TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS

               Subtitle A--Provisions Relating to Title I

SEC. 10101. AMENDMENTS TO SUBTITLE A.

    (a) Section 2711 of the Public Health Service Act, as added by 
section 1001(5) of this Act, is amended to read as follows:

``SEC. 2711. <<NOTE: 42 USC 300gg-11.>>  NO LIFETIME OR ANNUAL LIMITS.

    ``(a) Prohibition.--
            ``(1) In general.--A group health plan and a health 
        insurance issuer offering group or individual health insurance 
        coverage may not establish--
                    ``(A) lifetime limits on the dollar value of 
                benefits for any participant or beneficiary; or
                    ``(B) except as provided in paragraph (2), annual 
                limits on the dollar value of benefits for any 
                participant or beneficiary.
            ``(2) Annual limits prior to 2014.--With respect to plan 
        years beginning prior to January 1, 2014, a group health plan 
        and a health insurance issuer offering group or individual 
        health insurance coverage may only establish a restricted annual 
        limit on the dollar value of benefits for any participant or 
        beneficiary with respect to the scope of benefits that are 
        essential health benefits under section 1302(b) of the Patient

[[Page 124 STAT. 884]]

        Protection and Affordable Care Act, as determined by the 
        Secretary. In defining the term `restricted annual limit' for 
        purposes of the preceding sentence, the Secretary shall ensure 
        that access to needed services is made available with a minimal 
        impact on premiums.

    ``(b) Per Beneficiary Limits.--Subsection (a) shall not be construed 
to prevent a group health plan or health insurance coverage from placing 
annual or lifetime per beneficiary limits on specific covered benefits 
that are not essential health benefits under section 1302(b) of the 
Patient Protection and Affordable Care Act, to the extent that such 
limits are otherwise permitted under Federal or State law.''.
    (b) Section 2715(a) of the Public Health Service Act, as added by 
section 1001(5) of this Act, <<NOTE: 42 USC 300gg-15.>>  is amended by 
striking ``and providing to enrollees'' and inserting ``and providing to 
applicants, enrollees, and policyholders or certificate holders''.

    (c) Subpart II of part A of title XXVII of the Public Health Service 
Act, as added by section 1001(5), is amended by inserting after section 
2715, the following:

``SEC. 2715A. <<NOTE: Public information. 42 USC 300gg-15a.>>  PROVISION 
            OF ADDITIONAL INFORMATION.

    ``A group health plan and a health insurance issuer offering group 
or individual health insurance coverage shall comply with the provisions 
of section 1311(e)(3) of the Patient Protection and Affordable Care Act, 
except that a plan or coverage that is not offered through an Exchange 
shall only be required to submit the information required to the 
Secretary and the State insurance commissioner, and make such 
information available to the public.''.
    (d) Section 2716 of the Public Health Service Act, as added by 
section 1001(5) of this Act, is amended to read as follows:

``SEC. 2716. <<NOTE: 42 USC 300gg-16.>>  PROHIBITION ON DISCRIMINATION 
            IN FAVOR OF HIGHLY COMPENSATED INDIVIDUALS.

    ``(a) In General.--A group health plan (other than a self-insured 
plan) shall satisfy the requirements of section 105(h)(2) of the 
Internal Revenue Code of 1986 (relating to prohibition on discrimination 
in favor of highly compensated individuals).
    ``(b) Rules and Definitions.--For purposes of this section--
            ``(1) Certain rules to apply.--Rules similar to the rules 
        contained in paragraphs (3), (4), and (8) of section 105(h) of 
        such Code shall apply.
            ``(2) Highly compensated individual.--The term `highly 
        compensated individual' has the meaning given such term by 
        section 105(h)(5) of such Code.''.

    (e) Section 2717 of the Public Health Service Act, as added by 
section 1001(5) of this Act, <<NOTE: 42 USC 300gg-17.>>  is amended--
            (1) by redesignating subsections (c) and (d) as subsections 
        (d) and (e), respectively; and
            (2) by inserting after subsection (b), the following:

    ``(c) Protection of Second Amendment Gun Rights.--
            ``(1) Wellness and prevention programs.--A wellness and 
        health promotion activity implemented under subsection (a)(1)(D) 
        may not require the disclosure or collection of any information 
        relating to--
                    ``(A) the presence or storage of a lawfully-
                possessed firearm or ammunition in the residence or on 
                the property of an individual; or

[[Page 124 STAT. 885]]

                    ``(B) the lawful use, possession, or storage of a 
                firearm or ammunition by an individual.
            ``(2) Limitation on data collection.--None of the 
        authorities provided to the Secretary under the Patient 
        Protection and Affordable Care Act or an amendment made by that 
        Act shall be construed to authorize or may be used for the 
        collection of any information relating to--
                    ``(A) the lawful ownership or possession of a 
                firearm or ammunition;
                    ``(B) the lawful use of a firearm or ammunition; or
                    ``(C) the lawful storage of a firearm or ammunition.
            ``(3) Limitation on databases or data banks.--None of the 
        authorities provided to the Secretary under the Patient 
        Protection and Affordable Care Act or an amendment made by that 
        Act shall be construed to authorize or may be used to maintain 
        records of individual ownership or possession of a firearm or 
        ammunition.
            ``(4) Limitation on determination of premium rates or 
        eligibility for health insurance.--A premium rate may not be 
        increased, health insurance coverage may not be denied, and a 
        discount, rebate, or reward offered for participation in a 
        wellness program may not be reduced or withheld under any health 
        benefit plan issued pursuant to or in accordance with the 
        Patient Protection and Affordable Care Act or an amendment made 
        by that Act on the basis of, or on reliance upon--
                    ``(A) the lawful ownership or possession of a 
                firearm or ammunition; or
                    ``(B) the lawful use or storage of a firearm or 
                ammunition.
            ``(5) Limitation on data collection requirements for 
        individuals.--No individual shall be required to disclose any 
        information under any data collection activity authorized under 
        the Patient Protection and Affordable Care Act or an amendment 
        made by that Act relating to--
                    ``(A) the lawful ownership or possession of a 
                firearm or ammunition; or
                    ``(B) the lawful use, possession, or storage of a 
                firearm or ammunition.''.

    (f) Section 2718 of the Public Health Service Act, as added by 
section 1001(5), is amended to read as follows:

``SEC. 2718. <<NOTE: 42 USC 300gg-18. Reports.>>  BRINGING DOWN THE COST 
            OF HEALTH CARE COVERAGE.

    ``(a) Clear Accounting for Costs.--A health insurance issuer 
offering group or individual health insurance coverage (including a 
grandfathered health plan) shall, with respect to each plan year, submit 
to the Secretary a report concerning the ratio of the incurred loss (or 
incurred claims) plus the loss adjustment expense (or change in contract 
reserves) to earned premiums. Such report shall include the percentage 
of total premium revenue, after accounting for collections or receipts 
for risk adjustment and risk corridors and payments of reinsurance, that 
such coverage expends--
            ``(1) on reimbursement for clinical services provided to 
        enrollees under such coverage;
            ``(2) for activities that improve health care quality; and

[[Page 124 STAT. 886]]

            ``(3) on all other non-claims costs, including an 
        explanation of the nature of such costs, and excluding Federal 
        and State taxes and licensing or regulatory fees.

The Secretary <<NOTE: Public information. Web posting.>>  shall make 
reports received under this section available to the public on the 
Internet website of the Department of Health and Human Services.

    ``(b) Ensuring That Consumers Receive Value for Their Premium 
Payments.--
            ``(1) Requirement to provide value for premium payments.--
                    ``(A) <<NOTE: Deadline.>>  Requirement.--Beginning 
                not later than January 1, 2011, a health insurance 
                issuer offering group or individual health insurance 
                coverage (including a grandfathered health plan) shall, 
                with respect to each plan year, provide an annual rebate 
                to each enrollee under such coverage, on a pro rata 
                basis, if the ratio of the amount of premium revenue 
                expended by the issuer on costs described in paragraphs 
                (1) and (2) of subsection (a) to the total amount of 
                premium revenue (excluding Federal and State taxes and 
                licensing or regulatory fees and after accounting for 
                payments or receipts for risk adjustment, risk 
                corridors, and reinsurance under sections 1341, 1342, 
                and 1343 of the Patient Protection and Affordable Care 
                Act) for the plan year (except as provided in 
                subparagraph (B)(ii)), is less than--
                          ``(i) with respect to a health insurance 
                      issuer offering coverage in the large group 
                      market, 85 percent, or such higher percentage as a 
                      State may by regulation determine; or
                          ``(ii) with respect to a health insurance 
                      issuer offering coverage in the small group market 
                      or in the individual market, 80 percent, or such 
                      higher percentage as a State may by regulation 
                      determine, except that the Secretary may adjust 
                      such percentage with respect to a State if the 
                      Secretary determines that the application of such 
                      80 percent may destabilize the individual market 
                      in such State.
                    ``(B) Rebate amount.--
                          ``(i) Calculation of amount.--The total amount 
                      of an annual rebate required under this paragraph 
                      shall be in an amount equal to the product of--
                                    ``(I) the amount by which the 
                                percentage described in clause (i) or 
                                (ii) of subparagraph (A) exceeds the 
                                ratio described in such subparagraph; 
                                and
                                    ``(II) the total amount of premium 
                                revenue (excluding Federal and State 
                                taxes and licensing or regulatory fees 
                                and after accounting for payments or 
                                receipts for risk adjustment, risk 
                                corridors, and reinsurance under 
                                sections 1341, 1342, and 1343 of the 
                                Patient Protection and Affordable Care 
                                Act) for such plan year.
                          ``(ii) Calculation based on average ratio.--
                      Beginning on January 1, 2014, <<NOTE: Effective 
                      date.>>  the determination made under subparagraph 
                      (A) for the year involved shall be based on the 
                      averages of the premiums expended on the costs 
                      described in such subparagraph and total

[[Page 124 STAT. 887]]

                      premium revenue for each of the previous 3 years 
                      for the plan.
            ``(2) Consideration in setting percentages.--In determining 
        the percentages under paragraph (1), a State shall seek to 
        ensure adequate participation by health insurance issuers, 
        competition in the health insurance market in the State, and 
        value for consumers so that premiums are used for clinical 
        services and quality improvements.
            ``(3) <<NOTE: Regulations.>>  Enforcement.--The Secretary 
        shall promulgate regulations for enforcing the provisions of 
        this section and may provide for appropriate penalties.

    ``(c) <<NOTE: Deadline. Certification.>>  Definitions.--Not later 
than December 31, 2010, and subject to the certification of the 
Secretary, the National Association of Insurance Commissioners shall 
establish uniform definitions of the activities reported under 
subsection (a) and standardized methodologies for calculating measures 
of such activities, including definitions of which activities, and in 
what regard such activities, constitute activities described in 
subsection (a)(2). Such methodologies shall be designed to take into 
account the special circumstances of smaller plans, different types of 
plans, and newer plans.

    ``(d) Adjustments.--The Secretary may adjust the rates described in 
subsection (b) if the Secretary determines appropriate on account of the 
volatility of the individual market due to the establishment of State 
Exchanges.
    ``(e) Standard Hospital Charges.--Each hospital operating within the 
United States shall for each year establish (and update) and make public 
(in accordance with guidelines developed by the Secretary) a list of the 
hospital's standard charges for items and services provided by the 
hospital, including for diagnosis-related groups established under 
section 1886(d)(4) of the Social Security Act.''.
    (g) Section 2719 of the Public Health Service Act, as added by 
section 1001(4) of this Act, is amended to read as follows:

``SEC. 2719. <<NOTE: 42 USC 300gg-19.>>  APPEALS PROCESS.

    ``(a) Internal Claims Appeals.--
            ``(1) In general.--A group health plan and a health 
        insurance issuer offering group or individual health insurance 
        coverage shall implement an effective appeals process for 
        appeals of coverage determinations and claims, under which the 
        plan or issuer shall, at a minimum--
                    ``(A) have in effect an internal claims appeal 
                process;
                    ``(B) provide notice to enrollees, in a culturally 
                and linguistically appropriate manner, of available 
                internal and external appeals processes, and the 
                availability of any applicable office of health 
                insurance consumer assistance or ombudsman established 
                under section 2793 to assist such enrollees with the 
                appeals processes; and
                    ``(C) allow an enrollee to review their file, to 
                present evidence and testimony as part of the appeals 
                process, and to receive continued coverage pending the 
                outcome of the appeals process.
            ``(2) Established processes.--To comply with paragraph (1)--
                    ``(A) a group health plan and a health insurance 
                issuer offering group health coverage shall provide an 
                internal claims and appeals process that initially 
                incorporates the

[[Page 124 STAT. 888]]

                claims and appeals procedures (including urgent claims) 
                set forth at section 2560.503-1 of title 29, Code of 
                Federal Regulations, as published on November 21, 2000 
                (65 Fed. Reg. 70256), and shall update such process in 
                accordance with any standards established by the 
                Secretary of Labor for such plans and issuers; and
                    ``(B) a health insurance issuer offering individual 
                health coverage, and any other issuer not subject to 
                subparagraph (A), shall provide an internal claims and 
                appeals process that initially incorporates the claims 
                and appeals procedures set forth under applicable law 
                (as in existence on the date of enactment of this 
                section), and shall update such process in accordance 
                with any standards established by the Secretary of 
                Health and Human Services for such issuers.

    ``(b) External Review.--A group health plan and a health insurance 
issuer offering group or individual health insurance coverage--
            ``(1) shall comply with the applicable State external review 
        process for such plans and issuers that, at a minimum, includes 
        the consumer protections set forth in the Uniform External 
        Review Model Act promulgated by the National Association of 
        Insurance Commissioners and is binding on such plans; or
            ``(2) shall implement an effective external review process 
        that meets minimum standards established by the Secretary 
        through guidance and that is similar to the process described 
        under paragraph (1)--
                    ``(A) if the applicable State has not established an 
                external review process that meets the requirements of 
                paragraph (1); or
                    ``(B) if the plan is a self-insured plan that is not 
                subject to State insurance regulation (including a State 
                law that establishes an external review process 
                described in paragraph (1)).

    ``(c) Secretary Authority.--The Secretary may deem the external 
review process of a group health plan or health insurance issuer, in 
operation as of the date of enactment of this section, to be in 
compliance with the applicable process established under subsection (b), 
as determined appropriate by the Secretary.''.
    (h) Subpart II of part A of title XVIII of the Public Health Service 
Act, as added by section 1001(5) of this Act, is amended by inserting 
after section 2719 the following:

``SEC. 2719A. <<NOTE: 42 USC 300gg-19a.>>  PATIENT PROTECTIONS.

    ``(a) Choice of Health Care Professional.--If a group health plan, 
or a health insurance issuer offering group or individual health 
insurance coverage, requires or provides for designation by a 
participant, beneficiary, or enrollee of a participating primary care 
provider, then the plan or issuer shall permit each participant, 
beneficiary, and enrollee to designate any participating primary care 
provider who is available to accept such individual.
    ``(b) Coverage of Emergency Services.--
            ``(1) In general.--If a group health plan, or a health 
        insurance issuer offering group or individual health insurance 
        issuer, provides or covers any benefits with respect to services 
        in an emergency department of a hospital, the plan or issuer

[[Page 124 STAT. 889]]

        shall cover emergency services (as defined in paragraph 
        (2)(B))--
                    ``(A) without the need for any prior authorization 
                determination;
                    ``(B) whether the health care provider furnishing 
                such services is a participating provider with respect 
                to such services;
                    ``(C) in a manner so that, if such services are 
                provided to a participant, beneficiary, or enrollee--
                          ``(i) by a nonparticipating health care 
                      provider with or without prior authorization; or
                          ``(ii)(I) such services will be provided 
                      without imposing any requirement under the plan 
                      for prior authorization of services or any 
                      limitation on coverage where the provider of 
                      services does not have a contractual relationship 
                      with the plan for the providing of services that 
                      is more restrictive than the requirements or 
                      limitations that apply to emergency department 
                      services received from providers who do have such 
                      a contractual relationship with the plan; and
                          ``(II) if such services are provided out-of-
                      network, the cost-sharing requirement (expressed 
                      as a copayment amount or coinsurance rate) is the 
                      same requirement that would apply if such services 
                      were provided in-network;
                    ``(D) without regard to any other term or condition 
                of such coverage (other than exclusion or coordination 
                of benefits, or an affiliation or waiting period, 
                permitted under section 2701 of this Act, section 701 of 
                the Employee Retirement Income Security Act of 1974, or 
                section 9801 of the Internal Revenue Code of 1986, and 
                other than applicable cost-sharing).
            ``(2) Definitions.--In this subsection:
                    ``(A) Emergency medical condition.--The term 
                `emergency medical condition' means a medical condition 
                manifesting itself by acute symptoms of sufficient 
                severity (including severe pain) such that a prudent 
                layperson, who possesses an average knowledge of health 
                and medicine, could reasonably expect the absence of 
                immediate medical attention to result in a condition 
                described in clause (i), (ii), or (iii) of section 
                1867(e)(1)(A) of the Social Security Act.
                    ``(B) Emergency services.--The term `emergency 
                services' means, with respect to an emergency medical 
                condition--
                          ``(i) a medical screening examination (as 
                      required under section 1867 of the Social Security 
                      Act) that is within the capability of the 
                      emergency department of a hospital, including 
                      ancillary services routinely available to the 
                      emergency department to evaluate such emergency 
                      medical condition, and
                          ``(ii) within the capabilities of the staff 
                      and facilities available at the hospital, such 
                      further medical examination and treatment as are 
                      required under section 1867 of such Act to 
                      stabilize the patient.

[[Page 124 STAT. 890]]

                    ``(C) Stabilize.--The term `to stabilize', with 
                respect to an emergency medical condition (as defined in 
                subparagraph (A)), has the meaning give in section 
                1867(e)(3) of the Social Security Act (42 U.S.C. 
                1395dd(e)(3)).

    ``(c) Access to Pediatric Care.--
            ``(1) Pediatric care.--In the case of a person who has a 
        child who is a participant, beneficiary, or enrollee under a 
        group health plan, or health insurance coverage offered by a 
        health insurance issuer in the group or individual market, if 
        the plan or issuer requires or provides for the designation of a 
        participating primary care provider for the child, the plan or 
        issuer shall permit such person to designate a physician 
        (allopathic or osteopathic) who specializes in pediatrics as the 
        child's primary care provider if such provider participates in 
        the network of the plan or issuer.
            ``(2) Construction.--Nothing in paragraph (1) shall be 
        construed to waive any exclusions of coverage under the terms 
        and conditions of the plan or health insurance coverage with 
        respect to coverage of pediatric care.

    ``(d) Patient Access to Obstetrical and Gynecological Care.--
            ``(1) General rights.--
                    ``(A) Direct access.--A group health plan, or health 
                insurance issuer offering group or individual health 
                insurance coverage, described in paragraph (2) may not 
                require authorization or referral by the plan, issuer, 
                or any person (including a primary care provider 
                described in paragraph (2)(B)) in the case of a female 
                participant, beneficiary, or enrollee who seeks coverage 
                for obstetrical or gynecological care provided by a 
                participating health care professional who specializes 
                in obstetrics or gynecology. Such professional shall 
                agree to otherwise adhere to such plan's or issuer's 
                policies and procedures, including procedures regarding 
                referrals and obtaining prior authorization and 
                providing services pursuant to a treatment plan (if any) 
                approved by the plan or issuer.
                    ``(B) Obstetrical and gynecological care.--A group 
                health plan or health insurance issuer described in 
                paragraph (2) shall treat the provision of obstetrical 
                and gynecological care, and the ordering of related 
                obstetrical and gynecological items and services, 
                pursuant to the direct access described under 
                subparagraph (A), by a participating health care 
                professional who specializes in obstetrics or gynecology 
                as the authorization of the primary care provider.
            ``(2) Application of paragraph.--A group health plan, or 
        health insurance issuer offering group or individual health 
        insurance coverage, described in this paragraph is a group 
        health plan or coverage that--
                    ``(A) provides coverage for obstetric or gynecologic 
                care; and
                    ``(B) requires the designation by a participant, 
                beneficiary, or enrollee of a participating primary care 
                provider.
            ``(3) Construction.--Nothing in paragraph (1) shall be 
        construed to--
                    ``(A) waive any exclusions of coverage under the 
                terms and conditions of the plan or health insurance 
                coverage

[[Page 124 STAT. 891]]

                with respect to coverage of obstetrical or gynecological 
                care; or
                    ``(B) preclude the group health plan or health 
                insurance issuer involved from requiring that the 
                obstetrical or gynecological provider notify the primary 
                care health care professional or the plan or issuer of 
                treatment decisions.''.

    (i) Section 2794 of the Public Health Service Act, as added by 
section 1003 of this Act, <<NOTE: 42 USC 300gg-94.>>  is amended--
            (1) in subsection (c)(1)--
                    (A) in subparagraph (A), by striking ``and'' at the 
                end;
                    (B) in subparagraph (B), by striking the period and 
                inserting ``; and''; and
                    (C) by adding at the end the following:
                    ``(C) in establishing centers (consistent with 
                subsection (d)) at academic or other nonprofit 
                institutions to collect medical reimbursement 
                information from health insurance issuers, to analyze 
                and organize such information, and to make such 
                information available to such issuers, health care 
                providers, health researchers, health care policy 
                makers, and the general public.''; and
            (2) by adding at the end the following:

    ``(d) Medical Reimbursement Data Centers.--
            ``(1) Functions.--A center established under subsection 
        (c)(1)(C) shall--
                    ``(A) develop fee schedules and other database tools 
                that fairly and accurately reflect market rates for 
                medical services and the geographic differences in those 
                rates;
                    ``(B) use the best available statistical methods and 
                data processing technology to develop such fee schedules 
                and other database tools;
                    ``(C) regularly update such fee schedules and other 
                database tools to reflect changes in charges for medical 
                services;
                    ``(D) <<NOTE: Public information. Web posting.>>  
                make health care cost information readily available to 
                the public through an Internet website that allows 
                consumers to understand the amounts that health care 
                providers in their area charge for particular medical 
                services; and
                    ``(E) <<NOTE: Publication.>>  regularly publish 
                information concerning the statistical methodologies 
                used by the center to analyze health charge data and 
                make such data available to researchers and policy 
                makers.
            ``(2) <<NOTE: By-laws.>>  Conflicts of interest.--A center 
        established under subsection (c)(1)(C) shall adopt by-laws that 
        ensures that the center (and all members of the governing board 
        of the center) is independent and free from all conflicts of 
        interest. Such by-laws shall ensure that the center is not 
        controlled or influenced by, and does not have any corporate 
        relation to, any individual or entity that may make or receive 
        payments for health care services based on the center's analysis 
        of health care costs.
            ``(3) Rule of construction.--Nothing in this subsection 
        shall be construed to permit a center established under 
        subsection (c)(1)(C) to compel health insurance issuers to 
        provide data to the center.''.

[[Page 124 STAT. 892]]

SEC. 10102. AMENDMENTS TO SUBTITLE B.

    (a) <<NOTE: 42 USC 18002.>>  Section 1102(a)(2)(B) of this Act is 
amended--
            (1) in the matter preceding clause (i), by striking ``group 
        health benefits plan'' and inserting ``group benefits plan 
        providing health benefits''; and
            (2) in clause (i)(I), by inserting ``or any agency or 
        instrumentality of any of the foregoing'' before the closed 
        parenthetical.

    (b) <<NOTE: 42 USC 18003.>>  Section 1103(a) of this Act is 
amended--
            (1) in paragraph (1), by inserting ``, or small business 
        in,'' after ``residents of any''; and
            (2) by striking paragraph (2) and inserting the following:
            ``(2) Connecting to affordable coverage.--An Internet 
        website established under paragraph (1) shall, to the extent 
        practicable, provide ways for residents of, and small businesses 
        in, any State to receive information on at least the following 
        coverage options:
                    ``(A) Health insurance coverage offered by health 
                insurance issuers, other than coverage that provides 
                reimbursement only for the treatment or mitigation of--
                          ``(i) a single disease or condition; or
                          ``(ii) an unreasonably limited set of diseases 
                      or conditions (as determined by the Secretary).
                    ``(B) Medicaid coverage under title XIX of the 
                Social Security Act.
                    ``(C) Coverage under title XXI of the Social 
                Security Act.
                    ``(D) A State health benefits high risk pool, to the 
                extent that such high risk pool is offered in such 
                State; and
                    ``(E) Coverage under a high risk pool under section 
                1101.
                    ``(F) Coverage within the small group market for 
                small businesses and their employees, including 
                reinsurance for early retirees under section 1102, tax 
                credits available under section 45R of the Internal 
                Revenue Code of 1986 (as added by section 1421), and 
                other information specifically for small businesses 
                regarding affordable health care options.''.

SEC. 10103. AMENDMENTS TO SUBTITLE C.

    (a) Section 2701(a)(5) of the Public Health Service Act, as added by 
section 1201(4) of this Act, <<NOTE: 42 USC 300gg.>>  is amended by 
inserting ``(other than self-insured group health plans offered in such 
market)'' after ``such market''.

    (b) Section 2708 of the Public Health Service Act, as added by 
section 1201(4) of this Act, <<NOTE: 42 USC 300gg-7.>>  is amended by 
striking ``or individual''.

    (c) Subpart I of part A of title XXVII of the Public Health Service 
Act, as added by section 1201(4) of this Act, is amended by inserting 
after section 2708, the following:

``SEC. 2709. <<NOTE: 42 USC 300gg-8.>>  COVERAGE FOR INDIVIDUALS 
            PARTICIPATING IN APPROVED CLINICAL TRIALS.

    ``(a) Coverage.--
            ``(1) In general.--If a group health plan or a health 
        insurance issuer offering group or individual health insurance 
        coverage provides coverage to a qualified individual, then such 
        plan or issuer--

[[Page 124 STAT. 893]]

                    ``(A) may not deny the individual participation in 
                the clinical trial referred to in subsection (b)(2);
                    ``(B) subject to subsection (c), may not deny (or 
                limit or impose additional conditions on) the coverage 
                of routine patient costs for items and services 
                furnished in connection with participation in the trial; 
                and
                    ``(C) may not discriminate against the individual on 
                the basis of the individual's participation in such 
                trial.
            ``(2) Routine patient costs.--
                    ``(A) Inclusion.--For purposes of paragraph (1)(B), 
                subject to subparagraph (B), routine patient costs 
                include all items and services consistent with the 
                coverage provided in the plan (or coverage) that is 
                typically covered for a qualified individual who is not 
                enrolled in a clinical trial.
                    ``(B) Exclusion.--For purposes of paragraph (1)(B), 
                routine patient costs does not include--
                          ``(i) the investigational item, device, or 
                      service, itself;
                          ``(ii) items and services that are provided 
                      solely to satisfy data collection and analysis 
                      needs and that are not used in the direct clinical 
                      management of the patient; or
                          ``(iii) a service that is clearly inconsistent 
                      with widely accepted and established standards of 
                      care for a particular diagnosis.
            ``(3) Use of in-network providers.--If one or more 
        participating providers is participating in a clinical trial, 
        nothing in paragraph (1) shall be construed as preventing a plan 
        or issuer from requiring that a qualified individual participate 
        in the trial through such a participating provider if the 
        provider will accept the individual as a participant in the 
        trial.
            ``(4) <<NOTE: Applicability.>>  Use of out-of-network.--
        Notwithstanding paragraph (3), paragraph (1) shall apply to a 
        qualified individual participating in an approved clinical trial 
        that is conducted outside the State in which the qualified 
        individual resides.

    ``(b) Qualified Individual Defined.--For purposes of subsection (a), 
the term `qualified individual' means an individual who is a participant 
or beneficiary in a health plan or with coverage described in subsection 
(a)(1) and who meets the following conditions:
            ``(1) The individual is eligible to participate in an 
        approved clinical trial according to the trial protocol with 
        respect to treatment of cancer or other life-threatening disease 
        or condition.
            ``(2) Either--
                    ``(A) the referring health care professional is a 
                participating health care provider and has concluded 
                that the individual's participation in such trial would 
                be appropriate based upon the individual meeting the 
                conditions described in paragraph (1); or
                    ``(B) the participant or beneficiary provides 
                medical and scientific information establishing that the 
                individual's participation in such trial would be 
                appropriate based upon the individual meeting the 
                conditions described in paragraph (1).

    ``(c) Limitations on Coverage.--This section shall not be construed 
to require a group health plan, or a health insurance issuer

[[Page 124 STAT. 894]]

offering group or individual health insurance coverage, to provide 
benefits for routine patient care services provided outside of the 
plan's (or coverage's) health care provider network unless out-of-
network benefits are otherwise provided under the plan (or coverage).
    ``(d) Approved Clinical Trial Defined.--
            ``(1) In general.--In this section, the term `approved 
        clinical trial' means a phase I, phase II, phase III, or phase 
        IV clinical trial that is conducted in relation to the 
        prevention, detection, or treatment of cancer or other life-
        threatening disease or condition and is described in any of the 
        following subparagraphs:
                    ``(A) Federally funded trials.--The study or 
                investigation is approved or funded (which may include 
                funding through in-kind contributions) by one or more of 
                the following:
                          ``(i) The National Institutes of Health.
                          ``(ii) The Centers for Disease Control and 
                      Prevention.
                          ``(iii) The Agency for Health Care Research 
                      and Quality.
                          ``(iv) The Centers for Medicare & Medicaid 
                      Services.
                          ``(v) cooperative group or center of any of 
                      the entities described in clauses (i) through (iv) 
                      or the Department of Defense or the Department of 
                      Veterans Affairs.
                          ``(vi) A qualified non-governmental research 
                      entity identified in the guidelines issued by the 
                      National Institutes of Health for center support 
                      grants.
                          ``(vii) Any of the following if the conditions 
                      described in paragraph (2) are met:
                                    ``(I) The Department of Veterans 
                                Affairs.
                                    ``(II) The Department of Defense.
                                    ``(III) The Department of Energy.
                    ``(B) The study or investigation is conducted under 
                an investigational new drug application reviewed by the 
                Food and Drug Administration.
                    ``(C) The study or investigation is a drug trial 
                that is exempt from having such an investigational new 
                drug application.
            ``(2) <<NOTE: Determination.>>  Conditions for 
        departments.--The conditions described in this paragraph, for a 
        study or investigation conducted by a Department, are that the 
        study or investigation has been reviewed and approved through a 
        system of peer review that the Secretary determines--
                    ``(A) to be comparable to the system of peer review 
                of studies and investigations used by the National 
                Institutes of Health, and
                    ``(B) assures unbiased review of the highest 
                scientific standards by qualified individuals who have 
                no interest in the outcome of the review.

    ``(e) Life-threatening Condition Defined.--In this section, the term 
`life-threatening condition' means any disease or condition from which 
the likelihood of death is probable unless the course of the disease or 
condition is interrupted.
    ``(f) Construction.--Nothing in this section shall be construed to 
limit a plan's or issuer's coverage with respect to clinical trials.

[[Page 124 STAT. 895]]

    ``(g) Application to FEHBP.--Notwithstanding any provision of 
chapter 89 of title 5, United States Code, this section shall apply to 
health plans offered under the program under such chapter.
    ``(h) Preemption.--Notwithstanding any other provision of this Act, 
nothing in this section shall preempt State laws that require a clinical 
trials policy for State regulated health insurance plans that is in 
addition to the policy required under this section.''.
    (d) <<NOTE: 42 USC 18011.>>  Section 1251(a) of this Act is 
amended--
            (1) in paragraph (2), by striking ``With'' and inserting 
        ``Except as provided in paragraph (3), with''; and
            (2) by adding at the end the following:
            ``(3) Application of certain provisions.--The provisions of 
        sections 2715 and 2718 of the Public Health Service Act (as 
        added by subtitle A) shall apply to grandfathered health plans 
        for plan years beginning on or after the date of enactment of 
        this Act.''.

    (e) <<NOTE: Effective date. 42 USC 300gg note.>>  Section 1253 of 
this Act is amended insert before the period the following: ``, except 
that--
            ``(1) section 1251 shall take effect on the date of 
        enactment of this Act; and
            ``(2) the provisions of section 2704 of the Public Health 
        Service Act (as amended by section 1201), as they apply to 
        enrollees who are under 19 years of age, shall become effective 
        for plan years beginning on or after the date that is 6 months 
        after the date of enactment of this Act.''.

    (f) Subtitle C of title I of this Act is amended--
            (1) by redesignating section 1253 as section 1255; and
            (2) by inserting after section 1252, the following:

``SEC. 1253. <<NOTE: 42 USC 18013.>>  ANNUAL REPORT ON SELF-INSURED 
            PLANS.

    ``Not later than 1 year after the date of enactment of this Act, and 
annually thereafter, the Secretary of Labor shall prepare an aggregate 
annual report, using data collected from the Annual Return/Report of 
Employee Benefit Plan (Department of Labor Form 5500), that shall 
include general information on self-insured group health plans 
(including plan type, number of participants, benefits offered, funding 
arrangements, and benefit arrangements) as well as data from the 
financial filings of self-insured employers (including information on 
assets, liabilities, contributions, investments, and expenses). The 
Secretary shall submit such reports to the appropriate committees of 
Congress.

``SEC. 1254. STUDY OF LARGE GROUP MARKET.

    ``(a) In General.--The Secretary of Health and Human Services shall 
conduct a study of the fully-insured and self-insured group health plan 
markets to--
            ``(1) compare the characteristics of employers (including 
        industry, size, and other characteristics as determined 
        appropriate by the Secretary), health plan benefits, financial 
        solvency, capital reserve levels, and the risks of becoming 
        insolvent; and
            ``(2) determine the extent to which new insurance market 
        reforms are likely to cause adverse selection in the large group 
        market or to encourage small and midsize employers to self-
        insure.

    ``(b) Collection of Information.--In conducting the study under 
subsection (a), the Secretary, in coordination with the Secretary of 
Labor, shall collect information and analyze--

[[Page 124 STAT. 896]]

            ``(1) the extent to which self-insured group health plans 
        can offer less costly coverage and, if so, whether lower costs 
        are due to more efficient plan administration and lower overhead 
        or to the denial of claims and the offering very limited benefit 
        packages;
            ``(2) claim denial rates, plan benefit fluctuations (to 
        evaluate the extent that plans scale back health benefits during 
        economic downturns), and the impact of the limited recourse 
        options on consumers; and
            ``(3) any potential conflict of interest as it relates to 
        the health care needs of self-insured enrollees and self-insured 
        employer's financial contribution or profit margin, and the 
        impact of such conflict on administration of the health plan.

    ``(c) Report.--Not later than 1 year after the date of enactment of 
this Act, the Secretary shall submit to the appropriate committees of 
Congress a report concerning the results of the study conducted under 
subsection (a).''.

SEC. 10104. AMENDMENTS TO SUBTITLE D.

    (a) <<NOTE: 42 USC 18021.>>  Section 1301(a) of this Act is amended 
by striking paragraph (2) and inserting the following:
            ``(2) Inclusion of co-op plans and multi-state qualified 
        health plans.--Any reference in this title to a qualified health 
        plan shall be deemed to include a qualified health plan offered 
        through the CO-OP program under section 1322, and a multi-State 
        plan under section 1334, unless specifically provided for 
        otherwise.
            ``(3) Treatment of qualified direct primary care medical 
        home plans.--The Secretary <<NOTE: Criteria.>>  of Health and 
        Human Services shall permit a qualified health plan to provide 
        coverage through a qualified direct primary care medical home 
        plan that meets criteria established by the Secretary, so long 
        as the qualified health plan meets all requirements that are 
        otherwise applicable and the services covered by the medical 
        home plan are coordinated with the entity offering the qualified 
        health plan.
            ``(4) Variation based on rating area.--A qualified health 
        plan, including a multi-State qualified health plan, may as 
        appropriate vary premiums by rating area (as defined in section 
        2701(a)(2) of the Public Health Service Act).''.

    (b) <<NOTE: 42 USC 18022.>>  Section 1302 of this Act is amended--
            (1) in subsection (d)(2)(B), by striking ``may issue'' and 
        inserting ``shall issue''; and
            (2) by adding at the end the following:

    ``(g) Payments to Federally-qualified Health Centers.--If any item 
or service covered by a qualified health plan is provided by a 
Federally-qualified health center (as defined in section 1905(l)(2)(B) 
of the Social Security Act (42 U.S.C. 1396d(l)(2)(B)) to an enrollee of 
the plan, the offeror of the plan shall pay to the center for the item 
or service an amount that is not less than the amount of payment that 
would have been paid to the center under section 1902(bb) of such Act 
(42 U.S.C. 1396a(bb)) for such item or service.''.
    (c) Section 1303 of this Act is amended to read as follows:

``SEC. 1303. <<NOTE: 42 USC 18023.>>  SPECIAL RULES.

    ``(a) State Opt-out of Abortion Coverage.--

[[Page 124 STAT. 897]]

            ``(1) In general.--A State may elect to prohibit abortion 
        coverage in qualified health plans offered through an Exchange 
        in such State if such State enacts a law to provide for such 
        prohibition.
            ``(2) Termination of opt out.--A State may repeal a law 
        described in paragraph (1) and provide for the offering of such 
        services through the Exchange.

    ``(b) Special Rules Relating to Coverage of Abortion Services.--
            ``(1) Voluntary choice of coverage of abortion services.--
                    ``(A) In general.--Notwithstanding any other 
                provision of this title (or any amendment made by this 
                title)--
                          ``(i) nothing in this title (or any amendment 
                      made by this title), shall be construed to require 
                      a qualified health plan to provide coverage of 
                      services described in subparagraph (B)(i) or 
                      (B)(ii) as part of its essential health benefits 
                      for any plan year; and
                          ``(ii) subject to subsection (a), the issuer 
                      of a qualified health plan shall determine whether 
                      or not the plan provides coverage of services 
                      described in subparagraph (B)(i) or (B)(ii) as 
                      part of such benefits for the plan year.
                    ``(B) Abortion services.--
                          ``(i) Abortions for which public funding is 
                      prohibited.--The services described in this clause 
                      are abortions for which the expenditure of Federal 
                      funds appropriated for the Department of Health 
                      and Human Services is not permitted, based on the 
                      law as in effect as of the date that is 6 months 
                      before the beginning of the plan year involved.
                          ``(ii) Abortions for which public funding is 
                      allowed.--The services described in this clause 
                      are abortions for which the expenditure of Federal 
                      funds appropriated for the Department of Health 
                      and Human Services is permitted, based on the law 
                      as in effect as of the date that is 6 months 
                      before the beginning of the plan year involved.
            ``(2) Prohibition on the use of federal funds.--
                    ``(A) In general.--If a qualified health plan 
                provides coverage of services described in paragraph 
                (1)(B)(i), the issuer of the plan shall not use any 
                amount attributable to any of the following for purposes 
                of paying for such services:
                          ``(i) The credit under section 36B of the 
                      Internal Revenue Code of 1986 (and the amount (if 
                      any) of the advance payment of the credit under 
                      section 1412 of the Patient Protection and 
                      Affordable Care Act).
                          ``(ii) Any cost-sharing reduction under 
                      section 1402 of the Patient Protection and 
                      Affordable Care Act (and the amount (if any) of 
                      the advance payment of the reduction under section 
                      1412 of the Patient Protection and Affordable Care 
                      Act).
                    ``(B) Establishment of allocation accounts.--In the 
                case of a plan to which subparagraph (A) applies, the 
                issuer of the plan shall--

[[Page 124 STAT. 898]]

                          ``(i) collect from each enrollee in the plan 
                      (without regard to the enrollee's age, sex, or 
                      family status) a separate payment for each of the 
                      following:
                                    ``(I) an amount equal to the portion 
                                of the premium to be paid directly by 
                                the enrollee for coverage under the plan 
                                of services other than services 
                                described in paragraph (1)(B)(i) (after 
                                reduction for credits and cost-sharing 
                                reductions described in subparagraph 
                                (A)); and
                                    ``(II) an amount equal to the 
                                actuarial value of the coverage of 
                                services described in paragraph 
                                (1)(B)(i), and
                          ``(ii) shall deposit all such separate 
                      payments into separate allocation accounts as 
                      provided in subparagraph (C).
                In the case of an enrollee whose premium for coverage 
                under the plan is paid through employee payroll deposit, 
                the separate payments required under this subparagraph 
                shall each be paid by a separate deposit.
                    ``(C) Segregation of funds.--
                          ``(i) In general.--The issuer of a plan to 
                      which subparagraph (A) applies shall establish 
                      allocation accounts described in clause (ii) for 
                      enrollees receiving amounts described in 
                      subparagraph (A).
                          ``(ii) Allocation accounts.--The issuer of a 
                      plan to which subparagraph (A) applies shall 
                      deposit--
                                    ``(I) all payments described in 
                                subparagraph (B)(i)(I) into a separate 
                                account that consists solely of such 
                                payments and that is used exclusively to 
                                pay for services other than services 
                                described in paragraph (1)(B)(i); and
                                    ``(II) all payments described in 
                                subparagraph (B)(i)(II) into a separate 
                                account that consists solely of such 
                                payments and that is used exclusively to 
                                pay for services described in paragraph 
                                (1)(B)(i).
                    ``(D) Actuarial value.--
                          ``(i) In general.--The issuer of a qualified 
                      health plan shall estimate the basic per enrollee, 
                      per month cost, determined on an average actuarial 
                      basis, for including coverage under the qualified 
                      health plan of the services described in paragraph 
                      (1)(B)(i).
                          ``(ii) Considerations.--In making such 
                      estimate, the issuer--
                                    ``(I) may take into account the 
                                impact on overall costs of the inclusion 
                                of such coverage, but may not take into 
                                account any cost reduction estimated to 
                                result from such services, including 
                                prenatal care, delivery, or postnatal 
                                care;
                                    ``(II) shall estimate such costs as 
                                if such coverage were included for the 
                                entire population covered; and
                                    ``(III) may not estimate such a cost 
                                at less than $1 per enrollee, per month.
                    ``(E) Ensuring compliance with segregation 
                requirements.--

[[Page 124 STAT. 899]]

                          ``(i) In general.--Subject to clause (ii), 
                      State health insurance commissioners shall ensure 
                      that health plans comply with the segregation 
                      requirements in this subsection through the 
                      segregation of plan funds in accordance with 
                      applicable provisions of generally accepted 
                      accounting requirements, circulars on funds 
                      management of the Office of Management and Budget, 
                      and guidance on accounting of the Government 
                      Accountability Office.
                          ``(ii) Clarification.--Nothing in clause (i) 
                      shall prohibit the right of an individual or 
                      health plan to appeal such action in courts of 
                      competent jurisdiction.
            ``(3) Rules relating to notice.--
                    ``(A) Notice.--A qualified health plan that provides 
                for coverage of the services described in paragraph 
                (1)(B)(i) shall provide a notice to enrollees, only as 
                part of the summary of benefits and coverage 
                explanation, at the time of enrollment, of such 
                coverage.
                    ``(B) Rules relating to payments.--The notice 
                described in subparagraph (A), any advertising used by 
                the issuer with respect to the plan, any information 
                provided by the Exchange, and any other information 
                specified by the Secretary shall provide information 
                only with respect to the total amount of the combined 
                payments for services described in paragraph (1)(B)(i) 
                and other services covered by the plan.
            ``(4) No discrimination on basis of provision of abortion.--
        No qualified health plan offered through an Exchange may 
        discriminate against any individual health care provider or 
        health care facility because of its unwillingness to provide, 
        pay for, provide coverage of, or refer for abortions

    ``(c) Application of State and Federal Laws Regarding Abortion.--
            ``(1) No preemption of state laws regarding abortion.--
        Nothing in this Act shall be construed to preempt or otherwise 
        have any effect on State laws regarding the prohibition of (or 
        requirement of) coverage, funding, or procedural requirements on 
        abortions, including parental notification or consent for the 
        performance of an abortion on a minor.
            ``(2) No effect on federal laws regarding abortion.--
                    ``(A) In general.--Nothing in this Act shall be 
                construed to have any effect on Federal laws regarding--
                          ``(i) conscience protection;
                          ``(ii) willingness or refusal to provide 
                      abortion; and
                          ``(iii) discrimination on the basis of the 
                      willingness or refusal to provide, pay for, cover, 
                      or refer for abortion or to provide or participate 
                      in training to provide abortion.
            ``(3) No effect on federal civil rights law.--Nothing in 
        this subsection shall alter the rights and obligations of 
        employees and employers under title VII of the Civil Rights Act 
        of 1964.

    ``(d) Application of Emergency Services Laws.--Nothing in this Act 
shall be construed to relieve any health care provider from providing 
emergency services as required by State or Federal law, including 
section 1867 of the Social Security Act (popularly known as 
`EMTALA').''.

[[Page 124 STAT. 900]]

    (d) <<NOTE: 42 USC 18024.>>  Section 1304 of this Act is amended by 
adding at the end the following:

    ``(e) <<NOTE: Definition.>>  Educated Health Care Consumers.--The 
term `educated health care consumer' means an individual who is 
knowledgeable about the health care system, and has background or 
experience in making informed decisions regarding health, medical, and 
scientific matters.''.

    (e) <<NOTE: 42 USC 18031.>>  Section 1311(d) of this Act is 
amended--
            (1) in paragraph (3)(B), by striking clause (ii) and 
        inserting the following:
                          ``(ii) State must assume cost.--A State shall 
                      make payments--
                                    ``(I) to an individual enrolled in a 
                                qualified health plan offered in such 
                                State; or
                                    ``(II) on behalf of an individual 
                                described in subclause (I) directly to 
                                the qualified health plan in which such 
                                individual is enrolled;
                      to defray the cost of any additional benefits 
                      described in clause (i).''; and
            (2) in paragraph (6)(A), by inserting ``educated'' before 
        ``health care''.

    (f) Section 1311(e) of this Act is amended--
            (1) in paragraph (2), by striking ``may'' in the second 
        sentence and inserting ``shall''; and
            (2) by adding at the end the following:
            ``(3) Transparency in coverage.--
                    ``(A) <<NOTE: Public information.>>  In general.--
                The Exchange shall require health plans seeking 
                certification as qualified health plans to submit to the 
                Exchange, the Secretary, the State insurance 
                commissioner, and make available to the public, accurate 
                and timely disclosure of the following information:
                          ``(i) Claims payment policies and practices.
                          ``(ii) Periodic financial disclosures.
                          ``(iii) Data on enrollment.
                          ``(iv) Data on disenrollment.
                          ``(v) Data on the number of claims that are 
                      denied.
                          ``(vi) Data on rating practices.
                          ``(vii) Information on cost-sharing and 
                      payments with respect to any out-of-network 
                      coverage.
                          ``(viii) Information on enrollee and 
                      participant rights under this title.
                          ``(ix) Other information as determined 
                      appropriate by the Secretary.
                    ``(B) Use of plain language.--The information 
                required to be submitted under subparagraph (A) shall be 
                provided in plain language. <<NOTE: Definition.>>  The 
                term `plain language' means language that the intended 
                audience, including individuals with limited English 
                proficiency, can readily understand and use because that 
                language is concise, well-organized, and follows other 
                best practices of plain language 
                writing. <<NOTE: Guidance.>>  The Secretary and the 
                Secretary of Labor shall jointly develop and issue 
                guidance on best practices of plain language writing.
                    ``(C) Cost sharing transparency.--The Exchange shall 
                require health plans seeking certification as qualified 
                health plans to permit individuals to learn the amount 
                of cost-sharing (including deductibles, copayments, and

[[Page 124 STAT. 901]]

                coinsurance) under the individual's plan or coverage 
                that the individual would be responsible for paying with 
                respect to the furnishing of a specific item or service 
                by a participating provider in a timely manner upon the 
                request of the individual. <<NOTE: Web posting.>>  At a 
                minimum, such information shall be made available to 
                such individual through an Internet website and such 
                other means for individuals without access to the 
                Internet.
                    ``(D) Group health plans.--The Secretary of Labor 
                shall update and harmonize the Secretary's rules 
                concerning the accurate and timely disclosure to 
                participants by group health plans of plan disclosure, 
                plan terms and conditions, and periodic financial 
                disclosure with the standards established by the 
                Secretary under subparagraph (A).''.

    (g) <<NOTE: 42 USC 18031.>>  Section 1311(g)(1) of this Act is 
amended--
            (1) in subparagraph (C), by striking ``; and'' and inserting 
        a semicolon;
            (2) in subparagraph (D), by striking the period and 
        inserting ``; and''; and
            (3) by adding at the end the following:
                    ``(E) the implementation of activities to reduce 
                health and health care disparities, including through 
                the use of language services, community outreach, and 
                cultural competency trainings.''.

    (h) Section 1311(i)(2)((B) of this Act is amended by striking 
``small business development centers'' and inserting ``resource partners 
of the Small Business Administration''.
    (i) <<NOTE: 42 USC 18032.>>  Section 1312 of this Act is amended--
            (1) in subsection (a)(1), by inserting ``and for which such 
        individual is eligible'' before the period;
            (2) in subsection (e)--
                    (A) in paragraph (1), by inserting ``and employers'' 
                after ``enroll individuals''; and
                    (B) by striking the flush sentence at the end; and
            (3) in subsection (f)(1)(A)(ii), by striking the 
        parenthetical.

    (j)(1) Subparagraph (B) of section 1313(a)(6) <<NOTE: 42 USC 18033 
note.>>  of this Act is hereby deemed null, void, and of no effect.

    (2) Section 3730(e) of title 31, United States Code, is amended by 
striking paragraph (4) and inserting the following:
            ``(4)(A) <<NOTE: Courts.>>  The court shall dismiss an 
        action or claim under this section, unless opposed by the 
        Government, if substantially the same allegations or 
        transactions as alleged in the action or claim were publicly 
        disclosed--
                    ``(i) in a Federal criminal, civil, or 
                administrative hearing in which the Government or its 
                agent is a party;
                    ``(ii) in a congressional, Government Accountability 
                Office, or other Federal report, hearing, audit, or 
                investigation; or
                    ``(iii) from the news media,
        unless the action is brought by the Attorney General or the 
        person bringing the action is an original source of the 
        information.
            ``(B) <<NOTE: Definition.>>  For purposes of this paragraph, 
        ``original source'' means an individual who either (i) prior to 
        a public disclosure under subsection (e)(4)(a), has voluntarily 
        disclosed to the

[[Page 124 STAT. 902]]

        Government the information on which allegations or transactions 
        in a claim are based, or (2) who has knowledge that is 
        independent of and materially adds to the publicly disclosed 
        allegations or transactions, and who has voluntarily provided 
        the information to the Government before filing an action under 
        this section.''.

    (k) <<NOTE: 42 USC 18033.>>  Section 1313(b) of this Act is 
amended--
            (1) in paragraph (3), by striking ``and'' at the end;
            (2) by redesignating paragraph (4) as paragraph (5); and
            (3) by inserting after paragraph (3) the following:
            ``(4) a survey of the cost and affordability of health care 
        insurance provided under the Exchanges for owners and employees 
        of small business concerns (as defined under section 3 of the 
        Small Business Act (15 U.S.C. 632)), including data on enrollees 
        in Exchanges and individuals purchasing health insurance 
        coverage outside of Exchanges; and''.

    (l) <<NOTE: 42 USC 18042.>>  Section 1322(b) of this Act is 
amended--
            (1) by redesignating paragraph (3) as paragraph (4); and
            (2) by inserting after paragraph (2), the following:
            ``(3) <<NOTE: Deadlines. Regulations.>>  Repayment of loans 
        and grants.--Not later than July 1, 2013, and prior to awarding 
        loans and grants under the CO-OP program, the Secretary shall 
        promulgate regulations with respect to the repayment of such 
        loans and grants in a manner that is consistent with State 
        solvency regulations and other similar State laws that may 
        apply. In promulgating such regulations, the Secretary shall 
        provide that such loans shall be repaid within 5 years and such 
        grants shall be repaid within 15 years, taking into 
        consideration any appropriate State reserve requirements, 
        solvency regulations, and requisite surplus note arrangements 
        that must be constructed in a State to provide for such 
        repayment prior to awarding such loans and grants.''.

    (m) <<NOTE: 42 USC 18043.>>  Part III of subtitle D of title I of 
this Act is amended by striking section 1323.

    (n) <<NOTE: 42 USC 18044.>>  Section 1324(a) of this Act is amended 
by striking ``, a community health'' and all that follows through 
``1333(b)'' and inserting ``, or a multi-State qualified health plan 
under section 1334''.

    (o) <<NOTE: 42 USC 18051.>>  Section 1331 of this Act is amended--
            (1) in subsection (d)(3)(A)(i), by striking ``85'' and 
        inserting ``95''; and
            (2) in subsection (e)(1)(B), by inserting before the 
        semicolon the following: ``, or, in the case of an alien 
        lawfully present in the United States, whose income is not 
        greater than 133 percent of the poverty line for the size of the 
        family involved but who is not eligible for the Medicaid program 
        under title XIX of the Social Security Act by reason of such 
        alien status''.

    (p) <<NOTE: 42 USC 18053.>>  Section 1333 of this Act is amended by 
striking subsection (b).

    (q) Part IV of subtitle D of title I of this Act is amended by 
adding at the end the following:

``SEC. 1334. <<NOTE: Contracts. 42 USC 18054.>>  MULTI-STATE PLANS.

    ``(a) Oversight by the Office of Personnel Management.--
            ``(1) In general.--The Director of the Office of Personnel 
        Management (referred to in this section as the `Director') shall 
        enter into contracts with health insurance issuers (which may

[[Page 124 STAT. 903]]

        include a group of health insurance issuers affiliated either by 
        common ownership and control or by the common use of a 
        nationally licensed service mark), without regard to section 5 
        of title 41, United States Code, or other statutes requiring 
        competitive bidding, to offer at least 2 multi-State qualified 
        health plans through each Exchange in each State. Such plans 
        shall provide individual, or in the case of small employers, 
        group coverage.
            ``(2) Terms.--Each contract entered into under paragraph (1) 
        shall be for a uniform term of at least 1 year, but may be made 
        automatically renewable from term to term in the absence of 
        notice of termination by either party. In entering into such 
        contracts, the Director shall ensure that health benefits 
        coverage is provided in accordance with the types of coverage 
        provided for under section 2701(a)(1)(A)(i) of the Public Health 
        Service Act.
            ``(3) Non-profit entities.--In entering into contracts under 
        paragraph (1), the Director shall ensure that at least one 
        contract is entered into with a non-profit entity.
            ``(4) Administration.--The Director shall implement this 
        subsection in a manner similar to the manner in which the 
        Director implements the contracting provisions with respect to 
        carriers under the Federal employees health benefit program 
        under chapter 89 of title 5, United States Code, including 
        (through negotiating with each multi-state plan)--
                    ``(A) a medical loss ratio;
                    ``(B) a profit margin;
                    ``(C) the premiums to be charged; and
                    ``(D) such other terms and conditions of coverage as 
                are in the interests of enrollees in such plans.
            ``(5) Authority to protect consumers.--The Director may 
        prohibit the offering of any multi-State health plan that does 
        not meet the terms and conditions defined by the Director with 
        respect to the elements described in subparagraphs (A) through 
        (D) of paragraph (4).
            ``(6) Assured availability of varied coverage.--In entering 
        into contracts under this subsection, the Director shall ensure 
        that with respect to multi-State qualified health plans offered 
        in an Exchange, there is at least one such plan that does not 
        provide coverage of services described in section 
        1303(b)(1)(B)(i).
            ``(7) Withdrawal.--Approval of a contract under this 
        subsection may be withdrawn by the Director only after notice 
        and opportunity for hearing to the issuer concerned without 
        regard to subchapter II of chapter 5 and chapter 7 of title 5, 
        United States Code.

    ``(b) Eligibility.--A health insurance issuer shall be eligible to 
enter into a contract under subsection (a)(1) if such issuer--
            ``(1) agrees to offer a multi-State qualified health plan 
        that meets the requirements of subsection (c) in each Exchange 
        in each State;
            ``(2) is licensed in each State and is subject to all 
        requirements of State law not inconsistent with this section, 
        including the standards and requirements that a State imposes 
        that do not prevent the application of a requirement of part A 
        of title XXVII of the Public Health Service Act or a requirement 
        of this title;

[[Page 124 STAT. 904]]

            ``(3) otherwise complies with the minimum standards 
        prescribed for carriers offering health benefits plans under 
        section 8902(e) of title 5, United States Code, to the extent 
        that such standards do not conflict with a provision of this 
        title; and
            ``(4) meets such other requirements as determined 
        appropriate by the Director, in consultation with the Secretary.

    ``(c) Requirements for Multi-State Qualified Health Plan.--
            ``(1) In general.--A multi-State qualified health plan meets 
        the requirements of this subsection if, in the determination of 
        the Director--
                    ``(A) the plan offers a benefits package that is 
                uniform in each State and consists of the essential 
                benefits described in section 1302;
                    ``(B) the plan meets all requirements of this title 
                with respect to a qualified health plan, including 
                requirements relating to the offering of the bronze, 
                silver, and gold levels of coverage and catastrophic 
                coverage in each State Exchange;
                    ``(C) except as provided in paragraph (5), the 
                issuer provides for determinations of premiums for 
                coverage under the plan on the basis of the rating 
                requirements of part A of title XXVII of the Public 
                Health Service Act; and
                    ``(D) the issuer offers the plan in all geographic 
                regions, and in all States that have adopted adjusted 
                community rating before the date of enactment of this 
                Act.
            ``(2) States may offer additional benefits.--Nothing in 
        paragraph (1)(A) shall preclude a State from requiring that 
        benefits in addition to the essential health benefits required 
        under such paragraph be provided to enrollees of a multi-State 
        qualified health plan offered in such State.
            ``(3) Credits.--
                    ``(A) In general.--An individual enrolled in a 
                multi-State qualified health plan under this section 
                shall be eligible for credits under section 36B of the 
                Internal Revenue Code of 1986 and cost sharing 
                assistance under section 1402 in the same manner as an 
                individual who is enrolled in a qualified health plan.
                    ``(B) No additional federal cost.--A requirement by 
                a State under paragraph (2) that benefits in addition to 
                the essential health benefits required under paragraph 
                (1)(A) be provided to enrollees of a multi-State 
                qualified health plan shall not affect the amount of a 
                premium tax credit provided under section 36B of the 
                Internal Revenue Code of 1986 with respect to such plan.
            ``(4) State must assume cost.--A State shall make payments--
                    ``(A) to an individual enrolled in a multi-State 
                qualified health plan offered in such State; or
                    ``(B) on behalf of an individual described in 
                subparagraph (A) directly to the multi-State qualified 
                health plan in which such individual is enrolled;
        to defray the cost of any additional benefits described in 
        paragraph (2).
            ``(5) Application of certain state rating requirements.--
        With respect to a multi-State qualified health plan that is 
        offered in a State with age rating requirements that

[[Page 124 STAT. 905]]

        are lower than 3:1, the State may require that Exchanges 
        operating in such State only permit the offering of such multi-
        State qualified health plans if such plans comply with the 
        State's more protective age rating requirements.

    ``(d) Plans Deemed To Be Certified.--A multi-State qualified health 
plan that is offered under a contract under subsection (a) shall be 
deemed to be certified by an Exchange for purposes of section 
1311(d)(4)(A).
    ``(e) <<NOTE: Contracts.>>  Phase-in.--Notwithstanding paragraphs 
(1) and (2) of subsection (b), the Director shall enter into a contract 
with a health insurance issuer for the offering of a multi-State 
qualified health plan under subsection (a) if--
            ``(1) with respect to the first year for which the issuer 
        offers such plan, such issuer offers the plan in at least 60 
        percent of the States;
            ``(2) with respect to the second such year, such issuer 
        offers the plan in at least 70 percent of the States;
            ``(3) with respect to the third such year, such issuer 
        offers the plan in at least 85 percent of the States; and
            ``(4) with respect to each subsequent year, such issuer 
        offers the plan in all States.

    ``(f) Applicability.--The requirements under chapter 89 of title 5, 
United States Code, applicable to health benefits plans under such 
chapter shall apply to multi-State qualified health plans provided for 
under this section to the extent that such requirements do not conflict 
with a provision of this title.
    ``(g) Continued Support for FEHBP.--
            ``(1) Maintenance of effort.--Nothing in this section shall 
        be construed to permit the Director to allocate fewer financial 
        or personnel resources to the functions of the Office of 
        Personnel Management related to the administration of the 
        Federal Employees Health Benefit Program under chapter 89 of 
        title 5, United States Code.
            ``(2) Separate risk pool.--Enrollees in multi-State 
        qualified health plans under this section shall be treated as a 
        separate risk pool apart from enrollees in the Federal Employees 
        Health Benefit Program under chapter 89 of title 5, United 
        States Code.
            ``(3) Authority to establish separate entities.--The 
        Director may establish such separate units or offices within the 
        Office of Personnel Management as the Director determines to be 
        appropriate to ensure that the administration of multi-State 
        qualified health plans under this section does not interfere 
        with the effective administration of the Federal Employees 
        Health Benefit Program under chapter 89 of title 5, United 
        States Code.
            ``(4) Effective oversight.--The Director may appoint such 
        additional personnel as may be necessary to enable the Director 
        to carry out activities under this section.
            ``(5) Assurance of separate program.--In carrying out this 
        section, the Director shall ensure that the program under this 
        section is separate from the Federal Employees Health Benefit 
        Program under chapter 89 of title 5, United States Code. 
        Premiums paid for coverage under a multi-State qualified health 
        plan under this section shall not be considered to be Federal 
        funds for any purposes.

[[Page 124 STAT. 906]]

            ``(6) FEHBP plans not required to participate.--Nothing in 
        this section shall require that a carrier offering coverage 
        under the Federal Employees Health Benefit Program under chapter 
        89 of title 5, United States Code, also offer a multi-State 
        qualified health plan under this section.

    ``(h) <<NOTE: Establishment.>>  Advisory Board.--The Director shall 
establish an advisory board to provide recommendations on the activities 
described in this section. A significant percentage of the members of 
such board shall be comprised of enrollees in a multi-State qualified 
health plan, or representatives of such enrollees.

    ``(i) Authorization of Appropriations.--There is authorized to be 
appropriated, such sums as may be necessary to carry out this 
section.''.
    (r) <<NOTE: 42 USC 18061.>>  Section 1341 of this Act is amended--
            (1) in the section heading, by striking ``and small group 
        markets'' and inserting ``market'';
            (2) in subsection (b)(2)(B), by striking ``paragraph 
        (1)(A)'' and inserting ``paragraph (1)(B)''; and
            (3) in subsection (c)(1)(A), by striking ``and small group 
        markets'' and inserting ``market''.

SEC. 10105. AMENDMENTS TO SUBTITLE E.

    (a) Section 36B(b)(3)(A)(ii) of the Internal Revenue Code of 1986, 
as added by section 1401(a) of this Act, <<NOTE: 26 USC 36B.>>  is 
amended by striking ``is in excess of'' and inserting ``equals or 
exceeds''.

    (b) Section 36B(c)(1)(A) of the Internal Revenue Code of 1986, as 
added by section 1401(a) of this Act, is amended by inserting ``equals 
or'' before ``exceeds''.
    (c) Section 36B(c)(2)(C)(iv) of the Internal Revenue Code of 1986, 
as added by section 1401(a) of this Act, is amended by striking 
``subsection (b)(3)(A)(ii)'' and inserting ``subsection 
(b)(3)(A)(iii)''.
    (d) <<NOTE: 26 USC 6211.>>  Section 1401(d) of this Act is amended 
by adding at the end the following:
            ``(3) Section 6211(b)(4)(A) of the Internal Revenue Code of 
        1986 is amended by inserting `36B,' after `36A,'.''.

    (e)(1) Subparagraph (B) of section 45R(d)(3) of the Internal Revenue 
Code of 1986, as added by section 1421(a) <<NOTE: 26 USC 45R.>>  of this 
Act, is amended to read as follows:
                    ``(B) Dollar amount.--For purposes of paragraph 
                (1)(B) and subsection (c)(2)--
                          ``(i) 2010, 2011, 2012, and 2013.--The dollar 
                      amount in effect under this paragraph for taxable 
                      years beginning in 2010, 2011, 2012, or 2013 is 
                      $25,000.
                          ``(ii) Subsequent years.--In the case of a 
                      taxable year beginning in a calendar year after 
                      2013, the dollar amount in effect under this 
                      paragraph shall be equal to $25,000, multiplied by 
                      the cost-of-living adjustment under section 
                      1(f)(3) for the calendar year, determined by 
                      substituting `calendar year 2012' for `calendar 
                      year 1992' in subparagraph (B) thereof.''.

    (2) Subsection (g) of section 45R of the Internal Revenue Code of 
1986, as added by section 1421(a) of this Act, is amended by striking 
``2011'' both places it appears and inserting ``2010, 2011''.
    (3) Section 280C(h) of the Internal Revenue Code of 1986, as added 
by section 1421(d)(1) of this Act, <<NOTE: 26 USC 280C.>>  is amended by 
striking ``2011'' and inserting ``2010, 2011''.

[[Page 124 STAT. 907]]

    (4) <<NOTE: 26 USC 38 note.>>  Section 1421(f) of this Act is 
amended by striking ``2010'' both places it appears and inserting 
``2009''.

    (5) <<NOTE: 26 USC 45R note.>>  The amendments made by this 
subsection shall take effect as if included in the enactment of section 
1421 of this Act.

    (f) Part I of subtitle E of title I of this Act is amended by adding 
at the end of subpart B, the following:

``SEC. 1416. STUDY OF GEOGRAPHIC VARIATION IN APPLICATION OF FPL.

    ``(a) In General.--The Secretary shall conduct a study to examine 
the feasibility and implication of adjusting the application of the 
Federal poverty level under this subtitle (and the amendments made by 
this subtitle) for different geographic areas so as to reflect the 
variations in cost-of-living among different areas within the United 
States. <<NOTE: Determination.>>  If the Secretary determines that an 
adjustment is feasible, the study should include a methodology to make 
such an adjustment. <<NOTE: Deadline. Reports. Recommenda- tions.>>  Not 
later than January 1, 2013, the Secretary shall submit to Congress a 
report on such study and shall include such recommendations as the 
Secretary determines appropriate.

    ``(b) Inclusion of Territories.--
            ``(1) In general.--The Secretary shall ensure that the study 
        under subsection (a) covers the territories of the United States 
        and that special attention is paid to the disparity that exists 
        among poverty levels and the cost of living in such territories 
        and to the impact of such disparity on efforts to expand health 
        coverage and ensure health care.
            ``(2) Territories defined.--In this subsection, the term 
        `territories of the United States' includes the Commonwealth of 
        Puerto Rico, the United States Virgin Islands, Guam, the 
        Northern Mariana Islands, and any other territory or possession 
        of the United States.''.

SEC. 10106. AMENDMENTS TO SUBTITLE F.

    (a) <<NOTE: 42 USC 18091.>>  Section 1501(a)(2) of this Act is 
amended to read as follows:
            ``(2) Effects on the national economy and interstate 
        commerce.--The effects described in this paragraph are the 
        following:
                    ``(A) The requirement regulates activity that is 
                commercial and economic in nature: economic and 
                financial decisions about how and when health care is 
                paid for, and when health insurance is purchased. In the 
                absence of the requirement, some individuals would make 
                an economic and financial decision to forego health 
                insurance coverage and attempt to self-insure, which 
                increases financial risks to households and medical 
                providers.
                    ``(B) Health insurance and health care services are 
                a significant part of the national economy. National 
                health spending is projected to increase from 
                $2,500,000,000,000, or 17.6 percent of the economy, in 
                2009 to $4,700,000,000,000 in 2019. Private health 
                insurance spending is projected to be $854,000,000,000 
                in 2009, and pays for medical supplies, drugs, and 
                equipment that are shipped in interstate commerce. Since 
                most health insurance is sold by national or regional 
                health insurance companies, health insurance is sold in 
                interstate commerce and claims payments flow through 
                interstate commerce.

[[Page 124 STAT. 908]]

                    ``(C) The requirement, together with the other 
                provisions of this Act, will add millions of new 
                consumers to the health insurance market, increasing the 
                supply of, and demand for, health care services, and 
                will increase the number and share of Americans who are 
                insured.
                    ``(D) The requirement achieves near-universal 
                coverage by building upon and strengthening the private 
                employer-based health insurance system, which covers 
                176,000,000 Americans nationwide. In Massachusetts, a 
                similar requirement has strengthened private employer-
                based coverage: despite the economic downturn, the 
                number of workers offered employer-based coverage has 
                actually increased.
                    ``(E) The economy loses up to $207,000,000,000 a 
                year because of the poorer health and shorter lifespan 
                of the uninsured. By significantly reducing the number 
                of the uninsured, the requirement, together with the 
                other provisions of this Act, will significantly reduce 
                this economic cost.
                    ``(F) The cost of providing uncompensated care to 
                the uninsured was $43,000,000,000 in 2008. To pay for 
                this cost, health care providers pass on the cost to 
                private insurers, which pass on the cost to families. 
                This cost-shifting increases family premiums by on 
                average over $1,000 a year. By significantly reducing 
                the number of the uninsured, the requirement, together 
                with the other provisions of this Act, will lower health 
                insurance premiums.
                    ``(G) 62 percent of all personal bankruptcies are 
                caused in part by medical expenses. By significantly 
                increasing health insurance coverage, the requirement, 
                together with the other provisions of this Act, will 
                improve financial security for families.
                    ``(H) Under the Employee Retirement Income Security 
                Act of 1974 (29 U.S.C. 1001 et seq.), the Public Health 
                Service Act (42 U.S.C. 201 et seq.), and this Act, the 
                Federal Government has a significant role in regulating 
                health insurance. The requirement is an essential part 
                of this larger regulation of economic activity, and the 
                absence of the requirement would undercut Federal 
                regulation of the health insurance market.
                    ``(I) Under sections 2704 and 2705 of the Public 
                Health Service Act (as added by section 1201 of this 
                Act), if there were no requirement, many individuals 
                would wait to purchase health insurance until they 
                needed care. By significantly increasing health 
                insurance coverage, the requirement, together with the 
                other provisions of this Act, will minimize this adverse 
                selection and broaden the health insurance risk pool to 
                include healthy individuals, which will lower health 
                insurance premiums. The requirement is essential to 
                creating effective health insurance markets in which 
                improved health insurance products that are guaranteed 
                issue and do not exclude coverage of pre-existing 
                conditions can be sold.
                    ``(J) Administrative costs for private health 
                insurance, which were $90,000,000,000 in 2006, are 26 to 
                30 percent of premiums in the current individual and 
                small group

[[Page 124 STAT. 909]]

                markets. By significantly increasing health insurance 
                coverage and the size of purchasing pools, which will 
                increase economies of scale, the requirement, together 
                with the other provisions of this Act, will 
                significantly reduce administrative costs and lower 
                health insurance premiums. The requirement is essential 
                to creating effective health insurance markets that do 
                not require underwriting and eliminate its associated 
                administrative costs.''.

    (b)(1) Section 5000A(b)(1) of the Internal Revenue Code of 1986, as 
added by section 1501(b) of this Act, <<NOTE: 26 USC 5000A.>>  is 
amended to read as follows:
            ``(1) In general.--If a taxpayer who is an applicable 
        individual, or an applicable individual for whom the taxpayer is 
        liable under paragraph (3), fails to meet the requirement of 
        subsection (a) for 1 or more months, then, except as provided in 
        subsection (e), there is hereby imposed on the taxpayer a 
        penalty with respect to such failures in the amount determined 
        under subsection (c).''.
            (2) Paragraphs (1) and (2) of section 5000A(c) of the 
        Internal Revenue Code of 1986, as so added, are amended to read 
        as follows:
            ``(1) In general.--The amount of the penalty imposed by this 
        section on any taxpayer for any taxable year with respect to 
        failures described in subsection (b)(1) shall be equal to the 
        lesser of--
                    ``(A) the sum of the monthly penalty amounts 
                determined under paragraph (2) for months in the taxable 
                year during which 1 or more such failures occurred, or
                    ``(B) an amount equal to the national average 
                premium for qualified health plans which have a bronze 
                level of coverage, provide coverage for the applicable 
                family size involved, and are offered through Exchanges 
                for plan years beginning in the calendar year with or 
                within which the taxable year ends.
            ``(2) Monthly penalty amounts.--For purposes of paragraph 
        (1)(A), the monthly penalty amount with respect to any taxpayer 
        for any month during which any failure described in subsection 
        (b)(1) occurred is an amount equal to \1/12\ of the greater of 
        the following amounts:
                    ``(A) Flat dollar amount.--An amount equal to the 
                lesser of--
                          ``(i) the sum of the applicable dollar amounts 
                      for all individuals with respect to whom such 
                      failure occurred during such month, or
                          ``(ii) 300 percent of the applicable dollar 
                      amount (determined without regard to paragraph 
                      (3)(C)) for the calendar year with or within which 
                      the taxable year ends.
                    ``(B) Percentage of income.--An amount equal to the 
                following percentage of the taxpayer's household income 
                for the taxable year:
                          ``(i) 0.5 percent for taxable years beginning 
                      in 2014.
                          ``(ii) 1.0 percent for taxable years beginning 
                      in 2015.
                          ``(iii) 2.0 percent for taxable years 
                      beginning after 2015.''.

[[Page 124 STAT. 910]]

    (3) Section 5000A(c)(3) of the Internal Revenue Code of 1986, as 
added by section 1501(b) of this Act, <<NOTE: 26 USC 5000A.>>  is 
amended by striking ``$350'' and inserting ``$495''.

    (c) Section 5000A(d)(2)(A) of the Internal Revenue Code of 1986, as 
added by section 1501(b) of this Act, is amended to read as follows:
                    ``(A) Religious conscience exemption.--Such term 
                shall not include any individual for any month if such 
                individual has in effect an exemption under section 
                1311(d)(4)(H) of the Patient Protection and Affordable 
                Care Act which certifies that such individual is--
                          ``(i) a member of a recognized religious sect 
                      or division thereof which is described in section 
                      1402(g)(1), and
                          ``(ii) an adherent of established tenets or 
                      teachings of such sect or division as described in 
                      such section.''.

    (d) Section 5000A(e)(1)(C) of the Internal Revenue Code of 1986, as 
added by section 1501(b) of this Act, is amended to read as follows:
                    ``(C) Special rules for individuals related to 
                employees.--For purposes of subparagraph (B)(i), if an 
                applicable individual is eligible for minimum essential 
                coverage through an employer by reason of a relationship 
                to an employee, the determination under subparagraph (A) 
                shall be made by reference to required contribution of 
                the employee.''.

    (e) Section 4980H(b) of the Internal Revenue Code of 1986, as added 
by section 1513(a) of this Act, <<NOTE: 26 USC 4980H.>>  is amended to 
read as follows:

    ``(b) Large Employers With Waiting Periods Exceeding 60 Days.--
            ``(1) In general.--In the case of any applicable large 
        employer which requires an extended waiting period to enroll in 
        any minimum essential coverage under an employer-sponsored plan 
        (as defined in section 5000A(f)(2)), there is hereby imposed on 
        the employer an assessable payment of $600 for each full-time 
        employee of the employer to whom the extended waiting period 
        applies.
            ``(2) <<NOTE: Definition.>>  Extended waiting period.--The 
        term `extended waiting period' means any waiting period (as 
        defined in section 2701(b)(4) of the Public Health Service Act) 
        which exceeds 60 days.''.

    (f)(1) Subparagraph (A) of section 4980H(d)(4) of the Internal 
Revenue Code of 1986, as added by section 1513(a) of this Act, is 
amended by inserting ``, with respect to any month,'' after ``means''.
    (2) Section 4980H(d)(2) of the Internal Revenue Code of 1986, as 
added by section 1513(a) of this Act, is amended by adding at the end 
the following:
                    ``(D) Application to construction industry 
                employers.--In the case of any employer the substantial 
                annual gross receipts of which are attributable to the 
                construction industry--
                          ``(i) subparagraph (A) shall be applied by 
                      substituting `who employed an average of at least 
                      5 full-time employees on business days during the 
                      preceding calendar year and whose annual payroll 
                      expenses

[[Page 124 STAT. 911]]

                      exceed $250,000 for such preceding calendar year' 
                      for `who employed an average of at least 50 full-
                      time employees on business days during the 
                      preceding calendar year', and
                          ``(ii) subparagraph (B) shall be applied by 
                      substituting `5' for `50'.''.

    (3) <<NOTE: Applicability. 26 USC 4980H note.>>  The amendment made 
by paragraph (2) shall apply to months beginning after December 31, 
2013.

    (g) Section 6056(b) of the Internal Revenue Code of 1986, as added 
by section 1514(a) of the Act, <<NOTE: 26 USC 6056.>>  is amended by 
adding at the end the following new flush sentence:

``The Secretary shall have the authority to review the accuracy of the 
information provided under this subsection, including the applicable 
large employer's share under paragraph (2)(C)(iv).''.

SEC. 10107. AMENDMENTS TO SUBTITLE G.

    (a) Section 1562 of this Act <<NOTE: 42 USC 300gg-21.>>  is amended, 
in the amendment made by subsection (a)(2)(B)(iii), by striking 
``subpart 1'' and inserting ``subparts I and II''; and

    (b) Subtitle G of title I of this Act is amended--
            (1) <<NOTE: 26 USC 9815; 29 USC 1185d; 42 USC 300gg-1-- 
        300gg-3, 300gg-9, 300gg-11, 300gg-12, 300gg-21--300gg-23, 300gg-
        25--300gg-28, 300gg-62, 300gg-91, 18120.>>  by redesignating 
        section 1562 (as amended) as section 1563; and
            (2) by inserting after section 1561 the following:

``SEC. 1562. GAO STUDY REGARDING THE RATE OF DENIAL OF COVERAGE AND 
            ENROLLMENT BY HEALTH INSURANCE ISSUERS AND GROUP HEALTH 
            PLANS.

    ``(a) In General.--The Comptroller General of the United States 
(referred to in this section as the `Comptroller General') shall conduct 
a study of the incidence of denials of coverage for medical services and 
denials of applications to enroll in health insurance plans, as 
described in subsection (b), by group health plans and health insurance 
issuers.
    ``(b) Data.--
            ``(1) In general.--In conducting the study described in 
        subsection (a), the Comptroller General shall consider samples 
        of data concerning the following:
                    ``(A)(i) denials of coverage for medical services to 
                a plan enrollees, by the types of services for which 
                such coverage was denied; and
                    ``(ii) the reasons such coverage was denied; and
                    ``(B)(i) incidents in which group health plans and 
                health insurance issuers deny the application of an 
                individual to enroll in a health insurance plan offered 
                by such group health plan or issuer; and
                    ``(ii) the reasons such applications are denied.
            ``(2) Scope of data.--
                    ``(A) Favorably resolved disputes.--The data that 
                the Comptroller General considers under paragraph (1) 
                shall include data concerning denials of coverage for 
                medical services and denials of applications for 
                enrollment in a plan by a group health plan or health 
                insurance issuer, where such group health plan or health 
                insurance issuer later approves such coverage or 
                application.
                    ``(B) All health plans.--The study under this 
                section shall consider data from varied group health 
                plans and health insurance plans offered by health 
                insurance issuers,

[[Page 124 STAT. 912]]

                including qualified health plans and health plans that 
                are not qualified health plans.

    ``(c) Report.--Not later than one year after the date of enactment 
of this Act, the Comptroller General shall submit to the Secretaries of 
Health and Human Services and Labor a report describing the results of 
the study conducted under this section.
    ``(d) <<NOTE: Public information. Web posting.>>  Publication of 
Report.--The Secretaries of Health and Human Services and Labor shall 
make the report described in subsection (c) available to the public on 
an Internet website.

``SEC. 1563. <<NOTE: 42 USC 18119.>>  SMALL BUSINESS PROCUREMENT.

    ``Part 19 of the Federal Acquisition Regulation, section 15 of the 
Small Business Act (15 U.S.C. 644), and any other applicable laws or 
regulations establishing procurement requirements relating to small 
business concerns (as defined in section 3 of the Small Business Act (15 
U.S.C. 632)) may not be waived with respect to any contract awarded 
under any program or other authority under this Act or an amendment made 
by this Act.''.

SEC. 10108. <<NOTE: 42 USC 18101.>>  FREE CHOICE VOUCHERS.

    (a) In General.--An offering employer shall provide free choice 
vouchers to each qualified employee of such employer.
    (b) Offering Employer.--For purposes of this section, the term 
``offering employer'' means any employer who--
            (1) offers minimum essential coverage to its employees 
        consisting of coverage through an eligible employer-sponsored 
        plan; and
            (2) pays any portion of the costs of such plan.

    (c) Qualified Employee.--For purposes of this section--
            (1) <<NOTE: Definition.>>  In general.--The term ``qualified 
        employee'' means, with respect to any plan year of an offering 
        employer, any employee--
                    (A) whose required contribution (as determined under 
                section 5000A(e)(1)(B)) for minimum essential coverage 
                through an eligible employer-sponsored plan--
                          (i) exceeds 8 percent of such employee's 
                      household income for the taxable year described in 
                      section 1412(b)(1)(B) which ends with or within in 
                      the plan year; and
                          (ii) does not exceed 9.8 percent of such 
                      employee's household income for such taxable year;
                    (B) whose household income for such taxable year is 
                not greater than 400 percent of the poverty line for a 
                family of the size involved; and
                    (C) who does not participate in a health plan 
                offered by the offering employer.
            (2) Indexing.--In the case of any calendar year beginning 
        after 2014, the Secretary shall adjust the 8 percent under 
        paragraph (1)(A)(i) and 9.8 percent under paragraph (1)(A)(ii) 
        for the calendar year to reflect the rate of premium growth 
        between the preceding calendar year and 2013 over the rate of 
        income growth for such period.

    (d) Free Choice Voucher.--
            (1) Amount.--
                    (A) In general.--The amount of any free choice 
                voucher provided under subsection (a) shall be equal to 
                the monthly portion of the cost of the eligible 
                employer-sponsored plan which would have been paid by 
                the

[[Page 124 STAT. 913]]

                employer if the employee were covered under the plan 
                with respect to which the employer pays the largest 
                portion of the cost of the plan. Such amount shall be 
                equal to the amount the employer would pay for an 
                employee with self-only coverage unless such employee 
                elects family coverage (in which case such amount shall 
                be the amount the employer would pay for family 
                coverage).
                    (B) <<NOTE: Regulations.>>  Determination of cost.--
                The cost of any health plan shall be determined under 
                the rules similar to the rules of section 2204 of the 
                Public Health Service Act, except that such amount shall 
                be adjusted for age and category of enrollment in 
                accordance with regulations established by the 
                Secretary.
            (2) Use of vouchers.--An Exchange shall credit the amount of 
        any free choice voucher provided under subsection (a) to the 
        monthly premium of any qualified health plan in the Exchange in 
        which the qualified employee is enrolled and the offering 
        employer shall pay any amounts so credited to the Exchange.
            (3) Payment of excess amounts.--If the amount of the free 
        choice voucher exceeds the amount of the premium of the 
        qualified health plan in which the qualified employee is 
        enrolled for such month, such excess shall be paid to the 
        employee.

    (e) Other Definitions.--Any term used in this section which is also 
used in section 5000A of the Internal Revenue Code of 1986 shall have 
the meaning given such term under such section 5000A.
    (f) Exclusion From Income for Employee.--
            (1) In general.--Part III of subchapter B of chapter 1 of 
        the Internal Revenue Code of 1986 is amended by inserting after 
        section 139C the following new section:

``SEC. 139D. <<NOTE: 26 USC 139D.>>  FREE CHOICE VOUCHERS.

    ``Gross income shall not include the amount of any free choice 
voucher provided by an employer under section 10108 of the Patient 
Protection and Affordable Care Act to the extent that the amount of such 
voucher does not exceed the amount paid for a qualified health plan (as 
defined in section 1301 of such Act) by the taxpayer.''.
            (2) Clerical amendment.--The table of sections for part III 
        of subchapter B of chapter 1 of such Code is amended by 
        inserting after the item relating to section 139C the following 
        new item:

``Sec. 139D. Free choice vouchers.''.

            (3) <<NOTE: 26 USC 139D note.>>  Effective date.--The 
        amendments made by this subsection shall apply to vouchers 
        provided after December 31, 2013.

    (g) Deduction Allowed to Employer.--
            (1) In general.--Section 162(a) of the Internal Revenue Code 
        of 1986 <<NOTE: 26 USC 162.>>  is amended by adding at the end 
        the following new sentence: ``For purposes of paragraph (1), the 
        amount of a free choice voucher provided under section 10108 of 
        the Patient Protection and Affordable Care Act shall be treated 
        as an amount for compensation for personal services actually 
        rendered.''.

[[Page 124 STAT. 914]]

            (2) <<NOTE: 26 USC 162 note.>>  Effective date.--The 
        amendments made by this subsection shall apply to vouchers 
        provided after December 31, 2013.

    (h) Voucher Taken Into Account in Determining Premium Credit.--
            (1) In general.--Subsection (c)(2) of section 36B of the 
        Internal Revenue Code of 1986, <<NOTE: 26 USC 36B.>>  as added 
        by section 1401, is amended by adding at the end the following 
        new subparagraph:
                    ``(D) Exception for individual receiving free choice 
                vouchers.--The term `coverage month' shall not include 
                any month in which such individual has a free choice 
                voucher provided under section 10108 of the Patient 
                Protection and Affordable Care Act.''.
            (2) <<NOTE: 26 USC 36B note.>>  Effective date.--The 
        amendment made by this subsection shall apply to taxable years 
        beginning after December 31, 2013.

    (i) Coordination With Employer Responsibilities.--
            (1) Shared responsibility penalty.--
                    (A) In general.--Subsection (c) of section 4980H of 
                the Internal Revenue Code of 1986, as added by section 
                1513, is amended <<NOTE: 26 USC 4980H.>>  by adding at 
                the end the following new paragraph:
            ``(3) Special rules for employers providing free choice 
        vouchers.--No assessable payment shall be imposed under 
        paragraph (1) for any month with respect to any employee to whom 
        the employer provides a free choice voucher under section 10108 
        of the Patient Protection and Affordable Care Act for such 
        month.''.
                    (B) <<NOTE: 26 USC 4980H note.>>  Effective date.--
                The amendment made by this paragraph shall apply to 
                months beginning after December 31, 2013.
            (2) Notification requirement.--Section 18B(a)(3) of the Fair 
        Labor Standards Act of 1938, <<NOTE: 29 USC 218b.>>  as added by 
        section 1512, is amended--
                    (A) by inserting ``and the employer does not offer a 
                free choice voucher'' after ``Exchange''; and
                    (B) by striking ``will lose'' and inserting ``may 
                lose''.

    (j) Employer Reporting.--
            (1) In general.--Subsection (a) of section 6056 of the 
        Internal Revenue Code of 1986, <<NOTE: 26 USC 6056.>>  as added 
        by section 1514, is amended by inserting ``and every offering 
        employer'' before ``shall''.
            (2) Offering employers.--Subsection (f) of section 6056 of 
        such Code, as added by section 1514, is amended to read as 
        follows:

    ``(f) Definitions.--For purposes of this section--
            ``(1) Offering employer.--
                    ``(A) In general.--The term `offering employer' 
                means any offering employer (as defined in section 
                10108(b) of the Patient Protection and Affordable Care 
                Act) if the required contribution (within the meaning of 
                section 5000A(e)(1)(B)(i)) of any employee exceeds 8 
                percent of the wages (as defined in section 3121(a)) 
                paid to such employee by such employer.
                    ``(B) Indexing.--In the case of any calendar year 
                beginning after 2014, the 8 percent under subparagraph 
                (A)

[[Page 124 STAT. 915]]

                shall be adjusted for the calendar year to reflect the 
                rate of premium growth between the preceding calendar 
                year and 2013 over the rate of income growth for such 
                period.
            ``(2) Other definitions.--Any term used in this section 
        which is also used in section 4980H shall have the meaning given 
        such term by section 4980H.''.
            (3) Conforming amendments.--
                    (A) The heading of section 6056 of such Code, as 
                added by section 1514, <<NOTE: 26 USC 6056.>>  is 
                amended by striking ``large'' and inserting ``certain''.
                    (B) Section 6056(b)(2)(C) of such Code is amended--
                          (i) by inserting ``in the case of an 
                      applicable large employer,'' before ``the length'' 
                      in clause (i);
                          (ii) by striking ``and'' at the end of clause 
                      (iii);
                          (iii) by striking ``applicable large 
                      employer'' in clause (iv) and inserting 
                      ``employer'';
                          (iv) by inserting ``and'' at the end of clause 
                      (iv); and
                          (v) by inserting at the end the following new 
                      clause:
                          ``(v) in the case of an offering employer, the 
                      option for which the employer pays the largest 
                      portion of the cost of the plan and the portion of 
                      the cost paid by the employer in each of the 
                      enrollment categories under such option,''.
                    (C) Section 6056(d)(2) of such Code is amended by 
                inserting ``or offering employer'' after ``applicable 
                large employer''.
                    (D) Section 6056(e) of such Code is amended by 
                inserting ``or offering employer'' after ``applicable 
                large employer''.
                    (E) Section 6724(d)(1)(B)(xxv) of such Code, as 
                added by section 1514, is amended by striking ``large'' 
                and inserting ``certain''.
                    (F) Section 6724(d)(2)(HH) of such Code, as added by 
                section 1514, is amended by striking ``large'' and 
                inserting ``certain''.
                    (G) The table of sections for subpart D of part III 
                of subchapter A of chapter 1 of such Code, as amended by 
                section 1514, is amended by striking ``Large employers'' 
                in the item relating to section 6056 and inserting 
                ``Certain employers''.
            (4) <<NOTE: 26 USC 6056 note.>>  Effective date.--The 
        amendments made by this subsection shall apply to periods 
        beginning after December 31, 2013.

SEC. 10109. DEVELOPMENT OF STANDARDS FOR FINANCIAL AND ADMINISTRATIVE 
            TRANSACTIONS.

    (a) Additional Transaction Standards and Operating Rules.--
            (1) Development of additional transaction standards and 
        operating rules.--Section 1173(a) of the Social Security Act (42 
        U.S.C. 1320d-2(a)), as amended by section 1104(b)(2), is 
        amended--
                    (A) in paragraph (1)(B), by inserting before the 
                period the following: ``, and subject to the 
                requirements under paragraph (5)''; and

[[Page 124 STAT. 916]]

                    (B) by adding at the end the following new 
                paragraph:
            ``(5) Consideration of standardization of activities and 
        items.--
                    ``(A) <<NOTE: Deadlines.>>  In general.--For 
                purposes of carrying out paragraph (1)(B), the Secretary 
                shall solicit, not later than January 1, 2012, and not 
                less than every 3 years thereafter, input from entities 
                described in subparagraph (B) on--
                          ``(i) whether there could be greater 
                      uniformity in financial and administrative 
                      activities and items, as determined appropriate by 
                      the Secretary; and
                          ``(ii) whether such activities should be 
                      considered financial and administrative 
                      transactions (as described in paragraph (1)(B)) 
                      for which the adoption of standards and operating 
                      rules would improve the operation of the health 
                      care system and reduce administrative costs.
                    ``(B) Solicitation of input.--For purposes of 
                subparagraph (A), the Secretary shall seek input from--
                          ``(i) the National Committee on Vital and 
                      Health Statistics, the Health Information 
                      Technology Policy Committee, and the Health 
                      Information Technology Standards Committee; and
                          ``(ii) standard setting organizations and 
                      stakeholders, as determined appropriate by the 
                      Secretary.''.

    (b) <<NOTE: Deadline.>>  Activities and Items for Initial 
Consideration.--For purposes of section 1173(a)(5) of the Social 
Security Act, as added by subsection (a), the Secretary of Health and 
Human Services (in this section referred to as the ``Secretary'') shall, 
not later than January 1, 2012, seek input on activities and items 
relating to the following areas:
            (1) Whether the application process, including the use of a 
        uniform application form, for enrollment of health care 
        providers by health plans could be made electronic and 
        standardized.
            (2) Whether standards and operating rules described in 
        section 1173 of the Social Security Act should apply to the 
        health care transactions of automobile insurance, worker's 
        compensation, and other programs or persons not described in 
        section 1172(a) of such Act (42 U.S.C. 1320d-1(a)).
            (3) Whether standardized forms could apply to financial 
        audits required by health plans, Federal and State agencies 
        (including State auditors, the Office of the Inspector General 
        of the Department of Health and Human Services, and the Centers 
        for Medicare & Medicaid Services), and other relevant entities 
        as determined appropriate by the Secretary.
            (4) Whether there could be greater transparency and 
        consistency of methodologies and processes used to establish 
        claim edits used by health plans (as described in section 
        1171(5) of the Social Security Act (42 U.S.C. 1320d(5))).
            (5) Whether health plans should be required to publish their 
        timeliness of payment rules.

    (c) ICD Coding Crosswalks.--
            (1) <<NOTE: Meeting. Deadline.>>  ICD-9 to icd-10 
        crosswalk.--The Secretary shall task the ICD-9-CM Coordination 
        and Maintenance Committee to convene a meeting, not later than 
        January 1, 2011, to receive input from appropriate stakeholders 
        (including health plans, health care providers, and clinicians) 
        regarding the crosswalk

[[Page 124 STAT. 917]]

        between the Ninth and Tenth Revisions of the International 
        Classification of Diseases (ICD-9 and ICD-10, respectively) that 
        is posted on the website of the Centers for Medicare & Medicaid 
        Services, and make recommendations about appropriate revisions 
        to such crosswalk.
            (2) Revision of crosswalk.--For purposes of the crosswalk 
        described in paragraph (1), the Secretary shall make appropriate 
        revisions and post any such revised crosswalk on the website of 
        the Centers for Medicare & Medicaid Services.
            (3) Use of revised crosswalk.--For purposes of paragraph 
        (2), any revised crosswalk shall be treated as a code set for 
        which a standard has been adopted by the Secretary for purposes 
        of section 1173(c)(1)(B) of the Social Security Act (42 U.S.C. 
        1320d-2(c)(1)(B)).
            (4) <<NOTE: Deadline.>>  Subsequent crosswalks.--For 
        subsequent revisions of the International Classification of 
        Diseases that are adopted by the Secretary as a standard code 
        set under section 1173(c) of the Social Security Act (42 U.S.C. 
        1320d-2(c)), the Secretary shall, after consultation with the 
        appropriate stakeholders, post on the website of the Centers for 
        Medicare & Medicaid Services a crosswalk between the previous 
        and subsequent version of the International Classification of 
        Diseases not later than the date of implementation of such 
        subsequent revision.

               Subtitle B--Provisions Relating to Title II

                        PART I--MEDICAID AND CHIP

SEC. 10201. AMENDMENTS TO THE SOCIAL SECURITY ACT AND TITLE II OF THIS 
            ACT.

    (a)(1) Section 1902(a)(10)(A)(i)(IX) of the Social Security Act (42 
U.S.C. 1396a(a)(10)(A)(i)(IX)), as added by section 2004(a), is amended 
to read as follows:
                                    ``(IX) who--
                                            ``(aa) are under 26 years of 
                                        age;
                                            ``(bb) are not described in 
                                        or enrolled under any of 
                                        subclauses (I) through (VII) of 
                                        this clause or are described in 
                                        any of such subclauses but have 
                                        income that exceeds the level of 
                                        income applicable under the 
                                        State plan for eligibility to 
                                        enroll for medical assistance 
                                        under such subclause;
                                            ``(cc) were in foster care 
                                        under the responsibility of the 
                                        State on the date of attaining 
                                        18 years of age or such higher 
                                        age as the State has elected 
                                        under section 475(8)(B)(iii); 
                                        and
                                            ``(dd) were enrolled in the 
                                        State plan under this title or 
                                        under a waiver of the plan while 
                                        in such foster care;''.

    (2) Section 1902(a)(10) of the Social Security Act (42 U.S.C. 
1396a(a)(10), as amended by section 2001(a)(5)(A), is amended in the 
matter following subparagraph (G), by striking ``and (XV)'' and 
inserting ``(XV)'', and by inserting ``and (XVI) if an individual is 
described in subclause (IX) of subparagraph (A)(i) and is also described 
in subclause (VIII) of that subparagraph, the medical

[[Page 124 STAT. 918]]

assistance shall be made available to the individual through subclause 
(IX) instead of through subclause (VIII)'' before the semicolon.
    (3) <<NOTE: 42 USC 1396a note.>>  Section 2004(d) of this Act is 
amended by striking ``2019'' and inserting ``2014''.

    (b) Section 1902(k)(2) of the Social Security Act (42 U.S.C. 
1396a(k)(2)), as added by section 2001(a)(4)(A), is amended by striking 
``January 1, 2011'' and inserting ``April 1, 2010''.
    (c) Section 1905 of the Social Security Act (42 U.S.C. 1396d), as 
amended by sections 2001(a)(3), 2001(a)(5)(C), 2006, and 4107(a)(2), is 
amended--
            (1) in subsection (a), in the matter preceding paragraph 
        (1), by inserting in clause (xiv), ``or 1902(a)(10)(A)(i)(IX)'' 
        before the comma;
            (2) in subsection (b), in the first sentence, by inserting 
        ``, (z),'' before ``and (aa)'';
            (3) in subsection (y)--
                    (A) in paragraph (1)(B)(ii)(II), in the first 
                sentence, by inserting ``includes inpatient hospital 
                services,'' after ``100 percent of the poverty line, 
                that''; and
                    (B) in paragraph (2)(A), by striking ``on the date 
                of enactment of the Patient Protection and Affordable 
                Care Act'' and inserting ``as of December 1, 2009'';
            (4) by inserting after subsection (y) the following:

    ``(z) Equitable Support for Certain States.--
            ``(1)(A) <<NOTE: Time period.>>  During the period that 
        begins on January 1, 2014, and ends on September 30, 2019, 
        notwithstanding subsection (b), the Federal medical assistance 
        percentage otherwise determined under subsection (b) with 
        respect to a fiscal year occurring during that period shall be 
        increased by 2.2 percentage points for any State described in 
        subparagraph (B) for amounts expended for medical assistance for 
        individuals who are not newly eligible (as defined in subsection 
        (y)(2)) individuals described in subclause (VIII) of section 
        1902(a)(10)(A)(i).
            ``(B) For purposes of subparagraph (A), a State described in 
        this subparagraph is a State that--
                    ``(i) is an expansion State described in subsection 
                (y)(1)(B)(ii)(II);
                    ``(ii) the Secretary determines will not receive any 
                payments under this title on the basis of an increased 
                Federal medical assistance percentage under subsection 
                (y) for expenditures for medical assistance for newly 
                eligible individuals (as so defined); and
                    ``(iii) has not been approved by the Secretary to 
                divert a portion of the DSH allotment for a State to the 
                costs of providing medical assistance or other health 
                benefits coverage under a waiver that is in effect on 
                July 2009.

    ``(2)(A) <<NOTE: Time period.>>  During the period that begins on 
January 1, 2014, and ends on December 31, 2016, notwithstanding 
subsection (b), the Federal medical assistance percentage otherwise 
determined under subsection (b) with respect to all or any portion of a 
fiscal year occurring during that period shall be increased by .5 
percentage point for a State described in subparagraph (B) for amounts 
expended for medical assistance under the State plan under this title or 
under a waiver of that plan during that period.

    ``(B) For purposes of subparagraph (A), a State described in this 
subparagraph is a State that--

[[Page 124 STAT. 919]]

            ``(i) is described in clauses (i) and (ii) of paragraph 
        (1)(B); and
            ``(ii) is the State with the highest percentage of its 
        population insured during 2008, based on the Current Population 
        Survey.

    ``(3) <<NOTE: Nebraska. Determination.>> Notwithstanding subsection 
(b) and paragraphs (1) and (2) of this subsection, the Federal medical 
assistance percentage otherwise determined under subsection (b) with 
respect to all or any portion of a fiscal year that begins on or after 
January 1, 2017, for the State of Nebraska, with respect to amounts 
expended for newly eligible individuals described in subclause (VIII) of 
section 1902(a)(10)(A)(i), shall be determined as provided for under 
subsection (y)(1)(A) (notwithstanding the period provided for in such 
paragraph).

    ``(4) <<NOTE: Applicability.>> The increase in the Federal medical 
assistance percentage for a State under paragraphs (1), (2), or (3) 
shall apply only for purposes of this title and shall not apply with 
respect to--
            ``(A) disproportionate share hospital payments described in 
        section 1923;
            ``(B) payments under title IV;
            ``(C) payments under title XXI; and
            ``(D) payments under this title that are based on the 
        enhanced FMAP described in section 2105(b).'';
            (5) in subsection (aa), is amended by striking ``without 
        regard to this subsection and subsection (y)'' and inserting 
        ``without regard to this subsection, subsection (y), subsection 
        (z), and section 10202 of the Patient Protection and Affordable 
        Care Act'' each place it appears;
            (6) by adding after subsection (bb), the following:

    ``(cc) Requirement for Certain States.--Notwithstanding subsections 
(y), (z), and (aa), in the case of a State that requires political 
subdivisions within the State to contribute toward the non-Federal share 
of expenditures required under the State plan under section 1902(a)(2), 
the State shall not be eligible for an increase in its Federal medical 
assistance percentage under such subsections if it requires that 
political subdivisions pay a greater percentage of the non-Federal share 
of such expenditures, or a greater percentage of the non-Federal share 
of payments under section 1923, than the respective percentages that 
would have been required by the State under the State plan under this 
title, State law, or both, as in effect on December 31, 2009, and 
without regard to any such increase. Voluntary contributions by a 
political subdivision to the non-Federal share of expenditures under the 
State plan under this title or to the non-Federal share of payments 
under section 1923, shall not be considered to be required contributions 
for purposes of this subsection. The treatment of voluntary 
contributions, and the treatment of contributions required by a State 
under the State plan under this title, or State law, as provided by this 
subsection, shall also apply to the increases in the Federal medical 
assistance percentage under section 5001 of the American Recovery and 
Reinvestment Act of 2009.''.
    (d) Section 1108(g)(4)(B) of the Social Security Act (42 U.S.C. 
1308(g)(4)(B)), as added by section 2005(b), is amended by striking 
``income eligibility level in effect for that population under title XIX 
or under a waiver'' and inserting ``the highest income eligibility level 
in effect for parents under the commonwealth's or territory's State plan 
under title XIX or under a waiver of the plan''.

[[Page 124 STAT. 920]]

    (e)(1) Section 1923(f) of the Social Security Act (42 U.S.C. 1396r-
4(f)), as amended by section 2551, is amended--
            (A) in paragraph (6)--
                    (i) by striking the paragraph heading and inserting 
                the following: ``Allotment adjustments''; and
                    (ii) in subparagraph (B), by adding at the end the 
                following:
                          ``(iii) <<NOTE: Hawaii.>> Allotment for 2d, 
                      3rd, and 4th quarter of fiscal year 2012, fiscal 
                      year 2013, and succeeding fiscal years.--
                      Notwithstanding the table set forth in paragraph 
                      (2) or paragraph (7):
                                    ``(I) 2d, 3rd, and 4th quarter of 
                                fiscal year 2012.--The DSH allotment for 
                                Hawaii for the 2d, 3rd, and 4th quarters 
                                of fiscal year 2012 shall be $7,500,000.
                                    ``(II) Treatment as a low-dsh state 
                                for fiscal year 2013 and succeeding 
                                fiscal years.--With respect to fiscal 
                                year 2013, and each fiscal year 
                                thereafter, the DSH allotment for Hawaii 
                                shall be increased in the same manner as 
                                allotments for low DSH States are 
                                increased for such fiscal year under 
                                clause (iii) of paragraph (5)(B).
                                    ``(III) Certain hospital payments.--
                                The Secretary may not impose a 
                                limitation on the total amount of 
                                payments made to hospitals under the 
                                QUEST section 1115 Demonstration Project 
                                except to the extent that such 
                                limitation is necessary to ensure that a 
                                hospital does not receive payments in 
                                excess of the amounts described in 
                                subsection (g), or as necessary to 
                                ensure that such payments under the 
                                waiver and such payments pursuant to the 
                                allotment provided in this clause do 
                                not, in the aggregate in any year, 
                                exceed the amount that the Secretary 
                                determines is equal to the Federal 
                                medical assistance percentage component 
                                attributable to disproportionate share 
                                hospital payment adjustments for such 
                                year that is reflected in the budget 
                                neutrality provision of the QUEST 
                                Demonstration Project.''; and
            (B) in paragraph (7)--
                    (i) in subparagraph (A), in the matter preceding 
                clause (i), by striking ``subparagraph (E)'' and 
                inserting ``subparagraphs (E) and (G)'';
                    (ii) in subparagraph (B)--
                          (I) in clause (i), by striking subclauses (I) 
                      and (II), and inserting the following:
                                    ``(I) if the State is a low DSH 
                                State described in paragraph (5)(B) and 
                                has spent not more than 99.90 percent of 
                                the DSH allotments for the State on 
                                average for the period of fiscal years 
                                2004 through 2008, as of September 30, 
                                2009, the applicable percentage is equal 
                                to 25 percent;
                                    ``(II) if the State is a low DSH 
                                State described in paragraph (5)(B) and 
                                has spent more than 99.90 percent of the 
                                DSH allotments for the State on average 
                                for the period of fiscal years 2004 
                                through

[[Page 124 STAT. 921]]

                                2008, as of September 30, 2009, the 
                                applicable percentage is equal to 17.5 
                                percent;
                                    ``(III) if the State is not a low 
                                DSH State described in paragraph (5)(B) 
                                and has spent not more than 99.90 
                                percent of the DSH allotments for the 
                                State on average for the period of 
                                fiscal years 2004 through 2008, as of 
                                September 30, 2009, the applicable 
                                percentage is equal to 50 percent; and
                                    ``(IV) if the State is not a low DSH 
                                State described in paragraph (5)(B) and 
                                has spent more than 99.90 percent of the 
                                DSH allotments for the State on average 
                                for the period of fiscal years 2004 
                                through 2008, as of September 30, 2009, 
                                the applicable percentage is equal to 35 
                                percent.'';
                          (II) in clause (ii), by striking subclauses 
                      (I) and (II), and inserting the following:
                                    ``(I) if the State is a low DSH 
                                State described in paragraph (5)(B) and 
                                has spent not more than 99.90 percent of 
                                the DSH allotments for the State on 
                                average for the period of fiscal years 
                                2004 through 2008, as of September 30, 
                                2009, the applicable percentage is equal 
                                to the product of the percentage 
                                reduction in uncovered individuals for 
                                the fiscal year from the preceding 
                                fiscal year and 27.5 percent;
                                    ``(II) if the State is a low DSH 
                                State described in paragraph (5)(B) and 
                                has spent more than 99.90 percent of the 
                                DSH allotments for the State on average 
                                for the period of fiscal years 2004 
                                through 2008, as of September 30, 2009, 
                                the applicable percentage is equal to 
                                the product of the percentage reduction 
                                in uncovered individuals for the fiscal 
                                year from the preceding fiscal year and 
                                20 percent;
                                    ``(III) if the State is not a low 
                                DSH State described in paragraph (5)(B) 
                                and has spent not more than 99.90 
                                percent of the DSH allotments for the 
                                State on average for the period of 
                                fiscal years 2004 through 2008, as of 
                                September 30, 2009, the applicable 
                                percentage is equal to the product of 
                                the percentage reduction in uncovered 
                                individuals for the fiscal year from the 
                                preceding fiscal year and 55 percent; 
                                and
                                    ``(IV) if the State is not a low DSH 
                                State described in paragraph (5)(B) and 
                                has spent more than 99.90 percent of the 
                                DSH allotments for the State on average 
                                for the period of fiscal years 2004 
                                through 2008, as of September 30, 2009, 
                                the applicable percentage is equal to 
                                the product of the percentage reduction 
                                in uncovered individuals for the fiscal 
                                year from the preceding fiscal year and 
                                40 percent.'';
                          (III) in subparagraph (E), by striking ``35 
                      percent'' and inserting ``50 percent''; and
                          (IV) by adding at the end the following:

[[Page 124 STAT. 922]]

                    ``(G) Nonapplication.--The preceding provisions of 
                this paragraph shall not apply to the DSH allotment 
                determined for the State of Hawaii for a fiscal year 
                under paragraph (6).''.

    (f) Section 2551 of this Act <<NOTE: 42 USC 1396r-4 note.>> is 
amended by striking subsection (b).

    (g) Section 2105(d)(3)(B) of the Social Security Act (42 U.S.C. 
1397ee(d)(3)(B)), as added by section 2101(b)(1), is amended by adding 
at the end the following: ``For purposes of eligibility for premium 
assistance for the purchase of a qualified health plan under section 36B 
of the Internal Revenue Code of 1986 and reduced cost-sharing under 
section 1402 of the Patient Protection and Affordable Care Act, children 
described in the preceding sentence shall be deemed to be ineligible for 
coverage under the State child health plan.''.
    (h) Clause (i) of subparagraph (C) of section 513(b)(2) of the 
Social Security Act, <<NOTE: 42 USC 713.>> as added by section 2953 of 
this Act, is amended to read as follows:
                          ``(i) Healthy relationships, including 
                      marriage and family interactions.''.

    (i) Section 1115 of the Social Security Act (42 U.S.C. 1315) is 
amended by inserting after subsection (c) the following:
    ``(d)(1) An application or renewal of any experimental, pilot, or 
demonstration project undertaken under subsection (a) to promote the 
objectives of title XIX or XXI in a State that would result in an impact 
on eligibility, enrollment, benefits, cost-sharing, or financing with 
respect to a State program under title XIX or XXI (in this subsection 
referred to as a `demonstration project') shall be considered by the 
Secretary in accordance with the regulations required to be promulgated 
under paragraph (2).
    ``(2) <<NOTE: Deadline. Regulations.>> Not later than 180 days after 
the date of enactment of this subsection, the Secretary shall promulgate 
regulations relating to applications for, and renewals of, a 
demonstration project that provide for--
            ``(A) a process for public notice and comment at the State 
        level, including public hearings, sufficient to ensure a 
        meaningful level of public input;
            ``(B) requirements relating to--
                    ``(i) the goals of the program to be implemented or 
                renewed under the demonstration project;
                    ``(ii) the expected State and Federal costs and 
                coverage projections of the demonstration project; and
                    ``(iii) the specific plans of the State to ensure 
                that the demonstration project will be in compliance 
                with title XIX or XXI;
            ``(C) a process for providing public notice and comment 
        after the application is received by the Secretary, that is 
        sufficient to ensure a meaningful level of public input;
            ``(D) a process for the submission to the Secretary of 
        periodic reports by the State concerning the implementation of 
        the demonstration project; and
            ``(E) a process for the periodic evaluation by the Secretary 
        of the demonstration project.

    ``(3) <<NOTE: Deadline. Reports.>> The Secretary shall annually 
report to Congress concerning actions taken by the Secretary with 
respect to applications for demonstration projects under this 
section.''.

[[Page 124 STAT. 923]]

    (j) Subtitle F of title III of this Act is amended by adding at the 
end the following:

``SEC. 3512. GAO STUDY AND REPORT ON CAUSES OF ACTION.

    ``(a) Study.--
            ``(1) In general.--The Comptroller General of the United 
        States shall conduct a study of whether the development, 
        recognition, or implementation of any guideline or other 
        standards under a provision described in paragraph (2) would 
        result in the establishment of a new cause of action or claim.
            ``(2) Provisions described.--The provisions described in 
        this paragraph include the following:
                    ``(A) Section 2701 (adult health quality measures).
                    ``(B) Section 2702 (payment adjustments for health 
                care acquired conditions).
                    ``(C) Section 3001 (Hospital Value-Based Purchase 
                Program).
                    ``(D) Section 3002 (improvements to the Physician 
                Quality Reporting Initiative).
                    ``(E) Section 3003 (improvements to the Physician 
                Feedback Program).
                    ``(F) Section 3007 (value based payment modifier 
                under physician fee schedule).
                    ``(G) Section 3008 (payment adjustment for 
                conditions acquired in hospitals).
                    ``(H) Section 3013 (quality measure development).
                    ``(I) Section 3014 (quality measurement).
                    ``(J) Section 3021 (Establishment of Center for 
                Medicare and Medicaid Innovation).
                    ``(K) Section 3025 (hospital readmission reduction 
                program).
                    ``(L) Section 3501 (health care delivery system 
                research, quality improvement).
                    ``(M) Section 4003 (Task Force on Clinical and 
                Preventive Services).
                    ``(N) Section 4301 (research to optimize deliver of 
                public health services).

    ``(b) Report.--Not later than 2 years after the date of enactment of 
this Act, the Comptroller General of the United States shall submit to 
the appropriate committees of Congress, a report containing the findings 
made by the Comptroller General under the study under subsection (a).''.

SEC. 10202. <<NOTE: 42 USC 1396d note.>> INCENTIVES FOR STATES TO OFFER 
            HOME AND COMMUNITY-BASED SERVICES AS A LONG-TERM CARE 
            ALTERNATIVE TO NURSING HOMES.

    (a) State Balancing Incentive Payments Program.--Notwithstanding 
section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)), in the 
case of a balancing incentive payment State, as defined in subsection 
(b), that meets the conditions described in subsection (c), during the 
balancing incentive period, the Federal medical assistance percentage 
determined for the State under section 1905(b) of such Act and, if 
applicable, increased under subsection (z) or (aa) shall be increased by 
the applicable percentage points determined under subsection (d) with 
respect to eligible medical assistance expenditures described in 
subsection (e).
    (b) Balancing Incentive Payment State.--A balancing incentive 
payment State is a State--

[[Page 124 STAT. 924]]

            (1) in which less than 50 percent of the total expenditures 
        for medical assistance under the State Medicaid program for a 
        fiscal year for long-term services and supports (as defined by 
        the Secretary under subsection (f))(1)) are for non-
        institutionally-based long-term services and supports described 
        in subsection (f)(1)(B);
            (2) that submits an application and meets the conditions 
        described in subsection (c); and
            (3) that is selected by the Secretary to participate in the 
        State balancing incentive payment program established under this 
        section.

    (c) Conditions.--The conditions described in this subsection are the 
following:
            (1) Application.--The State submits an application to the 
        Secretary that includes, in addition to such other information 
        as the Secretary shall require--
                    (A) a proposed budget that details the State's plan 
                to expand and diversify medical assistance for non-
                institutionally-based long-term services and supports 
                described in subsection (f)(1)(B) under the State 
                Medicaid program during the balancing incentive period 
                and achieve the target spending percentage applicable to 
                the State under paragraph (2), including through 
                structural changes to how the State furnishes such 
                assistance, such as through the establishment of a ``no 
                wrong door--single entry point system'', optional 
                presumptive eligibility, case management services, and 
                the use of core standardized assessment instruments, and 
                that includes a description of the new or expanded 
                offerings of such services that the State will provide 
                and the projected costs of such services; and
                    (B) in the case of a State that proposes to expand 
                the provision of home and community-based services under 
                its State Medicaid program through a State plan 
                amendment under section 1915(i) of the Social Security 
                Act, at the option of the State, an election to increase 
                the income eligibility for such services from 150 
                percent of the poverty line to such higher percentage as 
                the State may establish for such purpose, not to exceed 
                300 percent of the supplemental security income benefit 
                rate established by section 1611(b)(1) of the Social 
                Security Act (42 U.S.C. 1382(b)(1)).
            (2) <<NOTE: Deadlines.>> Target spending percentages.--
                    (A) In the case of a balancing incentive payment 
                State in which less than 25 percent of the total 
                expenditures for long-term services and supports under 
                the State Medicaid program for fiscal year 2009 are for 
                home and community-based services, the target spending 
                percentage for the State to achieve by not later than 
                October 1, 2015, is that 25 percent of the total 
                expenditures for long-term services and supports under 
                the State Medicaid program are for home and community-
                based services.
                    (B) In the case of any other balancing incentive 
                payment State, the target spending percentage for the 
                State to achieve by not later than October 1, 2015, is 
                that 50 percent of the total expenditures for long-term 
                services and supports under the State Medicaid program 
                are for home and community-based services.

[[Page 124 STAT. 925]]

            (3) Maintenance of eligibility requirements.--The State does 
        not apply eligibility standards, methodologies, or procedures 
        for determining eligibility for medical assistance for non-
        institutionally-based long-term services and supports described 
        in subsection (f)(1)(B) under the State Medicaid program that 
        are more restrictive than the eligibility standards, 
        methodologies, or procedures in effect for such purposes on 
        December 31, 2010.
            (4) Use of additional funds.--The State agrees to use the 
        additional Federal funds paid to the State as a result of this 
        section only for purposes of providing new or expanded offerings 
        of non-institutionally-based long-term services and supports 
        described in subsection (f)(1)(B) under the State Medicaid 
        program.
            (5) Structural changes. <<NOTE: Deadline.>> --The State 
        agrees to make, not later than the end of the 6-month period 
        that begins on the date the State submits an application under 
        this section, the following changes:
                    (A) <<NOTE: Standards.>> ``No wrong door--single 
                entry point system''.--Development of a statewide system 
                to enable consumers to access all long-term services and 
                supports through an agency, organization, coordinated 
                network, or portal, in accordance with such standards as 
                the State shall establish and that shall provide 
                information regarding the availability of such services, 
                how to apply for such services, referral services for 
                services and supports otherwise available in the 
                community, and determinations of financial and 
                functional eligibility for such services and supports, 
                or assistance with assessment processes for financial 
                and functional eligibility.
                    (B) Conflict-free case management services.--
                Conflict-free case management services to develop a 
                service plan, arrange for services and supports, support 
                the beneficiary (and, if appropriate, the beneficiary's 
                caregivers) in directing the provision of services and 
                supports for the beneficiary, and conduct ongoing 
                monitoring to assure that services and supports are 
                delivered to meet the beneficiary's needs and achieve 
                intended outcomes.
                    (C) Core standardized assessment instruments.--
                Development of core standardized assessment instruments 
                for determining eligibility for non-institutionally-
                based long-term services and supports described in 
                subsection (f)(1)(B), which shall be used in a uniform 
                manner throughout the State, to determine a 
                beneficiary's needs for training, support services, 
                medical care, transportation, and other services, and 
                develop an individual service plan to address such 
                needs.
            (6) Data collection.--The State agrees to collect from 
        providers of services and through such other means as the State 
        determines appropriate the following data:
                    (A) <<NOTE: Procedures.>> Services data.--Services 
                data from providers of non-institutionally-based long-
                term services and supports described in subsection 
                (f)(1)(B) on a per-beneficiary basis and in accordance 
                with such standardized coding procedures as the State 
                shall establish in consultation with the Secretary.

[[Page 124 STAT. 926]]

                    (B) Quality data.--Quality data on a selected set of 
                core quality measures agreed upon by the Secretary and 
                the State that are linked to population-specific 
                outcomes measures and accessible to providers.
                    (C) Outcomes measures.--Outcomes measures data on a 
                selected set of core population-specific outcomes 
                measures agreed upon by the Secretary and the State that 
                are accessible to providers and include--
                          (i) measures of beneficiary and family 
                      caregiver experience with providers;
                          (ii) measures of beneficiary and family 
                      caregiver satisfaction with services; and
                          (iii) measures for achieving desired outcomes 
                      appropriate to a specific beneficiary, including 
                      employment, participation in community life, 
                      health stability, and prevention of loss in 
                      function.

    (d) Applicable Percentage Points Increase in FMAP.--The applicable 
percentage points increase is--
            (1) in the case of a balancing incentive payment State 
        subject to the target spending percentage described in 
        subsection (c)(2)(A), 5 percentage points; and
            (2) in the case of any other balancing incentive payment 
        State, 2 percentage points.

    (e) Eligible Medical Assistance Expenditures.--
            (1) In general.--Subject to paragraph (2), medical 
        assistance described in this subsection is medical assistance 
        for non-institutionally-based long-term services and supports 
        described in subsection (f)(1)(B) that is provided by a 
        balancing incentive payment State under its State Medicaid 
        program during the balancing incentive payment period.
            (2) Limitation on payments.--In no case may the aggregate 
        amount of payments made by the Secretary to balancing incentive 
        payment States under this section during the balancing incentive 
        period exceed $3,000,000,000.

    (f) Definitions.--In this section:
            (1) Long-term services and supports defined.--The term 
        ``long-term services and supports'' has the meaning given that 
        term by Secretary and may include any of the following (as 
        defined for purposes of State Medicaid programs):
                    (A) Institutionally-based long-term services and 
                supports.--Services provided in an institution, 
                including the following:
                          (i) Nursing facility services.
                          (ii) Services in an intermediate care facility 
                      for the mentally retarded described in subsection 
                      (a)(15) of section 1905 of such Act.
                    (B) Non-institutionally-based long-term services and 
                supports.--Services not provided in an institution, 
                including the following:
                          (i) Home and community-based services provided 
                      under subsection (c), (d), or (i) of section 1915 
                      of such Act or under a waiver under section 1115 
                      of such Act.
                          (ii) Home health care services.
                          (iii) Personal care services.

[[Page 124 STAT. 927]]

                          (iv) Services described in subsection (a)(26) 
                      of section 1905 of such Act (relating to PACE 
                      program services).
                          (v) Self-directed personal assistance services 
                      described in section 1915(j) of such Act.
            (2) Balancing incentive period.--The term ``balancing 
        incentive period'' means the period that begins on October 1, 
        2011, and ends on September 30, 2015.
            (3) Poverty line.--The term ``poverty line'' has the meaning 
        given that term in section 2110(c)(5) of the Social Security Act 
        (42 U.S.C. 1397jj(c)(5)).
            (4) State medicaid program.--The term ``State Medicaid 
        program'' means the State program for medical assistance 
        provided under a State plan under title XIX of the Social 
        Security Act and under any waiver approved with respect to such 
        State plan.

SEC. 10203. EXTENSION OF FUNDING FOR CHIP THROUGH FISCAL YEAR 2015 AND 
            OTHER CHIP-RELATED PROVISIONS.

    (a) Section 1311(c)(1) of this Act <<NOTE: 42 USC 18031.>> is 
amended by striking ``and'' at the end of subparagraph (G), by striking 
the period at the end of subparagraph (H) and inserting ``; and'', and 
by adding at the end the following:
                    ``(I) <<NOTE: Reports. Deadline.>> report to the 
                Secretary at least annually and in such manner as the 
                Secretary shall require, pediatric quality reporting 
                measures consistent with the pediatric quality reporting 
                measures established under section 1139A of the Social 
                Security Act.''.

    (b) <<NOTE: Effective date. 42 USC 1396e note.>> Effective as if 
included in the enactment of the Children's Health Insurance Program 
Reauthorization Act of 2009 (Public Law 111-3):
            (1) Section 1906(e)(2) of the Social Security Act (42 U.S.C. 
        1396e(e)(2)) is amended by striking ``means'' and all that 
        follows through the period and inserting ``has the meaning given 
        that term in section 2105(c)(3)(A).''.
            (2)(A) Section 1906A(a) of the Social Security Act (42 
        U.S.C. 1396e-1(a)), is amended by inserting before the period 
        the following: ``and the offering of such a subsidy is cost-
        effective, as defined for purposes of section 2105(c)(3)(A)''.
            (B) <<NOTE: Applicability. 42 USC 1396e-1 and note.>> This 
        Act shall be applied without regard to subparagraph (A) of 
        section 2003(a)(1) of this Act and that subparagraph and the 
        amendment made by that subparagraph are hereby deemed null, 
        void, and of no effect.
            (3) Section 2105(c)(10) of the Social Security Act (42 
        U.S.C. 1397ee(c)(10)) is amended--
                    (A) in subparagraph (A), in the first sentence, by 
                inserting before the period the following: ``if the 
                offering of such a subsidy is cost-effective, as defined 
                for purposes of paragraph (3)(A)'';
                    (B) by striking subparagraph (M); and
                    (C) by redesignating subparagraph (N) as 
                subparagraph (M).
            (4) Section 2105(c)(3)(A) of the Social Security Act (42 
        U.S.C. 1397ee(c)(3)(A)) is amended--
                    (A) in the matter preceding clause (i), by striking 
                ``to'' and inserting ``to--''; and

[[Page 124 STAT. 928]]

                    (B) in clause (ii), by striking the period and 
                inserting a semicolon.

    (c) Section 2105 of the Social Security Act (42 U.S.C. 1397ee), as 
amended by section 2101, is amended--
            (1) in subsection (b), in the second sentence, by striking 
        ``2013'' and inserting ``2015''; and
            (2) in subsection (d)(3)--
                    (A) in subparagraph (A)--
                          (i) in the first sentence, by inserting ``as a 
                      condition of receiving payments under section 
                      1903(a),'' after ``2019,'';
                          (ii) in clause (i), by striking ``or'' at the 
                      end;
                          (iii) by redesignating clause (ii) as clause 
                      (iii); and
                          (iv) by inserting after clause (i), the 
                      following:
                          ``(ii) after September 30, 2015, enrolling 
                      children eligible to be targeted low-income 
                      children under the State child health plan in a 
                      qualified health plan that has been certified by 
                      the Secretary under subparagraph (C); or'';
                    (B) <<NOTE: Procedures.>> in subparagraph (B), by 
                striking ``provided coverage'' and inserting ``screened 
                for eligibility for medical assistance under the State 
                plan under title XIX or a waiver of that plan and, if 
                found eligible, enrolled in such plan or a waiver. In 
                the case of such children who, as a result of such 
                screening, are determined to not be eligible for medical 
                assistance under the State plan or a waiver under title 
                XIX, the State shall establish procedures to ensure that 
                the children are enrolled in a qualified health plan 
                that has been certified by the Secretary under 
                subparagraph (C) and is offered''; and
                    (C) by adding at the end the following:
                    ``(C) Certification of comparability of pediatric 
                coverage offered by qualified health plans.-- 
                <<NOTE: Deadline. Review. Determination.>> With respect 
                to each State, the Secretary, not later than April 1, 
                2015, shall review the benefits offered for children and 
                the cost-sharing imposed with respect to such benefits 
                by qualified health plans offered through an Exchange 
                established by the State under section 1311 of the 
                Patient Protection and Affordable Care Act and shall 
                certify those plans that offer benefits for children and 
                impose cost-sharing with respect to such benefits that 
                the Secretary determines are at least comparable to the 
                benefits offered and cost-sharing protections provided 
                under the State child health plan.''.

    (d)(1) Section 2104(a) of such Act (42 U.S.C. 1397dd(a)) is 
amended--
            (A) in paragraph (15), by striking ``and'' at the end; and
            (B) by striking paragraph (16) and inserting the following:
            ``(16) for fiscal year 2013, $17,406,000,000;
            ``(17) for fiscal year 2014, $19,147,000,000; and
            ``(18) for fiscal year 2015, for purposes of making 2 semi-
        annual allotments--
                    ``(A) $2,850,000,000 for the period beginning on 
                October 1, 2014, and ending on March 31, 2015, and
                    ``(B) $2,850,000,000 for the period beginning on 
                April 1, 2015, and ending on September 30, 2015.''.

[[Page 124 STAT. 929]]

    (2)(A) Section 2104(m) of such Act (42 U.S.C. 1397dd(m)), as amended 
by section 2102(a)(1), is amended--
            (i) in the subsection heading, by striking ``2013'' and 
        inserting ``2015'';
            (ii) in paragraph (2)--
                    (I) in the paragraph heading, by striking ``2012'' 
                and inserting ``2014''; and
                    (II) by adding at the end the following:
                    ``(B) <<NOTE: Allotment.>> Fiscal years 2013 and 
                2014.--Subject to paragraphs (4) and (6), from the 
                amount made available under paragraphs (16) and (17) of 
                subsection (a) for fiscal years 2013 and 2014, 
                respectively, the Secretary shall compute a State 
                allotment for each State (including the District of 
                Columbia and each commonwealth and territory) for each 
                such fiscal year as follows:
                          ``(i) Rebasing in fiscal year 2013.--For 
                      fiscal year 2013, the allotment of the State is 
                      equal to the Federal payments to the State that 
                      are attributable to (and countable towards) the 
                      total amount of allotments available under this 
                      section to the State in fiscal year 2012 
                      (including payments made to the State under 
                      subsection (n) for fiscal year 2012 as well as 
                      amounts redistributed to the State in fiscal year 
                      2012), multiplied by the allotment increase factor 
                      under paragraph (5) for fiscal year 2013.
                          ``(ii) Growth factor update for fiscal year 
                      2014.--For fiscal year 2014, the allotment of the 
                      State is equal to the sum of--
                                    ``(I) the amount of the State 
                                allotment under clause (i) for fiscal 
                                year 2013; and
                                    ``(II) the amount of any payments 
                                made to the State under subsection (n) 
                                for fiscal year 2013,
                      multiplied by the allotment increase factor under 
                      paragraph (5) for fiscal year 2014.'';
                    (iii) in paragraph (3)--
                          (I) in the paragraph heading, by striking 
                      ``2013'' and inserting ``2015'';
                          (II) in subparagraphs (A) and (B), by striking 
                      ``paragraph (16)'' each place it appears and 
                      inserting ``paragraph (18)'';
                          (III) in subparagraph (C)--
                                    (aa) by striking ``2012'' each place 
                                it appears and inserting ``2014''; and
                                    (bb) by striking ``2013'' and 
                                inserting ``2015''; and
                          (IV) in subparagraph (D)--
                                    (aa) in clause (i)(I), by striking 
                                ``subsection (a)(16)(A)'' and inserting 
                                ``subsection (a)(18)(A)''; and
                                    (bb) in clause (ii)(II), by striking 
                                ``subsection (a)(16)(B)'' and inserting 
                                ``subsection (a)(18)(B)'';
                    (iv) in paragraph (4), by striking ``2013'' and 
                inserting ``2015'';
                    (v) in paragraph (6)--
                          (I) in subparagraph (A), by striking ``2013'' 
                      and inserting ``2015''; and

[[Page 124 STAT. 930]]

                          (II) in the flush language after and below 
                      subparagraph (B)(ii), by striking ``or fiscal year 
                      2012'' and inserting ``, fiscal year 2012, or 
                      fiscal year 2014''; and
                    (vi) in paragraph (8)--
                          (I) in the paragraph heading, by striking 
                      ``2013'' and inserting ``2015''; and
                          (II) by striking ``2013'' and inserting 
                      ``2015''.

    (B) Section 2104(n) of such Act (42 U.S.C. 1397dd(n)) is amended--
            (i) in paragraph (2)--
                    (I) in subparagraph (A)(ii)--
                          (aa) by striking ``2012'' and inserting 
                      ``2014''; and
                          (bb) by striking ``2013'' and inserting 
                      ``2015'';
                    (II) in subparagraph (B)--
                          (aa) by striking ``2012'' and inserting 
                      ``2014''; and
                          (bb) by striking ``2013'' and inserting 
                      ``2015''; and
            (ii) in paragraph (3)(A), by striking ``or a semi-annual 
        allotment period for fiscal year 2013'' and inserting ``fiscal 
        year 2013, fiscal year 2014, or a semi-annual allotment period 
        for fiscal year 2015''.

    (C) Section 2105(g)(4) of such Act (42 U.S.C. 1397ee(g)(4)) is 
amended--
            (i) in the paragraph heading, by striking ``2013'' and 
        inserting ``2015''; and
            (ii) in subparagraph (A), by striking ``2013'' and inserting 
        ``2015''.

    (D) Section 2110(b) of such Act (42 U.S.C. 1397jj(b)) is amended--
            (i) in paragraph (2)(B), by inserting ``except as provided 
        in paragraph (6),'' before ``a child''; and
            (ii) by adding at the end the following new paragraph:
            ``(6) Exceptions to exclusion of children of employees of a 
        public agency in the state.--
                    ``(A) In general.--A child shall not be considered 
                to be described in paragraph (2)(B) if--
                          ``(i) the public agency that employs a member 
                      of the child's family to which such paragraph 
                      applies satisfies subparagraph (B); or
                          ``(ii) <<NOTE: Applicability.>> subparagraph 
                      (C) applies to such child.
                    ``(B) Maintenance of effort with respect to per 
                person agency contribution for family coverage.--For 
                purposes of subparagraph (A)(i), a public agency 
                satisfies this subparagraph if the amount of annual 
                agency expenditures made on behalf of each employee 
                enrolled in health coverage paid for by the agency that 
                includes dependent coverage for the most recent State 
                fiscal year is not less than the amount of such 
                expenditures made by the agency for the 1997 State 
                fiscal year, increased by the percentage increase in the 
                medical care expenditure category of the Consumer Price 
                Index for All-Urban Consumers (all items: U.S. City 
                Average) for such preceding fiscal year.
                    ``(C) <<NOTE: Applicability.>> Hardship exception.--
                For purposes of subparagraph (A)(ii), this subparagraph 
                applies to a child if the State determines, on a case-
                by-case basis, that the annual aggregate amount of 
                premiums and cost-sharing imposed

[[Page 124 STAT. 931]]

                for coverage of the family of the child would exceed 5 
                percent of such family's income for the year 
                involved.''.

    (E) Section 2113 of such Act (42 U.S.C. 1397mm) is amended--
            (i) in subsection (a)(1), by striking ``2013'' and inserting 
        ``2015''; and
            (ii) in subsection (g), by striking ``$100,000,000 for the 
        period of fiscal years 2009 through 2013'' and inserting 
        ``$140,000,000 for the period of fiscal years 2009 through 
        2015''.

    (F) Section 108 of Public Law 111-3 <<NOTE: Time period. 123 Stat. 
25.>> is amended by striking ``$11,706,000,000'' and all that follows 
through the second sentence and inserting ``$15,361,000,000 to accompany 
the allotment made for the period beginning on October 1, 2014, and 
ending on March 31, 2015, under section 2104(a)(18)(A) of the Social 
Security Act (42 U.S.C. 1397dd(a)(18)(A)), to remain available until 
expended. Such <<NOTE: Applicability.>> amount shall be used to provide 
allotments to States under paragraph (3) of section 2104(m) of the 
Social Security Act (42 U.S.C. 1397dd(m)) for the first 6 months of 
fiscal year 2015 in the same manner as allotments are provided under 
subsection (a)(18)(A) of such section 2104 and subject to the same terms 
and conditions as apply to the allotments provided from such subsection 
(a)(18)(A).''.

       PART II--SUPPORT FOR PREGNANT AND PARENTING TEENS AND WOMEN

SEC. <<NOTE: 42 USC 18201.>> 10211. DEFINITIONS.

    In this part:
            (1) Accompaniment.--The term ``accompaniment'' means 
        assisting, representing, and accompanying a woman in seeking 
        judicial relief for child support, child custody, restraining 
        orders, and restitution for harm to persons and property, and in 
        filing criminal charges, and may include the payment of court 
        costs and reasonable attorney and witness fees associated 
        therewith.
            (2) Eligible institution of higher education.--The term 
        ``eligible institution of higher education'' means an 
        institution of higher education (as such term is defined in 
        section 101 of the Higher Education Act of 1965 (20 U.S.C. 
        1001)) that has established and operates, or agrees to establish 
        and operate upon the receipt of a grant under this part, a 
        pregnant and parenting student services office.
            (3) Community service center.--The term ``community service 
        center'' means a non-profit organization that provides social 
        services to residents of a specific geographical area via direct 
        service or by contract with a local governmental agency.
            (4) High school.--The term ``high school'' means any public 
        or private school that operates grades 10 through 12, inclusive, 
        grades 9 through 12, inclusive or grades 7 through 12, 
        inclusive.
            (5) Intervention services.--The term ``intervention 
        services'' means, with respect to domestic violence, sexual 
        violence, sexual assault, or stalking, 24-hour telephone hotline 
        services for police protection and referral to shelters.
            (6) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.

[[Page 124 STAT. 932]]

            (7) State.--The term ``State'' includes the District of 
        Columbia, any commonwealth, possession, or other territory of 
        the United States, and any Indian tribe or reservation.
            (8) Supportive social services.--The term ``supportive 
        social services'' means transitional and permanent housing, 
        vocational counseling, and individual and group counseling aimed 
        at preventing domestic violence, sexual violence, sexual 
        assault, or stalking.
            (9) Violence.--The term ``violence'' means actual violence 
        and the risk or threat of violence.

SEC. 10212. <<NOTE: Grants. 42 USC 18202.>> ESTABLISHMENT OF PREGNANCY 
            ASSISTANCE FUND.

    (a) In General.--The Secretary, in collaboration and coordination 
with the Secretary of Education (as appropriate), shall establish a 
Pregnancy Assistance Fund to be administered by the Secretary, for the 
purpose of awarding competitive grants to States to assist pregnant and 
parenting teens and women.
    (b) Use of Fund.--A State may apply for a grant under subsection (a) 
to carry out any activities provided for in section 10213.
    (c) Applications.--To be eligible to receive a grant under 
subsection (a), a State shall submit to the Secretary an application at 
such time, in such manner, and containing such information as the 
Secretary may require, including a description of the purposes for which 
the grant is being requested and the designation of a State agency for 
receipt and administration of funding received under this part.

SEC. 10213. <<NOTE: Grants. 42 USC 18203.>> PERMISSIBLE USES OF FUND.

    (a) In General.--A State shall use amounts received under a grant 
under section 10212 for the purposes described in this section to assist 
pregnant and parenting teens and women.
    (b) Institutions of Higher Education.--
            (1) In general.--A State may use amounts received under a 
        grant under section 10212 to make funding available to eligible 
        institutions of higher education to enable the eligible 
        institutions to establish, maintain, or operate pregnant and 
        parenting student services. Such funding shall be used to 
        supplement, not supplant, existing funding for such services.
            (2) Application.--An eligible institution of higher 
        education that desires to receive funding under this subsection 
        shall submit an application to the designated State agency at 
        such time, in such manner, and containing such information as 
        the State agency may require.
            (3) Matching requirement.--An eligible institution of higher 
        education that receives funding under this subsection shall 
        contribute to the conduct of the pregnant and parenting student 
        services office supported by the funding an amount from non-
        Federal funds equal to 25 percent of the amount of the funding 
        provided. The non-Federal share may be in cash or in-kind, 
        fairly evaluated, including services, facilities, supplies, or 
        equipment.
            (4) Use of funds for assisting pregnant and parenting 
        college students.--An eligible institution of higher education 
        that receives funding under this subsection shall use such funds 
        to establish, maintain or operate pregnant and parenting student 
        services and may use such funding for the following programs and 
        activities:

[[Page 124 STAT. 933]]

                    (A) Conduct a needs assessment on campus and within 
                the local community--
                          (i) to assess pregnancy and parenting 
                      resources, located on the campus or within the 
                      local community, that are available to meet the 
                      needs described in subparagraph (B); and
                          (ii) to set goals for--
                                    (I) improving such resources for 
                                pregnant, parenting, and prospective 
                                parenting students; and
                                    (II) improving access to such 
                                resources.
                    (B) Annually assess the performance of the eligible 
                institution in meeting the following needs of students 
                enrolled in the eligible institution who are pregnant or 
                are parents:
                          (i) The inclusion of maternity coverage and 
                      the availability of riders for additional family 
                      members in student health care.
                          (ii) Family housing.
                          (iii) Child care.
                          (iv) Flexible or alternative academic 
                      scheduling, such as telecommuting programs, to 
                      enable pregnant or parenting students to continue 
                      their education or stay in school.
                          (v) Education to improve parenting skills for 
                      mothers and fathers and to strengthen marriages.
                          (vi) Maternity and baby clothing, baby food 
                      (including formula), baby furniture, and similar 
                      items to assist parents and prospective parents in 
                      meeting the material needs of their children.
                          (vii) Post-partum counseling.
                    (C) Identify public and private service providers, 
                located on the campus of the eligible institution or 
                within the local community, that are qualified to meet 
                the needs described in subparagraph (B), and establishes 
                programs with qualified providers to meet such needs.
                    (D) Assist pregnant and parenting students, fathers 
                or spouses in locating and obtaining services that meet 
                the needs described in subparagraph (B).
                    (E) If appropriate, provide referrals for prenatal 
                care and delivery, infant or foster care, or adoption, 
                to a student who requests such information. An office 
                shall make such referrals only to service providers that 
                serve the following types of individuals:
                          (i) Parents.
                          (ii) Prospective parents awaiting adoption.
                          (iii) Women who are pregnant and plan on 
                      parenting or placing the child for adoption.
                          (iv) Parenting or prospective parenting 
                      couples.
            (5) Reporting.--
                    (A) Annual report by institutions.--
                          (i) In general.--For each fiscal year that an 
                      eligible institution of higher education receives 
                      funds under this subsection, the eligible 
                      institution shall prepare and submit to the State, 
                      by the date determined by the State, a report 
                      that--

[[Page 124 STAT. 934]]

                                    (I) itemizes the pregnant and 
                                parenting student services office's 
                                expenditures for the fiscal year;
                                    (II) contains a review and 
                                evaluation of the performance of the 
                                office in fulfilling the requirements of 
                                this section, using the specific 
                                performance criteria or standards 
                                established under subparagraph (B)(i); 
                                and
                                    (III) describes the achievement of 
                                the office in meeting the needs listed 
                                in paragraph (4)(B) of the students 
                                served by the eligible institution, and 
                                the frequency of use of the office by 
                                such students.
                          (ii) Performance criteria.-- 
                      <<NOTE: Deadline.>> Not later than 180 days before 
                      the date the annual report described in clause (i) 
                      is submitted, the State--
                                    (I) shall identify the specific 
                                performance criteria or standards that 
                                shall be used to prepare the report; and
                                    (II) may establish the form or 
                                format of the report.
                    (B) Report by state.--The State shall annually 
                prepare and submit a report on the findings under this 
                subsection, including the number of eligible 
                institutions of higher education that were awarded funds 
                and the number of students served by each pregnant and 
                parenting student services office receiving funds under 
                this section, to the Secretary.

    (c) Support for Pregnant and Parenting Teens.--A State may use 
amounts received under a grant under section 10212 to make funding 
available to eligible high schools and community service centers to 
establish, maintain or operate pregnant and parenting services in the 
same general manner and in accordance with all conditions and 
requirements described in subsection (b), except that paragraph (3) of 
such subsection shall not apply for purposes of this subsection.
    (d) Improving Services for Pregnant Women Who Are Victims of 
Domestic Violence, Sexual Violence, Sexual Assault, and Stalking.--
            (1) In general.--A State may use amounts received under a 
        grant under section 10212 to make funding available tp its State 
        Attorney General to assist Statewide offices in providing--
                    (A) intervention services, accompaniment, and 
                supportive social services for eligible pregnant women 
                who are victims of domestic violence, sexual violence, 
                sexual assault, or stalking.
                    (B) technical assistance and training (as described 
                in subsection (c)) relating to violence against eligible 
                pregnant women to be made available to the following:
                          (i) Federal, State, tribal, territorial, and 
                      local governments, law enforcement agencies, and 
                      courts.
                          (ii) Professionals working in legal, social 
                      service, and health care settings.
                          (iii) Nonprofit organizations.
                          (iv) Faith-based organizations.

[[Page 124 STAT. 935]]

            (2) Eligibility.--To be eligible for a grant under paragraph 
        (1), a State Attorney General shall submit an application to the 
        designated State agency at such time, in such manner, and 
        containing such information, as specified by the State.
            (3) Technical assistance and training described.--For 
        purposes of paragraph (1)(B), technical assistance and training 
        is--
                    (A) the identification of eligible pregnant women 
                experiencing domestic violence, sexual violence, sexual 
                assault, or stalking;
                    (B) the assessment of the immediate and short-term 
                safety of such a pregnant woman, the evaluation of the 
                impact of the violence or stalking on the pregnant 
                woman's health, and the assistance of the pregnant woman 
                in developing a plan aimed at preventing further 
                domestic violence, sexual violence, sexual assault, or 
                stalking, as appropriate;
                    (C) the maintenance of complete medical or forensic 
                records that include the documentation of any 
                examination, treatment given, and referrals made, 
                recording the location and nature of the pregnant 
                woman's injuries, and the establishment of mechanisms to 
                ensure the privacy and confidentiality of those medical 
                records; and
                    (D) the identification and referral of the pregnant 
                woman to appropriate public and private nonprofit 
                entities that provide intervention services, 
                accompaniment, and supportive social services.
            (4) <<NOTE: Definition.>> Eligible pregnant woman.--In this 
        subsection, the term ``eligible pregnant woman'' means any woman 
        who is pregnant on the date on which such woman becomes a victim 
        of domestic violence, sexual violence, sexual assault, or 
        stalking or who was pregnant during the one-year period before 
        such date.

    (e) Public Awareness and Education.--A State may use amounts 
received under a grant under section 10212 to make funding available to 
increase public awareness and education concerning any services 
available to pregnant and parenting teens and women under this part, or 
any other resources available to pregnant and parenting women in keeping 
with the intent and purposes of this part. <<NOTE: Guidelines.>> The 
State shall be responsible for setting guidelines or limits as to how 
much of funding may be utilized for public awareness and education in 
any funding award.

SEC. 10214. <<NOTE: 42 USC 18204.>> APPROPRIATIONS.

    There is authorized to be appropriated, and there are appropriated, 
$25,000,000 for each of fiscal years 2010 through 2019, to carry out 
this part.

                PART III--INDIAN HEALTH CARE IMPROVEMENT

SEC. 10221. INDIAN HEALTH CARE IMPROVEMENT.

    (a) In General. <<NOTE: Incorporation by reference. 25 USC 16013et 
seq.>> --Except as provided in subsection (b), S. 1790 entitled ``A bill 
to amend the Indian Health Care Improvement Act to revise and extend 
that Act, and for other purposes.'', as reported by the Committee on 
Indian Affairs of the Senate in December 2009, is enacted into law.

    (b) Amendments.--

[[Page 124 STAT. 936]]

            (1) Section 119 of the Indian Health Care Improvement Act 
        (as amended by section 111 of the bill referred to in subsection 
        (a)) <<NOTE: 25 USC 1616l.>>  is amended--
                    (A) in subsection (d)--
                          (i) in paragraph (2), by striking ``In 
                      establishing'' and inserting ``Subject to 
                      paragraphs (3) and (4), in establishing''; and
                          (ii) by adding at the end the following:
            ``(3) Election of indian tribe or tribal organization.--
                    ``(A) In general.--Subparagraph (B) of paragraph (2) 
                shall not apply in the case of an election made by an 
                Indian tribe or tribal organization located in a State 
                (other than Alaska) in which the use of dental health 
                aide therapist services or midlevel dental health 
                provider services is authorized under State law to 
                supply such services in accordance with State law.
                    ``(B) Action by secretary.--On an election by an 
                Indian tribe or tribal organization under subparagraph 
                (A), the Secretary, acting through the Service, shall 
                facilitate implementation of the services elected.
            ``(4) Vacancies.--The Secretary shall not fill any vacancy 
        for a certified dentist in a program operated by the Service 
        with a dental health aide therapist.''; and
                    (B) by adding at the end the following:

    ``(e) Effect of Section.--Nothing in this section shall restrict the 
ability of the Service, an Indian tribe, or a tribal organization to 
participate in any program or to provide any service authorized by any 
other Federal law.''.
            (2) The Indian Health Care Improvement Act (as amended by 
        section 134(b) of the bill referred to in subsection <<NOTE: 25 
        USC 1616r.>>  (a)) is amended by striking section 125 (relating 
        to treatment of scholarships for certain purposes).
            (3) Section 806 of the Indian Health Care Improvement Act 
        (25 U.S.C. 1676) is amended--
                    (A) by striking ``Any limitation'' and inserting the 
                following:

    ``(a) HHS Appropriations.--Any limitation''; and
                    (B) by adding at the end the following:

    ``(b) Limitations Pursuant to Other Federal Law.-- 
<<NOTE: Applicability. Abortions.>> Any limitation pursuant to other 
Federal laws on the use of Federal funds appropriated to the Service 
shall apply with respect to the performance or coverage of abortions.''.
            (4) The bill referred to in subsection (a) <<NOTE: 42 USC 
        1395l, 1395qq.>> is amended by striking section 201.

              Subtitle C--Provisions Relating to Title III

SEC. 10301. PLANS FOR A VALUE-BASED PURCHASING PROGRAM FOR AMBULATORY 
            SURGICAL CENTERS.

    (a) In General.--Section 3006 is amended by adding at the end the 
following new subsection:
    ``(f) Ambulatory Surgical Centers.--
            ``(1) In general.--The Secretary shall develop a plan to 
        implement a value-based purchasing program for payments under 
        the Medicare program under title XVIII of the Social

[[Page 124 STAT. 937]]

        Security Act for ambulatory surgical centers (as described in 
        section 1833(i) of the Social Security Act (42 U.S.C. 
        1395l(i))).
            ``(2) Details.--In developing the plan under paragraph (1), 
        the Secretary shall consider the following issues:
                    ``(A) The ongoing development, selection, and 
                modification process for measures (including under 
                section 1890 of the Social Security Act (42 U.S.C. 
                1395aaa) and section 1890A of such Act, as added by 
                section 3014), to the extent feasible and practicable, 
                of all dimensions of quality and efficiency in 
                ambulatory surgical centers.
                    ``(B) The reporting, collection, and validation of 
                quality data.
                    ``(C) The structure of value-based payment 
                adjustments, including the determination of thresholds 
                or improvements in quality that would substantiate a 
                payment adjustment, the size of such payments, and the 
                sources of funding for the value-based bonus payments.
                    ``(D) Methods for the public disclosure of 
                information on the performance of ambulatory surgical 
                centers.
                    ``(E) Any other issues determined appropriate by the 
                Secretary.
            ``(3) Consultation.--In developing the plan under paragraph 
        (1), the Secretary shall--
                    ``(A) consult with relevant affected parties; and
                    ``(B) consider experience with such demonstrations 
                that the Secretary determines are relevant to the value-
                based purchasing program described in paragraph (1).
            ``(4) Report to congress.--Not later than January 1, 2011, 
        the Secretary shall submit to Congress a report containing the 
        plan developed under paragraph (1).''.

    (b) Technical.--Section 3006(a)(2)(A) is amended by striking clauses 
(i) and (ii).

SEC. 10302. REVISION TO NATIONAL STRATEGY FOR QUALITY IMPROVEMENT IN 
            HEALTH CARE.

    Section 399HH(a)(2)(B)(iii) of the Public Health Service Act, as 
added by section 3011, <<NOTE: 42 USC 280j.>>  is amended by inserting 
``(taking into consideration the limitations set forth in subsections 
(c) and (d) of section 1182 of the Social Security Act)'' after 
``information''.

SEC. 10303. DEVELOPMENT OF OUTCOME MEASURES.

    (a) Development.--Section 931 of the Public Health Service Act, as 
added by section 3013(a), <<NOTE: 42 USC 299b-31.>> is amended by adding 
at the end the following new subsection:

    ``(f) Development of Outcome Measures.--
            ``(1) In general. <<NOTE: Deadline.>> --The Secretary shall 
        develop, and periodically update (not less than every 3 years), 
        provider-level outcome measures for hospitals and physicians, as 
        well as other providers as determined appropriate by the 
        Secretary.
            ``(2) Categories of measures.--The measures developed under 
        this subsection shall include, to the extent determined 
        appropriate by the Secretary--
                    ``(A) outcome measurement for acute and chronic 
                diseases, including, to the extent feasible, the 5 most 
                prevalent and resource-intensive acute and chronic 
                medical conditions; and
                    ``(B) outcome measurement for primary and 
                preventative care, including, to the extent feasible, 
                measurements

[[Page 124 STAT. 938]]

                that cover provision of such care for distinct patient 
                populations (such as healthy children, chronically ill 
                adults, or infirm elderly individuals).
            ``(3) Goals.--In developing such measures, the Secretary 
        shall seek to--
                    ``(A) address issues regarding risk adjustment, 
                accountability, and sample size;
                    ``(B) include the full scope of services that 
                comprise a cycle of care; and
                    ``(C) include multiple dimensions.
            ``(4) Timeframe.--
                    ``(A) Acute and chronic diseases.--Not later than 24 
                months after the date of enactment of this Act, the 
                Secretary shall develop not less than 10 measures 
                described in paragraph (2)(A).
                    ``(B) Primary and preventive care.--Not later than 
                36 months after the date of enactment of this Act, the 
                Secretary shall develop not less than 10 measures 
                described in paragraph (2)(B).''.

    (b) Hospital-acquired Conditions.--Section 1890A of the Social 
Security Act, as amended by section 3013(b), <<NOTE: 42 USC 1395aaa-
1.>> is amended by adding at the end the following new subsection:

    ``(f) Hospital Acquired Conditions. <<NOTE: Public information.>> --
The Secretary shall, to the extent practicable, publicly report on 
measures for hospital-acquired conditions that are currently utilized by 
the Centers for Medicare & Medicaid Services for the adjustment of the 
amount of payment to hospitals based on rates of hospital-acquired 
infections.''.

    (c) Clinical Practice Guidelines.--Section 304(b) of the Medicare 
Improvements for Patients and Providers Act of 2008 (Public Law 110-
275) <<NOTE: 42 USC 299 note.>> is amended by adding at the end the 
following new paragraph:
            ``(4) Identification.--
                    ``(A) In general. <<NOTE: Deadline. Contracts.>> --
                Following receipt of the report submitted under 
                paragraph (2), and not less than every 3 years 
                thereafter, the Secretary shall contract with the 
                Institute to employ the results of the study performed 
                under paragraph (1) and the best methods identified by 
                the Institute for the purpose of identifying existing 
                and new clinical practice guidelines that were developed 
                using such best methods, including guidelines listed in 
                the National Guideline Clearinghouse.
                    ``(B) Consultation.--In carrying out the 
                identification process under subparagraph (A), the 
                Secretary shall allow for consultation with professional 
                societies, voluntary health care organizations, and 
                expert panels.''.

SEC. 10304. SELECTION OF EFFICIENCY MEASURES.

    Sections 1890(b)(7) and 1890A of the Social Security Act, as added 
by section 3014, <<NOTE: 42 USC 1395aaa, 1395aaa-1.>> are amended by 
striking ``quality'' each place it appears and inserting ``quality and 
efficiency''.

SEC. 10305. DATA COLLECTION; PUBLIC REPORTING.

    Section 399II(a) of the Public Health Service Act, as added by 
section 3015 <<NOTE: 42 USC 280j-1.>> , is amended to read as follows:

    ``(a) In General.--

[[Page 124 STAT. 939]]

            ``(1) Establishment of strategic framework.--The Secretary 
        shall establish and implement an overall strategic framework to 
        carry out the public reporting of performance information, as 
        described in section 399JJ. Such strategic framework may include 
        methods and related timelines for implementing nationally 
        consistent data collection, data aggregation, and analysis 
        methods.
            ``(2) Collection and aggregation of data.--The Secretary 
        shall collect and aggregate consistent data on quality and 
        resource use measures from information systems used to support 
        health care delivery, and may award grants or contracts for this 
        purpose. The Secretary shall align such collection and 
        aggregation efforts with the requirements and assistance 
        regarding the expansion of health information technology 
        systems, the interoperability of such technology systems, and 
        related standards that are in effect on the date of enactment of 
        the Patient Protection and Affordable Care Act.
            ``(3) Scope.--The Secretary shall ensure that the data 
        collection, data aggregation, and analysis systems described in 
        paragraph (1) involve an increasingly broad range of patient 
        populations, providers, and geographic areas over time.''.

SEC. 10306. IMPROVEMENTS UNDER THE CENTER FOR MEDICARE AND MEDICAID 
            INNOVATION.

    Section 1115A of the Social Security Act, as added by section 
3021, <<NOTE: 42 USC 1315a.>> is amended--
            (1) in subsection (a), by inserting at the end the following 
        new paragraph:
            ``(5) Testing within certain geographic areas.--For purposes 
        of testing payment and service delivery models under this 
        section, the Secretary may elect to limit testing of a model to 
        certain geographic areas.'';
            (2) in subsection (b)(2)--
                    (A) in subparagraph (A)--
                          (i) in the second sentence, by striking ``the 
                      preceding sentence may include'' and inserting 
                      ``this subparagraph may include, but are not 
                      limited to,''; and
                          (ii) by inserting after the first sentence the 
                      following new sentence: ``The Secretary shall 
                      focus on models expected to reduce program costs 
                      under the applicable title while preserving or 
                      enhancing the quality of care received by 
                      individuals receiving benefits under such 
                      title.'';
                    (B) in subparagraph (B), by adding at the end the 
                following new clauses:
                          ``(xix) Utilizing, in particular in entities 
                      located in medically underserved areas and 
                      facilities of the Indian Health Service (whether 
                      operated by such Service or by an Indian tribe or 
                      tribal organization (as those terms are defined in 
                      section 4 of the Indian Health Care Improvement 
                      Act)), telehealth services--
                                    ``(I) in treating behavioral health 
                                issues (such as post-traumatic stress 
                                disorder) and stroke; and
                                    ``(II) to improve the capacity of 
                                non-medical providers and non-
                                specialized medical providers to

[[Page 124 STAT. 940]]

                                provide health services for patients 
                                with chronic complex conditions.
                          ``(xx) Utilizing a diverse network of 
                      providers of services and suppliers to improve 
                      care coordination for applicable individuals 
                      described in subsection (a)(4)(A)(i) with 2 or 
                      more chronic conditions and a history of prior-
                      year hospitalization through interventions 
                      developed under the Medicare Coordinated Care 
                      Demonstration Project under section 4016 of the 
                      Balanced Budget Act of 1997 (42 U.S.C. 1395b-1 
                      note).''; and
                    (C) in subparagraph (C), by adding at the end the 
                following new clause:
                          ``(viii) Whether the model demonstrates 
                      effective linkage with other public sector or 
                      private sector payers.'';
            (3) in subsection (b)(4), by adding at the end the following 
        new subparagraph:
                    ``(C) Measure selection.--To the extent feasible, 
                the Secretary shall select measures under this paragraph 
                that reflect national priorities for quality improvement 
                and patient-centered care consistent with the measures 
                described in 1890(b)(7)(B).''; and
            (4) in subsection (c)--
                    (A) in paragraph (1)(B), by striking ``care and 
                reduce spending; and'' and inserting ``patient care 
                without increasing spending;'';
                    (B) in paragraph (2), by striking ``reduce program 
                spending under applicable titles.'' and inserting 
                ``reduce (or would not result in any increase in) net 
                program spending under applicable titles; and''; and
                    (C) by adding at the end the following:
            ``(3) <<NOTE: Determination.>> the Secretary determines that 
        such expansion would not deny or limit the coverage or provision 
        of benefits under the applicable title for applicable 
        individuals.

In determining which models or demonstration projects to expand under 
the preceding sentence, the Secretary shall focus on models and 
demonstration projects that improve the quality of patient care and 
reduce spending.''.

SEC. 10307. IMPROVEMENTS TO THE MEDICARE SHARED SAVINGS PROGRAM.

    Section 1899 of the Social Security Act, as added by section 
3022, <<NOTE: 42 USC 1395jjj.>> is amended by adding at the end the 
following new subsections:

    ``(i) Option To Use Other Payment Models.--
            ``(1) In general.-- <<NOTE: Determination.>> If the 
        Secretary determines appropriate, the Secretary may use any of 
        the payment models described in paragraph (2) or (3) for making 
        payments under the program rather than the payment model 
        described in subsection (d).
            ``(2) Partial capitation model.--
                    ``(A) In general.--Subject to subparagraph (B), a 
                model described in this paragraph is a partial 
                capitation model in which an ACO is at financial risk 
                for some, but not all, of the items and services covered 
                under parts A and B, such as at risk for some or all 
                physicians' services or all items and services under 
                part B. The Secretary

[[Page 124 STAT. 941]]

                may limit a partial capitation model to ACOs that are 
                highly integrated systems of care and to ACOs capable of 
                bearing risk, as determined to be appropriate by the 
                Secretary.
                    ``(B) <<NOTE: Estimate.>> No additional program 
                expenditures.--Payments to an ACO for items and services 
                under this title for beneficiaries for a year under the 
                partial capitation model shall be established in a 
                manner that does not result in spending more for such 
                ACO for such beneficiaries than would otherwise be 
                expended for such ACO for such beneficiaries for such 
                year if the model were not implemented, as estimated by 
                the Secretary.
            ``(3) Other payment models.--
                    ``(A) <<NOTE: Determination.>> In general.--Subject 
                to subparagraph (B), a model described in this paragraph 
                is any payment model that the Secretary determines will 
                improve the quality and efficiency of items and services 
                furnished under this title.
                    ``(B) <<NOTE: Applicability.>> No additional program 
                expenditures.--Subparagraph (B) of paragraph (2) shall 
                apply to a payment model under subparagraph (A) in a 
                similar manner as such subparagraph (B) applies to the 
                payment model under paragraph (2).

    ``(j) Involvement in Private Payer and Other Third Party 
Arrangements.--The Secretary may give preference to ACOs who are 
participating in similar arrangements with other payers.
    ``(k) Treatment of Physician Group Practice Demonstration.-- 
<<NOTE: Time period. Contracts.>> During the period beginning on the 
date of the enactment of this section and ending on the date the program 
is established, the Secretary may enter into an agreement with an ACO 
under the demonstration under section 1866A, subject to rebasing and 
other modifications deemed appropriate by the Secretary.''.

SEC. 10308. REVISIONS TO NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING.

    (a) In General.--Section 1866D of the Social Security Act, as added 
by section 3023, <<NOTE: 42 USC 1395cc-4.>> is amended--
            (1) in paragraph (a)(2)(B), in the matter preceding clause 
        (i), by striking ``8 conditions'' and inserting ``10 
        conditions'';
            (2) by striking subsection (c)(1)(B) and inserting the 
        following:
                    ``(B) Expansion.-- <<NOTE: Determinations.>> The 
                Secretary may, at any point after January 1, 2016, 
                expand the duration and scope of the pilot program, to 
                the extent determined appropriate by the Secretary, if--
                          ``(i) the Secretary determines that such 
                      expansion is expected to--
                                    ``(I) reduce spending under title 
                                XVIII of the Social Security Act without 
                                reducing the quality of care; or
                                    ``(II) improve the quality of care 
                                and reduce spending;
                          ``(ii) <<NOTE: Certification.>> the Chief 
                      Actuary of the Centers for Medicare & Medicaid 
                      Services certifies that such expansion would 
                      reduce program spending under such title XVIII; 
                      and

[[Page 124 STAT. 942]]

                          ``(iii) the Secretary determines that such 
                      expansion would not deny or limit the coverage or 
                      provision of benefits under this title for 
                      individuals.''; and
            (3) by striking subsection (g) and inserting the following 
        new subsection:

    ``(g) Application of Pilot Program to Continuing Care Hospitals.--
            ``(1) In general.--In conducting the pilot program, the 
        Secretary shall apply the provisions of the program so as to 
        separately pilot test the continuing care hospital model.
            ``(2) Special rules.--In pilot testing the continuing care 
        hospital model under paragraph (1), the following rules shall 
        apply:
                    ``(A) Such model shall be tested without the 
                limitation to the conditions selected under subsection 
                (a)(2)(B).
                    ``(B) <<NOTE: Definition.>> Notwithstanding 
                subsection (a)(2)(D), an episode of care shall be 
                defined as the full period that a patient stays in the 
                continuing care hospital plus the first 30 days 
                following discharge from such hospital.
            ``(3) Continuing care hospital defined.--In this subsection, 
        the term `continuing care hospital' means an entity that has 
        demonstrated the ability to meet patient care and patient safety 
        standards and that provides under common management the medical 
        and rehabilitation services provided in inpatient rehabilitation 
        hospitals and units (as defined in section 1886(d)(1)(B)(ii)), 
        long term care hospitals (as defined in section 
        1886(d)(1)(B)(iv)(I)), and skilled nursing facilities (as 
        defined in section 1819(a)) that are located in a hospital 
        described in section 1886(d).''.

    (b) Technical Amendments.--
            (1) Section 3023 <<NOTE: 42 USC 1395cc-4.>> is amended by 
        striking ``1886C'' and inserting ``1866C''.
            (2) Title XVIII of the Social Security Act is amended by 
        redesignating section 1866D, as added by section 
        3024, <<NOTE: 42 USC 1395cc-5.>>  as section 1866E.

SEC. 10309. REVISIONS TO HOSPITAL READMISSIONS REDUCTION PROGRAM.

    Section 1886(q)(1) of the Social Security Act, as added by section 
3025, <<NOTE: 42 USC 1395ww.>> in the matter preceding subparagraph (A), 
is amended by striking ``the Secretary shall reduce the payments'' and 
all that follows through ``the product of'' and inserting ``the 
Secretary shall make payments (in addition to the payments described in 
paragraph (2)(A)(ii)) for such a discharge to such hospital under 
subsection (d) (or section 1814(b)(3), as the case may be) in an amount 
equal to the product of''.

SEC. 10310. REPEAL OF PHYSICIAN PAYMENT UPDATE.

    The provisions of, and the amendment made by, <<NOTE: 42 USC 1395w-
4.>> section 3101 are repealed.

SEC. 10311. REVISIONS TO EXTENSION OF AMBULANCE ADD-ONS.

    (a) Ground Ambulance.--Section 1834(l)(13)(A) of the Social Security 
Act (42 U.S.C. 1395m(l)(13)(A)), as amended by section 3105(a), is 
further amended--
            (1) in the matter preceding clause (i)--
                    (A) by striking ``2007, for'' and inserting ``2007, 
                and for''; and

[[Page 124 STAT. 943]]

                    (B) by striking ``2010, and for such services 
                furnished on or after April 1, 2010, and before January 
                1, 2011'' and inserting ``2011''; and
            (2) in each of clauses (i) and (ii)--
                    (A) by striking ``, and on or after April 1, 2010, 
                and before January 1, 2011'' each place it appears; and
                    (B) by striking ``January 1, 2010'' and inserting 
                ``January 1, 2011'' each place it appears.

    (b) Air Ambulance.--Section 146(b)(1) of the Medicare Improvements 
for Patients and Providers Act of 2008 (Public Law 110-275), as amended 
by section 3105(b), <<NOTE: 42 USC 1395m note.>> is further amended by 
striking ``December 31, 2009, and during the period beginning on April 
1, 2010, and ending on January 1, 2011'' and inserting ``December 31, 
2010''.

    (c) Super Rural Ambulance.--Section 1834(l)(12)(A) of the Social 
Security Act (42 U.S.C. 1395m(l)(12)(A)), as amended by section 3105(c), 
is further amended by striking ``2010, and on or after April 1, 2010, 
and before January 1, 2011'' and inserting ``2011''.

SEC. 10312. CERTAIN PAYMENT RULES FOR LONG-TERM CARE HOSPITAL SERVICES 
            AND MORATORIUM ON THE ESTABLISHMENT OF CERTAIN HOSPITALS AND 
            FACILITIES.

    (a) Certain Payment Rules.--Section 114(c) of the Medicare, 
Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395ww note), as 
amended by section 4302(a) of the American Recovery and Reinvestment Act 
(Public Law 111-5) and section 3106(a) of this Act, is further amended 
by striking ``4-year period'' each place it appears and inserting ``5-
year period''.
    (b) Moratorium.--Section 114(d) of such Act (42 U.S.C. 1395ww note), 
as amended by section 3106(b) of this Act, in the matter preceding 
subparagraph (A), is amended by striking ``4-year period'' and inserting 
``5-year period''.

SEC. 10313. REVISIONS TO THE EXTENSION FOR THE RURAL COMMUNITY HOSPITAL 
            DEMONSTRATION PROGRAM.

    (a) In General.--Subsection (g) of section 410A of the Medicare 
Prescription Drug, Improvement, and Modernization Act of 2003 (Public 
Law 108-173; 117 Stat. 2272), as added by section 3123(a) of this 
Act, <<NOTE: 42 USC 1395ww note.>> is amended to read as follows:

    ``(g) Five-Year Extension of Demonstration Program.--
            ``(1) In general.--Subject to the succeeding provisions of 
        this subsection, the Secretary shall conduct the demonstration 
        program under this section for an additional 5-year period (in 
        this section referred to as the `5-year extension period') that 
        begins on the date immediately following the last day of the 
        initial 5-year period under subsection (a)(5).
            ``(2) <<NOTE: Determination.>> Expansion of demonstration 
        states.--Notwithstanding subsection (a)(2), during the 5-year 
        extension period, the Secretary shall expand the number of 
        States with low population densities determined by the Secretary 
        under such subsection to 20. <<NOTE: Criteria.>> In determining 
        which States to include in such expansion, the Secretary shall 
        use the same criteria and data that the Secretary used to 
        determine the States under such subsection for purposes of the 
        initial 5-year period.
            ``(3) Increase in maximum number of hospitals participating 
        in the demonstration program.--Notwithstanding subsection 
        (a)(4), during the 5-year extension period, not more

[[Page 124 STAT. 944]]

        than 30 rural community hospitals may participate in the 
        demonstration program under this section.
            ``(4) Hospitals in demonstration program on date of 
        enactment.--In the case of a rural community hospital that is 
        participating in the demonstration program under this section as 
        of the last day of the initial 5-year period, the Secretary--
                    ``(A) shall provide for the continued participation 
                of such rural community hospital in the demonstration 
                program during the 5-year extension period unless the 
                rural community hospital makes an election, in such form 
                and manner as the Secretary may specify, to discontinue 
                such participation; and
                    ``(B) in calculating the amount of payment under 
                subsection (b) to the rural community hospital for 
                covered inpatient hospital services furnished by the 
                hospital during such 5-year extension period, shall 
                substitute, under paragraph (1)(A) of such subsection--
                          ``(i) the reasonable costs of providing such 
                      services for discharges occurring in the first 
                      cost reporting period beginning on or after the 
                      first day of the 5-year extension period, for
                          ``(ii) the reasonable costs of providing such 
                      services for discharges occurring in the first 
                      cost reporting period beginning on or after the 
                      implementation of the demonstration program.''.

    (b) Conforming Amendments.--Subsection (a)(5) of section 410A of the 
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 
(Public Law 108-173; 117 Stat. 2272), as amended by section 3123(b) of 
this Act, is amended by striking ``1-year extension'' and inserting ``5-
year extension''.

SEC. 10314. ADJUSTMENT TO LOW-VOLUME HOSPITAL PROVISION.

    Section 1886(d)(12) of the Social Security Act (42 U.S.C. 
1395ww(d)(12), as amended by section 3125, is amended--
            (1) in subparagraph (C)(i), by striking ``1,500 discharges'' 
        and inserting ``1,600 discharges''; and
            (2) in subparagraph (D), by striking ``1,500 discharges'' 
        and inserting ``1,600 discharges''.

SEC. 10315. REVISIONS TO HOME HEALTH CARE PROVISIONS.

    (a) Rebasing.--Section 1895(b)(3)(A)(iii) of the Social Security 
Act, as added by section 3131, <<NOTE: 42 USC 1395fff.>> is amended--
            (1) in the clause heading, by striking ``2013'' and 
        inserting ``2014'';
            (2) in subclause (I), by striking ``2013'' and inserting 
        ``2014''; and
            (3) in subclause (II), by striking ``2016'' and inserting 
        ``2017''.

    (b) <<NOTE: 42 USC 1395fff note.>> Revision of Home Health Study and 
Report.--Section 3131(d) is amended to read as follows:

    ``(d) Study and Report on the Development of Home Health Payment 
Revisions in Order to Ensure Access to Care and Payment for Severity of 
Illness.--
            ``(1) In general.--The Secretary of Health and Human 
        Services (in this section referred to as the `Secretary') shall 
        conduct a study on home health agency costs involved with

[[Page 124 STAT. 945]]

        providing ongoing access to care to low-income Medicare 
        beneficiaries or beneficiaries in medically underserved areas, 
        and in treating beneficiaries with varying levels of severity of 
        illness. In conducting the study, the Secretary may analyze 
        items such as the following:
                    ``(A) Methods to potentially revise the home health 
                prospective payment system under section 1895 of the 
                Social Security Act (42 U.S.C. 1395fff) to account for 
                costs related to patient severity of illness or to 
                improving beneficiary access to care, such as--
                          ``(i) payment adjustments for services that 
                      may involve additional or fewer resources;
                          ``(ii) changes to reflect resources involved 
                      with providing home health services to low-income 
                      Medicare beneficiaries or Medicare beneficiaries 
                      residing in medically underserved areas;
                          ``(iii) ways outlier payments might be revised 
                      to reflect costs of treating Medicare 
                      beneficiaries with high levels of severity of 
                      illness; and
                          ``(iv) other issues determined appropriate by 
                      the Secretary.
                    ``(B) Operational issues involved with potential 
                implementation of potential revisions to the home health 
                payment system, including impacts for both home health 
                agencies and administrative and systems issues for the 
                Centers for Medicare & Medicaid Services, and any 
                possible payment vulnerabilities associated with 
                implementing potential revisions.
                    ``(C) Whether additional research might be needed.
                    ``(D) Other items determined appropriate by the 
                Secretary.
            ``(2) Considerations.--In conducting the study under 
        paragraph (1), the Secretary may consider whether patient 
        severity of illness and access to care could be measured by 
        factors, such as--
                    ``(A) population density and relative patient access 
                to care;
                    ``(B) variations in service costs for providing care 
                to individuals who are dually eligible under the 
                Medicare and Medicaid programs;
                    ``(C) the presence of severe or chronic diseases, 
                which might be measured by multiple, discontinuous home 
                health episodes;
                    ``(D) poverty status, such as evidenced by the 
                receipt of Supplemental Security Income under title XVI 
                of the Social Security Act; and
                    ``(E) other factors determined appropriate by the 
                Secretary.
            ``(3) Report.--Not later than March 1, 2014, the Secretary 
        shall submit to Congress a report on the study conducted under 
        paragraph (1), together with recommendations for such 
        legislation and administrative action as the Secretary 
        determines appropriate.
            ``(4) Consultations.--In conducting the study under 
        paragraph (1), the Secretary shall consult with appropriate 
        stakeholders, such as groups representing home health agencies 
        and groups representing Medicare beneficiaries.

[[Page 124 STAT. 946]]

            ``(5) Medicare demonstration project based on the results of 
        the study.--
                    ``(A) In general.--Subject to subparagraph (D), 
                taking into account the results of the study conducted 
                under paragraph (1), the Secretary may, as determined 
                appropriate, provide for a demonstration project to test 
                whether making payment adjustments for home health 
                services under the Medicare program would substantially 
                improve access to care for patients with high severity 
                levels of illness or for low-income or underserved 
                Medicare beneficiaries.
                    ``(B) Waiving budget neutrality.--The Secretary 
                shall not reduce the standard prospective payment amount 
                (or amounts) under section 1895 of the Social Security 
                Act (42 U.S.C. 1395fff) applicable to home health 
                services furnished during a period to offset any 
                increase in payments during such period resulting from 
                the application of the payment adjustments under 
                subparagraph (A).
                    ``(C) No effect on subsequent periods.--A payment 
                adjustment resulting from the application of 
                subparagraph (A) for a period--
                          ``(i) shall not apply to payments for home 
                      health services under title XVIII after such 
                      period; and
                          ``(ii) shall not be taken into account in 
                      calculating the payment amounts applicable for 
                      such services after such period.
                    ``(D) <<NOTE: Determination.>> Duration.--If the 
                Secretary determines it appropriate to conduct the 
                demonstration project under this subsection, the 
                Secretary shall conduct the project for a four year 
                period beginning not later than January 1, 2015.
                    ``(E) Funding.--The Secretary shall provide for the 
                transfer from the Federal Hospital Insurance Trust Fund 
                under section 1817 of the Social Security Act (42 U.S.C. 
                1395i) and the Federal Supplementary Medical Insurance 
                Trust Fund established under section 1841 of such Act 
                (42 U.S.C. 1395t), in such proportion as the Secretary 
                determines appropriate, of $500,000,000 for the period 
                of fiscal years 2015 through 2018. Such funds shall be 
                made available for the study described in paragraph (1) 
                and the design, implementation and evaluation of the 
                demonstration described in this paragraph. Amounts 
                available under this subparagraph shall be available 
                until expended.
                    ``(F) Evaluation and report.--If the Secretary 
                determines it appropriate to conduct the demonstration 
                project under this subsection, the Secretary shall--
                          ``(i) provide for an evaluation of the 
                      project; and
                          ``(ii) submit to Congress, by a date specified 
                      by the Secretary, a report on the project.
                    ``(G) Administration.--Chapter 35 of title 44, 
                United States Code, shall not apply with respect to this 
                subsection.''.

SEC. 10316. MEDICARE DSH.

    Section 1886(r)(2)(B) of the Social Security Act, as added by 
section 3133, <<NOTE: 42 USC 1395ww.>> is amended--
            (1) in clause (i)--
                    (A) in the matter preceding subclause (I), by 
                striking ``(divided by 100)'';

[[Page 124 STAT. 947]]

                    (B) in subclause (I), by striking ``2012'' and 
                inserting ``2013'';
                    (C) in subclause (II), by striking the period at the 
                end and inserting a comma; and
                    (D) by adding at the end the following flush matter:
                      ``minus 1.5 percentage points.''.
            (2) in clause (ii)--
                    (A) in the matter preceding subclause (I), by 
                striking ``(divided by 100)'';
                    (B) in subclause (I), by striking ``2012'' and 
                inserting ``2013'';
                    (C) in subclause (II), by striking the period at the 
                end and inserting a comma; and
                    (D) by adding at the end the following flush matter:
                      ``and, for each of 2018 and 2019, minus 1.5 
                      percentage points.''.

SEC. 10317. <<NOTE: 42 USC 1395ww note.>> REVISIONS TO EXTENSION OF 
            SECTION 508 HOSPITAL PROVISIONS.

    Section 3137(a) is amended to read as follows:
    ``(a) Extension.--
            ``(1) In general.--Subsection (a) of section 106 of division 
        B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395 
        note), as amended by section 117 of the Medicare, Medicaid, and 
        SCHIP Extension Act of 2007 (Public Law 110-173) and section 124 
        of the Medicare Improvements for Patients and Providers Act of 
        2008 (Public Law 110-275), is amended by striking `September 30, 
        2009' and inserting `September 30, 2010'.
            ``(2) Special rule for fiscal year 2010.--
                    ``(A) In general.--Subject to subparagraph (B), for 
                purposes of implementation of the amendment made by 
                paragraph (1), including (notwithstanding paragraph (3) 
                of section 117(a) of the Medicare, Medicaid and SCHIP 
                Extension Act of 2007 (Public Law 110-173), as amended 
                by section 124(b) of the Medicare Improvements for 
                Patients and Providers Act of 2008 (Public Law 110-275)) 
                for purposes of the implementation of paragraph (2) of 
                such section 117(a), during fiscal year 2010, the 
                Secretary of Health and Human Services (in this 
                subsection referred to as the `Secretary') shall use the 
                hospital wage index that was promulgated by the 
                Secretary in the Federal Register on August 27, 2009 (74 
                Fed. Reg. 43754), and any subsequent corrections.
                    ``(B) <<NOTE: Effective date.>> Exception.--
                Beginning on April 1, 2010, in determining the wage 
                index applicable to hospitals that qualify for wage 
                index reclassification, the Secretary shall include the 
                average hourly wage data of hospitals whose 
                reclassification was extended pursuant to the amendment 
                made by paragraph (1) only if including such data 
                results in a higher applicable reclassified wage index.
            ``(3) Adjustment for certain hospitals in fiscal year 
        2010.--
                    ``(A) In general.--In the case of a subsection (d) 
                hospital (as defined in subsection (d)(1)(B) of section 
                1886 of the Social Security Act (42 U.S.C. 1395ww)) with 
                respect to which--

[[Page 124 STAT. 948]]

                          ``(i) a reclassification of its wage index for 
                      purposes of such section was extended pursuant to 
                      the amendment made by paragraph (1); and
                          ``(ii) <<NOTE: Time period.>> the wage index 
                      applicable for such hospital for the period 
                      beginning on October 1, 2009, and ending on March 
                      31, 2010, was lower than for the period beginning 
                      on April 1, 2010, and ending on September 30, 
                      2010, by reason of the application of paragraph 
                      (2)(B);
                the Secretary shall pay such hospital an additional 
                payment that reflects the difference between the wage 
                index for such periods.
                    ``(B) Timeframe for payments.--The Secretary shall 
                make payments required under subparagraph by not later 
                than December 31, 2010.''.

SEC. 10318. REVISIONS TO TRANSITIONAL EXTRA BENEFITS UNDER MEDICARE 
            ADVANTAGE.

    Section 1853(p)(3)(A) of the Social Security Act, as added by 
section 3201(h), <<NOTE: 42 USC 1395w-23.>> is amended by inserting ``in 
2009'' before the period at the end.

SEC. 10319. REVISIONS TO MARKET BASKET ADJUSTMENTS.

    (a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B)(xii) of the 
Social Security Act, as added by section 3401(a), <<NOTE: 42 USC 
1395ww.>> is amended--
            (1) in subclause (I), by striking ``and'' at the end;
            (2) by redesignating subclause (II) as subclause (III);
            (3) by inserting after subclause (II) the following new 
        subclause:
            ``(II) for each of fiscal years 2012 and 2013, by 0.1 
        percentage point; and''; and
            (4) in subclause (III), as redesignated by paragraph (2), by 
        striking ``2012'' and inserting ``2014''.

    (b) Long-term Care Hospitals.--Section 1886(m)(4) of the Social 
Security Act, as added by section 3401(c), is amended--
            (1) in subparagraph (A)--
                    (A) in clause (i)--
                          (i) by striking ``each of rate years 2010 and 
                      2011'' and inserting ``rate year 2010''; and
                          (ii) by striking ``and'' at the end;
                    (B) by redesignating clause (ii) as clause (iv);
                    (C) by inserting after clause (i) the following new 
                clauses:
                          ``(ii) for rate year 2011, 0.50 percentage 
                      point;
                          ``(iii) for each of the rate years beginning 
                      in 2012 and 2013, 0.1 percentage point; and''; and
                    (D) in clause (iv), as redesignated by subparagraph 
                (B), by striking ``2012'' and inserting ``2014''; and
            (2) in subparagraph (B), by striking ``(A)(ii)'' and 
        inserting ``(A)(iv)''.

    (c) Inpatient Rehabilitation Facilities.--Section 1886(j)(3)(D)(i) 
of the Social Security Act, as added by section 3401(d), is amended--
            (1) in subclause (I), by striking ``and'' at the end;
            (2) by redesignating subclause (II) as subclause (III);
            (3) by inserting after subclause (II) the following new 
        subclause:

[[Page 124 STAT. 949]]

                                    ``(II) for each of fiscal years 2012 
                                and 2013, 0.1 percentage point; and''; 
                                and
            (4) in subclause (III), as redesignated by paragraph (2), by 
        striking ``2012'' and inserting ``2014''.

    (d) Home Health Agencies.--Section 1895(b)(3)(B)(vi)(II) of such 
Act, as added by section 3401(e), <<NOTE: 42 USC 1395fff.>> is amended 
by striking ``and 2012'' and inserting ``, 2012, and 2013''.

    (e) Psychiatric Hospitals.--Section 1886(s)(3)(A) of the Social 
Security Act, as added by section 3401(f), <<NOTE: 42 USC 1395ww.>> is 
amended--
            (1) in clause (i), by striking ``and'' at the end;
            (2) by redesignating clause (ii) as clause (iii);
            (3) by inserting after clause (ii) the following new clause:
                          ``(ii) for each of the rate years beginning in 
                      2012 and 2013, 0.1 percentage point; and''; and
            (4) in clause (iii), as redesignated by paragraph (2), by 
        striking ``2012'' and inserting ``2014''.

    (f) Hospice Care.--Section 1814(i)(1)(C) of the Social Security Act 
(42 U.S.C. 1395f(i)(1)(C)), as amended by section 3401(g), is amended--
            (1) in clause (iv)(II), by striking ``0.5'' and inserting 
        ``0.3''; and
            (2) in clause (v), in the matter preceding subclause (I), by 
        striking ``0.5'' and inserting ``0.3''.

    (g) Outpatient Hospitals.--Section 1833(t)(3)(G)(i) of the Social 
Security Act, as added by section 3401(i), <<NOTE: 42 USC 1395l.>> is 
amended--
            (1) in subclause (I), by striking ``and'' at the end;
            (2) by redesignating subclause (II) as subclause (III);
            (3) by inserting after subclause (II) the following new 
        subclause:
                                    ``(II) for each of 2012 and 2013, 
                                0.1 percentage point; and''; and
            (4) in subclause (III), as redesignated by paragraph (2), by 
        striking ``2012'' and inserting ``2014''.

SEC. 10320. EXPANSION OF THE SCOPE OF, AND ADDITIONAL IMPROVEMENTS TO, 
            THE INDEPENDENT MEDICARE ADVISORY BOARD.

    (a) In General.--Section 1899A of the Social Security Act, as added 
by section 3403, <<NOTE: 42 USC 1395kkk.>> is amended--
            (1) in subsection (c)--
                    (A) in paragraph (1)(B), by adding at the end the 
                following new sentence: <<NOTE: Reports.>> ``In any year 
                (beginning with 2014) that the Board is not required to 
                submit a proposal under this section, the Board shall 
                submit to Congress an advisory report on matters related 
                to the Medicare program.'';
                    (B) in paragraph (2)(A)--
                          (i) in clause (iv), by inserting ``or the full 
                      premium subsidy under section 1860D-14(a)'' before 
                      the period at the end of the last sentence; and
                          (ii) by adding at the end the following new 
                      clause:
                          ``(vii) <<NOTE: Determination.>> If the Chief 
                      Actuary of the Centers for Medicare & Medicaid 
                      Services has made a determination described in 
                      subsection (e)(3)(B)(i)(II) in the determination 
                      year, the proposal shall be designed to help 
                      reduce the growth rate described in paragraph (8) 
                      while maintaining or enhancing beneficiary access 
                      to quality care under this title.'';

[[Page 124 STAT. 950]]

                    (C) in paragraph (2)(B)--
                          (i) in clause (v), by striking ``and'' at the 
                      end;
                          (ii) in clause (vi), by striking the period at 
                      the end and inserting ``; and''; and
                          (iii) by adding at the end the following new 
                      clause:
                          ``(vii) take into account the data and 
                      findings contained in the annual reports under 
                      subsection (n) in order to develop proposals that 
                      can most effectively promote the delivery of 
                      efficient, high quality care to Medicare 
                      beneficiaries.'';
                    (D) in paragraph (3)--
                          (i) in the heading, by striking ``Transmission 
                      of board proposal to president'' and inserting 
                      ``Submission of board proposal to congress and the 
                      president'';
                          (ii) in subparagraph (A)(i), by striking 
                      ``transmit a proposal under this section to the 
                      President'' and insert ``submit a proposal under 
                      this section to Congress and the President''; and
                          (iii) in subparagraph (A)(ii)--
                                    (I) in subclause (I), by inserting 
                                ``or'' at the end;
                                    (II) in subclause (II), by striking 
                                ``; or'' and inserting a period; and
                                    (III) by striking subclause (III);
                    (E) in paragraph (4)--
                          (i) by striking ``the Board under paragraph 
                      (3)(A)(i) or''; and
                          (ii) by striking ``immediately'' and inserting 
                      ``within 2 days'';
                    (F) in paragraph (5)--
                          (i) by striking ``to but'' and inserting 
                      ``but''; and
                          (ii) by inserting ``Congress and'' after 
                      ``submit a proposal to''; and
                    (G) in paragraph (6)(B)(i), by striking ``per 
                unduplicated enrollee'' and inserting ``(calculated as 
                the sum of per capita spending under each of parts A, B, 
                and D)'';
            (2) in subsection (d)--
                    (A) in paragraph (1)(A)--
                          (i) by inserting ``the Board or'' after ``a 
                      proposal is submitted by''; and
                          (ii) by inserting ``subsection (c)(3)(A)(i) 
                      or'' after ``the Senate under''; and
                    (B) in paragraph (2)(A), by inserting ``the Board 
                or'' after ``a proposal is submitted by'';
            (3) in subsection (e)--
                    (A) in paragraph (1), by inserting ``the Board or'' 
                after ``a proposal submitted by''; and
                    (B) in paragraph (3)--
                          (i) by striking ``Exception.--The Secretary 
                      shall not be required to implement the 
                      recommendations contained in a proposal submitted 
                      in a proposal year by'' and inserting 
                      ``Exceptions.--
                    ``(A) In general.--The Secretary shall not implement 
                the recommendations contained in a proposal submitted in 
                a proposal year by the Board or'';

[[Page 124 STAT. 951]]

                          (ii) by redesignating subparagraphs (A) and 
                      (B) as clauses (i) and (ii), respectively, and 
                      indenting appropriately; and
                          (iii) by adding at the end the following new 
                      subparagraph:
                    ``(B) Limited additional exception.--
                          ``(i) In general.--Subject to clause (ii), the 
                      Secretary shall not implement the recommendations 
                      contained in a proposal submitted by the Board or 
                      the President to Congress pursuant to this section 
                      in a proposal year (beginning with proposal year 
                      2019) if--
                                    ``(I) the Board was required to 
                                submit a proposal to Congress under this 
                                section in the year preceding the 
                                proposal year; and
                                    ``(II) <<NOTE: Determination.>> the 
                                Chief Actuary of the Centers for 
                                Medicare & Medicaid Services makes a 
                                determination in the determination year 
                                that the growth rate described in 
                                subsection (c)(8) exceeds the growth 
                                rate described in subsection 
                                (c)(6)(A)(i).
                          ``(ii) Limited additional exception may not be 
                      applied in two consecutive years.--This 
                      subparagraph shall not apply if the 
                      recommendations contained in a proposal submitted 
                      by the Board or the President to Congress pursuant 
                      to this section in the year preceding the proposal 
                      year were not required to be implemented by reason 
                      of this subparagraph.
                          ``(iii) No affect on requirement to submit 
                      proposals or for congressional consideration of 
                      proposals.--Clause (i) and (ii) shall not affect--
                                    ``(I) the requirement of the Board 
                                or the President to submit a proposal to 
                                Congress in a proposal year in 
                                accordance with the provisions of this 
                                section; or
                                    ``(II) Congressional consideration 
                                of a legislative proposal (described in 
                                subsection (c)(3)(B)(iv)) contained such 
                                a proposal in accordance with subsection 
                                (d).'';
            (4) in subsection (f)(3)(B)--
                    (A) by striking ``or advisory reports to Congress'' 
                and inserting ``, advisory reports, or advisory 
                recommendations''; and
                    (B) by inserting ``or produce the public report 
                under subsection (n)'' after ``this section''; and
            (5) by adding at the end the following new subsections:

    ``(n) Annual Public Report.--
            ``(1) In general.--Not later than July 1, 2014, and annually 
        thereafter, the Board shall produce a public report containing 
        standardized information on system-wide health care costs, 
        patient access to care, utilization, and quality-of-care that 
        allows for comparison by region, types of services, types of 
        providers, and both private payers and the program under this 
        title.
            ``(2) Requirements.--Each report produced pursuant to 
        paragraph (1) shall include information with respect to the 
        following areas:
                    ``(A) The quality and costs of care for the 
                population at the most local level determined practical 
                by the Board

[[Page 124 STAT. 952]]

                (with quality and costs compared to national benchmarks 
                and reflecting rates of change, taking into account 
                quality measures described in section 1890(b)(7)(B)).
                    ``(B) Beneficiary and consumer access to care, 
                patient and caregiver experience of care, and the cost-
                sharing or out-of-pocket burden on patients.
                    ``(C) Epidemiological shifts and demographic 
                changes.
                    ``(D) The proliferation, effectiveness, and 
                utilization of health care technologies, including 
                variation in provider practice patterns and costs.
                    ``(E) Any other areas that the Board determines 
                affect overall spending and quality of care in the 
                private sector.

    ``(o) Advisory Recommendations for Non-Federal Health Care 
Programs.--
            ``(1) In general.-- <<NOTE: Deadlines.>> Not later than 
        January 15, 2015, and at least once every two years thereafter, 
        the Board shall submit to Congress and the President 
        recommendations to slow the growth in national health 
        expenditures (excluding expenditures under this title and in 
        other Federal health care programs) while preserving or 
        enhancing quality of care, such as recommendations--
                    ``(A) that the Secretary or other Federal agencies 
                can implement administratively;
                    ``(B) that may require legislation to be enacted by 
                Congress in order to be implemented;
                    ``(C) that may require legislation to be enacted by 
                State or local governments in order to be implemented;
                    ``(D) that private sector entities can voluntarily 
                implement; and
                    ``(E) with respect to other areas determined 
                appropriate by the Board.
            ``(2) Coordination.--In making recommendations under 
        paragraph (1), the Board shall coordinate such recommendations 
        with recommendations contained in proposals and advisory reports 
        produced by the Board under subsection (c).
            ``(3) Available to public.--The Board shall make 
        recommendations submitted to Congress and the President under 
        this subsection available to the public.''.

    (b) Name Change.-- <<NOTE: 42 USC 1395kkk and note.>> Any reference 
in the provisions of, or amendments made by, section 3403 to the 
``Independent Medicare Advisory Board'' shall be deemed to be a 
reference to the ``Independent Payment Advisory Board''.

    (c) Rule of Construction.-- <<NOTE: 42 USC 1395kkk note.>> Nothing 
in the amendments made by this section shall preclude the Independent 
Medicare Advisory Board, as established under section 1899A of the 
Social Security Act (as added by section 3403), from solely using data 
from public or private sources to carry out the amendments made by 
subsection (a)(4).

SEC. 10321. REVISION TO COMMUNITY HEALTH TEAMS.

    Section 3502(c)(2)(A) <<NOTE: 42 USC 256a-1.>> is amended by 
inserting ``or other primary care providers'' after ``physicians''.

SEC. 10322. QUALITY REPORTING FOR PSYCHIATRIC HOSPITALS.

    (a) In General.--Section 1886(s) of the Social Security Act, as 
added by section 3401(f), <<NOTE: 42 USC 1395ww.>> is amended by adding 
at the end the following new paragraph:
            ``(4) Quality reporting.--

[[Page 124 STAT. 953]]

                    ``(A) Reduction in update for failure to report.--
                          ``(i) In general.--Under the system described 
                      in paragraph (1), for rate year 2014 and each 
                      subsequent rate year, in the case of a psychiatric 
                      hospital or psychiatric unit that does not submit 
                      data to the Secretary in accordance with 
                      subparagraph (C) with respect to such a rate year, 
                      any annual update to a standard Federal rate for 
                      discharges for the hospital during the rate year, 
                      and after application of paragraph (2), shall be 
                      reduced by 2 percentage points.
                          ``(ii) Special rule.--The application of this 
                      subparagraph may result in such annual update 
                      being less than 0.0 for a rate year, and may 
                      result in payment rates under the system described 
                      in paragraph (1) for a rate year being less than 
                      such payment rates for the preceding rate year.
                    ``(B) Noncumulative application.--Any reduction 
                under subparagraph (A) shall apply only with respect to 
                the rate year involved and the Secretary shall not take 
                into account such reduction in computing the payment 
                amount under the system described in paragraph (1) for a 
                subsequent rate year.
                    ``(C) Submission of quality data.--For rate year 
                2014 and each subsequent rate year, each psychiatric 
                hospital and psychiatric unit shall submit to the 
                Secretary data on quality measures specified under 
                subparagraph (D). Such data shall be submitted in a form 
                and manner, and at a time, specified by the Secretary 
                for purposes of this subparagraph.
                    ``(D) Quality measures.--
                          ``(i) In general.--Subject to clause (ii), any 
                      measure specified by the Secretary under this 
                      subparagraph must have been endorsed by the entity 
                      with a contract under section 1890(a).
                          ``(ii) Exception.--In the case of a specified 
                      area or medical topic determined appropriate by 
                      the Secretary for which a feasible and practical 
                      measure has not been endorsed by the entity with a 
                      contract under section 1890(a), the Secretary may 
                      specify a measure that is not so endorsed as long 
                      as due consideration is given to measures that 
                      have been endorsed or adopted by a consensus 
                      organization identified by the Secretary.
                          ``(iii) Time frame.--Not later than October 1, 
                      2012, the Secretary shall publish the measures 
                      selected under this subparagraph that will be 
                      applicable with respect to rate year 2014.
                    ``(E) Public availability of data submitted.-- 
                <<NOTE: Procedures.>> The Secretary shall establish 
                procedures for making data submitted under subparagraph 
                (C) available to the public. Such procedures shall 
                ensure that a psychiatric hospital and a psychiatric 
                unit has the opportunity to review the data that is to 
                be made public with respect to the hospital or unit 
                prior to such data being made 
                public. <<NOTE: Reports.>> The Secretary shall report 
                quality measures that relate to services furnished in 
                inpatient settings in psychiatric hospitals and

[[Page 124 STAT. 954]]

                psychiatric units on the Internet website of the Centers 
                for Medicare & Medicaid Services.''.

    (b) Conforming Amendment.--Section 1890(b)(7)(B)(i)(I) of the Social 
Security Act, as added by section 3014, <<NOTE: 42 USC 1395aaa.>> is 
amended by inserting ``1886(s)(4)(D),'' after ``1886(o)(2),''.

SEC. 10323. MEDICARE COVERAGE FOR INDIVIDUALS EXPOSED TO ENVIRONMENTAL 
            HEALTH HAZARDS.

    (a) In General.--Title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.) is amended by inserting after section 1881 the following 
new section:

``SEC. 1881A. <<NOTE: 42 USC 1395rr-1.>> MEDICARE COVERAGE FOR 
            INDIVIDUALS EXPOSED TO ENVIRONMENTAL HEALTH HAZARDS.

    ``(a) Deeming of Individuals as Eligible for Medicare Benefits.--
            ``(1) In general.--For purposes of eligibility for benefits 
        under this title, an individual determined under subsection (c) 
        to be an environmental exposure affected individual described in 
        subsection (e)(2) shall be deemed to meet the conditions 
        specified in section 226(a).
            ``(2) Discretionary deeming.--For purposes of eligibility 
        for benefits under this title, the Secretary may deem an 
        individual determined under subsection (c) to be an 
        environmental exposure affected individual described in 
        subsection (e)(3) to meet the conditions specified in section 
        226(a).
            ``(3) Effective date of coverage.--An Individual who is 
        deemed eligible for benefits under this title under paragraph 
        (1) or (2) shall be--
                    ``(A) entitled to benefits under the program under 
                Part A as of the date of such deeming; and
                    ``(B) eligible to enroll in the program under Part B 
                beginning with the month in which such deeming occurs.

    ``(b) Pilot Program for Care of Certain Individuals Residing in 
Emergency Declaration Areas.--
            ``(1) Program; purpose.--
                    ``(A) Primary pilot program.--The Secretary shall 
                establish a pilot program in accordance with this 
                subsection to provide innovative approaches to 
                furnishing comprehensive, coordinated, and cost-
                effective care under this title to individuals described 
                in paragraph (2)(A).
                    ``(B) Optional pilot programs.--The Secretary may 
                establish a separate pilot program, in accordance with 
                this subsection, with respect to each geographic area 
                subject to an emergency declaration (other than the 
                declaration of June 17, 2009), in order to furnish such 
                comprehensive, coordinated and cost-effective care to 
                individuals described in subparagraph (2)(B) who reside 
                in each such area.
            ``(2) Individual described.--For purposes of paragraph (1), 
        an individual described in this paragraph is an individual who 
        enrolls in part B, submits to the Secretary an application to 
        participate in the applicable pilot program under this 
        subsection, and--
                    ``(A) is an environmental exposure affected 
                individual described in subsection (e)(2) who resides in 
                or around the geographic area subject to an emergency 
                declaration made as of June 17, 2009; or

[[Page 124 STAT. 955]]

                    ``(B) is an environmental exposure affected 
                individual described in subsection (e)(3) who--
                          ``(i) is deemed under subsection (a)(2); and
                          ``(ii) meets such other criteria or conditions 
                      for participation in a pilot program under 
                      paragraph (1)(B) as the Secretary specifies.
            ``(3) Flexible benefits and services.--A pilot program under 
        this subsection may provide for the furnishing of benefits, 
        items, or services not otherwise covered or authorized under 
        this title, if the Secretary determines that furnishing such 
        benefits, items, or services will further the purposes of such 
        pilot program (as described in paragraph (1)).
            ``(4) Innovative reimbursement methodologies.--For purposes 
        of the pilot program under this subsection, the Secretary--
                    ``(A) shall develop and implement appropriate 
                methodologies to reimburse providers for furnishing 
                benefits, items, or services for which payment is not 
                otherwise covered or authorized under this title, if 
                such benefits, items, or services are furnished pursuant 
                to paragraph (3); and
                    ``(B) may develop and implement innovative 
                approaches to reimbursing providers for any benefits, 
                items, or services furnished under this subsection.
            ``(5) Limitation.--Consistent with section 1862(b), no 
        payment shall be made under the pilot program under this 
        subsection with respect to benefits, items, or services 
        furnished to an environmental exposure affected individual (as 
        defined in subsection (e)) to the extent that such individual is 
        eligible to receive such benefits, items, or services through 
        any other public or private benefits plan or legal agreement.
            ``(6) Waiver authority.--The Secretary may waive such 
        provisions of this title and title XI as are necessary to carry 
        out pilot programs under this subsection.
            ``(7) Funding.--For purposes of carrying out pilot programs 
        under this subsection, the Secretary shall provide for the 
        transfer, from the Federal Hospital Insurance Trust Fund under 
        section 1817 and the Federal Supplementary Medical Insurance 
        Trust Fund under section 1841, in such proportion as the 
        Secretary determines appropriate, of such sums as the Secretary 
        determines necessary, to the Centers for Medicare & Medicaid 
        Services Program Management Account.
            ``(8) Waiver of budget neutrality.--The Secretary shall not 
        require that pilot programs under this subsection be budget 
        neutral with respect to expenditures under this title.

    ``(c) Determinations.--
            ``(1) By the commissioner of social security.--For purposes 
        of this section, the Commissioner of Social Security, in 
        consultation with the Secretary, and using the cost allocation 
        method prescribed in section 201(g), shall determine whether 
        individuals are environmental exposure affected individuals.
            ``(2) By the secretary.--The Secretary shall determine 
        eligibility for pilot programs under subsection (b).

    ``(d) Emergency Declaration Defined.--For purposes of this section, 
the term `emergency declaration' means a declaration of a public health 
emergency under section 104(a) of the Comprehensive Environmental 
Response, Compensation, and Liability Act of 1980.

[[Page 124 STAT. 956]]

    ``(e) Environmental Exposure Affected Individual Defined.--
            ``(1) In general.--For purposes of this section, the term 
        `environmental exposure affected individual' means--
                    ``(A) an individual described in paragraph (2); and
                    ``(B) an individual described in paragraph (3).
            ``(2) Individual described.--
                    ``(A) In general.--An individual described in this 
                paragraph is any individual who--
                          ``(i) is diagnosed with 1 or more conditions 
                      described in subparagraph (B);
                          ``(ii) as demonstrated in such manner as the 
                      Secretary determines appropriate, has been present 
                      for an aggregate total of 6 months in the 
                      geographic area subject to an emergency 
                      declaration specified in subsection (b)(2)(A), 
                      during a period ending--
                                    ``(I) not less than 10 years prior 
                                to such diagnosis; and
                                    ``(II) prior to the implementation 
                                of all the remedial and removal actions 
                                specified in the Record of Decision for 
                                Operating Unit 4 and the Record of 
                                Decision for Operating Unit 7;
                          ``(iii) files an application for benefits 
                      under this title (or has an application filed on 
                      behalf of the individual), including pursuant to 
                      this section; and
                          ``(iv) is determined under this section to 
                      meet the criteria in this subparagraph.
                    ``(B) Conditions described.--For purposes of 
                subparagraph (A), the following conditions are described 
                in this subparagraph:
                          ``(i) Asbestosis, pleural thickening, or 
                      pleural plaques as established by--
                                    ``(I) interpretation by a `B Reader' 
                                qualified physician of a plain chest x-
                                ray or interpretation of a computed 
                                tomographic radiograph of the chest by a 
                                qualified physician, as determined by 
                                the Secretary; or
                                    ``(II) such other diagnostic 
                                standards as the Secretary specifies,
                      except that this clause shall not apply to pleural 
                      thickening or pleural plaques unless there are 
                      symptoms or conditions requiring medical treatment 
                      as a result of these diagnoses.
                          ``(ii) Mesothelioma, or malignancies of the 
                      lung, colon, rectum, larynx, stomach, esophagus, 
                      pharynx, or ovary, as established by--
                                    ``(I) pathologic examination of 
                                biopsy tissue;
                                    ``(II) cytology from 
                                bronchioalveolar lavage; or
                                    ``(III) such other diagnostic 
                                standards as the Secretary specifies.
                          ``(iii) Any other diagnosis which the 
                      Secretary, in consultation with the Commissioner 
                      of Social Security, determines is an asbestos-
                      related medical condition, as established by such 
                      diagnostic standards as the Secretary specifies.
            ``(3) Other individual described.--An individual described 
        in this paragraph is any individual who--

[[Page 124 STAT. 957]]

                    ``(A) is not an individual described in paragraph 
                (2);
                    ``(B) is diagnosed with a medical condition caused 
                by the exposure of the individual to a public health 
                hazard to which an emergency declaration applies, based 
                on such medical conditions, diagnostic standards, and 
                other criteria as the Secretary specifies;
                    ``(C) as demonstrated in such manner as the 
                Secretary determines appropriate, has been present for 
                an aggregate total of 6 months in the geographic area 
                subject to the emergency declaration involved, during a 
                period determined appropriate by the Secretary;
                    ``(D) files an application for benefits under this 
                title (or has an application filed on behalf of the 
                individual), including pursuant to this section; and
                    ``(E) is determined under this section to meet the 
                criteria in this paragraph.''.

    (b) Program for Early Detection of Certain Medical Conditions 
Related to Environmental Health Hazards.--Title XX of the Social 
Security Act (42 U.S.C. 1397 et seq.), as amended by section 5507, is 
amended by adding at the end the following:

``SEC. 2009. <<NOTE: 42 USC 1397h.>> PROGRAM FOR EARLY DETECTION OF 
            CERTAIN MEDICAL CONDITIONS RELATED TO ENVIRONMENTAL HEALTH 
            HAZARDS.

    ``(a) Program Establishment.--The Secretary shall establish a 
program in accordance with this section to make competitive grants to 
eligible entities specified in subsection (b) for the purpose of--
            ``(1) screening at-risk individuals (as defined in 
        subsection (c)(1)) for environmental health conditions (as 
        defined in subsection (c)(3)); and
            ``(2) developing and disseminating public information and 
        education concerning--
                    ``(A) the availability of screening under the 
                program under this section;
                    ``(B) the detection, prevention, and treatment of 
                environmental health conditions; and
                    ``(C) the availability of Medicare benefits for 
                certain individuals diagnosed with environmental health 
                conditions under section 1881A.

    ``(b) Eligible Entities.--
            ``(1) In general.--For purposes of this section, an eligible 
        entity is an entity described in paragraph (2) which submits an 
        application to the Secretary in such form and manner, and 
        containing such information and assurances, as the Secretary 
        determines appropriate.
            ``(2) Types of eligible entities.--The entities described in 
        this paragraph are the following:
                    ``(A) A hospital or community health center.
                    ``(B) A Federally qualified health center.
                    ``(C) A facility of the Indian Health Service.
                    ``(D) A National Cancer Institute-designated cancer 
                center.
                    ``(E) An agency of any State or local government.
                    ``(F) A nonprofit organization.
                    ``(G) Any other entity the Secretary determines 
                appropriate.

[[Page 124 STAT. 958]]

    ``(c) Definitions.--In this section:
            ``(1) At-risk individual.--The term `at-risk individual' 
        means an individual who--
                    ``(A)(i) as demonstrated in such manner as the 
                Secretary determines appropriate, has been present for 
                an aggregate total of 6 months in the geographic area 
                subject to an emergency declaration specified under 
                paragraph (2), during a period ending--
                          ``(I) not less than 10 years prior to the date 
                      of such individual's application under 
                      subparagraph (B); and
                          ``(II) prior to the implementation of all the 
                      remedial and removal actions specified in the 
                      Record of Decision for Operating Unit 4 and the 
                      Record of Decision for Operating Unit 7; or
                    ``(ii) meets such other criteria as the Secretary 
                determines appropriate considering the type of 
                environmental health condition at issue; and
                    ``(B) has submitted an application (or has an 
                application submitted on the individual's behalf), to an 
                eligible entity receiving a grant under this section, 
                for screening under the program under this section.
            ``(2) Emergency declaration.--The term `emergency 
        declaration' means a declaration of a public health emergency 
        under section 104(a) of the Comprehensive Environmental 
        Response, Compensation, and Liability Act of 1980.
            ``(3) Environmental health condition.--The term 
        `environmental health condition' means--
                    ``(A) asbestosis, pleural thickening, or pleural 
                plaques, as established by--
                          ``(i) interpretation by a `B Reader' qualified 
                      physician of a plain chest x-ray or interpretation 
                      of a computed tomographic radiograph of the chest 
                      by a qualified physician, as determined by the 
                      Secretary; or
                          ``(ii) such other diagnostic standards as the 
                      Secretary specifies;
                    ``(B) mesothelioma, or malignancies of the lung, 
                colon, rectum, larynx, stomach, esophagus, pharynx, or 
                ovary, as established by--
                          ``(i) pathologic examination of biopsy tissue;
                          ``(ii) cytology from bronchioalveolar lavage; 
                      or
                          ``(iii) such other diagnostic standards as the 
                      Secretary specifies; and
                    ``(C) any other medical condition which the 
                Secretary determines is caused by exposure to a 
                hazardous substance or pollutant or contaminant at a 
                Superfund site to which an emergency declaration 
                applies, based on such criteria and as established by 
                such diagnostic standards as the Secretary specifies.
            ``(4) Hazardous substance; pollutant; contaminant.--The 
        terms `hazardous substance', `pollutant', and `contaminant' have 
        the meanings given those terms in section 101 of the 
        Comprehensive Environmental Response, Compensation, and 
        Liability Act of 1980 (42 U.S.C. 9601).
            ``(5) Superfund site.--The term `Superfund site' means a 
        site included on the National Priorities List developed by the 
        President in accordance with section 105(a)(8)(B) of the

[[Page 124 STAT. 959]]

        Comprehensive Environmental Response, Compensation, and 
        Liability Act of 1980 (42 U.S.C. 9605(a)(8)(B)).

    ``(d) Health Coverage Unaffected.--Nothing in this section shall be 
construed to affect any coverage obligation of a governmental or private 
health plan or program relating to an at-risk individual.
    ``(e) Funding.--
            ``(1) In general.--Out of any funds in the Treasury not 
        otherwise appropriated, there are appropriated to the Secretary, 
        to carry out the program under this section--
                    ``(A) $23,000,000 for the period of fiscal years 
                2010 through 2014; and
                    ``(B) $20,000,000 for each 5-fiscal year period 
                thereafter.
            ``(2) Availability.--Funds appropriated under paragraph (1) 
        shall remain available until expended.

    ``(f) Nonapplication.--
            ``(1) In general.--Except as provided in paragraph (2), the 
        preceding sections of this title shall not apply to grants 
        awarded under this section.
            ``(2) Limitations on use of grants.--Section 2005(a) shall 
        apply to a grant awarded under this section to the same extent 
        and in the same manner as such section applies to payments to 
        States under this title, except that paragraph (4) of such 
        section shall not be construed to prohibit grantees from 
        conducting screening for environmental health conditions as 
        authorized under this section.''.

SEC. 10324. PROTECTIONS FOR FRONTIER STATES.

    (a) Floor on Area Wage Index for Hospitals in Frontier States.--
            (1) In general.--Section 1886(d)(3)(E) of the Social 
        Security Act (42 U.S.C. 1395ww(d)(3)(E)) is amended--
                    (A) in clause (i), by striking ``clause (ii)'' and 
                inserting ``clause (ii) or (iii)''; and
                    (B) by adding at the end the following new clause:
                          ``(iii) Floor on area wage index for hospitals 
                      in frontier states.--
                                    ``(I) In general.--Subject to 
                                subclause (IV), for discharges occurring 
                                on or after October 1, 2010, the area 
                                wage index applicable under this 
                                subparagraph to any hospital which is 
                                located in a frontier State (as defined 
                                in subclause (II)) may not be less than 
                                1.00.
                                    ``(II) Frontier state defined.--In 
                                this clause, the term `frontier State' 
                                means a State in which at least 50 
                                percent of the counties in the State are 
                                frontier counties.
                                    ``(III) Frontier county defined.--In 
                                this clause, the term `frontier county' 
                                means a county in which the population 
                                per square mile is less than 6.
                                    ``(IV) Limitation.--This clause 
                                shall not apply to any hospital located 
                                in a State that receives a non-labor 
                                related share adjustment under paragraph 
                                (5)(H).''.

[[Page 124 STAT. 960]]

            (2) Waiving budget neutrality.--Section 1886(d)(3)(E) of the 
        Social Security Act (42 U.S.C. 1395ww(d)(3)(E)), as amended by 
        subsection (a), is amended in the third sentence by inserting 
        ``and the amendments made by section 10324(a)(1) of the Patient 
        Protection and Affordable Care Act'' after ``2003''.

    (b) Floor on Area Wage Adjustment Factor for Hospital Outpatient 
Department Services in Frontier States.--Section 1833(t) of the Social 
Security Act (42 U.S.C. 1395l(t)), as amended by section 3138, is 
amended--
            (1) in paragraph (2)(D), by striking ``the Secretary'' and 
        inserting ``subject to paragraph (19), the Secretary''; and
            (2) by adding at the end the following new paragraph:
            ``(19) Floor on area wage adjustment factor for hospital 
        outpatient department services in frontier states.--
                    ``(A) In general.--Subject to subparagraph (B), with 
                respect to covered OPD services furnished on or after 
                January 1, 2011, the area wage adjustment factor 
                applicable under the payment system established under 
                this subsection to any hospital outpatient department 
                which is located in a frontier State (as defined in 
                section 1886(d)(3)(E)(iii)(II)) may not be less than 
                1.00. The preceding sentence shall not be applied in a 
                budget neutral manner.
                    ``(B) Limitation.--This paragraph shall not apply to 
                any hospital outpatient department located in a State 
                that receives a non-labor related share adjustment under 
                section 1886(d)(5)(H).''.

    (c) Floor for Practice Expense Index for Physicians' Services 
Furnished in Frontier States.--Section 1848(e)(1) of the Social Security 
Act (42 U.S.C. 1395w-4(e)(1)), as amended by section 3102, is amended--
            (1) in subparagraph (A), by striking ``and (H)'' and 
        inserting ``(H), and (I)''; and
            (2) by adding at the end the following new subparagraph:
                    ``(I) Floor for practice expense index for services 
                furnished in frontier states.--
                          ``(i) In general.--Subject to clause (ii), for 
                      purposes of payment for services furnished in a 
                      frontier State (as defined in section 
                      1886(d)(3)(E)(iii)(II)) on or after January 1, 
                      2011, after calculating the practice expense index 
                      in subparagraph (A)(i), the Secretary shall 
                      increase any such index to 1.00 if such index 
                      would otherwise be less that 1.00. The preceding 
                      sentence shall not be applied in a budget neutral 
                      manner.
                          ``(ii) Limitation.--This subparagraph shall 
                      not apply to services furnished in a State that 
                      receives a non-labor related share adjustment 
                      under section 1886(d)(5)(H).''.

SEC. 10325. REVISION TO SKILLED NURSING FACILITY PROSPECTIVE PAYMENT 
            SYSTEM.

    (a) Temporary Delay of RUG-IV.-- <<NOTE: Implementation 
dates.>> Notwithstanding any other provision of law, the Secretary of 
Health and Human Services shall not, prior to October 1, 2011, implement 
Version 4 of the Resource Utilization Groups (in this subsection 
refereed to as ``RUG-IV'') published in the Federal Register on August 
11, 2009, entitled ``Prospective Payment System and Consolidated Billing 
for

[[Page 124 STAT. 961]]

Skilled Nursing Facilities for FY 2010; Minimum Data Set, Version 3.0 
for Skilled Nursing Facilities and Medicaid Nursing Facilities'' (74 
Fed. Reg. 40288). Beginning on October 1, 2010, the Secretary of Health 
and Human Services shall implement the change specific to therapy 
furnished on a concurrent basis that is a component of RUG-IV and 
changes to the lookback period to ensure that only those services 
furnished after admission to a skilled nursing facility are used as 
factors in determining a case mix classification under the skilled 
nursing facility prospective payment system under section 1888(e) of the 
Social Security Act (42 U.S.C. 1395yy(e)).

    (b) Construction.--Nothing in this section shall be interpreted as 
delaying the implementation of Version 3.0 of the Minimum Data Sets (MDS 
3.0) beyond the planned implementation date of October 1, 2010.

SEC. 10326. <<NOTE: 42 USC 1395b-1 note.>> PILOT TESTING PAY-FOR-
            PERFORMANCE PROGRAMS FOR CERTAIN MEDICARE PROVIDERS.

    (a) In General.-- <<NOTE: Deadline.>> Not later than January 1, 
2016, the Secretary of Health and Human Services (in this section 
referred to as the ``Secretary'') shall, for each provider described in 
subsection (b), conduct a separate pilot program under title XVIII of 
the Social Security Act to test the implementation of a value-based 
purchasing program for payments under such title for the provider.

    (b) Providers Described.--The providers described in this paragraph 
are the following:
            (1) Psychiatric hospitals (as described in clause (i) of 
        section 1886(d)(1)(B) of such Act (42 U.S.C. 1395ww(d)(1)(B))) 
        and psychiatric units (as described in the matter following 
        clause (v) of such section).
            (2) Long-term care hospitals (as described in clause (iv) of 
        such section).
            (3) Rehabilitation hospitals (as described in clause (ii) of 
        such section).
            (4) PPS-exempt cancer hospitals (as described in clause (v) 
        of such section).
            (5) Hospice programs (as defined in section 1861(dd)(2) of 
        such Act (42 U.S.C. 1395x(dd)(2))).

    (c) Waiver Authority.--The Secretary may waive such requirements of 
titles XI and XVIII of the Social Security Act as may be necessary 
solely for purposes of carrying out the pilot programs under this 
section.
    (d) No Additional Program Expenditures.--Payments under this section 
under the separate pilot program for value based purchasing (as 
described in subsection (a)) for each provider type described in 
paragraphs (1) through (5) of subsection (b) for applicable items and 
services under title XVIII of the Social Security Act for a year shall 
be established in a manner that does not result in spending more under 
each such value based purchasing program for such year than would 
otherwise be expended for such provider type for such year if the pilot 
program were not implemented, as estimated by the Secretary.
    (e) <<NOTE: Determinations.>> Expansion of Pilot Program.--The 
Secretary may, at any point after January 1, 2018, expand the duration 
and scope of a pilot program conducted under this subsection, to the 
extent determined appropriate by the Secretary, if--
            (1) the Secretary determines that such expansion is expected 
        to--

[[Page 124 STAT. 962]]

                    (A) reduce spending under title XVIII of the Social 
                Security Act without reducing the quality of care; or
                    (B) improve the quality of care and reduce spending;
            (2) <<NOTE: Certification.>> the Chief Actuary of the 
        Centers for Medicare & Medicaid Services certifies that such 
        expansion would reduce program spending under such title XVIII; 
        and
            (3) the Secretary determines that such expansion would not 
        deny or limit the coverage or provision of benefits under such 
        title XIII for Medicare beneficiaries.

SEC. 10327. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING SYSTEM.

    (a) In General.--Section 1848(m) of the Social Security Act (42 
U.S.C. 1395w-4(m)) is amended by adding at the end the following new 
paragraph:
            ``(7) Additional incentive payment.--
                    ``(A) In general.-- <<NOTE: Time period.>> For 2011 
                through 2014, if an eligible professional meets the 
                requirements described in subparagraph (B), the 
                applicable quality percent for such year, as described 
                in clauses (iii) and (iv) of paragraph (1)(B), shall be 
                increased by 0.5 percentage points.
                    ``(B) Requirements described.--In order to qualify 
                for the additional incentive payment described in 
                subparagraph (A), an eligible professional shall meet 
                the following requirements:
                          ``(i) The eligible professional shall--
                                    ``(I) satisfactorily submit data on 
                                quality measures for purposes of 
                                paragraph (1) for a year; and
                                    ``(II) have such data submitted on 
                                their behalf through a Maintenance of 
                                Certification Program (as defined in 
                                subparagraph (C)(i)) that meets--
                                            ``(aa) the criteria for a 
                                        registry (as described in 
                                        subsection (k)(4)); or
                                            ``(bb) an alternative form 
                                        and manner determined 
                                        appropriate by the Secretary.
                          ``(ii) The eligible professional, more 
                      frequently than is required to qualify for or 
                      maintain board certification status--
                                    ``(I) participates in such a 
                                Maintenance of Certification program for 
                                a year; and
                                    ``(II) successfully completes a 
                                qualified Maintenance of Certification 
                                Program practice assessment (as defined 
                                in subparagraph (C)(ii)) for such year.
                          ``(iii) A Maintenance of Certification program 
                      submits to the Secretary, on behalf of the 
                      eligible professional, information--
                                    ``(I) in a form and manner specified 
                                by the Secretary, that the eligible 
                                professional has successfully met the 
                                requirements of clause (ii) (which may 
                                be in the form of a structural measure);
                                    ``(II) if requested by the 
                                Secretary, on the survey of patient 
                                experience with care (as described in 
                                subparagraph (C)(ii)(II)); and
                                    ``(III) as the Secretary may 
                                require, on the methods, measures, and 
                                data used under the Maintenance of 
                                Certification Program and the

[[Page 124 STAT. 963]]

                                qualified Maintenance of Certification 
                                Program practice assessment.
                    ``(C) Definitions.--For purposes of this paragraph:
                          ``(i) The term `Maintenance of Certification 
                      Program' means a continuous assessment program, 
                      such as qualified American Board of Medical 
                      Specialties Maintenance of Certification program 
                      or an equivalent program (as determined by the 
                      Secretary), that advances quality and the lifelong 
                      learning and self-assessment of board certified 
                      specialty physicians by focusing on the 
                      competencies of patient care, medical knowledge, 
                      practice-based learning, interpersonal and 
                      communication skills and professionalism. Such a 
                      program shall include the following:
                                    ``(I) The program requires the 
                                physician to maintain a valid, 
                                unrestricted medical license in the 
                                United States.
                                    ``(II) The program requires a 
                                physician to participate in educational 
                                and self-assessment programs that 
                                require an assessment of what was 
                                learned.
                                    ``(III) The program requires a 
                                physician to demonstrate, through a 
                                formalized, secure examination, that the 
                                physician has the fundamental diagnostic 
                                skills, medical knowledge, and clinical 
                                judgment to provide quality care in 
                                their respective specialty.
                                    ``(IV) The program requires 
                                successful completion of a qualified 
                                Maintenance of Certification Program 
                                practice assessment as described in 
                                clause (ii).
                          ``(ii) The term `qualified Maintenance of 
                      Certification Program practice assessment' means 
                      an assessment of a physician's practice that--
                                    ``(I) includes an initial assessment 
                                of an eligible professional's practice 
                                that is designed to demonstrate the 
                                physician's use of evidence-based 
                                medicine;
                                    ``(II) includes a survey of patient 
                                experience with care; and
                                    ``(III) requires a physician to 
                                implement a quality improvement 
                                intervention to address a practice 
                                weakness identified in the initial 
                                assessment under subclause (I) and then 
                                to remeasure to assess performance 
                                improvement after such intervention.''.

    (b) Authority.--Section 3002(c) of this Act <<NOTE: 42 USC 1395w-4 
note.>> is amended by adding at the end the following new paragraph:
            ``(3) Authority.-- <<NOTE: Determination.>> For years after 
        2014, if the Secretary of Health and Human Services determines 
        it to be appropriate, the Secretary may incorporate 
        participation in a Maintenance of Certification Program and 
        successful completion of a qualified Maintenance of 
        Certification Program practice assessment into the composite of 
        measures of quality of care furnished pursuant to the physician 
        fee schedule payment modifier, as described in section 
        1848(p)(2) of the Social Security Act (42 U.S.C. 1395w-
        4(p)(2)).''.

[[Page 124 STAT. 964]]

    (c) Elimination of MA Regional Plan Stabilization Fund.--
            (1) In general.--Section 1858 of the Social Security Act (42 
        U.S.C. 1395w-27a) is amended by striking subsection (e).
            (2) <<NOTE: 42 USC 1395w-27a note.>> Transition.--Any amount 
        contained in the MA Regional Plan Stabilization Fund as of the 
        date of the enactment of this Act shall be transferred to the 
        Federal Supplementary Medical Insurance Trust Fund.

SEC. 10328. IMPROVEMENT IN PART D MEDICATION THERAPY MANAGEMENT (MTM) 
            PROGRAMS.

    (a) In General.--Section 1860D-4(c)(2) of the Social Security Act 
(42 U.S.C. 1395w-104(c)(2)) is amended--
            (1) by redesignating subparagraphs (C), (D), and (E) as 
        subparagraphs (E), (F), and (G), respectively; and
            (2) by inserting after subparagraph (B) the following new 
        subparagraphs:
                    ``(C) Required interventions.--For plan years 
                beginning on or after the date that is 2 years after the 
                date of the enactment of the Patient Protection and 
                Affordable Care Act, prescription drug plan sponsors 
                shall offer medication therapy management services to 
                targeted beneficiaries described in subparagraph (A)(ii) 
                that include, at a minimum, the following to increase 
                adherence to prescription medications or other goals 
                deemed necessary by the Secretary:
                          ``(i) An annual comprehensive medication 
                      review furnished person-to-person or using 
                      telehealth technologies (as defined by the 
                      Secretary) by a licensed pharmacist or other 
                      qualified provider. The comprehensive medication 
                      review--
                                    ``(I) shall include a review of the 
                                individual's medications and may result 
                                in the creation of a recommended 
                                medication action plan or other actions 
                                in consultation with the individual and 
                                with input from the prescriber to the 
                                extent necessary and practicable; and
                                    ``(II) shall include providing the 
                                individual with a written or printed 
                                summary of the results of the review.
                      The Secretary, in consultation with relevant 
                      stakeholders, shall develop a standardized format 
                      for the action plan under subclause (I) and the 
                      summary under subclause (II).
                          ``(ii) Follow-up interventions as warranted 
                      based on the findings of the annual medication 
                      review or the targeted medication enrollment and 
                      which may be provided person-to-person or using 
                      telehealth technologies (as defined by the 
                      Secretary).
                    ``(D) Assessment.--The prescription drug plan 
                sponsor shall have in place a process to assess, at 
                least on a quarterly basis, the medication use of 
                individuals who are at risk but not enrolled in the 
                medication therapy management program, including 
                individuals who have experienced a transition in care, 
                if the prescription drug plan sponsor has access to that 
                information.

[[Page 124 STAT. 965]]

                    ``(E) Automatic enrollment with ability to opt-
                out.--The prescription drug plan sponsor shall have in 
                place a process to--
                          ``(i) subject to clause (ii), automatically 
                      enroll targeted beneficiaries described in 
                      subparagraph (A)(ii), including beneficiaries 
                      identified under subparagraph (D), in the 
                      medication therapy management program required 
                      under this subsection; and
                          ``(ii) permit such beneficiaries to opt-out of 
                      enrollment in such program.''.

    (b) <<NOTE: 42 USC 1395w-104 note.>> Rule of Construction.--Nothing 
in this section shall limit the authority of the Secretary of Health and 
Human Services to modify or broaden requirements for a medication 
therapy management program under part D of title XVIII of the Social 
Security Act or to study new models for medication therapy management 
through the Center for Medicare and Medicaid Innovation under section 
1115A of such Act, as added by section 3021.

SEC. 10329. DEVELOPING METHODOLOGY TO ASSESS HEALTH PLAN VALUE.

    (a) Development.--The Secretary of Health and Human Services 
(referred to in this section as the ``Secretary''), in consultation with 
relevant stakeholders including health insurance issuers, health care 
consumers, employers, health care providers, and other entities 
determined appropriate by the Secretary, shall develop a methodology to 
measure health plan value. Such methodology shall take into 
consideration, where applicable--
            (1) the overall cost to enrollees under the plan;
            (2) the quality of the care provided for under the plan;
            (3) the efficiency of the plan in providing care;
            (4) the relative risk of the plan's enrollees as compared to 
        other plans;
            (5) the actuarial value or other comparative measure of the 
        benefits covered under the plan; and
            (6) other factors determined relevant by the Secretary.

    (b) Report.--Not later than 18 months after the date of enactment of 
this Act, the Secretary shall submit to Congress a report concerning the 
methodology developed under subsection (a).

SEC. 10330. MODERNIZING COMPUTER AND DATA SYSTEMS OF THE CENTERS FOR 
            MEDICARE & MEDICAID SERVICES TO SUPPORT IMPROVEMENTS IN CARE 
            DELIVERY.

    (a) In General.-- <<NOTE: Plan.>> The Secretary of Health and Human 
Services (in this section referred to as the ``Secretary'') shall 
develop a plan (and detailed budget for the resources needed to 
implement such plan) to modernize the computer and data systems of the 
Centers for Medicare & Medicaid Services (in this section referred to as 
``CMS'').

    (b) Considerations.--In developing the plan, the Secretary shall 
consider how such modernized computer system could--
            (1) in accordance with the regulations promulgated under 
        section 264(c) of the Health Insurance Portability and 
        Accountability Act of 1996, make available data in a reliable 
        and timely manner to providers of services and suppliers to 
        support their efforts to better manage and coordinate care 
        furnished to beneficiaries of CMS programs; and
            (2) support consistent evaluations of payment and delivery 
        system reforms under CMS programs.

[[Page 124 STAT. 966]]

    (c) Posting of Plan.-- <<NOTE: Deadline. Web posting.>> By not later 
than 9 months after the date of the enactment of this Act, the Secretary 
shall post on the website of the Centers for Medicare & Medicaid 
Services the plan described in subsection (a).

SEC. 10331. <<NOTE: 42 USC 1395w-5.>> PUBLIC REPORTING OF PERFORMANCE 
            INFORMATION.

    (a) <<NOTE: Deadline.>> In General.--
            (1) Development.-- <<NOTE: Web site.>> Not later than 
        January 1, 2011, the Secretary shall develop a Physician Compare 
        Internet website with information on physicians enrolled in the 
        Medicare program under section 1866(j) of the Social Security 
        Act (42 U.S.C. 1395cc(j)) and other eligible professionals who 
        participate in the Physician Quality Reporting Initiative under 
        section 1848 of such Act (42 U.S.C. 1395w-4).
            (2) Plan.-- <<NOTE: Time period.>> Not later than January 1, 
        2013, and with respect to reporting periods that begin no 
        earlier than January 1, 2012, the Secretary shall also implement 
        a plan for making publicly available through Physician Compare, 
        consistent with subsection (c), information on physician 
        performance that provides comparable information for the public 
        on quality and patient experience measures with respect to 
        physicians enrolled in the Medicare program under such section 
        1866(j). To the extent scientifically sound measures that are 
        developed consistent with the requirements of this section are 
        available, such information, to the extent practicable, shall 
        include--
                    (A) measures collected under the Physician Quality 
                Reporting Initiative;
                    (B) an assessment of patient health outcomes and the 
                functional status of patients;
                    (C) an assessment of the continuity and coordination 
                of care and care transitions, including episodes of care 
                and risk-adjusted resource use;
                    (D) an assessment of efficiency;
                    (E) an assessment of patient experience and patient, 
                caregiver, and family engagement;
                    (F) an assessment of the safety, effectiveness, and 
                timeliness of care; and
                    (G) other information as determined appropriate by 
                the Secretary.

    (b) Other Required Considerations.--In developing and implementing 
the plan described in subsection (a)(2), the Secretary shall, to the 
extent practicable, include--
            (1) processes to assure that data made public, either by the 
        Centers for Medicare & Medicaid Services or by other entities, 
        is statistically valid and reliable, including risk adjustment 
        mechanisms used by the Secretary;
            (2) processes by which a physician or other eligible 
        professional whose performance on measures is being publicly 
        reported has a reasonable opportunity, as determined by the 
        Secretary, to review his or her individual results before they 
        are made public;
            (3) processes by the Secretary to assure that the 
        implementation of the plan and the data made available on 
        Physician Compare provide a robust and accurate portrayal of a 
        physician's performance;
            (4) data that reflects the care provided to all patients 
        seen by physicians, under both the Medicare program and,

[[Page 124 STAT. 967]]

        to the extent practicable, other payers, to the extent such 
        information would provide a more accurate portrayal of physician 
        performance;
            (5) processes to ensure appropriate attribution of care when 
        multiple physicians and other providers are involved in the care 
        of a patient;
            (6) processes to ensure timely statistical performance 
        feedback is provided to physicians concerning the data reported 
        under any program subject to public reporting under this 
        section; and
            (7) implementation of computer and data systems of the 
        Centers for Medicare & Medicaid Services that support valid, 
        reliable, and accurate public reporting activities authorized 
        under this section.

    (c) Ensuring Patient Privacy.--The Secretary shall ensure that 
information on physician performance and patient experience is not 
disclosed under this section in a manner that violates sections 552 or 
552a of title 5, United States Code, with regard to the privacy of 
individually identifiable health information.
    (d) Feedback From Multi-stakeholder Groups.--The Secretary shall 
take into consideration input provided by multi-stakeholder groups, 
consistent with sections 1890(b)(7) and 1890A of the Social Security 
Act, as added by section 3014 of this Act, in selecting quality measures 
for use under this section.
    (e) Consideration of Transition to Value-based Purchasing.--In 
developing the plan under this subsection (a)(2), the Secretary shall, 
as the Secretary determines appropriate, consider the plan to transition 
to a value-based purchasing program for physicians and other 
practitioners developed under section 131 of the Medicare Improvements 
for Patients and Providers Act of 2008 (Public Law 110-275).
    (f) Report to Congress.--Not later than January 1, 2015, the 
Secretary shall submit to Congress a report on the Physician Compare 
Internet website developed under subsection (a)(1). Such report shall 
include information on the efforts of and plans made by the Secretary to 
collect and publish data on physician quality and efficiency and on 
patient experience of care in support of value-based purchasing and 
consumer choice, together with recommendations for such legislation and 
administrative action as the Secretary determines appropriate.
    (g) Expansion.--At any time before the date on which the report is 
submitted under subsection (f), the Secretary may expand (including 
expansion to other providers of services and suppliers under title XVIII 
of the Social Security Act) the information made available on such 
website.
    (h) Financial Incentives To Encourage Consumers To Choose High 
Quality Providers.-- <<NOTE: Deadline.>> The Secretary may establish a 
demonstration program, not later than January 1, 2019, to provide 
financial incentives to Medicare beneficiaries who are furnished 
services by high quality physicians, as determined by the Secretary 
based on factors in subparagraphs (A) through (G) of subsection (a)(2). 
In no case may Medicare beneficiaries be required to pay increased 
premiums or cost sharing or be subject to a reduction in benefits under 
title XVIII of the Social Security Act as a result of such demonstration 
program. The Secretary shall ensure that

[[Page 124 STAT. 968]]

any such demonstration program does not disadvantage those beneficiaries 
without reasonable access to high performing physicians or create 
financial inequities under such title.

    (i) Definitions.--In this section:
            (1) Eligible professional.--The term ``eligible 
        professional'' has the meaning given that term for purposes of 
        the Physician Quality Reporting Initiative under section 1848 of 
        the Social Security Act (42 U.S.C. 1395w-4).
            (2) Physician.--The term ``physician'' has the meaning given 
        that term in section 1861(r) of such Act (42 U.S.C. 1395x(r)).
            (3) Physician compare.--The term ``Physician Compare'' means 
        the Internet website developed under subsection (a)(1).
            (4) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.

SEC. 10332. AVAILABILITY OF MEDICARE DATA FOR PERFORMANCE MEASUREMENT.

    (a) In General.--Section 1874 of the Social Security Act (42 U.S.C. 
1395kk) is amended by adding at the end the following new subsection:
    ``(e) Availability of Medicare Data.--
            ``(1) In general.--Subject to paragraph (4), the Secretary 
        shall make available to qualified entities (as defined in 
        paragraph (2)) data described in paragraph (3) for the 
        evaluation of the performance of providers of services and 
        suppliers.
            ``(2) Qualified entities.--For purposes of this subsection, 
        the term `qualified entity' means a public or private entity 
        that--
                    ``(A) is qualified (as determined by the Secretary) 
                to use claims data to evaluate the performance of 
                providers of services and suppliers on measures of 
                quality, efficiency, effectiveness, and resource use; 
                and
                    ``(B) agrees to meet the requirements described in 
                paragraph (4) and meets such other requirements as the 
                Secretary may specify, such as ensuring security of 
                data.
            ``(3) Data described.--The data described in this paragraph 
        are standardized extracts (as determined by the Secretary) of 
        claims data under parts A, B, and D for items and services 
        furnished under such parts for one or more specified geographic 
        areas and time periods requested by a qualified entity. The 
        Secretary shall take such actions as the Secretary deems 
        necessary to protect the identity of individuals entitled to or 
        enrolled for benefits under such parts.
            ``(4) Requirements.--
                    ``(A) Fee.--Data described in paragraph (3) shall be 
                made available to a qualified entity under this 
                subsection at a fee equal to the cost of making such 
                data available. Any fee collected pursuant to the 
                preceding sentence shall be deposited into the Federal 
                Supplementary Medical Insurance Trust Fund under section 
                1841.
                    ``(B) Specification of uses and methodologies.--A 
                qualified entity requesting data under this subsection 
                shall--
                          ``(i) submit to the Secretary a description of 
                      the methodologies that such qualified entity will 
                      use to

[[Page 124 STAT. 969]]

                      evaluate the performance of providers of services 
                      and suppliers using such data;
                          ``(ii)(I) except as provided in subclause 
                      (II), if available, use standard measures, such as 
                      measures endorsed by the entity with a contract 
                      under section 1890(a) and measures developed 
                      pursuant to section 931 of the Public Health 
                      Service Act; or
                          ``(II) use alternative measures if the 
                      Secretary, in consultation with appropriate 
                      stakeholders, determines that use of such 
                      alternative measures would be more valid, 
                      reliable, responsive to consumer preferences, 
                      cost-effective, or relevant to dimensions of 
                      quality and resource use not addressed by such 
                      standard measures;
                          ``(iii) include data made available under this 
                      subsection with claims data from sources other 
                      than claims data under this title in the 
                      evaluation of performance of providers of services 
                      and suppliers;
                          ``(iv) only include information on the 
                      evaluation of performance of providers and 
                      suppliers in reports described in subparagraph 
                      (C);
                          ``(v) make available to providers of services 
                      and suppliers, upon their request, data made 
                      available under this subsection; and
                          ``(vi) prior to their release, submit to the 
                      Secretary the format of reports under subparagraph 
                      (C).
                    ``(C) Reports.--Any report by a qualified entity 
                evaluating the performance of providers of services and 
                suppliers using data made available under this 
                subsection shall--
                          ``(i) include an understandable description of 
                      the measures, which shall include quality measures 
                      and the rationale for use of other measures 
                      described in subparagraph (B)(ii)(II), risk 
                      adjustment methods, physician attribution methods, 
                      other applicable methods, data specifications and 
                      limitations, and the sponsors, so that consumers, 
                      providers of services and suppliers, health plans, 
                      researchers, and other stakeholders can assess 
                      such reports;
                          ``(ii) be made available confidentially, to 
                      any provider of services or supplier to be 
                      identified in such report, prior to the public 
                      release of such report, and provide an opportunity 
                      to appeal and correct errors;
                          ``(iii) only include information on a provider 
                      of services or supplier in an aggregate form as 
                      determined appropriate by the Secretary; and
                          ``(iv) <<NOTE: Public information.>> except as 
                      described in clause (ii), be made available to the 
                      public.
                    ``(D) Approval and limitation of uses.--The 
                Secretary shall not make data described in paragraph (3) 
                available to a qualified entity unless the qualified 
                entity agrees to release the information on the 
                evaluation of performance of providers of services and 
                suppliers. Such entity shall only use such data, and 
                information derived from such evaluation, for the 
                reports under subparagraph (C). Data released to a 
                qualified entity under this subsection shall not be 
                subject to discovery or admission as

[[Page 124 STAT. 970]]

                evidence in judicial or administrative proceedings 
                without consent of the applicable provider of services 
                or supplier.''.

    (b) <<NOTE: 42 USC 1395kk note.>> Effective Date.--The amendment 
made by subsection (a) shall take effect on January 1, 2012.

SEC. 10333. COMMUNITY-BASED COLLABORATIVE CARE NETWORKS.

    Part D of title III of the Public Health Service Act (42 U.S.C. 254b 
et seq.) is amended by adding at the end the following new subpart:

    ``Subpart XI--Community-Based Collaborative Care Network Program

``SEC. 340H. <<NOTE: 42 USC 256i.>> COMMUNITY-BASED COLLABORATIVE CARE 
            NETWORK PROGRAM.

    ``(a) In General.--The Secretary may award grants to eligible 
entities to support community-based collaborative care networks that 
meet the requirements of subsection (b).
    ``(b) Community-based Collaborative Care Networks.--
            ``(1) Description.--A community-based collaborative care 
        network (referred to in this section as a `network') shall be a 
        consortium of health care providers with a joint governance 
        structure (including providers within a single entity) that 
        provides comprehensive coordinated and integrated health care 
        services (as defined by the Secretary) for low-income 
        populations.
            ``(2) Required inclusion.--A network shall include the 
        following providers (unless such provider does not exist within 
        the community, declines or refuses to participate, or places 
        unreasonable conditions on their participation):
                    ``(A) A hospital that meets the criteria in section 
                1923(b)(1) of the Social Security Act; and
                    ``(B) All Federally qualified health centers (as 
                defined in section 1861(aa) of the Social Security Act 
                located in the community.
            ``(3) Priority.--In awarding grants, the Secretary shall 
        give priority to networks that include--
                    ``(A) the capability to provide the broadest range 
                of services to low-income individuals;
                    ``(B) the broadest range of providers that currently 
                serve a high volume of low-income individuals; and
                    ``(C) a county or municipal department of health.

    ``(c) Application.--
            ``(1) Application.--A network described in subsection (b) 
        shall submit an application to the Secretary.
            ``(2) Renewal.--In subsequent years, based on the 
        performance of grantees, the Secretary may provide renewal 
        grants to prior year grant recipients.

    ``(d) Use of Funds.--
            ``(1) Use by grantees.--Grant funds may be used for the 
        following activities:
                    ``(A) Assist low-income individuals to--
                          ``(i) access and appropriately use health 
                      services;
                          ``(ii) enroll in health coverage programs; and
                          ``(iii) obtain a regular primary care provider 
                      or a medical home.
                    ``(B) Provide case management and care management.

[[Page 124 STAT. 971]]

                    ``(C) Perform health outreach using neighborhood 
                health workers or through other means.
                    ``(D) Provide transportation.
                    ``(E) Expand capacity, including through telehealth, 
                after-hours services or urgent care.
                    ``(F) Provide direct patient care services.
            ``(2) Grant funds to hrsa grantees.--The Secretary may limit 
        the percent of grant funding that may be spent on direct care 
        services provided by grantees of programs administered by the 
        Health Resources and Services Administration or impose other 
        requirements on such grantees deemed necessary.

    ``(e) Authorization of Appropriations.--There are authorized to be 
appropriated to carry out this section such sums as may be necessary for 
each of fiscal years 2011 through 2015.''.

SEC. 10334. MINORITY HEALTH.

    (a) Office of Minority Health.--
            (1) In general.--Section 1707 of the Public Health Service 
        Act (42 U.S.C. 300u-6) is amended--
                    (A) <<NOTE: Establishment.>> in subsection (a), by 
                striking ``within the Office of Public Health and 
                Science'' and all that follows through the end and 
                inserting ``. The Office of Minority Health as existing 
                on the date of enactment of the Patient Protection and 
                Affordable Care Act shall be transferred to the Office 
                of the Secretary in such manner that there is 
                established in the Office of the Secretary, the Office 
                of Minority Health, which shall be headed by the Deputy 
                Assistant Secretary for Minority Health who shall report 
                directly to the Secretary, and shall retain and 
                strengthen authorities (as in existence on such date of 
                enactment) for the purpose of improving minority health 
                and the quality of health care minorities receive, and 
                eliminating racial and ethnic 
                disparities. <<NOTE: Grants. Contracts. Memorandum.>> In 
                carrying out this subsection, the Secretary, acting 
                through the Deputy Assistant Secretary, shall award 
                grants, contracts, enter into memoranda of 
                understanding, cooperative, interagency, intra-agency 
                and other agreements with public and nonprofit private 
                entities, agencies, as well as Departmental and Cabinet 
                agencies and organizations, and with organizations that 
                are indigenous human resource providers in communities 
                of color to assure improved health status of racial and 
                ethnic minorities, and shall develop measures to 
                evaluate the effectiveness of activities aimed at 
                reducing health disparities and supporting the local 
                community. Such measures shall evaluate community 
                outreach activities, language services, workforce 
                cultural competence, and other areas as determined by 
                the Secretary.''; and
                    (B) by striking subsection (h) and inserting the 
                following:

    ``(h) Authorization of Appropriations.--For the purpose of carrying 
out this section, there are authorized to be appropriated such sums as 
may be necessary for each of fiscal years 2011 through 2016.''.
            (2) <<NOTE: 42 USC 300u-6 note.>> Transfer of functions.--
        There are transferred to the Office of Minority Health in the 
        office of the Secretary of Health and Human Services, all 
        duties, responsibilities, authorities, accountabilities, 
        functions, staff, funds, award

[[Page 124 STAT. 972]]

        mechanisms, and other entities under the authority of the Office 
        of Minority Health of the Public Health Service as in effect on 
        the date before the date of enactment of this Act, which shall 
        continue in effect according to the terms in effect on the date 
        before such date of enactment, until modified, terminated, 
        superseded, set aside, or revoked in accordance with law by the 
        President, the Secretary, a court of competent jurisdiction, or 
        by operation of law.
            (3) Reports.-- <<NOTE: 42 USC 300u-6 note.>> Not later than 
        1 year after the date of enactment of this section, and 
        biennially thereafter, the Secretary of Health and Human 
        Services shall prepare and submit to the appropriate committees 
        of Congress a report describing the activities carried out under 
        section 1707 of the Public Health Service Act (as amended by 
        this subsection) during the period for which the report is being 
        prepared. Not later than 1 year after the date of enactment of 
        this section, and biennially thereafter, the heads of each of 
        the agencies of the Department of Health and Human Services 
        shall submit to the Deputy Assistant Secretary for Minority 
        Health a report summarizing the minority health activities of 
        each of the respective agencies.

    (b) Establishment of Individual Offices of Minority Health Within 
the Department of Health and Human Services.--
            (1) In general.--Title XVII of the Public Health Service Act 
        (42 U.S.C. 300u et seq.) is amended by inserting after section 
        1707 the following section:

``SEC. 1707A. <<NOTE: 42 USC 300u-6a.>> INDIVIDUAL OFFICES OF MINORITY 
            HEALTH WITHIN THE DEPARTMENT.

    ``(a) In General.--The head of each agency specified in subsection 
(b)(1) shall establish within the agency an office to be known as the 
Office of Minority Health. <<NOTE: Appointment.>> The head of each such 
Office shall be appointed by the head of the agency within which the 
Office is established, and shall report directly to the head of the 
agency. The head of such agency shall carry out this section (as this 
section relates to the agency) acting through such Director.

    ``(b) Specified Agencies.--The agencies referred to in subsection 
(a) are the Centers for Disease Control and Prevention, the Health 
Resources and Services Administration, the Substance Abuse and Mental 
Health Services Administration, the Agency for Healthcare Research and 
Quality, the Food and Drug Administration, and the Centers for Medicare 
& Medicaid Services.
    ``(c) Director; Appointment.--Each Office of Minority Health 
established in an agency listed in subsection (a) shall be headed by a 
director, with documented experience and expertise in minority health 
services research and health disparities elimination.
    ``(d) References.--Except as otherwise specified, any reference in 
Federal law to an Office of Minority Health (in the Department of Health 
and Human Services) is deemed to be a reference to the Office of 
Minority Health in the Office of the Secretary.
    ``(e) Funding.--
            ``(1) Allocations.--Of the amounts appropriated for a 
        specified agency for a fiscal year, the Secretary must designate 
        an appropriate amount of funds for the purpose of carrying out 
        activities under this section through the minority health office 
        of the agency. In reserving an amount under the preceding

[[Page 124 STAT. 973]]

        sentence for a minority health office for a fiscal year, the 
        Secretary shall reduce, by substantially the same percentage, 
        the amount that otherwise would be available for each of the 
        programs of the designated agency involved.
            ``(2) Availability of funds for staffing.--The purposes for 
        which amounts made available under paragraph may be expended by 
        a minority health office include the costs of employing staff 
        for such office.''.
            (2) <<NOTE: 42 USC 300u-6a note.>> No new regulatory 
        authority.--Nothing in this subsection and the amendments made 
        by this subsection may be construed as establishing regulatory 
        authority or modifying any existing regulatory authority.
            (3) <<NOTE: 42 USC 300u-6a note.>> Limitation on 
        termination.--Notwithstanding any other provision of law, a 
        Federal office of minority health or Federal appointive position 
        with primary responsibility over minority health issues that is 
        in existence in an office of agency of the Department of Health 
        and Human Services on the date of enactment of this section 
        shall not be terminated, reorganized, or have any of its power 
        or duties transferred unless such termination, reorganization, 
        or transfer is approved by an Act of Congress.

    (c) Redesignation of National Center on Minority Health and Health 
Disparities.--
            (1) Redesignation.--Title IV of the Public Health Service 
        Act (42 U.S.C. 281 et seq.) is amended--
                    (A) by redesignating subpart 6 of part E as subpart 
                20;
                    (B) by transferring subpart 20, as so redesignated, 
                to part C of such title IV;
                    (C) by inserting subpart 20, as so redesignated, 
                after subpart 19 of such part C; and
                    (D) in subpart 20, as so redesignated--
                          (i) by redesignating <<NOTE: 42 USC 285t--
                      285t-3.>> sections 485E through 485H as sections 
                      464z-3 through 464z-6, respectively;
                          (ii) <<NOTE: 42 USC 285t.>> by striking 
                      ``National Center on Minority Health and Health 
                      Disparities'' each place such term appears and 
                      inserting ``National Institute on Minority Health 
                      and Health Disparities''; and
                          (iii) <<NOTE: 42 USC 285t--285t-3.>> by 
                      striking ``Center'' each place such term appears 
                      and inserting ``Institute''.
            (2) Purpose of institute; duties.--Section 464z-3 of the 
        Public Health Service Act, as so redesignated, <<NOTE: 42 USC 
        285t.>> is amended--
                    (A) in subsection (h)(1), by striking ``research 
                endowments at centers of excellence under section 736.'' 
                and inserting the following: ``research endowments--
            ``(1) at centers of excellence under section 736; and
            ``(2) at centers of excellence under section 464z-4.'';
                    (B) in subsection (h)(2)(A), by striking ``average'' 
                and inserting ``median''; and
                    (C) by adding at the end the following:

    ``(h) Interagency Coordination.--The Director of the Institute, as 
the primary Federal officials with responsibility for coordinating all 
research and activities conducted or supported by the National 
Institutes of Health on minority health and health disparities, shall 
plan, coordinate, review and evaluate research and other activities 
conducted or supported by the Institutes and Centers of the National 
Institutes of Health.''.

[[Page 124 STAT. 974]]

            (3) Technical and conforming amendments.--
                    (A) Section 401(b)(24) of the Public Health Service 
                Act (42 U.S.C. 281(b)(24)) is amended by striking 
                ``Center'' and inserting ``Institute''.
                    (B) Subsection (d)(1) of section 903 of the Public 
                Health Service Act (42 U.S.C. 299a-1(d)(1)) is amended 
                by striking ``section 485E'' and inserting ``section 
                464z-3''.

SEC. 10335. TECHNICAL CORRECTION TO THE HOSPITAL VALUE-BASED PURCHASING 
            PROGRAM.

    Section 1886(o)(2)A) of the Social Security Act, as added by section 
3001, <<NOTE: 42 USC 1395ww.>> is amended, in the first sentence, by 
inserting ``, other than measures of readmissions,'' after ``shall 
select measures''.

SEC. 10336. GAO STUDY AND REPORT ON MEDICARE BENEFICIARY ACCESS TO HIGH-
            QUALITY DIALYSIS SERVICES.

    (a) Study.--
            (1) In general.--The Comptroller General of the United 
        States shall conduct a study on the impact on Medicare 
        beneficiary access to high-quality dialysis services of 
        including specified oral drugs that are furnished to such 
        beneficiaries for the treatment of end stage renal disease in 
        the bundled prospective payment system under section 1881(b)(14) 
        of the Social Security Act (42 U.S.C. 1395rr(b)(14)) (pursuant 
        to the proposed rule published by the Secretary of Health and 
        Human Services in the Federal Register on September 29, 2009 (74 
        Fed. Reg. 49922 et seq.)). Such study shall include an analysis 
        of--
                    (A) the ability of providers of services and renal 
                dialysis facilities to furnish specified oral drugs or 
                arrange for the provision of such drugs;
                    (B) the ability of providers of services and renal 
                dialysis facilities to comply, if necessary, with 
                applicable State laws (such as State pharmacy licensure 
                requirements) in order to furnish specified oral drugs;
                    (C) whether appropriate quality measures exist to 
                safeguard care for Medicare beneficiaries being 
                furnished specified oral drugs by providers of services 
                and renal dialysis facilities; and
                    (D) other areas determined appropriate by the 
                Comptroller General.
            (2) Specified oral drug defined.--For purposes of paragraph 
        (1), the term ``specified oral drug'' means a drug or biological 
        for which there is no injectable equivalent (or other non-oral 
        form of administration).

    (b) Report.--Not later than 1 year after the date of the enactment 
of this Act, the Comptroller General of the United States shall submit 
to Congress a report containing the results of the study conducted under 
subsection (a), together with recommendations for such legislation and 
administrative action as the Comptroller General determines appropriate.

               Subtitle D--Provisions Relating to Title IV

SEC. 10401. AMENDMENTS TO SUBTITLE A.

    (a) Section 4001(h)(4) and (5) of this Act <<NOTE: 42 USC 300u-
10.>> is amended by striking ``2010'' each place such appears and 
inserting ``2020''.

    (b) Section 4002(c) of this Act <<NOTE: 42 USC 300u-11.>> is 
amended--

[[Page 124 STAT. 975]]

            (1) by striking ``research and health screenings'' and 
        inserting ``research, health screenings, and initiatives''; and
            (2) by striking ``for Preventive'' and inserting ``Regarding 
        Preventive''.

    (c) Section 4004(a)(4) of this Act <<NOTE: 42 USC 300u-12.>> is 
amended by striking ``a Gateway'' and inserting ``an Exchange''.

SEC. 10402. AMENDMENTS TO SUBTITLE B.

    (a) Section 399Z-1(a)(1(A) of the Public Health Service Act, as 
added by section 4101(b) of this Act, <<NOTE: 42 USC 280n-5.>> is 
amended by inserting ``and vision'' after ``oral''.

    (b) Section 1861(hhh)(4)(G) of the Social Security Act, as added by 
section 4103(b), <<NOTE: 42 USC 1395k.>> is amended to read as follows:
                    ``(G) A beneficiary shall be eligible to receive 
                only an initial preventive physical examination (as 
                defined under subsection (ww)(1)) during the 12-month 
                period after the date that the beneficiary's coverage 
                begins under part B and shall be eligible to receive 
                personalized prevention plan services under this 
                subsection each year thereafter provided that the 
                beneficiary has not received either an initial 
                preventive physical examination or personalized 
                prevention plan services within the preceding 12-month 
                period.''.

SEC. 10403. AMENDMENTS TO SUBTITLE C.

    Section 4201 of this Act <<NOTE: 42 USC 300u-13.>> is amended--
            (1) in subsection (a), by adding before the period the 
        following: ``, with not less than 20 percent of such grants 
        being awarded to rural and frontier areas'';
            (2) in subsection (c)(2)(B)(vii), by striking ``both urban 
        and rural areas'' and inserting ``urban, rural, and frontier 
        areas''; and
            (3) in subsection (f), by striking ``each fiscal years'' and 
        inserting ``each of fiscal year''.

SEC. 10404. AMENDMENTS TO SUBTITLE D.

    Section 399MM(2) of the Public Health Service Act, as added by 
section 4303 of this Act, <<NOTE: 42 USC 280l.>> is amended by striking 
``by ensuring'' and inserting ``and ensuring''.

SEC. 10405. AMENDMENTS TO SUBTITLE E.

    Subtitle E of title IV of this Act is amended by striking section 
4401.

SEC. 10406. AMENDMENT RELATING TO WAIVING COINSURANCE FOR PREVENTIVE 
            SERVICES.

    Section 4104(b) of this Act is amended to read as follows:
    ``(b) Payment and Elimination of Coinsurance in All Settings.--
Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), 
as amended by section 4103(c)(1), is amended--
            ``(1) in subparagraph (T), by inserting `(or 100 percent if 
        such services are recommended with a grade of A or B by the 
        United States Preventive Services Task Force for any indication 
        or population and are appropriate for the individual)' after `80 
        percent';
            ``(2) in subparagraph (W)--

[[Page 124 STAT. 976]]

                    ``(A) in clause (i), by inserting `(if such 
                subparagraph were applied, by substituting ``100 
                percent'' for ``80 percent'')' after `subparagraph (D)'; 
                and
                    ``(B) in clause (ii), by striking `80 percent' and 
                inserting `100 percent';
            ``(3) by striking `and' before `(X)'; and
            ``(4) by inserting before the semicolon at the end the 
        following: `, and (Y) with respect to preventive services 
        described in subparagraphs (A) and (B) of section 1861(ddd)(3) 
        that are appropriate for the individual and, in the case of such 
        services described in subparagraph (A), are recommended with a 
        grade of A or B by the United States Preventive Services Task 
        Force for any indication or population, the amount paid shall be 
        100 percent of (i) except as provided in clause (ii), the lesser 
        of the actual charge for the services or the amount determined 
        under the fee schedule that applies to such services under this 
        part, and (ii) in the case of such services that are covered OPD 
        services (as defined in subsection (t)(1)(B)), the amount 
        determined under subsection (t)'.''.

SEC. 10407. <<NOTE: Catalyst to Better Diabetes Care Act of 2009. 42 USC 
            247b-9g.>> BETTER DIABETES CARE.

    (a) Short Title.--This section may be cited as the ``Catalyst to 
Better Diabetes Care Act of 2009''.
    (b) National Diabetes Report Card.--
            (1) In general.--The Secretary, in collaboration with the 
        Director of the Centers for Disease Control and Prevention 
        (referred to in this section as the ``Director''), shall prepare 
        on a biennial basis a national diabetes report card (referred to 
        in this section as a ``Report Card'') and, to the extent 
        possible, for each State.
            (2) Contents.--
                    (A) In general.--Each Report Card shall include 
                aggregate health outcomes related to individuals 
                diagnosed with diabetes and prediabetes including--
                          (i) preventative care practices and quality of 
                      care;
                          (ii) risk factors; and
                          (iii) outcomes.
                    (B) Updated reports.--Each Report Card that is 
                prepared after the initial Report Card shall include 
                trend analysis for the Nation and, to the extent 
                possible, for each State, for the purpose of--
                          (i) tracking progress in meeting established 
                      national goals and objectives for improving 
                      diabetes care, costs, and prevalence (including 
                      Healthy People 2010); and
                          (ii) informing policy and program development.
            (3) <<NOTE: Public information. Web 
        posting.>> Availability.--The Secretary, in collaboration with 
        the Director, shall make each Report Card publicly available, 
        including by posting the Report Card on the Internet.

    (c) Improvement of Vital Statistics Collection.--
            (1) In general.--The Secretary, acting through the Director 
        of the Centers for Disease Control and Prevention and in 
        collaboration with appropriate agencies and States, shall--
                    (A) promote the education and training of physicians 
                on the importance of birth and death certificate data 
                and how to properly complete these documents, including 
                the

[[Page 124 STAT. 977]]

                collection of such data for diabetes and other chronic 
                diseases;
                    (B) encourage State adoption of the latest standard 
                revisions of birth and death certificates; and
                    (C) work with States to re-engineer their vital 
                statistics systems in order to provide cost-effective, 
                timely, and accurate vital systems data.
            (2) Death certificate additional language.--In carrying out 
        this subsection, the Secretary may promote improvements to the 
        collection of diabetes mortality data, including the addition of 
        a question for the individual certifying the cause of death 
        regarding whether the deceased had diabetes.

    (d) Study on Appropriate Level of Diabetes Medical Education.--
            (1) In general.--The Secretary shall, in collaboration with 
        the Institute of Medicine and appropriate associations and 
        councils, conduct a study of the impact of diabetes on the 
        practice of medicine in the United States and the 
        appropriateness of the level of diabetes medical education that 
        should be required prior to licensure, board certification, and 
        board recertification.
            (2) Report.--Not later than 2 years after the date of the 
        enactment of this Act, the Secretary shall submit a report on 
        the study under paragraph (1) to the Committees on Ways and 
        Means and Energy and Commerce of the House of Representatives 
        and the Committees on Finance and Health, Education, Labor, and 
        Pensions of the Senate.

    (e) Authorization of Appropriations.--There are authorized to be 
appropriated to carry out this section such sums as may be necessary.

SEC. 10408. GRANTS FOR SMALL BUSINESSES TO PROVIDE COMPREHENSIVE 
            WORKPLACE WELLNESS PROGRAMS.

    (a) Establishment.--The Secretary shall award grants to eligible 
employers to provide their employees with access to comprehensive 
workplace wellness programs (as described under subsection (c)).
    (b) Scope.--
            (1) Duration.--The grant program established under this 
        section shall be conducted for a 5-year period.
            (2) Eligible employer.-- <<NOTE: Definition.>> The term 
        ``eligible employer'' means an employer (including a non-profit 
        employer) that--
                    (A) employs less than 100 employees who work 25 
                hours or greater per week; and
                    (B) does not provide a workplace wellness program as 
                of the date of enactment of this Act.

    (c) Comprehensive Workplace Wellness Programs.--
            (1) Criteria.--The Secretary shall develop program criteria 
        for comprehensive workplace wellness programs under this section 
        that are based on and consistent with evidence-based research 
        and best practices, including research and practices as provided 
        in the Guide to Community Preventive Services, the Guide to 
        Clinical Preventive Services, and the National Registry for 
        Effective Programs.
            (2) Requirements.--A comprehensive workplace wellness 
        program shall be made available by an eligible employer to all 
        employees and include the following components:

[[Page 124 STAT. 978]]

                    (A) Health awareness initiatives (including health 
                education, preventive screenings, and health risk 
                assessments).
                    (B) Efforts to maximize employee engagement 
                (including mechanisms to encourage employee 
                participation).
                    (C) Initiatives to change unhealthy behaviors and 
                lifestyle choices (including counseling, seminars, 
                online programs, and self-help materials).
                    (D) Supportive environment efforts (including 
                workplace policies to encourage healthy lifestyles, 
                healthy eating, increased physical activity, and 
                improved mental health).

    (d) Application.--An eligible employer desiring to participate in 
the grant program under this section shall submit an application to the 
Secretary, in such manner and containing such information as the 
Secretary may require, which shall include a proposal for a 
comprehensive workplace wellness program that meet the criteria and 
requirements described under subsection (c).
    (e) Authorization of Appropriation.--For purposes of carrying out 
the grant program under this section, there is authorized to be 
appropriated $200,000,000 for the period of fiscal years 2011 through 
2015. Amounts appropriated pursuant to this subsection shall remain 
available until expended.

SEC. 10409. <<NOTE: Cures Acceleration Network Act of 2009. 42 USC 201 
            note.>> CURES ACCELERATION NETWORK.

    (a) Short Title.--This section may be cited as the ``Cures 
Acceleration Network Act of 2009''.
    (b) Requirement for the Director of NIH To Establish a Cures 
Acceleration Network.--Section 402(b) of the Public Health Service Act 
(42 U.S.C. 282(b)) is amended--
            (1) in paragraph (22), by striking ``and'' at the end;
            (2) in paragraph (23), by striking the period and inserting 
        ``; and''; and
            (3) by inserting after paragraph (23), the following:
            ``(24) implement the Cures Acceleration Network described in 
        section 402C.''.

    (c) Accepting Gifts To Support the Cures Acceleration Network.--
Section 499(c)(1) of the Public Health Service Act (42 U.S.C. 
290b(c)(1)) is amended by adding at the end the following:
                    ``(E) The Cures Acceleration Network described in 
                section 402C.''.

    (d) Establishment of the Cures Acceleration Network.--Part A of 
title IV of the Public Health Service Act is amended by inserting after 
section 402B (42 U.S.C. 282b) the following:

``SEC. 402C. <<NOTE: 42 USC 282d.>> CURES ACCELERATION NETWORK.

    ``(a) Definitions.--In this section:
            ``(1) Biological product.--The term `biological product' has 
        the meaning given such term in section 351 of the Public Health 
        Service Act.
            ``(2) Drug; device.--The terms `drug' and `device' have the 
        meanings given such terms in section 201 of the Federal Food, 
        Drug, and Cosmetic Act.
            ``(3) High need cure.--The term `high need cure' means a 
        drug (as that term is defined by section 201(g)(1) of the 
        Federal Food, Drug, and Cosmetic Act, biological product (as 
        that term is defined by section 262(i)), or device (as that term 
        is defined by section 201(h) of the Federal Food, Drug, and

[[Page 124 STAT. 979]]

        Cosmetic Act) that, in the determination of the Director of 
        NIH--
                    ``(A) is a priority to diagnose, mitigate, prevent, 
                or treat harm from any disease or condition; and
                    ``(B) for which the incentives of the commercial 
                market are unlikely to result in its adequate or timely 
                development.
            ``(4) Medical product.--The term `medical product' means a 
        drug, device, biological product, or product that is a 
        combination of drugs, devices, and biological products.

    ``(b) Establishment of the Cures Acceleration Network.--Subject to 
the appropriation of funds as described in subsection (g), there is 
established within the Office of the Director of NIH a program to be 
known as the Cures Acceleration Network (referred to in this section as 
`CAN'), which shall--
            ``(1) be under the direction of the Director of NIH, taking 
        into account the recommendations of a CAN Review Board (referred 
        to in this section as the `Board'), described in subsection (d); 
        and
            ``(2) <<NOTE: Grants. Contracts.>> award grants and 
        contracts to eligible entities, as described in subsection (e), 
        to accelerate the development of high need cures, including 
        through the development of medical products and behavioral 
        therapies.

    ``(c) Functions.--The functions of the CAN are to--
            ``(1) conduct and support revolutionary advances in basic 
        research, translating scientific discoveries from bench to 
        bedside;
            ``(2) award grants and contracts to eligible entities to 
        accelerate the development of high need cures;
            ``(3) provide the resources necessary for government 
        agencies, independent investigators, research organizations, 
        biotechnology companies, academic research institutions, and 
        other entities to develop high need cures;
            ``(4) reduce the barriers between laboratory discoveries and 
        clinical trials for new therapies; and
            ``(5) facilitate review in the Food and Drug Administration 
        for the high need cures funded by the CAN, through activities 
        that may include--
                    ``(A) the facilitation of regular and ongoing 
                communication with the Food and Drug Administration 
                regarding the status of activities conducted under this 
                section;
                    ``(B) ensuring that such activities are coordinated 
                with the approval requirements of the Food and Drug 
                Administration, with the goal of expediting the 
                development and approval of countermeasures and 
                products; and
                    ``(C) connecting interested persons with additional 
                technical assistance made available under section 565 of 
                the Federal Food, Drug, and Cosmetic Act.

    ``(d) CAN Board.--
            ``(1) Establishment.--There is established a Cures 
        Acceleration Network Review Board (referred to in this section 
        as the `Board'), which shall advise the Director of NIH on the 
        conduct of the activities of the Cures Acceleration Network.
            ``(2) Membership.--
                    ``(A) In general.--
                          ``(i) Appointment.--The Board shall be 
                      comprised of 24 members who are appointed by the 
                      Secretary and who serve at the pleasure of the 
                      Secretary.

[[Page 124 STAT. 980]]

                          ``(ii) Chairperson and vice chairperson.--The 
                      Secretary shall designate, from among the 24 
                      members appointed under clause (i), one 
                      Chairperson of the Board (referred to in this 
                      section as the `Chairperson') and one Vice 
                      Chairperson.
                    ``(B) Terms.--
                          ``(i) In general.--Each member shall be 
                      appointed to serve a 4-year term, except that any 
                      member appointed to fill a vacancy occurring prior 
                      to the expiration of the term for which the 
                      member's predecessor was appointed shall be 
                      appointed for the remainder of such term.
                          ``(ii) Consecutive appointments; maximum 
                      terms.--A member may be appointed to serve not 
                      more than 3 terms on the Board, and may not serve 
                      more than 2 such terms consecutively.
                    ``(C) Qualifications.--
                          ``(i) In general.--The Secretary shall appoint 
                      individuals to the Board based solely upon the 
                      individual's established record of distinguished 
                      service in one of the areas of expertise described 
                      in clause (ii). Each individual appointed to the 
                      Board shall be of distinguished achievement and 
                      have a broad range of disciplinary interests.
                          ``(ii) Expertise.--The Secretary shall select 
                      individuals based upon the following requirements:
                                    ``(I) For each of the fields of--
                                            ``(aa) basic research;
                                            ``(bb) medicine;
                                            ``(cc) biopharmaceuticals;
                                            ``(dd) discovery and 
                                        delivery of medical products;
                                            ``(ee) bioinformatics and 
                                        gene therapy;
                                            ``(ff) medical 
                                        instrumentation; and
                                            ``(gg) regulatory review and 
                                        approval of medical products,
                                the Secretary shall select at least 1 
                                individual who is eminent in such 
                                fields.
                                    ``(II) At least 4 individuals shall 
                                be recognized leaders in professional 
                                venture capital or private equity 
                                organizations and have demonstrated 
                                experience in private equity investing.
                                    ``(III) At least 8 individuals shall 
                                represent disease advocacy 
                                organizations.
            ``(3) Ex-officio members.--
                    ``(A) Appointment.--In addition to the 24 Board 
                members described in paragraph (2), the Secretary shall 
                appoint as ex-officio members of the Board--
                          ``(i) a representative of the National 
                      Institutes of Health, recommended by the Secretary 
                      of the Department of Health and Human Services;
                          ``(ii) a representative of the Office of the 
                      Assistant Secretary of Defense for Health Affairs, 
                      recommended by the Secretary of Defense;

[[Page 124 STAT. 981]]

                          ``(iii) a representative of the Office of the 
                      Under Secretary for Health for the Veterans Health 
                      Administration, recommended by the Secretary of 
                      Veterans Affairs;
                          ``(iv) a representative of the National 
                      Science Foundation, recommended by the Chair of 
                      the National Science Board; and
                          ``(v) a representative of the Food and Drug 
                      Administration, recommended by the Commissioner of 
                      Food and Drugs.
                    ``(B) Terms.--Each ex-officio member shall serve a 
                3-year term on the Board, except that the Chairperson 
                may adjust the terms of the initial ex-officio members 
                in order to provide for a staggered term of appointment 
                for all such members.
            ``(4) Responsibilities of the board and the director of 
        nih.--
                    ``(A) Responsibilities of the board.--
                          ``(i) In general.-- <<NOTE: Recommenda- 
                      tions.>> The Board shall advise, and provide 
                      recommendations to, the Director of NIH with 
                      respect to--
                                    ``(I) policies, programs, and 
                                procedures for carrying out the duties 
                                of the Director of NIH under this 
                                section; and
                                    ``(II) significant barriers to 
                                successful translation of basic science 
                                into clinical application (including 
                                issues under the purview of other 
                                agencies and departments).
                          ``(ii) Report.--In the case that the Board 
                      identifies a significant barrier, as described in 
                      clause (i)(II), the Board shall submit to the 
                      Secretary a report regarding such barrier.
                    ``(B) Responsibilities of the director of nih.--With 
                respect to each recommendation provided by the Board 
                under subparagraph (A)(i), the Director of NIH shall 
                respond in writing to the Board, indicating whether such 
                Director will implement such recommendation. In the case 
                that the Director of NIH indicates a recommendation of 
                the Board will not be implemented, such Director shall 
                provide an explanation of the reasons for not 
                implementing such recommendation.
            ``(5) Meetings.--
                    ``(A) In general.--The Board shall meet 4 times per 
                calendar year, at the call of the Chairperson.
                    ``(B) Quorum; requirements; limitations.--
                          ``(i) Quorum.--A quorum shall consist of a 
                      total of 13 members of the Board, excluding ex-
                      officio members, with diverse representation as 
                      described in clause (iii).
                          ``(ii) Chairperson or vice chairperson.--Each 
                      meeting of the Board shall be attended by either 
                      the Chairperson or the Vice Chairperson.
                          ``(iii) Diverse representation.--At each 
                      meeting of the Board, there shall be not less than 
                      one scientist, one representative of a disease 
                      advocacy organization, and one representative of a 
                      professional venture capital or private equity 
                      organization.

[[Page 124 STAT. 982]]

            ``(6) Compensation and travel expenses.--
                    ``(A) Compensation.--Members shall receive 
                compensation at a rate to be fixed by the Chairperson 
                but not to exceed a rate equal to the daily equivalent 
                of the annual rate of basic pay prescribed for level IV 
                of the Executive Schedule under section 5315 of title 5, 
                United States Code, for each day (including travel time) 
                during which the member is engaged in the performance of 
                the duties of the Board. All members of the Board who 
                are officers or employees of the United States shall 
                serve without compensation in addition to that received 
                for their services as officers or employees of the 
                United States.
                    ``(B) Travel expenses.--Members of the Board shall 
                be allowed travel expenses, including per diem in lieu 
                of subsistence, at rates authorized for persons employed 
                intermittently by the Federal Government under section 
                5703(b) of title 5, United States Code, while away from 
                their homes or regular places of business in the 
                performance of services for the Board.

    ``(e) Grant Program.--
            ``(1) Supporting innovation.-- <<NOTE: Contracts.>> To carry 
        out the purposes described in this section, the Director of NIH 
        shall award contracts, grants, or cooperative agreements to the 
        entities described in paragraph (2), to--
                    ``(A) promote innovation in technologies supporting 
                the advanced research and development and production of 
                high need cures, including through the development of 
                medical products and behavioral therapies.
                    ``(B) accelerate the development of high need cures, 
                including through the development of medical products, 
                behavioral therapies, and biomarkers that demonstrate 
                the safety or effectiveness of medical products; or
                    ``(C) help the award recipient establish protocols 
                that comply with Food and Drug Administration standards 
                and otherwise permit the recipient to meet regulatory 
                requirements at all stages of development, 
                manufacturing, review, approval, and safety surveillance 
                of a medical product.
            ``(2) Eligible entities.--To receive assistance under 
        paragraph (1), an entity shall--
                    ``(A) be a public or private entity, which may 
                include a private or public research institution, an 
                institution of higher education, a medical center, a 
                biotechnology company, a pharmaceutical company, a 
                disease advocacy organization, a patient advocacy 
                organization, or an academic research institution;
                    ``(B) submit an application containing--
                          ``(i) a detailed description of the project 
                      for which the entity seeks such grant or contract;
                          ``(ii) a timetable for such project;
                          ``(iii) an assurance that the entity will 
                      submit--
                                    ``(I) interim reports describing the 
                                entity's--
                                            ``(aa) progress in carrying 
                                        out the project; and
                                            ``(bb) compliance with all 
                                        provisions of this section and 
                                        conditions of receipt of such 
                                        grant or contract; and

[[Page 124 STAT. 983]]

                                    ``(II) a final report at the 
                                conclusion of the grant period, 
                                describing the outcomes of the project; 
                                and
                          ``(iv) a description of the protocols the 
                      entity will follow to comply with Food and Drug 
                      Administration standards and regulatory 
                      requirements at all stages of development, 
                      manufacturing, review, approval, and safety 
                      surveillance of a medical product; and
                    ``(C) provide such additional information as the 
                Director of NIH may require.
            ``(3) Awards.--
                    ``(A) The cures acceleration partnership awards.--
                          ``(i) Initial award amount.--Each award under 
                      this subparagraph shall be not more than 
                      $15,000,000 per project for the first fiscal year 
                      for which the project is funded, which shall be 
                      payable in one payment.
                          ``(ii) Funding in subsequent fiscal years.--An 
                      eligible entity receiving an award under clause 
                      (i) may apply for additional funding for such 
                      project by submitting to the Director of NIH the 
                      information required under subparagraphs (B) and 
                      (C) of paragraph (2). The Director may fund a 
                      project of such eligible entity in an amount not 
                      to exceed $15,000,000 for a fiscal year subsequent 
                      to the initial award under clause (i).
                          ``(iii) Matching funds.-- <<NOTE: Waiver 
                      authority.>> As a condition for receiving an award 
                      under this subsection, an eligible entity shall 
                      contribute to the project non-Federal funds in the 
                      amount of $1 for every $3 awarded under clauses 
                      (i) and (ii), except that the Director of NIH may 
                      waive or modify such matching requirement in any 
                      case where the Director determines that the goals 
                      and objectives of this section cannot adequately 
                      be carried out unless such requirement is waived.
                    ``(B) The cures acceleration grant awards.--
                          ``(i) Initial award amount.--Each award under 
                      this subparagraph shall be not more than 
                      $15,000,000 per project for the first fiscal year 
                      for which the project is funded, which shall be 
                      payable in one payment.
                          ``(ii) Funding in subsequent fiscal years.--An 
                      eligible entity receiving an award under clause 
                      (i) may apply for additional funding for such 
                      project by submitting to the Board the information 
                      required under subparagraphs (B) and (C) of 
                      paragraph (2). The Director of NIH may fund a 
                      project of such eligible entity in an amount not 
                      to exceed $15,000,000 for a fiscal year subsequent 
                      to the initial award under clause (i).
                    ``(C) The cures acceleration flexible research 
                awards.-- <<NOTE: Determination.>> If the Director of 
                NIH determines that the goals and objectives of this 
                section cannot adequately be carried out through a 
                contract, grant, or cooperative agreement, the Director 
                of NIH shall have flexible research authority to use 
                other transactions to fund projects in accordance with 
                the terms and conditions of this section. Awards made 
                under such flexible research authority for a fiscal year 
                shall not exceed 20 percent of the total funds 
                appropriated under subsection (g)(1) for such fiscal 
                year.

[[Page 124 STAT. 984]]

            ``(4) Suspension of awards for defaults, noncompliance with 
        provisions and plans, and diversion of funds; repayment of 
        funds.--The Director of NIH may suspend the award to any entity 
        upon noncompliance by such entity with provisions and plans 
        under this section or diversion of funds.
            ``(5) Audits.--The Director of NIH may enter into agreements 
        with other entities to conduct periodic audits of the projects 
        funded by grants or contracts awarded under this subsection.
            ``(6) Closeout procedures.--At the end of a grant or 
        contract period, a recipient shall follow the closeout 
        procedures under section 74.71 of title 45, Code of Federal 
        Regulations (or any successor regulation).
            ``(7) Review.--A determination by the Director of NIH as to 
        whether a drug, device, or biological product is a high need 
        cure (for purposes of subsection (a)(3)) shall not be subject to 
        judicial review.

    ``(f) Competitive Basis of Awards.--Any grant, cooperative 
agreement, or contract awarded under this section shall be awarded on a 
competitive basis.
    ``(g) Authorization of Appropriations.--
            ``(1) In general.--For purposes of carrying out this 
        section, there are authorized to be appropriated $500,000,000 
        for fiscal year 2010, and such sums as may be necessary for 
        subsequent fiscal years. Funds appropriated under this section 
        shall be available until expended.
            ``(2) Limitation on use of funds otherwise appropriated.--No 
        funds appropriated under this Act, other than funds appropriated 
        under paragraph (1), may be allocated to the Cures Acceleration 
        Network.''.

SEC. 10410. <<NOTE: Establishing a Network of Health-Advancing National 
            Centers of Excellence for Depression Act of 2009. 42 USC 201 
            note.>> CENTERS OF EXCELLENCE FOR DEPRESSION.

    (a) Short Title.--This section may be cited as the ``Establishing a 
Network of Health-Advancing National Centers of Excellence for 
Depression Act of 2009'' or the ``ENHANCED Act of 2009''.
    (b) Centers of Excellence for Depression.--Subpart 3 of part B of 
title V of the Public Health Service Act (42 U.S.C. 290bb et seq.) is 
amended by inserting after section 520A the following:

``SEC. 520B. <<NOTE: 42 USC 290bb-33.>> NATIONAL CENTERS OF EXCELLENCE 
            FOR DEPRESSION.

    ``(a) Depressive Disorder Defined.--In this section, the term 
`depressive disorder' means a mental or brain disorder relating to 
depression, including major depression, bipolar disorder, and related 
mood disorders.
    ``(b) Grant Program.--
            ``(1) In general.--The Secretary, acting through the 
        Administrator, shall award grants on a competitive basis to 
        eligible entities to establish national centers of excellence 
        for depression (referred to in this section as `Centers'), which 
        shall engage in activities related to the treatment of 
        depressive disorders.
            ``(2) Allocation of awards.-- <<NOTE: Deadlines.>> If the 
        funds authorized under subsection (f) are appropriated in the 
        amounts provided for under such subsection, the Secretary shall 
        allocate such amounts so that--

[[Page 124 STAT. 985]]

                    ``(A) not later than 1 year after the date of 
                enactment of the ENHANCED Act of 2009, not more than 20 
                Centers may be established; and
                    ``(B) not later than September 30, 2016, not more 
                than 30 Centers may be established.
            ``(3) Grant period.--
                    ``(A) In general.--A grant awarded under this 
                section shall be for a period of 5 years.
                    ``(B) Renewal.--A grant awarded under subparagraph 
                (A) may be renewed, on a competitive basis, for 1 
                additional 5-year period, at the discretion of the 
                Secretary. In determining whether to renew a grant, the 
                Secretary shall consider the report cards issued under 
                subsection (e)(2).
            ``(4) Use of funds.--Grant funds awarded under this 
        subsection shall be used for the establishment and ongoing 
        activities of the recipient of such funds.
            ``(5) Eligible entities.--
                    ``(A) Requirements.--To be eligible to receive a 
                grant under this section, an entity shall--
                          ``(i) be an institution of higher education or 
                      a public or private nonprofit research 
                      institution; and
                          ``(ii) submit an application to the Secretary 
                      at such time and in such manner as the Secretary 
                      may require, as described in subparagraph (B).
                    ``(B) Application.--An application described in 
                subparagraph (A)(ii) shall include--
                          ``(i) evidence that such entity--
                                    ``(I) provides, or is capable of 
                                coordinating with other entities to 
                                provide, comprehensive health services 
                                with a focus on mental health services 
                                and subspecialty expertise for 
                                depressive disorders;
                                    ``(II) collaborates with other 
                                mental health providers, as necessary, 
                                to address co-occurring mental 
                                illnesses;
                                    ``(III) is capable of training 
                                health professionals about mental 
                                health; and
                          ``(ii) such other information, as the 
                      Secretary may require.
                    ``(C) Priorities.--In awarding grants under this 
                section, the Secretary shall give priority to eligible 
                entities that meet 1 or more of the following criteria:
                          ``(i) Demonstrated capacity and expertise to 
                      serve the targeted population.
                          ``(ii) Existing infrastructure or expertise to 
                      provide appropriate, evidence-based and culturally 
                      and linguistically competent services.
                          ``(iii) A location in a geographic area with 
                      disproportionate numbers of underserved and at-
                      risk populations in medically underserved areas 
                      and health professional shortage areas.
                          ``(iv) Proposed innovative approaches for 
                      outreach to initiate or expand services.
                          ``(v) Use of the most up-to-date science, 
                      practices, and interventions available.
                          ``(vi) Demonstrated capacity to establish 
                      cooperative and collaborative agreements with 
                      community mental health centers and other 
                      community entities

[[Page 124 STAT. 986]]

                      to provide mental health, social, and human 
                      services to individuals with depressive disorders.
            ``(6) National coordinating center.--
                    ``(A) In general.-- <<NOTE: Designation.>> The 
                Secretary, acting through the Administrator, shall 
                designate 1 recipient of a grant under this section to 
                be the coordinating center of excellence for depression 
                (referred to in this section as the `coordinating 
                center'). The Secretary shall select such coordinating 
                center on a competitive basis, based upon the 
                demonstrated capacity of such center to perform the 
                duties described in subparagraph (C).
                    ``(B) Application.--A Center that has been awarded a 
                grant under paragraph (1) may apply for designation as 
                the coordinating center by submitting an application to 
                the Secretary at such time, in such manner, and 
                containing such information as the Secretary may 
                require.
                    ``(C) Duties.--The coordinating center shall--
                          ``(i) develop, administer, and coordinate the 
                      network of Centers under this section;
                          ``(ii) oversee and coordinate the national 
                      database described in subsection (d);
                          ``(iii) lead a strategy to disseminate the 
                      findings and activities of the Centers through 
                      such database; and
                          ``(iv) serve as a liaison with the 
                      Administration, the National Registry of Evidence-
                      based Programs and Practices of the 
                      Administration, and any Federal interagency or 
                      interagency forum on mental health.
            ``(7) Matching funds.--The Secretary may not award a grant 
        or contract under this section to an entity unless the entity 
        agrees that it will make available (directly or through 
        contributions from other public or private entities) non-Federal 
        contributions toward the activities to be carried out under the 
        grant or contract in an amount equal to $1 for each $5 of 
        Federal funds provided under the grant or contract. Such non-
        Federal matching funds may be provided directly or through 
        donations from public or private entities and may be in cash or 
        in-kind, fairly evaluated, including plant, equipment, or 
        services.

    ``(c) Activities of the Centers.--Each Center shall carry out the 
following activities:
            ``(1) General activities.--Each Center shall--
                    ``(A) integrate basic, clinical, or health services 
                interdisciplinary research and practice in the 
                development, implementation, and dissemination of 
                evidence-based interventions;
                    ``(B) involve a broad cross-section of stakeholders, 
                such as researchers, clinicians, consumers, families of 
                consumers, and voluntary health organizations, to 
                develop a research agenda and disseminate findings, and 
                to provide support in the implementation of evidence-
                based practices;
                    ``(C) provide training and technical assistance to 
                mental health professionals, and engage in and 
                disseminate translational research with a focus on 
                meeting the needs of individuals with depressive 
                disorders; and

[[Page 124 STAT. 987]]

                    ``(D) educate policy makers, employers, community 
                leaders, and the public about depressive disorders to 
                reduce stigma and raise awareness of treatments.
            ``(2) Improved treatment standards, clinical guidelines, 
        diagnostic protocols, and care coordination practice.--Each 
        Center shall collaborate with other Centers in the network to--
                    ``(A) develop and implement treatment standards, 
                clinical guidelines, and protocols that emphasize 
                primary prevention, early intervention, treatment for, 
                and recovery from, depressive disorders;
                    ``(B) foster communication with other providers 
                attending to co-occurring physical health conditions 
                such as cardiovascular, diabetes, cancer, and substance 
                abuse disorders;
                    ``(C) leverage available community resources, 
                develop and implement improved self-management programs, 
                and, when appropriate, involve family and other 
                providers of social support in the development and 
                implementation of care plans; and
                    ``(D) use electronic health records and telehealth 
                technology to better coordinate and manage, and improve 
                access to, care, as determined by the coordinating 
                center.
            ``(3) Translational research through collaboration of 
        centers and community-based organizations.--Each Center shall--
                    ``(A) demonstrate effective use of a public-private 
                partnership to foster collaborations among members of 
                the network and community-based organizations such as 
                community mental health centers and other social and 
                human services providers;
                    ``(B) expand interdisciplinary, translational, and 
                patient-oriented research and treatment; and
                    ``(C) coordinate with accredited academic programs 
                to provide ongoing opportunities for the professional 
                and continuing education of mental health providers.

    ``(d) National Database.--
            ``(1) In general.--The coordinating center shall establish 
        and maintain a national, publicly available database to improve 
        prevention programs, evidence-based interventions, and disease 
        management programs for depressive disorders, using data 
        collected from the Centers, as described in paragraph (2).
            ``(2) Data collection.--Each Center shall submit data 
        gathered at such center, as appropriate, to the coordinating 
        center regarding--
                    ``(A) the prevalence and incidence of depressive 
                disorders;
                    ``(B) the health and social outcomes of individuals 
                with depressive disorders;
                    ``(C) the effectiveness of interventions designed, 
                tested, and evaluated;
                    ``(D) other information, as the Secretary may 
                require.
            ``(3) Submission of data to the administrator.--The 
        coordinating center shall submit to the Administrator the data 
        and financial information gathered under paragraph (2).
            ``(4) Publication using data from the database.--A Center, 
        or an individual affiliated with a Center, may publish

[[Page 124 STAT. 988]]

        findings using the data described in paragraph (2) only if such 
        center submits such data to the coordinating center, as required 
        under such paragraph.

    ``(e) Establishment of Standards; Report Cards and Recommendations; 
Third Party Review.--
            ``(1) Establishment of standards.--The Secretary, acting 
        through the Administrator, shall establish performance standards 
        for--
                    ``(A) each Center; and
                    ``(B) the network of Centers as a whole.
            ``(2) Report cards.--The Secretary, acting through the 
        Administrator, shall--
                    ``(A) for each Center, not later than 3 years after 
                the date on which such center of excellence is 
                established and annually thereafter, issue a report card 
                to the coordinating center to rate the performance of 
                such Center; and
                    ``(B) not later than 3 years after the date on which 
                the first grant is awarded under subsection (b)(1) and 
                annually thereafter, issue a report card to Congress to 
                rate the performance of the network of centers of 
                excellence as a whole.
            ``(3) Recommendations.--Based upon the report cards 
        described in paragraph (2), the Secretary shall, not later than 
        September 30, 2015--
                    ``(A) make recommendations to the Centers regarding 
                improvements such centers shall make; and
                    ``(B) make recommendations to Congress for expanding 
                the Centers to serve individuals with other types of 
                mental disorders.
            ``(4) Third party review.--Not later than 3 years after the 
        date on which the first grant is awarded under subsection (b)(1) 
        and annually thereafter, the Secretary shall arrange for an 
        independent third party to conduct an evaluation of the network 
        of Centers to ensure that such centers are meeting the goals of 
        this section.

    ``(f) Authorization of Appropriations.--
            ``(1) In general.--To carry out this section, there are 
        authorized to be appropriated--
                    ``(A) $100,000,000 for each of the fiscal years 2011 
                through 2015; and
                    ``(B) $150,000,000 for each of the fiscal years 2016 
                through 2020.
            ``(2) Allocation of funds authorized.-- 
        <<NOTE: Determination.>> Of the amount appropriated under 
        paragraph (1) for a fiscal year, the Secretary shall determine 
        the allocation of each Center receiving a grant under this 
        section, but in no case may the allocation be more than 
        $5,000,000, except that the Secretary may allocate not more than 
        $10,000,000 to the coordinating center.''.

SEC. 10411. <<NOTE: Congenital Heart Futures Act. 42 USC 201 
            note.>> PROGRAMS RELATING TO CONGENITAL HEART DISEASE.

    (a) Short Title.--This subtitle may be cited as the ``Congenital 
Heart Futures Act''.
    (b) Programs Relating to Congenital Heart Disease.--
            (1) National congenital heart disease surveillance system.--
        Part P of title III of the Public Health Service Act (42 U.S.C. 
        280g et seq.), as amended by section 5405, is further amended by 
        adding at the end the following:

[[Page 124 STAT. 989]]

``SEC. 399V-2. <<NOTE: 42 USC 280g-13.>> NATIONAL CONGENITAL HEART 
            DISEASE SURVEILLANCE SYSTEM.

    ``(a) In General.--The Secretary, acting through the Director of the 
Centers for Disease Control and Prevention, may--
            ``(1) enhance and expand infrastructure to track the 
        epidemiology of congenital heart disease and to organize such 
        information into a nationally-representative, population-based 
        surveillance system that compiles data concerning actual 
        occurrences of congenital heart disease, to be known as the 
        `National Congenital Heart Disease Surveillance System'; or
            ``(2) award a grant to one eligible entity to undertake the 
        activities described in paragraph (1).

    ``(b) Purpose.--The purpose of the Congenital Heart Disease 
Surveillance System shall be to facilitate further research into the 
types of health services patients use and to identify possible areas for 
educational outreach and prevention in accordance with standard 
practices of the Centers for Disease Control and Prevention.
    ``(c) Content.--The Congenital Heart Disease Surveillance System--
            ``(1) may include information concerning the incidence and 
        prevalence of congenital heart disease in the United States;
            ``(2) may be used to collect and store data on congenital 
        heart disease, including data concerning--
                    ``(A) demographic factors associated with congenital 
                heart disease, such as age, race, ethnicity, sex, and 
                family history of individuals who are diagnosed with the 
                disease;
                    ``(B) risk factors associated with the disease;
                    ``(C) causation of the disease;
                    ``(D) treatment approaches; and
                    ``(E) outcome measures, such that analysis of the 
                outcome measures will allow derivation of evidence-based 
                best practices and guidelines for congenital heart 
                disease patients; and
            ``(3) may ensure the collection and analysis of longitudinal 
        data related to individuals of all ages with congenital heart 
        disease, including infants, young children, adolescents, and 
        adults of all ages.

    ``(d) Public Access.--The Congenital Heart Disease Surveillance 
System shall be made available to the public, as appropriate, including 
congenital heart disease researchers.
    ``(e) Patient Privacy.--The Secretary shall ensure that the 
Congenital Heart Disease Surveillance System is maintained in a manner 
that complies with the regulations promulgated under section 264 of the 
Health Insurance Portability and Accountability Act of 1996.
    ``(f) Eligibility for Grant.--To be eligible to receive a grant 
under subsection (a)(2), an entity shall--
            ``(1) be a public or private nonprofit entity with 
        specialized experience in congenital heart disease; and
            ``(2) submit to the Secretary an application at such time, 
        in such manner, and containing such information as the Secretary 
        may require.''.
            (2) Congenital heart disease research.--Subpart 2 of part C 
        of title IV of the Public Health Service Act (42 U.S.C. 285b et 
        seq.) is amended by adding at the end the following:

[[Page 124 STAT. 990]]

``SEC. 425. <<NOTE: 42 USC 285b-8.>> CONGENITAL HEART DISEASE.

    ``(a) In General.--The Director of the Institute may expand, 
intensify, and coordinate research and related activities of the 
Institute with respect to congenital heart disease, which may include 
congenital heart disease research with respect to--
            ``(1) causation of congenital heart disease, including 
        genetic causes;
            ``(2) long-term outcomes in individuals with congenital 
        heart disease, including infants, children, teenagers, adults, 
        and elderly individuals;
            ``(3) diagnosis, treatment, and prevention;
            ``(4) studies using longitudinal data and retrospective 
        analysis to identify effective treatments and outcomes for 
        individuals with congenital heart disease; and
            ``(5) identifying barriers to life-long care for individuals 
        with congenital heart disease.

    ``(b) Coordination of Research Activities.--The Director of the 
Institute may coordinate research efforts related to congenital heart 
disease among multiple research institutions and may develop research 
networks.
    ``(c) Minority and Medically Underserved Communities.--In carrying 
out the activities described in this section, the Director of the 
Institute shall consider the application of such research and other 
activities to minority and medically underserved communities.''.
    (c) Authorization of Appropriations.--There are authorized to be 
appropriated to carry out the amendments made by this section such sums 
as may be necessary for each of fiscal years 2011 through 2015.

SEC. 10412. AUTOMATED DEFIBRILLATION IN ADAM'S MEMORY ACT.

    Section 312 of the Public Health Service Act (42 U.S.C. 244) is 
amended--
            (1) in subsection (c)(6), after ``clearinghouse'' insert ``, 
        that shall be administered by an organization that has 
        substantial expertise in pediatric education, pediatric 
        medicine, and electrophysiology and sudden death,''; and
            (2) in the first sentence of subsection (e), by striking 
        ``fiscal year 2003'' and all that follows through ``2006'' and 
        inserting ``for each of fiscal years 2003 through 2014''.

SEC. 10413. <<NOTE: Young Women's Breast Health Education and Awareness 
            Requires Learning Young Act of 2009. 42 USC 201 
            note.>> YOUNG WOMEN'S BREAST HEALTH AWARENESS AND SUPPORT OF 
            YOUNG WOMEN DIAGNOSED WITH BREAST CANCER.

    (a) Short Title.--This section may be cited as the ``Young Women's 
Breast Health Education and Awareness Requires Learning Young Act of 
2009'' or the ``EARLY Act''.
    (b) Amendment.--Title III of the Public Health Service Act (42 
U.S.C. 241 et seq.), as amended by this Act, is further amended by 
adding at the end the following:

[[Page 124 STAT. 991]]

         ``PART V--PROGRAMS RELATING TO BREAST HEALTH AND CANCER

``SEC. 399NN. <<NOTE: 42 USC 280m.>> YOUNG WOMEN'S BREAST HEALTH 
            AWARENESS AND SUPPORT OF YOUNG WOMEN DIAGNOSED WITH BREAST 
            CANCER.

    ``(a) Public Education Campaign.--
            ``(1) In general.--The Secretary, acting through the 
        Director of the Centers for Disease Control and Prevention, 
        shall conduct a national evidence-based education campaign to 
        increase awareness of young women's knowledge regarding--
                    ``(A) breast health in young women of all racial, 
                ethnic, and cultural backgrounds;
                    ``(B) breast awareness and good breast health 
                habits;
                    ``(C) the occurrence of breast cancer and the 
                general and specific risk factors in women who may be at 
                high risk for breast cancer based on familial, racial, 
                ethnic, and cultural backgrounds such as Ashkenazi 
                Jewish populations;
                    ``(D) evidence-based information that would 
                encourage young women and their health care professional 
                to increase early detection of breast cancers; and
                    ``(E) the availability of health information and 
                other resources for young women diagnosed with breast 
                cancer.
            ``(2) Evidence-based, age appropriate messages.--The 
        campaign shall provide evidence-based, age-appropriate messages 
        and materials as developed by the Centers for Disease Control 
        and Prevention and the Advisory Committee established under 
        paragraph (4).
            ``(3) Media campaign.-- <<NOTE: Grants.>> In conducting the 
        education campaign under paragraph (1), the Secretary shall 
        award grants to entities to establish national multimedia 
        campaigns oriented to young women that may include advertising 
        through television, radio, print media, billboards, posters, all 
        forms of existing and especially emerging social networking 
        media, other Internet media, and any other medium determined 
        appropriate by the Secretary.
            ``(4) Advisory committee.--
                    ``(A) Establishment.-- <<NOTE: Deadline.>> Not later 
                than 60 days after the date of the enactment of this 
                section, the Secretary, acting through the Director of 
                the Centers for Disease Control and Prevention, shall 
                establish an advisory committee to assist in creating 
                and conducting the education campaigns under paragraph 
                (1) and subsection (b)(1).
                    ``(B) Membership.-- <<NOTE: Appointment.>> The 
                Secretary, acting through the Director of the Centers 
                for Disease Control and Prevention, shall appoint to the 
                advisory committee under subparagraph (A) such members 
                as deemed necessary to properly advise the Secretary, 
                and shall include organizations and individuals with 
                expertise in breast cancer, disease prevention, early 
                detection, diagnosis, public health, social marketing, 
                genetic screening and counseling, treatment, 
                rehabilitation, palliative care, and survivorship in 
                young women.

    ``(b) Health Care Professional Education Campaign.--The Secretary, 
acting through the Director of the Centers for Disease

[[Page 124 STAT. 992]]

Control and Prevention, and in consultation with the Administrator of 
the Health Resources and Services Administration, shall conduct an 
education campaign among physicians and other health care professionals 
to increase awareness--
            ``(1) of breast health, symptoms, and early diagnosis and 
        treatment of breast cancer in young women, including specific 
        risk factors such as family history of cancer and women that may 
        be at high risk for breast cancer, such as Ashkenazi Jewish 
        population;
            ``(2) on how to provide counseling to young women about 
        their breast health, including knowledge of their family cancer 
        history and importance of providing regular clinical breast 
        examinations;
            ``(3) concerning the importance of discussing healthy 
        behaviors, and increasing awareness of services and programs 
        available to address overall health and wellness, and making 
        patient referrals to address tobacco cessation, good nutrition, 
        and physical activity;
            ``(4) on when to refer patients to a health care provider 
        with genetics expertise;
            ``(5) on how to provide counseling that addresses long-term 
        survivorship and health concerns of young women diagnosed with 
        breast cancer; and
            ``(6) on when to provide referrals to organizations and 
        institutions that provide credible health information and 
        substantive assistance and support to young women diagnosed with 
        breast cancer.

    ``(c) Prevention Research Activities.--The Secretary, acting 
through--
            ``(1) the Director of the Centers for Disease Control and 
        Prevention, shall conduct prevention research on breast cancer 
        in younger women, including--
                    ``(A) behavioral, survivorship studies, and other 
                research on the impact of breast cancer diagnosis on 
                young women;
                    ``(B) formative research to assist with the 
                development of educational messages and information for 
                the public, targeted populations, and their families 
                about breast health, breast cancer, and healthy 
                lifestyles;
                    ``(C) testing and evaluating existing and new social 
                marketing strategies targeted at young women; and
                    ``(D) surveys of health care providers and the 
                public regarding knowledge, attitudes, and practices 
                related to breast health and breast cancer prevention 
                and control in high-risk populations; and
            ``(2) the Director of the National Institutes of Health, 
        shall conduct research to develop and validate new screening 
        tests and methods for prevention and early detection of breast 
        cancer in young women.

    ``(d) Support for Young Women Diagnosed With Breast Cancer.--
            ``(1) In general.-- <<NOTE: Grants.>> The Secretary shall 
        award grants to organizations and institutions to provide health 
        information from credible sources and substantive assistance 
        directed to young women diagnosed with breast cancer and pre-
        neoplastic breast diseases.

[[Page 124 STAT. 993]]

            ``(2) Priority.--In making grants under paragraph (1), the 
        Secretary shall give priority to applicants that deal 
        specifically with young women diagnosed with breast cancer and 
        pre-neoplastic breast disease.

    ``(e) No Duplication of Effort.--In conducting an education campaign 
or other program under subsections (a), (b), (c), or (d), the Secretary 
shall avoid duplicating other existing Federal breast cancer education 
efforts.
    ``(f) Measurement; Reporting.--The Secretary, acting through the 
Director of the Centers for Disease Control and Prevention, shall--
            ``(1) measure--
                    ``(A) young women's awareness regarding breast 
                health, including knowledge of family cancer history, 
                specific risk factors and early warning signs, and young 
                women's proactive efforts at early detection;
                    ``(B) the number or percentage of young women 
                utilizing information regarding lifestyle interventions 
                that foster healthy behaviors;
                    ``(C) the number or percentage of young women 
                receiving regular clinical breast exams; and
                    ``(D) the number or percentage of young women who 
                perform breast self exams, and the frequency of such 
                exams, before the implementation of this section;
            ``(2) not less than every 3 years, measure the impact of 
        such activities; and
            ``(3) submit reports to the Congress on the results of such 
        measurements.

    ``(g) Definition.--In this section, the term `young women' means 
women 15 to 44 years of age.
    ``(h) Authorization of Appropriations.--To carry out subsections 
(a), (b), (c)(1), and (d), there are authorized to be appropriated 
$9,000,000 for each of the fiscal years 2010 through 2014.''.

               Subtitle E--Provisions Relating to Title V

SEC. 10501. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT, THE SOCIAL 
            SECURITY ACT, AND TITLE V OF THIS ACT.

    (a) Section 5101 of this Act <<NOTE: 42 USC 294q.>> is amended--
            (1) in subsection (c)(2)(B)(i)(II), by inserting ``, 
        including representatives of small business and self-employed 
        individuals'' after ``employers'';
            (2) in subsection (d)(4)(A)--
                    (A) by redesignating clause (iv) as clause (v); and
                    (B) by inserting after clause (iii) the following:
                          ``(iv) An analysis of, and recommendations 
                      for, eliminating the barriers to entering and 
                      staying in primary care, including provider 
                      compensation.''; and
            (3) in subsection (i)(2)(B), by inserting ``optometrists, 
        ophthalmologists,'' after ``occupational therapists,''.

    (b) Subtitle B of title V of this Act is amended by adding at the 
end the following:

[[Page 124 STAT. 994]]

``SEC. 5104. INTERAGENCY TASK FORCE TO ASSESS AND IMPROVE ACCESS TO 
            HEALTH CARE IN THE STATE OF ALASKA.

    ``(a) Establishment.--There is established a task force to be known 
as the `Interagency Access to Health Care in Alaska Task Force' 
(referred to in this section as the `Task Force').
    ``(b) Duties.--The Task Force shall--
            ``(1) assess access to health care for beneficiaries of 
        Federal health care systems in Alaska; and
            ``(2) develop a strategy for the Federal Government to 
        improve delivery of health care to Federal beneficiaries in the 
        State of Alaska.

    ``(c) Membership.-- <<NOTE: Deadline.>> The Task Force shall be 
comprised of Federal members who shall be appointed, not later than 45 
days after the date of enactment of this Act, as follows:
            ``(1) The Secretary of Health and Human Services shall 
        appoint one representative of each of the following:
                    ``(A) The Department of Health and Human Services.
                    ``(B) The Centers for Medicare and Medicaid 
                Services.
                    ``(C) The Indian Health Service.
            ``(2) The Secretary of Defense shall appoint one 
        representative of the TRICARE Management Activity.
            ``(3) The Secretary of the Army shall appoint one 
        representative of the Army Medical Department.
            ``(4) The Secretary of the Air Force shall appoint one 
        representative of the Air Force, from among officers at the Air 
        Force performing medical service functions.
            ``(5) The Secretary of Veterans Affairs shall appoint one 
        representative of each of the following:
                    ``(A) The Department of Veterans Affairs.
                    ``(B) The Veterans Health Administration.
            ``(6) The Secretary of Homeland Security shall appoint one 
        representative of the United States Coast Guard.

    ``(d) Chairperson.--One chairperson of the Task Force shall be 
appointed by the Secretary at the time of appointment of members under 
subsection (c), selected from among the members appointed under 
paragraph (1).
    ``(e) Meetings.--The Task Force shall meet at the call of the 
chairperson.
    ``(f) Report.--Not later than 180 days after the date of enactment 
of this Act, the Task Force shall submit to Congress a report detailing 
the activities of the Task Force and containing the findings, 
strategies, recommendations, policies, and initiatives developed 
pursuant to the duty described in subsection (b)(2). In preparing such 
report, the Task Force shall consider completed and ongoing efforts by 
Federal agencies to improve access to health care in the State of 
Alaska.
    ``(g) Termination.--The Task Force shall be terminated on the date 
of submission of the report described in subsection (f).''.
    (c) Section 399V of the Public Health Service Act, as added by 
section 5313, <<NOTE: 42 USC 280g-11.>> is amended--
            (1) in subsection (b)(4), by striking ``identify, educate, 
        refer, and enroll'' and inserting ``identify and refer''; and
            (2) in subsection (k)(1), by striking ``, as defined by the 
        Department of Labor as Standard Occupational Classification [21-
        1094]''.

[[Page 124 STAT. 995]]

    (d) Section 738(a)(3) of the Public Health Service Act (42 U.S.C. 
293b(a)(3)) is amended by inserting ``schools offering physician 
assistant education programs,'' after ``public health,''.
    (e) Subtitle D of title V of this Act is amended by adding at the 
end the following:

``SEC. 5316. <<NOTE: 42 USC 296j-1.>> DEMONSTRATION GRANTS FOR FAMILY 
            NURSE PRACTITIONER TRAINING PROGRAMS.

    ``(a) Establishment of Program.--The Secretary of Health and Human 
Services (referred to in this section as the `Secretary') shall 
establish a training demonstration program for family nurse 
practitioners (referred to in this section as the `program') to employ 
and provide 1-year training for nurse practitioners who have graduated 
from a nurse practitioner program for careers as primary care providers 
in Federally qualified health centers (referred to in this section as 
`FQHCs') and nurse-managed health clinics (referred to in this section 
as `NMHCs').
    ``(b) Purpose.--The purpose of the program is to enable each grant 
recipient to--
            ``(1) provide new nurse practitioners with clinical training 
        to enable them to serve as primary care providers in FQHCs and 
        NMHCs;
            ``(2) train new nurse practitioners to work under a model of 
        primary care that is consistent with the principles set forth by 
        the Institute of Medicine and the needs of vulnerable 
        populations; and
            ``(3) create a model of FQHC and NMHC training for nurse 
        practitioners that may be replicated nationwide.

    ``(c) Grants.--The Secretary shall award 3-year grants to eligible 
entities that meet the requirements established by the Secretary, for 
the purpose of operating the nurse practitioner primary care programs 
described in subsection (a) in such entities.
    ``(d) Eligible Entities.--To be eligible to receive a grant under 
this section, an entity shall--
            ``(1)(A) be a FQHC as defined in section 1861(aa) of the 
        Social Security Act (42 U.S.C. 1395x(aa)); or
            ``(B) be a nurse-managed health clinic, as defined in 
        section 330A-1 of the Public Health Service Act (as added by 
        section 5208 of this Act); and
            ``(2) submit to the Secretary an application at such time, 
        in such manner, and containing such information as the Secretary 
        may require.

    ``(e) Priority in Awarding Grants.--In awarding grants under this 
section, the Secretary shall give priority to eligible entities that--
            ``(1) demonstrate sufficient infrastructure in size, scope, 
        and capacity to undertake the requisite training of a minimum of 
        3 nurse practitioners per year, and to provide to each awardee 
        12 full months of full-time, paid employment and benefits 
        consistent with the benefits offered to other full-time 
        employees of such entity;
            ``(2) will assign not less than 1 staff nurse practitioner 
        or physician to each of 4 precepted clinics;
            ``(3) will provide to each awardee specialty rotations, 
        including specialty training in prenatal care and women's 
        health, adult and child psychiatry, orthopedics, geriatrics, and 
        at least 3 other high-volume, high-burden specialty areas;

[[Page 124 STAT. 996]]

            ``(4) provide sessions on high-volume, high-risk health 
        problems and have a record of training health care professionals 
        in the care of children, older adults, and underserved 
        populations; and
            ``(5) collaborate with other safety net providers, schools, 
        colleges, and universities that provide health professions 
        training.

    ``(f) Eligibility of Nurse Practitioners.--
            ``(1) In general.--To be eligible for acceptance to a 
        program funded through a grant awarded under this section, an 
        individual shall--
                    ``(A) be licensed or eligible for licensure in the 
                State in which the program is located as an advanced 
                practice registered nurse or advanced practice nurse and 
                be eligible or board-certified as a family nurse 
                practitioner; and
                    ``(B) demonstrate commitment to a career as a 
                primary care provider in a FQHC or in a NMHC.
            ``(2) Preference.--In selecting awardees under the program, 
        each grant recipient shall give preference to bilingual 
        candidates that meet the requirements described in paragraph 
        (1).
            ``(3) Deferral of certain service.--The starting date of 
        required service of individuals in the National Health Service 
        Corps Service program under title II of the Public Health 
        Service Act (42 U.S.C. 202 et seq.) who receive training under 
        this section shall be deferred until the date that is 22 days 
        after the date of completion of the program.

    ``(g) Grant Amount.--Each grant awarded under this section shall be 
in an amount not to exceed $600,000 per year. A grant recipient may 
carry over funds from 1 fiscal year to another without obtaining 
approval from the Secretary.
    ``(h) Technical Assistance Grants.--The Secretary may award 
technical assistance grants to 1 or more FQHCs or NMHCs that have 
demonstrated expertise in establishing a nurse practitioner residency 
training program. Such technical assistance grants shall be for the 
purpose of providing technical assistance to other recipients of grants 
under subsection (c).
    ``(i) Authorization of Appropriations.--To carry out this section, 
there is authorized to be appropriated such sums as may be necessary for 
each of fiscal years 2011 through 2014.''.
    (f)(1) Section 399W of the Public Health Service Act, as added by 
section 5405, <<NOTE: 42 USC 280g-12.>> is redesignated as section 399V-
1.

    (2) Section 399V-1 of the Public Health Service Act, as so 
redesignated, is amended in subsection (b)(2)(A) by striking ``and the 
departments of 1 or more health professions schools in the State that 
train providers in primary care'' and inserting ``and the departments 
that train providers in primary care in 1 or more health professions 
schools in the State''.
    (3) Section 934 of the Public Health Service Act, as added by 
section 3501, <<NOTE: 42 USC 299b-34.>> is amended by striking ``399W'' 
each place such term appears and inserting ``399V-1''.

    (4) Section 935(b) of the Public Health Service Act, as added by 
section 3503, <<NOTE: 42 USC 299b-35.>> is amended by striking ``399W'' 
and inserting ``399V-1''.

    (g) Part P of title III of the Public Health Service Act 42 U.S.C. 
280g et seq.), as amended by section 10411, is amended by adding at the 
end the following:

[[Page 124 STAT. 997]]

``SEC. 399V-3. <<NOTE: 42 USC 280g-14.>> NATIONAL DIABETES PREVENTION 
            PROGRAM.

    ``(a) In General.--The Secretary, acting through the Director of the 
Centers for Disease Control and Prevention, shall establish a national 
diabetes prevention program (referred to in this section as the 
`program') targeted at adults at high risk for diabetes in order to 
eliminate the preventable burden of diabetes.
    ``(b) Program Activities.--The program described in subsection (a) 
shall include--
            ``(1) a grant program for community-based diabetes 
        prevention program model sites;
            ``(2) a program within the Centers for Disease Control and 
        Prevention to determine eligibility of entities to deliver 
        community-based diabetes prevention services;
            ``(3) a training and outreach program for lifestyle 
        intervention instructors; and
            ``(4) evaluation, monitoring and technical assistance, and 
        applied research carried out by the Centers for Disease Control 
        and Prevention.

    ``(c) Eligible Entities.--To be eligible for a grant under 
subsection (b)(1), an entity shall be a State or local health 
department, a tribal organization, a national network of community-based 
non-profits focused on health and wellbeing, an academic institution, or 
other entity, as the Secretary determines.
    ``(d) Authorization of Appropriations.--For the purpose of carrying 
out this section, there are authorized to be appropriated such sums as 
may be necessary for each of fiscal years 2010 through 2014.''.
    (h) The provisions of, and amendment made by, section 5501(c) of 
this Act <<NOTE: Repeals. 42 USC 1395w-4.>> are repealed.

    (i)(1) The provisions of, and amendments made by, section 5502 of 
this Act <<NOTE: 42 USC 1395m, 1395x and note. 42 USC 1395x.>> are 
repealed.

    (2)(A) Section 1861(aa)(3)(A) of the Social Security Act (42 U.S.C. 
1395w(aa)(3)(A)) is amended to read as follows:
            ``(A) services of the type described in subparagraphs (A) 
        through (C) of paragraph (1) and preventive services (as defined 
        in section 1861(ddd)(3)); and''.

    (B) <<NOTE: Applicability. 42 USC 1395x note.>> The amendment made 
by subparagraph (A) shall apply to services furnished on or after 
January 1, 2011.

    (3)(A) Section 1834 of the Social Security Act (42 U.S.C. 1395m), as 
amended by section 4105, is amended by adding at the end the following 
new subsection:
    ``(o) Development and Implementation of Prospective Payment 
System.--
            ``(1) Development.--
                    ``(A) In general.--The Secretary shall develop a 
                prospective payment system for payment for Federally 
                qualified health center services furnished by Federally 
                qualified health centers under this title. Such system 
                shall include a process for appropriately describing the 
                services furnished by Federally qualified health centers 
                and shall establish payment rates for specific payment 
                codes based on such appropriate descriptions of 
                services. Such system shall be established to take into 
                account the type, intensity, and duration of services 
                furnished by Federally qualified health centers. Such 
                system may include adjustments, including geographic 
                adjustments, determined appropriate by the Secretary.

[[Page 124 STAT. 998]]

                    ``(B) Collection of data and evaluation.-- 
                <<NOTE: Deadline.>> By not later than January 1, 2011, 
                the Secretary shall require Federally qualified health 
                centers to submit to the Secretary such information as 
                the Secretary may require in order to develop and 
                implement the prospective payment system under this 
                subsection, including the reporting of services using 
                HCPCS codes.
            ``(2) Implementation.--
                    ``(A) In general.--Notwithstanding section 
                1833(a)(3)(A), the Secretary shall provide, for cost 
                reporting periods beginning on or after October 1, 2014, 
                for payments of prospective payment rates for Federally 
                qualified health center services furnished by Federally 
                qualified health centers under this title in accordance 
                with the prospective payment system developed by the 
                Secretary under paragraph (1).
                    ``(B) Payments.--
                          ``(i) Initial payments.--The Secretary shall 
                      implement such prospective payment system so that 
                      the estimated aggregate amount of prospective 
                      payment rates (determined prior to the application 
                      of section 1833(a)(1)(Z)) under this title for 
                      Federally qualified health center services in the 
                      first year that such system is implemented is 
                      equal to 100 percent of the estimated amount of 
                      reasonable costs (determined without the 
                      application of a per visit payment limit or 
                      productivity screen and prior to the application 
                      of section 1866(a)(2)(A)(ii)) that would have 
                      occurred for such services under this title in 
                      such year if the system had not been implemented.
                          ``(ii) Payments in subsequent years.--Payment 
                      rates in years after the year of implementation of 
                      such system shall be the payment rates in the 
                      previous year increased--
                                    ``(I) in the first year after 
                                implementation of such system, by the 
                                percentage increase in the MEI (as 
                                defined in section 1842(i)(3)) for the 
                                year involved; and
                                    ``(II) in subsequent years, by the 
                                percentage increase in a market basket 
                                of Federally qualified health center 
                                goods and services as promulgated 
                                through regulations, or if such an index 
                                is not available, by the percentage 
                                increase in the MEI (as defined in 
                                section 1842(i)(3)) for the year 
                                involved.
                    ``(C) Preparation for pps implementation.--
                Notwithstanding any other provision of law, the 
                Secretary may establish and implement by program 
                instruction or otherwise the payment codes to be used 
                under the prospective payment system under this 
                section.''.

    (B) Section 1833(a)(1) of the Social Security Act (42 U.S.C. 
1395l(a)(1)), as amended by section 4104, is amended--
            (i) by striking ``and'' before ``(Y)''; and
            (ii) by inserting before the semicolon at the end the 
        following: ``, and (Z) with respect to Federally qualified 
        health center services for which payment is made under section 
        1834(o), the amounts paid shall be 80 percent of the lesser

[[Page 124 STAT. 999]]

        of the actual charge or the amount determined under such 
        section''.

    (C) Section 1833(a) of the Social Security Act (42 U.S.C. 1395l(a)) 
is amended--
            (i) in paragraph (3)(B)(i)--
                    (I) by inserting ``(I)'' after ``otherwise been 
                provided''; and
                    (II) by inserting ``, or (II) in the case of such 
                services furnished on or after the implementation date 
                of the prospective payment system under section 1834(o), 
                under such section (calculated as if `100 percent' were 
                substituted for `80 percent' in such section) for such 
                services if the individual had not been so enrolled'' 
                after ``been so enrolled''; and
            (ii) by adding at the end the following flush sentence:
        ``Paragraph (3)(A) shall not apply to Federally qualified health 
        center services furnished on or after the implementation date of 
        the prospective payment system under section 1834(0).''.

    (j) Section 5505 <<NOTE: 42 USC 1395ww note.>> is amended by adding 
at the end the following new subsection:

    ``(d) Application.--The amendments made by this section shall not be 
applied in a manner that requires reopening of any settled cost reports 
as to which there is not a jurisdictionally proper appeal pending as of 
the date of the enactment of this Act on the issue of payment for 
indirect costs of medical education under section 1886(d)(5)(B) of the 
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct graduate 
medical education costs under section 1886(h) of such Act (42 U.S.C. 
1395ww(h)).''.
    (k) Subtitle G of title V of this Act is amended by adding at the 
end the following:

``SEC. 5606. <<NOTE: 42 USC 254b-1.>> STATE GRANTS TO HEALTH CARE 
            PROVIDERS WHO PROVIDE SERVICES TO A HIGH PERCENTAGE OF 
            MEDICALLY UNDERSERVED POPULATIONS OR OTHER SPECIAL 
            POPULATIONS.

    ``(a) In General.--A State may award grants to health care providers 
who treat a high percentage, as determined by such State, of medically 
underserved populations or other special populations in such State.
    ``(b) Source of Funds.--A grant program established by a State under 
subsection (a) may not be established within a department, agency, or 
other entity of such State that administers the Medicaid program under 
title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), and no 
Federal or State funds allocated to such Medicaid program, the Medicare 
program under title XVIII of the Social Security Act (42 U.S.C. 1395 et 
seq.), or the TRICARE program under chapter 55 of title 10, United 
States Code, may be used to award grants or to pay administrative costs 
associated with a grant program established under subsection (a).''.
    (l) Part C of title VII of the Public Health Service Act (42 U.S.C. 
293k et seq.) is amended--
            (1) after the part heading, by inserting the following:

               ``Subpart I--Medical Training Generally'';

        and
            (2) by inserting at the end the following:

[[Page 124 STAT. 1000]]

            ``Subpart II--Training in Underserved Communities

``SEC. 749B. <<NOTE: 42 USC 293m.>> RURAL PHYSICIAN TRAINING GRANTS.

    ``(a) In General.--The Secretary, acting through the Administrator 
of the Health Resources and Services Administration, shall establish a 
grant program for the purposes of assisting eligible entities in 
recruiting students most likely to practice medicine in underserved 
rural communities, providing rural-focused training and experience, and 
increasing the number of recent allopathic and osteopathic medical 
school graduates who practice in underserved rural communities.
    ``(b) Eligible Entities.--In order to be eligible to receive a grant 
under this section, an entity shall--
            ``(1) be a school of allopathic or osteopathic medicine 
        accredited by a nationally recognized accrediting agency or 
        association approved by the Secretary for this purpose, or any 
        combination or consortium of such schools; and
            ``(2) submit an application to the Secretary that includes a 
        certification that such entity will use amounts provided to the 
        institution as described in subsection (d)(1).

    ``(c) Priority.--In awarding grant funds under this section, the 
Secretary shall give priority to eligible entities that--
            ``(1) demonstrate a record of successfully training 
        students, as determined by the Secretary, who practice medicine 
        in underserved rural communities;
            ``(2) demonstrate that an existing academic program of the 
        eligible entity produces a high percentage, as determined by the 
        Secretary, of graduates from such program who practice medicine 
        in underserved rural communities;
            ``(3) demonstrate rural community institutional 
        partnerships, through such mechanisms as matching or 
        contributory funding, documented in-kind services for 
        implementation, or existence of training partners with 
        interprofessional expertise in community health center training 
        locations or other similar facilities; or
            ``(4) submit, as part of the application of the entity under 
        subsection (b), a plan for the long-term tracking of where the 
        graduates of such entity practice medicine.

    ``(d) Use of Funds.--
            ``(1) Establishment.--An eligible entity receiving a grant 
        under this section shall use the funds made available under such 
        grant to establish, improve, or expand a rural-focused training 
        program (referred to in this section as the `Program') meeting 
        the requirements described in this subsection and to carry out 
        such program.
            ``(2) Structure of program.--An eligible entity shall--
                    ``(A) enroll no fewer than 10 students per class 
                year into the Program; and
                    ``(B) develop criteria for admission to the Program 
                that gives priority to students--
                          ``(i) who have originated from or lived for a 
                      period of 2 or more years in an underserved rural 
                      community; and
                          ``(ii) who express a commitment to practice 
                      medicine in an underserved rural community.

[[Page 124 STAT. 1001]]

            ``(3) Curricula.--The Program shall require students to 
        enroll in didactic coursework and clinical experience 
        particularly applicable to medical practice in underserved rural 
        communities, including--
                    ``(A) clinical rotations in underserved rural 
                communities, and in applicable specialties, or other 
                coursework or clinical experience deemed appropriate by 
                the Secretary; and
                    ``(B) in addition to core school curricula, 
                additional coursework or training experiences focused on 
                medical issues prevalent in underserved rural 
                communities.
            ``(4) Residency placement assistance.--Where available, the 
        Program shall assist all students of the Program in obtaining 
        clinical training experiences in locations with postgraduate 
        programs offering residency training opportunities in 
        underserved rural communities, or in local residency training 
        programs that support and train physicians to practice in 
        underserved rural communities.
            ``(5) Program student cohort support.--The Program shall 
        provide and require all students of the Program to participate 
        in group activities designed to further develop, maintain, and 
        reinforce the original commitment of such students to practice 
        in an underserved rural community.

    ``(e) Annual Reporting.--An eligible entity receiving a grant under 
this section shall submit an annual report to the Secretary on the 
success of the Program, based on criteria the Secretary determines 
appropriate, including the residency program selection of graduating 
students who participated in the Program.
    ``(f) Regulations.-- <<NOTE: Deadline.>> Not later than 60 days 
after the date of enactment of this section, the Secretary shall by 
regulation define `underserved rural community' for purposes of this 
section.

    ``(g) Supplement Not Supplant.--Any eligible entity receiving funds 
under this section shall use such funds to supplement, not supplant, any 
other Federal, State, and local funds that would otherwise be expended 
by such entity to carry out the activities described in this section.
    ``(h) Maintenance of Effort.--With respect to activities for which 
funds awarded under this section are to be expended, the entity shall 
agree to maintain expenditures of non-Federal amounts for such 
activities at a level that is not less than the level of such 
expenditures maintained by the entity for the fiscal year preceding the 
fiscal year for which the entity receives a grant under this section.
    ``(i) Authorization of Appropriations.--There are authorized to be 
appropriated $4,000,000 for each of the fiscal years 2010 through 
2013.''.
    (m)(1) Section 768 of the Public Health Service Act (42 U.S.C. 295c) 
is amended to read as follows:

``SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING GRANT 
            PROGRAM.

    ``(a) Grants. <<NOTE: Contracts.>> --The Secretary, acting through 
the Administrator of the Health Resources and Services Administration 
and in consultation with the Director of the Centers for Disease Control 
and Prevention, shall award grants to, or enter into contracts with, 
eligible entities to provide training to graduate medical residents in 
preventive medicine specialties.

[[Page 124 STAT. 1002]]

    ``(b) Eligibility.--To be eligible for a grant or contract under 
subsection (a), an entity shall be--
            ``(1) an accredited school of public health or school of 
        medicine or osteopathic medicine;
            ``(2) an accredited public or private nonprofit hospital;
            ``(3) a State, local, or tribal health department; or
            ``(4) a consortium of 2 or more entities described in 
        paragraphs (1) through (3).

    ``(c) Use of Funds.--Amounts received under a grant or contract 
under this section shall be used to--
            ``(1) plan, develop (including the development of 
        curricula), operate, or participate in an accredited residency 
        or internship program in preventive medicine or public health;
            ``(2) defray the costs of practicum experiences, as required 
        in such a program; and
            ``(3) establish, maintain, or improve--
                    ``(A) academic administrative units (including 
                departments, divisions, or other appropriate units) in 
                preventive medicine and public health; or
                    ``(B) programs that improve clinical teaching in 
                preventive medicine and public health.

    ``(d) Report.--The Secretary shall submit to the Congress an annual 
report on the program carried out under this section.''.
            (2) Section 770(a) of the Public Health Service Act (42 
        U.S.C. 295e(a)) is amended to read as follows:

    ``(a) In General.--For the purpose of carrying out this subpart, 
there is authorized to be appropriated $43,000,000 for fiscal year 2011, 
and such sums as may be necessary for each of the fiscal years 2012 
through 2015.''.
    (n)(1) Subsection (i) of section 331 of the Public Health Service 
Act (42 U.S.C. 254d) of the Public Health Service Act is amended--
            (A) in paragraph (1), by striking ``In carrying out subpart 
        III'' and all that follows through the period and inserting ``In 
        carrying out subpart III, the Secretary may, in accordance with 
        this subsection, issue waivers to individuals who have entered 
        into a contract for obligated service under the Scholarship 
        Program or the Loan Repayment Program under which the 
        individuals are authorized to satisfy the requirement of 
        obligated service through providing clinical practice that is 
        half time.'';
            (B) in paragraph (2)--
                    (i) in subparagraphs (A)(ii) and (B), by striking 
                ``less than full time'' each place it appears and 
                inserting ``half time'';
                    (ii) in subparagraphs (C) and (F), by striking 
                ``less than full-time service'' each place it appears 
                and inserting ``half-time service''; and
                    (iii) by amending subparagraphs (D) and (E) to read 
                as follows:
            ``(D) the entity and the Corps member agree in writing that 
        the Corps member will perform half-time clinical practice;
            ``(E) the Corps member agrees in writing to fulfill all of 
        the service obligations under section 338C through half-time 
        clinical practice and either--
                    ``(i) double the period of obligated service that 
                would otherwise be required; or

[[Page 124 STAT. 1003]]

                    ``(ii) in the case of contracts entered into under 
                section 338B, accept a minimum service obligation of 2 
                years with an award amount equal to 50 percent of the 
                amount that would otherwise be payable for full-time 
                service; and''; and
            (C) in paragraph (3), by striking ``In evaluating a 
        demonstration project described in paragraph (1)'' and inserting 
        ``In evaluating waivers issued under paragraph (1)''.

    (2) Subsection (j) of section 331 of the Public Health Service Act 
(42 U.S.C. 254d) is amended by adding at the end the following:
            ``(5) <<NOTE: Definitions.>> The terms `full time' and 
        `full-time' mean a minimum of 40 hours per week in a clinical 
        practice, for a minimum of 45 weeks per year.
            ``(6) The terms `half time' and `half-time' mean a minimum 
        of 20 hours per week (not to exceed 39 hours per week) in a 
        clinical practice, for a minimum of 45 weeks per year.''.

    (3) Section 337(b)(1) of the Public Health Service Act (42 U.S.C. 
254j(b)(1)) is amended by striking ``Members may not be reappointed to 
the Council.''.
    (4) Section 338B(g)(2)(A) of the Public Health Service Act (42 
U.S.C. 254l-1(g)(2)(A)) is amended by striking ``$35,000'' and inserting 
``$50,000, plus, beginning with fiscal year 2012, an amount determined 
by the Secretary on an annual basis to reflect inflation,''.
    (5) Subsection (a) of section 338C of the Public Health Service Act 
(42 U.S.C. 254m), as amended by section 5508, is amended--
            (A) by striking the second sentence and inserting the 
        following: ``The Secretary may treat teaching as clinical 
        practice for up to 20 percent of such period of obligated 
        service.''; and
            (B) by adding at the end the following: ``Notwithstanding 
        the preceding sentence, with respect to a member of the Corps 
        participating in the teaching health centers graduate medical 
        education program under section 340H, for the purpose of 
        calculating time spent in full-time clinical practice under this 
        section, up to 50 percent of time spent teaching by such member 
        may be counted toward his or her service obligation.''.

SEC. 10502. INFRASTRUCTURE TO EXPAND ACCESS TO CARE.

    (a) Appropriation.--There are authorized to be appropriated, and 
there are appropriated to the Department of Health and Human Services, 
$100,000,000 for fiscal year 2010, to remain available for obligation 
until September 30, 2011, to be used for debt service on, or direct 
construction or renovation of, a health care facility that provides 
research, inpatient tertiary care, or outpatient clinical services. Such 
facility shall be affiliated with an academic health center at a public 
research university in the United States that contains a State's sole 
public academic medical and dental school.
    (b) Requirement.-- <<NOTE: Certification.>> Amount appropriated 
under subsection (a) may only be made available by the Secretary of 
Health and Human Services upon the receipt of an application from the 
Governor of a State that certifies that--
            (1) the new health care facility is critical for the 
        provision of greater access to health care within the State;
            (2) such facility is essential for the continued financial 
        viability of the State's sole public medical and dental school 
        and its academic health center;
            (3) the request for Federal support represents not more than 
        40 percent of the total cost of the proposed new facility; and

[[Page 124 STAT. 1004]]

            (4) the State has established a dedicated funding mechanism 
        to provide all remaining funds necessary to complete the 
        construction or renovation of the proposed facility.

SEC. 10503. <<NOTE: 42 USC 254b-2.>> COMMUNITY HEALTH CENTERS AND THE 
            NATIONAL HEALTH SERVICE CORPS FUND.

    (a) Purpose.--It is the purpose of this section to establish a 
Community Health Center Fund (referred to in this section as the ``CHC 
Fund''), to be administered through the Office of the Secretary of the 
Department of Health and Human Services to provide for expanded and 
sustained national investment in community health centers under section 
330 of the Public Health Service Act and the National Health Service 
Corps.
    (b) Funding.--There is authorized to be appropriated, and there is 
appropriated, out of any monies in the Treasury not otherwise 
appropriated, to the CHC Fund--
            (1) to be transferred to the Secretary of Health and Human 
        Services to provide enhanced funding for the community health 
        center program under section 330 of the Public Health Service 
        Act--
                    (A) $700,000,000 for fiscal year 2011;
                    (B) $800,000,000 for fiscal year 2012;
                    (C) $1,000,000,000 for fiscal year 2013;
                    (D) $1,600,000,000 for fiscal year 2014; and
                    (E) $2,900,000,000 for fiscal year 2015; and
            (2) to be transferred to the Secretary of Health and Human 
        Services to provide enhanced funding for the National Health 
        Service Corps--
                    (A) $290,000,000 for fiscal year 2011;
                    (B) $295,000,000 for fiscal year 2012;
                    (C) $300,000,000 for fiscal year 2013;
                    (D) $305,000,000 for fiscal year 2014; and
                    (E) $310,000,000 for fiscal year 2015.

    (c) Construction.-- <<NOTE: Appropriation authorization.>> There is 
authorized to be appropriated, and there is appropriated, out of any 
monies in the Treasury not otherwise appropriated, $1,500,000,000 to be 
available for fiscal years 2011 through 2015 to be used by the Secretary 
of Health and Human Services for the construction and renovation of 
community health centers.

    (d) Use of Fund.--The Secretary of Health and Human Services shall 
transfer amounts in the CHC Fund to accounts within the Department of 
Health and Human Services to increase funding, over the fiscal year 2008 
level, for community health centers and the National Health Service 
Corps.
    (e) Availability.--Amounts appropriated under subsections (b) and 
(c) shall remain available until expended.

SEC. 10504. <<NOTE: 42 USC 256 note.>> DEMONSTRATION PROJECT TO PROVIDE 
            ACCESS TO AFFORDABLE CARE.

    (a) In General.-- <<NOTE: Deadline.>> Not later than 6 months after 
the date of enactment of this Act, the Secretary of Health and Human 
Services (referred to in this section as the ``Secretary''), acting 
through the Health Resources and Services Administration, shall 
establish a 3 year demonstration project in up to 10 States to provide 
access to comprehensive health care services to the uninsured at reduced 
fees. <<NOTE: Evaluation.>> The Secretary shall evaluate the feasibility 
of expanding the project to additional States.

[[Page 124 STAT. 1005]]

    (b) Eligibility.--To be eligible to participate in the demonstration 
project, an entity shall be a State-based, nonprofit, public-private 
partnership that provides access to comprehensive health care services 
to the uninsured at reduced fees. Each State in which a participant 
selected by the Secretary is located shall receive not more than 
$2,000,000 to establish and carry out the project for the 3-year 
demonstration period.
    (c) Authorization.--There is authorized to be appropriated such sums 
as may be necessary to carry out this section.

               Subtitle F--Provisions Relating to Title VI

SEC. 10601. REVISIONS TO LIMITATION ON MEDICARE EXCEPTION TO THE 
            PROHIBITION ON CERTAIN PHYSICIAN REFERRALS FOR HOSPITALS.

    (a) In General.--Section 1877(i) of the Social Security Act, as 
added by section 6001(a), <<NOTE: 42 USC 1395nn.>> is amended--
            (1) in paragraph (1)(A)(i), by striking ``February 1, 2010'' 
        and inserting ``August 1, 2010''; and
            (2) in paragraph (3)(A)--
                    (A) in clause (iii), by striking ``August 1, 2011'' 
                and inserting ``February 1, 2012''; and
                    (B) in clause (iv), by striking ``July 1, 2011'' and 
                inserting ``January 1, 2012''.

    (b) Conforming Amendment.--Section 6001(b)(2) <<NOTE: 42 USC 1395nn 
note.>> of this Act is amended by striking ``November 1, 2011'' and 
inserting ``May 1, 2012''.

SEC. 10602. CLARIFICATIONS TO PATIENT-CENTERED OUTCOMES RESEARCH.

    Section 1181 of the Social Security Act (as added by section 
6301) <<NOTE: 42 USC 1320e.>> is amended--
            (1) in subsection (d)(2)(B)--
                    (A) in clause (ii)(IV)--
                          (i) by inserting ``, as described in 
                      subparagraph (A)(ii),'' after ``original 
                      research''; and
                          (ii) by inserting ``, as long as the 
                      researcher enters into a data use agreement with 
                      the Institute for use of the data from the 
                      original research, as appropriate'' after 
                      ``publication''; and
                    (B) by amending clause (iv) to read as follows:
                          ``(iv) Subsequent use of the data.--The 
                      Institute shall not allow the subsequent use of 
                      data from original research in work-for-hire 
                      contracts with individuals, entities, or 
                      instrumentalities that have a financial interest 
                      in the results, unless approved under a data use 
                      agreement with the Institute.'';
            (2) in subsection (d)(8)(A)(iv), by striking ``not be 
        construed as mandates for'' and inserting ``do not include''; 
        and
            (3) in subsection (f)(1)(C), by amending clause (ii) to read 
        as follows:
                          ``(ii) 7 members representing physicians and 
                      providers, including 4 members representing 
                      physicians (at least 1 of whom is a surgeon), 1 
                      nurse, 1 State-licensed integrative health care 
                      practitioner, and 1 representative of a 
                      hospital.''.

[[Page 124 STAT. 1006]]

SEC. 10603. STRIKING PROVISIONS RELATING TO INDIVIDUAL PROVIDER 
            APPLICATION FEES.

    (a) In General.--Section 1866(j)(2)(C) of the Social Security Act, 
as added by section 6401(a), <<NOTE: 42 USC 1395cc.>> is amended--
            (1) by striking clause (i);
            (2) by redesignating clauses (ii) through (iv), 
        respectively, as clauses (i) through (iii); and
            (3) in clause (i), as redesignated by paragraph (2), by 
        striking ``clause (iii)'' and inserting ``clause (ii)''.

    (b) Technical Correction.--Section 6401(a)(2) of this Act is amended 
to read as follows:
            ``(2) by redesignating paragraph (2) as paragraph (8); 
        and''.

SEC. 10604. TECHNICAL CORRECTION TO SECTION 6405.

    Paragraphs (1) and (2) of section 6405(b) are amended to read as 
follows:
            ``(1) Part a.--Section 1814(a)(2) of the Social Security Act 
        ( <<NOTE: 42 USC 1395f.>> 42 U.S.C. 1395(a)(2)) is amended in 
        the matter preceding subparagraph (A) by inserting `, or, in the 
        case of services described in subparagraph (C), a physician 
        enrolled under section 1866(j),' after `in collaboration with a 
        physician,'.
            ``(2) Part b.--Section 1835(a)(2) of the Social Security Act 
        (42 U.S.C. 1395n(a)(2)) is amended in the matter preceding 
        subparagraph (A) by inserting `, or, in the case of services 
        described in subparagraph (A), a physician enrolled under 
        section 1866(j),' after `a physician'.''.

SEC. 10605. CERTAIN OTHER PROVIDERS PERMITTED TO CONDUCT FACE TO FACE 
            ENCOUNTER FOR HOME HEALTH SERVICES.

    (a) Part A.--Section 1814(a)(2)(C) of the Social Security Act (42 
U.S.C. 1395f(a)(2)(C)), as amended by section 6407(a)(1), is amended by 
inserting ``, or a nurse practitioner or clinical nurse specialist (as 
those terms are defined in section 1861(aa)(5)) who is working in 
collaboration with the physician in accordance with State law, or a 
certified nurse-midwife (as defined in section 1861(gg)) as authorized 
by State law, or a physician assistant (as defined in section 
1861(aa)(5)) under the supervision of the physician,'' after ``himself 
or herself''.
    (b) Part B.--Section 1835(a)(2)(A)(iv) of the Social Security Act, 
as added by section 6407(a)(2), is amended by inserting ``, or a nurse 
practitioner or clinical nurse specialist (as those terms are defined in 
section 1861(aa)(5)) who is working in collaboration with the physician 
in accordance with State law, or a certified nurse-midwife (as defined 
in section 1861(gg)) as authorized by State law, or a physician 
assistant (as defined in section 1861(aa)(5)) under the supervision of 
the physician,'' after ``must document that the physician''.

SEC. 10606. HEALTH CARE FRAUD ENFORCEMENT.

    (a) <<NOTE: 28 USC 994 note.>> Fraud Sentencing Guidelines.--
            (1) Definition.--In this subsection, the term ``Federal 
        health care offense'' has the meaning given that term in section 
        24 of title 18, United States Code, as amended by this Act.
            (2) Review and amendments.--Pursuant to the authority under 
        section 994 of title 28, United States Code, and in accordance 
        with this subsection, the United States Sentencing Commission 
        shall--

[[Page 124 STAT. 1007]]

                    (A) review the Federal Sentencing Guidelines and 
                policy statements applicable to persons convicted of 
                Federal health care offenses;
                    (B) amend the Federal Sentencing Guidelines and 
                policy statements applicable to persons convicted of 
                Federal health care offenses involving Government health 
                care programs to provide that the aggregate dollar 
                amount of fraudulent bills submitted to the Government 
                health care program shall constitute prima facie 
                evidence of the amount of the intended loss by the 
                defendant; and
                    (C) amend the Federal Sentencing Guidelines to 
                provide--
                          (i) a 2-level increase in the offense level 
                      for any defendant convicted of a Federal health 
                      care offense relating to a Government health care 
                      program which involves a loss of not less than 
                      $1,000,000 and less than $7,000,000;
                          (ii) a 3-level increase in the offense level 
                      for any defendant convicted of a Federal health 
                      care offense relating to a Government health care 
                      program which involves a loss of not less than 
                      $7,000,000 and less than $20,000,000;
                          (iii) a 4-level increase in the offense level 
                      for any defendant convicted of a Federal health 
                      care offense relating to a Government health care 
                      program which involves a loss of not less than 
                      $20,000,000; and
                          (iv) if appropriate, otherwise amend the 
                      Federal Sentencing Guidelines and policy 
                      statements applicable to persons convicted of 
                      Federal health care offenses involving Government 
                      health care programs.
            (3) Requirements.--In carrying this subsection, the United 
        States Sentencing Commission shall--
                    (A) ensure that the Federal Sentencing Guidelines 
                and policy statements--
                          (i) reflect the serious harms associated with 
                      health care fraud and the need for aggressive and 
                      appropriate law enforcement action to prevent such 
                      fraud; and
                          (ii) provide increased penalties for persons 
                      convicted of health care fraud offenses in 
                      appropriate circumstances;
                    (B) consult with individuals or groups representing 
                health care fraud victims, law enforcement officials, 
                the health care industry, and the Federal judiciary as 
                part of the review described in paragraph (2);
                    (C) ensure reasonable consistency with other 
                relevant directives and with other guidelines under the 
                Federal Sentencing Guidelines;
                    (D) account for any aggravating or mitigating 
                circumstances that might justify exceptions, including 
                circumstances for which the Federal Sentencing 
                Guidelines, as in effect on the date of enactment of 
                this Act, provide sentencing enhancements;
                    (E) make any necessary conforming changes to the 
                Federal Sentencing Guidelines; and
                    (F) ensure that the Federal Sentencing Guidelines 
                adequately meet the purposes of sentencing.

[[Page 124 STAT. 1008]]

    (b) Intent Requirement for Health Care Fraud.--Section 1347 of title 
18, United States Code, is amended--
            (1) by inserting ``(a)'' before ``Whoever knowingly''; and
            (2) by adding at the end the following:

    ``(b) With respect to violations of this section, a person need not 
have actual knowledge of this section or specific intent to commit a 
violation of this section.''.
    (c) Health Care Fraud Offense.--Section 24(a) of title 18, United 
States Code, is amended--
            (1) in paragraph (1), by striking the semicolon and 
        inserting ``or section 1128B of the Social Security Act (42 
        U.S.C. 1320a-7b); or''; and
            (2) in paragraph (2)--
                    (A) by inserting ``1349,'' after ``1343,''; and
                    (B) by inserting ``section 301 of the Federal Food, 
                Drug, and Cosmetic Act (21 U.S.C. 331), or section 501 
                of the Employee Retirement Income Security Act of 1974 
                (29 U.S.C. 1131),'' after ``title,''.

    (d) Subpoena Authority Relating to Health Care.--
            (1) Subpoenas under the health insurance portability and 
        accountability act of 1996.--Section 1510(b) of title 18, United 
        States Code, is amended--
                    (A) in paragraph (1), by striking ``to the grand 
                jury''; and
                    (B) in paragraph (2)--
                          (i) in subparagraph (A), by striking ``grand 
                      jury subpoena'' and inserting ``subpoena for 
                      records''; and
                          (ii) in the matter following subparagraph (B), 
                      by striking ``to the grand jury''.
            (2) Subpoenas under the civil rights of institutionalized 
        persons act.--The Civil Rights of Institutionalized Persons Act 
        (42 U.S.C. 1997 et seq.) is amended by inserting after section 3 
        the following:

``SEC. 3A. <<NOTE: 42 USC 1997a-1.>> SUBPOENA AUTHORITY.

    ``(a) Authority.--The Attorney General, or at the direction of the 
Attorney General, any officer or employee of the Department of Justice 
may require by subpoena access to any institution that is the subject of 
an investigation under this Act and to any document, record, material, 
file, report, memorandum, policy, procedure, investigation, video or 
audio recording, or quality assurance report relating to any institution 
that is the subject of an investigation under this Act to determine 
whether there are conditions which deprive persons residing in or 
confined to the institution of any rights, privileges, or immunities 
secured or protected by the Constitution or laws of the United States.
    ``(b) Issuance and Enforcement of Subpoenas.--
            ``(1) Issuance.--Subpoenas issued under this section--
                    ``(A) shall bear the signature of the Attorney 
                General or any officer or employee of the Department of 
                Justice as designated by the Attorney General; and
                    ``(B) shall be served by any person or class of 
                persons designated by the Attorney General or a 
                designated officer or employee for that purpose.
            ``(2) Enforcement.--In the case of contumacy or failure to 
        obey a subpoena issued under this section, the United States 
        district court for the judicial district in which the 
        institution

[[Page 124 STAT. 1009]]

        is located may issue an order requiring compliance. Any failure 
        to obey the order of the court may be punished by the court as a 
        contempt that court.

    ``(c) Protection of Subpoenaed Records and Information.--Any 
document, record, material, file, report, memorandum, policy, procedure, 
investigation, video or audio recording, or quality assurance report or 
other information obtained under a subpoena issued under this section--
            ``(1) may not be used for any purpose other than to protect 
        the rights, privileges, or immunities secured or protected by 
        the Constitution or laws of the United States of persons who 
        reside, have resided, or will reside in an institution;
            ``(2) may not be transmitted by or within the Department of 
        Justice for any purpose other than to protect the rights, 
        privileges, or immunities secured or protected by the 
        Constitution or laws of the United States of persons who reside, 
        have resided, or will reside in an institution; and
            ``(3) shall be redacted, obscured, or otherwise altered if 
        used in any publicly available manner so as to prevent the 
        disclosure of any personally identifiable information.''.

SEC. 10607. STATE DEMONSTRATION PROGRAMS TO EVALUATE ALTERNATIVES TO 
            CURRENT MEDICAL TORT LITIGATION.

    Part P of title III of the Public Health Service Act (42 U.S.C. 280g 
et seq.), as amended by this Act, is further amended by adding at the 
end the following:

``SEC. 399V-4. <<NOTE: Grants. 42 USC 280g-15.>> STATE DEMONSTRATION 
            PROGRAMS TO EVALUATE ALTERNATIVES TO CURRENT MEDICAL TORT 
            LITIGATION.

    ``(a) In General.--The Secretary is authorized to award 
demonstration grants to States for the development, implementation, and 
evaluation of alternatives to current tort litigation for resolving 
disputes over injuries allegedly caused by health care providers or 
health care organizations. In awarding such grants, the Secretary shall 
ensure the diversity of the alternatives so funded.
    ``(b) Duration.--The Secretary may award grants under subsection (a) 
for a period not to exceed 5 years.
    ``(c) Conditions for Demonstration Grants.--
            ``(1) Requirements.--Each State desiring a grant under 
        subsection (a) shall develop an alternative to current tort 
        litigation that--
                    ``(A) allows for the resolution of disputes over 
                injuries allegedly caused by health care providers or 
                health care organizations; and
                    ``(B) promotes a reduction of health care errors by 
                encouraging the collection and analysis of patient 
                safety data related to disputes resolved under 
                subparagraph (A) by organizations that engage in efforts 
                to improve patient safety and the quality of health 
                care.
            ``(2) Alternative to current tort litigation.--Each State 
        desiring a grant under subsection (a) shall demonstrate how the 
        proposed alternative described in paragraph (1)(A)--
                    ``(A) makes the medical liability system more 
                reliable by increasing the availability of prompt and 
                fair resolution of disputes;
                    ``(B) encourages the efficient resolution of 
                disputes;
                    ``(C) encourages the disclosure of health care 
                errors;

[[Page 124 STAT. 1010]]

                    ``(D) enhances patient safety by detecting, 
                analyzing, and helping to reduce medical errors and 
                adverse events;
                    ``(E) improves access to liability insurance;
                    ``(F) fully informs patients about the differences 
                in the alternative and current tort litigation;
                    ``(G) provides patients the ability to opt out of or 
                voluntarily withdraw from participating in the 
                alternative at any time and to pursue other options, 
                including litigation, outside the alternative;
                    ``(H) would not conflict with State law at the time 
                of the application in a way that would prohibit the 
                adoption of an alternative to current tort litigation; 
                and
                    ``(I) would not limit or curtail a patient's 
                existing legal rights, ability to file a claim in or 
                access a State's legal system, or otherwise abrogate a 
                patient's ability to file a medical malpractice claim.
            ``(3) Sources of compensation.--Each State desiring a grant 
        under subsection (a) shall identify the sources from and methods 
        by which compensation would be paid for claims resolved under 
        the proposed alternative to current tort litigation, which may 
        include public or private funding sources, or a combination of 
        such sources. Funding methods shall to the extent practicable 
        provide financial incentives for activities that improve patient 
        safety.
            ``(4) Scope.--
                    ``(A) In general.--Each State desiring a grant under 
                subsection (a) shall establish a scope of jurisdiction 
                (such as Statewide, designated geographic region, a 
                designated area of health care practice, or a designated 
                group of health care providers or health care 
                organizations) for the proposed alternative to current 
                tort litigation that is sufficient to evaluate the 
                effects of the alternative. No scope of jurisdiction 
                shall be established under this paragraph that is based 
                on a health care payer or patient population.
                    ``(B) Notification of patients.--A State shall 
                demonstrate how patients would be notified that they are 
                receiving health care services that fall within such 
                scope, and the process by which they may opt out of or 
                voluntarily withdraw from participating in the 
                alternative. The decision of the patient whether to 
                participate or continue participating in the alternative 
                process shall be made at any time and shall not be 
                limited in any way.
            ``(5) Preference in awarding demonstration grants.--In 
        awarding grants under subsection (a), the Secretary shall give 
        preference to States--
                    ``(A) that have developed the proposed alternative 
                through substantive consultation with relevant 
                stakeholders, including patient advocates, health care 
                providers and health care organizations, attorneys with 
                expertise in representing patients and health care 
                providers, medical malpractice insurers, and patient 
                safety experts;
                    ``(B) that make proposals that are likely to enhance 
                patient safety by detecting, analyzing, and helping to 
                reduce medical errors and adverse events; and
                    ``(C) that make proposals that are likely to improve 
                access to liability insurance.

    ``(d) Application.--

[[Page 124 STAT. 1011]]

            ``(1) In general.--Each State desiring a grant under 
        subsection (a) shall submit to the Secretary an application, at 
        such time, in such manner, and containing such information as 
        the Secretary may require.
            ``(2) Review panel.--
                    ``(A) In general.-- <<NOTE: Establishment.>> In 
                reviewing applications under paragraph (1), the 
                Secretary shall consult with a review panel composed of 
                relevant experts appointed by the Comptroller General.
                    ``(B) Composition.--
                          ``(i) Nominations.--The Comptroller General 
                      shall solicit nominations from the public for 
                      individuals to serve on the review panel.
                          ``(ii) Appointment.--The Comptroller General 
                      shall appoint, at least 9 but not more than 13, 
                      highly qualified and knowledgeable individuals to 
                      serve on the review panel and shall ensure that 
                      the following entities receive fair representation 
                      on such panel:
                                    ``(I) Patient advocates.
                                    ``(II) Health care providers and 
                                health care organizations.
                                    ``(III) Attorneys with expertise in 
                                representing patients and health care 
                                providers.
                                    ``(IV) Medical malpractice insurers.
                                    ``(V) State officials.
                                    ``(VI) Patient safety experts.
                    ``(C) Chairperson.--The Comptroller General, or an 
                individual within the Government Accountability Office 
                designated by the Comptroller General, shall be the 
                chairperson of the review panel.
                    ``(D) Availability of information.--The Comptroller 
                General shall make available to the review panel such 
                information, personnel, and administrative services and 
                assistance as the review panel may reasonably require to 
                carry out its duties.
                    ``(E) Information from agencies.--The review panel 
                may request directly from any department or agency of 
                the United States any information that such panel 
                considers necessary to carry out its duties. To the 
                extent consistent with applicable laws and regulations, 
                the head of such department or agency shall furnish the 
                requested information to the review panel.

    ``(e) Reports.--
            ``(1) By state.--Each State receiving a grant under 
        subsection (a) shall submit to the Secretary an annual report 
        evaluating the effectiveness of activities funded with grants 
        awarded under such subsection. Such report shall, at a minimum, 
        include the impact of the activities funded on patient safety 
        and on the availability and price of medical liability 
        insurance.
            ``(2) By secretary.--The Secretary shall submit to Congress 
        an annual compendium of the reports submitted under paragraph 
        (1) and an analysis of the activities funded under subsection 
        (a) that examines any differences that result from such 
        activities in terms of the quality of care, number and nature of 
        medical errors, medical resources used, length of

[[Page 124 STAT. 1012]]

        time for dispute resolution, and the availability and price of 
        liability insurance.

    ``(f) Technical Assistance.--
            ``(1) In general.--The Secretary shall provide technical 
        assistance to the States applying for or awarded grants under 
        subsection (a).
            ``(2) Requirements.--Technical assistance under paragraph 
        (1) shall include--
                    ``(A) guidance on non-economic damages, including 
                the consideration of individual facts and circumstances 
                in determining appropriate payment, guidance on 
                identifying avoidable injuries, and guidance on 
                disclosure to patients of health care errors and adverse 
                events; and
                    ``(B) the development, in consultation with States, 
                of common definitions, formats, and data collection 
                infrastructure for States receiving grants under this 
                section to use in reporting to facilitate aggregation 
                and analysis of data both within and between States.
            ``(3) Use of common definitions, formats, and data 
        collection infrastructure.--States not receiving grants under 
        this section may also use the common definitions, formats, and 
        data collection infrastructure developed under paragraph (2)(B).

    ``(g) Evaluation.--
            ``(1) In general.-- 
        <<NOTE: Contracts. Deadlines. Reports.>> The Secretary, in 
        consultation with the review panel established under subsection 
        (d)(2), shall enter into a contract with an appropriate research 
        organization to conduct an overall evaluation of the 
        effectiveness of grants awarded under subsection (a) and to 
        annually prepare and submit a report to Congress. Such an 
        evaluation shall begin not later than 18 months following the 
        date of implementation of the first program funded by a grant 
        under subsection (a).
            ``(2) Contents.--The evaluation under paragraph (1) shall 
        include--
                    ``(A) an analysis of the effects of the grants 
                awarded under subsection (a) with regard to the measures 
                described in paragraph (3);
                    ``(B) for each State, an analysis of the extent to 
                which the alternative developed under subsection (c)(1) 
                is effective in meeting the elements described in 
                subsection (c)(2);
                    ``(C) a comparison among the States receiving grants 
                under subsection (a) of the effectiveness of the various 
                alternatives developed by such States under subsection 
                (c)(1);
                    ``(D) a comparison, considering the measures 
                described in paragraph (3), of States receiving grants 
                approved under subsection (a) and similar States not 
                receiving such grants; and
                    ``(E) a comparison, with regard to the measures 
                described in paragraph (3), of--
                          ``(i) States receiving grants under subsection 
                      (a);
                          ``(ii) States that enacted, prior to the date 
                      of enactment of the Patient Protection and 
                      Affordable Care Act, any cap on non-economic 
                      damages; and
                          ``(iii) States that have enacted, prior to the 
                      date of enactment of the Patient Protection and 
                      Affordable Care Act, a requirement that the 
                      complainant obtain

[[Page 124 STAT. 1013]]

                      an opinion regarding the merit of the claim, 
                      although the substance of such opinion may have no 
                      bearing on whether the complainant may proceed 
                      with a case.
            ``(3) Measures.--The evaluations under paragraph (2) shall 
        analyze and make comparisons on the basis of--
                    ``(A) the nature and number of disputes over 
                injuries allegedly caused by health care providers or 
                health care organizations;
                    ``(B) the nature and number of claims in which tort 
                litigation was pursued despite the existence of an 
                alternative under subsection (a);
                    ``(C) the disposition of disputes and claims, 
                including the length of time and estimated costs to all 
                parties;
                    ``(D) the medical liability environment;
                    ``(E) health care quality;
                    ``(F) patient safety in terms of detecting, 
                analyzing, and helping to reduce medical errors and 
                adverse events;
                    ``(G) patient and health care provider and 
                organization satisfaction with the alternative under 
                subsection (a) and with the medical liability 
                environment; and
                    ``(H) impact on utilization of medical services, 
                appropriately adjusted for risk.
            ``(4) Funding.--The Secretary shall reserve 5 percent of the 
        amount appropriated in each fiscal year under subsection (k) to 
        carry out this subsection.

    ``(h) MedPAC and MACPAC Reports.--
            ``(1) MedPAC.--The Medicare Payment Advisory Commission 
        shall conduct an independent review of the alternatives to 
        current tort litigation that are implemented under grants under 
        subsection (a) to determine the impact of such alternatives on 
        the Medicare program under title XVIII of the Social Security 
        Act, and its beneficiaries.
            ``(2) MACPAC.--The Medicaid and CHIP Payment and Access 
        Commission shall conduct an independent review of the 
        alternatives to current tort litigation that are implemented 
        under grants under subsection (a) to determine the impact of 
        such alternatives on the Medicaid or CHIP programs under titles 
        XIX and XXI of the Social Security Act, and their beneficiaries.
            ``(3) Reports.--Not later than December 31, 2016, the 
        Medicare Payment Advisory Commission and the Medicaid and CHIP 
        Payment and Access Commission shall each submit to Congress a 
        report that includes the findings and recommendations of each 
        respective Commission based on independent reviews conducted 
        under paragraphs (1) and (2), including an analysis of the 
        impact of the alternatives reviewed on the efficiency and 
        effectiveness of the respective programs.

    ``(i) Option To Provide for Initial Planning Grants.--Of the funds 
appropriated pursuant to subsection (k), the Secretary may use a portion 
not to exceed $500,000 per State to provide planning grants to such 
States for the development of demonstration project applications meeting 
the criteria described in subsection (c). In selecting States to receive 
such planning grants, the Secretary shall give preference to those 
States in which State law at the time of the application would not 
prohibit the adoption of an alternative to current tort litigation.
    ``(j) Definitions.--In this section:

[[Page 124 STAT. 1014]]

            ``(1) Health care services.--The term `health care services' 
        means any services provided by a health care provider, or by any 
        individual working under the supervision of a health care 
        provider, that relate to--
                    ``(A) the diagnosis, prevention, or treatment of any 
                human disease or impairment; or
                    ``(B) the assessment of the health of human beings.
            ``(2) Health care organization.--The term `health care 
        organization' means any individual or entity which is obligated 
        to provide, pay for, or administer health benefits under any 
        health plan.
            ``(3) Health care provider.--The term `health care provider' 
        means any individual or entity--
                    ``(A) licensed, registered, or certified under 
                Federal or State laws or regulations to provide health 
                care services; or
                    ``(B) required to be so licensed, registered, or 
                certified but that is exempted by other statute or 
                regulation.

    ``(k) Authorization of Appropriations.--There are authorized to be 
appropriated to carry out this section, $50,000,000 for the 5-fiscal 
year period beginning with fiscal year 2011.
    ``(l) Current State Efforts To Establish Alternative To Tort 
Litigation.--Nothing in this section shall be construed to limit any 
prior, current, or future efforts of any State to establish any 
alternative to tort litigation.
    ``(m) Rule of Construction.--Nothing in this section shall be 
construed as limiting states' authority over or responsibility for their 
state justice systems.''.

SEC. 10608. EXTENSION OF MEDICAL MALPRACTICE COVERAGE TO FREE CLINICS.

    (a) In General.--Section 224(o)(1) of the Public Health Service Act 
(42 U.S.C. 233(o)(1)) is amended by inserting after ``to an individual'' 
the following: ``, or an officer, governing board member, employee, or 
contractor of a free clinic shall in providing services for the free 
clinic,''.
    (b) <<NOTE: 42 USC 233 note.>> Effective Date.--The amendment made 
by this section shall take effect on the date of enactment of this Act 
and apply to any act or omission which occurs on or after that date.

SEC. 10609. <<NOTE: Drugs and drug abuse.>> LABELING CHANGES.

    Section 505(j) of the Federal Food, Drug, and Cosmetic Act (21 
U.S.C. 355(j)) is amended by adding at the end the following:
    ``(10)(A) <<NOTE: Deadlines.>> If the proposed labeling of a drug 
that is the subject of an application under this subsection differs from 
the listed drug due to a labeling revision described under clause (i), 
the drug that is the subject of such application shall, notwithstanding 
any other provision of this Act, be eligible for approval and shall not 
be considered misbranded under section 502 if--
            ``(i) the application is otherwise eligible for approval 
        under this subsection but for expiration of patent, an 
        exclusivity period, or of a delay in approval described in 
        paragraph (5)(B)(iii), and a revision to the labeling of the 
        listed drug has been approved by the Secretary within 60 days of 
        such expiration;
            ``(ii) the labeling revision described under clause (i) does 
        not include a change to the `Warnings' section of the labeling;

[[Page 124 STAT. 1015]]

            ``(iii) the sponsor of the application under this subsection 
        agrees to submit revised labeling of the drug that is the 
        subject of such application not later than 60 days after the 
        notification of any changes to such labeling required by the 
        Secretary; and
            ``(iv) such application otherwise meets the applicable 
        requirements for approval under this subsection.

    ``(B) <<NOTE: Determination.>> If, after a labeling revision 
described in subparagraph (A)(i), the Secretary determines that the 
continued presence in interstate commerce of the labeling of the listed 
drug (as in effect before the revision described in subparagraph (A)(i)) 
adversely impacts the safe use of the drug, no application under this 
subsection shall be eligible for approval with such labeling.''.

              Subtitle G--Provisions Relating to Title VIII

SEC. 10801. PROVISIONS RELATING TO TITLE VIII.

    (a) Title XXXII of the Public Health Service Act, as added by 
section 8002(a)(1), is amended--
            (1) in section 3203 <<NOTE: 42 USC 300ll-2.>> --
                    (A) in subsection (a)(1), by striking subparagraph 
                (E);
                    (B) in subsection (b)(1)(C)(i), by striking ``for 
                enrollment'' and inserting ``for reenrollment''; and
                    (C) in subsection (c)(1), by striking ``, as part of 
                their automatic enrollment in the CLASS program,''; and
            (2) in section 3204 <<NOTE: 42 USC 300ll-3.>> --
                    (A) in subsection (c)(2), by striking subparagraph 
                (A) and inserting the following:
                    ``(A) receives wages or income on which there is 
                imposed a tax under section 3101(a) or 3201(a) of the 
                Internal Revenue Code of 1986; or'';
                    (B) in subsection (d), by striking ``subparagraph 
                (B) or (C) of subsection (c)(1)'' and inserting 
                ``subparagraph (A) or (B) of subsection (c)(2)'';
                    (C) in subsection (e)(2)(A), by striking 
                ``subparagraph (A)'' and inserting ``paragraph (1)''; 
                and
                    (D) in subsection (g)(1), by striking ``has elected 
                to waive enrollment'' and inserting ``has not 
                enrolled''.

    (b) Section 8002 of this Act is amended in the heading for 
subsection (d), by striking ``Information on Supplemental Coverage'' and 
inserting ``CLASS Program Information''.
    (c) Section 6021(d)(2)(A)(iv) of the Deficit Reduction Act of 2005, 
as added by section 8002(d) of this Act, <<NOTE: 42 USC 1396p note.>> is 
amended by striking ``and coverage available'' and all that follows 
through ``that program,''.

               Subtitle H--Provisions Relating to Title IX

SEC. 10901. MODIFICATIONS TO EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED 
            HEALTH COVERAGE.

    (a) Longshore Workers Treated as Employees Engaged in High-risk 
Professions.--Paragraph (3) of section 4980I(f) of the Internal Revenue 
Code of 1986, as added by section 9001 of this Act, <<NOTE: 26 USC 
4980I.>> is amended by inserting ``individuals whose primary

[[Page 124 STAT. 1016]]

work is longshore work (as defined in section 258(b) of the Immigration 
and Nationality Act (8 U.S.C. 1288(b)), determined without regard to 
paragraph (2) thereof),'' before ``and individuals engaged in the 
construction, mining''.

    (b) Exemption From High-cost Insurance Tax Includes Certain 
Additional Excepted Benefits.--Clause (i) of section 4980I(d)(1)(B) of 
the Internal Revenue Code of 1986, as added by section 9001 of this Act, 
is amended by striking ``section 9832(c)(1)(A)'' and inserting ``section 
9832(c)(1) (other than subparagraph (G) thereof)''.
    (c) <<NOTE: 26 USC 4980I note.>> Effective Date.--The amendments 
made by this section shall apply to taxable years beginning after 
December 31, 2012.

SEC. 10902. INFLATION ADJUSTMENT OF LIMITATION ON HEALTH FLEXIBLE 
            SPENDING ARRANGEMENTS UNDER CAFETERIA PLANS.

    (a) In General.--Subsection (i) of section 125 of the Internal 
Revenue Code of 1986, as added by section 9005 of this Act, <<NOTE: 26 
USC 125.>> is amended to read as follows:

    ``(i) Limitation on Health Flexible Spending Arrangements.--
            ``(1) In general.--For purposes of this section, if a 
        benefit is provided under a cafeteria plan through employer 
        contributions to a health flexible spending arrangement, such 
        benefit shall not be treated as a qualified benefit unless the 
        cafeteria plan provides that an employee may not elect for any 
        taxable year to have salary reduction contributions in excess of 
        $2,500 made to such arrangement.
            ``(2) Adjustment for inflation.-- <<NOTE: Effective 
        date.>> In the case of any taxable year beginning after December 
        31, 2011, the dollar amount in paragraph (1) shall be increased 
        by an amount equal to--
                    ``(A) such amount, multiplied by
                    ``(B) the cost-of-living adjustment determined under 
                section 1(f)(3) for the calendar year in which such 
                taxable year begins by substituting `calendar year 2010' 
                for `calendar year 1992' in subparagraph (B) thereof.
        If any increase determined under this paragraph is not a 
        multiple of $50, such increase shall be rounded to the next 
        lowest multiple of $50.''.

    (b) <<NOTE: 26 USC 125 note.>> Effective Date.--The amendment made 
by this section shall apply to taxable years beginning after December 
31, 2010.

SEC. 10903. MODIFICATION OF LIMITATION ON CHARGES BY CHARITABLE 
            HOSPITALS.

    (a) In General.--Subparagraph (A) of section 501(r)(5) of the 
Internal Revenue Code of 1986, as added by section 9007 of this 
Act, <<NOTE: 26 USC 501.>> is amended by striking ``the lowest amounts 
charged'' and inserting ``the amounts generally billed''.

    (b) <<NOTE: 26 USC 501 note.>> Effective Date.--The amendment made 
by this section shall apply to taxable years beginning after the date of 
the enactment of this Act.

SEC. 10904. MODIFICATION OF ANNUAL FEE ON MEDICAL DEVICE MANUFACTURERS 
            AND IMPORTERS.

    (a) In General.--Section 9009 of this Act <<NOTE: 26 USC 4001 note 
prec.>> is amended--
            (1) by striking ``2009'' in subsection (a)(1) and inserting 
        ``2010'',

[[Page 124 STAT. 1017]]

            (2) by inserting ``($3,000,000,000 after 2017)'' after 
        ``$2,000,000,000'', and
            (3) by striking ``2008'' in subsection (i) and inserting 
        ``2009''.

    (b) <<NOTE: 26 USC 4001 note prec.>> Effective Date.--The amendments 
made by this section shall take effect as if included in the enactment 
of section 9009.

SEC. 10905. <<NOTE: 26 USC 4001 note prec.>> MODIFICATION OF ANNUAL FEE 
            ON HEALTH INSURANCE PROVIDERS.

    (a) Determination of Fee Amount.--Subsection (b) of section 9010 of 
this Act is amended to read as follows:
    ``(b) Determination of Fee Amount.--
            ``(1) In general.--With respect to each covered entity, the 
        fee under this section for any calendar year shall be equal to 
        an amount that bears the same ratio to the applicable amount 
        as--
                    ``(A) the covered entity's net premiums written with 
                respect to health insurance for any United States health 
                risk that are taken into account during the preceding 
                calendar year, bears to
                    ``(B) the aggregate net premiums written with 
                respect to such health insurance of all covered entities 
                that are taken into account during such preceding 
                calendar year.
            ``(2) Amounts taken into account.--For purposes of paragraph 
        (1), the net premiums written with respect to health insurance 
        for any United States health risk that are taken into account 
        during any calendar year with respect to any covered entity 
        shall be determined in accordance with the following table:

 
  ``With respect to a covered entity's    The percentage of net premiums
    net premiums written during the        written that are taken into
        calendar year that are:                    account is:
 
  Not more than $25,000,000............  0 percent
  More than $25,000,000 but not more     50 percent
   than $50,000,000.
  More than $50,000,000................  100 percent.
 

            ``(3) Secretarial determination.--The Secretary shall 
        calculate the amount of each covered entity's fee for any 
        calendar year under paragraph (1). In calculating such amount, 
        the Secretary shall determine such covered entity's net premiums 
        written with respect to any United States health risk on the 
        basis of reports submitted by the covered entity under 
        subsection (g) and through the use of any other source of 
        information available to the Secretary.''.

    (b) Applicable Amount.--Subsection (e) of section 9010 of this Act 
is amended to read as follows:
    ``(e) Applicable Amount.--For purposes of subsection (b)(1), the 
applicable amount shall be determined in accordance with the following 
table:

``Calendar year                          Applicable amount
  2011.................................  $2,000,000,000
  2012.................................  $4,000,000,000

[[Page 124 STAT. 1018]]

 
  2013.................................  $7,000,000,000
  2014, 2015 and 2016..................  $9,000,000,000
  2017 and thereafter..................  $10,000,000,000.''.
 

    (c) Exemption From Annual Fee on Health Insurance for Certain 
Nonprofit Entities.--Section 9010(c)(2) of this Act is amended by 
striking ``or'' at the end of subparagraph (A), by striking the period 
at the end of subparagraph (B) and inserting a comma, and by adding at 
the end the following new subparagraphs:
                    ``(C) any entity--
                          ``(i)(I) which is incorporated as, is a wholly 
                      owned subsidiary of, or is a wholly owned 
                      affiliate of, a nonprofit corporation under a 
                      State law, or
                          ``(II) which is described in section 501(c)(4) 
                      of the Internal Revenue Code of 1986 and the 
                      activities of which consist of providing 
                      commercial-type insurance (within the meaning of 
                      section 501(m) of such Code),
                          ``(ii) the premium rate increases of which are 
                      regulated by a State authority,
                          ``(iii) which, as of the date of the enactment 
                      of this section, acts as the insurer of last 
                      resort in the State and is subject to State 
                      guarantee issue requirements, and
                          ``(iv) for which the medical loss ratio 
                      (determined in a manner consistent with the 
                      determination of such ratio under section 
                      2718(b)(1)(A) of the Public Health Service Act) 
                      with respect to the individual insurance market 
                      for such entity for the calendar year is not less 
                      than 100 percent,
                    ``(D) any entity--
                          ``(i)(I) which is incorporated as a nonprofit 
                      corporation under a State law, or
                          ``(II) which is described in section 501(c)(4) 
                      of the Internal Revenue Code of 1986 and the 
                      activities of which consist of providing 
                      commercial-type insurance (within the meaning of 
                      section 501(m) of such Code), and
                          ``(ii) for which the medical loss ratio (as so 
                      determined)--
                                    ``(I) with respect to each of the 
                                individual, small group, and large group 
                                insurance markets for such entity for 
                                the calendar year is not less than 90 
                                percent, and
                                    ``(II) with respect to all such 
                                markets for such entity for the calendar 
                                year is not less than 92 percent, or
                    ``(E) any entity--
                          ``(i) which is a mutual insurance company,
                          ``(ii) which for the period reported on the 
                      2008 Accident and Health Policy Experience Exhibit 
                      of the National Association of Insurance 
                      Commissioners had--
                                    ``(I) a market share of the insured 
                                population of a State of at least 40 but 
                                not more than 60 percent, and

[[Page 124 STAT. 1019]]

                                    ``(II) with respect to all markets 
                                described in subparagraph (D)(ii)(I), a 
                                medical loss ratio of not less than 90 
                                percent, and
                          ``(iii) with respect to annual payment dates 
                      in calendar years after 2011, for which the 
                      medical loss ratio (determined in a manner 
                      consistent with the determination of such ratio 
                      under section 2718(b)(1)(A) of the Public Health 
                      Service Act) with respect to all such markets for 
                      such entity for the preceding calendar year is not 
                      less than 89 percent (except that with respect to 
                      such annual payment date for 2012, the calculation 
                      under 2718(b)(1)(B)(ii) of such Act is determined 
                      by reference to the previous year, and with 
                      respect to such annual payment date for 2013, such 
                      calculation is determined by reference to the 
                      average for the previous 2 years).''.

    (d) Certain Insurance Exempted From Fee.--Paragraph (3) of section 
9010(h) of this Act is amended to read as follows:
            ``(3) Health insurance.--The term `health insurance' shall 
        not include--
                    ``(A) any insurance coverage described in paragraph 
                (1)(A) or (3) of section 9832(c) of the Internal Revenue 
                Code of 1986,
                    ``(B) any insurance for long-term care, or
                    ``(C) any medicare supplemental health insurance (as 
                defined in section 1882(g)(1) of the Social Security 
                Act).''.

    (e) Anti-avoidance Guidance.--Subsection (i) of section 9010 of this 
Act is amended by inserting ``and shall prescribe such regulations as 
are necessary or appropriate to prevent avoidance of the purposes of 
this section, including inappropriate actions taken to qualify as an 
exempt entity under subsection (c)(2)'' after ``section''.
    (f) Conforming Amendments.--
            (1) Section 9010(a)(1) of this Act is amended by striking 
        ``2009'' and inserting ``2010''.
            (2) Section 9010(c)(2)(B) of this Act is amended by striking 
        ``(except'' and all that follows through ``1323)''.
            (3) Section 9010(c)(3) of this Act is amended by adding at 
        the end the following new sentence: ``If any entity described in 
        subparagraph (C)(i)(I), (D)(i)(I), or (E)(i) of paragraph (2) is 
        treated as a covered entity by reason of the application of the 
        preceding sentence, the net premiums written with respect to 
        health insurance for any United States health risk of such 
        entity shall not be taken into account for purposes of this 
        section.''.
            (4) Section 9010(g)(1) of this Act is amended by striking 
        ``and third party administration agreement fees''.
            (5) Section 9010(j) of this Act is amended--
                    (A) by striking ``2008'' and inserting ``2009'', and
                    (B) by striking ``, and any third party 
                administration agreement fees received after such 
                date''.

    (g) Effective Date.--The amendments made by this section shall take 
effect as if included in the enactment of section 9010.

[[Page 124 STAT. 1020]]

SEC. 10906. MODIFICATIONS TO ADDITIONAL HOSPITAL INSURANCE TAX ON HIGH-
            INCOME TAXPAYERS.

    (a) FICA.--Section 3101(b)(2) of the Internal Revenue Code of 1986, 
as added by section 9015(a)(1) of this Act, <<NOTE: 26 USC 3101.>> is 
amended by striking ``0.5 percent'' and inserting ``0.9 percent''.

    (b) SECA.--Section 1401(b)(2)(A) of the Internal Revenue Code of 
1986, as added by section 9015(b)(1) of this Act, <<NOTE: 26 USC 
1401.>> is amended by striking ``0.5 percent'' and inserting ``0.9 
percent''.

    (c) <<NOTE: 26 USC 1401 note.>> Effective Date.--The amendments made 
by this section shall apply with respect to remuneration received, and 
taxable years beginning, after December 31, 2012.

SEC. 10907. EXCISE TAX ON INDOOR TANNING SERVICES IN LIEU OF ELECTIVE 
            COSMETIC MEDICAL PROCEDURES.

    (a) <<NOTE: 26 USC 5000B and note.>> In General.--The provisions of, 
and amendments made by, section 9017 of this Act are hereby deemed null, 
void, and of no effect.

    (b) Excise Tax on Indoor Tanning Services.--Subtitle D of the 
Internal Revenue Code of 1986, as amended by this Act, is amended by 
adding at the end the following new chapter:

                     ``CHAPTER 49--COSMETIC SERVICES

``Sec. 5000B. Imposition of tax on indoor tanning services.

``SEC. 5000B. <<NOTE: 26 USC 5000B.>> IMPOSITION OF TAX ON INDOOR 
            TANNING SERVICES.

    ``(a) In General.--There is hereby imposed on any indoor tanning 
service a tax equal to 10 percent of the amount paid for such service 
(determined without regard to this section), whether paid by insurance 
or otherwise.
    ``(b) Indoor Tanning Service.-- <<NOTE: Definitions.>> For purposes 
of this section--
            ``(1) In general.--The term `indoor tanning service' means a 
        service employing any electronic product designed to incorporate 
        1 or more ultraviolet lamps and intended for the irradiation of 
        an individual by ultraviolet radiation, with wavelengths in air 
        between 200 and 400 nanometers, to induce skin tanning.
            ``(2) Exclusion of phototherapy services.--Such term does 
        not include any phototherapy service performed by a licensed 
        medical professional.

    ``(c) Payment of Tax.--
            ``(1) In general.--The tax imposed by this section shall be 
        paid by the individual on whom the service is performed.
            ``(2) Collection.-- <<NOTE: Deadline.>> Every person 
        receiving a payment for services on which a tax is imposed under 
        subsection (a) shall collect the amount of the tax from the 
        individual on whom the service is performed and remit such tax 
        quarterly to the Secretary at such time and in such manner as 
        provided by the Secretary.
            ``(3) Secondary liability.--Where any tax imposed by 
        subsection (a) is not paid at the time payments for indoor 
        tanning services are made, then to the extent that such tax is 
        not collected, such tax shall be paid by the person who performs 
        the service.''.

    (c) Clerical Amendment.--The table of chapter for subtitle D of the 
Internal Revenue Code of 1986, as amended by this Act, is amended by 
inserting after the item relating to chapter 48 the following new item:

[[Page 124 STAT. 1021]]

                   ``Chapter 49--Cosmetic Services''.

    (d) <<NOTE: 26 USC 5000B note.>> Effective Date.--The amendments 
made by this section shall apply to services performed on or after July 
1, 2010.

SEC. 10908. EXCLUSION FOR ASSISTANCE PROVIDED TO PARTICIPANTS IN STATE 
            STUDENT LOAN REPAYMENT PROGRAMS FOR CERTAIN HEALTH 
            PROFESSIONALS.

    (a) In General.--Paragraph (4) of section 108(f) of the Internal 
Revenue Code of 1986 <<NOTE: 26 USC 108.>> is amended to read as 
follows:
            ``(4) Payments under national health service corps loan 
        repayment program and certain state loan repayment programs.--In 
        the case of an individual, gross income shall not include any 
        amount received under section 338B(g) of the Public Health 
        Service Act, under a State program described in section 338I of 
        such Act, or under any other State loan repayment or loan 
        forgiveness program that is intended to provide for the 
        increased availability of health care services in underserved or 
        health professional shortage areas (as determined by such 
        State).''.

    (b) <<NOTE: 26 USC 108 note.>> Effective Date.--The amendment made 
by this section shall apply to amounts received by an individual in 
taxable years beginning after December 31, 2008.

SEC. 10909. EXPANSION OF ADOPTION CREDIT AND ADOPTION ASSISTANCE 
            PROGRAMS.

    (a) Increase in Dollar Limitation.--
            (1) Adoption credit.--
                    (A) In general.--Paragraph (1) of section 23(b) of 
                the Internal Revenue Code of 1986 <<NOTE: 26 USC 
                23.>> (relating to dollar limitation) is amended by 
                striking ``$10,000'' and inserting ``$13,170''.
                    (B) Child with special needs.--Paragraph (3) of 
                section 23(a) of such Code (relating to $10,000 credit 
                for adoption of child with special needs regardless of 
                expenses) is amended--
                          (i) in the text by striking ``$10,000'' and 
                      inserting ``$13,170'', and
                          (ii) in the heading by striking ``$10,000'' 
                      and inserting ``$13,170''.
                    (C) Conforming amendment to inflation adjustment.--
                Subsection (h) of section 23 of such Code (relating to 
                adjustments for inflation) is amended to read as 
                follows:

    ``(h) <<NOTE: Effective dates.>> Adjustments for Inflation.--
            ``(1) Dollar limitations.--In the case of a taxable year 
        beginning after December 31, 2010, each of the dollar amounts in 
        subsections (a)(3) and (b)(1) shall be increased by an amount 
        equal to--
                    ``(A) such dollar amount, multiplied by
                    ``(B) the cost-of-living adjustment determined under 
                section 1(f)(3) for the calendar year in which the 
                taxable year begins, determined by substituting 
                `calendar year 2009' for `calendar year 1992' in 
                subparagraph (B) thereof.
        If any amount as increased under the preceding sentence is not a 
        multiple of $10, such amount shall be rounded to the nearest 
        multiple of $10.
            ``(2) Income limitation.--In the case of a taxable year 
        beginning after December 31, 2002, the dollar amount in 
        subsection (b)(2)(A)(i) shall be increased by an amount equal 
        to--

[[Page 124 STAT. 1022]]

                    ``(A) such dollar amount, multiplied by
                    ``(B) the cost-of-living adjustment determined under 
                section 1(f)(3) for the calendar year in which the 
                taxable year begins, determined by substituting 
                `calendar year 2001' for `calendar year 1992' in 
                subparagraph (B) thereof.
        If any amount as increased under the preceding sentence is not a 
        multiple of $10, such amount shall be rounded to the nearest 
        multiple of $10.''.
            (2) Adoption assistance programs.--
                    (A) In general.--Paragraph (1) of section 137(b) of 
                the Internal Revenue Code of 1986 <<NOTE: 26 USC 
                137.>> (relating to dollar limitation) is amended by 
                striking ``$10,000'' and inserting ``$13,170''.
                    (B) Child with special needs.--Paragraph (2) of 
                section 137(a) of such Code (relating to $10,000 
                exclusion for adoption of child with special needs 
                regardless of expenses) is amended--
                          (i) in the text by striking ``$10,000'' and 
                      inserting ``$13,170'', and
                          (ii) in the heading by striking ``$10,000'' 
                      and inserting ``$13,170''.
                    (C) Conforming amendment to inflation adjustment.--
                Subsection (f) of section 137 of such Code (relating to 
                adjustments for inflation) is amended to read as 
                follows:

    ``(f) <<NOTE: Effective dates.>> Adjustments for Inflation.--
            ``(1) Dollar limitations.--In the case of a taxable year 
        beginning after December 31, 2010, each of the dollar amounts in 
        subsections (a)(2) and (b)(1) shall be increased by an amount 
        equal to--
                    ``(A) such dollar amount, multiplied by
                    ``(B) the cost-of-living adjustment determined under 
                section 1(f)(3) for the calendar year in which the 
                taxable year begins, determined by substituting 
                `calendar year 2009' for `calendar year 1992' in 
                subparagraph (B) thereof.
        If any amount as increased under the preceding sentence is not a 
        multiple of $10, such amount shall be rounded to the nearest 
        multiple of $10.
            ``(2) Income limitation.--In the case of a taxable year 
        beginning after December 31, 2002, the dollar amount in 
        subsection (b)(2)(A) shall be increased by an amount equal to--
                    ``(A) such dollar amount, multiplied by
                    ``(B) the cost-of-living adjustment determined under 
                section 1(f)(3) for the calendar year in which the 
                taxable year begins, determined by substituting 
                `calendar year 2001' for `calendar year 1992' in 
                subparagraph thereof.
        If any amount as increased under the preceding sentence is not a 
        multiple of $10, such amount shall be rounded to the nearest 
        multiple of $10.''.

    (b) Credit Made Refundable.--
            (1) Credit moved to subpart relating to refundable 
        credits.--The Internal Revenue Code of 1986 is amended--
                    (A) by redesignating section 23, <<NOTE: 26 USC 
                36C.>> as amended by subsection (a), as section 36C, and
                    (B) by moving section 36C (as so redesignated) from 
                subpart A of part IV of subchapter A of chapter 1 to the 
                location immediately before section 37 in subpart C of 
                part IV of subchapter A of chapter 1.

[[Page 124 STAT. 1023]]

            (2) Conforming amendments.--
                    (A) Section 24(b)(3)(B) of such Code <<NOTE: 26 USC 
                24.>> is amended by striking ``23,''.
                    (B) Section 25(e)(1)(C) of such Code <<NOTE: 26 USC 
                25.>> is amended by striking ``23,'' both places it 
                appears.
                    (C) Section 25A(i)(5)(B) of such Code <<NOTE: 26 USC 
                25A.>> is amended by striking ``23, 25D,'' and inserting 
                ``25D''.
                    (D) Section 25B(g)(2) of such Code <<NOTE: 26 USC 
                25B.>> is amended by striking ``23,''.
                    (E) Section 26(a)(1) of such Code <<NOTE: 26 USC 
                26.>> is amended by striking ``23,''.
                    (F) Section 30(c)(2)(B)(ii) of such Code <<NOTE: 26 
                USC 30.>> is amended by striking ``23, 25D,'' and 
                inserting ``25D''.
                    (G) Section 30B(g)(2)(B)(ii) of such Code <<NOTE: 26 
                USC 30B.>> is amended by striking ``23,''.
                    (H) Section 30D(c)(2)(B)(ii) of such Code <<NOTE: 26 
                USC 30D.>> is amended by striking ``sections 23 and'' 
                and inserting ``section''.
                    (I) Section 36C of such Code, <<NOTE: 26 USC 
                36C.>> as so redesignated, is amended--
                          (i) by striking paragraph (4) of subsection 
                      (b), and
                          (ii) by striking subsection (c).
                    (J) Section 137 of such Code <<NOTE: 26 USC 
                137.>> is amended--
                          (i) by striking ``section 23(d)'' in 
                      subsection (d) and inserting ``section 36C(d)'', 
                      and
                          (ii) by striking ``section 23'' in subsection 
                      (e) and inserting ``section 36C''.
                    (K) Section 904(i) of such Code <<NOTE: 26 USC 
                904.>> is amended by striking ``23,''.
                    (L) Section 1016(a)(26) <<NOTE: 26 USC 1016.>> is 
                amended by striking ``23(g)'' and inserting ``36C(g)''.
                    (M) Section 1400C(d) of such Code <<NOTE: 26 USC 
                1400C.>> is amended by striking ``23,''.
                    (N) Section 6211(b)(4)(A) of such Code <<NOTE: 26 
                USC 6211.>> is amended by inserting ``36C,'' before 
                ``53(e)''.
                    (O) The table of sections for subpart A of part IV 
                of subchapter A of chapter 1 of such Code of 1986 is 
                amended by striking the item relating to section 23.
                    (P) Paragraph (2) of section 1324(b) of title 31, 
                United States Code, as amended by this Act, is amended 
                by inserting ``36C,'' after ``36B,''.
                    (Q) The table of sections for subpart C of part IV 
                of subchapter A of chapter 1 of the Internal Revenue 
                Code of 1986, as amended by this Act, is amended by 
                inserting after the item relating to section 36B the 
                following new item:

``Sec. 36C. Adoption expenses.''.

    (c) <<NOTE: 26 USC 1 note.>> Application and Extension of EGTRRA 
Sunset.--Notwithstanding section 901 of the Economic Growth and Tax 
Relief Reconciliation Act of 2001, such section shall apply to the 
amendments made by this section and the amendments made by section 202 
of such Act by substituting ``December 31, 2011'' for ``December 31, 
2010'' in subsection (a)(1) thereof.

[[Page 124 STAT. 1024]]

    (d) Effective Date.--The amendments <<NOTE: 26 USC 1 note.>>  made 
by this section shall apply to taxable years beginning after December 
31, 2009.