password protection) that limits such access 
to covered entities and adequately assures security 
and 
protection 
of 
privileged 
pricing 
data 
from 
unauthorized re-disclosure. 
‘‘(iv) The development of a mechanism by which— 
‘‘(I) rebates and other discounts provided by 
manufacturers to other purchasers subsequent to 
the sale of covered drugs to covered entities are 
reported to the Secretary; and 
‘‘(II) appropriate credits and refunds are issued 
to covered entities if such discounts or rebates 
have the effect of lowering the applicable ceiling 
price for the relevant quarter for the drugs 
involved. 
‘‘(v) Selective auditing of manufacturers and whole-
salers to ensure the integrity of the drug discount 
program under this section. 
Procedures. 
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124 STAT. 825 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(vi) The imposition of sanctions in the form of 
civil monetary penalties, which— 
‘‘(I) shall be assessed according to standards 
established in regulations to be promulgated by 
the Secretary not later than 180 days after the 
date of enactment of the Patient Protection and 
Affordable Care Act; 
‘‘(II) shall not exceed $5,000 for each instance 
of overcharging a covered entity that may have 
occurred; and 
‘‘(III) shall apply to any manufacturer with 
an agreement under this section that knowingly 
and intentionally charges a covered entity a price 
for purchase of a drug that exceeds the maximum 
applicable price under subsection (a)(1). 
‘‘(2) COVERED ENTITY COMPLIANCE.— 
‘‘(A) IN GENERAL.—From amounts appropriated under 
paragraph (4), the Secretary shall provide for improve-
ments in compliance by covered entities with the require-
ments of this section in order to prevent diversion and 
violations of the duplicate discount provision and other 
requirements specified under subsection (a)(5). 
‘‘(B) IMPROVEMENTS.—The improvements described in 
subparagraph (A) shall include the following: 
‘‘(i) The development of procedures to enable and 
require covered entities to regularly update (at least 
annually) the information on the Internet website of 
the Department of Health and Human Services 
relating to this section. 
‘‘(ii) The development of a system for the Secretary 
to verify the accuracy of information regarding covered 
entities that is listed on the website described in clause 
(i). 
‘‘(iii) The development of more detailed guidance 
describing methodologies and options available to cov-
ered entities for billing covered drugs to State Medicaid 
agencies in a manner that avoids duplicate discounts 
pursuant to subsection (a)(5)(A). 
‘‘(iv) The establishment of a single, universal, and 
standardized identification system by which each cov-
ered entity site can be identified by manufacturers, 
distributors, covered entities, and the Secretary for 
purposes of facilitating the ordering, purchasing, and 
delivery of covered drugs under this section, including 
the processing of chargebacks for such drugs. 
‘‘(v) The imposition of sanctions, in appropriate 
cases as determined by the Secretary, additional to 
those to which covered entities are subject under sub-
section (a)(5)(E), through one or more of the following 
actions: 
‘‘(I) Where a covered entity knowingly and 
intentionally violates subsection (a)(5)(B), the cov-
ered entity shall be required to pay a monetary 
penalty to a manufacturer or manufacturers in 
the form of interest on sums for which the covered 
entity is found liable under subsection (a)(5)(E), 
such interest to be compounded monthly and equal 
Sanctions. 
Determination. 
Guidance. 
Procedures. 
Applicability. 
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124 STAT. 826 
PUBLIC LAW 111–148—MAR. 23, 2010 
to the current short term interest rate as deter-
mined by the Federal Reserve for the time period 
for which the covered entity is liable. 
‘‘(II) Where the Secretary determines a viola-
tion of subsection (a)(5)(B) was systematic and 
egregious as well as knowing and intentional, 
removing the covered entity from the drug discount 
program under this section and disqualifying the 
entity from re-entry into such program for a 
reasonable period of time to be determined by the 
Secretary. 
‘‘(III) Referring matters to appropriate Federal 
authorities within the Food and Drug Administra-
tion, the Office of Inspector General of Department 
of Health and Human Services, or other Federal 
agencies for consideration of appropriate action 
under other Federal statutes, such as the Prescrip-
tion Drug Marketing Act (21 U.S.C. 353). 
‘‘(3) ADMINISTRATIVE DISPUTE RESOLUTION PROCESS.— 
‘‘(A) IN GENERAL.—Not later than 180 days after the 
date of enactment of the Patient Protection and Affordable 
Care Act, the Secretary shall promulgate regulations to 
establish and implement an administrative process for the 
resolution of claims by covered entities that they have 
been overcharged for drugs purchased under this section, 
and claims by manufacturers, after the conduct of audits 
as authorized by subsection (a)(5)(D), of violations of sub-
sections (a)(5)(A) or (a)(5)(B), including appropriate proce-
dures for the provision of remedies and enforcement of 
determinations made pursuant to such process through 
mechanisms and sanctions described in paragraphs (1)(B) 
and (2)(B). 
‘‘(B) 
DEADLINES
AND
PROCEDURES.—Regulations 
promulgated by the Secretary under subparagraph (A) 
shall— 
‘‘(i) designate or establish a decision-making offi-
cial or decision-making body within the Department 
of Health and Human Services to be responsible for 
reviewing and finally resolving claims by covered enti-
ties that they have been charged prices for covered 
drugs in excess of the ceiling price described in sub-
section (a)(1), and claims by manufacturers that viola-
tions of subsection (a)(5)(A) or (a)(5)(B) have occurred; 
‘‘(ii) establish such deadlines and procedures as 
may be necessary to ensure that claims shall be 
resolved fairly, efficiently, and expeditiously; 
‘‘(iii) establish procedures by which a covered 
entity may discover and obtain such information and 
documents from manufacturers and third parties as 
may be relevant to demonstrate the merits of a claim 
that charges for a manufacturer’s product have 
exceeded the applicable ceiling price under this section, 
and may submit such documents and information to 
the administrative official or body responsible for adju-
dicating such claim; 
‘‘(iv) require that a manufacturer conduct an audit 
of a covered entity pursuant to subsection (a)(5)(D) 
Audits. 
Deadline. 
Regulations. 
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124 STAT. 827 
PUBLIC LAW 111–148—MAR. 23, 2010 
as a prerequisite to initiating administrative dispute 
resolution proceedings against a covered entity; 
‘‘(v) permit the official or body designated under 
clause (i), at the request of a manufacturer or manufac-
turers, to consolidate claims brought by more than 
one manufacturer against the same covered entity 
where, in the judgment of such official or body, consoli-
dation is appropriate and consistent with the goals 
of fairness and economy of resources; and 
‘‘(vi) include provisions and procedures to permit 
multiple covered entities to jointly assert claims of 
overcharges by the same manufacturer for the same 
drug or drugs in one administrative proceeding, and 
permit such claims to be asserted on behalf of covered 
entities by associations or organizations representing 
the interests of such covered entities and of which 
the covered entities are members. 
‘‘(C) FINALITY
OF
ADMINISTRATIVE
RESOLUTION.—The 
administrative resolution of a claim or claims under the 
regulations promulgated under subparagraph (A) shall be 
a final agency decision and shall be binding upon the 
parties involved, unless invalidated by an order of a court 
of competent jurisdiction. 
‘‘(4) 
AUTHORIZATION
OF
APPROPRIATIONS.—There 
are 
authorized to be appropriated to carry out this subsection, 
such sums as may be necessary for fiscal year 2010 and each 
succeeding fiscal year.’’. 
(b) CONFORMING AMENDMENTS.—Section 340B(a) of the Public 
Health Service Act (42 U.S.C. 256b(a)) is amended— 
(1) in subsection (a)(1), by adding at the end the following: 
‘‘Each such agreement shall require that the manufacturer 
furnish the Secretary with reports, on a quarterly basis, of 
the price for each covered drug subject to the agreement that, 
according to the manufacturer, represents the maximum price 
that covered entities may permissibly be required to pay for 
the drug (referred to in this section as the ‘ceiling price’), 
and shall require that the manufacturer offer each covered 
entity covered drugs for purchase at or below the applicable 
ceiling price if such drug is made available to any other pur-
chaser at any price.’’; and 
(2) in the first sentence of subsection (a)(5)(E), as redesig-
nated by section 7101(c), by inserting ‘‘after audit as described 
in subparagraph (D) and’’ after ‘‘finds,’’. 
SEC. 7103. GAO STUDY TO MAKE RECOMMENDATIONS ON IMPROVING 
THE 340B PROGRAM. 
(a) REPORT.—Not later than 18 months after the date of enact-
ment of this Act, the Comptroller General of the United States 
shall submit to Congress a report that examines whether those 
individuals served by the covered entities under the program under 
section 340B of the Public Health Service Act (42 U.S.C. 256b) 
(referred to in this section as the ‘‘340B program’’) are receiving 
optimal health care services. 
(b) RECOMMENDATIONS.—The report under subsection (a) shall 
include recommendations on the following: 
Contracts. 
Reports. 
Deadlines. 
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124 STAT. 828 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) Whether the 340B program should be expanded since 
it is anticipated that the 47,000,000 individuals who are unin-
sured as of the date of enactment of this Act will have health 
care coverage once this Act is implemented. 
(2) Whether mandatory sales of certain products by the 
340B program could hinder patients access to those therapies 
through any provider. 
(3) Whether income from the 340B program is being used 
by the covered entities under the program to further the pro-
gram objectives. 
TITLE VIII—CLASS ACT 
SEC. 8001. SHORT TITLE OF TITLE. 
This title may be cited as the ‘‘Community Living Assistance 
Services and Supports Act’’ or the ‘‘CLASS Act’’. 
SEC. 8002. ESTABLISHMENT OF NATIONAL VOLUNTARY INSURANCE 
PROGRAM 
FOR 
PURCHASING 
COMMUNITY 
LIVING 
ASSISTANCE SERVICES AND SUPPORT. 
(a) ESTABLISHMENT OF CLASS PROGRAM.— 
(1) IN GENERAL.—The Public Health Service Act (42 U.S.C. 
201 et seq.), as amended by section 4302(a), is amended by 
adding at the end the following: 
‘‘TITLE XXXII—COMMUNITY LIVING 
ASSISTANCE SERVICES AND SUPPORTS 
‘‘SEC. 3201. PURPOSE. 
‘‘The purpose of this title is to establish a national voluntary 
insurance program for purchasing community living assistance serv-
ices and supports in order to— 
‘‘(1) provide individuals with functional limitations with 
tools that will allow them to maintain their personal and finan-
cial independence and live in the community through a new 
financing strategy for community living assistance services and 
supports; 
‘‘(2) establish an infrastructure that will help address the 
Nation’s community living assistance services and supports 
needs; 
‘‘(3) alleviate burdens on family caregivers; and 
‘‘(4) address institutional bias by providing a financing 
mechanism that supports personal choice and independence 
to live in the community. 
‘‘SEC. 3202. DEFINITIONS. 
‘‘In this title: 
‘‘(1) ACTIVE ENROLLEE.—The term ‘active enrollee’ means 
an individual who is enrolled in the CLASS program in accord-
ance with section 3204 and who has paid any premiums due 
to maintain such enrollment. 
‘‘(2) ACTIVELY
EMPLOYED.—The term ‘actively employed’ 
means an individual who— 
‘‘(A) is reporting for work at the individual’s usual 
place of employment or at another location to which the 
42 USC 300ll–1. 
42 USC 300ll. 
Community 
Living Assistance 
Services and 
Supports Act. 
42 USC 201 note. 
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124 STAT. 829 
PUBLIC LAW 111–148—MAR. 23, 2010 
individual is required to travel because of the individual’s 
employment (or in the case of an individual who is a 
member of the uniformed services, is on active duty and 
is physically able to perform the duties of the individual’s 
position); and 
‘‘(B) is able to perform all the usual and customary 
duties of the individual’s employment on the individual’s 
regular work schedule. 
‘‘(3) ACTIVITIES OF DAILY LIVING.—The term ‘activities of 
daily living’ means each of the following activities specified 
in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986: 
‘‘(A) Eating. 
‘‘(B) Toileting. 
‘‘(C) Transferring. 
‘‘(D) Bathing. 
‘‘(E) Dressing. 
‘‘(F) Continence. 
‘‘(4) CLASS PROGRAM.—The term ‘CLASS program’ means 
the program established under this title. 
‘‘(5) ELIGIBILITY ASSESSMENT SYSTEM.—The term ‘Eligibility 
Assessment System’ means the entity established by the Sec-
retary under section 3205(a)(2) to make functional eligibility 
determinations for the CLASS program. 
‘‘(6) ELIGIBLE BENEFICIARY.— 
‘‘(A) IN GENERAL.—The term ‘eligible beneficiary’ means 
any individual who is an active enrollee in the CLASS 
program and, as of the date described in subparagraph 
(B)— 
‘‘(i) has paid premiums for enrollment in such pro-
gram for at least 60 months; 
‘‘(ii) has earned, with respect to at least 3 calendar 
years that occur during the first 60 months for which 
the individual has paid premiums for enrollment in 
the program, at least an amount equal to the amount 
of wages and self-employment income which an indi-
vidual must have in order to be credited with a quarter 
of coverage under section 213(d) of the Social Security 
Act for the year; and 
‘‘(iii) has paid premiums for enrollment in such 
program for at least 24 consecutive months, if a lapse 
in premium payments of more than 3 months has 
occurred during the period that begins on the date 
of the individual’s enrollment and ends on the date 
of such determination. 
‘‘(B) DATE DESCRIBED.—For purposes of subparagraph 
(A), the date described in this subparagraph is the date 
on which the individual is determined to have a functional 
limitation described in section 3203(a)(1)(C) that is 
expected to last for a continuous period of more than 90 
days. 
‘‘(C) REGULATIONS.—The Secretary shall promulgate 
regulations specifying exceptions to the minimum earnings 
requirements under subparagraph (A)(ii) for purposes of 
being considered an eligible beneficiary for certain popu-
lations. 
‘‘(7) HOSPITAL; NURSING
FACILITY; INTERMEDIATE
CARE 
FACILITY
FOR
THE
MENTALLY
RETARDED; INSTITUTION
FOR 
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124 STAT. 830 
PUBLIC LAW 111–148—MAR. 23, 2010 
MENTAL
DISEASES.—The terms ‘hospital’, ‘nursing facility’, 
‘intermediate care facility for the mentally retarded’, and 
‘institution for mental diseases’ have the meanings given such 
terms for purposes of Medicaid. 
‘‘(8) CLASS INDEPENDENCE ADVISORY COUNCIL.—The term 
‘CLASS Independence Advisory Council’ or ‘Council’ means the 
Advisory Council established under section 3207 to advise the 
Secretary. 
‘‘(9) CLASS INDEPENDENCE
BENEFIT
PLAN.—The term 
‘CLASS Independence Benefit Plan’ means the benefit plan 
developed and designated by the Secretary in accordance with 
section 3203. 
‘‘(10) CLASS INDEPENDENCE
FUND.—The term ‘CLASS 
Independence Fund’ or ‘Fund’ means the fund established under 
section 3206. 
‘‘(11) MEDICAID.—The term ‘Medicaid’ means the program 
established under title XIX of the Social Security Act (42 U.S.C. 
1396 et seq.). 
‘‘(12) 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)). 
‘‘(13) PROTECTION
AND
ADVOCACY
SYSTEM.—The term 
‘Protection and Advocacy System’ means the system for each 
State established under section 143 of the Developmental 
Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 
15043). 
‘‘SEC. 3203. CLASS INDEPENDENCE BENEFIT PLAN. 
‘‘(a) PROCESS FOR DEVELOPMENT.— 
‘‘(1) IN
GENERAL.—The Secretary, in consultation with 
appropriate actuaries and other experts, shall develop at least 
3 actuarially sound benefit plans as alternatives for consider-
ation for designation by the Secretary as the CLASS Independ-
ence Benefit Plan under which eligible beneficiaries shall 
receive benefits under this title. Each of the plan alternatives 
developed shall be designed to provide eligible beneficiaries 
with the benefits described in section 3205 consistent with 
the following requirements: 
‘‘(A) PREMIUMS.— 
‘‘(i) IN GENERAL.—Beginning with the first year 
of the CLASS program, and for each year thereafter, 
subject to clauses (ii) and (iii), the Secretary shall 
establish all premiums to be paid by enrollees for the 
year based on an actuarial analysis of the 75-year 
costs of the program that ensures solvency throughout 
such 75-year period. 
‘‘(ii) NOMINAL PREMIUM FOR POOREST INDIVIDUALS 
AND FULL-TIME STUDENTS.— 
‘‘(I) IN GENERAL.—The monthly premium for 
enrollment in the CLASS program shall not exceed 
the applicable dollar amount per month deter-
mined under subclause (II) for— 
‘‘(aa) any individual whose income does 
not exceed the poverty line; and 
‘‘(bb) any individual who has not attained 
age 22, and is actively employed during any 
42 USC 300ll–2. 
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124 STAT. 831 
PUBLIC LAW 111–148—MAR. 23, 2010 
period in which the individual is a full-time 
student (as determined by the Secretary). 
‘‘(II) 
APPLICABLE
DOLLAR
AMOUNT.—The 
applicable dollar amount described in this sub-
clause is the amount equal to $5, increased by 
the percentage increase in the consumer price 
index for all urban consumers (U.S. city average) 
for each year occurring after 2009 and before such 
year. 
‘‘(iii) CLASS
INDEPENDENCE
FUND
RESERVES.—At 
such time as the CLASS program has been in operation 
for 10 years, the Secretary shall establish all premiums 
to be paid by enrollees for the year based on an actu-
arial analysis that accumulated reserves in the CLASS 
Independence Fund would not decrease in that year. 
At such time as the Secretary determines the CLASS 
program demonstrates a sustained ability to finance 
expected yearly expenses with expected yearly pre-
miums and interest credited to the CLASS Independ-
ence Fund, the Secretary may decrease the required 
amount of CLASS Independence Fund reserves. 
‘‘(B) VESTING PERIOD.—A 5-year vesting period for eligi-
bility for benefits. 
‘‘(C) BENEFIT TRIGGERS.—A benefit trigger for provision 
of benefits that requires a determination that an individual 
has a functional limitation, as certified by a licensed health 
care practitioner, described in any of the following clauses 
that is expected to last for a continuous period of more 
than 90 days: 
‘‘(i) The individual is determined to be unable to 
perform at least the minimum number (which may 
be 2 or 3) of activities of daily living as are required 
under the plan for the provision of benefits without 
substantial assistance (as defined by the Secretary) 
from another individual. 
‘‘(ii) The individual requires substantial super-
vision to protect the individual from threats to health 
and safety due to substantial cognitive impairment. 
‘‘(iii) The individual has a level of functional limita-
tion similar (as determined under regulations pre-
scribed by the Secretary) to the level of functional 
limitation described in clause (i) or (ii). 
‘‘(D) CASH BENEFIT.—Payment of a cash benefit that 
satisfies the following requirements: 
‘‘(i) MINIMUM
REQUIRED
AMOUNT.—The benefit 
amount provides an eligible beneficiary with not less 
than an average of $50 per day (as determined based 
on the reasonably expected distribution of beneficiaries 
receiving benefits at various benefit levels). 
‘‘(ii) AMOUNT
SCALED
TO
FUNCTIONAL
ABILITY.— 
The benefit amount is varied based on a scale of func-
tional ability, with not less than 2, and not more than 
6, benefit level amounts. 
‘‘(iii) DAILY OR WEEKLY.—The benefit is paid on 
a daily or weekly basis. 
‘‘(iv) NO LIFETIME OR AGGREGATE LIMIT.—The ben-
efit is not subject to any lifetime or aggregate limit. 
Regulations. 
Determination. 
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124 STAT. 832 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(E) COORDINATION
WITH
SUPPLEMENTAL
COVERAGE 
OBTAINED
THROUGH
THE
EXCHANGE.—The benefits allow 
for coordination with any supplemental coverage purchased 
through an Exchange established under section 1311 of 
the Patient Protection and Affordable Care Act. 
‘‘(2) 
REVIEW
AND
RECOMMENDATION
BY
THE
CLASS 
INDEPENDENCE ADVISORY COUNCIL.—The CLASS Independence 
Advisory Council shall— 
‘‘(A) evaluate the alternative benefit plans developed 
under paragraph (1); and 
‘‘(B) recommend for designation as the CLASS 
Independence Benefit Plan for offering to the public the 
plan that the Council determines best balances price and 
benefits to meet enrollees’ needs in an actuarially sound 
manner, while optimizing the probability of the long-term 
sustainability of the CLASS program. 
‘‘(3) DESIGNATION
BY
THE
SECRETARY.—Not later than 
October 1, 2012, the Secretary, taking into consideration the 
recommendation of the CLASS Independence Advisory Council 
under paragraph (2)(B), shall designate a benefit plan as the 
CLASS Independence Benefit Plan. The Secretary shall publish 
such designation, along with details of the plan and the reasons 
for the selection by the Secretary, in a final rule that allows 
for a period of public comment. 
‘‘(b) ADDITIONAL PREMIUM REQUIREMENTS.— 
‘‘(1) ADJUSTMENT OF PREMIUMS.— 
‘‘(A) IN
GENERAL.—Except as provided in subpara-
graphs (B), (C), (D), and (E), the amount of the monthly 
premium determined for an individual upon such individ-
ual’s enrollment in the CLASS program shall remain the 
same for as long as the individual is an active enrollee 
in the program. 
‘‘(B) RECALCULATED PREMIUM IF REQUIRED FOR PRO-
GRAM SOLVENCY.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), if the Sec-
retary determines, based on the most recent report 
of the Board of Trustees of the CLASS Independence 
Fund, the advice of the CLASS Independence Advisory 
Council, and the annual report of the Inspector General 
of the Department of Health and Human Services, 
and waste, fraud, and abuse, or such other information 
as the Secretary determines appropriate, that the 
monthly 
premiums 
and 
income 
to 
the 
CLASS 
Independence Fund for a year are projected to be 
insufficient with respect to the 20-year period that 
begins with that year, the Secretary shall adjust the 
monthly premiums for individuals enrolled in the 
CLASS program as necessary (but maintaining a 
nominal premium for enrollees whose income is below 
the poverty line or who are full-time students actively 
employed). 
‘‘(ii) EXEMPTION FROM INCREASE.—Any increase in 
a monthly premium imposed as result of a determina-
tion described in clause (i) shall not apply with respect 
to the monthly premium of any active enrollee who— 
‘‘(I) has attained age 65; 
Determination. 
Publication. 
Regulations. 
Public 
information. 
Deadline. 
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124 STAT. 833 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(II) has paid premiums for enrollment in the 
program for at least 20 years; and 
‘‘(III) is not actively employed. 
‘‘(C) RECALCULATED PREMIUM IF REENROLLMENT AFTER 
MORE THAN A 3-MONTH LAPSE.— 
‘‘(i) IN
GENERAL.—The reenrollment of an indi-
vidual after a 90-day period during which the indi-
vidual failed to pay the monthly premium required 
to maintain the individual’s enrollment in the CLASS 
program shall be treated as an initial enrollment for 
purposes of age-adjusting the premium for enrollment 
in the program. 
‘‘(ii) CREDIT
FOR
PRIOR
MONTHS
IF
REENROLLED 
WITHIN 5 YEARS.—An individual who reenrolls in the 
CLASS program after such a 90-day period and before 
the end of the 5-year period that begins with the 
first month for which the individual failed to pay the 
monthly premium required to maintain the individual’s 
enrollment in the program shall be— 
‘‘(I) credited with any months of paid pre-
miums that accrued prior to the individual’s lapse 
in enrollment; and 
‘‘(II) notwithstanding the total amount of any 
such credited months, required to satisfy section 
3202(6)(A)(ii) before being eligible to receive bene-
fits. 
‘‘(D) NO LONGER STATUS AS A FULL-TIME STUDENT.— 
An individual subject to a nominal premium on the basis 
of being described in subsection (a)(1)(A)(ii)(I)(bb) who 
ceases to be described in that subsection, beginning with 
the first month following the month in which the individual 
ceases to be so described, shall be subject to the same 
monthly premium as the monthly premium that applies 
to an individual of the same age who first enrolls in the 
program under the most similar circumstances as the indi-
vidual (such as the first year of eligibility for enrollment 
in the program or in a subsequent year). 
‘‘(E) PENALTY FOR REENOLLMENT AFTER 5-YEAR LAPSE.— 
In the case of an individual who reenrolls in the CLASS 
program after the end of the 5-year period described in 
subparagraph (C)(ii), the monthly premium required for 
the individual shall be the age-adjusted premium that 
would be applicable to an initially enrolling individual who 
is the same age as the reenrolling individual, increased 
by the greater of— 
‘‘(i) an amount that the Secretary determines is 
actuarially sound for each month that occurs during 
the period that begins with the first month for which 
the individual failed to pay the monthly premium 
required to maintain the individual’s enrollment in 
the CLASS program and ends with the month pre-
ceding the month in which the reenollment is effective; 
or 
‘‘(ii) 1 percent of the applicable age-adjusted pre-
mium for each such month occurring in such period. 
‘‘(2) 
ADMINISTRATIVE
EXPENSES.—In 
determining 
the 
monthly premiums for the CLASS program the Secretary may 
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124 STAT. 834 
PUBLIC LAW 111–148—MAR. 23, 2010 
factor in costs for administering the program, not to exceed 
for any year in which the program is in effect under this 
title, an amount equal to 3 percent of all premiums paid during 
the year. 
‘‘(3) NO UNDERWRITING REQUIREMENTS.—No underwriting 
(other than on the basis of age in accordance with subpara-
graphs (D) and (E) of paragraph (1)) shall be used to— 
‘‘(A) determine the monthly premium for enrollment 
in the CLASS program; or 
‘‘(B) prevent an individual from enrolling in the pro-
gram. 
‘‘(c) SELF-ATTESTATION AND VERIFICATION OF INCOME.—The Sec-
retary shall establish procedures to— 
‘‘(1) permit an individual who is eligible for the nominal 
premium required under subsection (a)(1)(A)(ii), as part of their 
automatic enrollment in the CLASS program, to self-attest 
that their income does not exceed the poverty line or that 
their status as a full-time student who is actively employed; 
‘‘(2) verify, using procedures similar to the procedures used 
by the Commissioner of Social Security under section 
1631(e)(1)(B)(ii) of the Social Security Act and consistent with 
the requirements applicable to the conveyance of data and 
information under section 1942 of such Act, the validity of 
such self-attestation; and 
‘‘(3) require an individual to confirm, on at least an annual 
basis, that their income does not exceed the poverty line or 
that they continue to maintain such status. 
‘‘SEC. 3204. ENROLLMENT AND DISENROLLMENT REQUIREMENTS. 
‘‘(a) AUTOMATIC ENROLLMENT.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), the Secretary, 
in coordination with the Secretary of the Treasury, shall estab-
lish procedures under which each individual described in sub-
section (c) may be automatically enrolled in the CLASS program 
by an employer of such individual in the same manner as 
an employer may elect to automatically enroll employees in 
a plan under section 401(k), 403(b), or 457 of the Internal 
Revenue Code of 1986. 
‘‘(2) ALTERNATIVE ENROLLMENT PROCEDURES.—The proce-
dures established under paragraph (1) shall provide for an 
alternative enrollment process for an individual described in 
subsection (c) in the case of such an individual— 
‘‘(A) who is self-employed; 
‘‘(B) who has more than 1 employer; or 
‘‘(C) whose employer does not elect to participate in 
the automatic enrollment process established by the Sec-
retary. 
‘‘(3) ADMINISTRATION.— 
‘‘(A) IN GENERAL.—The Secretary and the Secretary 
of the Treasury shall, by regulation, establish procedures 
to ensure that an individual is not automatically enrolled 
in the CLASS program by more than 1 employer. 
‘‘(B) FORM.—Enrollment in the CLASS program shall 
be made in such manner as the Secretary may prescribe 
in order to ensure ease of administration. 
‘‘(b) ELECTION TO OPT-OUT.—An individual described in sub-
section (c) may elect to waive enrollment in the CLASS program 
Regulations. 
Procedures. 
42 USC 300ll–3. 
Procedures. 
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124 STAT. 835 
PUBLIC LAW 111–148—MAR. 23, 2010 
at any time in such form and manner as the Secretary and the 
Secretary of the Treasury shall prescribe. 
‘‘(c) INDIVIDUAL DESCRIBED.—For purposes of enrolling in the 
CLASS program, an individual described in this paragraph is an 
individual— 
‘‘(1) who has attained age 18; 
‘‘(2) who— 
‘‘(A) receives wages on which there is imposed a tax 
under section 3201(a) of the Internal Revenue Code of 
1986; or 
‘‘(B) derives self-employment income on which there 
is imposed a tax under section 1401(a) of the Internal 
Revenue Code of 1986; 
‘‘(3) who is actively employed; and 
‘‘(4) who is not— 
‘‘(A) a patient in a hospital or nursing facility, an 
intermediate care facility for the mentally retarded, or 
an institution for mental diseases and receiving medical 
assistance under Medicaid; or 
‘‘(B) confined in a jail, prison, other penal institution 
or correctional facility, or by court order pursuant to convic-
tion of a criminal offense or in connection with a verdict 
or finding described in section 202(x)(1)(A)(ii) of the Social 
Security Act (42 U.S.C. 402(x)(1)(A)(ii)). 
‘‘(d) RULE OF CONSTRUCTION.—Nothing in this title shall be 
construed as requiring an active enrollee to continue to satisfy 
subparagraph (B) or (C) of subsection (c)(1) in order to maintain 
enrollment in the CLASS program. 
‘‘(e) PAYMENT.— 
‘‘(1) PAYROLL DEDUCTION.—An amount equal to the monthly 
premium for the enrollment in the CLASS program of an indi-
vidual shall be deducted from the wages or self-employment 
income of such individual in accordance with such procedures 
as the Secretary, in coordination with the Secretary of the 
Treasury, shall establish for employers who elect to deduct 
and withhold such premiums on behalf of enrolled employees. 
‘‘(2) ALTERNATIVE
PAYMENT
MECHANISM.—The Secretary, 
in coordination with the Secretary of the Treasury, shall estab-
lish alternative procedures for the payment of monthly pre-
miums by an individual enrolled in the CLASS program— 
‘‘(A) who does not have an employer who elects to 
deduct and withhold premiums in accordance with subpara-
graph (A); or 
‘‘(B) who does not earn wages or derive self-employ-
ment income. 
‘‘(f) TRANSFER OF PREMIUMS COLLECTED.— 
‘‘(1) IN GENERAL.—During each calendar year the Secretary 
of the Treasury shall deposit into the CLASS Independence 
Fund a total amount equal, in the aggregate, to 100 percent 
of the premiums collected during that year. 
‘‘(2) TRANSFERS BASED ON ESTIMATES.—The amount depos-
ited pursuant to paragraph (1) shall be transferred in at least 
monthly payments to the CLASS Independence Fund on the 
basis of estimates by the Secretary and certified to the Sec-
retary of the Treasury of the amounts collected in accordance 
with subparagraphs (A) and (B) of paragraph (5). Proper adjust-
ments shall be made in amounts subsequently transferred to 
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124 STAT. 836 
PUBLIC LAW 111–148—MAR. 23, 2010 
the Fund to the extent prior estimates were in excess of, or 
were less than, actual amounts collected. 
‘‘(g) OTHER ENROLLMENT
AND DISENROLLMENT OPPORTUNI-
TIES.—The Secretary, in coordination with the Secretary of the 
Treasury, shall establish procedures under which— 
‘‘(1) an individual who, in the year of the individual’s 
initial eligibility to enroll in the CLASS program, has elected 
to waive enrollment in the program, is eligible to elect to 
enroll in the program, in such form and manner as the Secre-
taries shall establish, only during an open enrollment period 
established by the Secretaries that is specific to the individual 
and that may not occur more frequently than biennially after 
the date on which the individual first elected to waive enroll-
ment in the program; and 
‘‘(2) an individual shall only be permitted to disenroll from 
the program (other than for nonpayment of premiums) during 
an annual disenrollment period established by the Secretaries 
and in such form and manner as the Secretaries shall establish. 
‘‘SEC. 3205. BENEFITS. 
‘‘(a) DETERMINATION OF ELIGIBILITY.— 
‘‘(1) APPLICATION FOR RECEIPT OF BENEFITS.—The Secretary 
shall establish procedures under which an active enrollee shall 
apply for receipt of benefits under the CLASS Independence 
Benefit Plan. 
‘‘(2) ELIGIBILITY ASSESSMENTS.— 
‘‘(A) IN GENERAL.—Not later than January 1, 2012, 
the Secretary shall— 
‘‘(i) establish an Eligibility Assessment System 
(other than a service with which the Commissioner 
of Social Security has entered into an agreement, with 
respect to any State, to make disability determinations 
for purposes of title II or XVI of the Social Security 
Act) to provide for eligibility assessments of active 
enrollees who apply for receipt of benefits; 
‘‘(ii) enter into an agreement with the Protection 
and Advocacy System for each State to provide 
advocacy services in accordance with subsection (d); 
and 
‘‘(iii) enter into an agreement with public and pri-
vate entities to provide advice and assistance coun-
seling in accordance with subsection (e). 
‘‘(B) REGULATIONS.—The Secretary shall promulgate 
regulations to develop an expedited nationally equitable 
eligibility determination process, as certified by a licensed 
health care practitioner, an appeals process, and a redeter-
mination process, as certified by a licensed health care 
practitioner, including whether an active enrollee is eligible 
for a cash benefit under the program and if so, the amount 
of the cash benefit (in accordance the sliding scale estab-
lished under the plan). 
‘‘(C) PRESUMPTIVE ELIGIBILITY FOR CERTAIN INSTITU-
TIONALIZED
ENROLLEES
PLANNING
TO
DISCHARGE.—An 
active enrollee shall be deemed presumptively eligible if 
the enrollee— 
‘‘(i) has applied for, and attests is eligible for, 
the maximum cash benefit available under the sliding 
Deadline. 
Contracts. 
42 USC 300ll–4. 
Procedures. 
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124 STAT. 837 
PUBLIC LAW 111–148—MAR. 23, 2010 
scale established under the CLASS Independence Ben-
efit Plan; 
‘‘(ii) is a patient in a hospital (but only if the 
hospitalization is for long-term care), nursing facility, 
intermediate care facility for the mentally retarded, 
or an institution for mental diseases; and 
‘‘(iii) is in the process of, or about to begin the 
process of, planning to discharge from the hospital, 
facility, or institution, or within 60 days from the date 
of discharge from the hospital, facility, or institution. 
‘‘(D) APPEALS.—The Secretary shall establish proce-
dures under which an applicant for benefits under the 
CLASS Independence Benefit Plan shall be guaranteed 
the right to appeal an adverse determination. 
‘‘(b) BENEFITS.—An eligible beneficiary shall receive the fol-
lowing benefits under the CLASS Independence Benefit Plan: 
‘‘(1) CASH BENEFIT.—A cash benefit established by the Sec-
retary in accordance with the requirements of section 
3203(a)(1)(D) that— 
‘‘(A) the first year in which beneficiaries receive the 
benefits under the plan, is not less than the average dollar 
amount specified in clause (i) of such section; and 
‘‘(B) for any subsequent year, is not less than the 
average per day dollar limit applicable under this subpara-
graph for the preceding year, increased by the percentage 
increase in the consumer price index for all urban con-
sumers (U.S. city average) over the previous year. 
‘‘(2) ADVOCACY SERVICES.—Advocacy services in accordance 
with subsection (d). 
‘‘(3) ADVICE
AND
ASSISTANCE
COUNSELING.—Advice and 
assistance counseling in accordance with subsection (e). 
‘‘(4) ADMINISTRATIVE
EXPENSES.—Advocacy services and 
advise and assistance counseling services under paragraphs 
(2) and (3) of this subsection shall be included as administrative 
expenses under section 3203(b)(3). 
‘‘(c) PAYMENT OF BENEFITS.— 
‘‘(1) LIFE INDEPENDENCE ACCOUNT.— 
‘‘(A) IN GENERAL.—The Secretary shall establish proce-
dures for administering the provision of benefits to eligible 
beneficiaries under the CLASS Independence Benefit Plan, 
including the payment of the cash benefit for the bene-
ficiary into a Life Independence Account established by 
the Secretary on behalf of each eligible beneficiary. 
‘‘(B) USE OF CASH BENEFITS.—Cash benefits paid into 
a Life Independence Account of an eligible beneficiary shall 
be used to purchase nonmedical services and supports that 
the beneficiary needs to maintain his or her independence 
at home or in another residential setting of their choice 
in the community, including (but not limited to) home 
modifications, assistive technology, accessible transpor-
tation, homemaker services, respite care, personal assist-
ance services, home care aides, and nursing support. 
Nothing in the preceding sentence shall prevent an eligible 
beneficiary from using cash benefits paid into a Life 
Independence Account for obtaining assistance with deci-
sion making concerning medical care, including the right 
to accept or refuse medical or surgical treatment and the 
Procedures. 
Procedures. 
Deadline. 
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124 STAT. 838 
PUBLIC LAW 111–148—MAR. 23, 2010 
right to formulate advance directives or other written 
instructions recognized under State law, such as a living 
will or durable power of attorney for health care, in the 
case that an injury or illness causes the individual to 
be unable to make health care decisions. 
‘‘(C) ELECTRONIC MANAGEMENT OF FUNDS.—The Sec-
retary shall establish procedures for— 
‘‘(i) crediting an account established on behalf of 
a beneficiary with the beneficiary’s cash daily benefit; 
‘‘(ii) allowing the beneficiary to access such account 
through debit cards; and 
‘‘(iii) accounting for withdrawals by the beneficiary 
from such account. 
‘‘(D) PRIMARY PAYOR RULES FOR BENEFICIARIES WHO 
ARE ENROLLED IN MEDICAID.—In the case of an eligible 
beneficiary who is enrolled in Medicaid, the following pay-
ment rules shall apply: 
‘‘(i) INSTITUTIONALIZED BENEFICIARY.—If the bene-
ficiary is a patient in a hospital, nursing facility, inter-
mediate care facility for the mentally retarded, or an 
institution for mental diseases, the beneficiary shall 
retain an amount equal to 5 percent of the beneficiary’s 
daily or weekly cash benefit (as applicable) (which 
shall be in addition to the amount of the beneficiary’s 
personal needs allowance provided under Medicaid), 
and the remainder of such benefit shall be applied 
toward the facility’s cost of providing the beneficiary’s 
care, and Medicaid shall provide secondary coverage 
for such care. 
‘‘(ii) BENEFICIARIES RECEIVING HOME AND COMMU-
NITY-BASED SERVICES.— 
‘‘(I) 50 PERCENT OF BENEFIT RETAINED BY BENE-
FICIARY.—Subject to subclause (II), if a beneficiary 
is receiving medical assistance under Medicaid for 
home and community based services, the bene-
ficiary shall retain an amount equal to 50 percent 
of the beneficiary’s daily or weekly cash benefit 
(as applicable), and the remainder of the daily 
or weekly cash benefit shall be applied toward 
the cost to the State of providing such assistance 
(and shall not be used to claim Federal matching 
funds under Medicaid), and Medicaid shall provide 
secondary coverage for the remainder of any costs 
incurred in providing such assistance. 
‘‘(II) REQUIREMENT
FOR
STATE
OFFSET.—A 
State shall be paid the remainder of a beneficiary’s 
daily or weekly cash benefit under subclause (I) 
only if the State home and community-based 
waiver under section 1115 of the Social Security 
Act (42 U.S.C. 1315) or subsection (c) or (d) of 
section 1915 of such Act (42 U.S.C. 1396n), or 
the State plan amendment under subsection (i) 
of such section does not include a waiver of the 
requirements of section 1902(a)(1) of the Social 
Security Act (relating to statewideness) or of sec-
tion 1902(a)(10)(B) of such Act (relating to com-
parability) and the State offers at a minimum 
Procedures. 
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124 STAT. 839 
PUBLIC LAW 111–148—MAR. 23, 2010 
case management services, personal care services, 
habilitation services, and respite care under such 
a waiver or State plan amendment. 
‘‘(III) DEFINITION OF HOME AND COMMUNITY- 
BASED SERVICES.—In this clause, the term ‘home 
and community-based services’ means any services 
which may be offered under a home and commu-
nity-based waiver authorized for a State under 
section 1115 of the Social Security Act (42 U.S.C. 
1315) or subsection (c) or (d) of section 1915 of 
such Act (42 U.S.C. 1396n) or under a State plan 
amendment under subsection (i) of such section. 
‘‘(iii) BENEFICIARIES
ENROLLED
IN
PROGRAMS
OF 
ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE).— 
‘‘(I) IN
GENERAL.—Subject to subclause (II), 
if a beneficiary is receiving medical assistance 
under Medicaid for PACE program services under 
section 1934 of the Social Security Act (42 U.S.C. 
1396u–4), the beneficiary shall retain an amount 
equal to 50 percent of the beneficiary’s daily or 
weekly cash benefit (as applicable), and the 
remainder of the daily or weekly cash benefit shall 
be applied toward the cost to the State of providing 
such assistance (and shall not be used to claim 
Federal matching funds under Medicaid), and 
Medicaid shall provide secondary coverage for the 
remainder of any costs incurred in providing such 
assistance. 
‘‘(II) INSTITUTIONALIZED RECIPIENTS OF PACE 
PROGRAM
SERVICES.—If a beneficiary receiving 
assistance under Medicaid for PACE program serv-
ices is a patient in a hospital, nursing facility, 
intermediate 
care 
facility 
for 
the 
mentally 
retarded, or an institution for mental diseases, 
the beneficiary shall be treated as in institutional-
ized beneficiary under clause (i). 
‘‘(2) AUTHORIZED REPRESENTATIVES.— 
‘‘(A) IN GENERAL.—The Secretary shall establish proce-
dures to allow access to a beneficiary’s cash benefits by 
an authorized representative of the eligible beneficiary on 
whose behalf such benefits are paid. 
‘‘(B) QUALITY
ASSURANCE
AND
PROTECTION
AGAINST 
FRAUD
AND
ABUSE.—The procedures established under 
subparagraph (A) shall ensure that authorized representa-
tives of eligible beneficiaries comply with standards of con-
duct established by the Secretary, including standards 
requiring that such representatives provide quality services 
on behalf of such beneficiaries, do not have conflicts of 
interest, and do not misuse benefits paid on behalf of 
such beneficiaries or otherwise engage in fraud or abuse. 
‘‘(3) COMMENCEMENT OF BENEFITS.—Benefits shall be paid 
to, or on behalf of, an eligible beneficiary beginning with the 
first month in which an application for such benefits is 
approved. 
‘‘(4) ROLLOVER
OPTION
FOR
LUMP-SUM
PAYMENT.—An 
eligible beneficiary may elect to— 
Procedures. 
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124 STAT. 840 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) defer payment of their daily or weekly benefit 
and to rollover any such deferred benefits from month- 
to-month, but not from year-to-year; and 
‘‘(B) receive a lump-sum payment of such deferred 
benefits in an amount that may not exceed the lesser 
of— 
‘‘(i) the total amount of the accrued deferred bene-
fits; or 
‘‘(ii) the applicable annual benefit. 
‘‘(5) PERIOD FOR DETERMINATION OF ANNUAL BENEFITS.— 
‘‘(A) IN
GENERAL.—The applicable period for deter-
mining with respect to an eligible beneficiary the applicable 
annual benefit and the amount of any accrued deferred 
benefits is the 12-month period that commences with the 
first month in which the beneficiary began to receive such 
benefits, and each 12-month period thereafter. 
‘‘(B) INCLUSION
OF
INCREASED
BENEFITS.—The Sec-
retary shall establish procedures under which cash benefits 
paid to an eligible beneficiary that increase or decrease 
as a result of a change in the functional status of the 
beneficiary before the end of a 12-month benefit period 
shall be included in the determination of the applicable 
annual benefit paid to the eligible beneficiary. 
‘‘(C) RECOUPMENT
OF
UNPAID, ACCRUED
BENEFITS.— 
‘‘(i) IN GENERAL.—The Secretary, in coordination 
with the Secretary of the Treasury, shall recoup any 
accrued benefits in the event of— 
‘‘(I) the death of a beneficiary; or 
‘‘(II) the failure of a beneficiary to elect under 
paragraph (4)(B) to receive such benefits as a 
lump-sum payment before the end of the 12-month 
period in which such benefits accrued. 
‘‘(ii) PAYMENT INTO CLASS INDEPENDENCE FUND.— 
Any benefits recouped in accordance with clause (i) 
shall be paid into the CLASS Independence Fund and 
used in accordance with section 3206. 
‘‘(6) REQUIREMENT TO RECERTIFY ELIGIBILITY FOR RECEIPT 
OF
BENEFITS.—An eligible beneficiary shall periodically, as 
determined by the Secretary— 
‘‘(A) recertify by submission of medical evidence the 
beneficiary’s continued eligibility for receipt of benefits; 
and 
‘‘(B) submit records of expenditures attributable to the 
aggregate cash benefit received by the beneficiary during 
the preceding year. 
‘‘(7) SUPPLEMENT, NOT SUPPLANT OTHER HEALTH CARE BENE-
FITS.—Subject to the Medicaid payment rules under paragraph 
(1)(D), benefits received by an eligible beneficiary shall supple-
ment, but not supplant, other health care benefits for which 
the beneficiary is eligible under Medicaid or any other Federally 
funded program that provides health care benefits or assistance. 
‘‘(d) ADVOCACY SERVICES.—An agreement entered into under 
subsection (a)(2)(A)(ii) shall require the Protection and Advocacy 
System for the State to— 
‘‘(1) assign, as needed, an advocacy counselor to each 
eligible beneficiary that is covered by such agreement and 
who shall provide an eligible beneficiary with— 
Contracts. 
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124 STAT. 841 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) information regarding how to access the appeals 
process established for the program; 
‘‘(B) assistance with respect to the annual recertifi-
cation and notification required under subsection (c)(6); 
and 
‘‘(C) such other assistance with obtaining services as 
the Secretary, by regulation, shall require; and 
‘‘(2) ensure that the System and such counselors comply 
with the requirements of subsection (h). 
‘‘(e) ADVICE
AND
ASSISTANCE
COUNSELING.—An agreement 
entered into under subsection (a)(2)(A)(iii) shall require the entity 
to assign, as requested by an eligible beneficiary that is covered 
by such agreement, an advice and assistance counselor who shall 
provide an eligible beneficiary with information regarding— 
‘‘(1) accessing and coordinating long-term services and sup-
ports in the most integrated setting; 
‘‘(2) possible eligibility for other benefits and services; 
‘‘(3) development of a service and support plan; 
‘‘(4) information about programs established under the 
Assistive Technology Act of 1998 and the services offered under 
such programs; 
‘‘(5) available assistance with decision making concerning 
medical care, including the right to accept or refuse medical 
or surgical treatment and the right to formulate advance direc-
tives or other written instructions recognized under State law, 
such as a living will or durable power of attorney for health 
care, in the case that an injury or illness causes the individual 
to be unable to make health care decisions; and 
‘‘(6) such other services as the Secretary, by regulation, 
may require. 
‘‘(f) NO EFFECT ON ELIGIBILITY FOR OTHER BENEFITS.—Benefits 
paid to an eligible beneficiary under the CLASS program shall 
be disregarded for purposes of determining or continuing the bene-
ficiary’s eligibility for receipt of benefits under any other Federal, 
State, or locally funded assistance program, including benefits paid 
under titles II, XVI, XVIII, XIX, or XXI of the Social Security 
Act (42 U.S.C. 401 et seq., 1381 et seq., 1395 et seq., 1396 et 
seq., 1397aa et seq.), under the laws administered by the Secretary 
of Veterans Affairs, under low-income housing assistance programs, 
or under the supplemental nutrition assistance program established 
under the Food and Nutrition Act of 2008 (7 U.S.C. 2011 et seq.). 
‘‘(g) RULE OF CONSTRUCTION.—Nothing in this title shall be 
construed as prohibiting benefits paid under the CLASS Independ-
ence Benefit Plan from being used to compensate a family caregiver 
for providing community living assistance services and supports 
to an eligible beneficiary. 
‘‘(h) PROTECTION AGAINST CONFLICT OF INTERESTS.—The Sec-
retary shall establish procedures to ensure that the Eligibility 
Assessment System, the Protection and Advocacy System for a 
State, advocacy counselors for eligible beneficiaries, and any other 
entities that provide services to active enrollees and eligible bene-
ficiaries under the CLASS program comply with the following: 
‘‘(1) If the entity provides counseling or planning services, 
such services are provided in a manner that fosters the best 
interests of the active enrollee or beneficiary. 
Procedures. 
Contracts. 
Regulations. 
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124 STAT. 842 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) The entity has established operating procedures that 
are designed to avoid or minimize conflicts of interest between 
the entity and an active enrollee or beneficiary. 
‘‘(3) The entity provides information about all services and 
options available to the active enrollee or beneficiary, to the 
best of its knowledge, including services available through other 
entities or providers. 
‘‘(4) The entity assists the active enrollee or beneficiary 
to access desired services, regardless of the provider. 
‘‘(5) The entity reports the number of active enrollees and 
beneficiaries provided with assistance by age, disability, and 
whether such enrollees and beneficiaries received services from 
the entity or another entity. 
‘‘(6) If the entity provides counseling or planning services, 
the entity ensures that an active enrollee or beneficiary is 
informed of any financial interest that the entity has in a 
service provider. 
‘‘(7) The entity provides an active enrollee or beneficiary 
with a list of available service providers that can meet the 
needs of the active enrollee or beneficiary. 
‘‘SEC. 3206. CLASS INDEPENDENCE FUND. 
‘‘(a) ESTABLISHMENT OF CLASS INDEPENDENCE FUND.—There 
is established in the Treasury of the United States a trust fund 
to be known as the ‘CLASS Independence Fund’. The Secretary 
of the Treasury shall serve as Managing Trustee of such Fund. 
The Fund shall consist of all amounts derived from payments into 
the Fund under sections 3204(f) and 3205(c)(5)(C)(ii), and remaining 
after investment of such amounts under subsection (b), including 
additional amounts derived as income from such investments. The 
amounts held in the Fund are appropriated and shall remain avail-
able without fiscal year limitation— 
‘‘(1) to be held for investment on behalf of individuals 
enrolled in the CLASS program; 
‘‘(2) to pay the administrative expenses related to the Fund 
and to investment under subsection (b); and 
‘‘(3) to pay cash benefits to eligible beneficiaries under 
the CLASS Independence Benefit Plan. 
‘‘(b) INVESTMENT
OF FUND BALANCE.—The Secretary of the 
Treasury shall invest and manage the CLASS Independence Fund 
in the same manner, and to the same extent, as the Federal Supple-
mentary Medical Insurance Trust Fund may be invested and man-
aged under subsections (c), (d), and (e) of section 1841(d) of the 
Social Security Act (42 U.S.C. 1395t). 
‘‘(c) BOARD OF TRUSTEES.— 
‘‘(1) IN GENERAL.—With respect to the CLASS Independence 
Fund, there is hereby created a body to be known as the 
Board of Trustees of the CLASS Independence Fund (herein-
after in this section referred to as the ‘Board of Trustees’) 
composed of the Secretary of the Treasury, the Secretary of 
Labor, and the Secretary of Health and Human Services, all 
ex officio, and of two members of the public (both of whom 
may not be from the same political party), who shall be nomi-
nated by the President for a term of 4 years and subject 
to confirmation by the Senate. A member of the Board of 
Trustees serving as a member of the public and nominated 
and confirmed to fill a vacancy occurring during a term shall 
Establishment. 
42 USC 300ll–5. 
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124 STAT. 843 
PUBLIC LAW 111–148—MAR. 23, 2010 
be nominated and confirmed only for the remainder of such 
term. An individual nominated and confirmed as a member 
of the public may serve in such position after the expiration 
of such member’s term until the earlier of the time at which 
the member’s successor takes office or the time at which a 
report of the Board is first issued under paragraph (2) after 
the expiration of the member’s term. The Secretary of the 
Treasury shall be the Managing Trustee of the Board of 
Trustees. The Board of Trustees shall meet not less frequently 
than once each calendar year. A person serving on the Board 
of Trustees shall not be considered to be a fiduciary and shall 
not be personally liable for actions taken in such capacity 
with respect to the Trust Fund. 
‘‘(2) DUTIES.— 
‘‘(A) IN GENERAL.—It shall be the duty of the Board 
of Trustees to do the following: 
‘‘(i) Hold the CLASS Independence Fund. 
‘‘(ii) Report to the Congress not later than the 
first day of April of each year on the operation and 
status of the CLASS Independence Fund during the 
preceding fiscal year and on its expected operation 
and status during the current fiscal year and the next 
2 fiscal years. 
‘‘(iii) Report immediately to the Congress whenever 
the Board is of the opinion that the amount of the 
CLASS Independence Fund is not actuarially sound 
in 
regards 
to 
the 
projection 
under 
section 
3203(b)(1)(B)(i). 
‘‘(iv) Review the general policies followed in man-
aging the CLASS Independence Fund, and recommend 
changes in such policies, including necessary changes 
in the provisions of law which govern the way in which 
the CLASS Independence Fund is to be managed. 
‘‘(B) REPORT.—The report provided for in subparagraph 
(A)(ii) shall— 
‘‘(i) include— 
‘‘(I) a statement of the assets of, and the 
disbursements made from, the CLASS Independ-
ence Fund during the preceding fiscal year; 
‘‘(II) an estimate of the expected income to, 
and disbursements to be made from, the CLASS 
Independence Fund during the current fiscal year 
and each of the next 2 fiscal years; 
‘‘(III) a statement of the actuarial status of 
the CLASS Independence Fund for the current 
fiscal year, each of the next 2 fiscal years, and 
as projected over the 75-year period beginning with 
the current fiscal year; and 
‘‘(IV) an actuarial opinion by the Chief Actuary 
of the Centers for Medicare & Medicaid Services 
certifying that the techniques and methodologies 
used are generally accepted within the actuarial 
profession and that the assumptions and cost esti-
mates used are reasonable; and 
‘‘(ii) be printed as a House document of the session 
of the Congress to which the report is made. 
Publication. 
Reports. 
Reports. 
Deadline. 
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124 STAT. 844 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(C) RECOMMENDATIONS.—If the Board of Trustees 
determines that enrollment trends and expected future ben-
efit claims on the CLASS Independence Fund are not 
actuarially sound in regards to the projection under section 
3203(b)(1)(B)(i) and are unlikely to be resolved with reason-
able premium increases or through other means, the Board 
of Trustees shall include in the report provided for in 
subparagraph (A)(ii) recommendations for such legislative 
action as the Board of Trustees determine to be appro-
priate, including whether to adjust monthly premiums or 
impose a temporary moratorium on new enrollments. 
‘‘SEC. 3207. CLASS INDEPENDENCE ADVISORY COUNCIL. 
‘‘(a) ESTABLISHMENT.—There is hereby created an Advisory 
Committee to be known as the ‘CLASS Independence Advisory 
Council’. 
‘‘(b) MEMBERSHIP.— 
‘‘(1) IN
GENERAL.—The CLASS Independence Advisory 
Council shall be composed of not more than 15 individuals, 
not otherwise in the employ of the United States— 
‘‘(A) who shall be appointed by the President without 
regard to the civil service laws and regulations; and 
‘‘(B) a majority of whom shall be representatives of 
individuals who participate or are likely to participate in 
the CLASS program, and shall include representatives of 
older and younger workers, individuals with disabilities, 
family caregivers of individuals who require services and 
supports to maintain their independence at home or in 
another residential setting of their choice in the community, 
individuals with expertise in long-term care or disability 
insurance, actuarial science, economics, and other relevant 
disciplines, as determined by the Secretary. 
‘‘(2) TERMS.— 
‘‘(A) IN
GENERAL.—The members of the CLASS 
Independence Advisory Council shall serve overlapping 
terms of 3 years (unless appointed to fill a vacancy occur-
ring prior to the expiration of a term, in which case the 
individual shall serve for the remainder of the term). 
‘‘(B) LIMITATION.—A member shall not be eligible to 
serve for more than 2 consecutive terms. 
‘‘(3) CHAIR.—The President shall, from time to time, appoint 
one of the members of the CLASS Independence Advisory 
Council to serve as the Chair. 
‘‘(c) DUTIES.—The CLASS Independence Advisory Council shall 
advise the Secretary on matters of general policy in the administra-
tion of the CLASS program established under this title and in 
the formulation of regulations under this title including with respect 
to— 
‘‘(1) the development of the CLASS Independence Benefit 
Plan under section 3203; 
‘‘(2) the determination of monthly premiums under such 
plan; and 
‘‘(3) the financial solvency of the program. 
‘‘(d) APPLICATION OF FACA.—The Federal Advisory Committee 
Act (5 U.S.C. App.), other than section 14 of that Act, shall apply 
to the CLASS Independence Advisory Council. 
‘‘(e) AUTHORIZATION OF APPROPRIATIONS.— 
President. 
Appointment. 
Appointment. 
President. 
42 USC 300ll–6. 
Determination. 
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124 STAT. 845 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) IN GENERAL.—There are authorized to be appropriated 
to the CLASS Independence Advisory Council to carry out 
its duties under this section, such sums as may be necessary 
for fiscal year 2011 and for each fiscal year thereafter. 
‘‘(2) AVAILABILITY.—Any sums appropriated under the 
authorization contained in this section shall remain available, 
without fiscal year limitation, until expended. 
‘‘SEC. 3208. SOLVENCY AND FISCAL INDEPENDENCE; REGULATIONS; 
ANNUAL REPORT. 
‘‘(a) SOLVENCY.—The Secretary shall regularly consult with the 
Board of Trustees of the CLASS Independence Fund and the CLASS 
Independence Advisory Council, for purposes of ensuring that 
enrollees premiums are adequate to ensure the financial solvency 
of the CLASS program, both with respect to fiscal years occurring 
in the near-term and fiscal years occurring over 20- and 75-year 
periods, taking into account the projections required for such periods 
under subsections (a)(1)(A)(i) and (b)(1)(B)(i) of section 3202. 
‘‘(b) NO TAXPAYER FUNDS USED TO PAY BENEFITS.—No taxpayer 
funds shall be used for payment of benefits under a CLASS Inde-
pendent Benefit Plan. For purposes of this subsection, the term 
‘taxpayer funds’ means any Federal funds from a source other 
than premiums deposited by CLASS program participants in the 
CLASS Independence Fund and any associated interest earnings. 
‘‘(c) REGULATIONS.—The Secretary shall promulgate such regu-
lations as are necessary to carry out the CLASS program in accord-
ance with this title. Such regulations shall include provisions to 
prevent fraud and abuse under the program. 
‘‘(d) ANNUAL REPORT.—Beginning January 1, 2014, the Sec-
retary shall submit an annual report to Congress on the CLASS 
program. Each report shall include the following: 
‘‘(1) The total number of enrollees in the program. 
‘‘(2) The total number of eligible beneficiaries during the 
fiscal year. 
‘‘(3) The total amount of cash benefits provided during 
the fiscal year. 
‘‘(4) A description of instances of fraud or abuse identified 
during the fiscal year. 
‘‘(5) Recommendations for such administrative or legislative 
action as the Secretary determines is necessary to improve 
the program, ensure the solvency of the program, or to prevent 
the occurrence of fraud or abuse. 
‘‘SEC. 3209. INSPECTOR GENERAL’S REPORT. 
‘‘The Inspector General of the Department of Health and 
Human Services shall submit an annual report to the Secretary 
and Congress relating to the overall progress of the CLASS program 
and of the existence of waste, fraud, and abuse in the CLASS 
program. Each such report shall include findings in the following 
areas: 
‘‘(1) The eligibility determination process. 
‘‘(2) The provision of cash benefits. 
‘‘(3) Quality assurance and protection against waste, fraud, 
and abuse. 
‘‘(4) Recouping of unpaid and accrued benefits. 
42 USC 300ll–8. 
Effective date. 
Definitions. 
Consultation. 
42 USC 300ll–7. 
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124 STAT. 846 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 3210. TAX TREATMENT OF PROGRAM. 
‘‘The CLASS program shall be treated for purposes of the 
Internal Revenue Code of 1986 in the same manner as a qualified 
long-term care insurance contract for qualified long-term care serv-
ices.’’. 
(2) CONFORMING
AMENDMENTS
TO
MEDICAID.—Section 
1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), as 
amended by section 6505, is amended by inserting after para-
graph (80) the following: 
‘‘(81) provide that the State will comply with such regula-
tions regarding the application of primary and secondary payor 
rules with respect to individuals who are eligible for medical 
assistance under this title and are eligible beneficiaries under 
the CLASS program established under title XXXII of the Public 
Health Service Act as the Secretary shall establish; and’’. 
(b) ASSURANCE OF ADEQUATE INFRASTRUCTURE FOR THE PROVI-
SION OF PERSONAL CARE ATTENDANT WORKERS.—Section 1902(a) 
of the Social Security Act (42 U.S.C. 1396a(a)), as amended by 
subsection (a)(2), is amended by inserting after paragraph (81) 
the following: 
‘‘(82) provide that, not later than 2 years after the date 
of enactment of the Community Living Assistance Services 
and Supports Act, each State shall— 
‘‘(A) assess the extent to which entities such as pro-
viders of home care, home health services, home and 
community service providers, public authorities created to 
provide personal care services to individuals eligible for 
medical assistance under the State plan, and nonprofit 
organizations, are serving or have the capacity to serve 
as fiscal agents for, employers of, and providers of employ-
ment-related benefits for, personal care attendant workers 
who provide personal care services to individuals receiving 
benefits under the CLASS program established under title 
XXXII of the Public Health Service Act, including in rural 
and underserved areas; 
‘‘(B) designate or create such entities to serve as fiscal 
agents for, employers of, and providers of employment- 
related benefits for, such workers to ensure an adequate 
supply of the workers for individuals receiving benefits 
under the CLASS program, including in rural and under-
served areas; and 
‘‘(C) ensure that the designation or creation of such 
entities will not negatively alter or impede existing pro-
grams, models, methods, or administration of service 
delivery that provide for consumer controlled or self- 
directed home and community services and further ensure 
that such entities will not impede the ability of individuals 
to direct and control their home and community services, 
including the ability to select, manage, dismiss, co-employ, 
or employ such workers or inhibit such individuals from 
relying on family members for the provision of personal 
care services.’’. 
(c) 
PERSONAL
CARE
ATTENDANTS
WORKFORCE
ADVISORY 
PANEL.— 
(1) ESTABLISHMENT.—Not later than 90 days after the date 
of enactment of this Act, the Secretary of Health and Human 
Services shall establish a Personal Care Attendants Workforce 
Deadline. 
42 USC 300ll 
note. 
Designation. 
Deadline. 
Regulations. 
42 USC 300ll–9. 
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124 STAT. 847 
PUBLIC LAW 111–148—MAR. 23, 2010 
Advisory Panel for the purpose of examining and advising 
the Secretary and Congress on workforce issues related to 
personal care attendant workers, including with respect to the 
adequacy of the number of such workers, the salaries, wages, 
and benefits of such workers, and access to the services provided 
by such workers. 
(2) MEMBERSHIP.—In appointing members to the Personal 
Care Attendants Workforce Advisory Panel, the Secretary shall 
ensure that such members include the following: 
(A) Individuals with disabilities of all ages. 
(B) Senior individuals. 
(C) Representatives of individuals with disabilities. 
(D) Representatives of senior individuals. 
(E) Representatives of workforce and labor organiza-
tions. 
(F) Representatives of home and community-based 
service providers. 
(G) Representatives of assisted living providers. 
(d) INCLUSION OF INFORMATION ON SUPPLEMENTAL COVERAGE 
IN THE NATIONAL CLEARINGHOUSE FOR LONG-TERM CARE INFORMA-
TION; EXTENSION
OF FUNDING.—Section 6021(d) of the Deficit 
Reduction Act of 2005 (42 U.S.C. 1396p note) is amended— 
(1) in paragraph (2)(A)— 
(A) in clause (ii), by striking ‘‘and’’ at the end; 
(B) in clause (iii), by striking the period at the end 
and inserting ‘‘; and’’; and 
(C) by adding at the end the following: 
‘‘(iv) include information regarding the CLASS pro-
gram established under title XXXII of the Public 
Health Service Act and coverage available for purchase 
through a Exchange established under section 1311 
of the Patient Protection and Affordable Care Act that 
is supplemental coverage to the benefits provided 
under a CLASS Independence Benefit Plan under that 
program, and information regarding how benefits pro-
vided under a CLASS Independence Benefit Plan differ 
from disability insurance benefits.’’; and 
(2) in paragraph (3), by striking ‘‘2010’’ and inserting 
‘‘2015’’. 
(e) EFFECTIVE DATE.—The amendments made by subsections 
(a), (b), and (d) take effect on January 1, 2011. 
(f) RULE OF CONSTRUCTION.—Nothing in this title or the amend-
ments made by this title are intended to replace or displace public 
or private disability insurance benefits, including such benefits 
that are for income replacement. 
TITLE IX—REVENUE PROVISIONS 
Subtitle A—Revenue Offset Provisions 
SEC. 9001. EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED HEALTH 
COVERAGE. 
(a) IN GENERAL.—Chapter 43 of the Internal Revenue Code 
of 1986, as amended by section 1513, is amended by adding at 
the end the following: 
42 USC 300ll 
note. 
42 USC 300ll 
note. 
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124 STAT. 848 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 4980I. EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED 
HEALTH COVERAGE. 
‘‘(a) IMPOSITION OF TAX.—If— 
‘‘(1) an employee is covered under any applicable employer- 
sponsored coverage of an employer at any time during a taxable 
period, and 
‘‘(2) there is any excess benefit with respect to the coverage, 
there is hereby imposed a tax equal to 40 percent of the excess 
benefit. 
‘‘(b) EXCESS BENEFIT.—For purposes of this section— 
‘‘(1) IN GENERAL.—The term ‘excess benefit’ means, with 
respect to any applicable employer-sponsored coverage made 
available by an employer to an employee during any taxable 
period, the sum of the excess amounts determined under para-
graph (2) for months during the taxable period. 
‘‘(2) MONTHLY EXCESS AMOUNT.—The excess amount deter-
mined under this paragraph for any month is the excess (if 
any) of— 
‘‘(A) the aggregate cost of the applicable employer- 
sponsored coverage of the employee for the month, over 
‘‘(B) an amount equal to 1⁄12 of the annual limitation 
under paragraph (3) for the calendar year in which the 
month occurs. 
‘‘(3) ANNUAL LIMITATION.—For purposes of this subsection— 
‘‘(A) IN GENERAL.—The annual limitation under this 
paragraph for any calendar year is the dollar limit deter-
mined under subparagraph (C) for the calendar year. 
‘‘(B) APPLICABLE
ANNUAL
LIMITATION.—The annual 
limitation which applies for any month shall be determined 
on the basis of the type of coverage (as determined under 
subsection (f)(1)) provided to the employee by the employer 
as of the beginning of the month. 
‘‘(C) APPLICABLE DOLLAR LIMIT.—Except as provided 
in subparagraph (D)— 
‘‘(i) 2013.—In the case of 2013, the dollar limit 
under this subparagraph is— 
‘‘(I) in the case of an employee with self-only 
coverage, $8,500, and 
‘‘(II) in the case of an employee with coverage 
other than self-only coverage, $23,000. 
‘‘(ii) EXCEPTION FOR CERTAIN INDIVIDUALS.—In the 
case of an individual who is a qualified retiree or 
who participates in a plan sponsored by an employer 
the majority of whose employees are engaged in a 
high-risk profession or employed to repair or install 
electrical or telecommunications lines— 
‘‘(I) the dollar amount in clause (i)(I) (deter-
mined after the application of subparagraph (D)) 
shall be increased by $1,350, and 
‘‘(II) the dollar amount in clause (i)(II) (deter-
mined after the application of subparagraph (D)) 
shall be increased by $3,000. 
‘‘(iii) SUBSEQUENT YEARS.—In the case of any cal-
endar year after 2013, each of the dollar amounts 
under clauses (i) and (ii) shall be increased to the 
amount equal to such amount as in effect for the 
Definition. 
26 USC 4980I. 
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124 STAT. 849 
PUBLIC LAW 111–148—MAR. 23, 2010 
calendar year preceding such year, increased by an 
amount equal to the product of— 
‘‘(I) such amount as so in effect, multiplied 
by 
‘‘(II) the cost-of-living adjustment determined 
under section 1(f)(3) for such year (determined by 
substituting the calendar year that is 2 years 
before such year for ‘1992’ in subparagraph (B) 
thereof), increased by 1 percentage point. 
If any amount determined under this clause is not 
a multiple of $50, such amount shall be rounded to 
the nearest multiple of $50. 
‘‘(D) TRANSITION RULE FOR STATES WITH HIGHEST COV-
ERAGE COSTS.— 
‘‘(i) IN
GENERAL.—If an employee is a resident 
of a high cost State on the first day of any month 
beginning in 2013, 2014, or 2015, the annual limitation 
under this paragraph for such month with respect 
to such employee shall be an amount equal to the 
applicable percentage of the annual limitation (deter-
mined without regard to this subparagraph or subpara-
graph (C)(ii)). 
‘‘(ii) APPLICABLE
PERCENTAGE.—The applicable 
percentage is 120 percent for 2013, 110 percent for 
2014, and 105 percent for 2015. 
‘‘(iii) HIGH COST STATE.—The term ‘high cost State’ 
means each of the 17 States which the Secretary of 
Health and Human Services, in consultation with the 
Secretary, estimates had the highest average cost 
during 2012 for employer-sponsored coverage under 
health plans. The Secretary’s estimate shall be made 
on the basis of aggregate premiums paid in the State 
for such health plans, determined using the most 
recent data available as of August 31, 2012. 
‘‘(c) LIABILITY TO PAY TAX.— 
‘‘(1) IN GENERAL.—Each coverage provider shall pay the 
tax imposed by subsection (a) on its applicable share of the 
excess benefit with respect to an employee for any taxable 
period. 
‘‘(2) COVERAGE PROVIDER.—For purposes of this subsection, 
the term ‘coverage provider’ means each of the following: 
‘‘(A) HEALTH INSURANCE COVERAGE.—If the applicable 
employer-sponsored coverage consists of coverage under a 
group health plan which provides health insurance cov-
erage, the health insurance issuer. 
‘‘(B) HSA AND MSA CONTRIBUTIONS.—If the applicable 
employer-sponsored coverage consists of coverage under an 
arrangement under which the employer makes contribu-
tions described in subsection (b) or (d) of section 106, the 
employer. 
‘‘(C) OTHER
COVERAGE.—In the case of any other 
applicable employer-sponsored coverage, the person that 
administers the plan benefits. 
‘‘(3) APPLICABLE SHARE.—For purposes of this subsection, 
a coverage provider’s applicable share of an excess benefit for 
any taxable period is the amount which bears the same ratio 
to the amount of such excess benefit as— 
Definitions. 
Definition. 
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124 STAT. 850 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) the cost of the applicable employer-sponsored cov-
erage provided by the provider to the employee during 
such period, bears to 
‘‘(B) the aggregate cost of all applicable employer-spon-
sored coverage provided to the employee by all coverage 
providers during such period. 
‘‘(4) RESPONSIBILITY TO CALCULATE TAX AND APPLICABLE 
SHARES.— 
‘‘(A) IN GENERAL.—Each employer shall— 
‘‘(i) calculate for each taxable period the amount 
of the excess benefit subject to the tax imposed by 
subsection (a) and the applicable share of such excess 
benefit for each coverage provider, and 
‘‘(ii) notify, at such time and in such manner as 
the Secretary may prescribe, the Secretary and each 
coverage provider of the amount so determined for 
the provider. 
‘‘(B) SPECIAL RULE FOR MULTIEMPLOYER PLANS.—In the 
case of applicable employer-sponsored coverage made avail-
able to employees through a multiemployer plan (as defined 
in section 414(f)), the plan sponsor shall make the calcula-
tions, and provide the notice, required under subparagraph 
(A). 
‘‘(d) APPLICABLE EMPLOYER-SPONSORED COVERAGE; COST.—For 
purposes of this section— 
‘‘(1) APPLICABLE EMPLOYER-SPONSORED COVERAGE.— 
‘‘(A) IN GENERAL.—The term ‘applicable employer-spon-
sored coverage’ means, with respect to any employee, cov-
erage under any group health plan made available to the 
employee by an employer which is excludable from the 
employee’s gross income under section 106, or would be 
so excludable if it were employer-provided coverage (within 
the meaning of such section 106). 
‘‘(B) EXCEPTIONS.—The term ‘applicable employer-spon-
sored coverage’ shall not include— 
‘‘(i) any coverage (whether through insurance or 
otherwise) described in section 9832(c)(1)(A) or for long- 
term care, or 
‘‘(ii) any coverage described in section 9832(c)(3) 
the payment for which is not excludable from gross 
income and for which a deduction under section 162(l) 
is not allowable. 
‘‘(C) COVERAGE INCLUDES EMPLOYEE PAID PORTION.— 
Coverage shall be treated as applicable employer-sponsored 
coverage without regard to whether the employer or 
employee pays for the coverage. 
‘‘(D) SELF-EMPLOYED INDIVIDUAL.—In the case of an 
individual who is an employee within the meaning of sec-
tion 401(c)(1), coverage under any group health plan pro-
viding health insurance coverage shall be treated as 
applicable employer-sponsored coverage if a deduction is 
allowable under section 162(l) with respect to all or any 
portion of the cost of the coverage. 
‘‘(E) GOVERNMENTAL
PLANS
INCLUDED.—Applicable 
employer-sponsored coverage shall include coverage under 
any group health plan established and maintained pri-
marily for its civilian employees by the Government of 
Definitions. 
Notification. 
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124 STAT. 851 
PUBLIC LAW 111–148—MAR. 23, 2010 
the United States, by the government of any State or 
political subdivision thereof, or by any agency or instrumen-
tality of any such government. 
‘‘(2) DETERMINATION OF COST.— 
‘‘(A) IN
GENERAL.—The cost of applicable employer- 
sponsored coverage shall be determined under rules similar 
to the rules of section 4980B(f)(4), except that in deter-
mining such cost, any portion of the cost of such coverage 
which is attributable to the tax imposed under this section 
shall not be taken into account and the amount of such 
cost shall be calculated separately for self-only coverage 
and other coverage. In the case of applicable employer- 
sponsored coverage which provides coverage to retired 
employees, the plan may elect to treat a retired employee 
who has not attained the age of 65 and a retired employee 
who has attained the age of 65 as similarly situated bene-
ficiaries. 
‘‘(B) HEALTH FSAS.—In the case of applicable employer- 
sponsored coverage consisting of coverage under a flexible 
spending arrangement (as defined in section 106(c)(2)), the 
cost of the coverage shall be equal to the sum of— 
‘‘(i) the amount of employer contributions under 
any salary reduction election under the arrangement, 
plus 
‘‘(ii) the amount determined under subparagraph 
(A) with respect to any reimbursement under the 
arrangement in excess of the contributions described 
in clause (i). 
‘‘(C) ARCHER MSAS AND HSAS.—In the case of applicable 
employer-sponsored coverage consisting of coverage under 
an arrangement under which the employer makes contribu-
tions described in subsection (b) or (d) of section 106, the 
cost of the coverage shall be equal to the amount of 
employer contributions under the arrangement. 
‘‘(D) ALLOCATION ON A MONTHLY BASIS.—If cost is deter-
mined on other than a monthly basis, the cost shall be 
allocated to months in a taxable period on such basis 
as the Secretary may prescribe. 
‘‘(e) PENALTY FOR FAILURE TO PROPERLY CALCULATE EXCESS 
BENEFIT.— 
‘‘(1) IN
GENERAL.—If, for any taxable period, the tax 
imposed by subsection (a) exceeds the tax determined under 
such subsection with respect to the total excess benefit cal-
culated by the employer or plan sponsor under subsection 
(c)(4)— 
‘‘(A) each coverage provider shall pay the tax on its 
applicable share (determined in the same manner as under 
subsection (c)(4)) of the excess, but no penalty shall be 
imposed on the provider with respect to such amount, 
and 
‘‘(B) the employer or plan sponsor shall, in addition 
to any tax imposed by subsection (a), pay a penalty in 
an amount equal to such excess, plus interest at the under-
payment rate determined under section 6621 for the period 
beginning on the due date for the payment of tax imposed 
by subsection (a) to which the excess relates and ending 
on the date of payment of the penalty. 
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124 STAT. 852 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) LIMITATIONS ON PENALTY.— 
‘‘(A) PENALTY
NOT
TO
APPLY
WHERE
FAILURE
NOT 
DISCOVERED EXERCISING REASONABLE DILIGENCE.—No pen-
alty shall be imposed by paragraph (1)(B) on any failure 
to properly calculate the excess benefit during any period 
for which it is established to the satisfaction of the Sec-
retary that the employer or plan sponsor neither knew, 
nor exercising reasonable diligence would have known, that 
such failure existed. 
‘‘(B) PENALTY NOT TO APPLY TO FAILURES CORRECTED 
WITHIN 30 DAYS.—No penalty shall be imposed by paragraph 
(1)(B) on any such failure if— 
‘‘(i) such failure was due to reasonable cause and 
not to willful neglect, and 
‘‘(ii) such failure is corrected during the 30-day 
period beginning on the 1st date that the employer 
knew, or exercising reasonable diligence would have 
known, that such failure existed. 
‘‘(C) WAIVER BY SECRETARY.—In the case of any such 
failure which is due to reasonable cause and not to willful 
neglect, the Secretary may waive part or all of the penalty 
imposed by paragraph (1), to the extent that the payment 
of such penalty would be excessive or otherwise inequitable 
relative to the failure involved. 
‘‘(f) OTHER DEFINITIONS
AND SPECIAL RULES.—For purposes 
of this section— 
‘‘(1) COVERAGE DETERMINATIONS.— 
‘‘(A) IN GENERAL.—Except as provided in subparagraph 
(B), an employee shall be treated as having self-only cov-
erage with respect to any applicable employer-sponsored 
coverage of an employer. 
‘‘(B) MINIMUM
ESSENTIAL
COVERAGE.—An employee 
shall be treated as having coverage other than self-only 
coverage only if the employee is enrolled in coverage other 
than self-only coverage in a group health plan which pro-
vides minimum essential coverage (as defined in section 
5000A(f)) to the employee and at least one other beneficiary, 
and the benefits provided under such minimum essential 
coverage do not vary based on whether any individual 
covered under such coverage is the employee or another 
beneficiary. 
‘‘(2) QUALIFIED
RETIREE.—The term ‘qualified retiree’ 
means any individual who— 
‘‘(A) is receiving coverage by reason of being a retiree, 
‘‘(B) has attained age 55, and 
‘‘(C) is not entitled to benefits or eligible for enrollment 
under the Medicare program under title XVIII of the Social 
Security Act. 
‘‘(3) EMPLOYEES ENGAGED IN HIGH-RISK PROFESSION.—The 
term ‘employees engaged in a high-risk profession’ means law 
enforcement officers (as such term is defined in section 1204 
of the Omnibus Crime Control and Safe Streets Act of 1968), 
employees in fire protection activities (as such term is defined 
in section 3(y) of the Fair Labor Standards Act of 1938), individ-
uals who provide out-of-hospital emergency medical care 
(including emergency medical technicians, paramedics, and 
first-responders), and individuals engaged in the construction, 
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124 STAT. 853 
PUBLIC LAW 111–148—MAR. 23, 2010 
mining, agriculture (not including food processing), forestry, 
and fishing industries. Such term includes an employee who 
is retired from a high-risk profession described in the preceding 
sentence, if such employee satisfied the requirements of such 
sentence for a period of not less than 20 years during the 
employee’s employment. 
‘‘(4) GROUP HEALTH PLAN.—The term ‘group health plan’ 
has the meaning given such term by section 5000(b)(1). 
‘‘(5) HEALTH
INSURANCE
COVERAGE; HEALTH
INSURANCE 
ISSUER.— 
‘‘(A) HEALTH INSURANCE COVERAGE.—The term ‘health 
insurance coverage’ has the meaning given such term by 
section 9832(b)(1) (applied without regard to subparagraph 
(B) thereof, except as provided by the Secretary in regula-
tions). 
‘‘(B) HEALTH
INSURANCE
ISSUER.—The term ‘health 
insurance issuer’ has the meaning given such term by 
section 9832(b)(2). 
‘‘(6) PERSON THAT ADMINISTERS THE PLAN BENEFITS.—The 
term ‘person that administers the plan benefits’ shall include 
the plan sponsor if the plan sponsor administers benefits under 
the plan. 
‘‘(7) PLAN
SPONSOR.—The term ‘plan sponsor’ has the 
meaning given such term in section 3(16)(B) of the Employee 
Retirement Income Security Act of 1974. 
‘‘(8) TAXABLE
PERIOD.—The term ‘taxable period’ means 
the calendar year or such shorter period as the Secretary may 
prescribe. The Secretary may have different taxable periods 
for employers of varying sizes. 
‘‘(9) AGGREGATION
RULES.—All employers treated as a 
single employer under subsection (b), (c), (m), or (o) of section 
414 shall be treated as a single employer. 
‘‘(10) DENIAL OF DEDUCTION.—For denial of a deduction 
for the tax imposed by this section, see section 275(a)(6). 
‘‘(g) REGULATIONS.—The Secretary shall prescribe such regula-
tions as may be necessary to carry out this section.’’. 
(b) CLERICAL AMENDMENT.—The table of sections for chapter 
43 of such Code, as amended by section 1513, is amended by 
adding at the end the following new item: 
‘‘Sec. 4980I. Excise tax on high cost employer-sponsored health coverage.’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to taxable years beginning after December 31, 2012. 
SEC. 9002. INCLUSION OF COST OF EMPLOYER-SPONSORED HEALTH 
COVERAGE ON W–2. 
(a) IN GENERAL.—Section 6051(a) of the Internal Revenue Code 
of 1986 (relating to receipts for employees) is amended by striking 
‘‘and’’ at the end of paragraph (12), by striking the period at the 
end of paragraph (13) and inserting ‘‘, and’’, and by adding after 
paragraph (13) the following new paragraph: 
‘‘(14) the aggregate cost (determined under rules similar 
to the rules of section 4980B(f)(4)) of applicable employer-spon-
sored coverage (as defined in section 4980I(d)(1)), except that 
this paragraph shall not apply to— 
‘‘(A) coverage to which paragraphs (11) and (12) apply, 
or 
26 USC 6051. 
26 USC 4980I 
note. 
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124 STAT. 854 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) the amount of any salary reduction contributions 
to a flexible spending arrangement (within the meaning 
of section 125).’’. 
(b) EFFECTIVE DATE.—The amendments made by this section 
shall apply to taxable years beginning after December 31, 2010. 
SEC. 9003. DISTRIBUTIONS FOR MEDICINE QUALIFIED ONLY IF FOR 
PRESCRIBED DRUG OR INSULIN. 
(a) HSAS.—Subparagraph (A) of section 223(d)(2) of the Internal 
Revenue Code of 1986 is amended by adding at the end the fol-
lowing: ‘‘Such term shall include an amount paid for medicine 
or a drug only if such medicine or drug is a prescribed drug 
(determined without regard to whether such drug is available with-
out a prescription) or is insulin.’’. 
(b) ARCHER MSAS.—Subparagraph (A) of section 220(d)(2) of 
the Internal Revenue Code of 1986 is amended by adding at the 
end the following: ‘‘Such term shall include an amount paid for 
medicine or a drug only if such medicine or drug is a prescribed 
drug (determined without regard to whether such drug is available 
without a prescription) or is insulin.’’. 
(c) HEALTH FLEXIBLE SPENDING ARRANGEMENTS AND HEALTH 
REIMBURSEMENT ARRANGEMENTS.—Section 106 of the Internal Rev-
enue Code of 1986 is amended by adding at the end the following 
new subsection: 
‘‘(f) REIMBURSEMENTS
FOR
MEDICINE
RESTRICTED
TO
PRE-
SCRIBED DRUGS AND INSULIN.—For purposes of this section and 
section 105, reimbursement for expenses incurred for a medicine 
or a drug shall be treated as a reimbursement for medical expenses 
only if such medicine or drug is a prescribed drug (determined 
without regard to whether such drug is available without a prescrip-
tion) or is insulin.’’. 
(d) EFFECTIVE DATES.— 
(1) DISTRIBUTIONS FROM SAVINGS ACCOUNTS.—The amend-
ments made by subsections (a) and (b) shall apply to amounts 
paid with respect to taxable years beginning after December 
31, 2010. 
(2) REIMBURSEMENTS.—The amendment made by sub-
section (c) shall apply to expenses incurred with respect to 
taxable years beginning after December 31, 2010. 
SEC. 9004. INCREASE IN ADDITIONAL TAX ON DISTRIBUTIONS FROM 
HSAS AND ARCHER MSAS NOT USED FOR QUALIFIED 
MEDICAL EXPENSES. 
(a) HSAS.—Section 223(f)(4)(A) of the Internal Revenue Code 
of 1986 is amended by striking ‘‘10 percent’’ and inserting ‘‘20 
percent’’. 
(b) ARCHER MSAS.—Section 220(f)(4)(A) of the Internal Revenue 
Code of 1986 is amended by striking ‘‘15 percent’’ and inserting 
‘‘20 percent’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to distributions made after December 31, 2010. 
SEC. 9005. LIMITATION ON HEALTH FLEXIBLE SPENDING ARRANGE-
MENTS UNDER CAFETERIA PLANS. 
(a) IN GENERAL.—Section 125 of the Internal Revenue Code 
of 1986 is amended— 
(1) by redesignating subsections (i) and (j) as subsections 
(j) and (k), respectively, and 
26 USC 125. 
26 USC 220 note. 
26 USC 106 note. 
26 USC 220 note. 
26 USC 106. 
26 USC 220. 
26 USC 223. 
26 USC 6051 
note. 
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124 STAT. 855 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) by inserting after subsection (h) the following new sub-
section: 
‘‘(i) LIMITATION
ON HEALTH FLEXIBLE SPENDING ARRANGE-
MENTS.—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 quali-
fied benefit unless the cafeteria plan provides that an employee 
may not elect for any taxable year to have salary reduction contribu-
tions in excess of $2,500 made to such arrangement.’’. 
(b) EFFECTIVE DATE.—The amendments made by this section 
shall apply to taxable years beginning after December 31, 2010. 
SEC. 9006. EXPANSION OF INFORMATION REPORTING REQUIREMENTS. 
(a) IN GENERAL.—Section 6041 of the Internal Revenue Code 
of 1986 is amended by adding at the end the following new sub-
sections: 
‘‘(h) APPLICATION
TO
CORPORATIONS.—Notwithstanding any 
regulation prescribed by the Secretary before the date of the enact-
ment of this subsection, for purposes of this section the term ‘person’ 
includes any corporation that is not an organization exempt from 
tax under section 501(a). 
‘‘(i) REGULATIONS.—The Secretary may prescribe such regula-
tions and other guidance as may be appropriate or necessary to 
carry out the purposes of this section, including rules to prevent 
duplicative reporting of transactions.’’. 
(b) PAYMENTS FOR PROPERTY AND OTHER GROSS PROCEEDS.— 
Subsection (a) of section 6041 of the Internal Revenue Code of 
1986 is amended— 
(1) by inserting ‘‘amounts in consideration for property,’’ 
after ‘‘wages,’’, 
(2) by inserting ‘‘gross proceeds,’’ after ‘‘emoluments, or 
other’’, and 
(3) by inserting ‘‘gross proceeds,’’ after ‘‘setting forth the 
amount of such’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to payments made after December 31, 2011. 
SEC. 9007. ADDITIONAL REQUIREMENTS FOR CHARITABLE HOSPITALS. 
(a) REQUIREMENTS TO QUALIFY AS SECTION 501(C)(3) CHARI-
TABLE HOSPITAL ORGANIZATION.—Section 501 of the Internal Rev-
enue Code of 1986 (relating to exemption from tax on corporations, 
certain trusts, etc.) is amended by redesignating subsection (r) 
as subsection (s) and by inserting after subsection (q) the following 
new subsection: 
‘‘(r) ADDITIONAL REQUIREMENTS FOR CERTAIN HOSPITALS.— 
‘‘(1) IN GENERAL.—A hospital organization to which this 
subsection applies shall not be treated as described in sub-
section (c)(3) unless the organization— 
‘‘(A) meets the community health needs assessment 
requirements described in paragraph (3), 
‘‘(B) meets the financial assistance policy requirements 
described in paragraph (4), 
‘‘(C) meets the requirements on charges described in 
paragraph (5), and 
‘‘(D) meets the billing and collection requirement 
described in paragraph (6). 
‘‘(2) HOSPITAL
ORGANIZATIONS
TO
WHICH
SUBSECTION 
APPLIES.— 
Applicability. 
26 USC 501. 
26 USC 6041. 
26 USC 125 note. 
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124 STAT. 856 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) IN
GENERAL.—This subsection shall apply to— 
‘‘(i) an organization which operates a facility which 
is required by a State to be licensed, registered, or 
similarly recognized as a hospital, and 
‘‘(ii) any other organization which the Secretary 
determines has the provision of hospital care as its 
principal function or purpose constituting the basis 
for its exemption under subsection (c)(3) (determined 
without regard to this subsection). 
‘‘(B) ORGANIZATIONS
WITH
MORE
THAN
1
HOSPITAL 
FACILITY.—If a hospital organization operates more than 
1 hospital facility— 
‘‘(i) the organization shall meet the requirements 
of this subsection separately with respect to each such 
facility, and 
‘‘(ii) the organization shall not be treated as 
described in subsection (c)(3) with respect to any such 
facility for which such requirements are not separately 
met. 
‘‘(3) COMMUNITY HEALTH NEEDS ASSESSMENTS.— 
‘‘(A) IN GENERAL.—An organization meets the require-
ments of this paragraph with respect to any taxable year 
only if the organization— 
‘‘(i) has conducted a community health needs 
assessment which meets the requirements of subpara-
graph (B) in such taxable year or in either of the 
2 taxable years immediately preceding such taxable 
year, and 
‘‘(ii) has adopted an implementation strategy to 
meet the community health needs identified through 
such assessment. 
‘‘(B) COMMUNITY
HEALTH
NEEDS
ASSESSMENT.—A 
community health needs assessment meets the require-
ments of this paragraph if such community health needs 
assessment— 
‘‘(i) takes into account input from persons who 
represent the broad interests of the community served 
by the hospital facility, including those with special 
knowledge of or expertise in public health, and 
‘‘(ii) is made widely available to the public. 
‘‘(4) FINANCIAL ASSISTANCE POLICY.—An organization meets 
the requirements of this paragraph if the organization estab-
lishes the following policies: 
‘‘(A) FINANCIAL ASSISTANCE POLICY.—A written finan-
cial assistance policy which includes— 
‘‘(i) eligibility criteria for financial assistance, and 
whether such assistance includes free or discounted 
care, 
‘‘(ii) the basis for calculating amounts charged to 
patients, 
‘‘(iii) the method for applying for financial assist-
ance, 
‘‘(iv) in the case of an organization which does 
not have a separate billing and collections policy, the 
actions the organization may take in the event of non- 
payment, including collections action and reporting to 
credit agencies, and 
Public 
information. 
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124 STAT. 857 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(v) measures to widely publicize the policy within 
the community to be served by the organization. 
‘‘(B) POLICY RELATING TO EMERGENCY MEDICAL CARE.— 
A written policy requiring the organization to provide, with-
out discrimination, care for emergency medical conditions 
(within the meaning of section 1867 of the Social Security 
Act (42 U.S.C. 1395dd)) to individuals regardless of their 
eligibility under the financial assistance policy described 
in subparagraph (A). 
‘‘(5) LIMITATION ON CHARGES.—An organization meets the 
requirements of this paragraph if the organization— 
‘‘(A) limits amounts charged for emergency or other 
medically necessary care provided to individuals eligible 
for assistance under the financial assistance policy 
described in paragraph (4)(A) to not more than the lowest 
amounts charged to individuals who have insurance cov-
ering such care, and 
‘‘(B) prohibits the use of gross charges. 
‘‘(6) 
BILLING
AND
COLLECTION
REQUIREMENTS.—An 
organization meets the requirement of this paragraph only 
if the organization does not engage in extraordinary collection 
actions before the organization has made reasonable efforts 
to determine whether the individual is eligible for assistance 
under the financial assistance policy described in paragraph 
(4)(A). 
‘‘(7) REGULATORY AUTHORITY.—The Secretary shall issue 
such regulations and guidance as may be necessary to carry 
out the provisions of this subsection, including guidance relating 
to what constitutes reasonable efforts to determine the eligi-
bility of a patient under a financial assistance policy for pur-
poses of paragraph (6).’’. 
(b) EXCISE TAX FOR FAILURES TO MEET HOSPITAL EXEMPTION 
REQUIREMENTS.— 
(1) IN
GENERAL.—Subchapter D of chapter 42 of the 
Internal Revenue Code of 1986 (relating to failure by certain 
charitable organizations to meet certain qualification require-
ments) is amended by adding at the end the following new 
section: 
‘‘SEC. 4959. TAXES ON FAILURES BY HOSPITAL ORGANIZATIONS. 
‘‘If a hospital organization to which section 501(r) applies fails 
to meet the requirement of section 501(r)(3) for any taxable year, 
there is imposed on the organization a tax equal to $50,000.’’. 
(2) CONFORMING AMENDMENT.—The table of sections for 
subchapter D of chapter 42 of such Code is amended by adding 
at the end the following new item: 
‘‘Sec. 4959. Taxes on failures by hospital organizations.’’. 
(c) MANDATORY REVIEW OF TAX EXEMPTION FOR HOSPITALS.— 
The Secretary of the Treasury or the Secretary’s delegate shall 
review at least once every 3 years the community benefit activities 
of each hospital organization to which section 501(r) of the Internal 
Revenue Code of 1986 (as added by this section) applies. 
(d) ADDITIONAL REPORTING REQUIREMENTS.— 
(1) COMMUNITY HEALTH NEEDS ASSESSMENTS AND AUDITED 
FINANCIAL STATEMENTS.—Section 6033(b) of the Internal Rev-
enue Code of 1986 (relating to certain organizations described 
in section 501(c)(3)) is amended by striking ‘‘and’’ at the end 
26 USC 6033. 
Deadline. 
26 USC 501 note. 
26 USC 4959. 
Regulations. 
Guidelines. 
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124 STAT. 858 
PUBLIC LAW 111–148—MAR. 23, 2010 
of paragraph (14), by redesignating paragraph (15) as para-
graph (16), and by inserting after paragraph (14) the following 
new paragraph: 
‘‘(15) in the case of an organization to which the require-
ments of section 501(r) apply for the taxable year— 
‘‘(A) a description of how the organization is addressing 
the needs identified in each community health needs 
assessment conducted under section 501(r)(3) and a descrip-
tion of any such needs that are not being addressed 
together with the reasons why such needs are not being 
addressed, and 
‘‘(B) the audited financial statements of such organiza-
tion (or, in the case of an organization the financial state-
ments of which are included in a consolidated financial 
statement with other organizations, such consolidated 
financial statement).’’. 
(2) TAXES.—Section 6033(b)(10) of such Code is amended 
by striking ‘‘and’’ at the end of subparagraph (B), by inserting 
‘‘and’’ at the end of subparagraph (C), and by adding at the 
end the following new subparagraph: 
‘‘(D) section 4959 (relating to taxes on failures by hos-
pital organizations),’’. 
(e) REPORTS.— 
(1) REPORT ON LEVELS OF CHARITY CARE.—The Secretary 
of the Treasury, in consultation with the Secretary of Health 
and Human Services, shall submit to the Committees on Ways 
and Means, Education and Labor, and Energy and Commerce 
of the House of Representatives and to the Committees on 
Finance and Health, Education, Labor, and Pensions of the 
Senate an annual report on the following: 
(A) Information with respect to private tax-exempt, 
taxable, and government-owned hospitals regarding— 
(i) levels of charity care provided, 
(ii) bad debt expenses, 
(iii) unreimbursed costs for services provided with 
respect to means-tested government programs, and 
(iv) unreimbursed costs for services provided with 
respect to non-means tested government programs. 
(B) Information with respect to private tax-exempt hos-
pitals regarding costs incurred for community benefit activi-
ties. 
(2) REPORT ON TRENDS.— 
(A) STUDY.—The Secretary of the Treasury, in consulta-
tion with the Secretary of Health and Human Services, 
shall conduct a study on trends in the information required 
to be reported under paragraph (1). 
(B) REPORT.—Not later than 5 years after the date 
of the enactment of this Act, the Secretary of the Treasury, 
in consultation with the Secretary of Health and Human 
Services, shall submit a report on the study conducted 
under subparagraph (A) to the Committees on Ways and 
Means, Education and Labor, and Energy and Commerce 
of the House of Representatives and to the Committees 
on Finance and Health, Education, Labor, and Pensions 
of the Senate. 
(f) EFFECTIVE DATES.— 
Applicability. 
26 USC 501 note. 
26 USC 501 note. 
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124 STAT. 859 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) IN
GENERAL.—Except as provided in paragraphs (2) 
and (3), the amendments made by this section shall apply 
to taxable years beginning after the date of the enactment 
of this Act. 
(2) COMMUNITY HEALTH NEEDS ASSESSMENT.—The require-
ments of section 501(r)(3) of the Internal Revenue Code of 
1986, as added by subsection (a), shall apply to taxable years 
beginning after the date which is 2 years after the date of 
the enactment of this Act. 
(3) EXCISE TAX.—The amendments made by subsection (b) 
shall apply to failures occurring after the date of the enactment 
of this Act. 
SEC. 9008. IMPOSITION OF ANNUAL FEE ON BRANDED PRESCRIPTION 
PHARMACEUTICAL MANUFACTURERS AND IMPORTERS. 
(a) IMPOSITION OF FEE.— 
(1) IN GENERAL.—Each covered entity engaged in the busi-
ness of manufacturing or importing branded prescription drugs 
shall pay to the Secretary of the Treasury not later than the 
annual payment date of each calendar year beginning after 
2009 a fee in an amount determined under subsection (b). 
(2) ANNUAL PAYMENT DATE.—For purposes of this section, 
the term ‘‘annual payment date’’ means with respect to any 
calendar year the date determined by the Secretary, but in 
no event later than September 30 of such calendar year. 
(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 $2,300,000,000 
as— 
(A) the covered entity’s branded prescription drug sales 
taken into account during the preceding calendar year, 
bear to 
(B) the aggregate branded prescription drug sales of 
all covered entities taken into account during such pre-
ceding calendar year. 
(2) SALES TAKEN INTO ACCOUNT.—For purposes of para-
graph (1), the branded prescription drug sales 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 aggregate 
branded prescription drug sales during the 
calendar year that are: 
The percentage of 
such sales taken 
into account is: 
Not more than $5,000,000 .......................
0 percent 
More than $5,000,000 but not more than 
$125,000,000.
10 percent 
More than $125,000,000 but not more 
than $225,000,000.
40 percent 
More than $225,000,000 but not more 
than $400,000,000.
75 percent 
More than $400,000,000 ...........................
100 percent. 
Definition. 
Deadlines. 
26 USC 4001 
note prec. 
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124 STAT. 860 
PUBLIC LAW 111–148—MAR. 23, 2010 
(3) SECRETARIAL
DETERMINATION.—The Secretary of the 
Treasury shall calculate the amount of each covered entity’s 
fee for any calendar year under paragraph (1). In calculating 
such amount, the Secretary of the Treasury shall determine 
such covered entity’s branded prescription drug sales on the 
basis of reports submitted under subsection (g) and through 
the use of any other source of information available to the 
Secretary of the Treasury. 
(c) TRANSFER OF FEES TO MEDICARE PART B TRUST FUND.— 
There is hereby appropriated to the Federal Supplementary Medical 
Insurance Trust Fund established under section 1841 of the Social 
Security Act an amount equal to the fees received by the Secretary 
of the Treasury under subsection (a). 
(d) COVERED ENTITY.— 
(1) IN GENERAL.—For purposes of this section, the term 
‘‘covered entity’’ means any manufacturer or importer with 
gross receipts from branded prescription drug sales. 
(2) CONTROLLED GROUPS.— 
(A) IN GENERAL.—For purposes of this subsection, all 
persons treated as a single employer under subsection (a) 
or (b) of section 52 of the Internal Revenue Code of 1986 
or subsection (m) or (o) of section 414 of such Code shall 
be treated as a single covered entity. 
(B) INCLUSION OF FOREIGN CORPORATIONS.—For pur-
poses of subparagraph (A), in applying subsections (a) and 
(b) of section 52 of such Code to this section, section 1563 
of such Code shall be applied without regard to subsection 
(b)(2)(C) thereof. 
(e) BRANDED PRESCRIPTION DRUG SALES.—For purposes of this 
section— 
(1) IN
GENERAL.—The term ‘‘branded prescription drug 
sales’’ means sales of branded prescription drugs to any speci-
fied government program or pursuant to coverage under any 
such program. 
(2) BRANDED PRESCRIPTION DRUGS.— 
(A) IN
GENERAL.—The term ‘‘branded prescription 
drug’’ means— 
(i) any prescription drug the application for which 
was submitted under section 505(b) of the Federal 
Food, Drug, and Cosmetic Act (21 U.S.C. 355(b)), or 
(ii) any biological product the license for which 
was submitted under section 351(a) of the Public 
Health Service Act (42 U.S.C. 262(a)). 
(B) PRESCRIPTION
DRUG.—For purposes of subpara-
graph (A)(i), the term ‘‘prescription drug’’ means any drug 
which is subject to section 503(b) of the Federal Food, 
Drug, and Cosmetic Act (21 U.S.C. 353(b)). 
(3) EXCLUSION OF ORPHAN DRUG SALES.—The term ‘‘branded 
prescription drug sales’’ shall not include sales of any drug 
or biological product with respect to which a credit was allowed 
for any taxable year under section 45C of the Internal Revenue 
Code of 1986. The preceding sentence shall not apply with 
respect to any such drug or biological product after the date 
on which such drug or biological product is approved by the 
Food and Drug Administration for marketing for any indication 
other than the treatment of the rare disease or condition with 
respect to which such credit was allowed. 
Definitions. 
Applicability. 
Definition. 
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124 STAT. 861 
PUBLIC LAW 111–148—MAR. 23, 2010 
(4) SPECIFIED GOVERNMENT PROGRAM.—The term ‘‘specified 
government program’’ means— 
(A) the Medicare Part D program under part D of 
title XVIII of the Social Security Act, 
(B) the Medicare Part B program under part B of 
title XVIII of the Social Security Act, 
(C) the Medicaid program under title XIX of the Social 
Security Act, 
(D) any program under which branded prescription 
drugs are procured by the Department of Veterans Affairs, 
(E) any program under which branded prescription 
drugs are procured by the Department of Defense, or 
(F) the TRICARE retail pharmacy program under sec-
tion 1074g of title 10, United States Code. 
(f) TAX TREATMENT OF FEES.—The fees imposed by this sec-
tion— 
(1) for purposes of subtitle F of the Internal Revenue Code 
of 1986, shall be treated as excise taxes with respect to which 
only civil actions for refund under procedures of such subtitle 
shall apply, and 
(2) for purposes of section 275 of such Code, shall be consid-
ered to be a tax described in section 275(a)(6). 
(g) REPORTING REQUIREMENT.—Not later than the date deter-
mined by the Secretary of the Treasury following the end of any 
calendar year, the Secretary of Health and Human Services, the 
Secretary of Veterans Affairs, and the Secretary of Defense shall 
report to the Secretary of the Treasury, in such manner as the 
Secretary of the Treasury prescribes, the total branded prescription 
drug sales for each covered entity with respect to each specified 
government program under such Secretary’s jurisdiction using the 
following methodology: 
(1) MEDICARE PART D PROGRAM.—The Secretary of Health 
and Human Services shall report, for each covered entity and 
for each branded prescription drug of the covered entity covered 
by the Medicare Part D program, the product of— 
(A) the per-unit ingredient cost, as reported to the 
Secretary of Health and Human Services by prescription 
drug plans and Medicare Advantage prescription drug 
plans, minus any per-unit rebate, discount, or other price 
concession provided by the covered entity, as reported to 
the Secretary of Health and Human Services by the 
prescription drug plans and Medicare Advantage prescrip-
tion drug plans, and 
(B) the number of units of the branded prescription 
drug paid for under the Medicare Part D program. 
(2) MEDICARE PART B PROGRAM.—The Secretary of Health 
and Human Services shall report, for each covered entity and 
for each branded prescription drug of the covered entity covered 
by the Medicare Part B program under section 1862(a) of the 
Social Security Act, the product of— 
(A) the per-unit average sales price (as defined in 
section 1847A(c) of the Social Security Act) or the per- 
unit Part B payment rate for a separately paid branded 
prescription drug without a reported average sales price, 
and 
(B) the number of units of the branded prescription 
drug paid for under the Medicare Part B program. 
Applicability. 
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124 STAT. 862 
PUBLIC LAW 111–148—MAR. 23, 2010 
The Centers for Medicare and Medicaid Services shall establish 
a process for determining the units and the allocated price 
for purposes of this section for those branded prescription drugs 
that are not separately payable or for which National Drug 
Codes are not reported. 
(3) MEDICAID
PROGRAM.—The Secretary of Health and 
Human Services shall report, for each covered entity and for 
each branded prescription drug of the covered entity covered 
under the Medicaid program, the product of— 
(A) the per-unit ingredient cost paid to pharmacies 
by States for the branded prescription drug dispensed to 
Medicaid beneficiaries, minus any per-unit rebate paid by 
the covered entity under section 1927 of the Social Security 
Act and any State supplemental rebate, and 
(B) the number of units of the branded prescription 
drug paid for under the Medicaid program. 
(4) DEPARTMENT
OF
VETERANS
AFFAIRS
PROGRAMS.—The 
Secretary of Veterans Affairs shall report, for each covered 
entity and for each branded prescription drug of the covered 
entity the total amount paid for each such branded prescription 
drug procured by the Department of Veterans Affairs for its 
beneficiaries. 
(5) DEPARTMENT OF DEFENSE PROGRAMS AND TRICARE.— 
The Secretary of Defense shall report, for each covered entity 
and for each branded prescription drug of the covered entity, 
the sum of— 
(A) the total amount paid for each such branded 
prescription drug procured by the Department of Defense 
for its beneficiaries, and 
(B) for each such branded prescription drug dispensed 
under the TRICARE retail pharmacy program, the product 
of— 
(i) the per-unit ingredient cost, minus any per- 
unit rebate paid by the covered entity, and 
(ii) the number of units of the branded prescription 
drug dispensed under such program. 
(h) SECRETARY.—For purposes of this section, the term ‘‘Sec-
retary’’ includes the Secretary’s delegate. 
(i) GUIDANCE.—The Secretary of the Treasury shall publish 
guidance necessary to carry out the purposes of this section. 
(j) APPLICATION OF SECTION.—This section shall apply to any 
branded prescription drug sales after December 31, 2008. 
(k) CONFORMING AMENDMENT.—Section 1841(a) of the Social 
Security Act is amended by inserting ‘‘or section 9008(c) of the 
Patient Protection and Affordable Care Act of 2009’’ after ‘‘this 
part’’. 
SEC. 9009. IMPOSITION OF ANNUAL FEE ON MEDICAL DEVICE MANU-
FACTURERS AND IMPORTERS. 
(a) IMPOSITION OF FEE.— 
(1) IN GENERAL.—Each covered entity engaged in the busi-
ness of manufacturing or importing medical devices shall pay 
to the Secretary not later than the annual payment date of 
each calendar year beginning after 2009 a fee in an amount 
determined under subsection (b). 
(2) ANNUAL PAYMENT DATE.—For purposes of this section, 
the term ‘‘annual payment date’’ means with respect to any 
Deadlines. 
26 USC 4001 
note prec. 
Definitions. 
42 USC 1395t. 
Publication. 
Process. 
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124 STAT. 863 
PUBLIC LAW 111–148—MAR. 23, 2010 
calendar year the date determined by the Secretary, but in 
no event later than September 30 of such calendar year. 
(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 $2,000,000,000 
as— 
(A) the covered entity’s gross receipts from medical 
device sales taken into account during the preceding cal-
endar year, bear to 
(B) the aggregate gross receipts of all covered entities 
from medical device sales taken into account during such 
preceding calendar year. 
(2) GROSS RECEIPTS FROM SALES TAKEN INTO ACCOUNT.— 
For purposes of paragraph (1), the gross receipts from medical 
device sales 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 aggregate 
gross receipts from medical device sales dur-
ing the calendar year that are: 
The percentage of 
gross receipts taken 
into account is: 
Not more than $5,000,000 .......................
0 percent 
More than $5,000,000 but not more than 
$25,000,000.
50 percent 
More than $25,000,000 .............................
100 percent. 
(3) SECRETARIAL DETERMINATION.—The Secretary shall cal-
culate the amount of each covered entity’s fee for any calendar 
year under paragraph (1). In calculating such amount, the 
Secretary shall determine such covered entity’s gross receipts 
from medical device sales on the basis of reports submitted 
by the covered entity under subsection (f) and through the 
use of any other source of information available to the Sec-
retary. 
(c) COVERED ENTITY.— 
(1) IN GENERAL.—For purposes of this section, the term 
‘‘covered entity’’ means any manufacturer or importer with 
gross receipts from medical device sales. 
(2) CONTROLLED GROUPS.— 
(A) IN GENERAL.—For purposes of this subsection, all 
persons treated as a single employer under subsection (a) 
or (b) of section 52 of the Internal Revenue Code of 1986 
or subsection (m) or (o) of section 414 of such Code shall 
be treated as a single covered entity. 
(B) INCLUSION OF FOREIGN CORPORATIONS.—For pur-
poses of subparagraph (A), in applying subsections (a) and 
(b) of section 52 of such Code to this section, section 1563 
of such Code shall be applied without regard to subsection 
(b)(2)(C) thereof. 
(d) MEDICAL DEVICE SALES.—For purposes of this section— 
(1) IN GENERAL.—The term ‘‘medical device sales’’ means 
sales for use in the United States of any medical device, other 
than the sales of a medical device that— 
(A) has been classified in class II under section 513 
of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 
Applicability. 
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124 STAT. 864 
PUBLIC LAW 111–148—MAR. 23, 2010 
360c) and is primarily sold to consumers at retail for not 
more than $100 per unit, or 
(B) has been classified in class I under such section. 
(2) UNITED STATES.—For purposes of paragraph (1), the 
term ‘‘United States’’ means the several States, the District 
of Columbia, the Commonwealth of Puerto Rico, and the posses-
sions of the United States. 
(3) MEDICAL DEVICE.—For purposes of paragraph (1), the 
term ‘‘medical device’’ means any device (as defined in section 
201(h) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 
321(h))) intended for humans. 
(e) TAX TREATMENT OF FEES.—The fees imposed by this sec-
tion— 
(1) for purposes of subtitle F of the Internal Revenue Code 
of 1986, shall be treated as excise taxes with respect to which 
only civil actions for refund under procedures of such subtitle 
shall apply, and 
(2) for purposes of section 275 of such Code, shall be consid-
ered to be a tax described in section 275(a)(6). 
(f) REPORTING REQUIREMENT.— 
(1) IN GENERAL.—Not later than the date determined by 
the Secretary following the end of any calendar year, each 
covered entity shall report to the Secretary, in such manner 
as the Secretary prescribes, the gross receipts from medical 
device sales of such covered entity during such calendar year. 
(2) PENALTY FOR FAILURE TO REPORT.— 
(A) IN GENERAL.—In the case of any failure to make 
a report containing the information required by paragraph 
(1) on the date prescribed therefor (determined with regard 
to any extension of time for filing), unless it is shown 
that such failure is due to reasonable cause, there shall 
be paid by the covered entity failing to file such report, 
an amount equal to— 
(i) $10,000, plus 
(ii) the lesser of— 
(I) an amount equal to $1,000, multiplied by 
the number of days during which such failure con-
tinues, or 
(II) the amount of the fee imposed by this 
section for which such report was required. 
(B) TREATMENT
OF
PENALTY.—The penalty imposed 
under subparagraph (A)— 
(i) shall be treated as a penalty for purposes of 
subtitle F of the Internal Revenue Code of 1986, 
(ii) shall be paid on notice and demand by the 
Secretary and in the same manner as tax under such 
Code, and 
(iii) with respect to which only civil actions for 
refund under procedures of such subtitle F shall apply. 
(g) SECRETARY.—For purposes of this section, the term ‘‘Sec-
retary’’ means the Secretary of the Treasury or the Secretary’s 
delegate. 
(h) GUIDANCE.—The Secretary shall publish guidance necessary 
to carry out the purposes of this section, including identification 
of medical devices described in subsection (d)(1)(A) and with respect 
to the treatment of gross receipts from sales of medical devices 
Publication. 
Applicability. 
Notice. 
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124 STAT. 865 
PUBLIC LAW 111–148—MAR. 23, 2010 
to another covered entity or to another entity by reason of the 
application of subsection (c)(2). 
(i) APPLICATION OF SECTION.—This section shall apply to any 
medical device sales after December 31, 2008. 
SEC. 9010. IMPOSITION OF ANNUAL FEE ON HEALTH INSURANCE PRO-
VIDERS. 
(a) IMPOSITION OF FEE.— 
(1) IN GENERAL.—Each covered entity engaged in the busi-
ness of providing health insurance shall pay to the Secretary 
not later than the annual payment date of each calendar year 
beginning after 2009 a fee in an amount determined under 
subsection (b). 
(2) ANNUAL PAYMENT DATE.—For purposes of this section, 
the term ‘‘annual payment date’’ means with respect to any 
calendar year the date determined by the Secretary, but in 
no event later than September 30 of such calendar year. 
(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 $6,700,000,000 
as— 
(A) the sum of— 
(i) the covered entity’s net premiums written with 
respect to health insurance for any United States 
health risk that are taken into account during the 
preceding calendar year, plus 
(ii) 200 percent of the covered entity’s third party 
administration agreement fees that are taken into 
account during the preceding calendar year, bears to 
(B) the sum of— 
(i) the aggregate net premiums written with 
respect to such health insurance of all covered entities 
that are taken into account during such preceding cal-
endar year, plus 
(ii) 200 percent of the aggregate third party 
administration agreement fees of all covered entities 
that are taken into account during such preceding cal-
endar year. 
(2) AMOUNTS TAKEN INTO ACCOUNT.—For purposes of para-
graph (1)— 
(A) NET PREMIUMS WRITTEN.—The net premiums writ-
ten 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 pre-
miums written during the calendar year that 
are: 
The percentage of 
net premiums writ-
ten 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. 
Definition. 
Deadline. 
26 USC 4001 
note prec. 
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124 STAT. 866 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) THIRD PARTY ADMINISTRATION AGREEMENT FEES.— 
The third party administration agreement fees 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 third party 
administration agreement fees during the 
calendar year that are: 
The percentage of 
third party admin-
istration agreement 
fees that are taken 
into account is: 
Not more than $5,000,000 .......................
0 percent 
More than $5,000,000 but not more than 
$10,000,000.
50 percent 
More than $10,000,000 .............................
100 percent. 
(3) SECRETARIAL DETERMINATION.—The Secretary shall cal-
culate the amount of each covered entity’s fee for any calendar 
year under paragraph (1). In calculating such amount, the 
Secretary shall determine such covered entity’s net premiums 
written with respect to any United States health risk and 
third party administration agreement fees on the basis of 
reports submitted by the covered entity under subsection (g) 
and through the use of any other source of information available 
to the Secretary. 
(c) COVERED ENTITY.— 
(1) IN GENERAL.—For purposes of this section, the term 
‘‘covered entity’’ means any entity which provides health insur-
ance for any United States health risk. 
(2) EXCLUSION.—Such term does not include— 
(A) any employer to the extent that such employer 
self-insures its employees’ health risks, or 
(B) any governmental entity (except to the extent such 
an entity provides health insurance coverage through the 
community health insurance option under section 1323). 
(3) CONTROLLED GROUPS.— 
(A) IN GENERAL.—For purposes of this subsection, all 
persons treated as a single employer under subsection (a) 
or (b) of section 52 of the Internal Revenue Code of 1986 
or subsection (m) or (o) of section 414 of such Code shall 
be treated as a single covered entity (or employer for pur-
poses of paragraph (2)). 
(B) INCLUSION OF FOREIGN CORPORATIONS.—For pur-
poses of subparagraph (A), in applying subsections (a) and 
(b) of section 52 of such Code to this section, section 1563 
of such Code shall be applied without regard to subsection 
(b)(2)(C) thereof. 
(d) UNITED STATES HEALTH RISK.—For purposes of this section, 
the term ‘‘United States health risk’’ means the health risk of 
any individual who is— 
(1) a United States citizen, 
(2) a resident of the United States (within the meaning 
of section 7701(b)(1)(A) of the Internal Revenue Code of 1986), 
or 
(3) located in the United States, with respect to the period 
such individual is so located. 
Definition. 
Applicability. 
Definition. 
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124 STAT. 867 
PUBLIC LAW 111–148—MAR. 23, 2010 
(e) THIRD PARTY ADMINISTRATION AGREEMENT FEES.—For pur-
poses of this section, the term ‘‘third party administration agree-
ment fees’’ means, with respect to any covered entity, amounts 
received from an employer which are in excess of payments made 
by such covered entity for health benefits under an arrangement 
under which such employer self-insures the United States health 
risk of its employees. 
(f) TAX TREATMENT OF FEES.—The fees imposed by this sec-
tion— 
(1) for purposes of subtitle F of the Internal Revenue Code 
of 1986, shall be treated as excise taxes with respect to which 
only civil actions for refund under procedures of such subtitle 
shall apply, and 
(2) for purposes of section 275 of such Code shall be consid-
ered to be a tax described in section 275(a)(6). 
(g) REPORTING REQUIREMENT.— 
(1) IN GENERAL.—Not later than the date determined by 
the Secretary following the end of any calendar year, each 
covered entity shall report to the Secretary, in such manner 
as the Secretary prescribes, the covered entity’s net premiums 
written with respect to health insurance for any United States 
health risk and third party administration agreement fees for 
such calendar year. 
(2) PENALTY FOR FAILURE TO REPORT.— 
(A) IN GENERAL.—In the case of any failure to make 
a report containing the information required by paragraph 
(1) on the date prescribed therefor (determined with regard 
to any extension of time for filing), unless it is shown 
that such failure is due to reasonable cause, there shall 
be paid by the covered entity failing to file such report, 
an amount equal to— 
(i) $10,000, plus 
(ii) the lesser of— 
(I) an amount equal to $1,000, multiplied by 
the number of days during which such failure con-
tinues, or 
(II) the amount of the fee imposed by this 
section for which such report was required. 
(B) TREATMENT
OF
PENALTY.—The penalty imposed 
under subparagraph (A)— 
(i) shall be treated as a penalty for purposes of 
subtitle F of the Internal Revenue Code of 1986, 
(ii) shall be paid on notice and demand by the 
Secretary and in the same manner as tax under such 
Code, and 
(iii) with respect to which only civil actions for 
refund under procedures of such subtitle F shall apply. 
(h) ADDITIONAL DEFINITIONS.—For purposes of this section— 
(1) SECRETARY.—The term ‘‘Secretary’’ means the Secretary 
of the Treasury or the Secretary’s delegate. 
(2) UNITED STATES.—The term ‘‘United States’’ means the 
several States, the District of Columbia, the Commonwealth 
of Puerto Rico, and the possessions of the United States. 
(3) HEALTH INSURANCE.—The term ‘‘health insurance’’ shall 
not include insurance for long-term care or disability. 
(i) GUIDANCE.—The Secretary shall publish guidance necessary 
to carry out the purposes of this section. 
Publication. 
Notice. 
Applicability. 
Definition. 
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124 STAT. 868 
PUBLIC LAW 111–148—MAR. 23, 2010 
(j) APPLICATION OF SECTION.—This section shall apply to any 
net premiums written after December 31, 2008, with respect to 
health insurance for any United States health risk, and any third 
party administration agreement fees received after such date. 
SEC. 9011. STUDY AND REPORT OF EFFECT ON VETERANS HEALTH 
CARE. 
(a) IN GENERAL.—The Secretary of Veterans Affairs shall con-
duct a study on the effect (if any) of the provisions of sections 
9008, 9009, and 9010 on— 
(1) the cost of medical care provided to veterans, and 
(2) veterans’ access to medical devices and branded 
prescription drugs. 
(b) REPORT.—The Secretary of Veterans Affairs shall report 
the results of the study under subsection (a) to the Committee 
on Ways and Means of the House of Representatives and to the 
Committee on Finance of the Senate not later than December 
31, 2012. 
SEC. 9012. ELIMINATION OF DEDUCTION FOR EXPENSES ALLOCABLE 
TO MEDICARE PART D SUBSIDY. 
(a) IN GENERAL.—Section 139A of the Internal Revenue Code 
of 1986 is amended by striking the second sentence. 
(b) EFFECTIVE DATE.—The amendment made by this section 
shall apply to taxable years beginning after December 31, 2010. 
SEC. 9013. MODIFICATION OF ITEMIZED DEDUCTION FOR MEDICAL 
EXPENSES. 
(a) IN GENERAL.—Subsection (a) of section 213 of the Internal 
Revenue Code of 1986 is amended by striking ‘‘7.5 percent’’ and 
inserting ‘‘10 percent’’. 
(b) TEMPORARY WAIVER OF INCREASE FOR CERTAIN SENIORS.— 
Section 213 of the Internal Revenue Code of 1986 is amended 
by adding at the end the following new subsection: 
‘‘(f) SPECIAL RULE FOR 2013, 2014, 2015, AND 2016.—In the 
case of any taxable year beginning after December 31, 2012, and 
ending before January 1, 2017, subsection (a) shall be applied 
with respect to a taxpayer by substituting ‘7.5 percent’ for ‘10 
percent’ if such taxpayer or such taxpayer’s spouse has attained 
age 65 before the close of such taxable year.’’. 
(c) CONFORMING
AMENDMENT.—Section 56(b)(1)(B) of the 
Internal Revenue Code of 1986 is amended by striking ‘‘by sub-
stituting ‘10 percent’ for ‘7.5 percent’ ’’ and inserting ‘‘without regard 
to subsection (f) of such section’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall apply to taxable years beginning after December 31, 2012. 
SEC. 9014. LIMITATION ON EXCESSIVE REMUNERATION PAID BY CER-
TAIN HEALTH INSURANCE PROVIDERS. 
(a) IN GENERAL.—Section 162(m) of the Internal Revenue Code 
of 1986 is amended by adding at the end the following new subpara-
graph: 
‘‘(6) SPECIAL RULE FOR APPLICATION TO CERTAIN HEALTH 
INSURANCE PROVIDERS.— 
‘‘(A) IN GENERAL.—No deduction shall be allowed under 
this chapter— 
Definitions. 
26 USC 162. 
26 USC 56 note. 
26 USC 56. 
Time period. 
Applicability. 
26 USC 213. 
26 USC 139A 
note. 
26 USC 139A. 
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124 STAT. 869 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) in the case of applicable individual remunera-
tion which is for any disqualified taxable year begin-
ning after December 31, 2012, and which is attrib-
utable to services performed by an applicable indi-
vidual during such taxable year, to the extent that 
the amount of such remuneration exceeds $500,000, 
or 
‘‘(ii) in the case of deferred deduction remuneration 
for any taxable year beginning after December 31, 
2012, which is attributable to services performed by 
an applicable individual during any disqualified tax-
able year beginning after December 31, 2009, to the 
extent that the amount of such remuneration exceeds 
$500,000 reduced (but not below zero) by the sum 
of— 
‘‘(I) the applicable individual remuneration for 
such disqualified taxable year, plus 
‘‘(II) the portion of the deferred deduction 
remuneration for such services which was taken 
into account under this clause in a preceding tax-
able year (or which would have been taken into 
account under this clause in a preceding taxable 
year if this clause were applied by substituting 
‘December 31, 2009’ for ‘December 31, 2012’ in 
the matter preceding subclause (I)). 
‘‘(B) DISQUALIFIED TAXABLE YEAR.—For purposes of this 
paragraph, the term ‘disqualified taxable year’ means, with 
respect to any employer, any taxable year for which such 
employer is a covered health insurance provider. 
‘‘(C) COVERED HEALTH INSURANCE PROVIDER.—For pur-
poses of this paragraph— 
‘‘(i) IN GENERAL.—The term ‘covered health insur-
ance provider’ means— 
‘‘(I) with respect to taxable years beginning 
after December 31, 2009, and before January 1, 
2013, any employer which is a health insurance 
issuer (as defined in section 9832(b)(2)) and which 
receives premiums from providing health insur-
ance coverage (as defined in section 9832(b)(1)), 
and 
‘‘(II) with respect to taxable years beginning 
after December 31, 2012, any employer which is 
a health insurance issuer (as defined in section 
9832(b)(2)) and with respect to which not less than 
25 percent of the gross premiums received from 
providing health insurance coverage (as defined 
in section 9832(b)(1)) is from minimum essential 
coverage (as defined in section 5000A(f)). 
‘‘(ii) AGGREGATION RULES.—Two or more persons 
who are treated as a single employer under subsection 
(b), (c), (m), or (o) of section 414 shall be treated 
as a single employer, except that in applying section 
1563(a) for purposes of any such subsection, para-
graphs (2) and (3) thereof shall be disregarded. 
‘‘(D) APPLICABLE INDIVIDUAL REMUNERATION.—For pur-
poses of this paragraph, the term ‘applicable individual 
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124 STAT. 870 
PUBLIC LAW 111–148—MAR. 23, 2010 
remuneration’ means, with respect to any applicable indi-
vidual for any disqualified taxable year, the aggregate 
amount allowable as a deduction under this chapter for 
such taxable year (determined without regard to this sub-
section) for remuneration (as defined in paragraph (4) with-
out regard to subparagraphs (B), (C), and (D) thereof) for 
services performed by such individual (whether or not 
during the taxable year). Such term shall not include any 
deferred deduction remuneration with respect to services 
performed during the disqualified taxable year. 
‘‘(E) DEFERRED DEDUCTION REMUNERATION.—For pur-
poses of this paragraph, the term ‘deferred deduction remu-
neration’ means remuneration which would be applicable 
individual remuneration for services performed in a dis-
qualified taxable year but for the fact that the deduction 
under this chapter (determined without regard to this para-
graph) for such remuneration is allowable in a subsequent 
taxable year. 
‘‘(F) APPLICABLE
INDIVIDUAL.—For purposes of this 
paragraph, the term ‘applicable individual’ means, with 
respect to any covered health insurance provider for any 
disqualified taxable year, any individual— 
‘‘(i) who is an officer, director, or employee in such 
taxable year, or 
‘‘(ii) who provides services for or on behalf of such 
covered health insurance provider during such taxable 
year. 
‘‘(G) COORDINATION.—Rules similar to the rules of sub-
paragraphs (F) and (G) of paragraph (4) shall apply for 
purposes of this paragraph. 
‘‘(H) REGULATORY AUTHORITY.—The Secretary may pre-
scribe such guidance, rules, or regulations as are necessary 
to carry out the purposes of this paragraph.’’. 
(b) EFFECTIVE DATE.—The amendment made by this section 
shall apply to taxable years beginning after December 31, 2009, 
with respect to services performed after such date. 
SEC. 9015. ADDITIONAL HOSPITAL INSURANCE TAX ON HIGH-INCOME 
TAXPAYERS. 
(a) FICA.— 
(1) IN GENERAL.—Section 3101(b) of the Internal Revenue 
Code of 1986 is amended— 
(A) by striking ‘‘In addition’’ and inserting the fol-
lowing: 
‘‘(1) IN GENERAL.—In addition’’, 
(B) by striking ‘‘the following percentages of the’’ and 
inserting ‘‘1.45 percent of the’’, 
(C) by striking ‘‘(as defined in section 3121(b))—’’ and 
all that follows and inserting ‘‘(as defined in section 
3121(b)).’’, and 
(D) by adding at the end the following new paragraph: 
‘‘(2) ADDITIONAL TAX.—In addition to the tax imposed by 
paragraph (1) and the preceding subsection, there is hereby 
imposed on every taxpayer (other than a corporation, estate, 
or trust) a tax equal to 0.5 percent of wages which are received 
with respect to employment (as defined in section 3121(b)) 
26 USC 3101. 
26 USC 162 note. 
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124 STAT. 871 
PUBLIC LAW 111–148—MAR. 23, 2010 
during any taxable year beginning after December 31, 2012, 
and which are in excess of— 
‘‘(A) in the case of a joint return, $250,000, and 
‘‘(B) in any other case, $200,000.’’. 
(2) COLLECTION OF TAX.—Section 3102 of the Internal Rev-
enue Code of 1986 is amended by adding at the end the fol-
lowing new subsection: 
‘‘(f) SPECIAL RULES FOR ADDITIONAL TAX.— 
‘‘(1) IN GENERAL.—In the case of any tax imposed by section 
3101(b)(2), subsection (a) shall only apply to the extent to 
which the taxpayer receives wages from the employer in excess 
of $200,000, and the employer may disregard the amount of 
wages received by such taxpayer’s spouse. 
‘‘(2) COLLECTION
OF
AMOUNTS
NOT
WITHHELD.—To the 
extent that the amount of any tax imposed by section 3101(b)(2) 
is not collected by the employer, such tax shall be paid by 
the employee. 
‘‘(3) TAX PAID BY RECIPIENT.—If an employer, in violation 
of this chapter, fails to deduct and withhold the tax imposed 
by section 3101(b)(2) and thereafter the tax is paid by the 
employee, the tax so required to be deducted and withheld 
shall not be collected from the employer, but this paragraph 
shall in no case relieve the employer from liability for any 
penalties or additions to tax otherwise applicable in respect 
of such failure to deduct and withhold.’’. 
(b) SECA.— 
(1) IN GENERAL.—Section 1401(b) of the Internal Revenue 
Code of 1986 is amended— 
(A) by striking ‘‘In addition’’ and inserting the fol-
lowing: 
‘‘(1) IN GENERAL.—In addition’’, and 
(B) by adding at the end the following new paragraph: 
‘‘(2) ADDITIONAL TAX.— 
‘‘(A) IN GENERAL.—In addition to the tax imposed by 
paragraph (1) and the preceding subsection, there is hereby 
imposed on every taxpayer (other than a corporation, 
estate, or trust) for each taxable year beginning after 
December 31, 2012, a tax equal to 0.5 percent of the self- 
employment income for such taxable year which is in excess 
of— 
‘‘(i) in the case of a joint return, $250,000, and 
‘‘(ii) in any other case, $200,000. 
‘‘(B) COORDINATION WITH FICA.—The amounts under 
clauses (i) and (ii) of subparagraph (A) shall be reduced 
(but not below zero) by the amount of wages taken into 
account in determining the tax imposed under section 
3121(b)(2) with respect to the taxpayer.’’. 
(2) NO DEDUCTION FOR ADDITIONAL TAX.— 
(A) IN
GENERAL.—Section 164(f) of such Code is 
amended by inserting ‘‘(other than the taxes imposed by 
section 1401(b)(2))’’ after ‘‘section 1401)’’. 
(B) DEDUCTION FOR NET EARNINGS FROM SELF-EMPLOY-
MENT.—Subparagraph (B) of section 1402(a)(12) is amended 
by inserting ‘‘(determined without regard to the rate 
imposed under paragraph (2) of section 1401(b))’’ after ‘‘for 
such year’’. 
26 USC 1402. 
26 USC 1401. 
26 USC 3102. 
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124 STAT. 872 
PUBLIC LAW 111–148—MAR. 23, 2010 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply with respect to remuneration received, and taxable 
years beginning, after December 31, 2012. 
SEC. 9016. MODIFICATION OF SECTION 833 TREATMENT OF CERTAIN 
HEALTH ORGANIZATIONS. 
(a) IN GENERAL.—Subsection (c) of section 833 of the Internal 
Revenue Code of 1986 is amended by adding at the end the following 
new paragraph: 
‘‘(5) NONAPPLICATION OF SECTION IN CASE OF LOW MEDICAL 
LOSS RATIO.—Notwithstanding the preceding paragraphs, this 
section shall not apply to any organization unless such 
organization’s percentage of total premium revenue expended 
on reimbursement for clinical services provided to enrollees 
under its policies during such taxable year (as reported under 
section 2718 of the Public Health Service Act) is not less than 
85 percent.’’. 
(b) EFFECTIVE DATE.—The amendment made by this section 
shall apply to taxable years beginning after December 31, 2009. 
SEC. 9017. EXCISE TAX ON ELECTIVE COSMETIC MEDICAL PROCE-
DURES. 
(a) IN GENERAL.—Subtitle D of the Internal Revenue Code 
of 1986, as amended by this Act, is amended by adding at the 
end the following new chapter: 
‘‘CHAPTER 49—ELECTIVE COSMETIC MEDICAL 
PROCEDURES 
‘‘Sec. 5000B. Imposition of tax on elective cosmetic medical procedures. 
‘‘SEC. 5000B. IMPOSITION OF TAX ON ELECTIVE COSMETIC MEDICAL 
PROCEDURES. 
‘‘(a) IN GENERAL.—There is hereby imposed on any cosmetic 
surgery and medical procedure a tax equal to 5 percent of the 
amount paid for such procedure (determined without regard to 
this section), whether paid by insurance or otherwise. 
‘‘(b) COSMETIC SURGERY AND MEDICAL PROCEDURE.—For pur-
poses of this section, the term ‘cosmetic surgery and medical proce-
dure’ means any cosmetic surgery (as defined in section 213(d)(9)(B)) 
or other similar procedure which— 
‘‘(1) is performed by a licensed medical professional, and 
‘‘(2) is not necessary to ameliorate a deformity arising 
from, or directly related to, a congenital abnormality, a personal 
injury resulting from an accident or trauma, or disfiguring 
disease. 
‘‘(c) PAYMENT OF TAX.— 
‘‘(1) IN GENERAL.—The tax imposed by this section shall 
be paid by the individual on whom the procedure is performed. 
‘‘(2) COLLECTION.—Every person receiving a payment for 
procedures on which a tax is imposed under subsection (a) 
shall collect the amount of the tax from the individual on 
whom the procedure 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 imposed by sub-
section (a) is not paid at the time payments for cosmetic surgery 
and medical procedures are made, then to the extent that 
26 USC 5000B. 
26 USC 853 note. 
26 USC 833. 
26 USC 164 note. 
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124 STAT. 873 
PUBLIC LAW 111–148—MAR. 23, 2010 
such tax is not collected, such tax shall be paid by the person 
who performs the procedure.’’. 
(b) CLERICAL AMENDMENT.—The table of chapters 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—ELECTIVE COSMETIC MEDICAL PROCEDURES’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to procedures performed on or after January 1, 2010. 
Subtitle B—Other Provisions 
SEC. 9021. EXCLUSION OF HEALTH BENEFITS PROVIDED BY INDIAN 
TRIBAL GOVERNMENTS. 
(a) 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. INDIAN HEALTH CARE BENEFITS. 
‘‘(a) GENERAL RULE.—Except as otherwise provided in this sec-
tion, gross income does not include the value of any qualified 
Indian health care benefit. 
‘‘(b) QUALIFIED INDIAN HEALTH CARE BENEFIT.—For purposes 
of this section, the term ‘qualified Indian health care benefit’ 
means— 
‘‘(1) any health service or benefit provided or purchased, 
directly or indirectly, by the Indian Health Service through 
a grant to or a contract or compact with an Indian tribe or 
tribal organization, or through a third-party program funded 
by the Indian Health Service, 
‘‘(2) medical care provided or purchased by, or amounts 
to reimburse for such medical care provided by, an Indian 
tribe or tribal organization for, or to, a member of an Indian 
tribe, including a spouse or dependent of such a member, 
‘‘(3) coverage under accident or health insurance (or an 
arrangement having the effect of accident or health insurance), 
or an accident or health plan, provided by an Indian tribe 
or tribal organization for medical care to a member of an 
Indian tribe, include a spouse or dependent of such a member, 
and 
‘‘(4) any other medical care provided by an Indian tribe 
or tribal organization that supplements, replaces, or substitutes 
for a program or service relating to medical care provided 
by the Federal government to Indian tribes or members of 
such a tribe. 
‘‘(c) DEFINITIONS.—For purposes of this section— 
‘‘(1) INDIAN TRIBE.—The term ‘Indian tribe’ has the meaning 
given such term by section 45A(c)(6). 
‘‘(2) TRIBAL ORGANIZATION.—The term ‘tribal organization’ 
has the meaning given such term by section 4(l) of the Indian 
Self-Determination and Education Assistance Act. 
‘‘(3) MEDICAL CARE.—The term ‘medical care’ has the same 
meaning as when used in section 213. 
‘‘(4) ACCIDENT OR HEALTH INSURANCE; ACCIDENT OR HEALTH 
PLAN.—The terms ‘accident or health insurance’ and ‘accident 
Definition. 
26 USC 139D. 
26 USC 5000B 
note. 
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124 STAT. 874 
PUBLIC LAW 111–148—MAR. 23, 2010 
or health plan’ have the same meaning as when used in section 
105. 
‘‘(5) DEPENDENT.—The term ‘dependent’ has the meaning 
given such term by section 152, determined without regard 
to subsections (b)(1), (b)(2), and (d)(1)(B) thereof. 
‘‘(d) DENIAL
OF DOUBLE BENEFIT.—Subsection (a) shall not 
apply to the amount of any qualified Indian health care benefit 
which is not includible in gross income of the beneficiary of such 
benefit under any other provision of this chapter, or to the amount 
of any such benefit for which a deduction is allowed to such bene-
ficiary under any other provision of this chapter.’’. 
(b) CLERICAL AMENDMENT.—The table of sections for part III 
of subchapter B of chapter 1 of the Internal Revenue Code of 
1986 is amended by inserting after the item relating to section 
139C the following new item: 
‘‘Sec. 139D. Indian health care benefits.’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to benefits and coverage provided after the date of 
the enactment of this Act. 
(d) NO INFERENCE.—Nothing in the amendments made by this 
section shall be construed to create an inference with respect to 
the exclusion from gross income of— 
(1) benefits provided by an Indian tribe or tribal organiza-
tion that are not within the scope of this section, and 
(2) benefits provided prior to the date of the enactment 
of this Act. 
SEC. 9022. ESTABLISHMENT OF SIMPLE CAFETERIA PLANS FOR SMALL 
BUSINESSES. 
(a) IN GENERAL.—Section 125 of the Internal Revenue Code 
of 1986 (relating to cafeteria plans), as amended by this Act, is 
amended by redesignating subsections (j) and (k) as subsections 
(k) and (l), respectively, and by inserting after subsection (i) the 
following new subsection: 
‘‘(j) SIMPLE CAFETERIA PLANS FOR SMALL BUSINESSES.— 
‘‘(1) IN
GENERAL.—An eligible employer maintaining a 
simple cafeteria plan with respect to which the requirements 
of this subsection are met for any year shall be treated as 
meeting any applicable nondiscrimination requirement during 
such year. 
‘‘(2) SIMPLE CAFETERIA PLAN.—For purposes of this sub-
section, the term ‘simple cafeteria plan’ means a cafeteria 
plan— 
‘‘(A) which is established and maintained by an eligible 
employer, and 
‘‘(B) with respect to which the contribution require-
ments of paragraph (3), and the eligibility and participation 
requirements of paragraph (4), are met. 
‘‘(3) CONTRIBUTION REQUIREMENTS.— 
‘‘(A) IN GENERAL.—The requirements of this paragraph 
are met if, under the plan the employer is required, without 
regard to whether a qualified employee makes any salary 
reduction contribution, to make a contribution to provide 
qualified benefits under the plan on behalf of each qualified 
employee in an amount equal to— 
‘‘(i) a uniform percentage (not less than 2 percent) 
of the employee’s compensation for the plan year, or 
26 USC 125. 
26 USC 139D 
note. 
26 USC 139D 
note. 
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124 STAT. 875 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(ii) an amount which is not less than the lesser 
of— 
‘‘(I) 6 percent of the employee’s compensation 
for the plan year, or 
‘‘(II) twice the amount of the salary reduction 
contributions of each qualified employee. 
‘‘(B) MATCHING CONTRIBUTIONS ON BEHALF OF HIGHLY 
COMPENSATED AND KEY EMPLOYEES.—The requirements of 
subparagraph (A)(ii) shall not be treated as met if, under 
the plan, the rate of contributions with respect to any 
salary reduction contribution of a highly compensated or 
key employee at any rate of contribution is greater than 
that with respect to an employee who is not a highly 
compensated or key employee. 
‘‘(C) ADDITIONAL CONTRIBUTIONS.—Subject to subpara-
graph (B), nothing in this paragraph shall be treated as 
prohibiting an employer from making contributions to pro-
vide qualified benefits under the plan in addition to con-
tributions required under subparagraph (A). 
‘‘(D) DEFINITIONS.—For purposes of this paragraph— 
‘‘(i) SALARY REDUCTION CONTRIBUTION.—The term 
‘salary reduction contribution’ means, with respect to 
a cafeteria plan, any amount which is contributed to 
the plan at the election of the employee and which 
is not includible in gross income by reason of this 
section. 
‘‘(ii) QUALIFIED
EMPLOYEE.—The term ‘qualified 
employee’ means, with respect to a cafeteria plan, any 
employee who is not a highly compensated or key 
employee and who is eligible to participate in the plan. 
‘‘(iii) HIGHLY COMPENSATED EMPLOYEE.—The term 
‘highly compensated employee’ has the meaning given 
such term by section 414(q). 
‘‘(iv) KEY EMPLOYEE.—The term ‘key employee’ has 
the meaning given such term by section 416(i). 
‘‘(4) MINIMUM
ELIGIBILITY
AND
PARTICIPATION
REQUIRE-
MENTS.— 
‘‘(A) IN GENERAL.—The requirements of this paragraph 
shall be treated as met with respect to any year if, under 
the plan— 
‘‘(i) all employees who had at least 1,000 hours 
of service for the preceding plan year are eligible to 
participate, and 
‘‘(ii) each employee eligible to participate in the 
plan may, subject to terms and conditions applicable 
to all participants, elect any benefit available under 
the plan. 
‘‘(B) CERTAIN EMPLOYEES MAY BE EXCLUDED.—For pur-
poses of subparagraph (A)(i), an employer may elect to 
exclude under the plan employees— 
‘‘(i) who have not attained the age of 21 before 
the close of a plan year, 
‘‘(ii) who have less than 1 year of service with 
the employer as of any day during the plan year, 
‘‘(iii) who are covered under an agreement which 
the Secretary of Labor finds to be a collective bar-
gaining agreement if there is evidence that the benefits 
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124 STAT. 876 
PUBLIC LAW 111–148—MAR. 23, 2010 
covered under the cafeteria plan were the subject of 
good faith bargaining between employee representa-
tives and the employer, or 
‘‘(iv) who are described in section 410(b)(3)(C) 
(relating to nonresident aliens working outside the 
United States). 
A plan may provide a shorter period of service or younger 
age for purposes of clause (i) or (ii). 
‘‘(5) ELIGIBLE EMPLOYER.—For purposes of this subsection— 
‘‘(A) IN GENERAL.—The term ‘eligible employer’ means, 
with respect to any year, any employer if such employer 
employed an average of 100 or fewer employees on business 
days during either of the 2 preceding years. For purposes 
of this subparagraph, a year may only be taken into account 
if the employer was in existence throughout the year. 
‘‘(B) EMPLOYERS NOT IN EXISTENCE DURING PRECEDING 
YEAR.—If an employer was not in existence throughout 
the preceding year, the determination under subparagraph 
(A) shall be based on the average number of employees 
that it is reasonably expected such employer will employ 
on business days in the current year. 
‘‘(C) GROWING EMPLOYERS RETAIN TREATMENT AS SMALL 
EMPLOYER.— 
‘‘(i) IN GENERAL.—If— 
‘‘(I) an employer was an eligible employer for 
any year (a ‘qualified year’), and 
‘‘(II) such employer establishes a simple cafe-
teria plan for its employees for such year, 
then, notwithstanding the fact the employer fails to 
meet the requirements of subparagraph (A) for any 
subsequent year, such employer shall be treated as 
an eligible employer for such subsequent year with 
respect to employees (whether or not employees during 
a qualified year) of any trade or business which was 
covered by the plan during any qualified year. 
‘‘(ii) EXCEPTION.—This subparagraph shall cease 
to apply if the employer employs an average of 200 
or more employees on business days during any year 
preceding any such subsequent year. 
‘‘(D) SPECIAL RULES.— 
‘‘(i) PREDECESSORS.—Any reference in this para-
graph to an employer shall include a reference to any 
predecessor of such employer. 
‘‘(ii) AGGREGATION RULES.—All persons treated as 
a single employer under subsection (a) or (b) of section 
52, or subsection (n) or (o) of section 414, shall be 
treated as one person. 
‘‘(6) APPLICABLE
NONDISCRIMINATION
REQUIREMENT.—For 
purposes of this subsection, the term ‘applicable nondiscrimina-
tion requirement’ means any requirement under subsection 
(b) of this section, section 79(d), section 105(h), or paragraph 
(2), (3), (4), or (8) of section 129(d). 
‘‘(7) COMPENSATION.—The term ‘compensation’ has the 
meaning given such term by section 414(s).’’. 
(b) EFFECTIVE DATE.—The amendments made by this section 
shall apply to years beginning after December 31, 2010. 
26 USC 125 note. 
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124 STAT. 877 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 9023. QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT. 
(a) IN GENERAL.—Subpart E of part IV of subchapter A of 
chapter 1 of the Internal Revenue Code of 1986 is amended by 
inserting after section 48C the following new section: 
‘‘SEC. 48D. QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT. 
‘‘(a) IN GENERAL.—For purposes of section 46, the qualifying 
therapeutic discovery project credit for any taxable year is an 
amount equal to 50 percent of the qualified investment for such 
taxable year with respect to any qualifying therapeutic discovery 
project of an eligible taxpayer. 
‘‘(b) QUALIFIED INVESTMENT.— 
‘‘(1) IN GENERAL.—For purposes of subsection (a), the quali-
fied investment for any taxable year is the aggregate amount 
of the costs paid or incurred in such taxable year for expenses 
necessary for and directly related to the conduct of a qualifying 
therapeutic discovery project. 
‘‘(2) LIMITATION.—The amount which is treated as qualified 
investment for all taxable years with respect to any qualifying 
therapeutic discovery project shall not exceed the amount cer-
tified by the Secretary as eligible for the credit under this 
section. 
‘‘(3) EXCLUSIONS.—The qualified investment for any taxable 
year with respect to any qualifying therapeutic discovery project 
shall not take into account any cost— 
‘‘(A) for remuneration for an employee described in 
section 162(m)(3), 
‘‘(B) for interest expenses, 
‘‘(C) for facility maintenance expenses, 
‘‘(D) which is identified as a service cost under section 
1.263A–1(e)(4) of title 26, Code of Federal Regulations, 
or 
‘‘(E) for any other expense as determined by the Sec-
retary as appropriate to carry out the purposes of this 
section. 
‘‘(4) 
CERTAIN
PROGRESS
EXPENDITURE
RULES
MADE 
APPLICABLE.—In the case of costs described in paragraph (1) 
that are paid for property of a character subject to an allowance 
for depreciation, rules similar to the rules of subsections (c)(4) 
and (d) of section 46 (as in effect on the day before the date 
of the enactment of the Revenue Reconciliation Act of 1990) 
shall apply for purposes of this section. 
‘‘(5) APPLICATION OF SUBSECTION.—An investment shall be 
considered a qualified investment under this subsection only 
if such investment is made in a taxable year beginning in 
2009 or 2010. 
‘‘(c) DEFINITIONS.— 
‘‘(1) QUALIFYING
THERAPEUTIC
DISCOVERY
PROJECT.—The 
term ‘qualifying therapeutic discovery project’ means a project 
which is designed— 
‘‘(A) to treat or prevent diseases or conditions by con-
ducting pre-clinical activities, clinical trials, and clinical 
studies, or carrying out research protocols, for the purpose 
of securing approval of a product under section 505(b) 
of the Federal Food, Drug, and Cosmetic Act or section 
351(a) of the Public Health Service Act, 
26 USC 48D. 
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124 STAT. 878 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) to diagnose diseases or conditions or to determine 
molecular factors related to diseases or conditions by devel-
oping molecular diagnostics to guide therapeutic decisions, 
or 
‘‘(C) to develop a product, process, or technology to 
further the delivery or administration of therapeutics. 
‘‘(2) ELIGIBLE TAXPAYER.— 
‘‘(A) IN GENERAL.—The term ‘eligible taxpayer’ means 
a taxpayer which employs not more than 250 employees 
in all businesses of the taxpayer at the time of the submis-
sion of the application under subsection (d)(2). 
‘‘(B) AGGREGATION RULES.—All persons treated as a 
single employer under subsection (a) or (b) of section 52, 
or subsection (m) or (o) of section 414, shall be so treated 
for purposes of this paragraph. 
‘‘(3) FACILITY MAINTENANCE EXPENSES.—The term ‘facility 
maintenance expenses’ means costs paid or incurred to main-
tain a facility, including— 
‘‘(A) mortgage or rent payments, 
‘‘(B) insurance payments, 
‘‘(C) utility and maintenance costs, and 
‘‘(D) costs of employment of maintenance personnel. 
‘‘(d) QUALIFYING THERAPEUTIC DISCOVERY PROJECT PROGRAM.— 
‘‘(1) ESTABLISHMENT.— 
‘‘(A) IN GENERAL.—Not later than 60 days after the 
date of the enactment of this section, the Secretary, in 
consultation with the Secretary of Health and Human Serv-
ices, shall establish a qualifying therapeutic discovery 
project program to consider and award certifications for 
qualified investments eligible for credits under this section 
to qualifying therapeutic discovery project sponsors. 
‘‘(B) LIMITATION.—The total amount of credits that may 
be 
allocated 
under 
the 
program 
shall 
not 
exceed 
$1,000,000,000 for the 2-year period beginning with 2009. 
‘‘(2) CERTIFICATION.— 
‘‘(A) APPLICATION PERIOD.—Each applicant for certifi-
cation under this paragraph shall submit an application 
containing such information as the Secretary may require 
during the period beginning on the date the Secretary 
establishes the program under paragraph (1). 
‘‘(B) TIME
FOR
REVIEW
OF
APPLICATIONS.—The Sec-
retary shall take action to approve or deny any application 
under subparagraph (A) within 30 days of the submission 
of such application. 
‘‘(C) MULTI-YEAR
APPLICATIONS.—An application for 
certification under subparagraph (A) may include a request 
for an allocation of credits for more than 1 of the years 
described in paragraph (1)(B). 
‘‘(3) SELECTION CRITERIA.—In determining the qualifying 
therapeutic discovery projects with respect to which qualified 
investments may be certified under this section, the Secretary— 
‘‘(A) shall take into consideration only those projects 
that show reasonable potential— 
‘‘(i) to result in new therapies— 
‘‘(I) to treat areas of unmet medical need, or 
‘‘(II) to prevent, detect, or treat chronic or 
acute diseases and conditions, 
Deadline. 
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124 STAT. 879 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(ii) to reduce long-term health care costs in the 
United States, or 
‘‘(iii) to significantly advance the goal of curing 
cancer within the 30-year period beginning on the date 
the Secretary establishes the program under paragraph 
(1), and 
‘‘(B) shall take into consideration which projects have 
the greatest potential— 
‘‘(i) to create and sustain (directly or indirectly) 
high quality, high-paying jobs in the United States, 
and 
‘‘(ii) to advance United States competitiveness in 
the fields of life, biological, and medical sciences. 
‘‘(4) DISCLOSURE
OF
ALLOCATIONS.—The Secretary shall, 
upon making a certification under this subsection, publicly 
disclose the identity of the applicant and the amount of the 
credit with respect to such applicant. 
‘‘(e) SPECIAL RULES.— 
‘‘(1) BASIS ADJUSTMENT.—For purposes of this subtitle, if 
a credit is allowed under this section for an expenditure related 
to property of a character subject to an allowance for deprecia-
tion, the basis of such property shall be reduced by the amount 
of such credit. 
‘‘(2) DENIAL OF DOUBLE BENEFIT.— 
‘‘(A) BONUS
DEPRECIATION.—A credit shall not be 
allowed under this section for any investment for which 
bonus depreciation is allowed under section 168(k), 
1400L(b)(1), or 1400N(d)(1). 
‘‘(B) DEDUCTIONS.—No deduction under this subtitle 
shall be allowed for the portion of the expenses otherwise 
allowable as a deduction taken into account in determining 
the credit under this section for the taxable year which 
is equal to the amount of the credit determined for such 
taxable year under subsection (a) attributable to such por-
tion. This subparagraph shall not apply to expenses related 
to property of a character subject to an allowance for depre-
ciation the basis of which is reduced under paragraph 
(1), or which are described in section 280C(g). 
‘‘(C) CREDIT FOR RESEARCH ACTIVITIES.— 
‘‘(i) IN
GENERAL.—Except as provided in clause 
(ii), any expenses taken into account under this section 
for a taxable year shall not be taken into account 
for purposes of determining the credit allowable under 
section 41 or 45C for such taxable year. 
‘‘(ii) EXPENSES
INCLUDED
IN
DETERMINING
BASE 
PERIOD
RESEARCH
EXPENSES.—Any expenses for any 
taxable year which are qualified research expenses 
(within the meaning of section 41(b)) shall be taken 
into account in determining base period research 
expenses for purposes of applying section 41 to subse-
quent taxable years. 
‘‘(f) COORDINATION WITH DEPARTMENT OF TREASURY GRANTS.— 
In the case of any investment with respect to which the Secretary 
makes a grant under section 9023(e) of the Patient Protection 
and Affordable Care Act of 2009— 
‘‘(1) DENIAL
OF
CREDIT.—No credit shall be determined 
under this section with respect to such investment for the 
Certification. 
Public 
information. 
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124 STAT. 880 
PUBLIC LAW 111–148—MAR. 23, 2010 
taxable year in which such grant is made or any subsequent 
taxable year. 
‘‘(2) RECAPTURE OF CREDITS FOR PROGRESS EXPENDITURES 
MADE BEFORE GRANT.—If a credit was determined under this 
section with respect to such investment for any taxable year 
ending before such grant is made— 
‘‘(A) the tax imposed under subtitle A on the taxpayer 
for the taxable year in which such grant is made shall 
be increased by so much of such credit as was allowed 
under section 38, 
‘‘(B) the general business carryforwards under section 
39 shall be adjusted so as to recapture the portion of 
such credit which was not so allowed, and 
‘‘(C) the amount of such grant shall be determined 
without regard to any reduction in the basis of any property 
of a character subject to an allowance for depreciation 
by reason of such credit. 
‘‘(3) TREATMENT
OF
GRANTS.—Any such grant shall not 
be includible in the gross income of the taxpayer.’’. 
(b) INCLUSION AS PART OF INVESTMENT CREDIT.—Section 46 
of the Internal Revenue Code of 1986 is amended— 
(1) by adding a comma at the end of paragraph (2), 
(2) by striking the period at the end of paragraph (5) 
and inserting ‘‘, and’’, and 
(3) by adding at the end the following new paragraph: 
‘‘(6) the qualifying therapeutic discovery project credit.’’. 
(c) CONFORMING AMENDMENTS.— 
(1) Section 49(a)(1)(C) of the Internal Revenue Code of 
1986 is amended— 
(A) by striking ‘‘and’’ at the end of clause (iv), 
(B) by striking the period at the end of clause (v) 
and inserting ‘‘, and’’, and 
(C) by adding at the end the following new clause: 
‘‘(vi) the basis of any property to which paragraph 
(1) of section 48D(e) applies which is part of a quali-
fying therapeutic discovery project under such section 
48D.’’. 
(2) Section 280C of such Code is amended by adding at 
the end the following new subsection: 
‘‘(g) QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT.— 
‘‘(1) IN GENERAL.—No deduction shall be allowed for that 
portion of the qualified investment (as defined in section 48D(b)) 
otherwise allowable as a deduction for the taxable year which— 
‘‘(A) would be qualified research expenses (as defined 
in section 41(b)), basic research expenses (as defined in 
section 41(e)(2)), or qualified clinical testing expenses (as 
defined in section 45C(b)) if the credit under section 41 
or section 45C were allowed with respect to such expenses 
for such taxable year, and 
‘‘(B) is equal to the amount of the credit determined 
for such taxable year under section 48D(a), reduced by— 
‘‘(i) the amount disallowed as a deduction by reason 
of section 48D(e)(2)(B), and 
‘‘(ii) the amount of any basis reduction under sec-
tion 48D(e)(1). 
‘‘(2) SIMILAR RULE WHERE TAXPAYER CAPITALIZES RATHER 
THAN DEDUCTS EXPENSES.—In the case of expenses described 
26 USC 280C. 
26 USC 49. 
26 USC 46. 
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124 STAT. 881 
PUBLIC LAW 111–148—MAR. 23, 2010 
in paragraph (1)(A) taken into account in determining the credit 
under section 48D for the taxable year, if— 
‘‘(A) the amount of the portion of the credit determined 
under such section with respect to such expenses, exceeds 
‘‘(B) the amount allowable as a deduction for such 
taxable year for such expenses (determined without regard 
to paragraph (1)), 
the amount chargeable to capital account for the taxable year 
for such expenses shall be reduced by the amount of such 
excess. 
‘‘(3) CONTROLLED GROUPS.—Paragraph (3) of subsection (b) 
shall apply for purposes of this subsection.’’. 
(d) CLERICAL AMENDMENT.—The table of sections for subpart 
E of part IV of subchapter A of chapter 1 of the Internal Revenue 
Code of 1986 is amended by inserting after the item relating to 
section 48C the following new item: 
‘‘Sec. 48D. Qualifying therapeutic discovery project credit.’’. 
(e) GRANTS FOR QUALIFIED INVESTMENTS IN THERAPEUTIC DIS-
COVERY PROJECTS IN LIEU OF TAX CREDITS.— 
(1) IN GENERAL.—Upon application, the Secretary of the 
Treasury shall, subject to the requirements of this subsection, 
provide a grant to each person who makes a qualified invest-
ment in a qualifying therapeutic discovery project in the amount 
of 50 percent of such investment. No grant shall be made 
under this subsection with respect to any investment unless 
such investment is made during a taxable year beginning in 
2009 or 2010. 
(2) APPLICATION.— 
(A) IN
GENERAL.—At the stated election of the 
applicant, an application for certification under section 
48D(d)(2) of the Internal Revenue Code of 1986 for a credit 
under such section for the taxable year of the applicant 
which begins in 2009 shall be considered to be an applica-
tion for a grant under paragraph (1) for such taxable year. 
(B) TAXABLE YEARS BEGINNING IN 2010.—An application 
for a grant under paragraph (1) for a taxable year beginning 
in 2010 shall be submitted— 
(i) not earlier than the day after the last day 
of such taxable year, and 
(ii) not later than the due date (including exten-
sions) for filing the return of tax for such taxable 
year. 
(C) INFORMATION TO BE SUBMITTED.—An application 
for a grant under paragraph (1) shall include such informa-
tion and be in such form as the Secretary may require 
to state the amount of the credit allowable (but for the 
receipt of a grant under this subsection) under section 
48D for the taxable year for the qualified investment with 
respect to which such application is made. 
(3) TIME FOR PAYMENT OF GRANT.— 
(A) IN GENERAL.—The Secretary of the Treasury shall 
make payment of the amount of any grant under paragraph 
(1) during the 30-day period beginning on the later of— 
(i) the date of the application for such grant, or 
(ii) the date the qualified investment for which 
the grant is being made is made. 
26 USC 48D 
note. 
Applicability. 
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124 STAT. 882 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) REGULATIONS.—In the case of investments of an 
ongoing nature, the Secretary shall issue regulations to 
determine the date on which a qualified investment shall 
be deemed to have been made for purposes of this para-
graph. 
(4) QUALIFIED
INVESTMENT.—For purposes of this sub-
section, the term ‘‘qualified investment’’ means a qualified 
investment that is certified under section 48D(d) of the Internal 
Revenue Code of 1986 for purposes of the credit under such 
section 48D. 
(5) APPLICATION OF CERTAIN RULES.— 
(A) IN GENERAL.—In making grants under this sub-
section, the Secretary of the Treasury shall apply rules 
similar to the rules of section 50 of the Internal Revenue 
Code of 1986. In applying such rules, any increase in 
tax under chapter 1 of such Code by reason of an invest-
ment ceasing to be a qualified investment shall be imposed 
on the person to whom the grant was made. 
(B) SPECIAL RULES.— 
(i) RECAPTURE OF EXCESSIVE GRANT AMOUNTS.— 
If the amount of a grant made under this subsection 
exceeds the amount allowable as a grant under this 
subsection, such excess shall be recaptured under 
subparagraph (A) as if the investment to which such 
excess portion of the grant relates had ceased to be 
a qualified investment immediately after such grant 
was made. 
(ii) GRANT INFORMATION NOT TREATED AS RETURN 
INFORMATION.—In no event shall the amount of a grant 
made under paragraph (1), the identity of the person 
to whom such grant was made, or a description of 
the investment with respect to which such grant was 
made be treated as return information for purposes 
of section 6103 of the Internal Revenue Code of 1986. 
(6) EXCEPTION
FOR
CERTAIN
NON-TAXPAYERS.—The Sec-
retary of the Treasury shall not make any grant under this 
subsection to— 
(A) any Federal, State, or local government (or any 
political subdivision, agency, or instrumentality thereof), 
(B) any organization described in section 501(c) of the 
Internal Revenue Code of 1986 and exempt from tax under 
section 501(a) of such Code, 
(C) any entity referred to in paragraph (4) of section 
54(j) of such Code, or 
(D) any partnership or other pass-thru entity any 
partner (or other holder of an equity or profits interest) 
of which is described in subparagraph (A), (B) or (C). 
In the case of a partnership or other pass-thru entity described 
in subparagraph (D), partners and other holders of any equity 
or profits interest shall provide to such partnership or entity 
such information as the Secretary of the Treasury may require 
to carry out the purposes of this paragraph. 
(7) SECRETARY.—Any reference in this subsection to the 
Secretary of the Treasury shall be treated as including the 
Secretary’s delegate. 
(8) OTHER TERMS.—Any term used in this subsection which 
is also used in section 48D of the Internal Revenue Code 
Definition. 
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124 STAT. 883 
PUBLIC LAW 111–148—MAR. 23, 2010 
of 1986 shall have the same meaning for purposes of this 
subsection as when used in such section. 
(9) DENIAL OF DOUBLE BENEFIT.—No credit shall be allowed 
under section 46(6) of the Internal Revenue Code of 1986 by 
reason of section 48D of such Code for any investment for 
which a grant is awarded under this subsection. 
(10) APPROPRIATIONS.—There is hereby appropriated to the 
Secretary of the Treasury such sums as may be necessary 
to carry out this subsection. 
(11) TERMINATION.—The Secretary of the Treasury shall 
not make any grant to any person under this subsection unless 
the application of such person for such grant is received before 
January 1, 2013. 
(12) PROTECTING
MIDDLE
CLASS
FAMILIES
FROM
TAX 
INCREASES.—It is the sense of the Senate that the Senate 
should reject any procedural maneuver that would raise taxes 
on middle class families, such as a motion to commit the 
pending legislation to the Committee on Finance, which is 
designed to kill legislation that provides tax cuts for American 
workers and families, including the affordability tax credit and 
the small business tax credit. 
(f) EFFECTIVE DATE.—The amendments made by subsections 
(a) through (d) of this section shall apply to amounts paid or 
incurred after December 31, 2008, in taxable years beginning after 
such date. 
TITLE 
X—STRENGTHENING 
QUALITY, 
AFFORDABLE HEALTH CARE FOR ALL 
AMERICANS 
Subtitle A—Provisions Relating to Title I 
SEC. 10101. AMENDMENTS TO SUBTITLE A. 
(a) Section 2711 of the Public Health Service Act, as added 
by section 1001(5) of this Act, is amended to read as follows: 
‘‘SEC. 2711. NO LIFETIME OR ANNUAL LIMITS. 
‘‘(a) PROHIBITION.— 
‘‘(1) IN GENERAL.—A group health plan and a health insur-
ance issuer offering group or individual health insurance cov-
erage may not establish— 
‘‘(A) lifetime limits on the dollar value of benefits for 
any participant or beneficiary; or 
‘‘(B) except as provided in paragraph (2), annual limits 
on the dollar value of benefits for any participant or bene-
ficiary. 
‘‘(2) ANNUAL LIMITS PRIOR TO 2014.—With respect to plan 
years beginning prior to January 1, 2014, a group health plan 
and a health insurance issuer offering group or individual 
health insurance coverage may only establish a restricted 
annual limit on the dollar value of benefits for any participant 
or beneficiary with respect to the scope of benefits that are 
essential health benefits under section 1302(b) of the Patient 
42 USC 
300gg–11. 
26 USC 46 note. 
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124 STAT. 884 
PUBLIC LAW 111–148—MAR. 23, 2010 
Protection and Affordable Care Act, as determined by the Sec-
retary. In defining the term ‘restricted annual limit’ for pur-
poses of the preceding sentence, the Secretary shall ensure 
that access to needed services is made available with a minimal 
impact on premiums. 
‘‘(b) PER BENEFICIARY LIMITS.—Subsection (a) shall not be con-
strued to prevent a group health plan or health insurance coverage 
from placing annual or lifetime per beneficiary limits on specific 
covered benefits that are not essential health benefits under section 
1302(b) of the Patient Protection and Affordable Care Act, to the 
extent that such limits are otherwise permitted under Federal 
or State law.’’. 
(b) Section 2715(a) of the Public Health Service Act, as added 
by section 1001(5) of this Act, is amended by striking ‘‘and providing 
to enrollees’’ and inserting ‘‘and providing to applicants, enrollees, 
and policyholders or certificate holders’’. 
(c) Subpart II of part A of title XXVII of the Public Health 
Service Act, as added by section 1001(5), is amended by inserting 
after section 2715, the following: 
‘‘SEC. 2715A. PROVISION OF ADDITIONAL INFORMATION. 
‘‘A group health plan and a health insurance issuer offering 
group or individual health insurance coverage shall comply with 
the provisions of section 1311(e)(3) of the Patient Protection and 
Affordable Care Act, except that a plan or coverage that is not 
offered through an Exchange shall only be required to submit 
the information required to the Secretary and the State insurance 
commissioner, and make such information available to the public.’’. 
(d) Section 2716 of the Public Health Service Act, as added 
by section 1001(5) of this Act, is amended to read as follows: 
‘‘SEC. 2716. PROHIBITION ON DISCRIMINATION IN FAVOR OF HIGHLY 
COMPENSATED INDIVIDUALS. 
‘‘(a) IN GENERAL.—A group health plan (other than a self- 
insured plan) shall satisfy the requirements of section 105(h)(2) 
of the Internal Revenue Code of 1986 (relating to prohibition on 
discrimination in favor of highly compensated individuals). 
‘‘(b) RULES AND DEFINITIONS.—For purposes of this section— 
‘‘(1) CERTAIN RULES TO APPLY.—Rules similar to the rules 
contained in paragraphs (3), (4), and (8) of section 105(h) of 
such Code shall apply. 
‘‘(2) HIGHLY COMPENSATED INDIVIDUAL.—The term ‘highly 
compensated individual’ has the meaning given such term by 
section 105(h)(5) of such Code.’’. 
(e) Section 2717 of the Public Health Service Act, as added 
by section 1001(5) of this Act, is amended— 
(1) by redesignating subsections (c) and (d) as subsections 
(d) and (e), respectively; and 
(2) by inserting after subsection (b), the following: 
‘‘(c) PROTECTION OF SECOND AMENDMENT GUN RIGHTS.— 
‘‘(1) WELLNESS AND PREVENTION PROGRAMS.—A wellness 
and health promotion activity implemented under subsection 
(a)(1)(D) may not require the disclosure or collection of any 
information relating to— 
‘‘(A) the presence or storage of a lawfully-possessed 
firearm or ammunition in the residence or on the property 
of an individual; or 
42 USC 
300gg–17. 
42 USC 
300gg–16. 
Public 
information. 
42 USC 
300gg–15a. 
42 USC 
300gg–15. 
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124 STAT. 885 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) the lawful use, possession, or storage of a firearm 
or ammunition by an individual. 
‘‘(2) LIMITATION
ON
DATA
COLLECTION.—None of the 
authorities provided to the Secretary under the Patient Protec-
tion and Affordable Care Act or an amendment made by that 
Act shall be construed to authorize or may be used for the 
collection of any information relating to— 
‘‘(A) the lawful ownership or possession of a firearm 
or ammunition; 
‘‘(B) the lawful use of a firearm or ammunition; or 
‘‘(C) the lawful storage of a firearm or ammunition. 
‘‘(3) LIMITATION ON DATABASES OR DATA BANKS.—None of 
the authorities provided to the Secretary under the Patient 
Protection and Affordable Care Act or an amendment made 
by that Act shall be construed to authorize or may be used 
to maintain records of individual ownership or possession of 
a firearm or ammunition. 
‘‘(4) LIMITATION ON DETERMINATION OF PREMIUM RATES OR 
ELIGIBILITY FOR HEALTH INSURANCE.—A premium rate may not 
be increased, health insurance coverage may not be denied, 
and a discount, rebate, or reward offered for participation in 
a wellness program may not be reduced or withheld under 
any health benefit plan issued pursuant to or in accordance 
with the Patient Protection and Affordable Care Act or an 
amendment made by that Act on the basis of, or on reliance 
upon— 
‘‘(A) the lawful ownership or possession of a firearm 
or ammunition; or 
‘‘(B) the lawful use or storage of a firearm or ammuni-
tion. 
‘‘(5) LIMITATION ON DATA COLLECTION REQUIREMENTS FOR 
INDIVIDUALS.—No individual shall be required to disclose any 
information under any data collection activity authorized under 
the Patient Protection and Affordable Care Act or an amend-
ment made by that Act relating to— 
‘‘(A) the lawful ownership or possession of a firearm 
or ammunition; or 
‘‘(B) the lawful use, possession, or storage of a firearm 
or ammunition.’’. 
(f) Section 2718 of the Public Health Service Act, as added 
by section 1001(5), is amended to read as follows: 
‘‘SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE COVERAGE. 
‘‘(a) CLEAR ACCOUNTING FOR COSTS.—A health insurance issuer 
offering group or individual health insurance coverage (including 
a grandfathered health plan) shall, with respect to each plan year, 
submit to the Secretary a report concerning the ratio of the incurred 
loss (or incurred claims) plus the loss adjustment expense (or change 
in contract reserves) to earned premiums. Such report shall include 
the percentage of total premium revenue, after accounting for collec-
tions or receipts for risk adjustment and risk corridors and pay-
ments of reinsurance, that such coverage expends— 
‘‘(1) on reimbursement for clinical services provided to 
enrollees under such coverage; 
‘‘(2) for activities that improve health care quality; and 
42 USC 
300gg–18. 
Reports. 
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124 STAT. 886 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(3) on all other non-claims costs, including an explanation 
of the nature of such costs, and excluding Federal and State 
taxes and licensing or regulatory fees. 
The Secretary shall make reports received under this section avail-
able to the public on the Internet website of the Department of 
Health and Human Services. 
‘‘(b) ENSURING THAT CONSUMERS RECEIVE VALUE FOR THEIR 
PREMIUM PAYMENTS.— 
‘‘(1) REQUIREMENT TO PROVIDE VALUE FOR PREMIUM PAY-
MENTS.— 
‘‘(A) REQUIREMENT.—Beginning not later than January 
1, 2011, a health insurance issuer offering group or indi-
vidual health insurance coverage (including a grand-
fathered health plan) shall, with respect to each plan year, 
provide an annual rebate to each enrollee under such cov-
erage, on a pro rata basis, if the ratio of the amount 
of premium revenue expended by the issuer on costs 
described in paragraphs (1) and (2) of subsection (a) to 
the total amount of premium revenue (excluding Federal 
and State taxes and licensing or regulatory fees and after 
accounting for payments or receipts for risk adjustment, 
risk corridors, and reinsurance under sections 1341, 1342, 
and 1343 of the Patient Protection and Affordable Care 
Act) for the plan year (except as provided in subparagraph 
(B)(ii)), is less than— 
‘‘(i) with respect to a health insurance issuer 
offering coverage in the large group market, 85 percent, 
or such higher percentage as a State may by regulation 
determine; or 
‘‘(ii) with respect to a health insurance issuer 
offering coverage in the small group market or in the 
individual market, 80 percent, or such higher percent-
age as a State may by regulation determine, except 
that the Secretary may adjust such percentage with 
respect to a State if the Secretary determines that 
the application of such 80 percent may destabilize the 
individual market in such State. 
‘‘(B) REBATE AMOUNT.— 
‘‘(i) CALCULATION OF AMOUNT.—The total amount 
of an annual rebate required under this paragraph 
shall be in an amount equal to the product of— 
‘‘(I) the amount by which the percentage 
described in clause (i) or (ii) of subparagraph (A) 
exceeds the ratio described in such subparagraph; 
and 
‘‘(II) the total amount of premium revenue 
(excluding Federal and State taxes and licensing 
or regulatory fees and after accounting for pay-
ments or receipts for risk adjustment, risk cor-
ridors, and reinsurance under sections 1341, 1342, 
and 1343 of the Patient Protection and Affordable 
Care Act) for such plan year. 
‘‘(ii) CALCULATION
BASED
ON
AVERAGE
RATIO.— 
Beginning on January 1, 2014, the determination made 
under subparagraph (A) for the year involved shall 
be based on the averages of the premiums expended 
on the costs described in such subparagraph and total 
Effective date. 
Deadline. 
Public 
information. 
Web posting. 
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124 STAT. 887 
PUBLIC LAW 111–148—MAR. 23, 2010 
premium revenue for each of the previous 3 years 
for the plan. 
‘‘(2) CONSIDERATION IN SETTING PERCENTAGES.—In deter-
mining the percentages under paragraph (1), a State shall 
seek to ensure adequate participation by health insurance 
issuers, competition in the health insurance market in the 
State, and value for consumers so that premiums are used 
for clinical services and quality improvements. 
‘‘(3) ENFORCEMENT.—The Secretary shall promulgate regu-
lations for enforcing the provisions of this section and may 
provide for appropriate penalties. 
‘‘(c) DEFINITIONS.—Not later than December 31, 2010, and sub-
ject to the certification of the Secretary, the National Association 
of Insurance Commissioners shall establish uniform definitions of 
the activities reported under subsection (a) and standardized meth-
odologies for calculating measures of such activities, including 
definitions of which activities, and in what regard such activities, 
constitute activities described in subsection (a)(2). Such methodolo-
gies shall be designed to take into account the special circumstances 
of smaller plans, different types of plans, and newer plans. 
‘‘(d) ADJUSTMENTS.—The Secretary may adjust the rates 
described in subsection (b) if the Secretary determines appropriate 
on account of the volatility of the individual market due to the 
establishment of State Exchanges. 
‘‘(e) STANDARD HOSPITAL CHARGES.—Each hospital operating 
within the United States shall for each year establish (and update) 
and make public (in accordance with guidelines developed by the 
Secretary) a list of the hospital’s standard charges for items and 
services provided by the hospital, including for diagnosis-related 
groups established under section 1886(d)(4) of the Social Security 
Act.’’. 
(g) Section 2719 of the Public Health Service Act, as added 
by section 1001(4) of this Act, is amended to read as follows: 
‘‘SEC. 2719. APPEALS PROCESS. 
‘‘(a) INTERNAL CLAIMS APPEALS.— 
‘‘(1) IN GENERAL.—A group health plan and a health insur-
ance issuer offering group or individual health insurance cov-
erage shall implement an effective appeals process for appeals 
of coverage determinations and claims, under which the plan 
or issuer shall, at a minimum— 
‘‘(A) have in effect an internal claims appeal process; 
‘‘(B) provide notice to enrollees, in a culturally and 
linguistically appropriate manner, of available internal and 
external appeals processes, and the availability of any 
applicable office of health insurance consumer assistance 
or ombudsman established under section 2793 to assist 
such enrollees with the appeals processes; and 
‘‘(C) allow an enrollee to review their file, to present 
evidence and testimony as part of the appeals process, 
and to receive continued coverage pending the outcome 
of the appeals process. 
‘‘(2) ESTABLISHED PROCESSES.—To comply with paragraph 
(1)— 
‘‘(A) a group health plan and a health insurance issuer 
offering group health coverage shall provide an internal 
claims and appeals process that initially incorporates the 
42 USC 
300gg–19. 
Deadline. 
Certification. 
Regulations. 
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124 STAT. 888 
PUBLIC LAW 111–148—MAR. 23, 2010 
claims and appeals procedures (including urgent claims) 
set forth at section 2560.503–1 of title 29, Code of Federal 
Regulations, as published on November 21, 2000 (65 Fed. 
Reg. 70256), and shall update such process in accordance 
with any standards established by the Secretary of Labor 
for such plans and issuers; and 
‘‘(B) a health insurance issuer offering individual 
health coverage, and any other issuer not subject to 
subparagraph (A), shall provide an internal claims and 
appeals process that initially incorporates the claims and 
appeals procedures set forth under applicable law (as in 
existence on the date of enactment of this section), and 
shall update such process in accordance with any standards 
established by the Secretary of Health and Human Services 
for such issuers. 
‘‘(b) EXTERNAL REVIEW.—A group health plan and a health 
insurance issuer offering group or individual health insurance cov-
erage— 
‘‘(1) shall comply with the applicable State external review 
process for such plans and issuers that, at a minimum, includes 
the consumer protections set forth in the Uniform External 
Review Model Act promulgated by the National Association 
of Insurance Commissioners and is binding on such plans; 
or 
‘‘(2) shall implement an effective external review process 
that meets minimum standards established by the Secretary 
through guidance and that is similar to the process described 
under paragraph (1)— 
‘‘(A) if the applicable State has not established an 
external review process that meets the requirements of 
paragraph (1); or 
‘‘(B) if the plan is a self-insured plan that is not subject 
to State insurance regulation (including a State law that 
establishes an external review process described in para-
graph (1)). 
‘‘(c) SECRETARY AUTHORITY.—The Secretary may deem the 
external review process of a group health plan or health insurance 
issuer, in operation as of the date of enactment of this section, 
to be in compliance with the applicable process established under 
subsection (b), as determined appropriate by the Secretary.’’. 
(h) Subpart II of part A of title XVIII of the Public Health 
Service Act, as added by section 1001(5) of this Act, is amended 
by inserting after section 2719 the following: 
‘‘SEC. 2719A. PATIENT PROTECTIONS. 
‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If a group health 
plan, or a health insurance issuer offering group or individual 
health insurance coverage, requires or provides for designation by 
a participant, beneficiary, or enrollee of a participating primary 
care provider, then the plan or issuer shall permit each participant, 
beneficiary, and enrollee to designate any participating primary 
care provider who is available to accept such individual. 
‘‘(b) COVERAGE OF EMERGENCY SERVICES.— 
‘‘(1) IN GENERAL.—If a group health plan, or a health insur-
ance issuer offering group or individual health insurance issuer, 
provides or covers any benefits with respect to services in 
an emergency department of a hospital, the plan or issuer 
42 USC 
300gg–19a. 
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124 STAT. 889 
PUBLIC LAW 111–148—MAR. 23, 2010 
shall cover emergency services (as defined in paragraph 
(2)(B))— 
‘‘(A) without the need for any prior authorization deter-
mination; 
‘‘(B) whether the health care provider furnishing such 
services is a participating provider with respect to such 
services; 
‘‘(C) in a manner so that, if such services are provided 
to a participant, beneficiary, or enrollee— 
‘‘(i) by a nonparticipating health care provider with 
or without prior authorization; or 
‘‘(ii)(I) such services will be provided without 
imposing any requirement under the plan for prior 
authorization of services or any limitation on coverage 
where the provider of services does not have a contrac-
tual relationship with the plan for the providing of 
services that is more restrictive than the requirements 
or limitations that apply to emergency department 
services received from providers who do have such 
a contractual relationship with the plan; and 
‘‘(II) if such services are provided out-of-network, 
the 
cost-sharing 
requirement 
(expressed 
as 
a 
copayment amount or coinsurance rate) is the same 
requirement that would apply if such services were 
provided in-network; 
‘‘(D) without regard to any other term or condition 
of such coverage (other than exclusion or coordination of 
benefits, or an affiliation or waiting period, permitted under 
section 2701 of this Act, section 701 of the Employee Retire-
ment Income Security Act of 1974, or section 9801 of the 
Internal Revenue Code of 1986, and other than applicable 
cost-sharing). 
‘‘(2) DEFINITIONS.—In this subsection: 
‘‘(A) EMERGENCY
MEDICAL
CONDITION.—The term 
‘emergency medical condition’ means a medical condition 
manifesting itself by acute symptoms of sufficient severity 
(including severe pain) such that a prudent layperson, who 
possesses an average knowledge of health and medicine, 
could reasonably expect the absence of immediate medical 
attention to result in a condition described in clause (i), 
(ii), or (iii) of section 1867(e)(1)(A) of the Social Security 
Act. 
‘‘(B) EMERGENCY SERVICES.—The term ‘emergency serv-
ices’ means, with respect to an emergency medical condi-
tion— 
‘‘(i) a medical screening examination (as required 
under section 1867 of the Social Security Act) that 
is within the capability of the emergency department 
of a hospital, including ancillary services routinely 
available to the emergency department to evaluate 
such emergency medical condition, and 
‘‘(ii) within the capabilities of the staff and facili-
ties available at the hospital, such further medical 
examination and treatment as are required under sec-
tion 1867 of such Act to stabilize the patient. 
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124 STAT. 890 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(C) STABILIZE.—The term ‘to stabilize’, with respect 
to an emergency medical condition (as defined in subpara-
graph (A)), has the meaning give in section 1867(e)(3) of 
the Social Security Act (42 U.S.C. 1395dd(e)(3)). 
‘‘(c) ACCESS TO PEDIATRIC CARE.— 
‘‘(1) PEDIATRIC CARE.—In the case of a person who has 
a child who is a participant, beneficiary, or enrollee under 
a group health plan, or health insurance coverage offered by 
a health insurance issuer in the group or individual market, 
if the plan or issuer requires or provides for the designation 
of a participating primary care provider for the child, the plan 
or issuer shall permit such person to designate a physician 
(allopathic or osteopathic) who specializes in pediatrics as the 
child’s primary care provider if such provider participates in 
the network of the plan or issuer. 
‘‘(2) CONSTRUCTION.—Nothing in paragraph (1) shall be 
construed to waive any exclusions of coverage under the terms 
and conditions of the plan or health insurance coverage with 
respect to coverage of pediatric care. 
‘‘(d) PATIENT ACCESS
TO OBSTETRICAL
AND GYNECOLOGICAL 
CARE.— 
‘‘(1) GENERAL RIGHTS.— 
‘‘(A) DIRECT ACCESS.—A group health plan, or health 
insurance issuer offering group or individual health insur-
ance coverage, described in paragraph (2) may not require 
authorization or referral by the plan, issuer, or any person 
(including a primary care provider described in paragraph 
(2)(B)) in the case of a female participant, beneficiary, 
or enrollee who seeks coverage for obstetrical or gyneco-
logical care provided by a participating health care profes-
sional who specializes in obstetrics or gynecology. Such 
professional shall agree to otherwise adhere to such plan’s 
or issuer’s policies and procedures, including procedures 
regarding referrals and obtaining prior authorization and 
providing services pursuant to a treatment plan (if any) 
approved by the plan or issuer. 
‘‘(B) OBSTETRICAL AND GYNECOLOGICAL CARE.—A group 
health plan or health insurance issuer described in para-
graph (2) shall treat the provision of obstetrical and gyneco-
logical care, and the ordering of related obstetrical and 
gynecological items and services, pursuant to the direct 
access described under subparagraph (A), by a participating 
health care professional who specializes in obstetrics or 
gynecology as the authorization of the primary care pro-
vider. 
‘‘(2) APPLICATION
OF
PARAGRAPH.—A group health plan, 
or health insurance issuer offering group or individual health 
insurance coverage, described in this paragraph is a group 
health plan or coverage that— 
‘‘(A) provides coverage for obstetric or gynecologic care; 
and 
‘‘(B) requires the designation by a participant, bene-
ficiary, or enrollee of a participating primary care provider. 
‘‘(3) CONSTRUCTION.—Nothing in paragraph (1) shall be 
construed to— 
‘‘(A) waive any exclusions of coverage under the terms 
and conditions of the plan or health insurance coverage 
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124 STAT. 891 
PUBLIC LAW 111–148—MAR. 23, 2010 
with respect to coverage of obstetrical or gynecological care; 
or 
‘‘(B) preclude the group health plan or health insurance 
issuer involved from requiring that the obstetrical or 
gynecological provider notify the primary care health care 
professional or the plan or issuer of treatment decisions.’’. 
(i) Section 2794 of the Public Health Service Act, as added 
by section 1003 of this Act, is amended— 
(1) in subsection (c)(1)— 
(A) in subparagraph (A), by striking ‘‘and’’ at the end; 
(B) in subparagraph (B), by striking the period and 
inserting ‘‘; and’’; and 
(C) by adding at the end the following: 
‘‘(C) in establishing centers (consistent with subsection 
(d)) at academic or other nonprofit institutions to collect 
medical reimbursement information from health insurance 
issuers, to analyze and organize such information, and 
to make such information available to such issuers, health 
care providers, health researchers, health care policy mak-
ers, and the general public.’’; and 
(2) by adding at the end the following: 
‘‘(d) MEDICAL REIMBURSEMENT DATA CENTERS.— 
‘‘(1) FUNCTIONS.—A center established under subsection 
(c)(1)(C) shall— 
‘‘(A) develop fee schedules and other database tools 
that fairly and accurately reflect market rates for medical 
services and the geographic differences in those rates; 
‘‘(B) use the best available statistical methods and 
data processing technology to develop such fee schedules 
and other database tools; 
‘‘(C) regularly update such fee schedules and other 
database tools to reflect changes in charges for medical 
services; 
‘‘(D) make health care cost information readily avail-
able to the public through an Internet website that allows 
consumers to understand the amounts that health care 
providers in their area charge for particular medical serv-
ices; and 
‘‘(E) regularly publish information concerning the 
statistical methodologies used by the center to analyze 
health charge data and make such data available to 
researchers and policy makers. 
‘‘(2) CONFLICTS OF INTEREST.—A center established under 
subsection (c)(1)(C) shall adopt by-laws that ensures that the 
center (and all members of the governing board of the center) 
is independent and free from all conflicts of interest. Such 
by-laws shall ensure that the center is not controlled or influ-
enced by, and does not have any corporate relation to, any 
individual or entity that may make or receive payments for 
health care services based on the center’s analysis of health 
care costs. 
‘‘(3) RULE OF CONSTRUCTION.—Nothing in this subsection 
shall be construed to permit a center established under sub-
section (c)(1)(C) to compel health insurance issuers to provide 
data to the center.’’. 
By-laws. 
Publication. 
Public 
information. 
Web posting. 
42 USC 
300gg–94. 
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124 STAT. 892 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 10102. AMENDMENTS TO SUBTITLE B. 
(a) Section 1102(a)(2)(B) of this Act is amended— 
(1) in the matter preceding clause (i), by striking ‘‘group 
health benefits plan’’ and inserting ‘‘group benefits plan pro-
viding health benefits’’; and 
(2) in clause (i)(I), by inserting ‘‘or any agency or instrumen-
tality of any of the foregoing’’ before the closed parenthetical. 
(b) Section 1103(a) of this Act is amended— 
(1) in paragraph (1), by inserting ‘‘, or small business 
in,’’ after ‘‘residents of any’’; and 
(2) by striking paragraph (2) and inserting the following: 
‘‘(2) CONNECTING TO AFFORDABLE COVERAGE.—An Internet 
website established under paragraph (1) shall, to the extent 
practicable, provide ways for residents of, and small businesses 
in, any State to receive information on at least the following 
coverage options: 
‘‘(A) Health insurance coverage offered by health insur-
ance issuers, other than coverage that provides reimburse-
ment only for the treatment or mitigation of— 
‘‘(i) a single disease or condition; or 
‘‘(ii) an unreasonably limited set of diseases or 
conditions (as determined by the Secretary). 
‘‘(B) Medicaid coverage under title XIX of the Social 
Security Act. 
‘‘(C) Coverage under title XXI of the Social Security 
Act. 
‘‘(D) A State health benefits high risk pool, to the 
extent that such high risk pool is offered in such State; 
and 
‘‘(E) Coverage under a high risk pool under section 
1101. 
‘‘(F) Coverage within the small group market for small 
businesses and their employees, including reinsurance for 
early retirees under section 1102, tax credits available 
under section 45R of the Internal Revenue Code of 1986 
(as added by section 1421), and other information specifi-
cally for small businesses regarding affordable health care 
options.’’. 
SEC. 10103. AMENDMENTS TO SUBTITLE C. 
(a) Section 2701(a)(5) of the Public Health Service Act, as 
added by section 1201(4) of this Act, is amended by inserting 
‘‘(other than self-insured group health plans offered in such market)’’ 
after ‘‘such market’’. 
(b) Section 2708 of the Public Health Service Act, as added 
by section 1201(4) of this Act, is amended by striking ‘‘or individual’’. 
(c) Subpart I of part A of title XXVII of the Public Health 
Service Act, as added by section 1201(4) of this Act, is amended 
by inserting after section 2708, the following: 
‘‘SEC. 
2709. 
COVERAGE 
FOR 
INDIVIDUALS 
PARTICIPATING 
IN 
APPROVED CLINICAL TRIALS. 
‘‘(a) COVERAGE.— 
‘‘(1) IN GENERAL.—If a group health plan or a health insur-
ance issuer offering group or individual health insurance cov-
erage provides coverage to a qualified individual, then such 
plan or issuer— 
42 USC 300gg–8. 
42 USC 300gg–7. 
42 USC 300gg. 
42 USC 18003. 
42 USC 18002. 
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124 STAT. 893 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) may not deny the individual participation in the 
clinical trial referred to in subsection (b)(2); 
‘‘(B) subject to subsection (c), may not deny (or limit 
or impose additional conditions on) the coverage of routine 
patient costs for items and services furnished in connection 
with participation in the trial; and 
‘‘(C) may not discriminate against the individual on 
the basis of the individual’s participation in such trial. 
‘‘(2) ROUTINE PATIENT COSTS.— 
‘‘(A) INCLUSION.—For purposes of paragraph (1)(B), 
subject to subparagraph (B), routine patient costs include 
all items and services consistent with the coverage provided 
in the plan (or coverage) that is typically covered for a 
qualified individual who is not enrolled in a clinical trial. 
‘‘(B) EXCLUSION.—For purposes of paragraph (1)(B), 
routine patient costs does not include— 
‘‘(i) the investigational item, device, or service, 
itself; 
‘‘(ii) items and services that are provided solely 
to satisfy data collection and analysis needs and that 
are not used in the direct clinical management of the 
patient; or 
‘‘(iii) a service that is clearly inconsistent with 
widely accepted and established standards of care for 
a particular diagnosis. 
‘‘(3) USE OF IN-NETWORK PROVIDERS.—If one or more partici-
pating providers is participating in a clinical trial, nothing 
in paragraph (1) shall be construed as preventing a plan or 
issuer from requiring that a qualified individual participate 
in the trial through such a participating provider if the provider 
will accept the individual as a participant in the trial. 
‘‘(4) USE OF OUT-OF-NETWORK.—Notwithstanding paragraph 
(3), paragraph (1) shall apply to a qualified individual partici-
pating in an approved clinical trial that is conducted outside 
the State in which the qualified individual resides. 
‘‘(b) QUALIFIED INDIVIDUAL DEFINED.—For purposes of sub-
section (a), the term ‘qualified individual’ means an individual 
who is a participant or beneficiary in a health plan or with coverage 
described in subsection (a)(1) and who meets the following condi-
tions: 
‘‘(1) The individual is eligible to participate in an approved 
clinical trial according to the trial protocol with respect to 
treatment of cancer or other life-threatening disease or condi-
tion. 
‘‘(2) Either— 
‘‘(A) the referring health care professional is a partici-
pating health care provider and has concluded that the 
individual’s participation in such trial would be appropriate 
based upon the individual meeting the conditions described 
in paragraph (1); or 
‘‘(B) the participant or beneficiary provides medical 
and scientific information establishing that the individual’s 
participation in such trial would be appropriate based upon 
the individual meeting the conditions described in para-
graph (1). 
‘‘(c) LIMITATIONS ON COVERAGE.—This section shall not be con-
strued to require a group health plan, or a health insurance issuer 
Applicability. 
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124 STAT. 894 
PUBLIC LAW 111–148—MAR. 23, 2010 
offering group or individual health insurance coverage, to provide 
benefits for routine patient care services provided outside of the 
plan’s (or coverage’s) health care provider network unless out-of- 
network benefits are otherwise provided under the plan (or cov-
erage). 
‘‘(d) APPROVED CLINICAL TRIAL DEFINED.— 
‘‘(1) IN GENERAL.—In this section, the term ‘approved clin-
ical trial’ means a phase I, phase II, phase III, or phase IV 
clinical trial that is conducted in relation to the prevention, 
detection, or treatment of cancer or other life-threatening dis-
ease or condition and is described in any of the following 
subparagraphs: 
‘‘(A) FEDERALLY FUNDED TRIALS.—The study or inves-
tigation is approved or funded (which may include funding 
through in-kind contributions) by one or more of the fol-
lowing: 
‘‘(i) The National Institutes of Health. 
‘‘(ii) The Centers for Disease Control and Preven-
tion. 
‘‘(iii) The Agency for Health Care Research and 
Quality. 
‘‘(iv) The Centers for Medicare & Medicaid Serv-
ices. 
‘‘(v) cooperative group or center of any of the enti-
ties described in clauses (i) through (iv) or the Depart-
ment of Defense or the Department of Veterans Affairs. 
‘‘(vi) A qualified non-governmental research entity 
identified in the guidelines issued by the National 
Institutes of Health for center support grants. 
‘‘(vii) Any of the following if the conditions 
described in paragraph (2) are met: 
‘‘(I) The Department of Veterans Affairs. 
‘‘(II) The Department of Defense. 
‘‘(III) The Department of Energy. 
‘‘(B) The study or investigation is conducted under 
an investigational new drug application reviewed by the 
Food and Drug Administration. 
‘‘(C) The study or investigation is a drug trial that 
is exempt from having such an investigational new drug 
application. 
‘‘(2) 
CONDITIONS
FOR
DEPARTMENTS.—The 
conditions 
described in this paragraph, for a study or investigation con-
ducted by a Department, are that the study or investigation 
has been reviewed and approved through a system of peer 
review that the Secretary determines— 
‘‘(A) to be comparable to the system of peer review 
of studies and investigations used by the National 
Institutes of Health, and 
‘‘(B) assures unbiased review of the highest scientific 
standards by qualified individuals who have no interest 
in the outcome of the review. 
‘‘(e) LIFE-THREATENING CONDITION DEFINED.—In this section, 
the term ‘life-threatening condition’ means any disease or condition 
from which the likelihood of death is probable unless the course 
of the disease or condition is interrupted. 
‘‘(f) CONSTRUCTION.—Nothing in this section shall be construed 
to limit a plan’s or issuer’s coverage with respect to clinical trials. 
Determination. 
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124 STAT. 895 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(g) APPLICATION TO FEHBP.—Notwithstanding any provision 
of chapter 89 of title 5, United States Code, this section shall 
apply to health plans offered under the program under such chapter. 
‘‘(h) PREEMPTION.—Notwithstanding any other provision of this 
Act, nothing in this section shall preempt State laws that require 
a clinical trials policy for State regulated health insurance plans 
that is in addition to the policy required under this section.’’. 
(d) Section 1251(a) of this Act is amended— 
(1) in paragraph (2), by striking ‘‘With’’ and inserting 
‘‘Except as provided in paragraph (3), with’’; and 
(2) by adding at the end the following: 
‘‘(3) APPLICATION OF CERTAIN PROVISIONS.—The provisions 
of sections 2715 and 2718 of the Public Health Service Act 
(as added by subtitle A) shall apply to grandfathered health 
plans for plan years beginning on or after the date of enactment 
of this Act.’’. 
(e) Section 1253 of this Act is amended insert before the period 
the following: ‘‘, except that— 
‘‘(1) section 1251 shall take effect on the date of enactment 
of this Act; and 
‘‘(2) the provisions of section 2704 of the Public Health 
Service Act (as amended by section 1201), as they apply to 
enrollees who are under 19 years of age, shall become effective 
for plan years beginning on or after the date that is 6 months 
after the date of enactment of this Act.’’. 
(f) Subtitle C of title I of this Act is amended— 
(1) by redesignating section 1253 as section 1255; and 
(2) by inserting after section 1252, the following: 
‘‘SEC. 1253. ANNUAL REPORT ON SELF-INSURED PLANS. 
‘‘Not later than 1 year after the date of enactment of this 
Act, and annually thereafter, the Secretary of Labor shall prepare 
an aggregate annual report, using data collected from the Annual 
Return/Report of Employee Benefit Plan (Department of Labor Form 
5500), that shall include general information on self-insured group 
health plans (including plan type, number of participants, benefits 
offered, funding arrangements, and benefit arrangements) as well 
as data from the financial filings of self-insured employers 
(including information on assets, liabilities, contributions, invest-
ments, and expenses). The Secretary shall submit such reports 
to the appropriate committees of Congress. 
‘‘SEC. 1254. STUDY OF LARGE GROUP MARKET. 
‘‘(a) IN GENERAL.—The Secretary of Health and Human Services 
shall conduct a study of the fully-insured and self-insured group 
health plan markets to— 
‘‘(1) compare the characteristics of employers (including 
industry, size, and other characteristics as determined appro-
priate by the Secretary), health plan benefits, financial sol-
vency, capital reserve levels, and the risks of becoming insol-
vent; and 
‘‘(2) determine the extent to which new insurance market 
reforms are likely to cause adverse selection in the large group 
market or to encourage small and midsize employers to self- 
insure. 
‘‘(b) COLLECTION OF INFORMATION.—In conducting the study 
under subsection (a), the Secretary, in coordination with the Sec-
retary of Labor, shall collect information and analyze— 
42 USC 18013. 
Effective date. 
42 USC 300gg 
note. 
42 USC 18011. 
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124 STAT. 896 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) the extent to which self-insured group health plans 
can offer less costly coverage and, if so, whether lower costs 
are due to more efficient plan administration and lower over-
head or to the denial of claims and the offering very limited 
benefit packages; 
‘‘(2) claim denial rates, plan benefit fluctuations (to 
evaluate the extent that plans scale back health benefits during 
economic downturns), and the impact of the limited recourse 
options on consumers; and 
‘‘(3) any potential conflict of interest as it relates to the 
health care needs of self-insured enrollees and self-insured 
employer’s financial contribution or profit margin, and the 
impact of such conflict on administration of the health plan. 
‘‘(c) REPORT.—Not later than 1 year after the date of enactment 
of this Act, the Secretary shall submit to the appropriate committees 
of Congress a report concerning the results of the study conducted 
under subsection (a).’’. 
SEC. 10104. AMENDMENTS TO SUBTITLE D. 
(a) Section 1301(a) of this Act is amended by striking paragraph 
(2) and inserting the following: 
‘‘(2) INCLUSION OF CO–OP PLANS AND MULTI-STATE QUALI-
FIED HEALTH PLANS.—Any reference in this title to a qualified 
health plan shall be deemed to include a qualified health plan 
offered through the CO–OP program under section 1322, and 
a multi-State plan under section 1334, unless specifically pro-
vided for otherwise. 
‘‘(3) TREATMENT OF QUALIFIED DIRECT PRIMARY CARE MED-
ICAL HOME PLANS.—The Secretary of Health and Human Serv-
ices shall permit a qualified health plan to provide coverage 
through a qualified direct primary care medical home plan 
that meets criteria established by the Secretary, so long as 
the qualified health plan meets all requirements that are other-
wise applicable and the services covered by the medical home 
plan are coordinated with the entity offering the qualified 
health plan. 
‘‘(4) VARIATION BASED ON RATING AREA.—A qualified health 
plan, including a multi-State qualified health plan, may as 
appropriate vary premiums by rating area (as defined in section 
2701(a)(2) of the Public Health Service Act).’’. 
(b) Section 1302 of this Act is amended— 
(1) in subsection (d)(2)(B), by striking ‘‘may issue’’ and 
inserting ‘‘shall issue’’; and 
(2) by adding at the end the following: 
‘‘(g) PAYMENTS TO FEDERALLY-QUALIFIED HEALTH CENTERS.— 
If any item or service covered by a qualified health plan is provided 
by a Federally-qualified health center (as defined in section 
1905(l)(2)(B) of the Social Security Act (42 U.S.C. 1396d(l)(2)(B)) 
to an enrollee of the plan, the offeror of the plan shall pay to 
the center for the item or service an amount that is not less 
than the amount of payment that would have been paid to the 
center under section 1902(bb) of such Act (42 U.S.C. 1396a(bb)) 
for such item or service.’’. 
(c) Section 1303 of this Act is amended to read as follows: 
‘‘SEC. 1303. SPECIAL RULES. 
‘‘(a) STATE OPT-OUT OF ABORTION COVERAGE.— 
42 USC 18023. 
42 USC 18022. 
Criteria. 
42 USC 18021. 
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124 STAT. 897 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) IN GENERAL.—A State may elect to prohibit abortion 
coverage in qualified health plans offered through an Exchange 
in such State if such State enacts a law to provide for such 
prohibition. 
‘‘(2) TERMINATION OF OPT OUT.—A State may repeal a law 
described in paragraph (1) and provide for the offering of such 
services through the Exchange. 
‘‘(b) SPECIAL RULES RELATING TO COVERAGE OF ABORTION SERV-
ICES.— 
‘‘(1) VOLUNTARY CHOICE OF COVERAGE OF ABORTION SERV-
ICES.— 
‘‘(A) IN GENERAL.—Notwithstanding any other provi-
sion of this title (or any amendment made by this title)— 
‘‘(i) nothing in this title (or any amendment made 
by this title), shall be construed to require a qualified 
health plan to provide coverage of services described 
in subparagraph (B)(i) or (B)(ii) as part of its essential 
health benefits for any plan year; and 
‘‘(ii) subject to subsection (a), the issuer of a quali-
fied health plan shall determine whether or not the 
plan provides coverage of services described in subpara-
graph (B)(i) or (B)(ii) as part of such benefits for the 
plan year. 
‘‘(B) ABORTION SERVICES.— 
‘‘(i) ABORTIONS
FOR
WHICH
PUBLIC
FUNDING
IS 
PROHIBITED.—The services described in this clause are 
abortions for which the expenditure of Federal funds 
appropriated for the Department of Health and Human 
Services is not permitted, based on the law as in effect 
as of the date that is 6 months before the beginning 
of the plan year involved. 
‘‘(ii) ABORTIONS
FOR
WHICH
PUBLIC
FUNDING
IS 
ALLOWED.—The services described in this clause are 
abortions for which the expenditure of Federal funds 
appropriated for the Department of Health and Human 
Services is permitted, based on the law as in effect 
as of the date that is 6 months before the beginning 
of the plan year involved. 
‘‘(2) PROHIBITION ON THE USE OF FEDERAL FUNDS.— 
‘‘(A) IN GENERAL.—If a qualified health plan provides 
coverage of services described in paragraph (1)(B)(i), the 
issuer of the plan shall not use any amount attributable 
to any of the following for purposes of paying for such 
services: 
‘‘(i) The credit under section 36B of the Internal 
Revenue Code of 1986 (and the amount (if any) of 
the advance payment of the credit under section 1412 
of the Patient Protection and Affordable Care Act). 
‘‘(ii) Any cost-sharing reduction under section 1402 
of the Patient Protection and Affordable Care Act (and 
the amount (if any) of the advance payment of the 
reduction under section 1412 of the Patient Protection 
and Affordable Care Act). 
‘‘(B) ESTABLISHMENT
OF
ALLOCATION
ACCOUNTS.—In 
the case of a plan to which subparagraph (A) applies, 
the issuer of the plan shall— 
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124 STAT. 898 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) collect from each enrollee in the plan (without 
regard to the enrollee’s age, sex, or family status) 
a separate payment for each of the following: 
‘‘(I) an amount equal to the portion of the 
premium to be paid directly by the enrollee for 
coverage under the plan of services other than 
services described in paragraph (1)(B)(i) (after 
reduction for credits and cost-sharing reductions 
described in subparagraph (A)); and 
‘‘(II) an amount equal to the actuarial value 
of the coverage of services described in paragraph 
(1)(B)(i), and 
‘‘(ii) shall deposit all such separate payments into 
separate allocation accounts as provided in subpara-
graph (C). 
In the case of an enrollee whose premium for coverage 
under the plan is paid through employee payroll deposit, 
the separate payments required under this subparagraph 
shall each be paid by a separate deposit. 
‘‘(C) SEGREGATION OF FUNDS.— 
‘‘(i) IN GENERAL.—The issuer of a plan to which 
subparagraph (A) applies shall establish allocation 
accounts described in clause (ii) for enrollees receiving 
amounts described in subparagraph (A). 
‘‘(ii) ALLOCATION ACCOUNTS.—The issuer of a plan 
to which subparagraph (A) applies shall deposit— 
‘‘(I) all payments described in subparagraph 
(B)(i)(I) into a separate account that consists solely 
of such payments and that is used exclusively to 
pay for services other than services described in 
paragraph (1)(B)(i); and 
‘‘(II) all payments described in subparagraph 
(B)(i)(II) into a separate account that consists 
solely of such payments and that is used exclu-
sively to pay for services described in paragraph 
(1)(B)(i). 
‘‘(D) ACTUARIAL VALUE.— 
‘‘(i) IN GENERAL.—The issuer of a qualified health 
plan shall estimate the basic per enrollee, per month 
cost, determined on an average actuarial basis, for 
including coverage under the qualified health plan of 
the services described in paragraph (1)(B)(i). 
‘‘(ii) CONSIDERATIONS.—In making such estimate, 
the issuer— 
‘‘(I) may take into account the impact on 
overall costs of the inclusion of such coverage, 
but may not take into account any cost reduction 
estimated to result from such services, including 
prenatal care, delivery, or postnatal care; 
‘‘(II) shall estimate such costs as if such cov-
erage were included for the entire population cov-
ered; and 
‘‘(III) may not estimate such a cost at less 
than $1 per enrollee, per month. 
‘‘(E) 
ENSURING
COMPLIANCE
WITH
SEGREGATION 
REQUIREMENTS.— 
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124 STAT. 899 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) IN
GENERAL.—Subject to clause (ii), State 
health insurance commissioners shall ensure that 
health plans comply with the segregation requirements 
in this subsection through the segregation of plan funds 
in accordance with applicable provisions of generally 
accepted accounting requirements, circulars on funds 
management of the Office of Management and Budget, 
and guidance on accounting of the Government 
Accountability Office. 
‘‘(ii) CLARIFICATION.—Nothing in clause (i) shall 
prohibit the right of an individual or health plan to 
appeal such action in courts of competent jurisdiction. 
‘‘(3) RULES RELATING TO NOTICE.— 
‘‘(A) NOTICE.—A qualified health plan that provides 
for coverage of the services described in paragraph (1)(B)(i) 
shall provide a notice to enrollees, only as part of the 
summary of benefits and coverage explanation, at the time 
of enrollment, of such coverage. 
‘‘(B) RULES
RELATING
TO
PAYMENTS.—The notice 
described in subparagraph (A), any advertising used by 
the issuer with respect to the plan, any information pro-
vided by the Exchange, and any other information specified 
by the Secretary shall provide information only with respect 
to the total amount of the combined payments for services 
described in paragraph (1)(B)(i) and other services covered 
by the plan. 
‘‘(4) NO DISCRIMINATION ON BASIS OF PROVISION OF ABOR-
TION.—No qualified health plan offered through an Exchange 
may discriminate against any individual health care provider 
or health care facility because of its unwillingness to provide, 
pay for, provide coverage of, or refer for abortions 
‘‘(c) APPLICATION
OF STATE
AND FEDERAL LAWS REGARDING 
ABORTION.— 
‘‘(1) NO
PREEMPTION
OF
STATE
LAWS
REGARDING
ABOR-
TION.—Nothing in this Act shall be construed to preempt or 
otherwise have any effect on State laws regarding the prohibi-
tion of (or requirement of) coverage, funding, or procedural 
requirements 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 con-
strued 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 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 Social Security Act (popularly 
known as ‘EMTALA’).’’. 
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124 STAT. 900 
PUBLIC LAW 111–148—MAR. 23, 2010 
(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 regarding health, medical, and sci-
entific 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 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 sen-
tence and inserting ‘‘shall’’; and 
(2) by adding at the end the following: 
‘‘(3) TRANSPARENCY IN COVERAGE.— 
‘‘(A) IN GENERAL.—The Exchange shall require health 
plans seeking certification as qualified 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. 
‘‘(vii) Information on cost-sharing and payments 
with respect to any out-of-network 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 information 
required to be submitted under subparagraph (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 lan-
guage writing. The Secretary 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 certification as qualified 
health plans to permit individuals to learn the amount 
of cost-sharing (including deductibles, copayments, and 
Guidance. 
Definition. 
Public 
information. 
42 USC 18031. 
Definition. 
42 USC 18024. 
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124 STAT. 901 
PUBLIC LAW 111–148—MAR. 23, 2010 
coinsurance) under the individual’s plan or coverage that 
the individual would be responsible for paying with respect 
to the furnishing of a specific item or service by a partici-
pating provider in a timely manner upon the request of 
the individual. At a minimum, such information shall be 
made available to such individual through an Internet 
website and such other means for individuals without 
access to the Internet. 
‘‘(D) GROUP HEALTH PLANS.—The Secretary of Labor 
shall update and harmonize the Secretary’s rules con-
cerning the accurate and timely disclosure to participants 
by group health plans of plan disclosure, plan terms and 
conditions, and periodic financial disclosure with the stand-
ards 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 reduce health 
and health care disparities, including through the use of 
language services, community outreach, and cultural com-
petency trainings.’’. 
(h) Section 1311(i)(2)((B) of this Act is amended by striking 
‘‘small business development centers’’ and inserting ‘‘resource part-
ners 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 following: 
‘‘(4)(A) The court shall dismiss an action or claim under 
this section, unless opposed by the Government, if substantially 
the same allegations or transactions as alleged in the action 
or claim were publicly disclosed— 
‘‘(i) in a Federal criminal, civil, or administrative 
hearing in which the Government or its agent is a party; 
‘‘(ii) in a congressional, Government Accountability 
Office, or other Federal report, hearing, audit, or investiga-
tion; or 
‘‘(iii) from the news media, 
unless the action is brought by the Attorney General or the 
person bringing the action is an original source of the informa-
tion. 
‘‘(B) For purposes of this paragraph, ‘‘original source’’ 
means an individual who either (i) prior to a public disclosure 
under subsection (e)(4)(a), has voluntarily disclosed to the 
Definition. 
Courts. 
42 USC 18033 
note. 
42 USC 18032. 
42 USC 18031. 
Web posting. 
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124 STAT. 902 
PUBLIC LAW 111–148—MAR. 23, 2010 
Government the information on which allegations or trans-
actions in a claim are based, or (2) who has knowledge that 
is independent of and materially adds to the publicly disclosed 
allegations or transactions, and who has voluntarily provided 
the information to the Government before filing an action under 
this section.’’. 
(k) Section 1313(b) of this Act is amended— 
(1) in paragraph (3), by striking ‘‘and’’ at the end; 
(2) by redesignating paragraph (4) as paragraph (5); and 
(3) by inserting after paragraph (3) the following: 
‘‘(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 Exchanges 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 paragraph (4); and 
(2) by inserting after paragraph (2), the following: 
‘‘(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 regula-
tions with respect to the repayment of such loans and grants 
in a manner that is consistent with State solvency regulations 
and other similar State laws that may apply. In promulgating 
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 requirements, solvency regulations, and requisite sur-
plus note arrangements that must be constructed in a State 
to provide for such repayment prior to awarding 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 income 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 status’’. 
(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 amended 
by adding at the end the following: 
‘‘SEC. 1334. MULTI-STATE PLANS. 
‘‘(a) OVERSIGHT BY THE OFFICE OF PERSONNEL MANAGEMENT.— 
‘‘(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 
Contracts. 
42 USC 18054. 
42 USC 18053. 
42 USC 18051. 
42 USC 18044. 
42 USC 18043. 
Deadlines. 
Regulations. 
42 USC 18042. 
42 USC 18033. 
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124 STAT. 903 
PUBLIC LAW 111–148—MAR. 23, 2010 
include a group of health insurance issuers affiliated either 
by common ownership and control or by the common use of 
a nationally licensed service mark), without regard to section 
5 of title 41, United States Code, or other statutes requiring 
competitive bidding, to offer at least 2 multi-State qualified 
health plans through each Exchange in each State. Such plans 
shall provide individual, or in the case of small employers, 
group coverage. 
‘‘(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 termination by either party. In entering 
into such contracts, the Director shall ensure that health bene-
fits coverage is provided in accordance with the types of cov-
erage provided for under section 2701(a)(1)(A)(i) of the Public 
Health Service Act. 
‘‘(3) NON-PROFIT
ENTITIES.—In entering into contracts 
under paragraph (1), the Director shall ensure that at least 
one contract is entered into with a non-profit entity. 
‘‘(4) ADMINISTRATION.—The Director shall implement this 
subsection in a manner similar to the manner in which the 
Director implements the contracting provisions with respect 
to carriers under the Federal employees health benefit program 
under chapter 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 conditions defined by the Director 
with respect to the elements described in subparagraphs (A) 
through (D) of paragraph (4). 
‘‘(6) ASSURED
AVAILABILITY
OF
VARIED
COVERAGE.—In 
entering into contracts under this subsection, the Director shall 
ensure that with respect to multi-State qualified health plans 
offered in an Exchange, 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 sub-
section may be withdrawn by the Director 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 require-
ments of State law not inconsistent with this section, including 
the standards and requirements 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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124 STAT. 904 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(3) otherwise complies with the minimum standards pre-
scribed for carriers offering health benefits 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 appro-
priate 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 determina-
tion of the Director— 
‘‘(A) the plan offers a benefits package that is uniform 
in each State and consists of the essential benefits 
described in section 1302; 
‘‘(B) the plan meets all requirements of this title with 
respect to a qualified health plan, including 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 premiums for coverage under 
the plan on the basis of the rating requirements of part 
A of title XXVII of the Public Health Service Act; and 
‘‘(D) the issuer offers the plan in all geographic regions, 
and in all States that have adopted adjusted community 
rating before the date of enactment of this Act. 
‘‘(2) STATES MAY OFFER ADDITIONAL BENEFITS.—Nothing in 
paragraph (1)(A) shall preclude a State from requiring that 
benefits in addition to the essential health benefits required 
under such paragraph be provided to enrollees of a multi- 
State qualified health plan offered in such State. 
‘‘(3) CREDITS.— 
‘‘(A) IN GENERAL.—An individual enrolled in a multi- 
State qualified health plan under this section shall be 
eligible for credits under section 36B of the Internal Rev-
enue Code of 1986 and cost sharing assistance under sec-
tion 1402 in the same manner as an individual who is 
enrolled in a qualified health plan. 
‘‘(B) NO
ADDITIONAL
FEDERAL
COST.—A requirement 
by a State under paragraph (2) that benefits in addition 
to the essential health benefits required under paragraph 
(1)(A) be provided to enrollees of a multi-State qualified 
health plan shall not affect the amount of a premium 
tax credit provided under section 36B of the Internal Rev-
enue Code of 1986 with respect to such plan. 
‘‘(4) STATE MUST ASSUME COST.—A State shall make pay-
ments— 
‘‘(A) to an individual enrolled in a multi-State qualified 
health plan offered in such State; or 
‘‘(B) on behalf of an individual described in subpara-
graph (A) directly to the multi-State qualified health plan 
in which such individual is enrolled; 
to defray the cost of any additional benefits described in para-
graph (2). 
‘‘(5) APPLICATION
OF
CERTAIN
STATE
RATING
REQUIRE-
MENTS.—With respect to a multi-State qualified health plan 
that is offered in a State with age rating requirements that 
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124 STAT. 905 
PUBLIC LAW 111–148—MAR. 23, 2010 
are lower than 3:1, the State may require that Exchanges 
operating in such State only permit the offering of such multi- 
State qualified health plans if such plans comply with the 
State’s more protective age rating requirements. 
‘‘(d) PLANS DEEMED TO BE CERTIFIED.—A multi-State qualified 
health plan that is offered under a contract under subsection (a) 
shall be deemed to be certified by an Exchange for purposes of 
section 1311(d)(4)(A). 
‘‘(e) PHASE-IN.—Notwithstanding paragraphs (1) and (2) of sub-
section (b), the Director shall enter into a contract with a health 
insurance issuer for the offering of a multi-State qualified health 
plan under subsection (a) if— 
‘‘(1) with respect to the first year for which the issuer 
offers such plan, such issuer offers the plan in at least 60 
percent of the States; 
‘‘(2) with respect to the second such year, such issuer 
offers the plan in at least 70 percent of the States; 
‘‘(3) with respect to the third such year, such issuer offers 
the plan in at least 85 percent of the States; and 
‘‘(4) with respect to each subsequent year, such issuer 
offers the plan in all States. 
‘‘(f) APPLICABILITY.—The requirements under chapter 89 of title 
5, United States Code, applicable to health benefits plans under 
such chapter shall apply to multi-State qualified health plans pro-
vided for under this section to the extent that such requirements 
do not conflict with a provision of this title. 
‘‘(g) CONTINUED SUPPORT FOR FEHBP.— 
‘‘(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 Employees Health Benefit Program under chapter 89 
of title 5, United States Code. 
‘‘(2) SEPARATE RISK POOL.—Enrollees in multi-State quali-
fied 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
ENTITIES.—The 
Director may establish such separate units or offices within 
the Office of Personnel Management as the Director determines 
to be appropriate to ensure that the administration of multi- 
State qualified health plans under this section does not inter-
fere with the effective administration of the Federal Employees 
Health Benefit Program under chapter 89 of title 5, United 
States Code. 
‘‘(4) EFFECTIVE OVERSIGHT.—The Director may appoint such 
additional personnel as may be necessary to enable the Director 
to carry out activities under this section. 
‘‘(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. 
Contracts. 
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124 STAT. 906 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(6) FEHBP PLANS
NOT
REQUIRED
TO
PARTICIPATE.— 
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 activities 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 necessary to carry out 
this section.’’. 
(r) Section 1341 of this Act is amended— 
(1) in the section heading, by striking ‘‘AND SMALL GROUP 
MARKETS’’ and inserting ‘‘MARKET’’; 
(2) in subsection (b)(2)(B), by striking ‘‘paragraph (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 
inserting 
‘‘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 Revenue Code 
of 1986 is amended by inserting ‘36B,’ after ‘36A,’.’’. 
(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 paragraph for taxable years begin-
ning in 2010, 2011, 2012, or 2013 is $25,000. 
‘‘(ii) SUBSEQUENT YEARS.—In the case of a taxable 
year beginning in a calendar year after 2013, the dollar 
amount in effect under this paragraph shall be equal 
to $25,000, multiplied by the cost-of-living adjustment 
under section 1(f)(3) for the calendar year, determined 
by substituting ‘calendar year 2012’ for ‘calendar year 
1992’ in subparagraph (B) thereof.’’. 
(2) Subsection (g) of section 45R of the Internal Revenue 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’’. 
26 USC 280C. 
26 USC 45R. 
26 USC 6211. 
26 USC 36B. 
42 USC 18061. 
Establishment. 
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124 STAT. 907 
PUBLIC LAW 111–148—MAR. 23, 2010 
(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 APPLICATION OF 
FPL. 
‘‘(a) IN GENERAL.—The Secretary shall conduct a study to 
examine the feasibility and implication of adjusting the application 
of the Federal poverty level under this subtitle (and the amend-
ments made by this subtitle) for different 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 deter-
mines appropriate. 
‘‘(b) INCLUSION OF TERRITORIES.— 
‘‘(1) IN
GENERAL.—The Secretary shall ensure that the 
study under subsection (a) covers the territories of the United 
States and that special attention is paid to the disparity that 
exists among poverty levels 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 Virgin 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 commer-
cial and economic in nature: economic and financial 
decisions about how and when health care is paid for, 
and when health insurance is purchased. In the absence 
of the requirement, some individuals would make an eco-
nomic and financial decision to forego health insurance 
coverage and attempt to self-insure, which increases finan-
cial risks to households and medical providers. 
‘‘(B) Health insurance and health care services are 
a significant part of the national economy. National health 
spending is projected to increase 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 projected 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 insur-
ance is sold by national or regional health insurance compa-
nies, health insurance is sold in interstate commerce and 
claims payments flow through interstate commerce. 
42 USC 18091. 
Deadline. 
Reports. 
Recommenda- 
tions. 
Determination. 
26 USC 45R note. 
26 USC 38 note. 
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124 STAT. 908 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(C) The requirement, together with the other provi-
sions 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-universal coverage 
by building upon and strengthening the private employer- 
based health insurance system, which covers 176,000,000 
Americans nationwide. In Massachusetts, a similar require-
ment 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 
uninsured, the requirement, together with the other provi-
sions 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 increases family premiums by on average over 
$1,000 a year. By significantly reducing the number of 
the uninsured, the requirement, together with the other 
provisions of this Act, will lower health insurance pre-
miums. 
‘‘(G) 62 percent of all personal bankruptcies are caused 
in part by medical expenses. By significantly increasing 
health insurance coverage, the requirement, together with 
the other provisions of this Act, will improve financial 
security for families. 
‘‘(H) Under the Employee Retirement Income 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 
Government 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 undercut 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 pur-
chase health insurance until they needed care. By signifi-
cantly increasing health insurance coverage, the require-
ment, 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 insurance premiums. The requirement 
is essential to creating effective health insurance markets 
in 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 
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124 STAT. 909 
PUBLIC LAW 111–148—MAR. 23, 2010 
markets. By significantly increasing health insurance cov-
erage 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 administra-
tive costs and lower health insurance premiums. The 
requirement is essential to creating effective health insur-
ance markets that do not require underwriting and elimi-
nate 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 applicable indi-
vidual, 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 subsection (e), there is hereby imposed on the taxpayer 
a penalty with respect to such failures in the amount deter-
mined 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 taxable year with respect 
to failures described in subsection (b)(1) shall be equal to the 
lesser of— 
‘‘(A) the sum of the monthly penalty amounts deter-
mined 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 average 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 
beginning in the calendar year with or within which the 
taxable year ends. 
‘‘(2) MONTHLY PENALTY AMOUNTS.—For purposes of para-
graph (1)(A), the monthly penalty amount with respect to any 
taxpayer for any month during which any failure described 
in subsection (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 dollar 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 beginning in 2014. 
‘‘(ii) 1.0 percent for taxable years beginning in 
2015. 
‘‘(iii) 2.0 percent for taxable years beginning after 
2015.’’. 
26 USC 5000A. 
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124 STAT. 910 
PUBLIC LAW 111–148—MAR. 23, 2010 
(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’’. 
(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
EXEMPTION.—Such term 
shall not include any individual 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 described 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
RELATED
TO 
EMPLOYEES.—For purposes of subparagraph (B)(i), if an 
applicable individual is eligible for minimum essential cov-
erage through an employer by reason of a relationship 
to an employee, the determination under subparagraph 
(A) shall be made by reference to required contribution 
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 EXCEEDING 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-spon-
sored plan (as defined in section 5000A(f)(2)), there is hereby 
imposed on the employer 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’’. 
(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
INDUSTRY 
EMPLOYERS.—In the case of any employer the substantial 
annual gross receipts of which are attributable to the 
construction industry— 
‘‘(i) subparagraph (A) shall be applied by sub-
stituting ‘who employed an average of at least 5 full- 
time employees on business days during the preceding 
calendar year and whose annual payroll expenses 
Definition. 
26 USC 4980H. 
26 USC 5000A. 
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124 STAT. 911 
PUBLIC LAW 111–148—MAR. 23, 2010 
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 cal-
endar year’, and 
‘‘(ii) subparagraph (B) shall be applied by sub-
stituting ‘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: 
‘‘The Secretary shall have the authority to review the accuracy 
of the information provided under this subsection, including the 
applicable large employer’s share under paragraph (2)(C)(iv).’’. 
SEC. 10107. AMENDMENTS TO SUBTITLE G. 
(a) Section 1562 of this Act is amended, in the amendment 
made by subsection (a)(2)(B)(iii), by striking ‘‘subpart 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 COV-
ERAGE 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 subsection (b), by group health 
plans and health insurance issuers. 
‘‘(b) DATA.— 
‘‘(1) IN GENERAL.—In conducting the study described in 
subsection (a), the Comptroller General shall consider samples 
of data concerning the following: 
‘‘(A)(i) denials of coverage for medical services 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 application 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 denied. 
‘‘(2) SCOPE OF DATA.— 
‘‘(A) FAVORABLY RESOLVED DISPUTES.—The data that 
the Comptroller General considers under paragraph (1) 
shall include data concerning denials of coverage for med-
ical 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 insurance issuer 
later approves such coverage or application. 
‘‘(B) ALL HEALTH PLANS.—The study under this section 
shall consider data from varied group health plans and 
health insurance plans offered by health insurance issuers, 
26 USC 9815; 29 
USC 1185d; 42 
USC 300gg–1— 
300gg–3, 
300gg–9, 
300gg–11, 
300gg–12, 
300gg–21— 
300gg–23, 
300gg–25— 
300gg–28, 
300gg–62, 
300gg–91, 18120. 
42 USC 
300gg–21. 
26 USC 6056. 
Applicability. 
26 USC 4980H 
note. 
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124 STAT. 912 
PUBLIC LAW 111–148—MAR. 23, 2010 
including qualified health plans and health plans that are 
not qualified health plans. 
‘‘(c) REPORT.—Not later than one year after the date of enact-
ment of this Act, the Comptroller General shall submit 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 report 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 procurement 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 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 employer. 
(b) OFFERING EMPLOYER.—For purposes of this section, the 
term ‘‘offering employer’’ means any employer who— 
(1) offers minimum essential coverage to its employees 
consisting of coverage through an eligible employer-sponsored 
plan; and 
(2) pays any portion of the costs of such plan. 
(c) QUALIFIED EMPLOYEE.—For purposes of this section— 
(1) IN GENERAL.—The term ‘‘qualified employee’’ means, 
with respect to any plan year of an offering employer, any 
employee— 
(A) whose required contribution (as determined under 
section 5000A(e)(1)(B)) for minimum essential coverage 
through an eligible employer-sponsored plan— 
(i) exceeds 8 percent of such employee’s household 
income for the taxable year described 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 taxable year; 
(B) whose household income for such taxable year is 
not greater than 400 percent of the poverty 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 preceding calendar year and 2013 over the rate 
of income 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 
Definition. 
42 USC 18101. 
42 USC 18119. 
Public 
information. 
Web posting. 
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124 STAT. 913 
PUBLIC LAW 111–148—MAR. 23, 2010 
employer if the employee were covered under the plan 
with respect 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 employee elects family cov-
erage (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 
established 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 employer shall pay any amounts so credited to 
the Exchange. 
(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 the qualified employee is 
enrolled for such month, such excess shall be paid to the 
employee. 
(e) OTHER DEFINITIONS.—Any term used in this section 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 tax-
payer.’’. 
(2) CLERICAL AMENDMENT.—The table of sections 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 sub-
section shall apply to vouchers provided after December 31, 
2013. 
(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 Protection and Affordable Care Act shall be treated 
as an amount for compensation for personal services actually 
rendered.’’. 
26 USC 162. 
26 USC 139D 
note. 
26 USC 139D. 
Regulations. 
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124 STAT. 914 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) EFFECTIVE DATE.—The amendments made by this sub-
section 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 subpara-
graph: 
‘‘(D) EXCEPTION
FOR
INDIVIDUAL
RECEIVING
FREE 
CHOICE VOUCHERS.—The term ‘coverage month’ shall not 
include any month in which such individual has a free 
choice voucher provided under section 10108 of the Patient 
Protection and Affordable Care Act.’’. 
(2) EFFECTIVE DATE.—The amendment made by this sub-
section shall apply to taxable years beginning after December 
31, 2013. 
(i) COORDINATION WITH EMPLOYER RESPONSIBILITIES.— 
(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 PROVIDING FREE CHOICE 
VOUCHERS.—No assessable payment shall be imposed under 
paragraph (1) for any month with respect to any employee 
to whom the employer 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— 
(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 offering 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 employer’ 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 employer. 
‘‘(B) INDEXING.—In the case of any calendar year begin-
ning after 2014, the 8 percent under subparagraph (A) 
26 USC 6056. 
29 USC 218b. 
26 USC 4980H 
note. 
26 USC 4980H. 
26 USC 36B note. 
26 USC 36B. 
26 USC 162 note. 
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124 STAT. 915 
PUBLIC LAW 111–148—MAR. 23, 2010 
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 period. 
‘‘(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 applicable large 
employer,’’ before ‘‘the length’’ in clause (i); 
(ii) by striking ‘‘and’’ at the end of clause (iii); 
(iii) by striking ‘‘applicable large employer’’ in 
clause (iv) and inserting ‘‘employer’’; 
(iv) by inserting ‘‘and’’ at the end of clause (iv); 
and 
(v) by inserting at the end the following new 
clause: 
‘‘(v) in the case of an offering employer, 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 categories 
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 amended by 
inserting ‘‘or offering employer’’ after ‘‘applicable 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 by striking ‘‘Large employers’’ 
in the item relating to section 6056 and inserting ‘‘Certain 
employers’’. 
(4) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply to periods beginning after December 31, 
2013. 
SEC. 10109. DEVELOPMENT OF STANDARDS FOR FINANCIAL AND 
ADMINISTRATIVE TRANSACTIONS. 
(a) ADDITIONAL
TRANSACTION
STANDARDS
AND
OPERATING 
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 amended— 
(A) in paragraph (1)(B), by inserting before the period 
the following: ‘‘, and subject to the requirements under 
paragraph (5)’’; and 
26 USC 6056 
note. 
26 USC 6056. 
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124 STAT. 916 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) by adding at the end the following new paragraph: 
‘‘(5) CONSIDERATION
OF
STANDARDIZATION
OF
ACTIVITIES 
AND ITEMS.— 
‘‘(A) IN GENERAL.—For purposes of carrying out para-
graph (1)(B), the Secretary shall solicit, not later than 
January 1, 2012, and not less than every 3 years thereafter, 
input from entities described in subparagraph (B) on— 
‘‘(i) whether there could be greater uniformity in 
financial and administrative activities and items, as 
determined appropriate 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 stand-
ards and operating rules would improve the operation 
of the health care system and reduce administrative 
costs. 
‘‘(B) SOLICITATION OF INPUT.—For purposes of subpara-
graph (A), the Secretary shall seek input from— 
‘‘(i) the National Committee on Vital and Health 
Statistics, the Health Information Technology Policy 
Committee, and the Health Information Technology 
Standards Committee; and 
‘‘(ii) standard setting organizations and stake-
holders, as determined appropriate by the Secretary.’’. 
(b) ACTIVITIES AND ITEMS FOR INITIAL CONSIDERATION.—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 pro-
viders by health plans could be made electronic and standard-
ized. 
(2) Whether standards and operating rules described in 
section 1173 of the Social Security Act should apply to the 
health care transactions of automobile insurance, worker’s com-
pensation, 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 Office 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. 
(4) Whether there could be greater transparency and 
consistency of methodologies and processes used to establish 
claim edits used by health plans (as described 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 Secretary shall task 
the ICD–9–CM Coordination and Maintenance Committee to 
convene a meeting, not later than January 1, 2011, to receive 
input from appropriate stakeholders (including health plans, 
health care providers, and clinicians) regarding the crosswalk 
Meeting. 
Deadline. 
Deadline. 
Deadlines. 
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124 STAT. 917 
PUBLIC LAW 111–148—MAR. 23, 2010 
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 appro-
priate revisions to such crosswalk. 
(2) REVISION OF CROSSWALK.—For purposes of the cross-
walk described in paragraph (1), the Secretary shall make 
appropriate revisions and post any such revised crosswalk on 
the website of the Centers for Medicare & Medicaid Services. 
(3) USE OF REVISED CROSSWALK.—For purposes of para-
graph (2), any revised crosswalk shall be treated as a code 
set for which a standard has been adopted 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 Diseases 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 subsequent 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 Security Act 
(42 U.S.C. 1396a(a)(10)(A)(i)(IX)), as added by section 2004(a), is 
amended to read as follows: 
‘‘(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 
subclauses but have income that exceeds the 
level of income applicable under the State plan 
for eligibility to enroll for medical assistance 
under such subclause; 
‘‘(cc) were in foster care under the respon-
sibility 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 striking ‘‘and (XV)’’ and 
inserting ‘‘(XV)’’, and by inserting ‘‘and (XVI) if an individual is 
described in subclause (IX) of subparagraph (A)(i) and is also 
described in subclause (VIII) of that subparagraph, the medical 
Deadline. 
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124 STAT. 918 
PUBLIC LAW 111–148—MAR. 23, 2010 
assistance shall be made available to the individual through sub-
clause (IX) instead of through subclause (VIII)’’ before the semicolon. 
(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 inserting 
‘‘, (z),’’ before ‘‘and (aa)’’; 
(3) in subsection (y)— 
(A) in paragraph (1)(B)(ii)(II), in the first sentence, 
by inserting ‘‘includes inpatient hospital 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 following: 
‘‘(z) EQUITABLE SUPPORT FOR CERTAIN STATES.— 
‘‘(1)(A) During the period that begins on January 1, 2014, 
and ends on September 30, 2019, notwithstanding subsection 
(b), the Federal medical assistance percentage otherwise deter-
mined under subsection (b) with respect to a fiscal year occur-
ring during that period shall be increased by 2.2 percentage 
points for any State described in subparagraph (B) for amounts 
expended for medical assistance for individuals who are not 
newly eligible (as defined in subsection (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 subsection 
(y)(1)(B)(ii)(II); 
‘‘(ii) the Secretary determines will not receive any pay-
ments under this title on the basis of an increased Federal 
medical assistance percentage under subsection (y) for 
expenditures for medical assistance for newly eligible 
individuals (as so defined); and 
‘‘(iii) has not been approved by the Secretary to divert 
a portion of the DSH allotment for a State to the costs 
of providing medical assistance 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 subsection (b), 
the Federal medical assistance percentage otherwise 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 described in subparagraph (B) for amounts 
expended for medical 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 described in 
this subparagraph is a State that— 
Time period. 
Time period. 
42 USC 1396a 
note. 
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124 STAT. 919 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) is described in clauses (i) and (ii) of paragraph (1)(B); 
and 
‘‘(ii) is the State with the highest percentage of its popu-
lation insured during 2008, based on the Current Population 
Survey. 
‘‘(3) Notwithstanding subsection (b) and paragraphs (1) and 
(2) of this subsection, the Federal medical assistance 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 sub-
section (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)’’ and inserting 
‘‘without regard to this subsection, subsection (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.—Notwithstanding 
subsections (y), (z), and (aa), in the case of a State that requires 
political subdivisions within the State to contribute toward the 
non-Federal share of expenditures required 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 
section 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 contributions 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 contribu-
tions for purposes of this subsection. The treatment of voluntary 
contributions, and the treatment of contributions required by a 
State under the State plan under this title, or State law, as provided 
by this subsection, shall also apply to the increases 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’’. 
Applicability. 
Nebraska. 
Determination. 
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124 STAT. 920 
PUBLIC LAW 111–148—MAR. 23, 2010 
(e)(1) Section 1923(f) of the Social Security Act (42 U.S.C. 
1396r–4(f)), as amended by section 2551, is amended— 
(A) in paragraph (6)— 
(i) by striking the paragraph heading and inserting 
the following: ‘‘ALLOTMENT ADJUSTMENTS’’; 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 YEARS.—Notwithstanding the table set forth in 
paragraph (2) or paragraph (7): 
‘‘(I) 2D, 3RD, AND 4TH QUARTER OF FISCAL YEAR 
2012.—The DSH allotment 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 SUCCEEDING 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 allot-
ments for low DSH States are increased for such 
fiscal year under clause (iii) of paragraph (5)(B). 
‘‘(III) CERTAIN HOSPITAL PAYMENTS.—The Sec-
retary may not impose a limitation on the total 
amount of payments made to hospitals under the 
QUEST section 1115 Demonstration Project except 
to the extent that such limitation is necessary 
to ensure that a hospital does not receive payments 
in excess of the amounts described in subsection 
(g), or as necessary 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 Fed-
eral medical assistance percentage component 
attributable to disproportionate share hospital pay-
ment adjustments 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 preceding clause 
(i), by striking ‘‘subparagraph (E)’’ and inserting ‘‘subpara-
graphs (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 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 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 
Hawaii. 
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124 STAT. 921 
PUBLIC LAW 111–148—MAR. 23, 2010 
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 per-
cent; 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 September 30, 2009, the 
applicable percentage is equal to 35 percent.’’; 
(II) in clause (ii), 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 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 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 equal to the product of the percent-
age 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 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 40 percent.’’; 
(III) in subparagraph (E), by striking ‘‘35 percent’’ 
and inserting ‘‘50 percent’’; and 
(IV) by adding at the end the following: 
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124 STAT. 922 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(G) NONAPPLICATION.—The preceding provisions of 
this paragraph shall not apply to the DSH allotment deter-
mined for the State of Hawaii 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.’’. 
(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 following: 
‘‘(d)(1) An application or renewal of any experimental, pilot, 
or demonstration project undertaken under subsection (a) to pro-
mote 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 subsection referred to as a ‘demonstration project’) 
shall be considered by the Secretary in accordance with the regula-
tions required to be promulgated under paragraph (2). 
‘‘(2) Not later than 180 days after the date of enactment of 
this subsection, the Secretary shall promulgate regulations 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 meaning-
ful level of public input; 
‘‘(B) requirements relating to— 
‘‘(i) the goals of the program to be implemented 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 ensure 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 Secretary, that is suffi-
cient to ensure a meaningful level of public input; 
‘‘(D) a process for the submission to the Secretary of peri-
odic 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.’’. 
Deadline. 
Reports. 
Deadline. 
Regulations. 
42 USC 713. 
42 USC 1396r–4 
note. 
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124 STAT. 923 
PUBLIC LAW 111–148—MAR. 23, 2010 
(j) Subtitle F of title III of this Act is amended by adding 
at the end the following: 
‘‘SEC. 3512. GAO STUDY AND REPORT ON CAUSES OF ACTION. 
‘‘(a) STUDY.— 
‘‘(1) IN GENERAL.—The Comptroller General of the United 
States shall conduct a study of whether the development, rec-
ognition, or implementation of any guideline or other standards 
under a provision described in paragraph (2) would result in 
the establishment 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 Pro-
gram). 
‘‘(D) Section 3002 (improvements to the Physician 
Quality Reporting Initiative). 
‘‘(E) Section 3003 (improvements to the Physician Feed-
back Program). 
‘‘(F) Section 3007 (value based payment modifier under 
physician fee schedule). 
‘‘(G) Section 3008 (payment adjustment for conditions 
acquired in hospitals). 
‘‘(H) Section 3013 (quality measure development). 
‘‘(I) Section 3014 (quality measurement). 
‘‘(J) Section 3021 (Establishment of Center for Medi-
care and Medicaid Innovation). 
‘‘(K) Section 3025 (hospital readmission reduction pro-
gram). 
‘‘(L) Section 3501 (health care delivery system research, 
quality improvement). 
‘‘(M) Section 4003 (Task Force on Clinical and Preven-
tive Services). 
‘‘(N) Section 4301 (research to optimize deliver of public 
health services). 
‘‘(b) REPORT.—Not later than 2 years after the date of enact-
ment 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 COMMU-
NITY-BASED SERVICES AS A LONG-TERM CARE ALTER-
NATIVE TO NURSING HOMES. 
(a) STATE BALANCING INCENTIVE PAYMENTS PROGRAM.—Not-
withstanding section 1905(b) of the Social Security Act (42 U.S.C. 
1396d(b)), in the case of a balancing 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 sec-
tion 1905(b) of such Act and, if applicable, increased under sub-
section (z) or (aa) shall be increased by the applicable percentage 
points determined under subsection (d) with respect to eligible 
medical assistance expenditures described in subsection (e). 
(b) BALANCING INCENTIVE PAYMENT STATE.—A balancing incen-
tive payment State is a State— 
42 USC 1396d 
note. 
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124 STAT. 924 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) in which less than 50 percent of the total expenditures 
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-institution-
ally-based long-term services and supports described in sub-
section (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 participate in the 
State balancing incentive payment program established under 
this section. 
(c) CONDITIONS.—The conditions described in this subsection 
are the following: 
(1) APPLICATION.—The State submits an application to the 
Secretary that includes, in addition to such other information 
as the Secretary shall require— 
(A) a proposed budget that details the State’s plan 
to expand and diversify medical assistance for non-institu-
tionally-based long-term services and supports described 
in subsection (f)(1)(B) under the State Medicaid program 
during the balancing incentive period and achieve the tar-
get spending percentage applicable to the State under para-
graph (2), including through structural changes to how 
the State furnishes such assistance, such as through the 
establishment of a ‘‘no wrong door—single entry point 
system’’, optional presumptive eligibility, case management 
services, and the use of core standardized assessment 
instruments, and that includes a description of the new 
or expanded offerings of such services that the State will 
provide 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 amend-
ment under section 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 exceed 300 percent of the supple-
mental security income 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 Med-
icaid program for fiscal year 2009 are for home and commu-
nity-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 community-based services. 
(B) In the case of any other balancing incentive pay-
ment State, the target spending percentage for the State 
to achieve by not later than October 1, 2015, is that 50 
percent of the total expenditures for long-term services 
and supports under the State Medicaid program are for 
home and community-based services. 
Deadlines. 
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124 STAT. 925 
PUBLIC LAW 111–148—MAR. 23, 2010 
(3) MAINTENANCE
OF
ELIGIBILITY
REQUIREMENTS.—The 
State does not apply eligibility standards, methodologies, or 
procedures for determining eligibility 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-institutionally-based long-term services and 
supports described 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 application under this section, the 
following changes: 
(A) ‘‘NO WRONG DOOR—SINGLE ENTRY POINT SYSTEM’’.— 
Development of a statewide 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 information regarding the avail-
ability of such services, how to apply for such services, 
referral services for services and supports otherwise avail-
able 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.—Con-
flict-free case management services to develop a service 
plan, arrange for services and supports, support the bene-
ficiary (and, if appropriate, the beneficiary’s caregivers) 
in directing the provision of services and supports for the 
beneficiary, and conduct ongoing monitoring to assure that 
services and supports are delivered to meet the bene-
ficiary’s needs and achieve intended outcomes. 
(C) CORE STANDARDIZED ASSESSMENT INSTRUMENTS.— 
Development of core standardized assessment instruments 
for determining eligibility for non-institutionally-based 
long-term services and supports described in subsection 
(f)(1)(B), which shall be used in a uniform manner through-
out the State, to determine a beneficiary’s needs for 
training, support services, medical care, transportation, and 
other services, and develop an individual service plan to 
address such needs. 
(6) DATA COLLECTION.—The State agrees to collect from 
providers of services and through such other means as the 
State determines appropriate the following 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 accordance with such standardized coding proce-
dures as the State shall establish in consultation with 
the Secretary. 
Procedures. 
Standards. 
Deadline. 
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124 STAT. 926 
PUBLIC LAW 111–148—MAR. 23, 2010 
(B) QUALITY
DATA.—Quality data on a selected set 
of core quality measures agreed upon by the Secretary 
and the State that are linked to population-specific out-
comes measures and accessible to providers. 
(C) OUTCOMES MEASURES.—Outcomes measures data 
on a selected set of core population-specific outcomes meas-
ures 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 beneficiary, including employ-
ment, participation 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 described in sub-
section (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 EXPENDITURES.— 
(1) IN GENERAL.—Subject to paragraph (2), medical assist-
ance described in this subsection is medical 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 aggre-
gate amount of payments made by the Secretary to balancing 
incentive payment States under this section during the bal-
ancing incentive period exceed $3,000,000,000. 
(f) DEFINITIONS.—In this section: 
(1) LONG-TERM
SERVICES
AND
SUPPORTS
DEFINED.—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 purposes 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 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 following: 
(i) Home and community-based services 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. 
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124 STAT. 927 
PUBLIC LAW 111–148—MAR. 23, 2010 
(iv) Services described in subsection (a)(26) of sec-
tion 1905 of such Act (relating to PACE program serv-
ices). 
(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)). 
(4) STATE MEDICAID PROGRAM.—The term ‘‘State Medicaid 
program’’ means the State program for medical assistance pro-
vided 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 striking ‘‘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 annually 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 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 subpara-
graph (A) of section 2003(a)(1) of this Act and that subpara-
graph 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 sentence, by 
inserting before the period the following: ‘‘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 subpara-
graph (M). 
(4) Section 2105(c)(3)(A) of the Social Security Act (42 
U.S.C. 1397ee(c)(3)(A)) is amended— 
(A) in the matter preceding clause (i), by striking ‘‘to’’ 
and inserting ‘‘to—’’; and 
Applicability. 
42 USC 1396e–1 
and note. 
Effective date. 
42 USC 1396e 
note. 
Reports. 
Deadline. 
42 USC 18031. 
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124 STAT. 928 
PUBLIC LAW 111–148—MAR. 23, 2010 
(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, enrolling children 
eligible to be targeted low-income children under the 
State child health plan in a qualified health plan that 
has been certified by the Secretary under subparagraph 
(C); or’’; 
(B) in subparagraph (B), by striking ‘‘provided cov-
erage’’ and inserting ‘‘screened for eligibility 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 result 
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 review the benefits offered for children and 
the cost-sharing imposed with respect to such benefits by 
qualified health plans offered through an Exchange estab-
lished by the State under section 1311 of the Patient Protec-
tion and Affordable Care Act and shall certify those plans 
that offer benefits for children and impose cost-sharing 
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 making 2 semi- 
annual allotments— 
‘‘(A) $2,850,000,000 for the period beginning on October 
1, 2014, and ending on March 31, 2015, and 
‘‘(B) $2,850,000,000 for the period beginning on April 
1, 2015, and ending on September 30, 2015.’’. 
Deadline. 
Review. 
Determination. 
Procedures. 
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124 STAT. 929 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2)(A) Section 2104(m) of such Act (42 U.S.C. 1397dd(m)), as 
amended by section 2102(a)(1), is amended— 
(i) in the subsection heading, by striking ‘‘2013’’ and 
inserting ‘‘2015’’; 
(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 para-
graphs (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 territory) 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 allotments 
available under this section to the State in fiscal year 
2012 (including payments made to the State under 
subsection (n) for fiscal year 2012 as well as amounts 
redistributed to the State in fiscal year 2012), multi-
plied by the allotment increase factor under paragraph 
(5) for fiscal year 2013. 
‘‘(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 allotment 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 para-
graph (5) for fiscal year 2014.’’; 
(iii) in paragraph (3)— 
(I) in the paragraph heading, by striking ‘‘2013’’ 
and inserting ‘‘2015’’; 
(II) in subparagraphs (A) and (B), by striking 
‘‘paragraph (16)’’ each place it appears 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 inserting ‘‘2015’’; 
and 
(IV) in subparagraph (D)— 
(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 
Allotment. 
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124 STAT. 930 
PUBLIC LAW 111–148—MAR. 23, 2010 
(II) in the flush language after and below subpara-
graph (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 striking ‘‘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)— 
(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 allot-
ment period for fiscal year 2013’’ and inserting ‘‘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: 
‘‘(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 RESPECT TO PER 
PERSON AGENCY CONTRIBUTION FOR FAMILY COVERAGE.— 
For purposes of subparagraph (A)(i), a public agency satis-
fies this subparagraph if the amount of annual agency 
expenditures made on behalf of each employee enrolled 
in health coverage paid for by the agency that includes 
dependent coverage for the most recent 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 percentage increase in the medical care expenditure 
category of the Consumer Price Index for All-Urban Con-
sumers (all items: U.S. City Average) for such preceding 
fiscal year. 
‘‘(C) HARDSHIP EXCEPTION.—For purposes of subpara-
graph (A)(ii), this subparagraph applies to a child if the 
State determines, on a case-by-case basis, that the annual 
aggregate amount of premiums and cost-sharing imposed 
Applicability. 
Applicability. 
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124 STAT. 931 
PUBLIC LAW 111–148—MAR. 23, 2010 
for coverage of the family of the child would exceed 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 accompany the allotment made 
for the period beginning on October 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. 
Such amount shall be used to provide allotments to States under 
paragraph (3) of section 2104(m) of the Social Security Act (42 
U.S.C. 1397dd(m)) for the first 6 months of fiscal year 2015 in 
the same manner as allotments are provided 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 sub-
section (a)(18)(A).’’. 
PART II—SUPPORT FOR PREGNANT AND 
PARENTING TEENS AND WOMEN 
SEC. 10211. DEFINITIONS. 
In this part: 
(1) ACCOMPANIMENT.—The term ‘‘accompaniment’’ means 
assisting, representing, and accompanying a woman in seeking 
judicial relief for child support, child custody, restraining 
orders, and restitution for harm to persons and property, and 
in filing criminal charges, and may include the payment of 
court costs and reasonable attorney and witness fees associated 
therewith. 
(2) ELIGIBLE INSTITUTION OF HIGHER EDUCATION.—The term 
‘‘eligible institution of higher education’’ 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 established and operates, or agrees to establish and operate 
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 organization that provides 
social services to residents of a specific geographical area via 
direct service or by contract 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 ‘‘intervention serv-
ices’’ means, with respect to domestic violence, 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. 
42 USC 18201. 
Applicability. 
Time period. 
123 Stat. 25. 
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124 STAT. 932 
PUBLIC LAW 111–148—MAR. 23, 2010 
(7) STATE.—The term ‘‘State’’ includes the District 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 individual and group counseling 
aimed at preventing domestic violence, sexual violence, sexual 
assault, or stalking. 
(9) VIOLENCE.—The term ‘‘violence’’ means actual violence 
and the risk or threat of violence. 
SEC. 10212. ESTABLISHMENT OF PREGNANCY ASSISTANCE FUND. 
(a) IN GENERAL.—The Secretary, in collaboration and coordina-
tion with the Secretary of Education (as appropriate), 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 parenting teens and women. 
(b) USE OF FUND.—A State may apply for a grant under sub-
section (a) to carry out any activities provided for in section 10213. 
(c) APPLICATIONS.—To be eligible to receive a grant under sub-
section (a), a State shall submit to the Secretary an application 
at such time, in such manner, and containing such information 
as the Secretary may require, including a description of the pur-
poses for which the grant is being requested and the designation 
of a State agency for receipt and administration of funding received 
under this part. 
SEC. 10213. PERMISSIBLE USES OF FUND. 
(a) IN GENERAL.—A State shall use amounts received under 
a grant under section 10212 for the purposes described in this 
section to assist pregnant and parenting teens and women. 
(b) INSTITUTIONS OF HIGHER EDUCATION.— 
(1) IN GENERAL.—A State may use amounts received under 
a grant under section 10212 to make funding available to 
eligible institutions of higher education to enable the eligible 
institutions to establish, maintain, or operate pregnant and 
parenting student services. Such funding shall be used to 
supplement, not supplant, existing funding for such services. 
(2) APPLICATION.—An eligible institution of higher edu-
cation that desires to receive funding under this subsection 
shall submit an application to the designated State agency 
at such time, in such manner, and containing such information 
as the State agency may require. 
(3) MATCHING
REQUIREMENT.—An eligible institution of 
higher education that receives funding under this subsection 
shall contribute to the conduct of the pregnant and parenting 
student services office supported by the funding an amount 
from non-Federal funds equal to 25 percent of the amount 
of the funding provided. The non-Federal share may be in 
cash or in-kind, fairly evaluated, including services, facilities, 
supplies, or equipment. 
(4) USE OF FUNDS FOR ASSISTING PREGNANT AND PARENTING 
COLLEGE STUDENTS.—An eligible institution 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: 
Grants. 
42 USC 18203. 
Grants. 
42 USC 18202. 
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124 STAT. 933 
PUBLIC LAW 111–148—MAR. 23, 2010 
(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, par-
enting, and prospective parenting students; and 
(II) improving access to such resources. 
(B) Annually assess the performance of the eligible 
institution in meeting the following needs 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 programs, to enable pregnant 
or parenting students to continue their education or 
stay in school. 
(v) Education to improve parenting skills for moth-
ers and fathers and to strengthen marriages. 
(vi) Maternity and baby clothing, baby food 
(including formula), baby furniture, and similar items 
to assist parents and prospective parents in meeting 
the material needs of their children. 
(vii) Post-partum counseling. 
(C) Identify public and private service providers, 
located on the campus of the eligible institution or within 
the local community, that are qualified to meet the needs 
described in subparagraph (B), and establishes programs 
with qualified providers to meet such needs. 
(D) Assist pregnant and parenting students, fathers 
or spouses in locating and obtaining services that meet 
the needs described in subparagraph (B). 
(E) If appropriate, provide referrals for prenatal care 
and delivery, infant or foster care, or adoption, to a student 
who requests such information. 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 par-
enting or placing the child for adoption. 
(iv) Parenting or prospective parenting couples. 
(5) REPORTING.— 
(A) ANNUAL REPORT BY INSTITUTIONS.— 
(i) IN
GENERAL.—For each fiscal year that an 
eligible institution of higher education receives funds 
under this subsection, the eligible institution shall pre-
pare and submit to the State, by the date determined 
by the State, a report that— 
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124 STAT. 934 
PUBLIC LAW 111–148—MAR. 23, 2010 
(I) itemizes the pregnant and parenting stu-
dent services office’s expenditures for the fiscal 
year; 
(II) contains a review and evaluation of the 
performance of the office in fulfilling the require-
ments of this section, using the specific perform-
ance 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 frequency of use of the office by such 
students. 
(ii) PERFORMANCE CRITERIA.—Not later than 180 
days before the date the annual report described in 
clause (i) is submitted, the State— 
(I) shall identify the specific performance cri-
teria or standards that shall be used to prepare 
the report; and 
(II) may establish the form or format of the 
report. 
(B) REPORT BY STATE.—The State shall annually pre-
pare and submit a report on the findings under this sub-
section, including the number of eligible institutions of 
higher education that were awarded funds and the number 
of students served by each pregnant and parenting 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 par-
enting 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 
purposes of this subsection. 
(d) IMPROVING SERVICES FOR PREGNANT WOMEN WHO ARE VIC-
TIMS OF DOMESTIC VIOLENCE, SEXUAL VIOLENCE, SEXUAL ASSAULT, 
AND STALKING.— 
(1) IN GENERAL.—A State may use amounts received under 
a grant under section 10212 to make funding available tp 
its State Attorney General to assist Statewide offices in pro-
viding— 
(A) intervention services, accompaniment, and sup-
portive social services for eligible pregnant women who 
are victims of domestic violence, 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, social service, 
and health care settings. 
(iii) Nonprofit organizations. 
(iv) Faith-based organizations. 
Deadline. 
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124 STAT. 935 
PUBLIC LAW 111–148—MAR. 23, 2010 
(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 DESCRIBED.—For 
purposes of paragraph (1)(B), technical assistance and training 
is— 
(A) the identification of eligible pregnant women 
experiencing domestic violence, sexual violence, 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 stalking on the pregnant woman’s 
health, and the assistance of the pregnant woman in devel-
oping a plan aimed at preventing further domestic violence, 
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 referrals made, recording the location 
and nature of the pregnant woman’s injuries, and the 
establishment 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 private nonprofit entities 
that provide intervention services, accompaniment, and 
supportive social services. 
(4) ELIGIBLE PREGNANT WOMAN.—In this subsection, the 
term ‘‘eligible pregnant woman’’ means 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 awareness and education con-
cerning 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 appro-
priated, $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 Indian Affairs of the Senate in 
December 2009, is enacted into law. 
(b) AMENDMENTS.— 
Incorporation by 
reference. 
25 USC 1601 
et seq. 
42 USC 18204. 
Guidelines. 
Definition. 
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124 STAT. 936 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) Section 119 of the Indian Health Care Improvement 
Act (as amended by section 111 of the bill referred to in sub-
section (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 ORGANIZATION.— 
‘‘(A) IN GENERAL.—Subparagraph (B) of paragraph (2) 
shall not apply in the case of an election made by an 
Indian tribe or tribal organization located in a State (other 
than Alaska) in which the use of dental health aide thera-
pist services or midlevel dental health provider services 
is authorized under State law to supply such services in 
accordance with State law. 
‘‘(B) ACTION
BY
SECRETARY.—On an election by an 
Indian tribe or tribal organization under subparagraph (A), 
the Secretary, acting through the Service, shall facilitate 
implementation of the services elected. 
‘‘(4) VACANCIES.—The Secretary shall not fill any vacancy 
for a certified dentist in a program operated by the Service 
with a dental health aide therapist.’’; 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 schol-
arships for certain purposes). 
(3) Section 806 of the Indian Health Care Improvement 
Act (25 U.S.C. 1676) is amended— 
(A) by striking ‘‘Any limitation’’ and inserting the fol-
lowing: 
‘‘(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 apply with respect to the 
performance or coverage of abortions.’’. 
(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 PROGRAM FOR 
AMBULATORY SURGICAL CENTERS. 
(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 program for payments 
under the Medicare program under title XVIII of the Social 
42 USC 1395l, 
1395qq. 
Applicability. 
Abortions. 
25 USC 1616r. 
25 USC 1616l. 
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124 STAT. 937 
PUBLIC LAW 111–148—MAR. 23, 2010 
Security Act for ambulatory 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 following issues: 
‘‘(A) The ongoing development, selection, and modifica-
tion process for measures (including under section 1890 
of the Social Security Act (42 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 validation of quality 
data. 
‘‘(C) The structure of value-based payment adjust-
ments, including the determination of thresholds or 
improvements in quality that would substantiate a pay-
ment adjustment, the size of such payments, and the 
sources of funding for the value-based bonus payments. 
‘‘(D) Methods for the public disclosure of information 
on the performance of ambulatory surgical centers. 
‘‘(E) Any other issues determined appropriate by the 
Secretary. 
‘‘(3) CONSULTATION.—In developing the plan under para-
graph (1), the Secretary shall— 
‘‘(A) consult with relevant affected parties; and 
‘‘(B) consider experience with such demonstrations that 
the Secretary determines are relevant to the value-based 
purchasing program described in paragraph (1). 
‘‘(4) REPORT TO CONGRESS.—Not later than January 1, 2011, 
the Secretary shall submit to Congress 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 
QUALITY 
IMPROVEMENT IN HEALTH CARE. 
Section 399HH(a)(2)(B)(iii) of the Public Health Service Act, 
as added by section 3011, is amended by inserting ‘‘(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 periodi-
cally update (not less than every 3 years), provider-level out-
come measures for hospitals and physicians, as well as other 
providers as determined appropriate by the Secretary. 
‘‘(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 dis-
eases, including, to the extent feasible, the 5 most prevalent 
and resource-intensive acute and chronic medical condi-
tions; and 
‘‘(B) outcome measurement for primary and preventa-
tive care, including, to the extent feasible, measurements 
Deadline. 
42 USC 299b–31. 
42 USC 280j. 
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124 STAT. 938 
PUBLIC LAW 111–148—MAR. 23, 2010 
that cover provision of such care for distinct patient popu-
lations (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 adjustment, account-
ability, 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). 
‘‘(B) PRIMARY AND PREVENTIVE CARE.—Not later than 
36 months after the date of enactment 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 Secretary 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 infec-
tions.’’. 
(c) CLINICAL PRACTICE GUIDELINES.—Section 304(b) of the Medi-
care 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 sub-
mitted 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 (1) and the best methods identified by 
the Institute for the purpose of identifying existing and 
new clinical practice guidelines that were developed using 
such best methods, including guidelines listed in the 
National Guideline Clearinghouse. 
‘‘(B) CONSULTATION.—In carrying out the identification 
process under subparagraph (A), the Secretary shall allow 
for consultation with professional societies, voluntary 
health care organizations, 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.— 
42 USC 280j–1. 
42 USC 1395aaa, 
1395aaa–1. 
Deadline. 
Contracts. 
42 USC 299 note. 
Public 
information. 
42 USC 
1395aaa–1. 
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124 STAT. 939 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) ESTABLISHMENT OF STRATEGIC FRAMEWORK.—The Sec-
retary shall establish and implement an overall strategic frame-
work to carry out the public reporting of performance informa-
tion, as described in section 399JJ. Such strategic framework 
may include methods and related timelines for implementing 
nationally consistent data collection, data aggregation, and 
analysis methods. 
‘‘(2) COLLECTION
AND
AGGREGATION
OF
DATA.—The Sec-
retary shall collect and aggregate consistent data on quality 
and resource use measures from information systems used to 
support health care delivery, and may award grants or contracts 
for this purpose. The Secretary shall align such collection and 
aggregation efforts with the requirements and assistance 
regarding the expansion of health information technology sys-
tems, 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 increasingly broad range of patient 
populations, providers, 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— 
(1) in subsection (a), by inserting at the end the following 
new paragraph: 
‘‘(5) TESTING WITHIN CERTAIN GEOGRAPHIC AREAS.—For pur-
poses 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 pre-
ceding sentence may include’’ and inserting ‘‘this 
subparagraph may include, but are not limited to,’’; 
and 
(ii) by inserting after the first sentence the fol-
lowing new sentence: ‘‘The Secretary shall focus on 
models expected to reduce program costs under the 
applicable title while preserving or enhancing the 
quality of care received by individuals receiving bene-
fits under such title.’’; 
(B) in subparagraph (B), by adding at the end the 
following new clauses: 
‘‘(xix) Utilizing, in particular in entities located 
in medically underserved areas and facilities of the 
Indian Health Service (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-specialized medical providers to 
42 USC 1315a. 
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124 STAT. 940 
PUBLIC LAW 111–148—MAR. 23, 2010 
provide health services for patients with chronic 
complex conditions. 
‘‘(xx) Utilizing a diverse network of providers of 
services and suppliers to improve care coordination 
for applicable individuals described in subsection 
(a)(4)(A)(i) with 2 or more chronic conditions and a 
history of prior-year hospitalization through interven-
tions developed under the Medicare Coordinated Care 
Demonstration Project under section 4016 of the Bal-
anced Budget Act of 1997 (42 U.S.C. 1395b–1 note).’’; 
and 
(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 ‘‘patient 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 increase in) net program 
spending under applicable titles; and’’; and 
(C) by adding at the end the following: 
‘‘(3) the Secretary determines that such expansion would 
not deny or limit the coverage or provision of benefits under 
the applicable title for applicable 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 PRO-
GRAM. 
Section 1899 of the Social Security Act, as added by section 
3022, is amended by adding at the end the following new sub-
sections: 
‘‘(i) OPTION TO USE OTHER PAYMENT MODELS.— 
‘‘(1) IN GENERAL.—If the Secretary determines appropriate, 
the Secretary may use any of the payment 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 subparagraph (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’ services 
or all items and services under part B. The Secretary 
Determination. 
42 USC 1395jjj. 
Determination. 
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124 STAT. 941 
PUBLIC LAW 111–148—MAR. 23, 2010 
may limit a partial capitation model to ACOs that are 
highly integrated systems of care and to ACOs capable 
of bearing risk, as determined to be appropriate by the 
Secretary. 
‘‘(B) NO
ADDITIONAL
PROGRAM
EXPENDITURES.—Pay-
ments 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 beneficiaries 
than would otherwise be expended for such ACO for such 
beneficiaries for such year if the model were not imple-
mented, as estimated by the Secretary. 
‘‘(3) OTHER PAYMENT MODELS.— 
‘‘(A) IN
GENERAL.—Subject to subparagraph (B), a 
model described in this paragraph is any payment model 
that the Secretary determines will improve the quality 
and efficiency of items and services furnished under this 
title. 
‘‘(B) 
NO
ADDITIONAL
PROGRAM
EXPENDITURES.— 
Subparagraph (B) of paragraph (2) shall apply to a payment 
model under subparagraph (A) in a similar manner as 
such subparagraph (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 arrangements with other payers. 
‘‘(k) TREATMENT OF PHYSICIAN GROUP PRACTICE DEMONSTRA-
TION.—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 Security Act, 
as added by section 3023, is amended— 
(1) in paragraph (a)(2)(B), in the matter preceding clause 
(i), by striking ‘‘8 conditions’’ and inserting ‘‘10 conditions’’; 
(2) by striking subsection (c)(1)(B) and inserting the fol-
lowing: 
‘‘(B) EXPANSION.—The Secretary may, at any point 
after January 1, 2016, expand the duration and scope of 
the pilot program, to the extent 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 without 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 
Certification. 
Determinations. 
42 USC 
1395cc–4. 
Time period. 
Contracts. 
Applicability. 
Determination. 
Estimate. 
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124 STAT. 942 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(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 CONTINUING CARE HOS-
PITALS.— 
‘‘(1) IN GENERAL.—In conducting the pilot program, the 
Secretary shall apply the provisions of the program so as to 
separately pilot test the continuing care hospital model. 
‘‘(2) SPECIAL RULES.—In pilot testing the continuing 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 subsection (a)(2)(B). 
‘‘(B) Notwithstanding subsection (a)(2)(D), an episode 
of care shall be defined as the full period that a patient 
stays in the continuing care hospital plus the first 30 
days following discharge from such hospital. 
‘‘(3) CONTINUING
CARE
HOSPITAL
DEFINED.—In this sub-
section, 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 rehabilitation hospitals and units (as defined in 
section 1886(d)(1)(B)(ii)), long term care hospitals (as defined 
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.— 
(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 sec-
tion 1866E. 
SEC. 10309. REVISIONS TO HOSPITAL READMISSIONS REDUCTION PRO-
GRAM. 
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 payments’’ 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, section 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)— 
(A) by striking ‘‘2007, for’’ and inserting ‘‘2007, and 
for’’; and 
42 USC 1395w–4. 
42 USC 1395ww. 
42 USC 
1395cc–5. 
42 USC 
1395cc–4. 
Definition. 
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124 STAT. 943 
PUBLIC LAW 111–148—MAR. 23, 2010 
(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 inserting 
‘‘January 1, 2011’’ each place it appears. 
(b) AIR
AMBULANCE.—Section 146(b)(1) of the Medicare 
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 during 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’’. 
SEC. 10312. CERTAIN PAYMENT RULES FOR LONG-TERM CARE HOS-
PITAL SERVICES AND MORATORIUM ON THE ESTABLISH-
MENT OF CERTAIN HOSPITALS 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 inserting ‘‘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 COMMU-
NITY HOSPITAL DEMONSTRATION PROGRAM. 
(a) IN GENERAL.—Subsection (g) of section 410A of the Medicare 
Prescription Drug, Improvement, and Modernization 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 PROGRAM.— 
‘‘(1) IN GENERAL.—Subject to the succeeding provisions of 
this subsection, the Secretary shall conduct 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.—Notwith-
standing subsection (a)(2), during the 5-year extension period, 
the Secretary shall expand the number of States with low 
population densities determined by the Secretary under such 
subsection to 20. In determining which States to include in 
such expansion, 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 HOSPITALS PARTICI-
PATING
IN
THE
DEMONSTRATION
PROGRAM.—Notwithstanding 
subsection (a)(4), during the 5-year extension period, not more 
Criteria. 
Determination. 
42 USC 1395ww 
note. 
42 USC 1395m 
note. 
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124 STAT. 944 
PUBLIC LAW 111–148—MAR. 23, 2010 
than 30 rural community hospitals may participate in the dem-
onstration program under this section. 
‘‘(4) HOSPITALS IN DEMONSTRATION PROGRAM ON DATE OF 
ENACTMENT.—In the case of a rural community hospital that 
is participating in the demonstration program under this sec-
tion as of the last day of the initial 5-year period, the Sec-
retary— 
‘‘(A) shall provide for the continued participation of 
such rural community hospital in the demonstration pro-
gram during the 5-year extension 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 sub-
section (b) to the rural community hospital for covered 
inpatient hospital services furnished by the hospital during 
such 5-year extension period, shall substitute, under para-
graph (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 after the implementation of 
the demonstration program.’’. 
(b) CONFORMING AMENDMENTS.—Subsection (a)(5) of section 
410A of the Medicare Prescription Drug, Improvement, and Mod-
ernization 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 inserting ‘‘5-year extension’’. 
SEC. 10314. ADJUSTMENT TO LOW-VOLUME HOSPITAL PROVISION. 
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 discharges’’ 
and inserting ‘‘1,600 discharges’’. 
SEC. 10315. REVISIONS TO HOME HEALTH CARE PROVISIONS. 
(a) REBASING.—Section 1895(b)(3)(A)(iii) of the Social 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 inserting ‘‘2014’’; 
and 
(3) in subclause (II), by striking ‘‘2016’’ and inserting 
‘‘2017’’. 
(b) REVISION OF HOME HEALTH STUDY AND REPORT.—Section 
3131(d) is amended to read as follows: 
‘‘(d) STUDY
AND REPORT
ON
THE DEVELOPMENT
OF HOME 
HEALTH PAYMENT REVISIONS IN ORDER TO ENSURE 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 
42 USC 1395fff 
note. 
42 USC 1395fff. 
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124 STAT. 945 
PUBLIC LAW 111–148—MAR. 23, 2010 
providing ongoing access to care to low-income Medicare bene-
ficiaries or beneficiaries in medically underserved areas, and 
in treating beneficiaries with varying levels of severity of ill-
ness. In conducting the study, the Secretary may analyze 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 severity of illness or to improving bene-
ficiary access to care, such as— 
‘‘(i) payment adjustments for services that may 
involve additional or fewer resources; 
‘‘(ii) changes to reflect resources involved with pro-
viding 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 appropriate by the 
Secretary. 
‘‘(B) 
Operational 
issues 
involved 
with 
potential 
implementation of potential revisions to the home health 
payment system, including impacts for both home health 
agencies and administrative and systems issues for the 
Centers for Medicare & Medicaid Services, and any possible 
payment vulnerabilities associated with implementing 
potential revisions. 
‘‘(C) Whether additional research might be needed. 
‘‘(D) Other items determined appropriate by the Sec-
retary. 
‘‘(2) CONSIDERATIONS.—In conducting the study under para-
graph (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 patient access to 
care; 
‘‘(B) variations in service costs for providing care to 
individuals who are dually eligible under the Medicare 
and Medicaid programs; 
‘‘(C) the presence of severe or chronic diseases, which 
might be measured by multiple, discontinuous 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 Sec-
retary. 
‘‘(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 legisla-
tion and administrative action as the Secretary determines 
appropriate. 
‘‘(4) CONSULTATIONS.—In conducting the study under para-
graph (1), the Secretary shall consult with appropriate stake-
holders, such as groups representing home health agencies 
and groups representing Medicare beneficiaries. 
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124 STAT. 946 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(5) MEDICARE
DEMONSTRATION
PROJECT
BASED
ON
THE 
RESULTS OF THE STUDY.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (D), taking 
into account the results of the study conducted under para-
graph (1), the Secretary may, as determined appropriate, 
provide for a demonstration project to test whether making 
payment adjustments for home health services under the 
Medicare program would substantially 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 prospective payment amount 
(or amounts) under section 1895 of the Social Security 
Act (42 U.S.C. 1395fff) applicable to home health services 
furnished during a period to offset any increase in pay-
ments during such period resulting from the application 
of the payment adjustments under subparagraph (A). 
‘‘(C) NO EFFECT ON SUBSEQUENT PERIODS.—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 determines it appro-
priate to conduct the demonstration project under this sub-
section, the Secretary shall conduct the project for a four 
year period beginning not later than January 1, 2015. 
‘‘(E) FUNDING.—The Secretary shall provide 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 Secretary 
determines appropriate, of $500,000,000 for the period of 
fiscal years 2015 through 2018. Such funds shall be made 
available for the study described in paragraph (1) and 
the design, implementation and evaluation of the dem-
onstration described in this paragraph. Amounts available 
under this subparagraph shall be available until expended. 
‘‘(F) EVALUATION AND REPORT.—If the Secretary deter-
mines 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 respect to this sub-
section.’’. 
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)’’; 
42 USC 1395ww. 
Determination. 
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124 STAT. 947 
PUBLIC LAW 111–148—MAR. 23, 2010 
(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 117 of the Medicare, Med-
icaid, and SCHIP Extension Act of 2007 (Public Law 110– 
173) and section 124 of the Medicare Improvements for Patients 
and Providers Act of 2008 (Public Law 110–275), is amended 
by striking ‘September 30, 2009’ and inserting ‘September 30, 
2010’. 
‘‘(2) SPECIAL RULE FOR FISCAL YEAR 2010.— 
‘‘(A) IN
GENERAL.—Subject to subparagraph (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 Improvements 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 hospital wage index 
that was promulgated by the Secretary in the Federal 
Register on August 27, 2009 (74 Fed. Reg. 43754), and 
any subsequent corrections. 
‘‘(B) EXCEPTION.—Beginning on April 1, 2010, in deter-
mining the wage index applicable to hospitals that qualify 
for wage index reclassification, the Secretary shall include 
the average hourly wage data of hospitals whose reclassi-
fication 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 subsection (d) hos-
pital (as defined in subsection (d)(1)(B) of section 1886 
of the Social Security Act (42 U.S.C. 1395ww)) with respect 
to which— 
Effective date. 
42 USC 1395ww 
note. 
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124 STAT. 948 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(i) a reclassification of its wage index for purposes 
of such section was extended pursuant to the amend-
ment made by paragraph (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 
beginning on April 1, 2010, and ending on September 
30, 2010, by reason of the application of paragraph 
(2)(B); 
the Secretary shall pay such hospital an additional pay-
ment that reflects the difference between 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 sub-
clause: 
‘‘(II) for each of fiscal years 2012 and 2013, by 0.1 percent-
age point; and’’; and 
(4) in subclause (III), as redesignated by paragraph (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 following new 
clauses: 
‘‘(ii) for rate year 2011, 0.50 percentage point; 
‘‘(iii) for each of the rate years beginning in 2012 
and 2013, 0.1 percentage point; and’’; and 
(D) in clause (iv), as redesignated by subparagraph 
(B), by striking ‘‘2012’’ and inserting ‘‘2014’’; and 
(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 section 
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 sub-
clause: 
42 USC 1395ww. 
42 USC 
1395w–23. 
Time period. 
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124 STAT. 949 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(II) for each of fiscal years 2012 and 2013, 
0.1 percentage point; and’’; and 
(4) in subclause (III), as redesignated by paragraph (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); 
(3) by inserting after clause (ii) the following new clause: 
‘‘(ii) for each of the rate years beginning 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 Social 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 inserting ‘‘0.3’’; 
and 
(2) in clause (v), in the matter preceding subclause (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 section 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 sub-
clause: 
‘‘(II) for each of 2012 and 2013, 0.1 percentage 
point; and’’; and 
(4) in subclause (III), as redesignated by paragraph (2), 
by striking ‘‘2012’’ and inserting ‘‘2014’’. 
SEC. 10320. EXPANSION OF THE SCOPE OF, AND ADDITIONAL IMPROVE-
MENTS TO, THE INDEPENDENT MEDICARE ADVISORY 
BOARD. 
(a) IN GENERAL.—Section 1899A of the Social Security 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 required to submit a proposal under 
this section, the Board shall submit to Congress an advisory 
report on matters related to the Medicare program.’’; 
(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 Centers for Medi-
care & Medicaid Services has made a determination 
described in subsection (e)(3)(B)(i)(II) in the determina-
tion year, the proposal shall be designed to help reduce 
the growth rate described in paragraph (8) while 
maintaining or enhancing beneficiary access to quality 
care under this title.’’; 
Determination. 
Reports. 
42 USC 1395kkk. 
42 USC 1395l. 
42 USC 1395ww. 
42 USC 1395fff. 
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124 STAT. 950 
PUBLIC LAW 111–148—MAR. 23, 2010 
(C) in paragraph (2)(B)— 
(i) in clause (v), by striking ‘‘and’’ at the end; 
(ii) in clause (vi), by striking the period 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 con-
tained 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 ‘‘TRANSMISSION OF 
BOARD PROPOSAL TO PRESIDENT’’ and inserting ‘‘SUBMIS-
SION OF BOARD PROPOSAL TO CONGRESS AND THE PRESI-
DENT’’; 
(ii) in subparagraph (A)(i), by striking ‘‘transmit 
a proposal under this section to the President’’ and 
insert ‘‘submit a proposal under this section to Con-
gress 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 paragraph (3)(A)(i) 
or’’; and 
(ii) by striking ‘‘immediately’’ and inserting ‘‘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 ‘‘(calculated as the sum of per capita 
spending under each of parts A, B, and D)’’; 
(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 Secretary shall 
not be required to implement the recommendations 
contained in a proposal 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’’; 
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124 STAT. 951 
PUBLIC LAW 111–148—MAR. 23, 2010 
(ii) by redesignating subparagraphs (A) and (B) 
as clauses (i) and (ii), respectively, and indenting 
appropriately; and 
(iii) by adding at the end the following new 
subparagraph: 
‘‘(B) LIMITED ADDITIONAL EXCEPTION.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), the Sec-
retary shall not implement the recommendations con-
tained in a proposal submitted by the Board or the 
President to Congress pursuant to this section in a 
proposal year (beginning with proposal year 2019) if— 
‘‘(I) the Board was required to submit a pro-
posal to Congress under this section in the year 
preceding the proposal year; and 
‘‘(II) the Chief Actuary of the Centers for Medi-
care & Medicaid Services makes a determination 
in the determination 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 subpara-
graph shall not apply if the recommendations contained 
in a proposal submitted by the Board or the President 
to Congress pursuant to this section in the year pre-
ceding the proposal year were not required to be imple-
mented by reason of this subparagraph. 
‘‘(iii) NO AFFECT ON REQUIREMENT TO SUBMIT PRO-
POSALS OR FOR CONGRESSIONAL CONSIDERATION OF PRO-
POSALS.—Clause (i) and (ii) shall not affect— 
‘‘(I) the requirement of the Board or the Presi-
dent to submit a proposal to Congress in a proposal 
year in accordance with the provisions of this sec-
tion; or 
‘‘(II) Congressional consideration of a legisla-
tive proposal (described in subsection (c)(3)(B)(iv)) 
contained such a proposal in accordance with sub-
section (d).’’; 
(4) in subsection (f)(3)(B)— 
(A) by striking ‘‘or advisory reports to Congress’’ and 
inserting ‘‘, advisory reports, or advisory recommendations’’; 
and 
(B) by inserting ‘‘or produce the public report under 
subsection (n)’’ after ‘‘this section’’; and 
(5) by adding at the end the following new subsections: 
‘‘(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 comparison by region, types of services, 
types of providers, 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 
Determination. 
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124 STAT. 952 
PUBLIC LAW 111–148—MAR. 23, 2010 
(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, and the cost-sharing or 
out-of-pocket burden on patients. 
‘‘(C) Epidemiological shifts and demographic 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 determines affect 
overall spending and quality of care in the private sector. 
‘‘(o) ADVISORY RECOMMENDATIONS FOR NON-FEDERAL 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 recommendations to slow the 
growth in national health expenditures (excluding expenditures 
under this title and in other Federal health care programs) 
while preserving 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 enacted by Con-
gress in order to be implemented; 
‘‘(C) that may require legislation to be enacted by State 
or local governments in order to be implemented; 
‘‘(D) that private sector entities can voluntarily imple-
ment; and 
‘‘(E) with respect to other areas determined appropriate 
by the Board. 
‘‘(2) COORDINATION.—In making recommendations under 
paragraph (1), the Board shall coordinate such recommenda-
tions with recommendations contained in proposals and 
advisory reports produced by the Board under subsection (c). 
‘‘(3) AVAILABLE
TO
PUBLIC.—The Board shall make rec-
ommendations submitted to Congress and the President under 
this subsection available to the public.’’. 
(b) NAME CHANGE.—Any reference in the provisions of, or 
amendments made by, section 3403 to the ‘‘Independent Medicare 
Advisory Board’’ shall be deemed to be a reference to the ‘‘Inde-
pendent Payment Advisory Board’’. 
(c) RULE OF CONSTRUCTION.—Nothing in the amendments 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 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 HOSPITALS. 
(a) IN GENERAL.—Section 1886(s) of the Social Security Act, 
as added by section 3401(f), is amended by adding at the end 
the following new paragraph: 
‘‘(4) QUALITY REPORTING.— 
42 USC 1395ww. 
42 USC 256a–1. 
42 USC 1395kkk 
note. 
42 USC 1395kkk 
and note. 
Deadlines. 
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124 STAT. 953 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(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 psy-
chiatric unit that does not submit data to the Secretary 
in accordance with subparagraph (C) with respect to 
such a rate year, any annual 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. 
‘‘(ii) SPECIAL
RULE.—The application of this 
subparagraph may result in such annual 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 payment 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 reduction 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 Secretary for purposes of this 
subparagraph. 
‘‘(D) QUALITY MEASURES.— 
‘‘(i) IN
GENERAL.—Subject to clause (ii), any 
measure specified by the Secretary under this subpara-
graph 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 Sec-
retary 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 measures 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 subparagraph that will be applicable with 
respect to rate year 2014. 
‘‘(E) PUBLIC AVAILABILITY OF DATA SUBMITTED.—The 
Secretary shall establish procedures for making data sub-
mitted under subparagraph (C) available to the public. 
Such procedures shall ensure that a psychiatric hospital 
and a psychiatric unit has the opportunity to review the 
data that is to be made public with respect to the hospital 
or unit prior to such data being made public. The Secretary 
shall report quality measures that relate to services fur-
nished in inpatient settings in psychiatric hospitals and 
Reports. 
Procedures. 
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124 STAT. 954 
PUBLIC LAW 111–148—MAR. 23, 2010 
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 EXPOSED TO 
ENVIRONMENTAL HEALTH HAZARDS. 
(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 EXPOSED TO 
ENVIRONMENTAL HEALTH HAZARDS. 
‘‘(a) DEEMING OF INDIVIDUALS AS ELIGIBLE FOR MEDICARE BENE-
FITS.— 
‘‘(1) IN GENERAL.—For purposes of eligibility for benefits 
under this title, an individual determined under subsection 
(c) to be an environmental exposure 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 indi-
vidual determined under subsection (c) to be an environmental 
exposure affected individual described in subsection (e)(3) to 
meet the conditions specified in section 226(a). 
‘‘(3) EFFECTIVE DATE OF COVERAGE.—An Individual 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
INDIVIDUALS 
RESIDING IN EMERGENCY DECLARATION AREAS.— 
‘‘(1) PROGRAM; PURPOSE.— 
‘‘(A) PRIMARY
PILOT
PROGRAM.—The Secretary shall 
establish a pilot program in accordance with this subsection 
to provide innovative approaches to furnishing comprehen-
sive, coordinated, 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 program, in accordance with this 
subsection, with respect to each geographic area subject 
to an emergency declaration (other than the declaration 
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 paragraph is an individual 
who enrolls in part B, submits to the Secretary an application 
to participate in the applicable pilot program under this sub-
section, and— 
‘‘(A) is an environmental exposure affected individual 
described in subsection (e)(2) who resides in or around 
the geographic area subject to an emergency declaration 
made as of June 17, 2009; or 
42 USC 
1395rr–1. 
42 USC 1395aaa. 
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124 STAT. 955 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) is an environmental exposure affected individual 
described in subsection (e)(3) who— 
‘‘(i) is deemed under subsection (a)(2); and 
‘‘(ii) meets such other criteria or conditions 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 otherwise covered or authorized under 
this title, if the Secretary determines that furnishing such 
benefits, items, or services will further the purposes of such 
pilot program (as described in paragraph (1)). 
‘‘(4) INNOVATIVE
REIMBURSEMENT
METHODOLOGIES.—For 
purposes of the pilot program under this subsection, the Sec-
retary— 
‘‘(A) shall develop and implement appropriate meth-
odologies to reimburse providers for furnishing benefits, 
items, or services for which payment is not otherwise cov-
ered or authorized under this title, if such benefits, items, 
or services are furnished pursuant to paragraph (3); and 
‘‘(B) may develop and implement innovative approaches 
to reimbursing providers for any benefits, items, or services 
furnished under this subsection. 
‘‘(5) LIMITATION.—Consistent with section 1862(b), no pay-
ment shall be made under the pilot program under this sub-
section with respect to benefits, items, or services furnished 
to an environmental exposure affected individual (as defined 
in subsection (e)) to the extent that such individual is eligible 
to receive such benefits, items, or services through any other 
public or private benefits plan or legal agreement. 
‘‘(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 subsection. 
‘‘(7) FUNDING.—For purposes of carrying out pilot programs 
under this subsection, 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 such proportion as the 
Secretary determines appropriate, of such sums as the Sec-
retary determines necessary, to the Centers for Medicare & 
Medicaid Services Program Management Account. 
‘‘(8) WAIVER OF BUDGET NEUTRALITY.—The Secretary shall 
not require that pilot programs under this subsection be budget 
neutral with respect to expenditures under this title. 
‘‘(c) DETERMINATIONS.— 
‘‘(1) BY THE COMMISSIONER OF SOCIAL SECURITY.—For pur-
poses 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 subsection (b). 
‘‘(d) EMERGENCY DECLARATION DEFINED.—For purposes of this 
section, the term ‘emergency declaration’ means a declaration of 
a public health emergency under section 104(a) of the Comprehen-
sive Environmental Response, Compensation, and Liability Act of 
1980. 
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124 STAT. 956 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(e) 
ENVIRONMENTAL
EXPOSURE
AFFECTED
INDIVIDUAL 
DEFINED.— 
‘‘(1) IN GENERAL.—For purposes of this section, the term 
‘environmental exposure affected individual’ means— 
‘‘(A) an individual described in paragraph (2); and 
‘‘(B) an individual described in paragraph (3). 
‘‘(2) INDIVIDUAL DESCRIBED.— 
‘‘(A) IN GENERAL.—An individual described in this para-
graph is any individual who— 
‘‘(i) is diagnosed with 1 or more conditions 
described in subparagraph (B); 
‘‘(ii) as demonstrated in such manner as the Sec-
retary 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 diag-
nosis; 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 on behalf of the indi-
vidual), including pursuant to this section; and 
‘‘(iv) is determined under this section to meet the 
criteria in this subparagraph. 
‘‘(B) CONDITIONS DESCRIBED.—For purposes of subpara-
graph (A), the following conditions are described in this 
subparagraph: 
‘‘(i) Asbestosis, pleural thickening, or pleural 
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 physician, as determined by the 
Secretary; or 
‘‘(II) such other diagnostic standards as the 
Secretary specifies, 
except that this clause shall not apply to pleural thick-
ening or pleural plaques unless there are symptoms 
or conditions requiring medical treatment as a result 
of these diagnoses. 
‘‘(ii) 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 lavage; or 
‘‘(III) such other diagnostic standards as the 
Secretary specifies. 
‘‘(iii) Any other diagnosis which the Secretary, in 
consultation with the Commissioner of Social Security, 
determines is an asbestos-related medical condition, 
as established by such diagnostic standards as the 
Secretary specifies. 
‘‘(3) 
OTHER
INDIVIDUAL
DESCRIBED.—An 
individual 
described in this paragraph is any individual who— 
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124 STAT. 957 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(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 declaration applies, based on such 
medical conditions, diagnostic standards, and other criteria 
as the Secretary specifies; 
‘‘(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 declaration involved, during a period deter-
mined appropriate 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 cri-
teria 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 ENVIRONMENTAL 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— 
‘‘(1) screening at-risk individuals (as defined in subsection 
(c)(1)) for environmental health conditions (as defined in sub-
section (c)(3)); and 
‘‘(2) developing and disseminating public information and 
education concerning— 
‘‘(A) the availability of screening under the program 
under this section; 
‘‘(B) the detection, prevention, and treatment of 
environmental health conditions; and 
‘‘(C) the availability of Medicare benefits for certain 
individuals diagnosed with environmental 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 information and assurances, as the Sec-
retary determines appropriate. 
‘‘(2) TYPES OF ELIGIBLE ENTITIES.—The entities 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 Service. 
‘‘(D) A National Cancer Institute-designated cancer 
center. 
‘‘(E) An agency of any State or local government. 
‘‘(F) A nonprofit organization. 
‘‘(G) Any other entity the Secretary determines appro-
priate. 
42 USC 1397h. 
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124 STAT. 958 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(c) DEFINITIONS.—In this section: 
‘‘(1) AT-RISK
INDIVIDUAL.—The term ‘at-risk individual’ 
means an individual who— 
‘‘(A)(i) as demonstrated in such manner as the Sec-
retary determines appropriate, has been present for an 
aggregate total of 6 months in the geographic area subject 
to an emergency declaration specified under paragraph (2), 
during a period 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 specified in the Record of Decision 
for Operating Unit 4 and the Record of Decision for 
Operating Unit 7; or 
‘‘(ii) meets such other criteria as the Secretary deter-
mines appropriate considering the type of environmental 
health condition at issue; and 
‘‘(B) has submitted an application (or has an applica-
tion submitted on the individual’s behalf), to an eligible 
entity receiving a grant under this section, for screening 
under the program under this section. 
‘‘(2) EMERGENCY DECLARATION.—The term ‘emergency dec-
laration’ means a declaration of a public health emergency 
under section 104(a) of the Comprehensive Environmental 
Response, Compensation, and Liability Act of 1980. 
‘‘(3) 
ENVIRONMENTAL
HEALTH
CONDITION.—The 
term 
‘environmental health condition’ means— 
‘‘(A) asbestosis, pleural thickening, or pleural plaques, 
as established by— 
‘‘(i) interpretation by a ‘B Reader’ qualified physi-
cian of a plain chest x-ray or interpretation of a com-
puted tomographic radiograph of the chest by a quali-
fied physician, as determined by the Secretary; or 
‘‘(ii) such other diagnostic standards as the Sec-
retary specifies; 
‘‘(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 lavage; or 
‘‘(iii) such other diagnostic standards as the Sec-
retary 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 declaration applies, based on such criteria 
and as established by such diagnostic standards as the 
Secretary specifies. 
‘‘(4) HAZARDOUS SUBSTANCE; POLLUTANT; CONTAMINANT.— 
The terms ‘hazardous substance’, ‘pollutant’, and ‘contaminant’ 
have the meanings given those terms in section 101 of the 
Comprehensive Environmental 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 section 105(a)(8)(B) of the 
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124 STAT. 959 
PUBLIC LAW 111–148—MAR. 23, 2010 
Comprehensive Environmental Response, Compensation, and 
Liability Act of 1980 (42 U.S.C. 9605(a)(8)(B)). 
‘‘(d) HEALTH COVERAGE UNAFFECTED.—Nothing in this section 
shall be construed to affect any coverage obligation of a govern-
mental or private health plan or program relating to an at-risk 
individual. 
‘‘(e) FUNDING.— 
‘‘(1) IN GENERAL.—Out of any funds in the Treasury not 
otherwise appropriated, there are appropriated to the Secretary, 
to carry out the program under this section— 
‘‘(A) $23,000,000 for the period of fiscal years 2010 
through 2014; and 
‘‘(B) $20,000,000 for each 5-fiscal year period there-
after. 
‘‘(2) AVAILABILITY.—Funds appropriated under paragraph 
(1) shall remain available until expended. 
‘‘(f) NONAPPLICATION.— 
‘‘(1) IN GENERAL.—Except as provided in paragraph (2), 
the preceding sections of this title shall not apply to grants 
awarded under this section. 
‘‘(2) LIMITATIONS ON USE OF GRANTS.—Section 2005(a) shall 
apply to a grant awarded under this section to the same extent 
and in the same manner as such section applies to payments 
to States under this title, except that paragraph (4) of such 
section shall not be construed to prohibit grantees from con-
ducting screening for environmental health conditions as 
authorized under this section.’’. 
SEC. 10324. PROTECTIONS FOR FRONTIER STATES. 
(a) FLOOR ON AREA WAGE INDEX FOR HOSPITALS IN FRONTIER 
STATES.— 
(1) IN GENERAL.—Section 1886(d)(3)(E) of the Social Secu-
rity Act (42 U.S.C. 1395ww(d)(3)(E)) is amended— 
(A) in clause (i), by striking ‘‘clause (ii)’’ and inserting 
‘‘clause (ii) or (iii)’’; and 
(B) by adding at the end the following new clause: 
‘‘(iii) FLOOR ON AREA WAGE INDEX FOR HOSPITALS 
IN FRONTIER STATES.— 
‘‘(I) IN GENERAL.—Subject to subclause (IV), 
for discharges occurring on or after October 1, 
2010, the area wage index applicable under this 
subparagraph to any hospital which is located in 
a frontier State (as defined in subclause (II)) may 
not be less than 1.00. 
‘‘(II) FRONTIER STATE DEFINED.—In this clause, 
the term ‘frontier State’ means a State in which 
at least 50 percent of the counties in the State 
are frontier counties. 
‘‘(III) FRONTIER
COUNTY
DEFINED.—In this 
clause, the term ‘frontier county’ means a county 
in which the population per square mile is less 
than 6. 
‘‘(IV) LIMITATION.—This clause shall not apply 
to any hospital located in a State that receives 
a non-labor related share adjustment under para-
graph (5)(H).’’. 
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124 STAT. 960 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) WAIVING BUDGET NEUTRALITY.—Section 1886(d)(3)(E) of 
the Social Security Act (42 U.S.C. 1395ww(d)(3)(E)), as amended 
by subsection (a), is amended in the third sentence by inserting 
‘‘and the amendments made by section 10324(a)(1) of the 
Patient Protection and Affordable Care Act’’ after ‘‘2003’’. 
(b) FLOOR ON AREA WAGE ADJUSTMENT FACTOR FOR HOSPITAL 
OUTPATIENT DEPARTMENT SERVICES IN FRONTIER STATES.—Section 
1833(t) of the Social Security Act (42 U.S.C. 1395l(t)), as amended 
by section 3138, is amended— 
(1) in paragraph (2)(D), by striking ‘‘the Secretary’’ and 
inserting ‘‘subject to paragraph (19), the Secretary’’; and 
(2) by adding at the end the following new paragraph: 
‘‘(19) FLOOR ON AREA WAGE ADJUSTMENT FACTOR FOR HOS-
PITAL OUTPATIENT DEPARTMENT SERVICES IN FRONTIER STATES.— 
‘‘(A) IN GENERAL.—Subject to subparagraph (B), with 
respect to covered OPD services furnished on or after 
January 1, 2011, the area wage adjustment factor 
applicable under the payment system established under 
this subsection to any hospital outpatient department 
which is located in a frontier State (as defined in section 
1886(d)(3)(E)(iii)(II)) may not be less than 1.00. The pre-
ceding sentence shall not be applied in a budget neutral 
manner. 
‘‘(B) LIMITATION.—This paragraph shall not apply to 
any hospital outpatient department located in a State that 
receives a non-labor related share adjustment under section 
1886(d)(5)(H).’’. 
(c) FLOOR FOR PRACTICE EXPENSE INDEX FOR PHYSICIANS’ SERV-
ICES FURNISHED IN FRONTIER STATES.—Section 1848(e)(1) of the 
Social Security Act (42 U.S.C. 1395w–4(e)(1)), as amended by section 
3102, is amended— 
(1) in subparagraph (A), by striking ‘‘and (H)’’ and inserting 
‘‘(H), and (I)’’; and 
(2) by adding at the end the following new subparagraph: 
‘‘(I) FLOOR FOR PRACTICE EXPENSE INDEX FOR SERVICES 
FURNISHED IN FRONTIER STATES.— 
‘‘(i) IN GENERAL.—Subject to clause (ii), for pur-
poses of payment for services furnished in a frontier 
State (as defined in section 1886(d)(3)(E)(iii)(II)) on 
or after January 1, 2011, after calculating the practice 
expense index in subparagraph (A)(i), the Secretary 
shall increase any such index to 1.00 if such index 
would otherwise be less that 1.00. The preceding sen-
tence shall not be applied in a budget neutral manner. 
‘‘(ii) LIMITATION.—This subparagraph shall not 
apply to services furnished in a State that receives 
a non-labor related share adjustment under section 
1886(d)(5)(H).’’. 
SEC. 10325. REVISION TO SKILLED NURSING FACILITY PROSPECTIVE 
PAYMENT SYSTEM. 
(a) TEMPORARY DELAY OF RUG–IV.—Notwithstanding any other 
provision of law, the Secretary of Health and Human Services 
shall not, prior to October 1, 2011, implement Version 4 of the 
Resource Utilization Groups (in this subsection refereed to as 
‘‘RUG–IV’’) published in the Federal Register on August 11, 2009, 
entitled ‘‘Prospective Payment System and Consolidated Billing for 
Implementation 
dates. 
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124 STAT. 961 
PUBLIC LAW 111–148—MAR. 23, 2010 
Skilled Nursing Facilities for FY 2010; Minimum Data Set, Version 
3.0 for Skilled Nursing Facilities and Medicaid Nursing Facilities’’ 
(74 Fed. Reg. 40288). Beginning on October 1, 2010, the Secretary 
of Health and Human Services shall implement the change specific 
to therapy furnished on a concurrent basis that is a component 
of RUG–IV and changes to the lookback period to ensure that 
only those services furnished after admission to a skilled nursing 
facility are used as factors in determining a case mix classification 
under the skilled nursing facility prospective payment system under 
section 1888(e) of the Social Security Act (42 U.S.C. 1395yy(e)). 
(b) CONSTRUCTION.—Nothing in this section shall be interpreted 
as delaying the implementation of Version 3.0 of the Minimum 
Data Sets (MDS 3.0) beyond the planned implementation date 
of October 1, 2010. 
SEC. 10326. PILOT TESTING PAY-FOR-PERFORMANCE PROGRAMS FOR 
CERTAIN MEDICARE PROVIDERS. 
(a) IN GENERAL.—Not later than January 1, 2016, the Secretary 
of Health and Human Services (in this section referred to as the 
‘‘Secretary’’) shall, for each provider described in subsection (b), 
conduct a separate pilot program under title XVIII of the Social 
Security Act to test the implementation of a value-based purchasing 
program for payments under such title for the provider. 
(b) PROVIDERS DESCRIBED.—The providers described in this 
paragraph are the following: 
(1) Psychiatric hospitals (as described in clause (i) of section 
1886(d)(1)(B) of such Act (42 U.S.C. 1395ww(d)(1)(B))) and psy-
chiatric units (as described in the matter following clause (v) 
of such section). 
(2) Long-term care hospitals (as described in clause (iv) 
of such section). 
(3) Rehabilitation hospitals (as described in clause (ii) of 
such section). 
(4) PPS-exempt cancer hospitals (as described in clause 
(v) of such section). 
(5) Hospice programs (as defined in section 1861(dd)(2) 
of such Act (42 U.S.C. 1395x(dd)(2))). 
(c) WAIVER
AUTHORITY.—The Secretary may waive such 
requirements of titles XI and XVIII of the Social Security Act 
as may be necessary solely for purposes of carrying out the pilot 
programs under this section. 
(d) NO ADDITIONAL PROGRAM EXPENDITURES.—Payments under 
this section under the separate pilot program for value based pur-
chasing (as described in subsection (a)) for each provider type 
described in paragraphs (1) through (5) of subsection (b) for 
applicable items and services under title XVIII of the Social Security 
Act for a year shall be established in a manner that does not 
result in spending more under each such value based purchasing 
program for such year than would otherwise be expended for such 
provider type for such year if the pilot program were not imple-
mented, as estimated by the Secretary. 
(e) EXPANSION
OF PILOT PROGRAM.—The Secretary may, at 
any point after January 1, 2018, expand the duration and scope 
of a pilot program conducted under this subsection, to the extent 
determined appropriate by the Secretary, if— 
(1) the Secretary determines that such expansion is 
expected to— 
Determinations. 
Deadline. 
42 USC 1395b–1 
note. 
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124 STAT. 962 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) reduce spending under title XVIII of the Social 
Security Act without reducing the quality of care; or 
(B) improve the quality of care and reduce spending; 
(2) the Chief Actuary of the Centers for Medicare & Med-
icaid Services certifies that such expansion would reduce pro-
gram spending under such title XVIII; and 
(3) the Secretary determines that such expansion would 
not deny or limit the coverage or provision of benefits under 
such title XIII for Medicare beneficiaries. 
SEC. 10327. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING 
SYSTEM. 
(a) IN GENERAL.—Section 1848(m) of the Social Security Act 
(42 U.S.C. 1395w–4(m)) is amended by adding at the end the 
following new paragraph: 
‘‘(7) ADDITIONAL INCENTIVE PAYMENT.— 
‘‘(A) IN GENERAL.—For 2011 through 2014, if an eligible 
professional meets the requirements described in subpara-
graph (B), the applicable quality percent for such year, 
as described in clauses (iii) and (iv) of paragraph (1)(B), 
shall be increased by 0.5 percentage points. 
‘‘(B) REQUIREMENTS DESCRIBED.—In order to qualify 
for the additional incentive payment described in subpara-
graph (A), an eligible professional shall meet the following 
requirements: 
‘‘(i) The eligible professional shall— 
‘‘(I) satisfactorily submit data on quality meas-
ures for purposes of paragraph (1) for a year; and 
‘‘(II) have such data submitted on their behalf 
through a Maintenance of Certification Program 
(as defined in subparagraph (C)(i)) that meets— 
‘‘(aa) the criteria for a registry (as 
described in subsection (k)(4)); or 
‘‘(bb) an alternative form and manner 
determined appropriate by the Secretary. 
‘‘(ii) The eligible professional, more frequently than 
is required to qualify for or maintain board certification 
status— 
‘‘(I) participates in such a Maintenance of Cer-
tification program for a year; and 
‘‘(II) successfully completes a qualified Mainte-
nance of Certification Program practice assessment 
(as defined in subparagraph (C)(ii)) for such year. 
‘‘(iii) A Maintenance of Certification program sub-
mits to the Secretary, on behalf of the eligible profes-
sional, information— 
‘‘(I) in a form and manner specified by the 
Secretary, that the eligible professional has 
successfully met the requirements of clause (ii) 
(which may be in the form of a structural 
measure); 
‘‘(II) if requested by the Secretary, on the 
survey of patient experience with care (as 
described in subparagraph (C)(ii)(II)); and 
‘‘(III) as the Secretary may require, on the 
methods, measures, and data used under the 
Maintenance of Certification Program and the 
Time period. 
Certification. 
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124 STAT. 963 
PUBLIC LAW 111–148—MAR. 23, 2010 
qualified Maintenance of Certification Program 
practice assessment. 
‘‘(C) DEFINITIONS.—For purposes of this paragraph: 
‘‘(i) The term ‘Maintenance of Certification Pro-
gram’ means a continuous assessment program, such 
as qualified American Board of Medical Specialties 
Maintenance of Certification program or an equivalent 
program (as determined by the Secretary), that 
advances quality and the lifelong learning and self- 
assessment of board certified specialty physicians by 
focusing on the competencies of patient care, medical 
knowledge, practice-based learning, interpersonal and 
communication skills and professionalism. Such a pro-
gram shall include the following: 
‘‘(I) The program requires the physician to 
maintain a valid, unrestricted medical license in 
the United States. 
‘‘(II) The program requires a physician to 
participate in educational and self-assessment pro-
grams that require an assessment of what was 
learned. 
‘‘(III) The program requires a physician to 
demonstrate, through a formalized, secure exam-
ination, that the physician has the fundamental 
diagnostic skills, medical knowledge, and clinical 
judgment to provide quality care in their respective 
specialty. 
‘‘(IV) The program requires successful comple-
tion of a qualified Maintenance of Certification 
Program practice assessment as described in 
clause (ii). 
‘‘(ii) The term ‘qualified Maintenance of Certifi-
cation Program practice assessment’ means an assess-
ment of a physician’s practice that— 
‘‘(I) includes an initial assessment of an 
eligible professional’s practice that is designed to 
demonstrate the physician’s use of evidence-based 
medicine; 
‘‘(II) includes a survey of patient experience 
with care; and 
‘‘(III) requires a physician to implement a 
quality improvement intervention to address a 
practice weakness identified in the initial assess-
ment under subclause (I) and then to remeasure 
to assess performance improvement after such 
intervention.’’. 
(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 Program and successful completion of a qualified 
Maintenance of Certification Program practice assessment into 
the composite of measures of quality of care furnished pursuant 
to the physician fee schedule payment modifier, as described 
in section 1848(p)(2) of the Social Security Act (42 U.S.C. 
1395w–4(p)(2)).’’. 
Determination. 
42 USC 1395w–4 
note. 
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124 STAT. 964 
PUBLIC LAW 111–148—MAR. 23, 2010 
(c) ELIMINATION OF MA REGIONAL PLAN STABILIZATION FUND.— 
(1) IN GENERAL.—Section 1858 of the Social Security 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 enact-
ment of this Act shall be transferred to the Federal Supple-
mentary Medical Insurance Trust Fund. 
SEC. 10328. IMPROVEMENT IN PART D MEDICATION THERAPY MANAGE-
MENT (MTM) PROGRAMS. 
(a) IN GENERAL.—Section 1860D–4(c)(2) of the Social Security 
Act (42 U.S.C. 1395w–104(c)(2)) is amended— 
(1) by redesignating subparagraphs (C), (D), and (E) as 
subparagraphs (E), (F), and (G), respectively; and 
(2) by inserting after subparagraph (B) the following new 
subparagraphs: 
‘‘(C) REQUIRED INTERVENTIONS.—For plan years begin-
ning on or after the date that is 2 years after the date 
of the enactment of the Patient Protection and Affordable 
Care Act, prescription drug plan sponsors shall offer medi-
cation therapy management services to targeted bene-
ficiaries described in subparagraph (A)(ii) that include, at 
a minimum, the following to increase adherence to prescrip-
tion medications or other goals deemed necessary by the 
Secretary: 
‘‘(i) An annual comprehensive medication review 
furnished person-to-person or using telehealth tech-
nologies (as defined by the Secretary) by a licensed 
pharmacist or other qualified provider. The comprehen-
sive medication review— 
‘‘(I) shall include a review of the individual’s 
medications and may result in the creation of a 
recommended medication action plan or other 
actions in consultation with the individual and 
with input from the prescriber to the extent nec-
essary 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 stake-
holders, shall develop a standardized format for the 
action plan under subclause (I) and the summary under 
subclause (II). 
‘‘(ii) Follow-up interventions as warranted based 
on the findings of the annual medication review or 
the targeted medication 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 assess, at least on a 
quarterly basis, the medication use of individuals who are 
at risk but not enrolled in the medication therapy manage-
ment program, including individuals who have experienced 
a transition in care, if the prescription drug plan sponsor 
has access to that information. 
42 USC 
1395w–27a note. 
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124 STAT. 965 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(E) AUTOMATIC
ENROLLMENT
WITH
ABILITY
TO
OPT- 
OUT.—The prescription drug plan sponsor shall have in 
place a process to— 
‘‘(i) subject to clause (ii), automatically enroll tar-
geted beneficiaries described in subparagraph (A)(ii), 
including beneficiaries identified under subparagraph 
(D), in the medication therapy management program 
required under this subsection; and 
‘‘(ii) permit such beneficiaries to opt-out of enroll-
ment 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 manage-
ment program under part D of title XVIII of the Social Security 
Act or to study new models for medication therapy management 
through the Center for Medicare and Medicaid Innovation under 
section 1115A of such Act, as added by section 3021. 
SEC. 10329. DEVELOPING METHODOLOGY TO ASSESS HEALTH PLAN 
VALUE. 
(a) DEVELOPMENT.—The Secretary of Health and Human Serv-
ices (referred to in this section as the ‘‘Secretary’’), in consultation 
with relevant stakeholders including health insurance issuers, 
health care consumers, employers, 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 Secretary. 
(b) REPORT.—Not later than 18 months after the date of enact-
ment of this Act, the Secretary shall submit to Congress a report 
concerning the methodology developed under subsection (a). 
SEC. 10330. MODERNIZING COMPUTER AND DATA SYSTEMS OF THE 
CENTERS FOR MEDICARE & MEDICAID SERVICES TO SUP-
PORT IMPROVEMENTS IN CARE DELIVERY. 
(a) IN GENERAL.—The Secretary of Health and Human Services 
(in this section referred to as the ‘‘Secretary’’) 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 system could— 
(1) in accordance with the regulations promulgated under 
section 264(c) of the Health Insurance Portability and Account-
ability Act of 1996, make available data in a reliable and 
timely manner to providers of services and suppliers to support 
their efforts 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. 
Plans. 
42 USC 
1395w–104 note. 
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124 STAT. 966 
PUBLIC LAW 111–148—MAR. 23, 2010 
(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 & Medicaid Services the 
plan described in subsection (a). 
SEC. 10331. PUBLIC REPORTING OF PERFORMANCE INFORMATION. 
(a) IN GENERAL.— 
(1) DEVELOPMENT.—Not later than January 1, 2011, the 
Secretary shall develop a Physician Compare Internet website 
with information on physicians enrolled in the Medicare pro-
gram under section 1866(j) of the Social Security Act (42 U.S.C. 
1395cc(j)) and other eligible professionals who participate in 
the Physician Quality Reporting Initiative 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 implement a plan for making 
publicly available through Physician Compare, consistent with 
subsection (c), information on physician performance that pro-
vides comparable information for the public on quality and 
patient experience measures with respect to physicians enrolled 
in the Medicare program under such section 1866(j). To the 
extent scientifically sound measures that are developed con-
sistent with the requirements of this section are available, 
such information, to the extent practicable, shall include— 
(A) measures collected under the Physician Quality 
Reporting Initiative; 
(B) an assessment of patient health outcomes and the 
functional status of patients; 
(C) an assessment of the continuity and coordination 
of care and care transitions, including 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 time-
liness of care; and 
(G) other information as determined appropriate by 
the Secretary. 
(b) OTHER REQUIRED CONSIDERATIONS.—In developing and 
implementing the plan described in subsection (a)(2), the Secretary 
shall, to the extent practicable, include— 
(1) processes to assure that data made public, either by 
the Centers for Medicare & Medicaid Services or by other 
entities, is statistically valid and reliable, including risk adjust-
ment mechanisms used by the Secretary; 
(2) processes by which a physician or other eligible profes-
sional 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 available on 
Physician Compare provide a robust and accurate portrayal 
of a physician’s performance; 
(4) data that reflects the care provided to all patients 
seen by physicians, under both the Medicare program and, 
Time period. 
Web site. 
Deadline. 
42 USC 1395w–5. 
Deadline. 
Web posting. 
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124 STAT. 967 
PUBLIC LAW 111–148—MAR. 23, 2010 
to the extent practicable, other payers, to the extent such 
information would provide a more accurate portrayal of physi-
cian 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 performance feed-
back is provided to physicians concerning the data reported 
under any program subject to public reporting under this sec-
tion; and 
(7) implementation of computer and data systems of the 
Centers for Medicare & Medicaid Services that support valid, 
reliable, and accurate public reporting activities authorized 
under this section. 
(c) ENSURING PATIENT PRIVACY.—The Secretary shall ensure 
that information on physician performance and patient 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 Sec-
retary shall take into consideration input provided by multi-stake-
holder 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
PUR-
CHASING.—In developing the plan under this subsection (a)(2), the 
Secretary shall, as the Secretary determines 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 (Public 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 and publish data on physician quality 
and efficiency and on patient experience of care in support of 
value-based purchasing and consumer choice, together with rec-
ommendations 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 Security Act) the information made 
available on such website. 
(h) FINANCIAL INCENTIVES TO ENCOURAGE CONSUMERS 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 
Deadline. 
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124 STAT. 968 
PUBLIC LAW 111–148—MAR. 23, 2010 
any such demonstration program does not disadvantage those bene-
ficiaries without reasonable access to high performing physicians 
or create financial inequities under such title. 
(i) DEFINITIONS.—In this section: 
(1) ELIGIBLE
PROFESSIONAL.—The term ‘‘eligible profes-
sional’’ has the meaning given that term for purposes of the 
Physician Quality Reporting Initiative 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 PERFORMANCE 
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 para-
graph (2)) data described in paragraph (3) for the evaluation 
of the performance of providers of services and suppliers. 
‘‘(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 Secretary) to 
use claims data to evaluate the performance of providers 
of services and suppliers on measures of quality, efficiency, 
effectiveness, and resource use; and 
‘‘(B) agrees to meet the requirements described in para-
graph (4) and meets such other requirements as the Sec-
retary may specify, such as ensuring security of data. 
‘‘(3) DATA DESCRIBED.—The data described in this para-
graph are standardized extracts (as determined by the Sec-
retary) of claims data under parts A, B, and D for items 
and services furnished under such parts for one or more speci-
fied 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 of making such data available. 
Any fee collected pursuant to the preceding sentence shall 
be deposited into the Federal Supplementary Medical 
Insurance Trust Fund under section 1841. 
‘‘(B) SPECIFICATION OF USES AND METHODOLOGIES.— 
A qualified entity requesting data under this subsection 
shall— 
‘‘(i) submit to the Secretary a description of the 
methodologies that such qualified entity will use to 
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124 STAT. 969 
PUBLIC LAW 111–148—MAR. 23, 2010 
evaluate the performance of providers of services and 
suppliers using such data; 
‘‘(ii)(I) except as provided in subclause (II), if avail-
able, 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, deter-
mines that use of such alternative measures would 
be more valid, reliable, responsive to consumer pref-
erences, cost-effective, or relevant to dimensions of 
quality and resource use not addressed by such 
standard measures; 
‘‘(iii) include data made available under this sub-
section 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 subparagraph (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 evalu-
ating the performance of providers of services and suppliers 
using data made available under this subsection shall— 
‘‘(i) include an understandable description of the 
measures, which shall include quality measures and 
the rationale for use of other measures described in 
subparagraph (B)(ii)(II), risk adjustment methods, 
physician 
attribution 
methods, 
other 
applicable 
methods, data specifications and limitations, and the 
sponsors, so that consumers, providers of services and 
suppliers, health plans, researchers, and other stake-
holders can assess such reports; 
‘‘(ii) be made available confidentially, to any pro-
vider of services or supplier to be identified in such 
report, prior to the public release of such report, and 
provide an opportunity to appeal and correct errors; 
‘‘(iii) only include information on a provider of 
services or supplier in an aggregate 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 Sec-
retary shall not make data described 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 
entity shall only use such data, and information derived 
from such evaluation, for the reports under subparagraph 
(C). Data released to a qualified entity under this sub-
section shall not be subject to discovery or admission as 
Public 
information. 
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124 STAT. 970 
PUBLIC LAW 111–148—MAR. 23, 2010 
evidence in judicial or administrative proceedings without 
consent of the applicable provider of services or supplier.’’. 
(b) EFFECTIVE DATE.—The amendment made by subsection (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 NETWORKS.— 
‘‘(1) DESCRIPTION.—A community-based collaborative care 
network (referred to in this section as a ‘network’) shall be 
a consortium of health care providers with a joint governance 
structure (including providers within a single entity) that pro-
vides comprehensive coordinated and integrated health care 
services (as defined by the Secretary) for low-income popu-
lations. 
‘‘(2) REQUIRED INCLUSION.—A network shall include the 
following providers (unless such provider does not exist within 
the community, declines or refuses to participate, or places 
unreasonable conditions on their participation): 
‘‘(A) A hospital that meets the criteria in section 
1923(b)(1) of the Social Security Act; and 
‘‘(B) All Federally qualified health centers (as defined 
in section 1861(aa) of the Social Security Act located in 
the community. 
‘‘(3) PRIORITY.—In awarding grants, the Secretary shall 
give priority to networks that include— 
‘‘(A) the capability to provide the broadest range of 
services to low-income individuals; 
‘‘(B) the broadest range of providers that currently 
serve a high volume of low-income individuals; and 
‘‘(C) a county or municipal department of health. 
‘‘(c) APPLICATION.— 
‘‘(1) APPLICATION.—A network described in subsection (b) 
shall submit an application to the Secretary. 
‘‘(2) RENEWAL.—In subsequent years, based on the perform-
ance of grantees, the Secretary may provide renewal grants 
to prior year grant recipients. 
‘‘(d) USE OF FUNDS.— 
‘‘(1) USE BY GRANTEES.—Grant funds may be used for the 
following activities: 
‘‘(A) Assist low-income individuals to— 
‘‘(i) access and appropriately use health services; 
‘‘(ii) enroll in health coverage programs; and 
‘‘(iii) obtain a regular primary care provider or 
a medical home. 
‘‘(B) Provide case management and care management. 
42 USC 256i. 
42 USC 1395kk 
note. 
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124 STAT. 971 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(C) Perform health outreach using neighborhood 
health workers or through other means. 
‘‘(D) Provide transportation. 
‘‘(E) Expand capacity, including through telehealth, 
after-hours services or urgent care. 
‘‘(F) Provide direct patient care services. 
‘‘(2) GRANT FUNDS TO HRSA GRANTEES.—The Secretary may 
limit the percent of grant funding that may be spent on direct 
care services provided by grantees of programs administered 
by the Health Resources and Services Administration or impose 
other requirements on such grantees deemed necessary. 
‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated to carry out this section such sums as may 
be necessary for each of fiscal years 2011 through 2015.’’. 
SEC. 10334. MINORITY HEALTH. 
(a) OFFICE OF MINORITY HEALTH.— 
(1) IN GENERAL.—Section 1707 of the Public Health Service 
Act (42 U.S.C. 300u–6) is amended— 
(A) in subsection (a), by striking ‘‘within the Office 
of Public Health and Science’’ and all that follows through 
the end and inserting ‘‘. The Office of Minority Health 
as existing on the date of enactment of the Patient Protec-
tion and Affordable Care Act shall be transferred to the 
Office of the Secretary in such manner that there is estab-
lished in the Office of the Secretary, the Office of Minority 
Health, which shall be headed by the Deputy Assistant 
Secretary for Minority Health who shall report directly 
to the Secretary, and shall retain and strengthen authori-
ties (as in existence on such date of enactment) for the 
purpose of improving minority health and the quality of 
health care minorities receive, and eliminating racial and 
ethnic disparities. In carrying out this subsection, the Sec-
retary, acting through the Deputy Assistant Secretary, 
shall award grants, contracts, enter into memoranda of 
understanding, cooperative, interagency, intra-agency and 
other agreements with public and nonprofit private entities, 
agencies, as well as Departmental and Cabinet agencies 
and organizations, and with organizations that are indige-
nous human resource providers in communities of color 
to assure improved health status of racial and ethnic 
minorities, and shall develop measures to evaluate the 
effectiveness of activities aimed at reducing health dispari-
ties and supporting the local community. Such measures 
shall evaluate community outreach activities, language 
services, workforce cultural competence, and other areas 
as determined by the Secretary.’’; and 
(B) by striking subsection (h) and inserting the fol-
lowing: 
‘‘(h) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of 
carrying out this section, there are authorized to be appropriated 
such sums as may be necessary for each of fiscal years 2011 through 
2016.’’. 
(2) TRANSFER OF FUNCTIONS.—There are transferred to the 
Office of Minority Health in the office of the Secretary of 
Health and Human Services, all duties, responsibilities, 
authorities, accountabilities, functions, staff, funds, award 
42 USC 300u–6 
note. 
Grants. 
Contracts. 
Memorandum. 
Establishment. 
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124 STAT. 972 
PUBLIC LAW 111–148—MAR. 23, 2010 
mechanisms, and other entities under the authority of the 
Office of Minority Health of the Public Health Service as in 
effect on the date before the date of enactment of this Act, 
which shall continue in effect according to the terms in effect 
on the date before such date of enactment, until modified, 
terminated, superseded, set aside, or revoked in accordance 
with law by the President, the Secretary, a court of competent 
jurisdiction, or by operation of law. 
(3) REPORTS.—Not later than 1 year after the date of enact-
ment of this section, and biennially thereafter, the Secretary 
of Health and Human Services shall prepare and submit to 
the appropriate committees of Congress a report describing 
the activities carried out under section 1707 of the Public 
Health Service Act (as amended by this subsection) during 
the period for which the report is being prepared. Not later 
than 1 year after the date of enactment of this section, and 
biennially thereafter, the heads of each of the agencies of the 
Department of Health and Human Services shall submit to 
the Deputy Assistant Secretary for Minority Health a report 
summarizing the minority health activities of each of the 
respective agencies. 
(b) ESTABLISHMENT
OF
INDIVIDUAL
OFFICES
OF
MINORITY 
HEALTH WITHIN THE DEPARTMENT OF HEALTH AND HUMAN SERV-
ICES.— 
(1) IN GENERAL.—Title XVII of the Public Health Service 
Act (42 U.S.C. 300u et seq.) is amended by inserting after 
section 1707 the following section: 
‘‘SEC. 1707A. INDIVIDUAL OFFICES OF MINORITY HEALTH WITHIN THE 
DEPARTMENT. 
‘‘(a) IN GENERAL.—The head of each agency specified in sub-
section (b)(1) shall establish within the agency an office to be 
known as the Office of Minority Health. The head of each such 
Office shall be appointed by the head of the agency within which 
the Office is established, and shall report directly to the head 
of the agency. The head of such agency shall carry out this section 
(as this section relates to the agency) acting through such Director. 
‘‘(b) SPECIFIED AGENCIES.—The agencies referred to in sub-
section (a) are the Centers for Disease Control and Prevention, 
the Health Resources and Services Administration, the Substance 
Abuse and Mental Health Services Administration, the Agency for 
Healthcare Research and Quality, the Food and Drug Administra-
tion, and the Centers for Medicare & Medicaid Services. 
‘‘(c) DIRECTOR; APPOINTMENT.—Each Office of Minority Health 
established in an agency listed in subsection (a) shall be headed 
by a director, with documented experience and expertise in minority 
health services research and health disparities elimination. 
‘‘(d) REFERENCES.—Except as otherwise specified, any reference 
in Federal law to an Office of Minority Health (in the Department 
of Health and Human Services) is deemed to be a reference to 
the Office of Minority Health in the Office of the Secretary. 
‘‘(e) FUNDING.— 
‘‘(1) ALLOCATIONS.—Of the amounts appropriated for a 
specified agency for a fiscal year, the Secretary must designate 
an appropriate amount of funds for the purpose of carrying 
out activities under this section through the minority health 
office of the agency. In reserving an amount under the preceding 
Appointment. 
42 USC 300u–6a. 
42 USC 300u–6 
note. 
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124 STAT. 973 
PUBLIC LAW 111–148—MAR. 23, 2010 
sentence for a minority health office for a fiscal year, the 
Secretary shall reduce, by substantially the same percentage, 
the amount that otherwise would be available for each of the 
programs of the designated agency involved. 
‘‘(2) AVAILABILITY OF FUNDS FOR STAFFING.—The purposes 
for which amounts made available under paragraph may be 
expended by a minority health office include the costs of 
employing staff for such office.’’. 
(2) NO NEW REGULATORY AUTHORITY.—Nothing in this sub-
section and the amendments made by this subsection may 
be construed as establishing regulatory authority or modifying 
any existing regulatory authority. 
(3) LIMITATION
ON
TERMINATION.—Notwithstanding any 
other provision of law, a Federal office of minority health or 
Federal appointive position with primary responsibility over 
minority health issues that is in existence in an office of agency 
of the Department of Health and Human Services on the date 
of enactment of this section shall not be terminated, reorga-
nized, or have any of its power or duties transferred unless 
such termination, reorganization, or transfer is approved by 
an Act of Congress. 
(c) REDESIGNATION OF NATIONAL CENTER ON MINORITY HEALTH 
AND HEALTH DISPARITIES.— 
(1) REDESIGNATION.—Title IV of the Public Health Service 
Act (42 U.S.C. 281 et seq.) is amended— 
(A) by redesignating subpart 6 of part E as subpart 
20; 
(B) by transferring subpart 20, as so redesignated, 
to part C of such title IV; 
(C) by inserting subpart 20, as so redesignated, after 
subpart 19 of such part C; and 
(D) in subpart 20, as so redesignated— 
(i) by redesignating sections 485E through 485H 
as sections 464z–3 through 464z–6, respectively; 
(ii) by striking ‘‘National Center on Minority 
Health and Health Disparities’’ each place such term 
appears and inserting ‘‘National Institute on Minority 
Health and Health Disparities’’; and 
(iii) by striking ‘‘Center’’ each place such term 
appears and inserting ‘‘Institute’’. 
(2) PURPOSE OF INSTITUTE; DUTIES.—Section 464z–3 of the 
Public Health Service Act, as so redesignated, is amended— 
(A) in subsection (h)(1), by striking ‘‘research endow-
ments at centers of excellence under section 736.’’ and 
inserting the following: ‘‘research endowments— 
‘‘(1) at centers of excellence under section 736; and 
‘‘(2) at centers of excellence under section 464z–4.’’; 
(B) in subsection (h)(2)(A), by striking ‘‘average’’ and 
inserting ‘‘median’’; and 
(C) by adding at the end the following: 
‘‘(h) 
INTERAGENCY
COORDINATION.—The 
Director 
of 
the 
Institute, as the primary Federal officials with responsibility for 
coordinating all research and activities conducted or supported by 
the National Institutes of Health on minority health and health 
disparities, shall plan, coordinate, review and evaluate research 
and other activities conducted or supported by the Institutes and 
Centers of the National Institutes of Health.’’. 
42 USC 285t. 
42 USC 
285t—285t–3. 
42 USC 285t. 
42 USC 
285t—285t–3. 
42 USC 300u–6a 
note. 
42 USC 300u–6a 
note. 
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124 STAT. 974 
PUBLIC LAW 111–148—MAR. 23, 2010 
(3) TECHNICAL AND CONFORMING AMENDMENTS.— 
(A) Section 401(b)(24) of the Public Health Service 
Act (42 U.S.C. 281(b)(24)) is amended by striking ‘‘Center’’ 
and inserting ‘‘Institute’’. 
(B) Subsection (d)(1) of section 903 of the Public Health 
Service Act (42 U.S.C. 299a–1(d)(1)) is amended by striking 
‘‘section 485E’’ and inserting ‘‘section 464z–3’’. 
SEC. 10335. TECHNICAL CORRECTION TO THE HOSPITAL VALUE-BASED 
PURCHASING PROGRAM. 
Section 1886(o)(2)A) of the Social Security Act, as added by 
section 3001, is amended, in the first sentence, by inserting ‘‘, 
other than measures of readmissions,’’ after ‘‘shall select measures’’. 
SEC. 10336. GAO STUDY AND REPORT ON MEDICARE BENEFICIARY 
ACCESS TO HIGH-QUALITY DIALYSIS SERVICES. 
(a) STUDY.— 
(1) IN GENERAL.—The Comptroller General of the United 
States shall conduct a study on the impact on Medicare bene-
ficiary access to high-quality dialysis services of including speci-
fied oral drugs that are furnished to such beneficiaries for 
the treatment of end stage renal disease in the bundled prospec-
tive payment system under section 1881(b)(14) of the Social 
Security Act (42 U.S.C. 1395rr(b)(14)) (pursuant to the proposed 
rule published by the Secretary of Health and Human Services 
in the Federal Register on September 29, 2009 (74 Fed. Reg. 
49922 et seq.)). Such study shall include an analysis of— 
(A) the ability of providers of services and renal dialysis 
facilities to furnish specified oral drugs or arrange for 
the provision of such drugs; 
(B) the ability of providers of services and renal dialysis 
facilities to comply, if necessary, with applicable State laws 
(such as State pharmacy licensure requirements) in order 
to furnish specified oral drugs; 
(C) whether appropriate quality measures exist to safe-
guard care for Medicare beneficiaries being furnished speci-
fied oral drugs by providers of services and renal dialysis 
facilities; and 
(D) other areas determined appropriate by the Comp-
troller General. 
(2) SPECIFIED ORAL DRUG DEFINED.—For purposes of para-
graph (1), the term ‘‘specified oral drug’’ means a drug or 
biological for which there is no injectable equivalent (or other 
non-oral form of administration). 
(b) REPORT.—Not later than 1 year after the date of the enact-
ment of this Act, the Comptroller General of the United States 
shall submit to Congress a report containing the results of the 
study conducted under subsection (a), together with recommenda-
tions for such legislation and administrative action as the Comp-
troller General determines appropriate. 
Subtitle D—Provisions Relating to Title IV 
SEC. 10401. AMENDMENTS TO SUBTITLE A. 
(a) Section 4001(h)(4) and (5) of this Act is amended by striking 
‘‘2010’’ each place such appears and inserting ‘‘2020’’. 
(b) Section 4002(c) of this Act is amended— 
42 USC 300u–11. 
42 USC 300u–10. 
42 USC 1395ww. 
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124 STAT. 975 
PUBLIC LAW 111–148—MAR. 23, 2010 
(1) by striking ‘‘research and health screenings’’ and 
inserting ‘‘research, health screenings, and initiatives’’; and 
(2) by striking ‘‘for Preventive’’ and inserting ‘‘Regarding 
Preventive’’. 
(c) Section 4004(a)(4) of this Act is amended by striking ‘‘a 
Gateway’’ and inserting ‘‘an Exchange’’. 
SEC. 10402. AMENDMENTS TO SUBTITLE B. 
(a) Section 399Z–1(a)(1(A) of the Public Health Service Act, 
as added by section 4101(b) of this Act, is amended by inserting 
‘‘and vision’’ after ‘‘oral’’. 
(b) Section 1861(hhh)(4)(G) of the Social Security Act, as added 
by section 4103(b), is amended to read as follows: 
‘‘(G) A beneficiary shall be eligible to receive only an 
initial preventive physical examination (as defined under 
subsection (ww)(1)) during the 12-month period after the 
date that the beneficiary’s coverage begins under part B 
and shall be eligible to receive personalized prevention 
plan services under this subsection each year thereafter 
provided that the beneficiary has not received either an 
initial preventive physical examination or personalized 
prevention plan services within the preceding 12-month 
period.’’. 
SEC. 10403. AMENDMENTS TO SUBTITLE C. 
Section 4201 of this Act is amended— 
(1) in subsection (a), by adding before the period the fol-
lowing: ‘‘, with not less than 20 percent of such grants being 
awarded to rural and frontier areas’’; 
(2) in subsection (c)(2)(B)(vii), by striking ‘‘both urban and 
rural areas’’ and inserting ‘‘urban, rural, and frontier areas’’; 
and 
(3) in subsection (f), by striking ‘‘each fiscal years’’ and 
inserting ‘‘each of fiscal year’’. 
SEC. 10404. AMENDMENTS TO SUBTITLE D. 
Section 399MM(2) of the Public Health Service Act, as added 
by section 4303 of this Act, is amended by striking ‘‘by ensuring’’ 
and inserting ‘‘and ensuring’’. 
SEC. 10405. AMENDMENTS TO SUBTITLE E. 
Subtitle E of title IV of this Act is amended by striking section 
4401. 
SEC. 10406. AMENDMENT RELATING TO WAIVING COINSURANCE FOR 
PREVENTIVE SERVICES. 
Section 4104(b) of this Act is amended to read as follows: 
‘‘(b) PAYMENT AND ELIMINATION OF COINSURANCE IN ALL SET-
TINGS.—Section 1833(a)(1) of the Social Security Act (42 U.S.C. 
1395l(a)(1)), as amended by section 4103(c)(1), is amended— 
‘‘(1) in subparagraph (T), by inserting ‘(or 100 percent 
if such services are recommended with a grade of A or B 
by the United States Preventive Services Task Force for any 
indication or population and are appropriate for the individual)’ 
after ‘80 percent’; 
‘‘(2) in subparagraph (W)— 
42 USC 280l. 
42 USC 300u–13. 
42 USC 1395k. 
42 USC 280n–5. 
42 USC 300u–12. 
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124 STAT. 976 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) in clause (i), by inserting ‘(if such subparagraph 
were applied, by substituting ‘‘100 percent’’ for ‘‘80 per-
cent’’)’ after ‘subparagraph (D)’; and 
‘‘(B) in clause (ii), by striking ‘80 percent’ and inserting 
‘100 percent’; 
‘‘(3) by striking ‘and’ before ‘(X)’; and 
‘‘(4) by inserting before the semicolon at the end the fol-
lowing: ‘, and (Y) with respect to preventive services described 
in subparagraphs (A) and (B) of section 1861(ddd)(3) that are 
appropriate for the individual and, in the case of such services 
described in subparagraph (A), are recommended with a grade 
of A or B by the United States Preventive Services Task Force 
for any indication or population, the amount paid shall be 
100 percent of (i) except as provided in clause (ii), the lesser 
of the actual charge for the services or the amount determined 
under the fee schedule that applies to such services under 
this part, and (ii) in the case of such services that are covered 
OPD services (as defined in subsection (t)(1)(B)), the amount 
determined under subsection (t)’.’’. 
SEC. 10407. BETTER DIABETES CARE. 
(a) SHORT TITLE.—This section may be cited as the ‘‘Catalyst 
to Better Diabetes Care Act of 2009’’. 
(b) NATIONAL DIABETES REPORT CARD.— 
(1) IN GENERAL.—The Secretary, in collaboration with the 
Director of the Centers for Disease Control and Prevention 
(referred to in this section as the ‘‘Director’’), shall prepare 
on a biennial basis a national diabetes report card (referred 
to in this section as a ‘‘Report Card’’) and, to the extent possible, 
for each State. 
(2) CONTENTS.— 
(A) IN
GENERAL.—Each Report Card shall include 
aggregate health outcomes related to individuals diagnosed 
with diabetes and prediabetes including— 
(i) preventative care practices and quality of care; 
(ii) risk factors; and 
(iii) outcomes. 
(B) UPDATED REPORTS.—Each Report Card that is pre-
pared after the initial Report Card shall include trend 
analysis for the Nation and, to the extent possible, for 
each State, for the purpose of— 
(i) tracking progress in meeting established 
national goals and objectives for improving diabetes 
care, costs, and prevalence (including Healthy People 
2010); and 
(ii) informing policy and program development. 
(3) AVAILABILITY.—The Secretary, in collaboration with the 
Director, shall make each Report Card publicly available, 
including by posting the Report Card on the Internet. 
(c) IMPROVEMENT OF VITAL STATISTICS COLLECTION.— 
(1) IN
GENERAL.—The Secretary, acting through the 
Director of the Centers for Disease Control and Prevention 
and in collaboration with appropriate agencies and States, 
shall— 
(A) promote the education and training of physicians 
on the importance of birth and death certificate data and 
how to properly complete these documents, including the 
Public 
information. 
Web posting. 
Catalyst to 
Better Diabetes 
Care Act of 2009. 
42 USC 247b–9g. 
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124 STAT. 977 
PUBLIC LAW 111–148—MAR. 23, 2010 
collection of such data for diabetes and other chronic dis-
eases; 
(B) encourage State adoption of the latest standard 
revisions of birth and death certificates; and 
(C) work with States to re-engineer their vital statistics 
systems in order to provide cost-effective, timely, and 
accurate vital systems data. 
(2) DEATH
CERTIFICATE
ADDITIONAL
LANGUAGE.—In car-
rying out this subsection, the Secretary may promote improve-
ments to the collection of diabetes mortality data, including 
the addition of a question for the individual certifying the 
cause of death regarding whether the deceased had diabetes. 
(d) STUDY ON APPROPRIATE LEVEL OF DIABETES MEDICAL EDU-
CATION.— 
(1) IN GENERAL.—The Secretary shall, in collaboration with 
the Institute of Medicine and appropriate associations and coun-
cils, conduct a study of the impact of diabetes on the practice 
of medicine in the United States and the appropriateness of 
the level of diabetes medical education that should be required 
prior to licensure, board certification, and board recertification. 
(2) REPORT.—Not later than 2 years after the date of the 
enactment of this Act, the Secretary shall submit a report 
on the study under paragraph (1) to the Committees on Ways 
and Means and Energy and Commerce of the House of Rep-
resentatives and the Committees on Finance and Health, Edu-
cation, Labor, and Pensions of the Senate. 
(e) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated to carry out this section such sums as may 
be necessary. 
SEC. 10408. GRANTS FOR SMALL BUSINESSES TO PROVIDE COM-
PREHENSIVE WORKPLACE WELLNESS PROGRAMS. 
(a) ESTABLISHMENT.—The Secretary shall award grants to 
eligible employers to provide their employees with access to com-
prehensive workplace wellness programs (as described under sub-
section (c)). 
(b) SCOPE.— 
(1) DURATION.—The grant program established under this 
section shall be conducted for a 5-year period. 
(2) ELIGIBLE
EMPLOYER.—The term ‘‘eligible employer’’ 
means an employer (including a non-profit employer) that— 
(A) employs less than 100 employees who work 25 
hours or greater per week; and 
(B) does not provide a workplace wellness program 
as of the date of enactment of this Act. 
(c) COMPREHENSIVE WORKPLACE WELLNESS PROGRAMS.— 
(1) CRITERIA.—The Secretary shall develop program criteria 
for comprehensive workplace wellness programs under this sec-
tion that are based on and consistent with evidence-based 
research and best practices, including research and practices 
as provided in the Guide to Community Preventive Services, 
the Guide to Clinical Preventive Services, and the National 
Registry for Effective Programs. 
(2) REQUIREMENTS.—A comprehensive workplace wellness 
program shall be made available by an eligible employer to 
all employees and include the following components: 
Definition. 
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124 STAT. 978 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) Health awareness initiatives (including health edu-
cation, preventive screenings, and health risk assessments). 
(B) 
Efforts 
to 
maximize 
employee 
engagement 
(including mechanisms to encourage employee participa-
tion). 
(C) Initiatives to change unhealthy behaviors and life-
style choices (including counseling, seminars, online pro-
grams, and self-help materials). 
(D) Supportive environment efforts (including work-
place policies to encourage healthy lifestyles, healthy 
eating, increased physical activity, and improved mental 
health). 
(d) APPLICATION.—An eligible employer desiring to participate 
in the grant program under this section shall submit an application 
to the Secretary, in such manner and containing such information 
as the Secretary may require, which shall include a proposal for 
a comprehensive workplace wellness program that meet the criteria 
and requirements described under subsection (c). 
(e) AUTHORIZATION OF APPROPRIATION.—For purposes of car-
rying out the grant program under this section, there is authorized 
to be appropriated $200,000,000 for the period of fiscal years 2011 
through 2015. Amounts appropriated pursuant to this subsection 
shall remain available until expended. 
SEC. 10409. CURES ACCELERATION NETWORK. 
(a) SHORT TITLE.—This section may be cited as the ‘‘Cures 
Acceleration Network Act of 2009’’. 
(b) REQUIREMENT FOR THE DIRECTOR OF NIH TO ESTABLISH 
A CURES ACCELERATION NETWORK.—Section 402(b) of the Public 
Health Service Act (42 U.S.C. 282(b)) is amended— 
(1) in paragraph (22), by striking ‘‘and’’ at the end; 
(2) in paragraph (23), by striking the period and inserting 
‘‘; and’’; and 
(3) by inserting after paragraph (23), the following: 
‘‘(24) implement the Cures Acceleration Network described 
in section 402C.’’. 
(c) ACCEPTING GIFTS TO SUPPORT THE CURES ACCELERATION 
NETWORK.—Section 499(c)(1) of the Public Health Service Act (42 
U.S.C. 290b(c)(1)) is amended by adding at the end the following: 
‘‘(E) The Cures Acceleration Network described in sec-
tion 402C.’’. 
(d) ESTABLISHMENT OF THE CURES ACCELERATION NETWORK.— 
Part A of title IV of the Public Health Service Act is amended 
by inserting after section 402B (42 U.S.C. 282b) the following: 
‘‘SEC. 402C. CURES ACCELERATION NETWORK. 
‘‘(a) DEFINITIONS.—In this section: 
‘‘(1) BIOLOGICAL PRODUCT.—The term ‘biological product’ 
has the meaning given such term in section 351 of the Public 
Health Service Act. 
‘‘(2) DRUG; DEVICE.—The terms ‘drug’ and ‘device’ have 
the meanings given such terms in section 201 of the Federal 
Food, Drug, and Cosmetic Act. 
‘‘(3) HIGH NEED CURE.—The term ‘high need cure’ means 
a drug (as that term is defined by section 201(g)(1) of the 
Federal Food, Drug, and Cosmetic Act, biological product (as 
that term is defined by section 262(i)), or device (as that term 
is defined by section 201(h) of the Federal Food, Drug, and 
42 USC 282d. 
Cures 
Acceleration 
Network Act 
of 2009. 
42 USC 201 note. 
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124 STAT. 979 
PUBLIC LAW 111–148—MAR. 23, 2010 
Cosmetic Act) that, in the determination of the Director of 
NIH— 
‘‘(A) is a priority to diagnose, mitigate, prevent, or 
treat harm from any disease or condition; and 
‘‘(B) for which the incentives of the commercial market 
are unlikely to result in its adequate or timely development. 
‘‘(4) MEDICAL PRODUCT.—The term ‘medical product’ means 
a drug, device, biological product, or product that is a combina-
tion of drugs, devices, and biological products. 
‘‘(b) ESTABLISHMENT OF THE CURES ACCELERATION NETWORK.— 
Subject to the appropriation of funds as described in subsection 
(g), there is established within the Office of the Director of NIH 
a program to be known as the Cures Acceleration Network (referred 
to in this section as ‘CAN’), which shall— 
‘‘(1) be under the direction of the Director of NIH, taking 
into account the recommendations of a CAN Review Board 
(referred to in this section as the ‘Board’), described in sub-
section (d); and 
‘‘(2) award grants and contracts to eligible entities, as 
described in subsection (e), to accelerate the development of 
high need cures, including through the development of medical 
products and behavioral therapies. 
‘‘(c) FUNCTIONS.—The functions of the CAN are to— 
‘‘(1) conduct and support revolutionary advances in basic 
research, translating scientific discoveries from bench to bed-
side; 
‘‘(2) award grants and contracts to eligible entities to accel-
erate the development of high need cures; 
‘‘(3) provide the resources necessary for government agen-
cies, independent investigators, research organizations, bio-
technology companies, academic research institutions, and other 
entities to develop high need cures; 
‘‘(4) reduce the barriers between laboratory discoveries and 
clinical trials for new therapies; and 
‘‘(5) facilitate review in the Food and Drug Administration 
for the high need cures funded by the CAN, through activities 
that may include— 
‘‘(A) the facilitation of regular and ongoing communica-
tion with the Food and Drug Administration regarding 
the status of activities conducted under this section; 
‘‘(B) ensuring that such activities are coordinated with 
the approval requirements of the Food and Drug Adminis-
tration, with the goal of expediting the development and 
approval of countermeasures and products; and 
‘‘(C) connecting interested persons with additional tech-
nical assistance made available under section 565 of the 
Federal Food, Drug, and Cosmetic Act. 
‘‘(d) CAN BOARD.— 
‘‘(1) ESTABLISHMENT.—There is established a Cures Accel-
eration Network Review Board (referred to in this section as 
the ‘Board’), which shall advise the Director of NIH on the 
conduct of the activities of the Cures Acceleration Network. 
‘‘(2) MEMBERSHIP.— 
‘‘(A) IN GENERAL.— 
‘‘(i) APPOINTMENT.—The Board shall be comprised 
of 24 members who are appointed by the Secretary 
and who serve at the pleasure of the Secretary. 
Grants. 
Contracts. 
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124 STAT. 980 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(ii) CHAIRPERSON
AND
VICE
CHAIRPERSON.—The 
Secretary shall designate, from among the 24 members 
appointed under clause (i), one Chairperson of the 
Board (referred to in this section as the ‘Chairperson’) 
and one Vice Chairperson. 
‘‘(B) TERMS.— 
‘‘(i) IN GENERAL.—Each member shall be appointed 
to serve a 4-year term, except that any member 
appointed to fill a vacancy occurring prior to the expira-
tion of the term for which the member’s predecessor 
was appointed shall be appointed for the remainder 
of such term. 
‘‘(ii) 
CONSECUTIVE
APPOINTMENTS; 
MAXIMUM 
TERMS.—A member may be appointed to serve not 
more than 3 terms on the Board, and may not serve 
more than 2 such terms consecutively. 
‘‘(C) QUALIFICATIONS.— 
‘‘(i) IN
GENERAL.—The Secretary shall appoint 
individuals to the Board based solely upon the individ-
ual’s established record of distinguished service in one 
of the areas of expertise described in clause (ii). Each 
individual appointed to the Board shall be of distin-
guished achievement and have a broad range of dis-
ciplinary interests. 
‘‘(ii) 
EXPERTISE.—The 
Secretary 
shall 
select 
individuals based upon the following requirements: 
‘‘(I) For each of the fields of— 
‘‘(aa) basic research; 
‘‘(bb) medicine; 
‘‘(cc) biopharmaceuticals; 
‘‘(dd) discovery and delivery of medical 
products; 
‘‘(ee) bioinformatics and gene therapy; 
‘‘(ff) medical instrumentation; and 
‘‘(gg) regulatory review and approval of 
medical products, 
the Secretary shall select at least 1 individual 
who is eminent in such fields. 
‘‘(II) At least 4 individuals shall be recognized 
leaders in professional venture capital or private 
equity organizations and have demonstrated 
experience in private equity investing. 
‘‘(III) At least 8 individuals shall represent 
disease advocacy organizations. 
‘‘(3) EX-OFFICIO MEMBERS.— 
‘‘(A) APPOINTMENT.—In addition to the 24 Board mem-
bers described in paragraph (2), the Secretary shall appoint 
as ex-officio members of the Board— 
‘‘(i) a representative of the National Institutes of 
Health, recommended by the Secretary of the Depart-
ment of Health and Human Services; 
‘‘(ii) a representative of the Office of the Assistant 
Secretary of Defense for Health Affairs, recommended 
by the Secretary of Defense; 
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124 STAT. 981 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(iii) a representative of the Office of the Under 
Secretary for Health for the Veterans Health Adminis-
tration, recommended by the Secretary of Veterans 
Affairs; 
‘‘(iv) a representative of the National Science 
Foundation, recommended by the Chair of the National 
Science Board; and 
‘‘(v) a representative of the Food and Drug 
Administration, recommended by the Commissioner of 
Food and Drugs. 
‘‘(B) TERMS.—Each ex-officio member shall serve a 3- 
year term on the Board, except that the Chairperson may 
adjust the terms of the initial ex-officio members in order 
to provide for a staggered term of appointment for all 
such members. 
‘‘(4) RESPONSIBILITIES OF THE BOARD AND THE DIRECTOR 
OF NIH.— 
‘‘(A) RESPONSIBILITIES OF THE BOARD.— 
‘‘(i) IN GENERAL.—The Board shall advise, and pro-
vide recommendations to, the Director of NIH with 
respect to— 
‘‘(I) policies, programs, and procedures for car-
rying out the duties of the Director of NIH under 
this section; and 
‘‘(II) significant barriers to successful trans-
lation of basic science into clinical application 
(including issues under the purview of other agen-
cies and departments). 
‘‘(ii) REPORT.—In the case that the Board identifies 
a significant barrier, as described in clause (i)(II), the 
Board shall submit to the Secretary a report regarding 
such barrier. 
‘‘(B) RESPONSIBILITIES OF THE DIRECTOR OF NIH.—With 
respect to each recommendation provided by the Board 
under subparagraph (A)(i), the Director of NIH shall 
respond in writing to the Board, indicating whether such 
Director will implement such recommendation. In the case 
that the Director of NIH indicates a recommendation of 
the Board will not be implemented, such Director shall 
provide an explanation of the reasons for not implementing 
such recommendation. 
‘‘(5) MEETINGS.— 
‘‘(A) IN GENERAL.—The Board shall meet 4 times per 
calendar year, at the call of the Chairperson. 
‘‘(B) QUORUM; REQUIREMENTS; LIMITATIONS.— 
‘‘(i) QUORUM.—A quorum shall consist of a total 
of 13 members of the Board, excluding ex-officio mem-
bers, with diverse representation as described in clause 
(iii). 
‘‘(ii) CHAIRPERSON
OR
VICE
CHAIRPERSON.—Each 
meeting of the Board shall be attended by either the 
Chairperson or the Vice Chairperson. 
‘‘(iii) DIVERSE REPRESENTATION.—At each meeting 
of the Board, there shall be not less than one scientist, 
one representative of a disease advocacy organization, 
and one representative of a professional venture capital 
or private equity organization. 
Recommenda- 
tions. 
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124 STAT. 982 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(6) COMPENSATION AND TRAVEL EXPENSES.— 
‘‘(A) COMPENSATION.—Members shall receive com-
pensation at a rate to be fixed by the Chairperson but 
not to exceed a rate equal to the daily equivalent of the 
annual rate of basic pay prescribed for level IV of the 
Executive Schedule under section 5315 of title 5, United 
States Code, for each day (including travel time) during 
which the member is engaged in the performance of the 
duties of the Board. All members of the Board who are 
officers or employees of the United States shall serve with-
out compensation in addition to that received for their 
services as officers or employees of the United States. 
‘‘(B) TRAVEL EXPENSES.—Members of the Board shall 
be allowed travel expenses, including per diem in lieu 
of subsistence, at rates authorized for persons employed 
intermittently by the Federal Government under section 
5703(b) of title 5, United States Code, while away from 
their homes or regular places of business in the perform-
ance of services for the Board. 
‘‘(e) GRANT PROGRAM.— 
‘‘(1) SUPPORTING INNOVATION.—To carry out the purposes 
described in this section, the Director of NIH shall award 
contracts, grants, or cooperative agreements to the entities 
described in paragraph (2), to— 
‘‘(A) promote innovation in technologies supporting the 
advanced research and development and production of high 
need cures, including through the development of medical 
products and behavioral therapies. 
‘‘(B) accelerate the development of high need cures, 
including through the development of medical products, 
behavioral therapies, and biomarkers that demonstrate the 
safety or effectiveness of medical products; or 
‘‘(C) help the award recipient establish protocols that 
comply with Food and Drug Administration standards and 
otherwise permit the recipient to meet regulatory require-
ments at all stages of development, manufacturing, review, 
approval, and safety surveillance of a medical product. 
‘‘(2) ELIGIBLE ENTITIES.—To receive assistance under para-
graph (1), an entity shall— 
‘‘(A) be a public or private entity, which may include 
a private or public research institution, an institution of 
higher education, a medical center, a biotechnology com-
pany, a pharmaceutical company, a disease advocacy 
organization, a patient advocacy organization, or an aca-
demic research institution; 
‘‘(B) submit an application containing— 
‘‘(i) a detailed description of the project for which 
the entity seeks such grant or contract; 
‘‘(ii) a timetable for such project; 
‘‘(iii) an assurance that the entity will submit— 
‘‘(I) interim reports describing the entity’s— 
‘‘(aa) progress in carrying out the project; 
and 
‘‘(bb) compliance with all provisions of this 
section and conditions of receipt of such grant 
or contract; and 
Contracts. 
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124 STAT. 983 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(II) a final report at the conclusion of the 
grant period, describing the outcomes of the 
project; and 
‘‘(iv) a description of the protocols the entity will 
follow to comply with Food and Drug Administration 
standards and regulatory requirements at all stages 
of development, manufacturing, review, approval, and 
safety surveillance of a medical product; and 
‘‘(C) provide such additional information as the Director 
of NIH may require. 
‘‘(3) AWARDS.— 
‘‘(A) THE CURES ACCELERATION PARTNERSHIP AWARDS.— 
‘‘(i) INITIAL AWARD AMOUNT.—Each award under 
this subparagraph shall be not more than $15,000,000 
per project for the first fiscal year for which the project 
is funded, which shall be payable in one payment. 
‘‘(ii) FUNDING IN SUBSEQUENT FISCAL YEARS.—An 
eligible entity receiving an award under clause (i) may 
apply for additional funding for such project by submit-
ting to the Director of NIH the information required 
under subparagraphs (B) and (C) of paragraph (2). 
The Director may fund a project of such eligible entity 
in an amount not to exceed $15,000,000 for a fiscal 
year subsequent to the initial award under clause (i). 
‘‘(iii) MATCHING
FUNDS.—As a condition for 
receiving an award under this subsection, an eligible 
entity shall contribute to the project non-Federal funds 
in the amount of $1 for every $3 awarded under clauses 
(i) and (ii), except that the Director of NIH may waive 
or modify such matching requirement in any case 
where the Director determines that the goals and objec-
tives of this section cannot adequately be carried out 
unless such requirement is waived. 
‘‘(B) THE CURES ACCELERATION GRANT AWARDS.— 
‘‘(i) INITIAL AWARD AMOUNT.—Each award under 
this subparagraph shall be not more than $15,000,000 
per project for the first fiscal year for which the project 
is funded, which shall be payable in one payment. 
‘‘(ii) FUNDING IN SUBSEQUENT FISCAL YEARS.—An 
eligible entity receiving an award under clause (i) may 
apply for additional funding for such project by submit-
ting to the Board the information required under sub-
paragraphs (B) and (C) of paragraph (2). The Director 
of NIH may fund a project of such eligible entity in 
an amount not to exceed $15,000,000 for a fiscal year 
subsequent to the initial award under clause (i). 
‘‘(C) THE
CURES
ACCELERATION
FLEXIBLE
RESEARCH 
AWARDS.—If the Director of NIH determines that the goals 
and objectives of this section cannot adequately be carried 
out through a contract, grant, or cooperative agreement, 
the Director of NIH shall have flexible research authority 
to use other transactions to fund projects in accordance 
with the terms and conditions of this section. Awards made 
under such flexible research authority for a fiscal year 
shall not exceed 20 percent of the total funds appropriated 
under subsection (g)(1) for such fiscal year. 
Determination. 
Waiver authority. 
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124 STAT. 984 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(4) SUSPENSION OF AWARDS FOR DEFAULTS, NONCOMPLI-
ANCE WITH PROVISIONS AND PLANS, AND DIVERSION OF FUNDS; 
REPAYMENT OF FUNDS.—The Director of NIH may suspend the 
award to any entity upon noncompliance by such entity with 
provisions and plans under this section or diversion of funds. 
‘‘(5) AUDITS.—The Director of NIH may enter into agree-
ments with other entities to conduct periodic audits of the 
projects funded by grants or contracts awarded under this 
subsection. 
‘‘(6) CLOSEOUT
PROCEDURES.—At the end of a grant or 
contract period, a recipient shall follow the closeout procedures 
under section 74.71 of title 45, Code of Federal Regulations 
(or any successor regulation). 
‘‘(7) REVIEW.—A determination by the Director of NIH as 
to whether a drug, device, or biological product is a high need 
cure (for purposes of subsection (a)(3)) shall not be subject 
to judicial review. 
‘‘(f) COMPETITIVE BASIS OF AWARDS.—Any grant, cooperative 
agreement, or contract awarded under this section shall be awarded 
on a competitive basis. 
‘‘(g) AUTHORIZATION OF APPROPRIATIONS.— 
‘‘(1) IN GENERAL.—For purposes of carrying out this section, 
there are authorized to be appropriated $500,000,000 for fiscal 
year 2010, and such sums as may be necessary for subsequent 
fiscal years. Funds appropriated under this section shall be 
available until expended. 
‘‘(2) LIMITATION
ON
USE
OF
FUNDS
OTHERWISE
APPRO-
PRIATED.—No funds appropriated under this Act, other than 
funds appropriated under paragraph (1), may be allocated to 
the Cures Acceleration Network.’’. 
SEC. 10410. CENTERS OF EXCELLENCE FOR DEPRESSION. 
(a) SHORT TITLE.—This section may be cited as the ‘‘Estab-
lishing a Network of Health-Advancing National Centers of Excel-
lence for Depression Act of 2009’’ or the ‘‘ENHANCED Act of 2009’’. 
(b) CENTERS OF EXCELLENCE FOR DEPRESSION.—Subpart 3 of 
part B of title V of the Public Health Service Act (42 U.S.C. 
290bb et seq.) is amended by inserting after section 520A the 
following: 
‘‘SEC. 520B. NATIONAL CENTERS OF EXCELLENCE FOR DEPRESSION. 
‘‘(a) DEPRESSIVE DISORDER DEFINED.—In this section, the term 
‘depressive disorder’ means a mental or brain disorder relating 
to depression, including major depression, bipolar disorder, and 
related mood disorders. 
‘‘(b) GRANT PROGRAM.— 
‘‘(1) IN
GENERAL.—The Secretary, acting through the 
Administrator, shall award grants on a competitive basis to 
eligible entities to establish national centers of excellence for 
depression (referred to in this section as ‘Centers’), which shall 
engage in activities related to the treatment of depressive dis-
orders. 
‘‘(2) ALLOCATION
OF
AWARDS.—If the funds authorized 
under subsection (f) are appropriated in the amounts provided 
for under such subsection, the Secretary shall allocate such 
amounts so that— 
Deadlines. 
42 USC 
290bb–33. 
Establishing a 
Network of 
Health- 
Advancing 
National Centers 
of Excellence for 
Depression Act 
of 2009. 
42 USC 201 note. 
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124 STAT. 985 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) not later than 1 year after the date of enactment 
of the ENHANCED Act of 2009, not more than 20 Centers 
may be established; and 
‘‘(B) not later than September 30, 2016, not more than 
30 Centers may be established. 
‘‘(3) GRANT PERIOD.— 
‘‘(A) IN GENERAL.—A grant awarded under this section 
shall be for a period of 5 years. 
‘‘(B) RENEWAL.—A grant awarded under subparagraph 
(A) may be renewed, on a competitive basis, for 1 additional 
5-year period, at the discretion of the Secretary. In deter-
mining whether to renew a grant, the Secretary shall con-
sider the report cards issued under subsection (e)(2). 
‘‘(4) USE OF FUNDS.—Grant funds awarded under this sub-
section shall be used for the establishment and ongoing activi-
ties of the recipient of such funds. 
‘‘(5) ELIGIBLE ENTITIES.— 
‘‘(A) REQUIREMENTS.—To be eligible to receive a grant 
under this section, an entity shall— 
‘‘(i) be an institution of higher education or a public 
or private nonprofit research institution; and 
‘‘(ii) submit an application to the Secretary at such 
time and in such manner as the Secretary may require, 
as described in subparagraph (B). 
‘‘(B) 
APPLICATION.—An 
application 
described 
in 
subparagraph (A)(ii) shall include— 
‘‘(i) evidence that such entity— 
‘‘(I) provides, or is capable of coordinating with 
other entities to provide, comprehensive health 
services with a focus on mental health services 
and subspecialty expertise for depressive disorders; 
‘‘(II) collaborates with other mental health pro-
viders, as necessary, to address co-occurring 
mental illnesses; 
‘‘(III) is capable of training health profes-
sionals about mental health; and 
‘‘(ii) such other information, as the Secretary may 
require. 
‘‘(C) PRIORITIES.—In awarding grants under this sec-
tion, the Secretary shall give priority to eligible entities 
that meet 1 or more of the following criteria: 
‘‘(i) Demonstrated capacity and expertise to serve 
the targeted population. 
‘‘(ii) Existing infrastructure or expertise to provide 
appropriate, evidence-based and culturally and linguis-
tically competent services. 
‘‘(iii) A location in a geographic area with dis-
proportionate numbers of underserved and at-risk 
populations in medically underserved areas and health 
professional shortage areas. 
‘‘(iv) Proposed innovative approaches for outreach 
to initiate or expand services. 
‘‘(v) Use of the most up-to-date science, practices, 
and interventions available. 
‘‘(vi) Demonstrated capacity to establish coopera-
tive and collaborative agreements with community 
mental health centers and other community entities 
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124 STAT. 986 
PUBLIC LAW 111–148—MAR. 23, 2010 
to provide mental health, social, and human services 
to individuals with depressive disorders. 
‘‘(6) NATIONAL COORDINATING CENTER.— 
‘‘(A) IN GENERAL.—The Secretary, acting through the 
Administrator, shall designate 1 recipient of a grant under 
this section to be the coordinating center of excellence 
for depression (referred to in this section as the ‘coordi-
nating center’). The Secretary shall select such coordinating 
center on a competitive basis, based upon the demonstrated 
capacity of such center to perform the duties described 
in subparagraph (C). 
‘‘(B) APPLICATION.—A Center that has been awarded 
a grant under paragraph (1) may apply for designation 
as the coordinating center by submitting an application 
to the Secretary at such time, in such manner, and con-
taining such information as the Secretary may require. 
‘‘(C) DUTIES.—The coordinating center shall— 
‘‘(i) develop, administer, and coordinate the net-
work of Centers under this section; 
‘‘(ii) oversee and coordinate the national database 
described in subsection (d); 
‘‘(iii) lead a strategy to disseminate the findings 
and activities of the Centers through such database; 
and 
‘‘(iv) serve as a liaison with the Administration, 
the National Registry of Evidence-based Programs and 
Practices of the Administration, and any Federal inter-
agency or interagency forum on mental health. 
‘‘(7) MATCHING FUNDS.—The Secretary may not award a 
grant or contract under this section to an entity unless the 
entity agrees that it will make available (directly or through 
contributions from other public or private entities) non-Federal 
contributions toward the activities to be carried out under 
the grant or contract in an amount equal to $1 for each $5 
of Federal funds provided under the grant or contract. Such 
non-Federal matching funds may be provided directly or 
through donations from public or private entities and may 
be in cash or in-kind, fairly evaluated, including plant, equip-
ment, or services. 
‘‘(c) ACTIVITIES OF THE CENTERS.—Each Center shall carry out 
the following activities: 
‘‘(1) GENERAL ACTIVITIES.—Each Center shall— 
‘‘(A) integrate basic, clinical, or health services inter-
disciplinary research and practice in the development, 
implementation, and dissemination of evidence-based inter-
ventions; 
‘‘(B) involve a broad cross-section of stakeholders, such 
as researchers, clinicians, consumers, families of con-
sumers, and voluntary health organizations, to develop a 
research agenda and disseminate findings, and to provide 
support in the implementation of evidence-based practices; 
‘‘(C) provide training and technical assistance to mental 
health professionals, and engage in and disseminate 
translational research with a focus on meeting the needs 
of individuals with depressive disorders; and 
Designation. 
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124 STAT. 987 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(D) educate policy makers, employers, community 
leaders, and the public about depressive disorders to reduce 
stigma and raise awareness of treatments. 
‘‘(2) IMPROVED
TREATMENT
STANDARDS, CLINICAL
GUIDE-
LINES, DIAGNOSTIC PROTOCOLS, AND CARE COORDINATION PRAC-
TICE.—Each Center shall collaborate with other Centers in 
the network to— 
‘‘(A) develop and implement treatment standards, clin-
ical guidelines, and protocols that emphasize primary 
prevention, early intervention, treatment for, and recovery 
from, depressive disorders; 
‘‘(B) 
foster 
communication 
with 
other 
providers 
attending to co-occurring physical health conditions such 
as cardiovascular, diabetes, cancer, and substance abuse 
disorders; 
‘‘(C) leverage available community resources, develop 
and implement improved self-management programs, and, 
when appropriate, involve family and other providers of 
social support in the development and implementation of 
care plans; and 
‘‘(D) use electronic health records and telehealth tech-
nology to better coordinate and manage, and improve access 
to, care, as determined by the coordinating center. 
‘‘(3) TRANSLATIONAL
RESEARCH
THROUGH
COLLABORATION 
OF
CENTERS
AND
COMMUNITY-BASED
ORGANIZATIONS.—Each 
Center shall— 
‘‘(A) demonstrate effective use of a public-private part-
nership to foster collaborations among members of the net-
work and community-based organizations such as commu-
nity mental health centers and other social and human 
services providers; 
‘‘(B) 
expand 
interdisciplinary, 
translational, 
and 
patient-oriented research and treatment; and 
‘‘(C) coordinate with accredited academic programs to 
provide ongoing opportunities for the professional and con-
tinuing education of mental health providers. 
‘‘(d) NATIONAL DATABASE.— 
‘‘(1) IN GENERAL.—The coordinating center shall establish 
and maintain a national, publicly available database to improve 
prevention programs, evidence-based interventions, and disease 
management programs for depressive disorders, using data col-
lected from the Centers, as described in paragraph (2). 
‘‘(2) DATA
COLLECTION.—Each Center shall submit data 
gathered at such center, as appropriate, to the coordinating 
center regarding— 
‘‘(A) the prevalence and incidence of depressive dis-
orders; 
‘‘(B) the health and social outcomes of individuals with 
depressive disorders; 
‘‘(C) the effectiveness of interventions designed, tested, 
and evaluated; 
‘‘(D) other information, as the Secretary may require. 
‘‘(3) SUBMISSION
OF
DATA
TO
THE
ADMINISTRATOR.—The 
coordinating center shall submit to the Administrator the data 
and financial information gathered under paragraph (2). 
‘‘(4) PUBLICATION
USING
DATA
FROM
THE
DATABASE.—A 
Center, or an individual affiliated with a Center, may publish 
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124 STAT. 988 
PUBLIC LAW 111–148—MAR. 23, 2010 
findings using the data described in paragraph (2) only if such 
center submits such data to the coordinating center, as required 
under such paragraph. 
‘‘(e) ESTABLISHMENT OF STANDARDS; REPORT CARDS AND REC-
OMMENDATIONS; THIRD PARTY REVIEW.— 
‘‘(1) ESTABLISHMENT OF STANDARDS.—The Secretary, acting 
through the Administrator, shall establish performance stand-
ards for— 
‘‘(A) each Center; and 
‘‘(B) the network of Centers as a whole. 
‘‘(2) REPORT
CARDS.—The Secretary, acting through the 
Administrator, shall— 
‘‘(A) for each Center, not later than 3 years after the 
date on which such center of excellence is established and 
annually thereafter, issue a report card to the coordinating 
center to rate the performance of such Center; and 
‘‘(B) not later than 3 years after the date on which 
the first grant is awarded under subsection (b)(1) and 
annually thereafter, issue a report card to Congress to 
rate the performance of the network of centers of excellence 
as a whole. 
‘‘(3) RECOMMENDATIONS.—Based upon the report cards 
described in paragraph (2), the Secretary shall, not later than 
September 30, 2015— 
‘‘(A) make recommendations to the Centers regarding 
improvements such centers shall make; and 
‘‘(B) make recommendations to Congress for expanding 
the Centers to serve individuals with other types of mental 
disorders. 
‘‘(4) THIRD PARTY REVIEW.—Not later than 3 years after 
the date on which the first grant is awarded under subsection 
(b)(1) and annually thereafter, the Secretary shall arrange for 
an independent third party to conduct an evaluation of the 
network of Centers to ensure that such centers are meeting 
the goals of this section. 
‘‘(f) AUTHORIZATION OF APPROPRIATIONS.— 
‘‘(1) IN
GENERAL.—To carry out this section, there are 
authorized to be appropriated— 
‘‘(A) $100,000,000 for each of the fiscal years 2011 
through 2015; and 
‘‘(B) $150,000,000 for each of the fiscal years 2016 
through 2020. 
‘‘(2) ALLOCATION OF FUNDS AUTHORIZED.—Of the amount 
appropriated under paragraph (1) for a fiscal year, the Secretary 
shall determine the allocation of each Center receiving a grant 
under this section, but in no case may the allocation be more 
than $5,000,000, except that the Secretary may allocate not 
more than $10,000,000 to the coordinating center.’’. 
SEC. 10411. PROGRAMS RELATING TO CONGENITAL HEART DISEASE. 
(a) SHORT TITLE.—This subtitle may be cited as the ‘‘Congenital 
Heart Futures Act’’. 
(b) PROGRAMS RELATING
TO CONGENITAL HEART DISEASE.— 
(1) NATIONAL CONGENITAL HEART DISEASE SURVEILLANCE 
SYSTEM.—Part P of title III of the Public Health Service Act 
(42 U.S.C. 280g et seq.), as amended by section 5405, is further 
amended by adding at the end the following: 
Congenital Heart 
Futures Act. 
42 USC 201 note. 
Determination. 
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124 STAT. 989 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 399V–2. NATIONAL CONGENITAL HEART DISEASE SURVEILLANCE 
SYSTEM. 
‘‘(a) IN GENERAL.—The Secretary, acting through the Director 
of the Centers for Disease Control and Prevention, may— 
‘‘(1) enhance and expand infrastructure to track the epide-
miology of congenital heart disease and to organize such 
information into a nationally-representative, population-based 
surveillance system that compiles data concerning actual occur-
rences of congenital heart disease, to be known as the ‘National 
Congenital Heart Disease Surveillance System’; or 
‘‘(2) award a grant to one eligible entity to undertake 
the activities described in paragraph (1). 
‘‘(b) PURPOSE.—The purpose of the Congenital Heart Disease 
Surveillance System shall be to facilitate further research into 
the types of health services patients use and to identify possible 
areas for educational outreach and prevention in accordance with 
standard practices of the Centers for Disease Control and Preven-
tion. 
‘‘(c) CONTENT.—The Congenital Heart Disease Surveillance 
System— 
‘‘(1) may include information concerning the incidence and 
prevalence of congenital heart disease in the United States; 
‘‘(2) may be used to collect and store data on congenital 
heart disease, including data concerning— 
‘‘(A) demographic factors associated with congenital 
heart disease, such as age, race, ethnicity, sex, and family 
history of individuals who are diagnosed with the disease; 
‘‘(B) risk factors associated with the disease; 
‘‘(C) causation of the disease; 
‘‘(D) treatment approaches; and 
‘‘(E) outcome measures, such that analysis of the out-
come measures will allow derivation of evidence-based best 
practices and guidelines for congenital heart disease 
patients; and 
‘‘(3) may ensure the collection and analysis of longitudinal 
data related to individuals of all ages with congenital heart 
disease, including infants, young children, adolescents, and 
adults of all ages. 
‘‘(d) PUBLIC ACCESS.—The Congenital Heart Disease Surveil-
lance System shall be made available to the public, as appropriate, 
including congenital heart disease researchers. 
‘‘(e) PATIENT PRIVACY.—The Secretary shall ensure that the 
Congenital Heart Disease Surveillance System is maintained in 
a manner that complies with the regulations promulgated under 
section 264 of the Health Insurance Portability and Accountability 
Act of 1996. 
‘‘(f) ELIGIBILITY FOR GRANT.—To be eligible to receive a grant 
under subsection (a)(2), an entity shall— 
‘‘(1) be a public or private nonprofit entity with specialized 
experience in congenital heart disease; and 
‘‘(2) submit to the Secretary an application at such time, 
in such manner, and containing such information as the Sec-
retary may require.’’. 
(2) CONGENITAL HEART DISEASE RESEARCH.—Subpart 2 of 
part C of title IV of the Public Health Service Act (42 U.S.C. 
285b et seq.) is amended by adding at the end the following: 
42 USC 280g–13. 
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124 STAT. 990 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 425. CONGENITAL HEART DISEASE. 
‘‘(a) IN GENERAL.—The Director of the Institute may expand, 
intensify, and coordinate research and related activities of the 
Institute with respect to congenital heart disease, which may 
include congenital heart disease research with respect to— 
‘‘(1) causation of congenital heart disease, including genetic 
causes; 
‘‘(2) long-term outcomes in individuals with congenital 
heart disease, including infants, children, teenagers, adults, 
and elderly individuals; 
‘‘(3) diagnosis, treatment, and prevention; 
‘‘(4) studies using longitudinal data and retrospective anal-
ysis to identify effective treatments and outcomes for individ-
uals with congenital heart disease; and 
‘‘(5) identifying barriers to life-long care for individuals 
with congenital heart disease. 
‘‘(b) COORDINATION OF RESEARCH ACTIVITIES.—The Director of 
the Institute may coordinate research efforts related to congenital 
heart disease among multiple research institutions and may develop 
research networks. 
‘‘(c) MINORITY AND MEDICALLY UNDERSERVED COMMUNITIES.— 
In carrying out the activities described in this section, the Director 
of the Institute shall consider the application of such research 
and other activities to minority and medically underserved commu-
nities.’’. 
(c) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated to carry out the amendments made by this 
section such sums as may be necessary for each of fiscal years 
2011 through 2015. 
SEC. 10412. AUTOMATED DEFIBRILLATION IN ADAM’S MEMORY ACT. 
Section 312 of the Public Health Service Act (42 U.S.C. 244) 
is amended— 
(1) in subsection (c)(6), after ‘‘clearinghouse’’ insert ‘‘, that 
shall be administered by an organization that has substantial 
expertise in pediatric education, pediatric medicine, and 
electrophysiology and sudden death,’’; and 
(2) in the first sentence of subsection (e), by striking ‘‘fiscal 
year 2003’’ and all that follows through ‘‘2006’’ and inserting 
‘‘for each of fiscal years 2003 through 2014’’. 
SEC. 10413. YOUNG WOMEN’S BREAST HEALTH AWARENESS AND SUP-
PORT OF YOUNG WOMEN DIAGNOSED WITH BREAST 
CANCER. 
(a) SHORT TITLE.—This section may be cited as the ‘‘Young 
Women’s Breast Health Education and Awareness Requires 
Learning Young Act of 2009’’ or the ‘‘EARLY Act’’. 
(b) AMENDMENT.—Title III of the Public Health Service Act 
(42 U.S.C. 241 et seq.), as amended by this Act, is further amended 
by adding at the end the following: 
Young Women’s 
Breast Health 
Education and 
Awareness 
Requires 
Learning Young 
Act of 2009. 
42 USC 201 note. 
42 USC 285b–8. 
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124 STAT. 991 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘PART V—PROGRAMS RELATING TO BREAST 
HEALTH AND CANCER 
‘‘SEC. 399NN. YOUNG WOMEN’S BREAST HEALTH AWARENESS AND SUP-
PORT OF YOUNG WOMEN DIAGNOSED WITH BREAST 
CANCER. 
‘‘(a) PUBLIC EDUCATION CAMPAIGN.— 
‘‘(1) IN
GENERAL.—The Secretary, acting through the 
Director of the Centers for Disease Control and Prevention, 
shall conduct a national evidence-based education campaign 
to increase awareness of young women’s knowledge regarding— 
‘‘(A) breast health in young women of all racial, ethnic, 
and cultural backgrounds; 
‘‘(B) breast awareness and good breast health habits; 
‘‘(C) the occurrence of breast cancer and the general 
and specific risk factors in women who may be at high 
risk for breast cancer based on familial, racial, ethnic, 
and cultural backgrounds such as Ashkenazi Jewish popu-
lations; 
‘‘(D) evidence-based information that would encourage 
young women and their health care professional to increase 
early detection of breast cancers; and 
‘‘(E) the availability of health information and other 
resources for young women diagnosed with breast cancer. 
‘‘(2) EVIDENCE-BASED, AGE
APPROPRIATE
MESSAGES.—The 
campaign shall provide evidence-based, age-appropriate mes-
sages and materials as developed by the Centers for Disease 
Control and Prevention and the Advisory Committee estab-
lished under paragraph (4). 
‘‘(3) MEDIA CAMPAIGN.—In conducting the education cam-
paign under paragraph (1), the Secretary shall award grants 
to entities to establish national multimedia campaigns oriented 
to young women that may include advertising through tele-
vision, radio, print media, billboards, posters, all forms of 
existing and especially emerging social networking media, other 
Internet media, and any other medium determined appropriate 
by the Secretary. 
‘‘(4) ADVISORY COMMITTEE.— 
‘‘(A) ESTABLISHMENT.—Not later than 60 days after 
the date of the enactment of this section, the Secretary, 
acting through the Director of the Centers for Disease 
Control and Prevention, shall establish an advisory com-
mittee to assist in creating and conducting the education 
campaigns under paragraph (1) and subsection (b)(1). 
‘‘(B) MEMBERSHIP.—The Secretary, acting through the 
Director of the Centers for Disease Control and Prevention, 
shall appoint to the advisory committee under subpara-
graph (A) such members as deemed necessary to properly 
advise the Secretary, and shall include organizations and 
individuals with expertise in breast cancer, disease preven-
tion, early detection, diagnosis, public health, social mar-
keting, genetic screening and counseling, treatment, 
rehabilitation, palliative care, and survivorship in young 
women. 
‘‘(b) HEALTH CARE PROFESSIONAL EDUCATION CAMPAIGN.—The 
Secretary, acting through the Director of the Centers for Disease 
Appointment. 
Deadline. 
Grants. 
42 USC 280m. 
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124 STAT. 992 
PUBLIC LAW 111–148—MAR. 23, 2010 
Control and Prevention, and in consultation with the Administrator 
of the Health Resources and Services Administration, shall conduct 
an education campaign among physicians and other health care 
professionals to increase awareness— 
‘‘(1) of breast health, symptoms, and early diagnosis and 
treatment of breast cancer in young women, including specific 
risk factors such as family history of cancer and women that 
may be at high risk for breast cancer, such as Ashkenazi 
Jewish population; 
‘‘(2) on how to provide counseling to young women about 
their breast health, including knowledge of their family cancer 
history and importance of providing regular clinical breast 
examinations; 
‘‘(3) concerning the importance of discussing healthy behav-
iors, and increasing awareness of services and programs avail-
able to address overall health and wellness, and making patient 
referrals to address tobacco cessation, good nutrition, and phys-
ical activity; 
‘‘(4) on when to refer patients to a health care provider 
with genetics expertise; 
‘‘(5) on how to provide counseling that addresses long- 
term survivorship and health concerns of young women 
diagnosed with breast cancer; and 
‘‘(6) on when to provide referrals to organizations and 
institutions that provide credible health information and sub-
stantive assistance and support to young women diagnosed 
with breast cancer. 
‘‘(c) PREVENTION RESEARCH ACTIVITIES.—The Secretary, acting 
through— 
‘‘(1) the Director of the Centers for Disease Control and 
Prevention, shall conduct prevention research on breast cancer 
in younger women, including— 
‘‘(A) behavioral, survivorship studies, and other 
research on the impact of breast cancer diagnosis on young 
women; 
‘‘(B) formative research to assist with the development 
of educational messages and information for the public, 
targeted populations, and their families about breast 
health, breast cancer, and healthy lifestyles; 
‘‘(C) testing and evaluating existing and new social 
marketing strategies targeted at young women; and 
‘‘(D) surveys of health care providers and the public 
regarding knowledge, attitudes, and practices related to 
breast health and breast cancer prevention and control 
in high-risk populations; and 
‘‘(2) the Director of the National Institutes of Health, shall 
conduct research to develop and validate new screening tests 
and methods for prevention and early detection of breast cancer 
in young women. 
‘‘(d) SUPPORT FOR YOUNG WOMEN DIAGNOSED WITH BREAST 
CANCER.— 
‘‘(1) IN
GENERAL.—The Secretary shall award grants to 
organizations and institutions to provide health information 
from credible sources and substantive assistance directed to 
young women diagnosed with breast cancer and pre-neoplastic 
breast diseases. 
Grants. 
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124 STAT. 993 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(2) PRIORITY.—In making grants under paragraph (1), the 
Secretary shall give priority to applicants that deal specifically 
with young women diagnosed with breast cancer and pre-neo-
plastic breast disease. 
‘‘(e) NO DUPLICATION OF EFFORT.—In conducting an education 
campaign or other program under subsections (a), (b), (c), or (d), 
the Secretary shall avoid duplicating other existing Federal breast 
cancer education efforts. 
‘‘(f) MEASUREMENT; REPORTING.—The Secretary, acting through 
the Director of the Centers for Disease Control and Prevention, 
shall— 
‘‘(1) measure— 
‘‘(A) young women’s awareness regarding breast health, 
including knowledge of family cancer history, specific risk 
factors and early warning signs, and young women’s 
proactive efforts at early detection; 
‘‘(B) the number or percentage of young women uti-
lizing information regarding lifestyle interventions that 
foster healthy behaviors; 
‘‘(C) the number or percentage of young women 
receiving regular clinical breast exams; and 
‘‘(D) the number or percentage of young women who 
perform breast self exams, and the frequency of such 
exams, before the implementation of this section; 
‘‘(2) not less than every 3 years, measure the impact of 
such activities; and 
‘‘(3) submit reports to the Congress on the results of such 
measurements. 
‘‘(g) DEFINITION.—In this section, the term ‘young women’ 
means women 15 to 44 years of age. 
‘‘(h) AUTHORIZATION OF APPROPRIATIONS.—To carry out sub-
sections (a), (b), (c)(1), and (d), there are authorized to be appro-
priated $9,000,000 for each of the fiscal years 2010 through 2014.’’. 
Subtitle E—Provisions Relating to Title V 
SEC. 10501. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT, THE 
SOCIAL SECURITY ACT, AND TITLE V OF THIS ACT. 
(a) Section 5101 of this Act is amended— 
(1) in subsection (c)(2)(B)(i)(II), by inserting ‘‘, including 
representatives of small business and self-employed individ-
uals’’ after ‘‘employers’’; 
(2) in subsection (d)(4)(A)— 
(A) by redesignating clause (iv) as clause (v); and 
(B) by inserting after clause (iii) the following: 
‘‘(iv) An analysis of, and recommendations for, 
eliminating the barriers to entering and staying in 
primary care, including provider compensation.’’; and 
(3) in subsection (i)(2)(B), by inserting ‘‘optometrists, 
ophthalmologists,’’ after ‘‘occupational therapists,’’. 
(b) Subtitle B of title V of this Act is amended by adding 
at the end the following: 
42 USC 294q. 
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124 STAT. 994 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 5104. INTERAGENCY TASK FORCE TO ASSESS AND IMPROVE 
ACCESS TO HEALTH CARE IN THE STATE OF ALASKA. 
‘‘(a) ESTABLISHMENT.—There is established a task force to be 
known as the ‘Interagency Access to Health Care in Alaska Task 
Force’ (referred to in this section as the ‘Task Force’). 
‘‘(b) DUTIES.—The Task Force shall— 
‘‘(1) assess access to health care for beneficiaries of Federal 
health care systems in Alaska; and 
‘‘(2) develop a strategy for the Federal Government to 
improve delivery of health care to Federal beneficiaries in the 
State of Alaska. 
‘‘(c) MEMBERSHIP.—The Task Force shall be comprised of Fed-
eral members who shall be appointed, not later than 45 days 
after the date of enactment of this Act, as follows: 
‘‘(1) The Secretary of Health and Human Services shall 
appoint one representative of each of the following: 
‘‘(A) The Department of Health and Human Services. 
‘‘(B) The Centers for Medicare and Medicaid Services. 
‘‘(C) The Indian Health Service. 
‘‘(2) The Secretary of Defense shall appoint one representa-
tive of the TRICARE Management Activity. 
‘‘(3) The Secretary of the Army shall appoint one represent-
ative of the Army Medical Department. 
‘‘(4) The Secretary of the Air Force shall appoint one rep-
resentative of the Air Force, from among officers at the Air 
Force performing medical service functions. 
‘‘(5) The Secretary of Veterans Affairs shall appoint one 
representative of each of the following: 
‘‘(A) The Department of Veterans Affairs. 
‘‘(B) The Veterans Health Administration. 
‘‘(6) The Secretary of Homeland Security shall appoint one 
representative of the United States Coast Guard. 
‘‘(d) CHAIRPERSON.—One chairperson of the Task Force shall 
be appointed by the Secretary at the time of appointment of mem-
bers under subsection (c), selected from among the members 
appointed under paragraph (1). 
‘‘(e) MEETINGS.—The Task Force shall meet at the call of the 
chairperson. 
‘‘(f) REPORT.—Not later than 180 days after the date of enact-
ment of this Act, the Task Force shall submit to Congress a report 
detailing the activities of the Task Force and containing the 
findings, strategies, recommendations, policies, and initiatives 
developed pursuant to the duty described in subsection (b)(2). In 
preparing such report, the Task Force shall consider completed 
and ongoing efforts by Federal agencies to improve access to health 
care in the State of Alaska. 
‘‘(g) TERMINATION.—The Task Force shall be terminated on 
the date of submission of the report described in subsection (f).’’. 
(c) Section 399V of the Public Health Service Act, as added 
by section 5313, is amended— 
(1) in subsection (b)(4), by striking ‘‘identify, educate, refer, 
and enroll’’ and inserting ‘‘identify and refer’’; and 
(2) in subsection (k)(1), by striking ‘‘, as defined by the 
Department of Labor as Standard Occupational Classification 
[21–1094]’’. 
42 USC 280g–11. 
Deadline. 
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124 STAT. 995 
PUBLIC LAW 111–148—MAR. 23, 2010 
(d) Section 738(a)(3) of the Public Health Service Act (42 U.S.C. 
293b(a)(3)) is amended by inserting ‘‘schools offering physician 
assistant education programs,’’ after ‘‘public health,’’. 
(e) Subtitle D of title V of this Act is amended by adding 
at the end the following: 
‘‘SEC. 5316. DEMONSTRATION GRANTS FOR FAMILY NURSE PRACTI-
TIONER TRAINING PROGRAMS. 
‘‘(a) ESTABLISHMENT OF PROGRAM.—The Secretary of Health 
and Human Services (referred to in this section as the ‘Secretary’) 
shall establish a training demonstration program for family nurse 
practitioners (referred to in this section as the ‘program’) to employ 
and provide 1-year training for nurse practitioners who have grad-
uated from a nurse practitioner program for careers as primary 
care providers in Federally qualified health centers (referred to 
in this section as ‘FQHCs’) and nurse-managed health clinics 
(referred to in this section as ‘NMHCs’). 
‘‘(b) PURPOSE.—The purpose of the program is to enable each 
grant recipient to— 
‘‘(1) provide new nurse practitioners with clinical training 
to enable them to serve as primary care providers in FQHCs 
and NMHCs; 
‘‘(2) train new nurse practitioners to work under a model 
of primary care that is consistent with the principles set forth 
by the Institute of Medicine and the needs of vulnerable popu-
lations; and 
‘‘(3) create a model of FQHC and NMHC training for nurse 
practitioners that may be replicated nationwide. 
‘‘(c) GRANTS.—The Secretary shall award 3-year grants to 
eligible entities that meet the requirements established by the 
Secretary, for the purpose of operating the nurse practitioner pri-
mary care programs described in subsection (a) in such entities. 
‘‘(d) ELIGIBLE ENTITIES.—To be eligible to receive a grant under 
this section, an entity shall— 
‘‘(1)(A) be a FQHC as defined in section 1861(aa) of the 
Social Security Act (42 U.S.C. 1395x(aa)); or 
‘‘(B) be a nurse-managed health clinic, as defined in section 
330A–1 of the Public Health Service Act (as added by section 
5208 of this Act); and 
‘‘(2) submit to the Secretary an application at such time, 
in such manner, and containing such information as the Sec-
retary may require. 
‘‘(e) PRIORITY IN AWARDING GRANTS.—In awarding grants under 
this section, the Secretary shall give priority to eligible entities 
that— 
‘‘(1) demonstrate sufficient infrastructure in size, scope, 
and capacity to undertake the requisite training of a minimum 
of 3 nurse practitioners per year, and to provide to each awardee 
12 full months of full-time, paid employment and benefits con-
sistent with the benefits offered to other full-time employees 
of such entity; 
‘‘(2) will assign not less than 1 staff nurse practitioner 
or physician to each of 4 precepted clinics; 
‘‘(3) will provide to each awardee specialty rotations, 
including specialty training in prenatal care and women’s 
health, adult and child psychiatry, orthopedics, geriatrics, and 
at least 3 other high-volume, high-burden specialty areas; 
42 USC 296j–1. 
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124 STAT. 996 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(4) provide sessions on high-volume, high-risk health prob-
lems and have a record of training health care professionals 
in the care of children, older adults, and underserved popu-
lations; and 
‘‘(5) collaborate with other safety net providers, schools, 
colleges, and universities that provide health professions 
training. 
‘‘(f) ELIGIBILITY OF NURSE PRACTITIONERS.— 
‘‘(1) IN GENERAL.—To be eligible for acceptance to a pro-
gram funded through a grant awarded under this section, an 
individual shall— 
‘‘(A) be licensed or eligible for licensure in the State 
in which the program is located as an advanced practice 
registered nurse or advanced practice nurse and be eligible 
or board-certified as a family nurse practitioner; and 
‘‘(B) demonstrate commitment to a career as a primary 
care provider in a FQHC or in a NMHC. 
‘‘(2) PREFERENCE.—In selecting awardees under the pro-
gram, each grant recipient shall give preference to bilingual 
candidates that meet the requirements described in paragraph 
(1). 
‘‘(3) DEFERRAL
OF
CERTAIN
SERVICE.—The starting date 
of required service of individuals in the National Health Service 
Corps Service program under title II of the Public Health 
Service Act (42 U.S.C. 202 et seq.) who receive training under 
this section shall be deferred until the date that is 22 days 
after the date of completion of the program. 
‘‘(g) GRANT AMOUNT.—Each grant awarded under this section 
shall be in an amount not to exceed $600,000 per year. A grant 
recipient may carry over funds from 1 fiscal year to another without 
obtaining approval from the Secretary. 
‘‘(h) TECHNICAL
ASSISTANCE
GRANTS.—The Secretary may 
award technical assistance grants to 1 or more FQHCs or NMHCs 
that have demonstrated expertise in establishing a nurse practi-
tioner residency training program. Such technical assistance grants 
shall be for the purpose of providing technical assistance to other 
recipients of grants under subsection (c). 
‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—To carry out this sec-
tion, there is authorized to be appropriated such sums as may 
be necessary for each of fiscal years 2011 through 2014.’’. 
(f)(1) Section 399W of the Public Health Service Act, as added 
by section 5405, is redesignated as section 399V–1. 
(2) Section 399V–1 of the Public Health Service Act, as so 
redesignated, is amended in subsection (b)(2)(A) by striking ‘‘and 
the departments of 1 or more health professions schools in the 
State that train providers in primary care’’ and inserting ‘‘and 
the departments that train providers in primary care in 1 or more 
health professions schools in the State’’. 
(3) Section 934 of the Public Health Service Act, as added 
by section 3501, is amended by striking ‘‘399W’’ each place such 
term appears and inserting ‘‘399V–1’’. 
(4) Section 935(b) of the Public Health Service Act, as added 
by section 3503, is amended by striking ‘‘399W’’ and inserting 
‘‘399V–1’’. 
(g) Part P of title III of the Public Health Service Act 42 
U.S.C. 280g et seq.), as amended by section 10411, is amended 
by adding at the end the following: 
42 USC 299b–35. 
42 USC 299b–34. 
42 USC 280g–12. 
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124 STAT. 997 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘SEC. 399V–3. NATIONAL DIABETES PREVENTION PROGRAM. 
‘‘(a) IN GENERAL.—The Secretary, acting through the Director 
of the Centers for Disease Control and Prevention, shall establish 
a national diabetes prevention program (referred to in this section 
as the ‘program’) targeted at adults at high risk for diabetes in 
order to eliminate the preventable burden of diabetes. 
‘‘(b) PROGRAM ACTIVITIES.—The program described in sub-
section (a) shall include— 
‘‘(1) a grant program for community-based diabetes preven-
tion program model sites; 
‘‘(2) a program within the Centers for Disease Control 
and Prevention to determine eligibility of entities to deliver 
community-based diabetes prevention services; 
‘‘(3) a training and outreach program for lifestyle interven-
tion instructors; and 
‘‘(4) evaluation, monitoring and technical assistance, and 
applied research carried out by the Centers for Disease Control 
and Prevention. 
‘‘(c) ELIGIBLE ENTITIES.—To be eligible for a grant under sub-
section (b)(1), an entity shall be a State or local health department, 
a tribal organization, a national network of community-based non- 
profits focused on health and wellbeing, an academic institution, 
or other entity, as the Secretary determines. 
‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of 
carrying out this section, there are authorized to be appropriated 
such sums as may be necessary for each of fiscal years 2010 through 
2014.’’. 
(h) The provisions of, and amendment made by, section 5501(c) 
of this Act are repealed. 
(i)(1) The provisions of, and amendments made by, section 
5502 of this Act are repealed. 
(2)(A) Section 1861(aa)(3)(A) of the Social Security Act (42 
U.S.C. 1395w(aa)(3)(A)) is amended to read as follows: 
‘‘(A) services of the type described in subparagraphs (A) 
through (C) of paragraph (1) and preventive services (as defined 
in section 1861(ddd)(3)); and’’. 
(B) The amendment made by subparagraph (A) shall apply 
to services furnished on or after January 1, 2011. 
(3)(A) Section 1834 of the Social Security Act (42 U.S.C. 1395m), 
as amended by section 4105, is amended by adding at the end 
the following new subsection: 
‘‘(o) DEVELOPMENT AND IMPLEMENTATION OF PROSPECTIVE PAY-
MENT SYSTEM.— 
‘‘(1) DEVELOPMENT.— 
‘‘(A) IN
GENERAL.—The Secretary shall develop a 
prospective payment system for payment for Federally 
qualified health center services furnished by Federally 
qualified health centers under this title. Such system shall 
include a process for appropriately describing the services 
furnished by Federally qualified health centers and shall 
establish payment rates for specific payment codes based 
on such appropriate descriptions of services. Such system 
shall be established to take into account the type, intensity, 
and duration of services furnished by Federally qualified 
health centers. Such system may include adjustments, 
including geographic adjustments, determined appropriate 
by the Secretary. 
Applicability. 
42 USC 1395x 
note. 
42 USC 1395m, 
1395x and note. 
42 USC 1395x. 
Repeals. 
42 USC 1395w–4. 
42 USC 280g–14. 
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124 STAT. 998 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(B) COLLECTION OF DATA AND EVALUATION.—By not 
later than January 1, 2011, the Secretary shall require 
Federally qualified health centers to submit to the Sec-
retary such information as the Secretary may require in 
order to develop and implement the prospective payment 
system under this subsection, including the reporting of 
services using HCPCS codes. 
‘‘(2) IMPLEMENTATION.— 
‘‘(A) 
IN
GENERAL.—Notwithstanding 
section 
1833(a)(3)(A), the Secretary shall provide, for cost reporting 
periods beginning on or after October 1, 2014, for payments 
of prospective payment rates for Federally qualified health 
center services furnished by Federally qualified health cen-
ters under this title in accordance with the prospective 
payment system developed by the Secretary under para-
graph (1). 
‘‘(B) PAYMENTS.— 
‘‘(i) INITIAL PAYMENTS.—The Secretary shall imple-
ment such prospective payment system so that the 
estimated aggregate amount of prospective payment 
rates (determined prior to the application of section 
1833(a)(1)(Z)) under this title for Federally qualified 
health center services in the first year that such system 
is implemented is equal to 100 percent of the estimated 
amount of reasonable costs (determined without the 
application of a per visit payment limit or productivity 
screen and prior to the application of section 
1866(a)(2)(A)(ii)) that would have occurred for such 
services under this title in such year if the system 
had not been implemented. 
‘‘(ii) PAYMENTS IN SUBSEQUENT YEARS.—Payment 
rates in years after the year of implementation of 
such system shall be the payment rates in the previous 
year increased— 
‘‘(I) in the first year after implementation of 
such system, by the percentage increase in the 
MEI (as defined in section 1842(i)(3)) for the year 
involved; and 
‘‘(II) in subsequent years, by the percentage 
increase in a market basket of Federally qualified 
health center goods and services as promulgated 
through regulations, or if such an index is not 
available, by the percentage increase in the MEI 
(as defined in section 1842(i)(3)) for the year 
involved. 
‘‘(C) PREPARATION FOR PPS IMPLEMENTATION.—Notwith-
standing any other provision of law, the Secretary may 
establish and implement by program instruction or other-
wise the payment codes to be used under the prospective 
payment system under this section.’’. 
(B) Section 1833(a)(1) of the Social Security Act (42 U.S.C. 
1395l(a)(1)), as amended by section 4104, is amended— 
(i) by striking ‘‘and’’ before ‘‘(Y)’’; and 
(ii) by inserting before the semicolon at the end the fol-
lowing: ‘‘, and (Z) with respect to Federally qualified health 
center services for which payment is made under section 
1834(o), the amounts paid shall be 80 percent of the lesser 
Deadline. 
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124 STAT. 999 
PUBLIC LAW 111–148—MAR. 23, 2010 
of the actual charge or the amount determined under such 
section’’. 
(C) Section 1833(a) of the Social Security Act (42 U.S.C. 
1395l(a)) is amended— 
(i) in paragraph (3)(B)(i)— 
(I) by inserting ‘‘(I)’’ after ‘‘otherwise been provided’’; 
and 
(II) by inserting ‘‘, or (II) in the case of such services 
furnished on or after the implementation date of the 
prospective payment system under section 1834(o), under 
such section (calculated as if ‘100 percent’ were substituted 
for ‘80 percent’ in such section) for such services if the 
individual had not been so enrolled’’ after ‘‘been so 
enrolled’’; and 
(ii) by adding at the end the following flush sentence: 
‘‘Paragraph (3)(A) shall not apply to Federally qualified health 
center services furnished on or after the implementation date 
of the prospective payment system under section 1834(0).’’. 
(j) Section 5505 is amended by adding at the end the following 
new subsection: 
‘‘(d) APPLICATION.—The amendments made by this section shall 
not be applied in a manner that requires reopening of any settled 
cost reports as to which there is not a jurisdictionally proper appeal 
pending as of the date of the enactment of this Act on the issue 
of payment for indirect costs of medical education under section 
1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) 
or for direct graduate medical education costs under section 1886(h) 
of such Act (42 U.S.C. 1395ww(h)).’’. 
(k) Subtitle G of title V of this Act is amended by adding 
at the end the following: 
‘‘SEC. 5606. STATE GRANTS TO HEALTH CARE PROVIDERS WHO PRO-
VIDE SERVICES TO A HIGH PERCENTAGE OF MEDICALLY 
UNDERSERVED POPULATIONS OR OTHER SPECIAL POPU-
LATIONS. 
‘‘(a) IN GENERAL.—A State may award grants to health care 
providers who treat a high percentage, as determined by such 
State, of medically underserved populations or other special popu-
lations in such State. 
‘‘(b) SOURCE OF FUNDS.—A grant program established by a 
State under subsection (a) may not be established within a depart-
ment, agency, or other entity of such State that administers the 
Medicaid program under title XIX of the Social Security Act (42 
U.S.C. 1396 et seq.), and no Federal or State funds allocated to 
such Medicaid program, the Medicare program under title XVIII 
of the Social Security Act (42 U.S.C. 1395 et seq.), or the TRICARE 
program under chapter 55 of title 10, United States Code, may 
be used to award grants or to pay administrative costs associated 
with a grant program established under subsection (a).’’. 
(l) Part C of title VII of the Public Health Service Act (42 
U.S.C. 293k et seq.) is amended— 
(1) after the part heading, by inserting the following: 
‘‘Subpart I—Medical Training Generally’’; 
and 
(2) by inserting at the end the following: 
42 USC 254b–1. 
42 USC 1395ww 
note. 
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124 STAT. 1000 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘Subpart II—Training in Underserved 
Communities 
‘‘SEC. 749B. RURAL PHYSICIAN TRAINING GRANTS. 
‘‘(a) IN GENERAL.—The Secretary, acting through the Adminis-
trator of the Health Resources and Services Administration, shall 
establish a grant program for the purposes of assisting eligible 
entities in recruiting students most likely to practice medicine 
in underserved rural communities, providing rural-focused training 
and experience, and increasing the number of recent allopathic 
and osteopathic medical school graduates who practice in under-
served rural communities. 
‘‘(b) ELIGIBLE ENTITIES.—In order to be eligible to receive a 
grant under this section, an entity shall— 
‘‘(1) be a school of allopathic or osteopathic medicine accred-
ited by a nationally recognized accrediting agency or association 
approved by the Secretary for this purpose, or any combination 
or consortium of such schools; and 
‘‘(2) submit an application to the Secretary that includes 
a certification that such entity will use amounts provided to 
the institution as described in subsection (d)(1). 
‘‘(c) PRIORITY.—In awarding grant funds under this section, 
the Secretary shall give priority to eligible entities that— 
‘‘(1) demonstrate a record of successfully training students, 
as determined by the Secretary, who practice medicine in under-
served rural communities; 
‘‘(2) demonstrate that an existing academic program of 
the eligible entity produces a high percentage, as determined 
by the Secretary, of graduates from such program who practice 
medicine in underserved rural communities; 
‘‘(3) demonstrate rural community institutional partner-
ships, through such mechanisms as matching or contributory 
funding, documented in-kind services for implementation, or 
existence of training partners with interprofessional expertise 
in community health center training locations or other similar 
facilities; or 
‘‘(4) submit, as part of the application of the entity under 
subsection (b), a plan for the long-term tracking of where the 
graduates of such entity practice medicine. 
‘‘(d) USE OF FUNDS.— 
‘‘(1) ESTABLISHMENT.—An eligible entity receiving a grant 
under this section shall use the funds made available under 
such grant to establish, improve, or expand a rural-focused 
training program (referred to in this section as the ‘Program’) 
meeting the requirements described in this subsection and to 
carry out such program. 
‘‘(2) STRUCTURE OF PROGRAM.—An eligible entity shall— 
‘‘(A) enroll no fewer than 10 students per class year 
into the Program; and 
‘‘(B) develop criteria for admission to the Program that 
gives priority to students— 
‘‘(i) who have originated from or lived for a period 
of 2 or more years in an underserved rural community; 
and 
‘‘(ii) who express a commitment to practice medi-
cine in an underserved rural community. 
42 USC 293m. 
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124 STAT. 1001 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(3) CURRICULA.—The Program shall require students to 
enroll in didactic coursework and clinical experience particu-
larly applicable to medical practice in underserved rural 
communities, including— 
‘‘(A) clinical rotations in underserved rural commu-
nities, and in applicable specialties, or other coursework 
or clinical experience deemed appropriate by the Secretary; 
and 
‘‘(B) in addition to core school curricula, additional 
coursework or training experiences focused on medical 
issues prevalent in underserved rural communities. 
‘‘(4) RESIDENCY PLACEMENT ASSISTANCE.—Where available, 
the Program shall assist all students of the Program in 
obtaining clinical training experiences in locations with post-
graduate programs offering residency training opportunities in 
underserved rural communities, or in local residency training 
programs that support and train physicians to practice in 
underserved rural communities. 
‘‘(5) PROGRAM STUDENT COHORT SUPPORT.—The Program 
shall provide and require all students of the Program to partici-
pate in group activities designed to further develop, maintain, 
and reinforce the original commitment of such students to 
practice in an underserved rural community. 
‘‘(e) ANNUAL REPORTING.—An eligible entity receiving a grant 
under this section shall submit an annual report to the Secretary 
on the success of the Program, based on criteria the Secretary 
determines appropriate, including the residency program selection 
of graduating students who participated in the Program. 
‘‘(f) REGULATIONS.—Not later than 60 days after the date of 
enactment of this section, the Secretary shall by regulation define 
‘underserved rural community’ for purposes of this section. 
‘‘(g) SUPPLEMENT NOT SUPPLANT.—Any eligible entity receiving 
funds under this section shall use such funds to supplement, not 
supplant, any other Federal, State, and local funds that would 
otherwise be expended by such entity to carry out the activities 
described in this section. 
‘‘(h) MAINTENANCE OF EFFORT.—With respect to activities for 
which funds awarded under this section are to be expended, the 
entity shall agree to maintain expenditures of non-Federal amounts 
for such activities at a level that is not less than the level of 
such expenditures maintained by the entity for the fiscal year 
preceding the fiscal year for which the entity receives a grant 
under this section. 
‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There are authorized 
to be appropriated $4,000,000 for each of the fiscal years 2010 
through 2013.’’. 
(m)(1) Section 768 of the Public Health Service Act (42 U.S.C. 
295c) is amended to read as follows: 
‘‘SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING 
GRANT PROGRAM. 
‘‘(a) GRANTS.—The Secretary, acting through the Administrator 
of the Health Resources and Services Administration and in con-
sultation with the Director of the Centers for Disease Control and 
Prevention, shall award grants to, or enter into contracts with, 
eligible entities to provide training to graduate medical residents 
in preventive medicine specialties. 
Contracts. 
Deadline. 
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124 STAT. 1002 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(b) ELIGIBILITY.—To be eligible for a grant or contract under 
subsection (a), an entity shall be— 
‘‘(1) an accredited school of public health or school of medi-
cine or osteopathic medicine; 
‘‘(2) an accredited public or private nonprofit hospital; 
‘‘(3) a State, local, or tribal health department; or 
‘‘(4) a consortium of 2 or more entities described in para-
graphs (1) through (3). 
‘‘(c) USE OF FUNDS.—Amounts received under a grant or con-
tract under this section shall be used to— 
‘‘(1) plan, develop (including the development of curricula), 
operate, or participate in an accredited residency or internship 
program in preventive medicine or public health; 
‘‘(2) defray the costs of practicum experiences, as required 
in such a program; and 
‘‘(3) establish, maintain, or improve— 
‘‘(A) academic administrative units (including depart-
ments, divisions, or other appropriate units) in preventive 
medicine and public health; or 
‘‘(B) programs that improve clinical teaching in preven-
tive medicine and public health. 
‘‘(d) REPORT.—The Secretary shall submit to the Congress 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 follows: 
‘‘(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 period 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 Scholar-
ship Program or the Loan Repayment Program under which 
the individuals are authorized to satisfy the requirement of 
obligated service through providing clinical practice that is 
half time.’’; 
(B) in paragraph (2)— 
(i) in subparagraphs (A)(ii) and (B), by striking ‘‘less 
than full time’’ each place it appears and inserting ‘‘half 
time’’; 
(ii) in subparagraphs (C) and (F), by striking ‘‘less 
than full-time service’’ each place it appears 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 fulfill 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 
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124 STAT. 1003 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(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 dem-
onstration project described in paragraph (1)’’ 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 minimum 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 fiscal 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 fol-
lowing: ‘‘The Secretary may treat teaching as clinical practice 
for up to 20 percent of such period of obligated service.’’; and 
(B) by adding at the end the following: ‘‘Notwithstanding 
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 calcu-
lating 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 service obligation.’’. 
SEC. 10502. INFRASTRUCTURE TO EXPAND ACCESS TO CARE. 
(a) APPROPRIATION.—There are authorized to be appropriated, 
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 construction or renovation of, a health care facility 
that provides research, inpatient tertiary care, or outpatient clinical 
services. 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. 
(b) REQUIREMENT.—Amount appropriated under subsection (a) 
may only be made available by the Secretary of Health and Human 
Services upon the receipt of an application 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 financial 
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 
Certification. 
Definitions. 
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124 STAT. 1004 
PUBLIC LAW 111–148—MAR. 23, 2010 
(4) the State has established a dedicated funding mecha-
nism to provide all remaining funds necessary to complete 
the construction or renovation of the proposed facility. 
SEC. 10503. COMMUNITY HEALTH CENTERS AND THE NATIONAL 
HEALTH SERVICE CORPS FUND. 
(a) PURPOSE.—It is the purpose of this section to establish 
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 commu-
nity health centers 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 Treasury 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. 
(c) CONSTRUCTION.—There is authorized to be appropriated, 
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 construction and renovation of commu-
nity health centers. 
(d) USE OF FUND.—The Secretary of Health and Human Serv-
ices 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 subsections (b) 
and (c) shall remain available until expended. 
SEC. 10504. DEMONSTRATION PROJECT TO PROVIDE ACCESS 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 ‘‘Secretary’’), 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. 
Evaluation. 
Deadline. 
42 USC 256 note. 
Appropriation 
authorization. 
42 USC 254b–2. 
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124 STAT. 1005 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b) ELIGIBILITY.—To be eligible to participate in the demonstra-
tion 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 appropriated 
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 EXCEPTION TO 
THE PROHIBITION ON CERTAIN PHYSICIAN REFERRALS 
FOR HOSPITALS. 
(a) IN GENERAL.—Section 1877(i) of the Social Security Act, 
as added by section 6001(a), is amended— 
(1) in paragraph (1)(A)(i), by striking ‘‘February 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’’. 
(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 OUTCOMES 
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 subparagraph 
(A)(ii),’’ after ‘‘original research’’; and 
(ii) by inserting ‘‘, as long as the researcher 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 follows: 
‘‘(iv) SUBSEQUENT USE OF THE DATA.—The Institute 
shall not allow the subsequent use of data from original 
research in work-for-hire contracts with individuals, 
entities, or instrumentalities that have a financial 
interest in the results, unless 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 physicians and pro-
viders, including 4 members representing physicians 
(at least 1 of whom is a surgeon), 1 nurse, 1 State- 
licensed integrative health care practitioner, and 1 rep-
resentative of a hospital.’’. 
42 USC 1320e. 
42 USC 1395nn 
note. 
42 USC 1395nn. 
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124 STAT. 1006 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 10603. STRIKING PROVISIONS RELATING TO INDIVIDUAL PRO-
VIDER 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), respectively, 
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: 
‘‘(2) by redesignating paragraph (2) as paragraph (8); and’’. 
SEC. 10604. TECHNICAL CORRECTION TO SECTION 6405. 
Paragraphs (1) and (2) of section 6405(b) are amended 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 sec-
tion 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 sec-
tion 1866(j),’ after ‘a physician’.’’. 
SEC. 10605. CERTAIN OTHER PROVIDERS PERMITTED TO CONDUCT 
FACE TO FACE ENCOUNTER FOR HOME HEALTH SERV-
ICES. 
(a) PART A.—Section 1814(a)(2)(C) of the Social Security Act 
(42 U.S.C. 1395f(a)(2)(C)), as amended by section 6407(a)(1), is 
amended by inserting ‘‘, or a nurse practitioner or clinical nurse 
specialist (as those terms are defined in section 1861(aa)(5)) who 
is working in collaboration 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 specialist (as those terms 
are defined in section 1861(aa)(5)) who is working in collaboration 
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 ‘‘must document 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 accord-
ance with this subsection, the United States Sentencing 
Commission shall— 
28 USC 994 note. 
42 USC 1395f. 
42 USC 1395cc. 
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124 STAT. 1007 
PUBLIC LAW 111–148—MAR. 23, 2010 
(A) review the Federal Sentencing Guidelines and 
policy statements applicable to persons convicted of Federal 
health care offenses; 
(B) amend the Federal Sentencing Guidelines and 
policy statements applicable to persons convicted of Federal 
health care offenses involving Government health care pro-
grams 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 Guidelines to pro-
vide— 
(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 Federal health care offense 
relating to a Government health care program which 
involves 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 Federal health care offense 
relating to a Government 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 policy statements applicable 
to persons convicted of Federal health care offenses 
involving Government health care programs. 
(3) REQUIREMENTS.—In carrying this subsection, 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 aggressive and appropriate 
law enforcement action to prevent such fraud; and 
(ii) provide increased penalties for persons con-
victed of health care fraud offenses in appropriate cir-
cumstances; 
(B) consult with individuals or groups representing 
health care fraud victims, law enforcement 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 mitigating cir-
cumstances that might justify exceptions, including cir-
cumstances for which the Federal 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 ade-
quately meet the purposes of sentencing. 
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124 STAT. 1008 
PUBLIC LAW 111–148—MAR. 23, 2010 
(b) INTENT REQUIREMENT FOR HEALTH CARE FRAUD.—Section 
1347 of title 18, United States Code, is amended— 
(1) by inserting ‘‘(a)’’ before ‘‘Whoever knowingly’’; and 
(2) by adding at the end the following: 
‘‘(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 Security 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 Income 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)— 
(i) in subparagraph (A), by striking ‘‘grand jury 
subpoena’’ and inserting ‘‘subpoena for records’’; and 
(ii) in the matter following subparagraph (B), by 
striking ‘‘to the grand jury’’. 
(2) SUBPOENAS UNDER THE CIVIL RIGHTS OF INSTITUTIONAL-
IZED PERSONS ACT.—The Civil Rights of Institutionalized Per-
sons 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 investigation under this Act and to any docu-
ment, record, material, file, report, memorandum, policy, procedure, 
investigation, video or audio recording, or quality assurance report 
relating to any institution that is the subject of an investigation 
under this Act to determine whether there are conditions which 
deprive persons residing in or confined to the institution of any 
rights, privileges, or immunities secured or protected by the Con-
stitution or laws of the United States. 
‘‘(b) ISSUANCE AND ENFORCEMENT OF SUBPOENAS.— 
‘‘(1) ISSUANCE.—Subpoenas issued under this section— 
‘‘(A) shall bear the signature of the Attorney General 
or any officer or employee of the Department of Justice 
as designated by the Attorney 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 contumacy or failure 
to obey a subpoena issued under this section, the United States 
district court for the judicial district in which the institution 
42 USC 1997a–1. 
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124 STAT. 1009 
PUBLIC LAW 111–148—MAR. 23, 2010 
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 INFORMATION.— 
Any document, record, material, file, report, memorandum, policy, 
procedure, investigation, video or audio recording, or quality assur-
ance report or other information obtained under a subpoena issued 
under this section— 
‘‘(1) may not be used 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 reside 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 Constitu-
tion or laws of the United States of persons who reside, have 
resided, or will reside in an institution; and 
‘‘(3) shall be redacted, obscured, or otherwise altered if 
used in any publicly available manner so as to prevent the 
disclosure of any personally identifiable information.’’. 
SEC. 10607. STATE DEMONSTRATION PROGRAMS TO EVALUATE ALTER-
NATIVES 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 MEDICAL TORT LITIGA-
TION. 
‘‘(a) IN GENERAL.—The Secretary is authorized to award dem-
onstration grants to States for the development, implementation, 
and evaluation of alternatives to current tort litigation for resolving 
disputes over injuries allegedly caused by health care providers 
or health care organizations. In awarding such grants, the Secretary 
shall ensure the diversity of the alternatives so funded. 
‘‘(b) DURATION.—The Secretary may award grants under sub-
section (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 alternative to current tort litiga-
tion that— 
‘‘(A) allows for the resolution of disputes over injuries 
allegedly caused by health care providers or health care 
organizations; and 
‘‘(B) promotes a reduction of health care errors 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
LITIGATION.—Each 
State desiring a grant under subsection (a) shall demonstrate 
how the proposed alternative described in paragraph (1)(A)— 
‘‘(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; 
Grants. 
42 USC 280g–15. 
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124 STAT. 1010 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(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 differences in 
the alternative and current tort litigation; 
‘‘(G) provides patients the ability to opt out of or volun-
tarily withdraw from participating in the alternative at 
any time and to pursue other options, including litigation, 
outside the alternative; 
‘‘(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 access a State’s legal 
system, or otherwise abrogate a patient’s ability to file 
a medical malpractice 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 litiga-
tion, which may include public or private funding sources, 
or a combination of such sources. Funding methods shall to 
the extent practicable provide financial incentives for activities 
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 geographic region, a designated 
area of health care practice, or a designated group of health 
care providers or health care organizations) for the pro-
posed alternative to current tort litigation that is sufficient 
to evaluate the effects of the alternative. No scope of juris-
diction shall be established under this paragraph that is 
based on a health care payer or patient population. 
‘‘(B) NOTIFICATION OF PATIENTS.—A State shall dem-
onstrate 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 continue 
participating in the alternative process shall be made at 
any time and shall not be limited in any way. 
‘‘(5) PREFERENCE IN AWARDING DEMONSTRATION GRANTS.— 
In awarding grants under subsection (a), the Secretary shall 
give preference to States— 
‘‘(A) that have developed the proposed alternative 
through substantive consultation with relevant stake-
holders, including patient advocates, health care providers 
and health care organizations, attorneys with expertise 
in representing patients and health care providers, medical 
malpractice 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 
‘‘(C) that make proposals that are likely to improve 
access to liability insurance. 
‘‘(d) APPLICATION.— 
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124 STAT. 1011 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) IN GENERAL.—Each State desiring a grant under sub-
section (a) shall submit to the Secretary an application, at 
such time, in such manner, and containing such information 
as the Secretary may require. 
‘‘(2) REVIEW PANEL.— 
‘‘(A) IN
GENERAL.—In reviewing applications under 
paragraph (1), the Secretary shall consult with a review 
panel composed of relevant experts appointed by the Comp-
troller 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 knowledgeable individuals to serve on 
the review panel and shall ensure that the following 
entities receive fair representation on such panel: 
‘‘(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 insurers. 
‘‘(V) State officials. 
‘‘(VI) Patient safety experts. 
‘‘(C) CHAIRPERSON.—The Comptroller General, or an 
individual within the Government Accountability Office 
designated by the Comptroller General, shall be the chair-
person of the review 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 review panel may reasonably require 
to carry out its duties. 
‘‘(E) INFORMATION FROM AGENCIES.—The review panel 
may request directly from any department or agency of 
the United States any information that such panel con-
siders necessary to 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 sub-
section (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 min-
imum, 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 submit to Con-
gress an annual compendium of the reports submitted under 
paragraph (1) and an analysis of the activities funded under 
subsection (a) that examines 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 
Establishment. 
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124 STAT. 1012 
PUBLIC LAW 111–148—MAR. 23, 2010 
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). 
‘‘(2) REQUIREMENTS.—Technical assistance under para-
graph (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 injuries, 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 infrastruc-
ture 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, for-
mats, and data collection infrastructure developed under para-
graph (2)(B). 
‘‘(g) EVALUATION.— 
‘‘(1) IN GENERAL.—The Secretary, in consultation with the 
review panel established under subsection (d)(2), shall enter 
into a contract with an appropriate research organization to 
conduct an overall evaluation of the effectiveness of grants 
awarded 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 paragraph (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 extent to which 
the alternative developed under subsection (c)(1) is effective 
in meeting the elements described in subsection (c)(2); 
‘‘(C) a comparison among the States receiving grants 
under subsection (a) of the effectiveness of the various 
alternatives developed by such States under subsection 
(c)(1); 
‘‘(D) a comparison, considering the measures described 
in paragraph (3), of States receiving 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— 
‘‘(i) States receiving grants under subsection (a); 
‘‘(ii) States that enacted, prior to the date of enact-
ment 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 Protection and Affordable 
Care Act, a requirement that the complainant obtain 
Contracts. 
Deadlines. 
Reports. 
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124 STAT. 1013 
PUBLIC LAW 111–148—MAR. 23, 2010 
an opinion regarding 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 paragraph (2) shall 
analyze and make comparisons on the basis of— 
‘‘(A) the nature and number of disputes over injuries 
allegedly caused by health care providers or health care 
organizations; 
‘‘(B) the nature and number of claims in which tort 
litigation was pursued despite the existence of an alter-
native under subsection (a); 
‘‘(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 liability environment; and 
‘‘(H) impact on utilization of medical services, appro-
priately 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 Advisory Commis-
sion shall conduct an independent review of the alternatives 
to current tort litigation that are implemented under grants 
under subsection (a) to determine the impact of such alter-
natives on the Medicare program under title XVIII of the Social 
Security Act, and its beneficiaries. 
‘‘(2) MACPAC.—The Medicaid and CHIP Payment and 
Access Commission shall conduct an independent review of 
the alternatives to current tort litigation that are implemented 
under grants under subsection (a) to determine the impact 
of such alternatives on the Medicaid or CHIP programs under 
titles XIX and XXI of the Social Security Act, and their bene-
ficiaries. 
‘‘(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 recommenda-
tions of each respective Commission based on independent 
reviews conducted under paragraphs (1) and (2), including an 
analysis of the impact of the alternatives reviewed on the 
efficiency and effectiveness of the respective programs. 
‘‘(i) OPTION TO PROVIDE FOR INITIAL PLANNING GRANTS.—Of 
the funds appropriated pursuant to subsection (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 applications meeting the criteria described in subsection 
(c). In selecting States to receive such planning grants, the Secretary 
shall give preference to those States in which State law at the 
time of the application would not prohibit the adoption of an alter-
native to current tort litigation. 
‘‘(j) DEFINITIONS.—In this section: 
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124 STAT. 1014 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(1) HEALTH CARE SERVICES.—The term ‘health care serv-
ices’ 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 administer health benefits under any 
health plan. 
‘‘(3) HEALTH CARE PROVIDER.—The term ‘health care pro-
vider’ means any individual or entity— 
‘‘(A) licensed, registered, or certified under Federal or 
State laws or regulations to provide health care services; 
or 
‘‘(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 fiscal year 2011. 
‘‘(l) CURRENT STATE EFFORTS TO ESTABLISH ALTERNATIVE TO 
TORT LITIGATION.—Nothing in this section shall be construed to 
limit any prior, current, or future efforts of any State to establish 
any alternative to tort litigation. 
‘‘(m) RULE OF CONSTRUCTION.—Nothing in this section shall 
be construed as limiting states’ authority over or responsibility 
for their state justice systems.’’. 
SEC. 10608. EXTENSION OF MEDICAL MALPRACTICE COVERAGE 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 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 Cosmetic 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 approval under 
this subsection but for expiration of patent, 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’ section of the labeling; 
Deadlines. 
Drugs and drug 
abuse. 
42 USC 233 note. 
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124 STAT. 1015 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(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 than 60 days after the notification 
of any changes to such labeling required by the Secretary; 
and 
‘‘(iv) such application otherwise meets the applicable 
requirements for approval under this subsection. 
‘‘(B) If, after a labeling revision described in subparagraph 
(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 subparagraph (A)(i)) adversely 
impacts the safe use of the drug, no application under this sub-
section shall be eligible for approval 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 subparagraph (E); 
(B) in subsection (b)(1)(C)(i), by striking ‘‘for enroll-
ment’’ and inserting ‘‘for reenrollment’’; and 
(C) in subsection (c)(1), by striking ‘‘, as part of their 
automatic enrollment in the CLASS program,’’; and 
(2) in section 3204— 
(A) in subsection (c)(2), by striking subparagraph (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 ‘‘subparagraph (B) 
or (C) of subsection (c)(1)’’ and inserting ‘‘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 SUPPLEMENTAL COV-
ERAGE’’ and inserting ‘‘CLASS PROGRAM INFORMATION’’. 
(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,’’. 
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 
26 USC 4980I. 
42 USC 1396p 
note. 
42 USC 300ll–3. 
42 USC 300ll–2. 
Determination. 
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124 STAT. 1016 
PUBLIC LAW 111–148—MAR. 23, 2010 
work is longshore work (as defined in section 258(b) of the Immigra-
tion and Nationality Act (8 U.S.C. 1288(b)), determined without 
regard to paragraph (2) thereof),’’ before ‘‘and individuals engaged 
in the construction, mining’’. 
(b) EXEMPTION FROM HIGH-COST INSURANCE TAX INCLUDES CER-
TAIN
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 subpara-
graph (G) thereof)’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply to taxable years beginning after December 31, 2012. 
SEC. 10902. INFLATION ADJUSTMENT OF LIMITATION ON HEALTH 
FLEXIBLE SPENDING ARRANGEMENTS UNDER CAFE-
TERIA 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 ARRANGE-
MENTS.— 
‘‘(1) IN GENERAL.—For purposes of this section, if a benefit 
is provided under a cafeteria plan through employer contribu-
tions 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 tax-
able year beginning after December 31, 2011, the dollar amount 
in paragraph (1) shall be increased by an amount equal to— 
‘‘(A) such amount, multiplied by 
‘‘(B) the cost-of-living adjustment determined under 
section 1(f)(3) for the calendar year in which such taxable 
year begins by substituting ‘calendar year 2010’ for ‘cal-
endar year 1992’ in subparagraph (B) thereof. 
If any increase determined under this paragraph is not a mul-
tiple 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 December 31, 2010. 
SEC. 10903. MODIFICATION OF LIMITATION ON CHARGES BY CHARI-
TABLE 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 generally billed’’. 
(b) EFFECTIVE DATE.—The amendment made by this section 
shall apply to taxable years beginning after the date of the enact-
ment of this Act. 
SEC. 10904. MODIFICATION OF ANNUAL FEE ON MEDICAL DEVICE 
MANUFACTURERS AND IMPORTERS. 
(a) IN GENERAL.—Section 9009 of this Act is amended— 
(1) by striking ‘‘2009’’ in subsection (a)(1) and inserting 
‘‘2010’’, 
26 USC 4001 
note prec. 
26 USC 501 note. 
26 USC 501. 
26 USC 125 note. 
Effective date. 
26 USC 125. 
26 USC 4980I 
note. 
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124 STAT. 1017 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) by inserting ‘‘($3,000,000,000 after 2017)’’ after 
‘‘$2,000,000,000’’, and 
(3) by striking ‘‘2008’’ in subsection (i) and inserting ‘‘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 INSURANCE 
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 account during the preceding cal-
endar year, bears to 
‘‘(B) the aggregate net premiums written with respect 
to such health insurance of all covered entities that are 
taken into account during such preceding calendar year. 
‘‘(2) AMOUNTS TAKEN INTO ACCOUNT.—For purposes of para-
graph (1), the net premiums written 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 fol-
lowing table: 
‘‘With respect to a covered entity’s net pre-
miums written during the calendar year that 
are: 
The percentage of 
net premiums writ-
ten 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 Secretary shall 
calculate the amount of each covered entity’s fee for any cal-
endar year under paragraph (1). In calculating such amount, 
the Secretary shall determine such covered entity’s net pre-
miums written with respect to any United States health risk 
on the basis of reports submitted by the covered entity under 
subsection (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 subsection (b)(1), 
the applicable amount shall be determined in accordance with the 
following table: 
‘‘Calendar year 
Applicable 
amount 
2011 ...........................................................
$2,000,000,000 
2012 ...........................................................
$4,000,000,000 
26 USC 4001 
note prec. 
26 USC 4001 
note prec. 
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124 STAT. 1018 
PUBLIC LAW 111–148—MAR. 23, 2010 
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 INSURANCE 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 adding 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 non-
profit 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 
(within the meaning of section 501(m) of such Code), 
‘‘(ii) the premium rate increases of which are regu-
lated by a State authority, 
‘‘(iii) which, as of the date of the enactment of 
this section, acts as the insurer of last resort in the 
State and is subject to State guarantee issue require-
ments, and 
‘‘(iv) for which the medical loss ratio (determined 
in a manner consistent with the determination of such 
ratio under section 2718(b)(1)(A) of the Public Health 
Service Act) with respect to the individual insurance 
market for such entity for the calendar year is not 
less than 100 percent, 
‘‘(D) any entity— 
‘‘(i)(I) which is incorporated as a nonprofit corpora-
tion 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 
(within the meaning of section 501(m) of such Code), 
and 
‘‘(ii) for which the medical loss ratio (as so deter-
mined)— 
‘‘(I) with respect to each of the individual, 
small group, and large group insurance markets 
for such entity for the calendar year is not less 
than 90 percent, and 
‘‘(II) with respect to all such markets for such 
entity for the calendar year is not less than 92 
percent, or 
‘‘(E) any entity— 
‘‘(i) which is a mutual insurance company, 
‘‘(ii) which for the period reported on the 2008 
Accident and Health Policy Experience Exhibit of the 
National Association of Insurance Commissioners 
had— 
‘‘(I) a market share of the insured population 
of a State of at least 40 but not more than 60 
percent, and 
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124 STAT. 1019 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(II) with respect to all markets described in 
subparagraph (D)(ii)(I), a medical loss ratio of not 
less than 90 percent, and 
‘‘(iii) with respect to annual payment dates in cal-
endar years after 2011, for which the medical loss 
ratio (determined in a manner consistent with the 
determination of such ratio under section 2718(b)(1)(A) 
of the Public Health Service Act) with respect to all 
such markets for such entity for the preceding calendar 
year is not less than 89 percent (except that with 
respect to such annual payment date for 2012, the 
calculation under 2718(b)(1)(B)(ii) of such Act is deter-
mined by reference to the previous year, and with 
respect to such annual payment date for 2013, such 
calculation is determined by reference to the average 
for the previous 2 years).’’. 
(d) CERTAIN INSURANCE EXEMPTED FROM FEE.—Paragraph (3) 
of section 9010(h) of this Act is amended to read as follows: 
‘‘(3) HEALTH INSURANCE.—The term ‘health insurance’ shall 
not include— 
‘‘(A) any insurance coverage described in paragraph 
(1)(A) or (3) of section 9832(c) of the Internal Revenue 
Code of 1986, 
‘‘(B) any insurance for long-term care, or 
‘‘(C) any medicare supplemental health insurance (as 
defined in section 1882(g)(1) of the Social Security Act).’’. 
(e) ANTI-AVOIDANCE GUIDANCE.—Subsection (i) of section 9010 
of this Act is amended by inserting ‘‘and shall prescribe such regula-
tions as are necessary or appropriate to prevent avoidance of the 
purposes of this section, including inappropriate actions taken to 
qualify as an exempt entity under subsection (c)(2)’’ after ‘‘section’’. 
(f) CONFORMING AMENDMENTS.— 
(1) Section 9010(a)(1) of this Act is amended by striking 
‘‘2009’’ and inserting ‘‘2010’’. 
(2) Section 9010(c)(2)(B) of this Act is amended by striking 
‘‘(except’’ and all that follows through ‘‘1323)’’. 
(3) Section 9010(c)(3) of this Act is amended by adding 
at the end the following new sentence: ‘‘If any entity described 
in subparagraph (C)(i)(I), (D)(i)(I), or (E)(i) of paragraph (2) 
is treated as a covered entity by reason of the application 
of the preceding sentence, the net premiums written with 
respect to health insurance for any United States health risk 
of such entity shall not be taken into account for purposes 
of this section.’’. 
(4) Section 9010(g)(1) of this Act is amended by striking 
‘‘and third party administration agreement fees’’. 
(5) Section 9010(j) of this Act is amended— 
(A) by striking ‘‘2008’’ and inserting ‘‘2009’’, and 
(B) by striking ‘‘, and any third party administration 
agreement fees received after such date’’. 
(g) EFFECTIVE DATE.—The amendments made by this section 
shall take effect as if included in the enactment of section 9010. 
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124 STAT. 1020 
PUBLIC LAW 111–148—MAR. 23, 2010 
SEC. 10906. MODIFICATIONS TO ADDITIONAL HOSPITAL INSURANCE 
TAX ON HIGH-INCOME TAXPAYERS. 
(a) FICA.—Section 3101(b)(2) of the Internal Revenue Code 
of 1986, as added by section 9015(a)(1) of this Act, is amended 
by striking ‘‘0.5 percent’’ and inserting ‘‘0.9 percent’’. 
(b) SECA.—Section 1401(b)(2)(A) of the Internal Revenue Code 
of 1986, as added by section 9015(b)(1) of this Act, is amended 
by striking ‘‘0.5 percent’’ and inserting ‘‘0.9 percent’’. 
(c) EFFECTIVE DATE.—The amendments made by this section 
shall apply with respect to remuneration received, and taxable 
years beginning, after December 31, 2012. 
SEC. 10907. EXCISE TAX ON INDOOR TANNING SERVICES IN LIEU OF 
ELECTIVE COSMETIC MEDICAL PROCEDURES. 
(a) IN GENERAL.—The provisions of, and amendments made 
by, section 9017 of this Act are hereby deemed null, void, and 
of no effect. 
(b) EXCISE TAX
ON INDOOR TANNING SERVICES.—Subtitle D 
of the Internal Revenue Code of 1986, as amended by this Act, 
is amended by adding at the end the following new chapter: 
‘‘CHAPTER 49—COSMETIC SERVICES 
‘‘Sec. 5000B. Imposition of tax on indoor tanning services. 
‘‘SEC. 5000B. IMPOSITION OF TAX ON INDOOR TANNING SERVICES. 
‘‘(a) IN GENERAL.—There is hereby imposed on any indoor tan-
ning service a tax equal to 10 percent of the amount paid for 
such service (determined without regard to this section), whether 
paid by insurance or otherwise. 
‘‘(b) INDOOR TANNING SERVICE.—For purposes of this section— 
‘‘(1) IN GENERAL.—The term ‘indoor tanning service’ means 
a service employing any electronic product designed to incor-
porate 1 or more ultraviolet lamps and intended for the irradia-
tion of an individual by ultraviolet radiation, with wavelengths 
in air between 200 and 400 nanometers, to induce skin tanning. 
‘‘(2) EXCLUSION OF PHOTOTHERAPY SERVICES.—Such term 
does not include any phototherapy service performed by a 
licensed medical professional. 
‘‘(c) PAYMENT OF TAX.— 
‘‘(1) IN GENERAL.—The tax imposed by this section 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 imposed by sub-
section (a) is not paid at the time payments 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: 
Deadline. 
Definitions. 
26 USC 5000B. 
26 USC 5000B 
and note. 
26 USC 1401 
note. 
26 USC 1401. 
26 USC 3101. 
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124 STAT. 1021 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘CHAPTER 49—COSMETIC SERVICES’’. 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall apply to services performed on or after July 1, 2010. 
SEC. 10908. EXCLUSION FOR ASSISTANCE PROVIDED TO PARTICIPANTS 
IN STATE STUDENT LOAN REPAYMENT PROGRAMS FOR 
CERTAIN HEALTH PROFESSIONALS. 
(a) IN GENERAL.—Paragraph (4) of section 108(f) of the Internal 
Revenue Code of 1986 is amended to read as follows: 
‘‘(4) PAYMENTS UNDER NATIONAL HEALTH SERVICE CORPS 
LOAN REPAYMENT PROGRAM AND CERTAIN STATE LOAN REPAY-
MENT PROGRAMS.—In the case of an individual, gross income 
shall not include any amount received under section 338B(g) 
of the Public Health Service Act, under a State program 
described in section 338I of such Act, or under any other 
State loan repayment or loan forgiveness program that is 
intended to provide for the increased availability of health 
care services in underserved or health professional shortage 
areas (as determined by such State).’’. 
(b) EFFECTIVE DATE.—The amendment made by this section 
shall apply to amounts received by an individual in taxable years 
beginning after December 31, 2008. 
SEC. 10909. EXPANSION OF ADOPTION CREDIT AND ADOPTION ASSIST-
ANCE PROGRAMS. 
(a) INCREASE IN DOLLAR LIMITATION.— 
(1) ADOPTION CREDIT.— 
(A) IN
GENERAL.—Paragraph (1) of section 23(b) of 
the Internal Revenue Code of 1986 (relating to dollar 
limitation) is amended by striking ‘‘$10,000’’ and inserting 
‘‘$13,170’’. 
(B) CHILD WITH SPECIAL NEEDS.—Paragraph (3) of sec-
tion 23(a) of such Code (relating to $10,000 credit for adop-
tion of child with special needs regardless of expenses) 
is amended— 
(i) in the text by striking ‘‘$10,000’’ and inserting 
‘‘$13,170’’, and 
(ii) in the heading by striking ‘‘$10,000’’ and 
inserting ‘‘$13,170’’. 
(C) CONFORMING AMENDMENT TO INFLATION ADJUST-
MENT.—Subsection (h) of section 23 of such Code (relating 
to adjustments for inflation) is amended to read as follows: 
‘‘(h) ADJUSTMENTS FOR INFLATION.— 
‘‘(1) DOLLAR LIMITATIONS.—In the case of a taxable year 
beginning after December 31, 2010, each of the dollar amounts 
in subsections (a)(3) and (b)(1) shall be increased by an amount 
equal to— 
‘‘(A) such dollar amount, multiplied by 
‘‘(B) the cost-of-living adjustment determined under 
section 1(f)(3) for the calendar year in which the taxable 
year begins, determined by substituting ‘calendar year 
2009’ for ‘calendar year 1992’ in subparagraph (B) thereof. 
If any amount as increased under the preceding sentence is 
not a multiple of $10, such amount shall be rounded to the 
nearest multiple of $10. 
‘‘(2) INCOME LIMITATION.—In the case of a taxable year 
beginning after December 31, 2002, the dollar amount in sub-
section (b)(2)(A)(i) shall be increased by an amount equal to— 
Effective dates. 
26 USC 23. 
26 USC 108 note. 
26 USC 108. 
26 USC 5000B 
note. 
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124 STAT. 1022 
PUBLIC LAW 111–148—MAR. 23, 2010 
‘‘(A) such dollar amount, multiplied by 
‘‘(B) the cost-of-living adjustment determined under 
section 1(f)(3) for the calendar year in which the taxable 
year begins, determined by substituting ‘calendar year 
2001’ for ‘calendar year 1992’ in subparagraph (B) thereof. 
If any amount as increased under the preceding sentence is 
not a multiple of $10, such amount shall be rounded to the 
nearest multiple of $10.’’. 
(2) ADOPTION ASSISTANCE PROGRAMS.— 
(A) IN GENERAL.—Paragraph (1) of section 137(b) of 
the Internal Revenue Code of 1986 (relating to dollar 
limitation) is amended by striking ‘‘$10,000’’ and inserting 
‘‘$13,170’’. 
(B) CHILD WITH SPECIAL NEEDS.—Paragraph (2) of sec-
tion 137(a) of such Code (relating to $10,000 exclusion 
for adoption of child with special needs regardless of 
expenses) is amended— 
(i) in the text by striking ‘‘$10,000’’ and inserting 
‘‘$13,170’’, and 
(ii) in the heading by striking ‘‘$10,000’’ and 
inserting ‘‘$13,170’’. 
(C) CONFORMING AMENDMENT TO INFLATION ADJUST-
MENT.—Subsection (f) of section 137 of such Code (relating 
to adjustments for inflation) is amended to read as follows: 
‘‘(f) ADJUSTMENTS FOR INFLATION.— 
‘‘(1) DOLLAR LIMITATIONS.—In the case of a taxable year 
beginning after December 31, 2010, each of the dollar amounts 
in subsections (a)(2) and (b)(1) shall be increased by an amount 
equal to— 
‘‘(A) such dollar amount, multiplied by 
‘‘(B) the cost-of-living adjustment determined under 
section 1(f)(3) for the calendar year in which the taxable 
year begins, determined by substituting ‘calendar year 
2009’ for ‘calendar year 1992’ in subparagraph (B) thereof. 
If any amount as increased under the preceding sentence is 
not a multiple of $10, such amount shall be rounded to the 
nearest multiple of $10. 
‘‘(2) INCOME LIMITATION.—In the case of a taxable year 
beginning after December 31, 2002, the dollar amount in sub-
section (b)(2)(A) shall be increased by an amount equal to— 
‘‘(A) such dollar amount, multiplied by 
‘‘(B) the cost-of-living adjustment determined under 
section 1(f)(3) for the calendar year in which the taxable 
year begins, determined by substituting ‘calendar year 
2001’ for ‘calendar year 1992’ in subparagraph thereof. 
If any amount as increased under the preceding sentence is 
not a multiple of $10, such amount shall be rounded to the 
nearest multiple of $10.’’. 
(b) CREDIT MADE REFUNDABLE.— 
(1) CREDIT MOVED TO SUBPART RELATING TO REFUNDABLE 
CREDITS.—The Internal Revenue Code of 1986 is amended— 
(A) by redesignating section 23, as amended by sub-
section (a), as section 36C, and 
(B) by moving section 36C (as so redesignated) from 
subpart A of part IV of subchapter A of chapter 1 to 
the location immediately before section 37 in subpart C 
of part IV of subchapter A of chapter 1. 
26 USC 36C. 
Effective dates. 
26 USC 137. 
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124 STAT. 1023 
PUBLIC LAW 111–148—MAR. 23, 2010 
(2) CONFORMING AMENDMENTS.— 
(A) Section 24(b)(3)(B) of such Code is amended by 
striking ‘‘23,’’. 
(B) Section 25(e)(1)(C) of such Code is amended by 
striking ‘‘23,’’ both places it appears. 
(C) Section 25A(i)(5)(B) of such Code is amended by 
striking ‘‘23, 25D,’’ and inserting ‘‘25D’’. 
(D) Section 25B(g)(2) of such Code is amended by 
striking ‘‘23,’’. 
(E) Section 26(a)(1) of such Code is amended by striking 
‘‘23,’’. 
(F) Section 30(c)(2)(B)(ii) of such Code is amended by 
striking ‘‘23, 25D,’’ and inserting ‘‘25D’’. 
(G) Section 30B(g)(2)(B)(ii) of such Code is amended 
by striking ‘‘23,’’. 
(H) Section 30D(c)(2)(B)(ii) of such Code is amended 
by striking ‘‘sections 23 and’’ and inserting ‘‘section’’. 
(I) Section 36C of such Code, as so redesignated, is 
amended— 
(i) by striking paragraph (4) of subsection (b), and 
(ii) by striking subsection (c). 
(J) Section 137 of such Code is amended— 
(i) by striking ‘‘section 23(d)’’ in subsection (d) and 
inserting ‘‘section 36C(d)’’, and 
(ii) by striking ‘‘section 23’’ in subsection (e) and 
inserting ‘‘section 36C’’. 
(K) Section 904(i) of such Code is amended by striking 
‘‘23,’’. 
(L) Section 1016(a)(26) is amended by striking ‘‘23(g)’’ 
and inserting ‘‘36C(g)’’. 
(M) Section 1400C(d) of such Code is amended by 
striking ‘‘23,’’. 
(N) Section 6211(b)(4)(A) of such Code is amended by 
inserting ‘‘36C,’’ before ‘‘53(e)’’. 
(O) The table of sections for subpart A of part IV 
of subchapter A of chapter 1 of such Code of 1986 is 
amended by striking the item relating to section 23. 
(P) Paragraph (2) of section 1324(b) of title 31, United 
States Code, as amended by this Act, is amended by 
inserting ‘‘36C,’’ after ‘‘36B,’’. 
(Q) The table of sections for subpart C of part IV 
of subchapter A of chapter 1 of the Internal Revenue Code 
of 1986, as amended by this Act, is amended by inserting 
after the item relating to section 36B the following new 
item: 
‘‘Sec. 36C. Adoption expenses.’’. 
(c) APPLICATION AND EXTENSION OF EGTRRA SUNSET.—Not-
withstanding section 901 of the Economic Growth and Tax Relief 
Reconciliation Act of 2001, such section shall apply to the amend-
ments made by this section and the amendments made by section 
202 of such Act by substituting ‘‘December 31, 2011’’ for ‘‘December 
31, 2010’’ in subsection (a)(1) thereof. 
26 USC 1 note. 
26 USC 6211. 
26 USC 1400C. 
26 USC 1016. 
26 USC 904. 
26 USC 137. 
26 USC 36C. 
26 USC 30D. 
26 USC 30B. 
26 USC 30. 
26 USC 26. 
26 USC 25B. 
26 USC 25A. 
26 USC 25. 
26 USC 24. 
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124 STAT. 1024 
PUBLIC LAW 111–148—MAR. 23, 2010 
LEGISLATIVE HISTORY—H.R. 3590: 
CONGRESSIONAL RECORD: 
Vol. 155 (2009): Oct. 7, 8, considered and passed House. 
Nov. 21, 30, Dec. 1–10, 13, 15, 16, 19–24, considered and 
passed Senate, amended. 
Vol. 156 (2010): Mar. 21, House concurred in Senate amendments. 
DAILY COMPILATION OF PRESIDENTIAL DOCUMENTS (2010): 
Mar. 23, Presidential remarks. 
(d) EFFECTIVE DATE.—The amendments made by this section 
shall apply to taxable years beginning after December 31, 2009. 
Approved March 23, 2010. 
26 USC 1 note. 
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