TITLE II--ROLE OF PUBLIC PROGRAMS

                 Subtitle A--Improved Access to Medicaid



SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME POPULATIONS.

    (a) Coverage for Individuals With Income at or Below 133 Percent of 
the Poverty Line.--
            (1) Beginning 2014.-- <<NOTE: Effective date.>> 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 coverage.--
                    (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)

[[Page 124 STAT. 272]]

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), <<NOTE: 42 USC 13966.>>  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 
        subsection (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) <<NOTE: Time periods.>>  Amount of increase.--
                    ``(A) 100 percent fmap.--During the period that 
                begins on January 1, 2014, and ends on December 31, 
                2016, notwithstanding 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 individuals 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 subparagraph (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 occurring 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:

[[Page 124 STAT. 273]]



 
------------------------------------------------------------------------
                            If the State is an    If the State is not an
 ``For any fiscal year     expansion State, the    expansion State, the
  quarter occurring in    applicable percentage    applicable percentage
   the calendar year:       point increase is:      point increase 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 expansion 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 coverage, employer 
                                contribution, or employment and is not 
                                limited to premium assistance, hospital-
                                only benefits, a high deductible health 
                                plan, or alternative 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 preceding sentence 
                                shall not be considered to be an 
                                expansion State.
                    ``(C) 2019 and succeeding years. <<NOTE: Effective 
                date.>> --Beginning January 1, 2019, notwithstanding 
                subsection (b) but subject to subparagraph (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 quarter occurring 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 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.

[[Page 124 STAT. 274]]

                    ``(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 coverage for parents to 
        be eligible.--
                    (A) In general.--Subsection (k) of section 1902 of 
                the Social Security Act (as added by paragraph 
                (2)), <<NOTE: 42 USC 1396a.>>  is amended by inserting 
                after paragraph (1) the following:

    ``(2) <<NOTE: Effective date. Time period.>>  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 subclause (VIII) of subsection (a)(10)(A)(i) if that 
subclause were effective 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) <<NOTE: Guidelines.>>  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 
                subparagraph (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''.

[[Page 124 STAT. 275]]

                    (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 
        subsection (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 <<NOTE: Time 
        period. Determination.>>  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 calendar quarters occurring during such period, a 
        State shall not have in effect eligibility standards, 
        methodologies, or procedures 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 children 
        until october 1, 2019.-- <<NOTE: Applicability.>> The 
        requirement under paragraph (1) shall continue to apply to a 
        State through September 30, 2019, with respect to the 
        eligibility standards, methodologies, and procedures under the 
        State plan under this title or under any waiver of such plan 
        that are applicable to determining 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.-- <<NOTE: Time 
        period. Deadline. Certification.>> During the period that begins 
        on January 1, 2011, and ends on December 31, 2013, the 
        requirement under paragraph (1) shall not apply to a State with 
        respect to nonpregnant, nondisabled adults who are eligible

[[Page 124 STAT. 276]]

        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 
        certification 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 
                subsection (e)(14) shall not be considered to be 
                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 Protection and Affordable 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 paragraph (1), 
                (2), or (3), a State that applies eligibility standards, 
                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, 
                methodologies, 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 Protection 
                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 
                ``subsection (a)(1),'';

[[Page 124 STAT. 277]]

                    (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.-- <<NOTE: Effective 
        date.>> 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 
                benefit 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 section 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, diagnostic, 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) <<NOTE: Effective date.>>  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

[[Page 124 STAT. 278]]

                categories or sub-categories of individuals eligible for 
                medical 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 
                population, 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.-- <<NOTE: Effective date. 42 USC 
        1396a note.>> Beginning April 2015, and annually thereafter, the 
        Secretary of Health and Human Services shall submit a report to 
        the appropriate committees of Congress on the total enrollment 
        and new enrollment in Medicaid 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 administrative 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 
                      subclause:
                                    ``(XX) <<NOTE: Effective 
                                date.>> 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 poverty 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,

[[Page 124 STAT. 279]]

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 
                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, 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 Affordable Care Act. For 
                purposes of complying with the maintenance 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. <<NOTE: Waiver authority.>> 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 
                beneficiaries.
                    ``(B) No income or expense disregards.--No type of 
                expense, block, or other income disregard shall be 
                applied

[[Page 124 STAT. 280]]

                by a State to determine income eligibility for medical 
                assistance 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 
                eligibility 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 benefits 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 section 1902(e)(3).
                                    ``(IV) Individuals described in 
                                subsection (a)(10)(C).
                                    ``(V) Individuals described in any 
                                clause of subsection (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

[[Page 124 STAT. 281]]

                      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 eligibility of individuals for purposes of 
                      medical assistance for nursing facility services, 
                      a level of care in any institution equivalent to 
                      that of nursing facility services, 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 
                      individual 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 
                      regularly scheduled redetermination of eligibility 
                      is to occur, whichever is later.
                    ``(E) Transition planning and oversight.-- 
                <<NOTE: Submission.>> 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 
                practicable, 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 
                Secretary 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.

[[Page 124 STAT. 282]]

                    ``(G) Definitions of modified gross income and 
                household income.--In this paragraph, the terms 
                `modified 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) <<NOTE: 42 USC 1396a note.>>  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 individual (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.

[[Page 124 STAT. 283]]

    (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) <<NOTE: 42 USC 1396e-1 note.>>  Effective Date.--The amendments 
made by this section take effect on January 1, 2014.



SEC. 2004. MEDICAID COVERAGE FOR FORMER FOSTER CARE CHILDREN.

    (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 responsibility 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) <<NOTE: 42 USC 1396a note.>>  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 percent.''.

    (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'';

[[Page 124 STAT. 284]]

            (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, 
                payments 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)) 
                nonpregnant 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 respectively) the income eligibility level in 
                effect for that population 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) <<NOTE: 42 USC 1396d note.>>  Effective date.--The 
        amendment made by paragraph (1) takes effect on January 1, 2011.



SEC. 2006. SPECIAL ADJUSTMENT TO FMAP DETERMINATION FOR CERTAIN 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) <<NOTE: Effective date.>> 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 
        subsections (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

[[Page 124 STAT. 285]]

        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.

    ``(2) <<NOTE: Definition.>>  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 Government 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 
        subsections (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) <<NOTE: Applicability.>>  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''.

[[Page 124 STAT. 286]]

Subtitle B--Enhanced Support for the Children's Health Insurance Program



SEC. 2101. ADDITIONAL FEDERAL FINANCIAL PARTICIPATION FOR CHIP.

    (a) In General.-- <<NOTE: Time period.>> 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 preceding 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 subsection (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 children 
        until october 1, 2019.--
                    ``(A) In general.-- <<NOTE: Time period.>> During 
                the period that begins on the date of enactment of the 
                Patient Protection and Affordable 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 children 
                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, methodologies, 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 expenditures 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 targeted 
                low-income children unable to be provided child health 
                assistance as a result of funding 
                shortfalls. <<NOTE: Procedures.>> --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

[[Page 124 STAT. 287]]

                establish procedures to ensure that such children are 
                provided 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) <<NOTE: Effective date.>>  shall, 
                      beginning January 1, 2014, use modified gross 
                      income and household income (as defined in section 
                      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.--Section 
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) <<NOTE: 42 USC 1397jj note.>>  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

[[Page 124 STAT. 288]]

implemented under title XIX or XXI, or both, of the Social Security 
Act).



SEC. 2102. TECHNICAL CORRECTIONS.

    (a) <<NOTE: Effective date. 42 USC 1396b note.>>  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, <<NOTE: 42 USC 1397dd.>>  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 assistance percentage matching rate for such 
        population.''.
            (2) Section 605 of CHIPRA <<NOTE: 42 USC 1396 note.>>  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)), <<NOTE: 42 USC 1397ee.>>  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 <<NOTE: 42 USC 1396b.>>  
        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).

[[Page 124 STAT. 289]]

    (b) <<NOTE: 42 USC 13960-1 note.>>  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. <<NOTE: 42 USC 1396w-3.>>  ENROLLMENT SIMPLIFICATION AND 
            COORDINATION WITH STATE HEALTH INSURANCE EXCHANGES.

    ``(a) Condition for Participation in Medicaid. <<NOTE: Effective 
date.>> --As a condition 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.-- <<NOTE: Procedures.>> A State shall 
        establish procedures for--
                    ``(A) <<NOTE: Web site.>>  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 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), 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

[[Page 124 STAT. 290]]

                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 premium 
                assistance, and enrollment in the State plan under this 
                title, title XXI, or a qualified health plan, as 
                appropriate;
                    ``(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 populations, 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 established 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 prescribe to reduce administrative 
        costs and the likelihood of eligibility errors and disruptions 
        in coverage.
            ``(3) Streamlined enrollment system.--The State Medicaid 
        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).

[[Page 124 STAT. 291]]

            ``(4) Enrollment website requirements.-- 
        <<NOTE: Deadline.>> The procedures 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 individual 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 ELIGIBILITY 
            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) <<NOTE: Guidelines.>>  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

[[Page 124 STAT. 292]]

        of presumptive eligibility made by a hospital that elects under 
        section 1902(a)(47)(B) to be a qualified entity for such 
        purpose''.

    (c) <<NOTE: Applicability. 42 USC 1396a note.>>  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 
        subsection (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) <<NOTE: Definitions.>>  The term `freestanding birth center 
services' means services 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) <<NOTE: Payments.>>  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 registered 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 supervision 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

[[Page 124 STAT. 293]]

matter preceding clause (i) by striking ``and (21)'' and inserting ``, 
(21), and (28)''.
    (c) <<NOTE: 42 USC 1396a note.>>  Effective Date.--
            (1) In general.-- <<NOTE: Applicability.>> 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.-- 
        <<NOTE: Determination.>> 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 SERVICES.

    (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:

[[Page 124 STAT. 294]]

    ``(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) 
        pursuant 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 
        subsection, 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 diagnosis 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.  <<NOTE: 42 USC 1396r-1c.>>  (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

[[Page 124 STAT. 295]]

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 `presumptive 
        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 
                paragraph shall be construed as preventing a State from 
                limiting 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) <<NOTE: Deadline.>>  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 
                determination 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 determination is made.
            ``(3) Application for medical assistance.-- 
        <<NOTE: Deadline.>> 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.

[[Page 124 STAT. 296]]

    ``(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 supplies.--
        Notwithstanding the previous provisions of this section, a State 
        may not provide for medical assistance through enrollment 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. <<NOTE: Applicability. 42 USC 1396a note.>> --
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''.

[[Page 124 STAT. 297]]

  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.-- <<NOTE: Effective date.>> 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 assistance 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 supports 
                to eligible individuals, as needed, to assist in 
                accomplishing activities of daily living, instrumental 
                activities of daily living, and health-related tasks 
                through hands-on assistance, supervision, or cueing--
                          ``(i) <<NOTE: Contracts.>>  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 mentally 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 possible, 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 qualified 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,

[[Page 124 STAT. 298]]

                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 
                      enhancement of skills necessary for the individual 
                      to accomplish 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 attendant 
                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 individual 
                      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 assistance, 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) <<NOTE: Establishment.>>  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

[[Page 124 STAT. 299]]

                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 individual's age, type 
                or nature of disability, severity of disability, or the 
                form of home and community-based attendant services 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 
                implemented, 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 individuals with disabilities or elderly 
                individuals attributable to the preceding fiscal year;
                    ``(D) establish and maintain a comprehensive, 
                continuous 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, providers, families of disabled or 
                      elderly individuals, members of the community, and 
                      others and maximizes consumer 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 resolution 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) <<NOTE: Reports. Determination.>>  collect and 
                report information, as determined necessary 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 individuals 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 community-based 
        attendant services and supports under a State plan

[[Page 124 STAT. 300]]

        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 
                compensation insurance;
                    ``(C) maintenance of general liability insurance; 
                and
                    ``(D) occupational health and safety.
            ``(5) Evaluation, data collection, and report to congress.--
                    ``(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 institutional 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 services 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 
                      community 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 subparagraph (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.

[[Page 124 STAT. 301]]

                    ``(B) Consumer controlled.--The term `consumer 
                controlled' means a method of selecting and providing 
                services and supports that allow the individual, or 
                where appropriate, 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 consumer controlled services and supports. Such 
                      models may include the provision of vouchers, 
                      direct cash payments, 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 
                `individual'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, communicating by phone or other media, and 
                traveling around and participating in the community.''.

SEC. 2402. REMOVAL OF BARRIERS TO PROVIDING HOME AND COMMUNITY-BASED 
            SERVICES.

    (a) <<NOTE: 42 USC 1396n note.>>  Oversight and Assessment of the 
Administration of Home and Community-based Services.-- 
<<NOTE: Regulations.>> 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 
        supports (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 
        beneficiary in need of such services (and their family 
        caregivers or representative, if applicable) to design an 
        individualized, self-directed, community-supported life; and

[[Page 124 STAT. 302]]

            (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 
                      complaint 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 
                subsection 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 services to such individuals, elect to 
                provide home and community-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 
                individuals satisfying needs-based criteria.--Subject to 
                subparagraph (C), a State shall provide home and 
                community-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 established under paragraph (1)(A).
                    ``(C) Authority to offer different type, amount, 
                duration, or scope of home and community-based 
                services.--A State may offer home and community-based 
                services to individuals under this paragraph that differ 
                in type, amount, duration, or scope from the home and 
                community-based services offered for individuals who 
                satisfy 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.

[[Page 124 STAT. 303]]

            ``(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 
                subsection 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 
                      permitted 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 
                      provided, before the end of the initial 5-year 
                      period.
                    ``(C) Renewal. <<NOTE: Time 
                period. Determination. Deadline.>> --An election by a 
                State under this paragraph 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.--Paragraph (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 Medicaid 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 community-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;''.
            (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),

[[Page 124 STAT. 304]]

                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 preceding 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 
        community-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 Individuals if Eligibility Criteria 
Is Modified.--Paragraph (1) of section 1915(i) of such Act (42 U.S.C. 
1396n(i)) is amended--
            (1) by striking subparagraph (C) and inserting the 
        following:
                    ``(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; Addition of Option 
To Waive Comparability.--Paragraph (3) of section 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) <<NOTE: 42 USC 1396a note.>>  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 DEMONSTRATION.

    (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''.

[[Page 124 STAT. 305]]

            (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 
        payment 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) <<NOTE: 42 USC 1396a note.>>  Effective date.--The 
        amendments made by this subsection take effect 30 days after the 
        date of enactment of this Act.

SEC. 2404. <<NOTE: 42 USC 1396r-5 note.>>  PROTECTION FOR RECIPIENTS OF 
            HOME AND COMMUNITY-BASED SERVICES AGAINST SPOUSAL 
            IMPOVERISHMENT.

     <<NOTE: Time period. Applicability.>> 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 assistance for home and community-based services 
provided under subsection (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 Services, 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

[[Page 124 STAT. 306]]

        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 average, 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 available 
        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 
        Security 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 
                      subclause:
                                    ``(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.

[[Page 124 STAT. 307]]

                                    ``(II) Drug described.--For purposes 
                                of subclause (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.--Section 
        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. <<NOTE: Time period.>> --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 payments 
                      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 estimated 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.
                      <<NOTE: Determination.>> 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

[[Page 124 STAT. 308]]

                    (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) <<NOTE: Contracts. Reports. Determination.
                      >>  such contract provides that (I) covered 
                      outpatient drugs dispensed to individuals eligible 
                      for medical assistance who are enrolled with the 
                      entity shall be subject to the same rebate 
                      required by the agreement 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 
                      regulations 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 individuals enrolled with a medicaid 
                      managed care organization 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 
        requirements of this section if such drugs are--
                    ``(A) dispensed by health maintenance organizations, 
                including Medicaid managed care organizations that 
                contract under section 1903(m); and
                    ``(B) subject to discounts under section 340B of the 
                Public Health Service Act.''.

[[Page 124 STAT. 309]]

    (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 
                      section 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) <<NOTE: 42 USC 1396r-8 note.>>  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).

[[Page 124 STAT. 310]]

            (2) <<NOTE: 42 USC 256b note.>>  Effective date.--The 
        amendments made by this subsection 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), 
                respectively; 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 
                Administration under the over-the-counter monograph 
                process for purposes of promoting, and when used to 
                promote, tobacco cessation.
                    ``(B) Barbiturates.
                    ``(C) Benzodiazepines.''.

    (b) <<NOTE: 42 USC 1396r-8 note.>>  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 
                following:
            ``(5) Use of amp in upper payment limits.--The Secretary 
        shall calculate the Federal upper reimbursement limit 
        established 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 multiple 
        source drug products that are available for purchase by retail 
        community pharmacies on a nationwide basis. The Secretary shall 
        implement a smoothing process for average manufacturer 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:

[[Page 124 STAT. 311]]

                    ``(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 manufacturers to wholesalers or 
                                retail community pharmacies, including 
                                (but 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 
                                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, manufacturers, or 
                                any other entity that does not conduct 
                                business as a wholesaler or a retail 
                                community pharmacy.
                          ``(ii) Inclusion of other discounts and 
                      payments.--Notwithstanding clause (i), any other 
                      discounts, rebates, payments, or other financial 
                      transactions that are received by, paid by, or 
                      passed through to, retail community pharmacies 
                      shall be included in the average manufacturer 
                      price for a covered outpatient drug.''; and
                    (C) in subparagraph (C), by striking ``the retail 
                pharmacy class of trade'' and inserting ``retail 
                community pharmacies''.
            (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 semicolon;
                          (ii) in clause (ii), by striking ``; and'' and 
                      inserting a period; and
                          (iii) by striking clause (iii).
            (4) Definitions of retail community pharmacy; wholesaler.--
        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 merchandiser 
        pharmacy that is licensed as a pharmacy by the State and that 
        dispenses medications to the general public at retail

[[Page 124 STAT. 312]]

        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 
        pharmacies, government pharmacies, or pharmacy benefit managers.
            ``(11) Wholesaler.--The term `wholesaler' means a drug 
        wholesaler that is engaged in wholesale distribution of 
        prescription drugs to retail community pharmacies, including 
        (but not limited to) manufacturers, repackers, distributors, 
        own-label distributors, private-label distributors, jobbers, 
        brokers, warehouses (including manufacturer's and distributor's 
        warehouses, chain drug warehouses, and wholesale drug 
        warehouses) independent wholesale drug traders, and retail 
        community pharmacies that conduct wholesale distributions.''.

    (b) Disclosure of Price Information to the Public.--Section 
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 
        manufacturer 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) <<NOTE: 42 USC 1396r-8 note.>>  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)'';

[[Page 124 STAT. 313]]

            (3) by redesignating paragraph (7) as paragraph (8); and
            (4) by inserting after paragraph (6) the following new 
        paragraph:
            ``(7) Reduction of state dsh allotments once reduction 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 subsection for the State for the fiscal 
                      year without application of this paragraph (but 
                      after the application of subparagraph (D)), 
                      reduced by the applicable percentage 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 determined for the State for 
                      the fiscal year under subparagraph (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 <<NOTE: Determination.>> .--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 preceding 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. <<NOTE: Determination.>> --For purposes of 
                subparagraph (A), the fiscal year described in this 
                subparagraph with respect to a State is the first fiscal 
                year that

[[Page 124 STAT. 314]]

                occurs after fiscal year 2012 for which 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 at least 45 percent less than the percentage of 
                such individuals 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. <<NOTE: Definition.>> --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) <<NOTE: 42 USC 1396r-4 note.>>  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) <<NOTE: Determination.>>  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 individuals 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.

[[Page 124 STAT. 315]]

    ``(B) <<NOTE: Definition.>>  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. <<NOTE: 42 USC 1315b.>>  PROVIDING FEDERAL COVERAGE AND 
            PAYMENT COORDINATION FOR DUAL ELIGIBLE BENEFICIARIES.

    (a) Establishment of Federal Coordinated Health Care Office.--
            (1) In general.-- <<NOTE: Deadline.>> Not later than March 
        1, 2010, the Secretary 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 administrator.--The 
        Federal Coordinated Health Care Office--
                    (A) shall be established within the Centers for 
                Medicare & Medicaid Services; and
                    (B) <<NOTE: Appointment.>>  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 Medicare 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 Government 
        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 
        Medicare and Medicaid programs.

[[Page 124 STAT. 316]]

            (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 Medicaid 
        programs.
            (5) Eliminating regulatory conflicts between rules under the 
        Medicare and Medicaid programs.
            (6) Improving care continuity and ensuring safe and 
        effective 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 programs.

    (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 
        Security Act (42 U.S.C. 1395w-28(b)(6))), physicians and other 
        relevant entities or individuals with the education and tools 
        necessary 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 section 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 transmitted 
under section 1105(a) of title 31, United States Code, submit to 
Congress an annual report containing recommendations for legislation 
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

[[Page 124 STAT. 317]]

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. <<NOTE: 42 USC 1320b-9b.>>  ADULT HEALTH QUALITY MEASURES.

    ``(a) Development of Core Set of Health Care Quality Measures for 
Adults Eligible for Benefits Under Medicaid.--
The <<NOTE: Publication.>> 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 
sponsored 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.-- <<NOTE: Publication.>> 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.-- <<NOTE: Publication.>> 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 
        voluntarily 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 establish 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

[[Page 124 STAT. 318]]

                and innovative evidence-based measures under such 
                program 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. <<NOTE: Publication.>> --Beginning not 
                later than 24 months after the establishment of the 
                Medicaid Quality Measurement Program, and annually 
                thereafter, the Secretary shall publish 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 
                measures 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.-- <<NOTE: Deadlines. Public 
        information.>> 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. <<NOTE: 42 USC 1396b-1.>>  PAYMENT ADJUSTMENT FOR HEALTH 
            CARE-ACQUIRED CONDITIONS.

    (a) In General. <<NOTE: Determination. Regulations.      Effective 
date.>> --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 Security 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.

Effective 
date.

    (b) Health Care-Acquired Condition. <<NOTE: Definition.>> --In this 
section. the term ``health care-acquired condition'' means a medical 
condition for which an individual was diagnosed that could be identified

[[Page 124 STAT. 319]]

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) <<NOTE: Applicability.>> 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 regulations, 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 inapplicable 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. <<NOTE: 42 USC 1396w-4.>>  State Option To Provide 
Coordinated Care Through a Health Home for Individuals With Chronic 
Conditions.--

    ``(a) <<NOTE: Determination. Effective date.>> 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 determines 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 designated 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 
        provider, 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 professionals, or health team as the individual's 
        health home. Payments 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 
                services. Such methodology for determining payment--

[[Page 124 STAT. 320]]

                          ``(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 
                      professionals, or health team; and
                          ``(ii) shall be established consistent with 
                      section 1902(a)(30)(A).
                    ``(B) Alternate models of payment.--The methodology 
                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) <<NOTE: Effective date.>> In general.--
                Beginning January 1, 2011, the Secretary 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 
                planning 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 conditions who seek 
or need treatment in a hospital emergency department 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 
        readmissions 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

[[Page 124 STAT. 321]]

the quality of such services. When appropriate and feasible, a 
designated provider shall use health information technology in providing 
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 
                paragraph 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 
        designated provider (including a provider that operates in 
        coordination 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 
                designated provider, a team of health care professionals 
                operating 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 
                      authorized representatives);
                          ``(v) referral to community and social support 
                      services, 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

[[Page 124 STAT. 322]]

        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, academic 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.-- <<NOTE: Contracts.>> The Secretary 
                shall enter into a contract 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 conditions 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 
                evaluation and assessment conducted under subparagraph 
                (A).
            (2) <<NOTE: 42 USC 1396w-4 note.>> 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 
                      clinical outcomes under such option; and

[[Page 124 STAT. 323]]

                          (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 Secretary, 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. <<NOTE: 42 USC 1396a note.>> 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 conducted in 
accordance with the following:
            (1) <<NOTE: Determination.>>  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 beneficiaries, 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 
        demonstration project. States shall ensure that Medicaid 
        beneficiaries are not liable for any additional cost sharing 
        than

[[Page 124 STAT. 324]]

        if their care had not been subject to payment under the 
        demonstration 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 demonstration 
        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 Medicaid 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 
        demonstration project under this section shall provide to the 
        Secretary, 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. <<NOTE: 42 USC 1315a note.>>  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 
established 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 conducted under 
this section shall operate during a period of fiscal years 2010 through 
2012. <<NOTE: Selection.>>  The Secretary shall select not more than 5 
States to participate in the demonstration project.

    (c) Eligible Safety Net Hospital System or 
Network. <<NOTE: Definition.>> --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

[[Page 124 STAT. 325]]

        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 section 
        1115A(b)(3) of the Social Security Act (as so added) shall not 
        be applicable.
            (3) Modification.--During the testing period under paragraph 
        (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 completion 
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. <<NOTE: 42 USC 1396a note.>> PEDIATRIC ACCOUNTABLE CARE 
            ORGANIZATION DEMONSTRATION 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 
        Demonstration Project to authorize a participating State to 
        allow pediatric medical providers that meet specified 
        requirements to be recognized as an accountable care 
        organization for purposes of receiving incentive payments (as 
        described under subsection (d)), in the same manner as an 
        accountable care organization is recognized and provided with 
        incentive payments 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 Secretary 
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 consultation 
        with the States and pediatric providers, shall establish 
        guidelines to ensure that the quality of care delivered to 
        individuals by a provider recognized as an accountable care 
        organization 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 
        consultation 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) <<NOTE: Contracts.>> Minimum participation period.--A 
        provider desiring to be recognized as an accountable care 
        organization under

[[Page 124 STAT. 326]]

        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 subsection (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. <<NOTE: 42 USC 1396a note.>> 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 requirements 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 
        emergency medical condition.

    (b) Stabilization Review.--A State shall specify in its application 
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)). <<NOTE: Commencement date.>> 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 utilization 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 paragraphs (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, 
        provisions, 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

[[Page 124 STAT. 327]]

        paragraph (1). In selecting State applications for the 
        demonstration 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 
                represents 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 paragraph 
        (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 Federal oversight and conducting an evaluation under 
        subsection (f)(1).

    (f) Evaluation and Report to Congress.--
            (1) Evaluation.--The Secretary shall conduct an evaluation 
        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 
                participating 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

[[Page 124 STAT. 328]]

                those admitted to these same facilities through other 
                means.
                    (E) A recommendation regarding whether the 
                demonstration project should be continued after December 
                31, 2013, and expanded on a national basis.
            (2) Report.--Not later than December 31, 2013, the Secretary 
        shall submit to Congress and make available to the public a 
        report on the findings of the evaluation under paragraph (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 
        comparability)) only to extent necessary to carry out the 
        demonstration 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 
        gestures, 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 ``institution 
        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 
                           Commission (MACPAC)

SEC. 2801. MACPAC ASSESSMENT OF POLICIES AFFECTING ALL MEDICAID 
            BENEFICIARIES.

    (a) In General.--Section 1900 of the Social Security Act (42 U.S.C. 
1396) is amended--
            (1) in subsection (b)--

[[Page 124 STAT. 329]]

                    (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 Secretary, 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, 
                                        Federally-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 beneficiaries 
                                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 
                                ``beneficiaries'';
                          (ii) by redesignating subparagraphs (B) and 
                      (C) as subparagraphs (F) and (H), respectively;
                          (iii) by inserting after subparagraph (A), the 
                      following:
                    ``(B) Eligibility policies.--Medicaid and CHIP 
                eligibility policies, including a determination of the 
                degree to which Federal and State policies provide 
                health care coverage to needy populations.
                    ``(C) Enrollment and retention processes.--Medicaid 
                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 individuals 
                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

[[Page 124 STAT. 330]]

                interact with similar goals established by other 
                purchasers of health care services.'';
                          (iv) by inserting after subparagraph (F) (as 
                      redesignated 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 services 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 submission 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 `` <<NOTE: Reports.>> , 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

[[Page 124 STAT. 331]]

                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 recommendations to 
                change Medicare policy regarding Medicare 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 regularly 
        consult with States in carrying out its duties under this 
        section, including with respect to developing processes for 
        carrying out such duties, and shall ensure that input from 
        States is taken into account and represented in MACPAC's 
        recommendations and reports.
            ``(13) Coordinate and consult with the federal coordinated 
        health care office.--MACPAC 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.
            ``(14) Programmatic oversight vested in the secretary.--
        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 
                representatives of children, pregnant women, the 
                elderly, individuals with disabilities, caregivers, and 
                dual eligible individuals, current or former 
                representatives of State agencies responsible for 
                administering Medicaid, and current or former 
                representatives of State agencies responsible for 
                administering CHIP.''.

[[Page 124 STAT. 332]]

            (3) in subsection (d)(2), by inserting ``and State'' after 
        ``Federal'';
            (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 
                ``Authorization 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 paragraphs 
        (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 significant portion of revenue or 
        services is associated with the Medicaid program. Where 
        appropriate, the Commission shall conduct 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 coordinated 
        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 beneficiaries who are dually 
        eligible for Medicare and Medicaid,

[[Page 124 STAT. 333]]

        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) <<NOTE: 25 USC 1623.>> 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) <<NOTE: 25 USC 1623.>> 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 Furnished 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.-- <<NOTE: Applicability. 42 USC 1395qq 
note.>> The amendments made by this section shall apply to items or 
services furnished on or after January 1, 2010.

[[Page 124 STAT. 334]]

             Subtitle L--Maternal and Child Health Services

SEC. 2951. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING 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. <<NOTE: 42 USC 711.>> MATERNAL, INFANT, AND EARLY CHILDHOOD 
            HOME VISITING 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 
        communities; and
            ``(3) to identify and provide comprehensive services to 
        improve outcomes for families who reside in at risk communities.

    ``(b) Requirement for All States To Assess Statewide Needs and 
Identify at Risk Communities.--
            ``(1) In general.-- <<NOTE: Deadline.>> 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, newborn, 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 
                      families 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 
                      initiatives 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 families in need of such treatment or services.
            ``(2) Coordination with other assessments.--In conducting 
        the statewide needs assessment required under paragraph (1), the 
        State shall coordinate with, and take into account, other 
        appropriate needs assessments conducted by

[[Page 124 STAT. 335]]

        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 Programs.--
            ``(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 subsection (d).
            ``(3) <<NOTE: Determination.>> 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 activities 
        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 benchmark 
        areas.--
                    ``(A) In general.--The eligible entity establishes, 
                subject to the approval of the Secretary, quantifiable, 
                measurable 3- and 5-year benchmarks for demonstrating 
                that the

[[Page 124 STAT. 336]]

                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 
                      achievement.
                          ``(iv) Reduction in crime or domestic 
                      violence.
                          ``(v) Improvements in family economic self-
                      sufficiency.
                          ``(vi) Improvements in the coordination and 
                      referrals 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 
                      submitted 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 implement 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. <<NOTE: Establishment.>> --The 
                                Secretary shall establish an advisory 
                                panel for purposes of obtaining 
                                recommendations regarding the technical 
                                assistance provided to entities in 
                                accordance with subclause (I).
                          ``(iv) No improvement or failure to submit 
                      report. <<NOTE: Determination. Termination.>> --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 unexpended grant funds 
                      in grants made to nonprofit organizations under 
                      subsection (h)(2)(B).

[[Page 124 STAT. 337]]

                    ``(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 families.--
                    ``(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 subparagraph (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 
                outcomes described in this subparagraph are the 
                following:
                          ``(i) Improvements in prenatal, maternal, and 
                      newborn health, including improved pregnancy 
                      outcomes
                          ``(ii) Improvements in child health and 
                      development, including the prevention of child 
                      injuries and maltreatment and improvements in 
                      cognitive, language, 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-
                      sufficiency.
                          ``(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 following 
        core components:
                    ``(A) Service delivery model or models.--
                          ``(i) In general.--Subject to clause (ii), the 
                      program is conducted using 1 or more of the 
                      service delivery models described in item (aa) or 
                      (bb) of subclause (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 education that 
                                has comprehensive home visitation 
                                program standards that ensure high 
                                quality service delivery and continuous 
                                program quality improvement, 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--

[[Page 124 STAT. 338]]

                                            ``(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 
                      evidence-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 specified 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 
                      competent staff, as demonstrated by education or 
                      training, such as nurses, social workers, 
                      educators, child development specialists, or other 
                      well-trained and competent staff, and provides 
                      ongoing and specific training on the model being 
                      delivered.
                          ``(iii) The program maintains high quality 
                      supervision to establish home visitor 
                      competencies.
                          ``(iv) The program demonstrates strong 
                      organizational 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.

[[Page 124 STAT. 339]]

                    ``(D) Eligible families that have a history of child 
                abuse or neglect or have had interactions with child 
                welfare services.
                    ``(E) Eligible families that have a history of 
                substance abuse or need substance abuse treatment.
                    ``(F) Eligible families that have users of tobacco 
                products 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 Secretary 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 
        populations 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 
        organization 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

[[Page 124 STAT. 340]]

                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. <<NOTE: Establishment.>> --The Secretary, 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 
                paragraph (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) <<NOTE: Grants. Contracts.>> 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 agreement, 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 
                mortality, and State actions in response to the 
                assessments; and
                    ``(B) an assessment of <<NOTE: Assessment.>> --
                          ``(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.

[[Page 124 STAT. 341]]

            ``(3) Report.--Not later than March 31, 2015, the Secretary 
        shall submit a report to Congress on the results of the 
        evaluation 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 
                subsections (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) <<NOTE: Requirements.>> 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 Organization, 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 
                beginning 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 paragraph (3) of that subsection to make a grant 
                to an eligible entity that is a nonprofit organization 
                described in subsection (k)(1)(B) to conduct an early 
                childhood home visitation 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

[[Page 124 STAT. 342]]

                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 
                      activities includes consultation with independent 
                      researchers, State officials, and developers and 
                      providers 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 
                administrative 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 
                payments 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 
                administrative expenditures).
                    ``(D) 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.

[[Page 124 STAT. 343]]

                    ``(E) Section 507 (relating to penalties for false 
                statements).
                    ``(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 noncustodial 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.''.

[[Page 124 STAT. 344]]

SEC. 2952. <<NOTE: 42 USC 712 note.>> 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 
        conducting 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 conditions.
                    (C) The development of improved screening and 
                diagnostic techniques.
                    (D) Clinical research for the development and 
                evaluation 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 parenting 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

[[Page 124 STAT. 345]]

                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. <<NOTE: 42 USC 712.>> SERVICES TO INDIVIDUALS WITH A 
            POSTPARTUM CONDITION 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 
appropriate, the Secretary shall ensure that projects funded under 
subsection (a) provide education and services with respect to the 
diagnosis 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, 
                      concerning 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 practicable 
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 requirements 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 requirement for each eligible 
entity that receives a grant to submit, for

[[Page 124 STAT. 346]]

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 technical 
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 
                payments 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 
                administrative expenditures).
                    ``(D) 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.
                    ``(E) Section 507 (relating to penalties for false 
                statements).
                    ``(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-
                private 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.

[[Page 124 STAT. 347]]

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. <<NOTE: 42 USC 713.>> PERSONAL RESPONSIBILITY EDUCATION.

    ``(a) Allotments to States.--
            ``(1) Amount.--
                    ``(A) In general.--For the purpose described in 
                subsection (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 
                      determined 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 Secretary 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 following as well as such additional 
                      information as the Secretary may require:
                                    ``(I) Based on data from the Centers 
                                for Disease 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 
                                preceding 5-year period for which such 
                                data are available.
                                    ``(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

[[Page 124 STAT. 348]]

                                populations that are the most high-risk 
                                or vulnerable for pregnancies or 
                                otherwise have special circumstances, 
                                including youth in foster care, homeless 
                                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 
        paragraph (4)(A), amounts allotted to a State pursuant to this 
        subsection for a fiscal year shall remain available for 
        expenditure 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), programs 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 consortia.
                    ``(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

[[Page 124 STAT. 349]]

        a grant under paragraph (4), if the expenditure of non-federal 
        funds by the State, organization, or entity for activities, 
        programs, 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 
        subsection (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) <<NOTE: Definition.>> 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 
                      complete.
                          ``(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 particular population group to which they 
                      are directed.
                    ``(C) Adulthood preparation subjects.--The adulthood 
                preparation subjects described in this subparagraph are 
                the following:

[[Page 124 STAT. 350]]

                          ``(i) Healthy relationships, such as positive 
                      self-esteem and relationship dynamics, 
                      friendships, dating, romantic involvement, 
                      marriage, and family interactions.
                          ``(ii) Adolescent development, such as the 
                      development 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 
                      developing skills for employment preparation, job 
                      seeking, independent living, financial self-
                      sufficiency, and workplace productivity.
                          ``(vi) Healthy life skills, such as goal-
                      setting, decision making, negotiation, 
                      communication and interpersonal 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 innovative 
        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 
                organizations.--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 appropriate.
                    ``(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 
                      provide, directly or through a competitive grant 
                      process, research, training and technical 
                      assistance, including dissemination of research 
                      and information regarding effective and promising 
                      practices, providing consultation and resources on 
                      a broad array of teen pregnancy prevention 
                      strategies, including abstinence and 
                      contraception, and developing resources and 
                      materials to support the activities of recipients 
                      of grants and other State, tribal, and community 
                      organizations working

[[Page 124 STAT. 351]]

                      to reduce teen pregnancy. In carrying out such 
                      functions, the Secretary shall collaborate with a 
                      variety of entities that have expertise in the 
                      prevention of teen pregnancy, HIV and sexually 
                      transmitted infections, healthy relationships, 
                      financial literacy, and other topics addressed 
                      through the personal responsibility 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 
        section 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 section 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 
        developing 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)).

[[Page 124 STAT. 352]]

            ``(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 section, 
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) <<NOTE: Certification.>> 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 provided 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

[[Page 124 STAT. 353]]

                      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 recognized under State law, and 
                      to provide the child with the option to execute 
                      such a document, are met; and''.

    (d) <<NOTE: 42 USC 622 note.>> Effective Date.--The amendments made 
by this section take effect on October 1, 2010.