Prepared by Committees on Energy and Commerce, Ways and Means, and Education and Labor Nov. 2, 2009

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HR3962,theAffordableHealthCareForAmericaActSection‐by‐SectionAnalysis

DIVISIONA–AFFORDABLEHEALTHCARECHOICES

Sec.100.Purpose;tableofcontentsofdivision;generaldefinitions.Providesanoutlineofthebillstructureandaglossaryoftermsusedthroughout.

TITLEI—IMMEDIATEREFORMSSec.101.NationalHigh‐RiskPoolProgram.Enactsatemporaryinsuranceprogramwithfinancialassistanceforthosewhohavebeenuninsuredforseveralmonthsordeniedapolicybecauseofpre‐existingconditions.Thefundingforthisprogramiscappedat$5billionanditterminateswhenthosefundsareexhaustedorwhentheHealthInsuranceExchangeisupandrunning.Sec.102.Ensuringvalueandlowerpremiums.AmendsthePublicHealthServiceActtorequirehealthinsuranceissuersinthesmallandlargegroupmarkettomeetamedicallossratioofnotlessthan85%,effectiveforplanyearsbeginningJanuary1,2010.DirectstheSecretarytorequirethatplansintheindividualmarketalsomeetamedicallossratioofnotlessthan85%solongasitdoesnotdestabilizetheexistingindividualmarket.Ifplansexceedthatlimit,rebatestoenrolleesarerequired.Indeterminingthemethodologyforthemedicallossratio,theSecretaryistodesignittoensureadequateparticipationbyissuers,competitioninthemarket,andvalueforconsumers.Sec.103.Endinghealthinsurancerescissionabuse.Prohibitshealthinsurancecompaniesfromrescindingcoverageexceptininstancesoffraudandrequiresindependentreviewofanyrescissiondetermination,effectiveJuly1,2010.Sec.104.Sunshineonpricegougingbyhealthinsuranceissuers.EstablishesanannualreviewprocessforincreasesinhealthinsurancepremiumsbytheSecretaryofHHSinconjunctionwiththeStatesthatrequiresinsurerstosubmitajustificationforanypremiumincreasespriortoimplementation.EffectiveforplanyearsbeginningJanuary1,2010.Sec.105.RequiringtheOptionofExtensionofDependentCoverageforUninsuredYoungAdults.Requireshealthinsurerstoallowindividualsuntiltheyreachtheageof27,nototherwisecovered,toremainontheirparents’healthinsuranceattheirparents’choiceforplanyearsbeginningJanuary1,2010.Sec.106.Limitationsonpre‐existingconditionexclusionsbygrouphealthplansinadvanceofapplicabilityofnewprohibitionofpre‐existingconditionexclusions.Priortothebill’scompleteprohibitiononpre‐existingconditionexclusionsbeginningin2013,thisprovisionshortensthetimethatplanscanlookbackforpre‐existingconditionsfrom6monthsto30daysandshortensthetimeplansmayexcludecoverageofcertainbenefitsgenerallyfrom12monthsto3months.EffectiveforplanyearsbeginningJanuary1,2010.Sec.107.Prohibitingactsofdomesticviolencefrombeingtreatedaspre‐existingconditions.ProhibitsinsurersfromlimitingordenyingcoveragebasedonactsstemmingfromdomesticviolenceforplanyearsbeginningJanuary1,2010.

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Sec.108.Endinghealthinsurancedenialsanddelaysofnecessarytreatmentforchildrenwithdeformities.RequiresplanstopayforreconstructivesurgeryforchildrenwithdeformitiesforplanyearsbeginningJanuary1,2010.Sec.109.Eliminationoflifetimeaggregatelimits.ProhibitshealthinsurersfromutilizinglifetimelimitsonbenefitsforplanyearsbeginningJanuary1,2010.Sec110.Prohibitionagainstpost‐retirementreductionsofretireehealthbenefitsbygrouphealthplans.Prohibitsemployersfromreducingretireehealthbenefitsbelowwhatwasofferedtoretireesatthetimeoftheirretirementunlessreductionsarealsomadetoactiveworkers’healthbenefits.Effectiveasofdateofenactment.Sec.111.Reinsuranceprogramforretirees.Establishesatemporaryreinsuranceprogramtoprovidereimbursementtoparticipatingemployment‐basedplansforpartofthecostofprovidinghealthbenefitstoretirees(age55‐64)andtheirfamilies.Theprogramreimbursesparticipatingemployment‐basedplansfor80%ofthecostofbenefitsprovidedperenrolleeinexcessof$15,000andbelow$90,000.Theplansarerequiredtousethefundstolowercostsbornedirectlybyparticipantsandbeneficiaries.Theactappropriates$10billionforthisfundandthosefundsareavailableuntilexpended.Sec.112.WellnessProgramGrants.Establishesagrantprogramforsmallemployerstoassistwiththecreationofemployeewellnessprogramsthatpromotehealthybehaviorsinanon‐discriminatorymanner.Sec.113.ExtensionofCOBRAcontinuationcoverage.ExtendsCOBRAeligibilitytopermitindividualstoremainintheirCOBRApolicyuntiltheHealthInsuranceExchangeisupandrunning.Sec.114.StateHealthAccessProgramGrants.Buildsonanexistinggrantprogramtoenhanceincentivesforstatestomoveforwardwithavarietyofhealthreforminitiativesthatwouldexpandaccesstoaffordablehealthcarefortheuninsuredpriorto2013.Sec.115.Administrativesimplification.RequirestheSecretaryofHHStoadoptstandardsfortypicaltransactionsbetweeninsurersandproviderssuchasclaims,eligibility,enrollment,andpriorauthorizationbuildingonthestandardsintheHealthInsurancePortabilityandAccountabilityActof1996.Itestablishesimplementationandenforcementmechanismsforsuchstandards.

TITLEII–PROTECTIONSANDSTANDARDSFORQUALIFIEDHEALTHBENEFITSPLANSSUBTITLEA–GENERALSTANDARDSSec.201.Requirementsreforminghealthinsurancemarketplace.Broadlyoutlinesthestandardsforreformingthehealthinsurancemarketplace.Sec.202.Protectingthechoicetokeepcurrentcoverage.Allowsthemaintenanceofcurrentindividualhealthplansas“grandfatheredplans”andprovidesforafiveyeargraceperiodforcurrentgrouphealthplanstomeetspecifiedstandards(insuranceandbenefitrequirements).SUBTITLEB–STANDARDSGUARANTEEINGACCESSTOAFFORDABLECOVERAGESec.211.Prohibitingpre‐existingconditionexclusions.Prohibitstheapplicationofpre‐existingconditionexclusions.

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Sec.212.Guaranteedissueandrenewalforinsuredplansandprohibitingrescissions.Requiresguaranteedissue(noonecanbedeniedhealthinsurance)andrenewalofinsurancepoliciesandprohibitstheuseofrescissionsexceptininstancesoffraud.Sec.213.Insuranceratingrules.Limitsageratingtoaratioof2to1;allowsvariationbasedongeographicareaandfamilysizeaspermittedbystateinsurancecommissionersandtheHealthChoicesCommissioner.RequiresastudyandreportsbytheHealthChoicesCommissionerdescribingthedifferencesbetweeninsuredandself‐insuredplansandprovidingrecommendationsasappropriatetoensurethatthelawdoesnotcreateincentivesforsmallandmidsizeemployerstoselfinsureorcreateadverseselectionintheriskpoolsofinsuredplans.Sec.214.Nondiscriminationinbenefits;parityinmentalhealthandsubstanceabusedisorderbenefits.ProvidesauthoritytotheHealthChoicesCommissionertosetnon‐discriminationrulesandensuresthatmentalhealthandsubstanceusedisorderparityandgeneticnondiscriminationlawsapplytoqualifiedhealthbenefitsplans.Sec.215.Ensuringadequacyofprovidernetworks.ProvidesauthoritytotheHealthChoicesCommissionertosetnetworkadequacystandardsthatqualifiedplansmustmeet.Sec.216.Requiringtheoptionofextensionofdependentcoverageforuninsuredyoungadults.Permanentlyextendstherequirementthathealthplansallowindividuals,nototherwisecovered,toremainontheirparents’healthinsuranceattheirparents’choiceuntiltheyreachtheageof27.Sec.217.Consistencyofcostsandcoverageunderqualifiedhealthbenefitsplansduringplanyear.Requiresqualifiedhealthbenefitsplanstoprovideatleast90daysnoticeinadvanceofanyincreaseordecreaseincoverage,butincludesanexceptiontoprotectthehealthandsafetyofenrollees.SUBTITLEC–STANDARDSGUARANTEEINGACCESSTOESSENTIALBENEFITSSec.221.Coverageofessentialbenefitspackage.RequiresqualifiedplanstomeetthebenefitstandardsrecommendedbytheBenefitsAdvisoryCommitteeandadoptedbytheSecretaryofHHS.PlansoutsidetheExchangemustofferatleasttheessentialbenefitsandothersastheychoose.PlanswithintheExchangemustmeetthespecifiedbenefitpackages,includingbeingabletoofferadditionalbenefitsinaspecifiedtier.Allowsforthecontinuedofferingofseparateexceptedbenefitspackages,asincurrentlaw,outsideoftheExchange.Sec.222.Essentialbenefitspackagedefined.Outlinesthebroadcategoriesofbenefitsrequiredtobeincludedintheessentialbenefitspackage,prohibitsanycost‐sharingforpreventivebenefits(includingwellchildandwellbabycare),andlimitsannualout‐of‐pocketspendingintheessentialbenefitspackageto$5,000foranindividualand$10,000(indexedtoCPI)forafamily.Definestheinitialessentialbenefitpackageasbeingactuariallyequivalentto70%ofthepackageiftherewerenocost‐sharingimposed.RequirestheSecretarytoassessaddingcounselingfordomesticviolenceaspartofthebehavioralhealthorprimarycarevisit.Prohibitsabortionservicesfrombeingmadepartofessentialbenefitspackage.Prohibitsfederalfundsfrombeingusedtopayforabortion(exceptincasesofrape,incest,andtosavelifeofthewoman).Onlyprivatepremiumdollarscanbeusedtoprovideabortioncoverage.Whereabortioncoverageisprovided,fundsforthispurposemustbesegregatedfromotherfunds,includingaffordabilitycredits.Includesareportregardingtheneedandcostofprovidingoralhealthcaretoadultsaspartoftheessentialbenefitspackage.Inthedevelopingtheessentialbenefitpackage,theSecretaryshallsupporttheneedforassessmentandcounselingfordomesticviolenceaspartofthebehavioralhealthassessmentorprimarycarevisit.

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Sec. 223. HealthBenefitsAdvisoryCommittee.EstablishesaHealthBenefitsAdvisoryCommittee,chairedbytheSurgeonGeneral,withprivatemembersappointedbythePresident,theComptrollerGeneral,andrepresentativesofrelevantfederalagencies.TheAdvisoryCommitteewillmakerecommendationstotheSecretaryofHHSregardingthedetailsofcoveredhealthbenefitsasoutlinedinSec.222,includingtheestablishmentofthethreetiersofcoverage:basic,enhancedandpremium.Sec. 224. Processforadoptionofrecommendations;adoptionofbenefitstandards.EstablishesthetimelinefortheinitialadoptionofbenefitsbytheSecretaryofHHSandtheperiodicupdatingofstandardsinthefuture.SUBTITLED–ADDITIONALCONSUMERPROTECTIONSSec. 231. Requiringfairmarketingpracticesbyhealthinsurers.ProvidestheHealthChoicesCommissionerwiththeauthoritytodefinemarketingstandardsthatqualifiedplansarerequiredtomeet.Sec. 232. Requiringfairgrievanceandappealsmechanisms.RequireseachqualifiedplantomeetstandardsdefinedbytheHealthChoicesCommissionerfortimelyinternalgrievanceandappealsmechanismsandtoestablishanexternalreviewprocessthatprovidesforanimpartial,independentanddenovoreviewofdeniedclaims.Thedeterminationisbinding.Sec. 233. Requiringinformationtransparencyandplandisclosure.RequiresqualifiedplanstomeetstandardsestablishedbytheHealthChoicesCommissionerrelatingtotransparencyandtimelydisclosureofplandocumentsandinformation,includingprovidinghealthcareproviderswithinformationregardingtheirpayments.Italsorequirestheuseofplainlanguageinthedisclosures(includingtheissuanceofguidanceastowhat“plainlanguage”means)andadvancenoticeofchangestotheplans.Sec. 234. ApplicationtoqualifiedhealthbenefitsplansnotofferedthroughtheHealthInsuranceExchange.ProvidesflexibilitytotheHealthChoicesCommissionertodecidewhatprotectionsofsections231‐233shouldapplytoqualifiedplansoutsideoftheHealthInsuranceExchange.Sec. 235. Timelypaymentofclaims.AppliesMedicare’stimelypaymentofclaimsstandardstotheplansofferingcoveragethroughtheExchange.Sec. 236. Standardizedrulesforcoordinationandsubrogationofbenefits.RequirestheHealthChoicesCommissionertoestablishstandardsforthecoordinationofbenefitsinvolvingindividualsandmultiplesourcesofcoverage(likeworkers’compensationcoordination)andreimbursementofhealthcarepaymentsbyinsurersincaseswhereanindividualrecoversmoney.Sec.237.ApplicationofAdministrativeSimplification.Requiresinsurersandproviderstousecommonstandardsfortransactionssuchasclaimspayment,eligibilityandenrollmentbuildingontheHealthInsurancePortabilityandAccountabilityActof1996.Sec.238.Stateprohibitionsondiscriminationagainsthealthcareproviders.ClarifiesthatthisActdoesnotsupersedestatelawsthatprohibithealthplansfromdiscriminatingagainsthealthcareprovidersactingwithinthescopeoftheirlicensesorcertifications.Sec.239.Protectionofphysicianprescriberinformation.RequiresastudybytheSecretaryofHHSontheuseofphysicianprescriberinformationinsalesandmarketingpracticesofpharmaceuticalmanufacturersandmakerecommendationsastotheactionsneededbyCongressortheSecretarytoprotectprovidersfrombiasedmarketingandsalespractices.

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Sec.240.Disseminationofadvancecareplanninginformation.ProvidesthathealthinsurersintheExchangepresentenrolleeswithinformationaboutresourcesavailableforadvancedcareplanningwhichisvoluntarytotheindividual.SUBTITLEE–GOVERNANCESec. 241. HealthChoicesAdministration;HealthChoicesCommissioner.EstablishestheHealthChoicesAdministration,anindependentexecutivebranchagency.TheHealthChoicesCommissionerisappointedbythePresident.Sec. 242. DutiesandauthorityofCommissioner.TheHealthChoicesCommissionercarriesoutfunctionsincluding:establishmentofqualifiedplanstandards,establishmentandoperationoftheHealthInsuranceExchange,administrationofaffordabilitycredits,andadditionalfunctionsaslaidoutwithinthebill.TheCommissionercancollectdatanecessarytocarryouthisorherdutiesandtopromotequalityandvalueandaddressdisparitiesinhealthcare.SuchinformationcanalsobesharedwithHHS.TheCommissioneralsohasoversightandenforcementauthorityincludingtheauthoritytoimposesanctionsandsuspendenrollmentofaplan.ThisauthorityrequirestheCommissionertocoordinatewiththeDepartmentofHHS,theDepartmentofLaborandStateinsuranceregulators.Sec. 243. Consultationandcoordination.RequirestheHealthChoicesCommissionertoconsultwithotherregulatorybodiesandstateandfederalagenciesincarryingouthisorherdutiesandtoensureappropriateoversightandenforcement.Sec. 244. HealthInsuranceOmbudsman.EstablishesaQualifiedHealthBenefitsPlanOmbudsmantoassistindividualsinnavigatingthenewhealthreformsystemandreporttoCongressonrecommendationsforimprovementsinadministrationoftheprogram.SUBTITLEF–RELATIONTOOTHERREQUIREMENTS;MISCELLANEOUSSec. 251. Relationtootherrequirements.MakesclearthatthisactdoesnotsupersedeCOBRA,HIPAAorstatelaws,includingmentalhealthparityandthegeneticnondiscriminationact,unlesstheirrequirementspreventtheapplicationofarequirementofthistitle.PreservesindividualrightsunderStatelaw.Sec. 252. Prohibitingdiscriminationinhealthcare.Prohibitsdiscriminationbyhealthinsurerswithregardtotheprovisionofhighqualitycareorservices.Sec.253.Whistleblowerprotection.ProtectsemployeesfromretaliationbytheiremployerforthereportingofanyviolationsofthisactandprovidesremediesforsuchretaliationinaccordancewithexistinglawintheConsumerProductSafetyAct.Sec.254.Constructionregardingcollectivebargaining.Preservesstatutoryobligationsofemployerstocollectivelybargainwithemployeerepresentativesoverhealthcare.Sec.255.Severability.Providesthatifanypartofthisactisfoundunconstitutional,thatotherpartsoftheactshallnotbeaffected.Sec.256.TreatmentofHawaiiprepaidhealthcareact.ClarifiesthatthisActdoesn’tchangeHawaii’sexistingERISAwaiverfortheirstate‐basedhealthreformaslongastheSecretaryofLabordeterminesthatsuch

Prepared by Committees on Energy and Commerce, Ways and Means, and Education and Labor Nov. 2, 2009

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coverageisatleastsubstantiallyequivalenttothecoveragerequiredunderthisAct.AlsorequirestheHealthChoicesCommissionertoworkwithHawaiitocoordinatetheirStateprogramandthisnewAct.Sec.257.Actionsbystateattorneysgeneral.Clarifiesthatstateattorneysgeneralhaveauthoritytohelpenforcethisact.Sec.258.Applicationofstateandfederallawsregardingabortion.Makesclearthatnothinginthisactpre‐emptsstatelawswithregardtoabortionnorchangesexistingfederallawsregardingconscienceprotections,willingnessorrefusaltoprovideabortion,anddiscriminationonthebasisofsuchwillingnessorrefusal.Sec.259.Nondiscriminationonabortionandrespectforrightsofconscience.Nofederalagency,program,oranystateorlocalgovernmentthatreceivesfinancialassistanceunderthisactmaydiscriminateagainstaprovideronthebasisofwhethertheyprovidecoverageorreferforabortionservices.Sec.260.AuthorityofFederalTradeCommissiontoConductStudy.AuthorizestheFederalTradeCommissiontoincludeauthoritytoconductstudiesandpreparereportsonhealthinsuranceplans.Sec.261.Constructionregardingstandardofcare.ClarifiesthatprovisionsinthisActrelatingtodeliverysystemreform,reducinghospitalacquiredinfections,andotherprovisionsshallnotbeusedtoestablishthestandardordutyofcareinamalpracticesuit.Sec.262.Restoringapplicationofanti‐trustlawstohealthinsurers.Removestheanti‐trustexemptionforhealthinsurersandmedicalmalpracticeinsurers.Sec.263.StudyandreportonmethodstoincreaseEHRusebysmallhealthcareproviders.RequirestheSecretaryofHealthandHumanServicestoconductastudyofpotentialmethodstoincreasetheuseofqualifiedelectronichealthrecordsbysmallprovidersincludinghigherreimbursementrates,training,andeducation.

TITLEIII—HEALTHINSURANCEEXCHANGEANDRELATEDPROVISIONSSUBTITLEA–HEALTHINSURANCEEXCHANGESec. 301. EstablishmentofHealthInsuranceExchange;outlineofduties;definitions.EstablishesaHealthInsuranceExchangeunderthepurviewoftheHealthChoicesAdministrationthatwillfacilitatetheofferingofhealthinsurancechoices.TheHealthChoicesCommissionerestablishesaprocessthroughwhichtoobtainbids,negotiateandenterintocontractswithqualifiedplans,andensurethatthedifferentlevelsofbenefitsareofferedwithappropriateoversightandenforcement.TheCommissioneralsofacilitatesoutreachandenrollment,createsandoperatesariskpoolingmechanism,andensuresconsumerprotections.Sec. 302. Exchange‐eligibleindividualsandemployers.DefineswhoiseligibleforparticipationintheHealthInsuranceExchangeincludingemployersandindividuals.Inyearone,individualsnotenrolledinotheracceptablecoverageaswellassmallemployerswith25orfeweremployeesareallowedintotheExchange.Inyeartwo,employerswith50andfeweremployeesareallowedintotheExchange.Inyearthree,theCommissioneris,ataminimum,requiredtoopentheExchangetoemployerswith100andfeweremployees,butispermittedfromthisyearforwardtoexpandemployerparticipationasappropriate,withthegoalofallowingallemployersaccesstotheExchange.Definesacceptablecoveragetoincludeenrollmentinotherqualifiedcoverageandmostotherfederalhealthprograms.

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Medicaid‐eligibleindividualswillbeenrolledinMedicaid,nottheExchange.OnceanindividualoranemployerenrollsincoveragethroughtheExchange,theyremaineligibleforExchangecoverageevenifcircumstanceschangethatwouldotherwiseexcludethem.RequiresthatemployerswhooffercoveragethroughtheExchangecontributeatleasttherequiredcontributiontowardsuchcoverageandpermittheiremployeesthefreedomtochooseanyplanwithintheExchange.RequirestheCommissionertoconductperiodicsurveysofExchange‐eligibleindividualsandemployerstomeasuresatisfaction.RequirestheCommissionertoconductastudyregardingaccesstotheExchangetodetermineiftherearesignificantgroupsandtypesofindividualsandemployerswhoarenotExchangeeligible,butwhowouldhaveimprovedbenefitsandaffordabilityifmadeeligible.ThereportisdueinyearthreeandyearsixoftheExchangeandcontinuedthereafter.Itistoincluderecommendationsasappropriateforchangestotheeligibilitystandards.Sec. 303. Benefitspackagelevels.TheHealthChoicesCommissionerspecifiesthebenefitsthatmustbemadeavailableineachyear–includingarequirementthateachparticipatingplanprovideonebasicplanineachserviceareainwhichtheyoperate.Itisthenoptionalfortheplantoofferoneenhancedandonepremiumplan.Thedifferencesbetweenthethreemainplans(i.e.basic,enhancedandpremium)arethelevelsofcost‐sharingrequired,notthebenefitscovered.TheCommissionershallestablishapermissiblerangeofcost‐sharingvariationthatisnottoexceedplusorminus10%withregardtoeachbenefitcategory.Thereisafourthtiercalledpremium‐plus.Inthispackage,planscanofferextrabenefitslikedentalorvisioncoverageforadults,orothernon‐coveredbenefits.Toensureconsumersknowwhattheyarepayingextrafor,thesepackagesmustdetailthecostoftheextrabenefitsseparately.Plansmayoffermultiplepremium‐plusoptions.StatescanrequiretheapplicationofstatebenefitmandatestoallExchangeparticipatingplans,butonlyifthereisanagreementwiththeCommissionerthatthestatewillreimbursetheCommissionerforanyadditionalcostsofaffordabilitycreditsinthatstateduetotheStatebenefitrequirements.Sec.304.ContractsfortheofferingofExchange‐participatinghealthbenefitsplans.LaysouttheresponsibilitiesfortheHealthChoicesCommissioner’scontractingauthorityincludingsolicitationofbids,negotiationwithplansandtheenteringintocontractswithapprovedplans(thatwillbeforatleastoneyearofdurationandcanbeautomaticallyrenewed).Requirementsincludethatplansbelicensedinthestateinwhichtheywilldobusiness,abidebydatareportingrequirementsasoutlinedbytheCommissioner,providefortheimplementationofaffordabilitycredits,participateinriskpooling,provideforculturallyandlinguisticallyappropriateservicesandcommunications,andwithrespecttothebasicplan,contractforoutpatientserviceswithessentialcommunityprovidersasdefinedinthe340Bprogram.TheSecretaryhasspecialauthoritywithrespecttoIndianenrolleesandIndianhealthcareproviders.TheCommissioneroutlinesthebidprocess,thetermofthecontractisforaminimumofayear,andtheCommissionerenforcesnetworkadequacyincludinganallowanceforenrolleestoreceiveservicesout‐of‐networkatnogreatercostiftheprovidernetworkdoesnotmeetthestandardsforadequacy.PlansmustalsojustifyproposedpremiumsorpremiumincreasesandthroughthisratereviewtheCommissionerhastheauthoritytodenyexcessivepremiumsorpremiumincreases.

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TheCommissionerisrequiredtoestablishprocessestooversee,monitor,andenforcerequirementsontheplans.TheCommissionerhastheauthoritytoterminateplansthatfailtomeettherequiredstandards.Sec. 305. OutreachandenrollmentofExchange‐eligibleindividualsandemployersinExchange‐participatinghealthbenefitsplan.RequirestheHealthChoicesCommissionertoconductoutreachandenrollmentactivitiestoensureExchange‐eligibleindividualsandbusinessesareenrolledintotheExchangeinatimelymanner,includingatoll‐freehotline,maintenanceofawebsite,creationofoutreachmaterialswritteninculturallyandlinguisticallyappropriatelanguage,andcommunitylocationsforenrollment.Setsupanannualopenenrollmentperiodaswellasspecialenrollmentperiodsforspecialcircumstances.RequirestheCommissionertocreateanauto‐enrollmentprocessforindividualswhoareExchange‐eligiblebuthavenotselectedaplan.TheCommissionerprovidesforbroaddisseminationofinformationonExchange‐participatinghealthplansinacomparativemannerandcanworkwithotherappropriateentitiestoensurethedisseminationofthisinformation.EstablishesrulestoensurecontinuityofcoverageforcertainnewbornsinMedicaidandforchildreneligibleforCHIP.RequirestheCommissionertoenterintomemorandumsofunderstandingwithstateMedicaidagenciestocoordinateenrollmentinMedicaidandtheExchangeforMedicaid‐eligibleindividuals.RequirestheHealthChoicesCommissionertoconsultwiththeSmallBusinessAdministrationandsmallemployerbenefitarrangementstoprovideconsumerinformation,outreach,counselingandtechnicalassistancewithrespecttoparticipatingintheHealthInsuranceExchange.Sec. 306. Otherfunctions.TheHealthChoicesCommissionercoordinatesaffordabilitycreditsandrisk‐pooling.Inordertopreventwaste,fraudandabuse,institutesaspecialinspectorgeneraltooverseeoperationoftheprogram.Sec.307. HealthInsuranceExchangeTrustFund.CreatesaHealthInsuranceTrustFundtoprovidenecessaryfundingfortheHealthChoicesAdministration.Sec.308. OptionaloperationofState‐basedhealthinsuranceexchanges.PermitsstatestooffertheirownExchangeorjoinwithagroupofstatestocreatetheirownexchangeinlieuofthefederalHealthInsuranceExchange,providedthatthestate(s)performallofthedutiesofthefederalExchangeasapprovedbytheHealthChoicesCommissioner.TheCommissionerhasauthoritytoterminatestateexchangesiftheyarenotmeetingtheirobligations.PresumesthatanyStateoperatinganExchangepriorto2010isallowedtocontinuedoingso.Sec.309.Interstatehealthinsurancecompacts.EffectiveJanuary1,2015,wouldallow2ormoreStatestoformHealthCareChoiceCompactstofacilitatethepurchaseofindividualhealthinsuranceacrossStatelines.CallsontheNationalAssociationofInsuranceCommissionerstodevelopmodelguidelinesforsuchcompacts.EnsuresthatsuchcompactsrequirelicensureineachstateandmaintainsauthorityoftheStateinwhichacoveredindividualresidestoprotecttheindividual.AllowsStatestoapplyforgrantsfromtheSecretaryofHHStohelpimplementsuchcompacts.Sec.310.HealthInsuranceCooperatives.RequirestheHealthChoicesCommissionertoestablisha“ConsumerOperatedandOrientedPlanProgram”knownastheCO‐OPProgram,toassistorganizationsthatwishtostartupanon‐profithealthinsurancecooperativeandprovidesstartuploansfortheseorganizations.

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Sec.311.RetentionofDODandVAAuthority.MakesclearthatnothinginthisactinterfereswiththeDepartmentofVeterans’AffairsorDepartmentofDefense’sexistingauthorities.SUBTITLEB–PUBLICHEALTHINSURANCEOPTIONSec. 321. EstablishmentandadministrationofapublichealthinsuranceoptionasanExchange‐qualifiedhealthbenefitsplan.RequirestheSecretaryofHealthandHumanServicestodevelopapublichealthinsuranceoptiontobeofferedstartingin2013asaplanchoicewithintheHealthInsuranceExchange.Itparticipatesonalevelplayingfieldwithprivateplanchoices.Likeprivateplans,itmustofferthesamebenefits,abidebythesameinsurancemarketreforms,followprovidernetworkrequirementsandotherconsumerprotections.Sec. 322. Premiumsandfinancing.Premiumsforthepublicoptionaregeographically‐adjustedandarerequiredtobesetsoastofullycoverthecostofcoverageaswellasadministrativecostsoftheplan.Thisincludesarequirementthatthepublicoption,likeprivateplans,includeacontingencymargininitspremiumtocoverunexpectedcostvariations.Inordertoestablishthepublicoption,thereisaninitialappropriationof$2billionforadministrativecostsandinordertoprovideforinitialclaimsreservesbeforethecollectionofpremiumssuchsumsasnecessarytocover90daysworthofclaimsreservesbasedonprojectedenrollment.Thesestartupfundsareamortizedintothepremiumsforthepublicoptiontoberecoupedoverthefirst10yearsofoperation.Theplanmustbeself‐sustainingafterthatinitialfunding.Sec. 323. Paymentratesforitemsandservices.TheSecretaryofHealthandHumanServicesnegotiatespaymentforhealthcareprovidersanditemsandservices,includingprescriptiondrugs,forthepublichealthinsuranceoption.Medicareprovidersarepresumedtobeparticipatinginthepublicoptionunlesstheyoptout.Therearenopenaltiesforoptingoutandprovidershaveatleastaone‐yearperiodpriortothebeginningofthepublicoptiontooptout.Sec.324. Modernizedpaymentinitiativesanddeliverysystemreform.TheSecretaryshallevaluatetheprogressofpaymentanddeliverysystemreformsandapplythemtothepublicoptionandhowitpaysformedicalservicestopromotebetterqualityandmoreefficientuseofmedicalcare.Suchpaymentchangesmustseektoreducecostforenrollees,improvehealthoutcomes,reducehealthdisparities,addressgeographicvariationintheprovisionofmedicalservices,preventormanagechronicillnesses,orpromoteintegratedpatient‐centeredcare.Sec.325.Providerparticipation.ProvidestheSecretaryofHHSwiththeauthoritytodevelopconditionsofparticipationforthepublichealthinsuranceoption.Providersmustbelicensedorotherwiserecognizedinthestateinwhichtheydobusiness.Physicianparticipationcomesintwotypes:preferredphysiciansarethosephysicianswhoagreetoacceptthepublicoption’spaymentrate(withoutregardtocost‐sharing)aspaymentinfull,participatingnon‐preferredphysiciansarethosewhoagreenottoimposechargesinexcessofthebalancebillinglimitationsassetforthbytheSecretary.Providersmustbeexcludedfromparticipatinginthepublicoptioniftheyareexcludedfromotherfederalhealthprograms.Sec.326.Applicationoffraudandabuseprovisions.AppliesMedicare’santi‐fraudandabuseprotectionstothepublichealthinsuranceoption.Sec.327.ApplicationofHIPAAinsurancerequirements.AppliesconsumerprotectionstandardsputforthundertheHealthInsurancePortabilityandAccessActtothepublichealthinsuranceoption.Sec.328.Applicationofhealthinformationprivacy,security,andelectronictransactionrequirements.Assuresthatprivacyprotectionsofexistinglawapplytothepublichealthinsuranceoptionaswell.

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Sec.329.EnrollmentinPublicHealthInsuranceOptionisvoluntary.Clarifiesthatnooneisrequiredtoparticipateinthepublichealthinsuranceoption–itisavoluntarychoice.Sec.330.EnrollmentinPublicHealthInsuranceOptionbyMembersofCongress.MakesclearthatMembersofCongressareeligibletojointhepublichealthinsuranceoption.Sec.331.ReimbursementofSecretaryofVeteransAffairs.CallsontheSecretaryofHHStoenterintoamemorandumofunderstandingwiththeSecretaryofVeteransAffairsregardingtherecoveryofcostsrelatedtonon‐service‐connectedcareorservicesthatareprovidedbyVAtoanenrolleeinthepublichealthinsuranceoption.SUBTITLEC–INDIVIDUALAFFORDABILITYCREDITSSec. 341. AvailabilitythroughHealthInsuranceExchange.Createsaffordabilitycreditstoensurethatpeoplewithincomesupto400%offederalpovertyhaveaffordablehealthcoverage.Thesecreditsarephasedoutaccordingtoascheduledefinedintheactasindividualandfamilyincomesupto400%ofpovertyandthecreditsapplyonlytoExchange‐participatingplans.Affordabilitycreditsreducethecostsofbothpremiumandannualout‐of‐pocketspending.IndividualsapplythroughtheCommissionerorHealthInsuranceExchangeforthecredits,orthroughotherentitiesapprovedbytheCommissioner.TheCommissioner,throughanagreementwiththeCommissionerofSocialSecurity,mustconductaverificationprocesstoconfirmcitizenshiporlawfulpresenceintheUnitedStatesbeforeanyindividualiseligibleforaffordabilitycredits.Inthefirsttwoyears,affordabilitycreditscanonlybeusedtopurchaseabasicplan.Afterthat,theCommissionerestablishesaprocesstoallowthemtobeusedforenhancedandpremiumplansinawaythatmakescleartheindividualswhoselectthoseoptionswillberesponsibleforanydifferenceincosts.Sec.342. Affordabilitycrediteligibleindividual.Inordertoreceiveaffordabilitycredits,individualsmusthaveindividualcoveragethroughanExchange‐participatinghealthbenefitsplan(thoughnotthroughanemployerpurchasingcoveragethroughtheExchange).Familyandindividualincomesmustbebelow400%ofthefederalpovertylimittoaccesstheaffordabilitycredits,andtheindividualmustnotbeeligibleforMedicaidorenrolledinMedicareorotheracceptablecoverage.Ingeneral,employeeswhoareofferedemployercoverageareineligibleforaffordabilitycreditswithintheExchange.Beginninginyeartwo,employeeswhomeetanaffordabilitytestshowingthatcoverageundertheiremployer‐providedplanwouldcostmorethan12%ofincome,areeligibletoobtainincome‐basedaffordabilitycreditsintheExchange.Sec.343.Affordabilitypremiumcredit.Theaffordabilitypremiumamountiscalculatedonaslidingscalestartingat1.5%ofincomeforthoseatorbelow133%ofpovertyandphasingoutat12%ofincomeforthoseat400%ofpoverty.Thewaythisphaseoutworksisspecificallydetailedintheact.Thereferencepremiumistheaveragepremiumforthethreelowestcostbasicplansintheareainwhichtheindividualresides.Thereisanout‐of‐pocketmaximumsetat$500foranindividualand$1000forafamilyatthelowestincometierrisingto$5,000foranindividualand$10,000forafamilyatthehighestincometierforindividualsreceivingaffordabilitycredits.Sec. 344.Affordabilitycost‐sharingcredit.Theaffordabilitycost‐sharingcreditreducescost‐sharingforindividualsandfamiliesatorbelow133%ofpovertyupto400%ofthefederalpovertylimitasspecifiedintheact.Sec. 345. Incomedeterminations.Todetermineincome,theHealthChoicesCommissionerusesincomedatafromtheindividual’smostrecenttaxreturn.Thefederalpovertylevelappliedisthelevelineffectasofthedate

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oftheapplication.TheCommissionertakessuchstepsasareappropriatetoensureaccuracyofdeterminationsandredeterminationstoprotectprogramintegrity.ProcessesareestablishedforindividualswithsignificantchangesinincometoinformtheCommissionerofsuchchange.Therearepenaltiesformisrepresentationofincome.TheSecretaryofHealthandHumanServicesisrequiredtoconductastudyexaminingthefeasibilityandimplicationofadjustingtheapplicationofthefederalpovertylevelfordifferentgeographicareassoastoreflectthevariationsinthecost‐of‐livingamongvariousareasinthecountry.Sec.346.Specialrulesforapplicationtoterritories.CreatesaprocessbywhichaterritorycanelecttoparticipateintheHealthInsuranceExchangeandprovidesuptofourbilliondollarstofundaffordabilitycreditsiftheterritoryadoptstheinsurancereforms,consumerprotections,andotherrequirementsforindividualandemployerresponsibilityintheAct.Sec.347.NoFederalpaymentforundocumentedaliens.ProhibitsanyonenotlawfullypresentintheUnitedStatesfromobtainingaffordabilitycredits.

TITLEIV—SHAREDRESPONSIBILITYSUBTITLEA–INDIVIDUALRESPONSIBILITYSec.401.Individualresponsibility.Cross‐referencesthesharedresponsibilityprovisionintheInternalRevenueCodewhereanindividualhasthechoiceofmaintainingacceptablecoverageorpayingatax.SUBTITLEB–EMPLOYERRESPONSIBILITYPART1—HealthCoverageParticipationRequirementsSec.411.Healthcoverageparticipationrequirements.Providestherulesthatapplytoanemployerthatelectstoprovidehealthcoverage(an“offeringemployer”)inlieuofthepayrollcontributionthatappliestoanon‐offeringemployer.Anofferingemployergenerallymustofferallofitsemployeestheoptionofselectingindividualorfamilyhealthcoverage.Sec.412. Employerresponsibilitytocontributetowardemployeeanddependentcoverage.Providesthattheminimumemployercontributioninthecaseofanofferingemployeris72.5%ofthepremiumforindividualcoverage,and65%ofthepremiumforfamilycoverageoraproportionalamountfornon‐fulltimeemployees.Familycoverageforthispurposeincludestheemployee’sspouseandqualifyingchildren.Requiresemployerstoprovideforautomaticenrollmentoftheiremployeeintotheiremployment‐basedhealthplanwiththelowestapplicableemployeepremium.Sec.413. Employercontributionsinlieuofcoverage.RequiresanofferingemployertocontributetotheExchangeforeachemployeewhodeclinestheemployer’scoverageofferandenterstheExchangeviatheaffordabilitytestoutlinedintheact.Thecontributionisgenerally8%oftheaveragesalaryfortheemployer.Smallemployerswithannualpayrollsatorbelow$500,000,areexemptfromthisrequirement.Thecontributionphasesupfrom0‐8%betweenanannualpayrollof$500,000and$750,00,atwhichpointemployersaresubjecttothefull8%contributionrequirement.Sec. 414. Authorityrelatedtoimpropersteering.Authorizesthecreationofrulesthatwouldprohibitemployersfromengaginginpracticesthatsteeremployeesawayfromemployer‐offeredcoverageandintocoverageofferedundertheExchange.

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Sec.415.Impactstudyonemployerresponsibilityrequirements.RequirestheSecretaryofLabortoconductastudytoexaminetheeffectofthesmallbusinessexemptionsfromtheemployercontributionandtoproviderecommendationsannuallyafter2012astowhethertheserequirementsarehavingdetrimentalimpactsorcreatinginequitiesamongemployers,healthplansandenrolleesandshallsubmitrecommendationstoCongressiftheSecretaryfindsthatchangesshouldbemadetothelawinthisregard.Sec.416.Studyonemployerhardshipexemption.TheSecretariesofLabor,TreasuryandHealthandHumanServicesandtheHealthChoicesCommissionershalltogetherconductastudytoexaminewhetheranemployerhardshipexemptionshouldbeaddedtothelaw.PART2—SatisfactionofHealthCoverageParticipationRequirementsSec.421. SatisfactionofhealthcoverageparticipationrequirementsundertheEmployeeRetirementIncomeSecurityActof1974.ProvidesrulesunderwhichanemployerthatissubjecttoERISAmakesanelectiontoofferhealthcoverage(an“offeringemployer”)inlieuofthepayrolltaxthatappliestoanon‐offeringemployer.Theemployercanmakeaseparateelectionforfull‐timeemployees,non‐fulltimeemployees,andseparatelinesofbusiness.ThesectionalsoprovidesenforcementauthoritytotheDepartmentofLaborandemployeesofanofferingemployeriftheemployerdoesnotfollowtherulesthatapplytoacoverageoffer.Sec. 422. SatisfactionofhealthcoverageparticipationrequirementsundertheInternalRevenueCodeof1986.Cross‐referencestherulesintheInternalRevenueCoderelatingtoanemployer’selectiontobeanofferingemployer.Sec.423. SatisfactionofhealthcoverageparticipationrequirementsunderthePublicHealthServiceAct.ProvidesrulesunderwhichanemployerthatissubjecttothePublicHealthServiceActmakesanelectiontoofferhealthcoverage(an“offeringemployer”)inlieuofthepayrolltaxthatappliestoanon‐offeringemployer.Theemployercanmakeaseparateelectionforfull‐timeemployeesandnon‐fulltimeemployees.ThesectionalsoprovidesremediestotheDepartmentofHealthandHumanServicesandemployeesofanofferingemployeriftheemployerdoesnotfollowtherulesthatapplytoacoverageoffer.Sec.424. Additionalrulesrelatingtohealthcoverageparticipationrequirements.RequirestheExchangeandtheDepartmentsofHHS,Labor,andTreasurytodevelopcoordinatedinterpretativeandenforcementmeasureswithrespecttoofferingemployers.

TITLEV—AMENDMENTSTOINTERNALREVENUECODEOF1986SUBTITLEA–PROVISIONSRELATINGTOHEALTHCAREREFORMPART1—SHAREDRESPONSIBILITYSubpartA—IndividualResponsibilitySec. 501. Taxonindividualswithoutacceptablehealthcarecoverage.Providesfora2.5%additionaltaxonthemodifiedadjustedgrossincomeofanindividualwhodoesnotobtainacceptablehealthcoveragefortheindividualordependentsclaimedontheindividual’staxreturn.AuthorizestheDepartmentofTreasuryandtheExchangetoestablishahardshipexemptionfromtheadditionaltax.Acceptablecoverageincludesgrandfatheredindividualandemployercoverage,certaingovernmentcoverage(e.g.,Medicare,Medicaid,certaincoverageprovidedtoveterans,militaryemployees,retirees,andtheirfamilies,andmembersofIndiantribes),andcoverageobtainedpursuanttotheExchangeoranemployerofferofcoverage.

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SubpartB—EmployerResponsibilitySec. 511. Electiontosatisfyhealthcoverageparticipationrequirements.Providesrulesunderwhichanemployermakesanelectiontoofferhealthcoverage(an“offeringemployer”)inlieuofthepayrolltaxthatappliestoanon‐offeringemployer.Thissectionalsoprovidesforanexcisetaxthatappliestoanofferingemployeriftheemployerfailstofollowtherulesgoverninganofferofcoverage.Sec. 512. Healthcarecontributionsofnonelectingemployers.Establishesapayrolltaxof8%ofthewagesthatanemployerpaystoitsemployeesforemployerswhochoosenottooffercoverage.Certainsmallemployersareexemptfromthisoraresubjecttoagraduatedtaxrate.Anexemptsmallbusinessisanemployerwithanannualpayrollthatdoesnotexceed$500,000.The8%payrolltaxphasesinforemployerswithannualpayrollfrom$500,000through$750,000.PART2—CREDITFORSMALLBUSINESSEMPLOYEEHEALTHCOVERAGEEXPENSESSec. 521. Creditforsmallbusinessemployeehealthcoverageexpenses.Providesforataxcreditequalto50%oftheamountpaidbyasmallemployerforemployeehealthcoverage.Thetaxcreditisphasedoutinthecaseofanemployerwith10to25employees,andisalsophasedoutinthecaseofanemployerwithaveragewagesof$20,000to$40,000peryear.Anemployermayelecttousethecreditforamaximumof2taxableyears.PART3—LIMITATIONSONHEALTHCARERELATEDEXPENDITURESSec.531.Distributionsformedicinequalifiedonlyifforprescribeddrugorinsulin.Providesthatnontaxablereimbursementsfromhealthflexiblespendingaccounts,healthreimbursementarrangements,andhealthsavingsaccountsdonotincludeamedicineordrugunlessthemedicineordrugisprescribedorisinsulin.Sec.532.Limitationonhealthflexiblespendingarrangementsundercafeteriaplans.Limitssalaryreductioncontributionstohealthflexiblespendingarrangementsto$2,500(indexedtotheconsumerpriceindex).Sec.533.Increaseinpenaltyfornonqualifieddistributionsfromhealthsavingsaccounts.Increasesthe10percentpenaltyondistributionsfromhealthsavingsaccountsthatarenotusedtopayforhealthrelatedexpendituresto20percent.Sec.534.DenialofdeductionforFederalsubsidiesforprescriptiondrugplanswhichhavebeenexcludedfromgrossincome.CertainemployersareeligibleforFederalsubsidieswithrespecttoprescriptiondrugbenefitsprovidedtoretireesandthesubsidiesareexcludedfromgrossincome.Provisioneliminatestheabilityofemployerstodeductexpensesforwhichtheyaresubsidized.PART4—OTHERPROVISIONSTOCARRYOUTHEALTHINSURANCEREFORMSec. 541. Disclosurestocarryouthealthinsuranceexchangesubsidies.PermitstheExchangetoreceivelimitedtaxpayerreturninformationfromtheInternalRevenueServiceforindividualswhoapplyforaffordabilitycredits.Informationreceivedissubjecttoconfidentialityanduserestrictions,enforcedbycivilandcriminalpenalties.Sec.542.Offeringofexchange‐participatinghealthbenefitplansthroughcafeteriaplans.ProvidesthatcoveragepurchasedthroughtheExchangemaynotbepurchasedonapre‐taxsalaryreductionbasisunlessthepurchaser’semployeriseligibletoofferemployercoveragethroughtheExchange.

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Sec.543.Exclusionfromgrossincomeofpaymentsmadeunderreinsuranceprogramforretirees.Providesthatsubsidiesreceivedbyanemployerorhealthplanundersection111ofthebillarenotincludableingrossincome.Sec.544.CLASSProgramtreatedinsamemanneraslong‐termcareinsurance.ProvidesthatpremiumsforparticipationintheCLASSProgram,andbenefitsreceivedundertheprogram,aretreatedinthesamemanneraspremiumsforandbenefitsunderqualifiedlong‐termcareinsurancepolicies.Sec.545.ExclusionfromgrossincomeformedicalcareprovidedforIndians.Providesthathealthservicesandcoverageprovidedbyatribeortribalorganizationtoamemberofthetribeisexcludedfromgrossincome.SUBTITLEB–OTHERREVENUEPROVISIONSPART1—GENERALPROVISIONSSec.551.Surchargeonhighincomeindividuals.Establishesa5.4percenttaxonmodifiedadjustedgrossincomeinexcessof$1millioninthecaseofajointreturn($500,000inthecaseofotherreturns).Thetaxisestimatedtoaffectonly0.3percentofallhouseholdsandonly1.2percentofsoleproprietors,partners,ands‐corporationshareholdersoperatingabusiness.Sec.552.Excisetaxonmedicaldevices.Establishesa2.5percentexcisetaxonmedicaldevicessoldforuseintheU.S.Theexcisetaxdoesnotapplytoexporteddevicesanddoesnotapplytoretailsalesofdevices.Sec.553.Expansionofinformationreportingrequirements.Requiresinformationreportingwithrespecttopaymentsmadeinthecourseofatradeorbusinesstoacorporation.Sec.554.Delayinapplicationofworldwideallocationofinterest.ProvisiondelaystheapplicationofaliberalizedruleforallocatinginterestexpensesbetweenU.S.andforeignsourcedincomeforpurposeofataxpayer’sforeigntaxcreditlimitation.PART2—PREVENTIONOFTAXAVOIDANCESec.561.Limitationontreatybenefitsforcertaindeductiblepayments.PreventsforeignmultinationalcorporationsincorporatedintaxhavensfromavoidingtaxonincomeearnedintheU.S.Sec.562.Codificationofeconomicsubstancedoctrine;penalties.Clarifiestheapplicationoftheeconomicsubstancedoctrine,whichhasbeenusedbycourtstodenytaxbenefitsfortransactionsthatlackeconomicsubstance.Sec.563.Certainlargeorpubliclytradedpersonsmadesubjecttoamorelikelythannotstandardforavoidingtaxpenaltiesonunderpayments.Providesthattaxpenaltiesonunderpaymentsbycertainlargeorpubliclytradedentitiescannotbeavoidedunlessthebasisforthetaxtreatmentthatcausedtheunderpaymentisbasedonareasonablebeliefthatsuchtaxtreatmentismorelikelythannotthepropertaxtreatment.

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PART3—PARITYINHEALTHBENEFITSSec.571.Certainhealthrelatedbenefitsapplicabletospousesanddependentsextendedtoeligiblebeneficiaries.Extendstheexclusionforemployerprovidedhealthcoveragetoapersonwhoiseligibleforcoverageundertheemployer’splanandwhoisnotaspouseordependent.

DIVISIONB—MEDICAREANDMEDICAIDIMPROVEMENTS

TITLEI—IMPROVINGHEALTHCAREVALUESUBTITLEA–PROVISIONSRELATEDTOMEDICAREPARTAPART1—MarketBasketUpdatesSec.1101.Skillednursingfacilitypaymentupdate.Providesforamarketbasketfreezeforthesecond,thirdandfourthquartersoffiscalyear2010.Sec.1102.Inpatientrehabilitationfacilitypaymentupdate.Providesforamarketbasketfreezeforthesecond,thirdandfourthquartersoffiscalyear2010.Sec.1103.Incorporatingproductivityimprovementsintomarketbasketupdatesthatdonotalreadyincorporatesuchimprovements.Incorporatesaproductivityadjustmentintothemarketbasketupdateforinpatienthospitals,psychiatrichospitalsandhospicecarebeginningin2010(beginningin2011forskillednursingfacilitiesandinpatientrehabilitationhospitals).Setsafloorfortheinpatienthospitalmarketbasketupdatesothatthecombinationoftheproductivityadjustmentandanyadjustmentsforqualityreportingormeaningfuluseofelectronichealthrecordscannotcausethemarketbasketupdatetogobelowzero.PART2—OtherMedicarePartAProvisionsSec.1111.Paymentstoskillednursingfacilities.CodifiestherecalibrationfactorincludedintheFY2010NoticeofProposedRulemakingfortheMedicareskillednursingfacilityprospectivepaymentsystem.Providesabudgetneutraladjustmentwithinthepaymentsystemtoimprovepaymentaccuracyfornon‐therapyancillaryservicesandtherapyservices,directstheSecretaryofHealthandHumanServicestoanalyzepaymentsfornon‐therapyancillaryservicesforinclusioninafutureSNFcasemixreclassificationsystem,andcreatesanoutlierpaymentfornontherapyancillaryservices.Sec. 1112.MedicareDSHreportandpaymentadjustmentsinresponsetocoverageexpansion.DirectstheSecretarytosubmitareporttoCongressbyJanuary1,2016onMedicaredisproportionatesharehospital(DSH)payments.Iftheuninsuredratedropsacertainnumberofpercentagepointsbetween2012and2014,directstheSecretarytoadjustMedicareDSHpaymentsstartinginFY2017totheempiricallyjustifiedlevelplusanadjustmentreflectinguncompensatedcarecosts.Sec.1113.HospiceRegulatoryMoratorium.Extendsaone‐yearmoratoriumonregulatorychangesthatwouldphaseoutthebudgetneutralityadjustmentfactorforhospiceproviderstoensurethathospicescontinuetoreceivethesamewagereimbursementrateforfiscalyear2010.Sec.1114.ExpandingPhysicianAssistants’RoleinMedicare.Allowsphysicianassistantstoorderskillednursingfacilitycareandliststhemasaneligibleproviderforhospicecare.

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SUBTITLEB—PROVISIONSRELATEDTOPARTBPART1—Physicians’ServicesSec. 1121. Resource‐basedfeedbackprogramforphysiciansinMedicare.ExpandsMedicare’sphysicianresourceusefeedbackprogramtoprovidefordevelopmentofareportfornationaluseby2012,tobefollowedbysignificantnationaldisseminationofsuchreport.Startingin2014,reportsarerequiredtobedistributedtoatleastphysiciansamongthetop5%inuseofresources.Sec. 1122. Misvaluedcodesunderthephysicianfeeschedule.DirectstheSecretarytoregularlyreviewfeescheduleratesforphysicianservicespaidforbyMedicare,includingservicesthathaveexperiencedhighgrowthrates.StrengthenstheSecretary’sauthoritytoadjustfeescheduleratesthatarefoundtobemisvaluedorinaccurate.Sec. 1123. Paymentsforefficientareas.ProvidesincentivepaymentsintheMedicareprogramtophysicianspracticinginareasthatareidentifiedasbeingthemostcost‐efficientareasofthecountry.Sec. 1124.ModificationstothePhysicianQualityReportingInitiative(PQRI).Extendsthrough2012paymentsunderthePQRIprogram,whichprovideincentivestophysicianswhoreportqualitydatatoMedicare.CreatesareviewprocessforphysicianswhochoosetohavetheirPQRIsubmissionsreviewedanddirectstheSecretarytointegratethePQRIprogramandthe“meaningfuluse”measuresusedbythehealthinformationtechnologyincentiveprogram.Sec. 1125.AdjustmenttoMedicarepaymentlocalities.UpdatesthemethodusedtodeterminethelocalitiesusedforMedicare’sgeographicadjustmentfactorinCalifornia,utilizinganapproachthatisbasedonmetropolitanstatisticalareas.PART2—MarketBasketUpdatesSec. 1131.Incorporatingproductivityadjustmentintomarketbasketupdatesthatdonotalreadyincorporatesuchimprovements.Incorporatesaproductivityadjustmentintothemarketbasketupdateforoutpatienthospitalservicesbeginningin2010.Setsafloorfortheoutpatienthospitalmarketbasketupdatesothatthecombinationoftheproductivityadjustmentandanyadjustmentsforqualityreportingcannotcausethemarketbasketupdatetogobelowzero.Incorporatesaproductivityadjustmentbeginningin2010forambulanceservices,ambulatorysurgicalcenters,anddurablemedicalequipmentnotsubjecttocompetitivebidding.ReplacestheexistingupdateforlaboratoryservicesofCPIminus0.5withanupdateofCPIlessproductivity.PART3—OtherProvisionsSec. 1141.Rentalandpurchaseofpower‐drivenwheelchairs.EliminatestheoptionforMedicaretopurchasepower‐drivenwheelchairswithalump‐sumpaymentatthetimethechairissupplied.Medicarewouldcontinuetomakethesamepaymentsforpower‐drivenchairsovera13‐monthperiod.Purchaseoptionforcomplexrehabilitativepowerwheelchairswouldbemaintained.Sec.1141A.Electiontotakeownership,ortodeclineownership,ofacertainitemofcomplexdurablemedicalequipmentafterthe13‐monthcappedrentalperiodends.Followingtherentalperiodof13months,thisprovisionallowsbeneficiariestoreturngroup3supportsurfacestotheoriginalsupplierortoelecttotakeownershipofsuchequipment.Thisprovisionassuresthatbeneficiarieswillcontinuetohaveaccesstosuchitemintheeventofarecurrentmedicalneed.

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Sec.1142.Extensionofpaymentruleforbrachytherapy.Extendspaymentatcostforbrachytherapyfortwoyearsthrough2011.Sec.1143.HomeinfusiontherapyreporttoCongress.Inmanysituations,Medicaredoesnotcoverequipmentandservicesrelatedtohomeinfusionofprescriptiondrugs.ThisprovisiondirectstheSecretarytomakerecommendationsonthemostappropriatewayforMedicaretocoverandpayforhomeinfusionservices.Sec.1144.Requireambulatorysurgicalcenters(ASCs)tosubmitcostdataandotherdata.DirectstheSecretarytodevelopacostreportforASCswithintwoyearsofenactmentandtorequirereportingofcostdatabyASCsforcostreportingperiodsbeginningonorafterthedatewhenthecostreportisdeveloped.DirectstheSecretarytorequireASCstosubmitqualitydatabeginningin2012.Sec.1145.Treatmentofcertaincancerhospitals.DirectstheSecretarytostudywhetherexistingcancerhospitalsthatareexemptfromtheinpatientprospectivepaymentsystemhavecostsundertheoutpatientprospectivepaymentsystem(OPPS)thatexceedcostsofotherhospitals,andtomakeanappropriatepaymentadjustmentunderOPPSbasedonthatanalysis.Sec. 1146. Paymentforimagingservices.Increasesthepracticeexpenseunitsforimagingservicestoreflectapresumedutilizationrateof75%insteadof50%.Excludeslow‐techimagingsuchasultrasound,x‐raysandEKGsfromthisadjustment.Alsoadjuststhetechnicalcomponentdiscountonsinglesessionimagingstudiesoncontiguousbodypartsfrom25%to50%.Sec.1147.Durablemedicalequipmentprogramimprovements.Providesprotectionsforbeneficiariesreceivingoxygentherapyintheeventanoxygensuppliergoesoutofbusiness.Exemptscertainpharmaciesandsuppliersofeyewearfromthesuretybondrequirement.Exemptscertainpharmaciesfromtheneedtobeaccreditedtoselldiabetictestingsuppliesandcertainotheritems.Sec.1148.MedPACstudyandreportonbonemassmeasurement.InstructsMedPACtoconductastudyontheadequacyofMedicarepaymentforbonemassmeasurementservicesunderthephysicianfeeschedule.Sec.1149A.Paymentforbiosimilarbiologicalproducts.EstablishesPartBpaymentmethodologiesforinterchangeableandbiosimilarproducts.Sec.1149B.StudyandreportonDMEcompetitivebiddingprocess.InstructstheGovernmentAccountabilityOfficetoevaluateestablishmentofacompetitivebiddingprogramformanufacturersofdurablemedicalequipmentandsupplies.SUBTITLEC—PROVISIONSRELATEDTOMEDICAREPARTSAANDBSec.1151.Reducingpotentiallypreventablehospitalreadmissions.Beginninginfiscalyear2012,adjustspaymentsfor1886(d)hospitals,criticalaccesshospitalsandhospitalspaidunder1814(b)(3)basedonthedollarvalueofeachhospital’spercentageofpotentiallypreventableMedicarereadmissionsfor3conditionswithriskadjustedreadmissionmeasuresthatareendorsedbytheNationalQualityForum.DirectstheSecretarytoexpandthepolicytoadditionalconditionsinfutureyearsandauthorizestheSecretarytomodifytheadjustmentbasedonahospital’sperformanceinreadmissionscomparedtoarankingofhospitalsnationally.Providesassistancetocertainhospitalsfortransitionalcareactivitiestoaddresspatientnoncomplianceissuesthatmayresultinhighreadmissionrates.Createsaninterimreadmissionspolicyforpost‐acuteprovidersbeginninginFY2012,anddirectstheSecretarytodevelopriskadjustedreadmissionratesforpost‐acuteprovidersand

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implementareadmissionspaymentsystemforthoseproviderssimilartothehospitalsystemonorafterFY2015.DirectstheSecretarytosubmitareporttoCongressnolaterthanoneyearafterdateofenactmentonhowphysicianscanbeincorporatedintothereadmissionspolicy.DirectstheSecretarytomonitorinappropriatechangesinadmissionpracticesbyhospitalsandpost‐acuteprovidersandauthorizestheSecretarytopenalizeprovidersthatareavoidingpatientsatriskofareadmission. Sec.1152.Postacutecare(PAC)servicespaymentreformplan.DirectstheSecretarytosubmittoCongressnolaterthan3yearsafterdateofenactmentadetailedplanonhowtoimplementpost‐acutebundledpayments.ConvertstheexistingAcuteCareEpisodedemonstrationprojecttoapilotprogramandexpandstheprogramsothatitmayincludebundlingofpaymentsforhospitalsandpost‐acuteproviders,effectiveJanuary1,2011.Sec.1153.Homehealthpaymentupdatefor2010.Providesafreezeinthemarketbasketupdateforhomehealthagenciesfor2010.Sec.1154.Paymentadjustmentsforhomehealthcare.Acceleratestheregulatoryadjustmentforcasemixcurrentlyscheduledfor2011sothatitoccursin2010.DirectstheSecretarytorebasethehomehealthprospectivepaymentsystemfor2011,takingintoaccountchangesintheaveragenumberandtypesofvisitsperepisode,changeinintensityofvisits,andgrowthincostperepisode.Sec.1155.Incorporatingproductivityimprovementsintomarketbasketupdateforhomehealthservices.Incorporatesaproductivityadjustmentintothemarketbasketupdateforhomehealthagenciesbeginningin2010.Setsafloorforthehomehealthmarketbasketsothatthecombinationoftheproductivityadjustmentandanyadjustmentsforqualityreportingcannotcausethemarketbasketupdatetogobelowzero.Sec.1155A.MedPACstudyonvariationinhomehealthmargins.RequiresMedPACtoundertakeastudytoexaminethevariationinMedicaremarginsamonghomehealthagencies.Factorsconsideredwillincludepatientcharacteristics(includinghealthandsocioeconomicfactors),agencycharacteristics,andthetypesofservicesprovidedbydifferentagencies.Sec.1155B.AllowshomehealthagenciestoassignthemostappropriateskilledservicestomaketheinitialassessmentunderaMedicarehomehealthplanofcareforrehabilitationcases.Allowshomehealthagenciestoassignanoccupationaltherapisttomakeaninitialhomeassessmentifoccupationaltherapyisorderedaspartofthereferralforhomehealthservices.Sec. 1156.LimitationonMedicareexceptionstotheprohibitiononcertainphysicianreferralsmadetohospitals.Closesaloopholeintheself‐referralrulesthatallowsphysicianstoreferpatientstohospitalsinwhichtheyhaveadirectfinancialinterest.ProhibitsphysicianownershipinhospitalsthatarenewasofJanuary1,2009.Grandfatherstheownershipstructuresofallphysician‐ownedhospitalswithMedicareprovidernumberspriorJanuary1,2009.Allowsforgrowthofexistingphysician‐ownedhospitalswithincertainparameters.Sec.1157.InstituteofMedicineStudyonGeographicAdjustmentFactorsUnderMedicare.RequirestheSecretarytocontractwiththeInstituteofMedicineoftheNationalAcademiestoundertakeastudyonthevalidityandeffectsofthegeographicadjustersusedforMedicarephysicianandhospitalpayments,andtorecommendimprovements.Sec.1158.RevisionofMedicarePaymentSystemstoAddressGeographicInequities.CMSisinstructedtorespondtorecommendationsundersection1157andmayspendupto$4billionperyear,fortwoyears,toeffectanyneededincreasesinpaymentratesandto“holdharmless”providersthatwouldotherwisehavetheir

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paymentsreduced.AmountsintheMedicareImprovementFundarereducedto$8billion,anamountsufficienttofundthissection.Sec.1159.InstituteofMedicinestudyofgeographicvariationinhealthcarespendingandpromotinghigh‐valuehealthcare.RequirestheSecretarytocontractwiththeInstituteofMedicineoftheNationalAcademiestoundertakeastudyofgeographicvariationinhealthcarespendingamongallpayers.Factorsconsideredshallincludepatientdemographicsandsocioeconomiccharacteristics,healthstatus,thesupplyofprovidersofservices,inputprices,andotherfactors.ThereportshallalsoincluderecommendationsforchangestoMedicarepaymentsystemstoaddresssuchgeographicvariationandtoimprovethevalueofhealthspendingintheprogram.Sec.1160.Implementation,andCongressionalReview,ofproposaltoreviseMedicarepaymentstopromotehighvaluehealthcare.TheSecretaryofHHSisinstructedtodevelopanimplementationplanforchangingMedicarepaymentsystems,asappropriate,basedonrecommendationsundersection1159.HHSisrequiredtosubmittheimplementationplantoCongressunderaschedulethatpermitsampletimetoreviewthereportandconsideritsimplications.Theplanwillbeimplementedstartingin2013unlessCongressvotestodisapproveit.SUBTITLED–MEDICAREADVANTAGEREFORMSPART1—PaymentandAdministrationSec.1161.Phase‐inofpaymentbasedonfee‐for‐servicecosts;qualitybonuspayments.ReducesMedicareAdvantagebenchmarkstofee‐for‐servicelevelsoverthreeyears,reachingequalityofpaymentratesin2013.Createsanincentivesystemtoincreasepaymentstohigh‐qualityplansinlow‐costareas,phased‐inover2011‐2013.Sec.1162.ExtensionofSecretarialcodingintensityadjustmentauthority.ExtendsCMSauthoritytoadjustriskscoresinMedicareAdvantageforobserveddifferencesincodingpatternsrelativetofee‐for‐service.Sec.1163.Simplificationofannualbeneficiaryelectionperiods.ProvidesextratimeforCMSandhealthplanstoprocessenrollmentpaperworkduringannualenrollmentperiodsandeliminatesaduplicativeopenenrollmentperiodforMedicareAdvantageplans.Sec.1164.Extensionofreasonablecostcontracts.Extendstheperiodoftimeforwhichcostplansmayoperateinareasthathaveotherhealthplanoptions.Sec.1165.Limitationofwaiverauthorityforemployergroupplans.RestrictstheabilityofMedicareAdvantageplanstooffercoverageoutsidetheirserviceareaandgrandfatherscurrentcontracts.Sec.1166.Improvingriskadjustmentforpayments.RequiresastudyontheeffectivenessoftheMedicareAdvantageriskadjustmentsystemforlow‐incomeandchronicallyillpopulations.Sec.1167.EliminationofMARegionalPlanStabilizationFund.EliminatestheMedicareAdvantageregionalplanstabilizationfund.Sec.1168.StudyregardingtheeffectsofcalculatingMedicareAdvantagepaymentratesonaregionalaverageofMedicarefeeforservicerates.RequiresCMStostudytheeffectsofpayingMedicareAdvantageplansonamoreaggregatedbasisthanatthecountylevel.

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PART2–BeneficiaryProtectionsandAnti‐FraudSec.1171.Limitationoncost‐sharingforindividualhealthservices.EnsuresthatbeneficiariesinMedicareAdvantageplansarenotsubjectedtohighercost‐sharingthantheywouldfaceinfee‐for‐serviceMedicare.EnsuresthatbeneficiariesduallyeligibleforMedicareandMedicaidarenotsubjecttohighercost‐sharingthantheywouldfaceunderMedicaidweretheynotenrolledinMedicare.Sec.1172.Continuousopenenrollmentforenrolleesinplanswithenrollmentsuspension.AllowsbeneficiariesinMedicareAdvantageplansfacingsanctionsforfailuretomeetprogramrulestooptoutoftheplanatanytimeforanotherplanorfee‐for‐serviceMedicare.Sec.1173.InformationforbeneficiariesonMAplanadministrativecosts.RequiresCMStopublishstandardizedinformationonmedicallossratiosandotherplaninformationtobeneficiariesandthepublic.Forplanswithmedicallossratiosbelow85%,theprovisionrequiresrebatesandincreasingpenaltiesovertime,includingeventualterminationofcontracts.Sec.1174.Strengtheningauditauthority.StrengthenstheabilityofCMStorecoveroverpaymentstoplansdiscoveredbyaudits.Sec.1175.Authoritytodenyplanbids.ClarifiesthatCMSisnotobligatedtoacceptanyoreverybidsubmittedbyaMedicareAdvantageorPartDplan.Sec.1175A.Stateauthoritytoenforcestandardizedmarketingrequirements.PermitsstatestoimposecivilmonetarypenaltiesandprovidesforFederal‐statecoordinationofintermediatesanctionsagainstPartDandMedicareAdvantageplansfoundviolatingmarketingrules.EnsuresthatplanswillnotfacedoubleStateandFederaljeopardyforthesameviolation.PART3–TreatmentofSpecialNeedsPlansSec.1176.LimitationonenrollmentoutsideopenenrollmentperiodofindividualsintochroniccarespecializedMAplansforspecialneedsindividuals.Ensuresthatchronicconditionspecialneedsplans(SNPs)enrollbeneficiariesonlyduringtheannualelectionperiodandspecialelectionperiodstobedeterminedbyCMS.Sec.1177.Extensionofauthorityofspecialneedsplanstorestrictenrollment.ExtendstheSNPprogramthrough2012,andextendscertainfullyintegrateddualeligibleSNPsthrough2015.AlsoextendsthemoratoriumonserviceareaexpansionsfordualeligibleSNPsthatdonotmeetcertainrequirements.Sec.1178.ExtensionofMedicareseniorhousingplans.ExtendsSNPsthatserveresidentsincontinuingcareretirementcommunities.SUBTITLEE–IMPROVEMENTSTOMEDICAREPARTDSec.1181.Eliminationofcoveragegap.EliminatesPartDdonuthole,beginningwitha$500reductionin2010,andcompletingphase‐outby2019.PaysfortheeliminationofthegapwithfundsraisedbyrequiringdrugmanufacturerstoprovideMedicaidrebatesfordrugsusedbyfulldualeligiblesandlow‐incomesubsidyrecipients.

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Sec.1182.DiscountsforcertainPartDdrugsinoriginalcoveragegap.IncorporatesvoluntaryPhRMAagreementtoprovidediscountsof50%forbrand‐namedrugsusedbyPartDenrolleesinthePartDdonuthole,beginningin2010.Sec.1183.Repealofprovisionrelatingtosubmissionofclaimsbypharmacieslocatedinorcontractingwithlong‐termcarefacilities.Eliminatesdeadlinesforlong‐termcarepharmaciststofilePartDclaimstoallowmoretimeforimprovedcoordinationwithstateMedicaidprograms.Sec.1184.IncludingcostsincurredbyAIDSDrugAssistanceProgramsandIndianHealthServiceinprovidingprescriptiondrugstowardstheannualout‐of‐pocketthresholdunderPartD.AllowsdrugsprovidedtopatientsbyAIDSDrugAssistanceProgramsortheIndianHealthServicetocounttowardout‐of‐pocketcosts,allowingtheseindividualstoqualifyforPartDcatastrophicbenefits.Sec.1185.Nomid‐yearformularychangespermitted.PreventsPartDplansfrommakinganyformularychangethatincreasecost‐sharingorotherwisereducecoverageoncetheplanmarketingperiodbegins.Sec.1186.NegotiationoflowercoveredPartDdrugpricesonbehalfofMedicarebeneficiaries.RequirestheSecretaryofHHStonegotiatewithdrugmanufacturersforlowerPartDdrugprices.Sec.1187.Accuratedispensinginlong‐termcarefacilities.RequiresPartDplanstodeveloputilizationmanagementtechniquestoreduceprescriptiondrugwasteinlong‐termcarefacilities.Sec.1188.Freegenericfill.ClarifiesthatPartDplansmayoffergenericdrugstoenrolleeswithzerocopaymenttoencourageuseoflower‐costgenericdrugs.Sec.1189.StatecertificationpriortowaiveroflicensurerequirementsunderMedicareprescriptiondrugprogram.LimitsCMS’authoritytowaivestatelicensurerequirementstosituationswheretheStatehascertifiedthatthePartDplan’sapplicationissubstantiallycomplete.SUBTITLEF—MEDICARERURALACCESSPROTECTIONSSec. 1191. Telehealthexpansionandenhancements.Streamlinesthecredentialingprocessforhospitalsandcriticalaccesshospitalswishingtousetelehealthservices.ExpandsMedicare’stelehealthbenefittobeneficiarieswhoarereceivingcareatfreestandingdialysiscenters.AlsoestablishesaTelehealthAdvisoryCommitteetoprovideHHSwithadditionalexpertiseonthetelehealthprogram.Sec.1192.Extensionofoutpatientholdharmlessprovision.ExtendstheexistingoutpatientholdharmlessprovisionthroughFY2011.Sec.1193.Extensionofsection508hospitalreclassifications.Extendsreclassificationsundersection508oftheMedicareModernizationActthroughFY2011.Sec. 1194. Extensionofgeographicfloorforwork.Medicareadjustsfeespaidforphysicianservicesbasedongeographicvariationsincosts.Extendsafloorongeographicadjustmentstotheworkportionofthefeeschedulethroughtheendof2011,withtheeffectofincreasingpractitionerfeesinruralareas.Sec. 1195. Extensionofpaymentfortechnicalcomponentofcertainphysicianpathologyservices.Extendsaprovisionthatdirectlyreimbursesqualifiedruralhospitalsforcertainclinicallaboratoryservicesthroughtheendof2011.

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Sec. 1196. Extensionofambulanceadd‐ons.ExtendsbonuspaymentsmadebyMedicareforgroundandairambulanceservicesinruralandotherareasthroughtheendof2011.

TITLEII–MEDICAREBENEFICIARYIMPROVEMENTSSUBTITLEA–IMPROVINGANDSIMPLIFYINGFINANCIALASSISTANCEFORLOWINCOMEMEDICAREBENEFICIARIESSec. 1201.ImprovingassetstestsforMedicareSavingsProgramandlow‐incomesubsidyprogram.IncreasestheassetstestforeligibilityforthePartDlow‐incomesubsidyandMedicareSavingsProgramsto$17,000forindividualsand$34,000forcouplesindexedannuallybyCPI.Sec.1202.EliminationofPartDcost‐sharingforcertainnon‐institutionalizedfull‐benefitdualeligibleindividuals.Eliminatescostsharingforpeoplereceivingcareunderahomeandcommunitybasedwaiverwhowouldotherwiserequireinstitutionalcare.Sec.1203.Eliminatingbarrierstoenrollment.Reducesbarrierstothelow‐incomesubsidybyallowingself‐certificationandadministrativeverificationofincomeanddatasharingbetweenIRSandSSA.Sec.1204.Enhancedoversightrelatingtoreimbursementsforretroactivelowincomesubsidyenrollment.Enhancesoversighttomakesurethatlow‐incomebeneficiarieswhoareowedretroactivereimbursementpaymentsfromtheirdrugplansreceivethem.Sec.1205.Intelligentassignmentinenrollment.GivesCMSauthoritytouseanenrollmentprocessforsubsidy‐eligibleindividualsintoPartDplansthataccountsforthequality,costand/orformularyofplans.Sec.1206.Specialenrollmentperiodandautomaticenrollmentprocessforcertainsubsidyeligibleindividuals.GivesCMSauthoritytoenrollsubsidy‐eligiblebeneficiariesintoplansusingaprocessthataccountsforthequality,costand/orformularyofplans,whilealsogivingbeneficiariestheoptionofchoosinganotherplan.Sec.1207.ApplicationofMApremiumspriortorebateandqualitybonuspaymentsincalculationoflowincomesubsidybenchmark.RemovesMedicareAdvantagerebatesandqualitybonuspaymentsfromthecalculationofthelow‐incomesubsidybenchmarkinordertoreduceinvoluntaryswitchingoffulllow‐incomesubsidyPartDenrollees.SUBTITLEB–REDUCINGHEALTHDISPARITIESSec.1221.EnsuringeffectivecommunicationinMedicare.RequirestheSecretaryofHHStoconductastudythatexaminestheextenttowhichMedicareprovidersutilize,offerormakeavailablelanguageservicesforbeneficiarieswhoarelimitedEnglishproficientandwaysthatMedicareshoulddeveloppaymentsystemsforlanguageservices.Sec.1222.DemonstrationtopromoteaccessforMedicarebeneficiarieswithlimitedEnglishproficiencybyprovidingreimbursementforculturallyandlinguisticallyappropriateservices.InstructstheSecretarytocarryoutademonstrationprogramtoreimburseMedicareproviders,inmultipleprovidersettings,fortheprovision

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oflanguageservices.RequirestheSecretarytoevaluatethedemonstrationprogramandmakerecommendationsontheexpansionofsuchservicestotheentireMedicareprogram.Sec.1223.InstituteofMedicinereportonimpactoflanguageaccessservices.RequirestheSecretarytocontractwiththeInstituteofMedicinetoconductastudythatexaminestheimpactonthequalityofcare,accesstocare,thereductioninmedicalerrorsandcostsorsavingsassociatedwiththeprovisionoflanguageaccessservicestolimitedEnglishproficientpopulations.Sec.1224.Definitions.Definescertaintermssuchas“CompetentInterpreterServices”,“LanguageServices”and“LimitedEnglishProficient”usedinSubtitleB.SUBTITLEC—MISCELLANEOUSIMPROVEMENTSSec.1231.Extensionoftherapycapsexceptionsprocess.Extendstheprocessallowingexceptionstolimitationsonmedicallynecessarytherapythrough2011.Sec.1232.Extendedmonthsofcoverageofimmunosuppressivedrugsforkidneytransplantpatientsandotherrenaldialysisprovisions.Liftsthecurrent36‐monthlimitationonMedicarecoverageofimmunosuppressivedrugsforkidneytransplantpatientswhowouldotherwiselosethiscoverageonorafterJanuary1,2012andmakestechnicalchangestothebundledpaymentsystemfordialysisservices.Sec.1233.Voluntaryadvancecareplanningconsultation.Providescoverageforoptionalconsultationbetweenenrolleesandpractitionerstodiscussordersforlife‐sustainingtreatmentandotheroptionsforadvancecareplanning.Sec.1234.PartBspecialenrollmentperiodandwaiveroflimitedpremiumenrollmentpenaltyforTRICAREbeneficiaries.Providesfora12‐monthMedicarePartBspecialenrollmentperiodfordisabledTRICAREbeneficiariesandwaivesincreasedpremiumpenaltiesifbeneficiariessignupduringsuchperiod.Sec.1235.PartBPremiumAdjustedforCapitalGains.Allowscapitalgainsfromthesaleofaprimaryresidencetocountasalife‐changingeventforpurposesofusingamorerecenttaxyearfordeterminationofthePartBincomerelatedpremium.Sec.1236.Demonstrationprogramonuseofpatientdecisionaids.Createsademonstrationprogramthatusesdecisionaidsandothertechnologiestohelppatientsandconsumersimprovetheirunderstandingoftherisksandbenefitsoftheirtreatmentoptionsandmakeinformeddecisionsabouttheirmedicalcare.

TITLEIII—PROMOTINGPRIMARYCARE,MENTALHEALTHSERVICES,ANDCOORDINATEDCARESec.1301.AccountableCareOrganizationpilotprogram.Createsanalternativepaymentmodelwithinfee‐for‐serviceMedicaretorewardphysician‐ledorganizationsthattakeresponsibilityforthecostsandqualityofcarereceivedbytheirpatientpanelovertime.AccountableCareOrganizations(ACOs)canincludegroupsofphysiciansorganizedaroundacommondeliverysystem(includingahospital),anindependentpracticeassociation,agrouppractice,orothercommonpracticeorganizations.ACOscanincludenursepractitionersandphysicianassistantsandotherprovidersasdesignatedbytheACO.ACOsthatreducethecostsoftheirpatientsrelativetoaspendingbenchmarkarerewardedwithashareoftheprogrammaticsavings,conditionalonmeetingqualitytargetsaswell.CMSmayallowACOstocontinue

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operatingsolongastheyarereducingcostswhilemaintainingqualityorimprovingqualitywhilemaintainingcosts.Sec.1302.Medicalhomepilotprogram.AnexpansionandreorientationofthemedicalhomedemoinMedicare.Establishesamedicalhomepilotprogramtoassessthefeasibilityofreimbursingforqualifiedpatient‐centeredmedicalhomes.Therearetwomodelsintheprovision:1)theindependentpatient‐centeredmedicalhome,structuredaroundaprovider,istargetedatthetophalfofhigh‐needMedicarebeneficiarieswithmultiplechronicdiseases,and2)thecommunitybasedmedicalhome,whichmayincludeanyeligiblebeneficiary,istargetedatabroaderpopulationofMedicarebeneficiariesandallowsforState‐basedornon‐profitentitiestoprovidecare‐managementsupervisedbyabeneficiarydesignatedprimarycareprovider.Providesapproximately$1.8billionforthepilotprograms.TheSecretaryisauthorizedtoexpandtheprogramonlyifqualitymeasureshavebeenmetandbudgetneutralityisdemonstrated.Sec.1303.Paymentincentiveforselectedprimarycareservices.IncreasestheMedicarepaymentrateby5%forprimarycareservicesofphysiciansspecializinginprimarycare.Physiciansspecializinginprimarycarearedefinedbothbyspecialty(e.g.,familypractitioners,internists,andothers)andbyshareofapracticeinprimarycare(atleast50%ofallowedchargesareforprimarycareservices).Eligiblepractitionerspracticinginhealthprofessionsshortageareasreceiveanadditional5%.Sec.1304.Increasedreimbursementrateforcertifiednurse‐midwives.Increasesthepaymentratefornursemidwivesforcoveredservicesfrom65%oftheratethatwouldbepaidwereaphysicianperformingaservicetothefullrate.Sec.1305.Coverageandwaiverofcost‐sharingforpreventiveservices.WaivesallMedicarecostsharing(bothco‐insuranceanddeductibles)forpreventiveservices.Sec.1306.Waiverofdeductibleforcolorectalcancerscreeningtestsregardlessofcoding,subsequentdiagnosis,orancillarytissueremoval.Clarifiesthatthedeductibleiswaivedforascreeningcolonoscopyevenifadiagnosisisestablishedasaresultofatestoriftissueisremovedduringtheprocedure.Sec.1307.ExcludingclinicalsocialworkerservicesfromcoverageundertheMedicareskillednursingfacilityprospectivepaymentsystemandconsolidatedpayment.Removesclinicalsocialworkerservicesfromcoverageundertheskillednursingfacilityprospectivepaymentsystem,whichallowsclinicalsocialworkerstobillseparatelyfortheirservicesintheskillednursingfacilitysetting.Sec.1308.Coverageofmarriageandfamilytherapistservicesandmentalhealthcounselorservices.Addsstate‐licensedorcertifiedmarriageandfamilytherapistsandmentalhealthcounselorsasMedicareprovidersandpaysthematthesamerateassocialworkers.Sec.1309.Extensionofphysicianfeeschedulementalhealthadd‐on.Increasesthepaymentrateforpsychiatricservicesby5%fortwoyears,throughtheendof2011.Sec.1310.Expandingaccesstovaccines.TransferscoveragefromMedicarePartDtoMedicarePartBforallMedicare‐coveredvaccines.Vaccinesbutforinfluenzawillbepaidforaccordingtotheaveragesalespricemethodology.Sec.1311.ExpansionofMedicare‐CoveredPreventiveServicesatFederallyQualifiedHealthCenters.ExpandsMedicarereimbursementsforpreventiveservicesfurnishedbyfederallyqualifiedhealthcenters.

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Sec.1312.IndependenceatHomeDemonstrationProgram.CreatesanewdemonstrationprogramforchronicallyillMedicarebeneficiariestotestapaymentincentiveandservicedeliverysystemthatutilizesphysicianandnursepractitionerdirectedhome‐basedprimarycareteamsaimedatreducingexpendituresandimprovinghealthoutcomes.Sec.1313.RecognitionofcertifieddiabetesprovidersforpurposesofMedicarediabetesoutpatientself‐managementtrainingservices.AllowscertifieddiabeteseducatorstoreceivepaymentfromMedicaredirectlyfortheprovisionofoutpatientself‐managementtrainingservices.

TITLEIV—QUALITYSUBTITLEA—COMPARATIVEEFFECTIVENESSRESEARCHSec.1401.ComparativeEffectivenessResearch(CER).CreatesanewCenterattheAgencyforHealthcareResearchandQuality,supportedbyacombinationofpublicandprivatefundingthatwillconduct,supportandsynthesizeCER.EstablishesanindependentstakeholdercommissionwhichrecommendstotheCenterresearchpriorities,studymethods,andwaystodisseminateresearch.ThecommissionwouldhaveitsownsourceoffundingandalsoberesponsibleforevaluatingtheprocessesofthecenterandauthorizedtomakereportsdirectlytoCongress.AmajorityoftheCommissionmemberswouldberequiredtobephysicians,otherhealthcarepractitioners,consumersorpatients.Containsprotectionstoensurethatsubpopulationsareappropriatelyaccountedforinresearchstudydesignanddissemination;protectionstopreventtheCenterandCommissionfrommandatingpayment,coverageorreimbursementpolicies;protectionstoensurethatresearchfindingsarenotconstruedtomandatecoverage,reimbursementorotherpoliciestoanypublicorprivatepayer,andclarifythatfederalofficersandemployeeswillnotinterfereinthepracticeofmedicine.SUBTITLEB‐‐NURSINGHOMETRANSPARENCYPART1‐ImprovingTransparencyofInformationonSkilledNursingFacilities,NursingFacilities,andOtherLong‐TermCareFacilitiesSec.1411.Requireddisclosureofownershipandadditionaldisclosablepartiesinformation.Requiresskillednursingfacilities(SNFs)andnursingfacilities(NFs)todiscloseinformationonownershipandfacilityorganizationalstructureandrequirestheSecretaryofHHStodevelopastandardizedformatforsuchinformationwithintwoyearsofdateofenactment.Sec.1412.AccountabilityRequirements.RequiresSNFsandNFstooperatecomplianceandethicsprogramsonorafterthedatethatis36monthsafterenactment.DirectstheSecretarytodevelopaqualityassuranceandimprovementprogramforSNFsandNFsnolaterthanDecember31,2011.Sec.1413.NursinghomecompareMedicarewebsite.DirectstheSecretarytoincludeadditionalinformationontheNursingHomeComparewebsite,includestaffingdatabasedoninformationcollectedundersection1416andsummaryinformationoncomplaintsfiledforSNFsandNFs.Sec.1414.Reportingofexpenditures.RequiresSNFstoseparatelyreportexpendituresfordirectcareservices,indirectcareservices,capitalassets,andadministrativecostsoncostreportsforcostreportingperiods.Effectiveonoraftertwoyearsafterdateofenactment.

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Sec.1415.Standardizedcomplaintform.DirectstheSecretarytocreateastandardizedcomplaintformandrequiresStatestoestablishcomplaintresolutionprocesses.Provideswhistleblowerprotectionforemployeeswhocomplainingoodfaithaboutthequalityofcareorservicesatafacility.Sec.1416.Ensuringstaffingaccountability.RequirestheSecretarytodevelopaprogramforfacilitiestoreportstaffinginformationinauniformformatbasedonpayrolldata,includinginformationonagencyorcontractstaff.Effectivetwoyearsafterdateofenactment.Sec.1417.NationwideprogramfornationalandStatebackgroundchecksondirectpatientaccessemployeesoflong‐termcarefacilitiesandproviders.Establishesanationalprogramforlongtermcarefacilitiesandproviderstoconductscreeningandcriminalandotherbackgroundchecksonprospectivedirectaccesspatientemployees.PART2–TargetingEnforcementSec.1421.Civilmonetarypenalties.AuthorizestheSecretarytoimposecivilmonetarypenaltiesforadeficiencythatresultsinthedirectproximatecauseofdeathofaresident.ProvidesadditionalauthoritytotheSecretarytoraiseoradjustCMPsundercertaincircumstances.Sec.1422.Nationalindependentmonitorpilotprogram.DirectstheSecretarytoestablish,inconsultationwiththeHHSInspectorGeneral,apilotprogramtodevelop,testandimplementuseofanindependentmonitortooverseeinterstateandlargeintrastatechainsofSNFsandNFs.Sec.1423.Notificationoffacilityclosure.Requirestheadministratorofafacilitythatispreparingtoclosetoprovidewrittennotificationtoresidentsandotherpartiesandtoprepareaplanforclosingthatensuresafetransferofresidentstonewfacilities.PART3–ImprovingStaffTrainingSec.1431.Dementiaandabusepreventiontraining.RequiresSNFsandNFstoconductdementiamanagementandabusepreventiontrainingpriortoemploymentand,iftheSecretarydeterminesappropriate,aspartofongoingtraining.Sec.1432.Studyandreportontrainingrequiredforcertifiednurseaidesandsupervisorystaff.RequirestheSecretarytostudythecontentoftrainingrequirementsforcertifiednurseaidsandsupervisorystaffofSNFsandNFsandtosubmitareportwithrecommendationsoncontentandlengthoftrainingtoCongresswithintwoyearsofdateofenactment.Sec.1433.Qualificationofadirectoroffoodservicesofaskillednursingfacilityoranursingfacility.Requiresthatfull‐timedirectorsoffoodservicesshallbeaCertifiedDietaryManager,DieteticTechnician,orhaveequivalentmilitary,academic,orotherqualificationsasspecifiedbytheSecretary.SUBTITLEC—QUALITYMEASUREMENTSSec.1441.Establishmentofnationalprioritiesforqualityimprovement.DirectstheSecretarytoestablishnationalprioritiesforperformanceimprovement,incorporatingrecommendationsfromoutsideentities.Theseprioritiesshouldreflectareasthatcontributetoalargeburdenofdisease,havehighpotentialtodecreasemorbidityandmortalityandimproveperformance,addresshealthdisparities,andhavethepotentialtoproducethemostrapidchangebasedoncurrentevidence.

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Sec.1442.Developmentofnewqualitymeasures;GAOevaluationofdatacollectionprocessforqualitymeasurement.Basedonthenationalprioritiesforperformanceimprovementestablishedinthispart,theSecretaryshalldevelop,testandupdatenewpatient‐centeredandpopulation‐basedqualitymeasuresfortheassessmentofhealthcareservices.Provides$25millionforthissection.InstructsGAOtoperiodicallyevaluatetheprogramtodeterminetheeffectivenessofthequalitymeasuresandtheextenttowhichthesemeasurescanresultinqualityimprovementandcostsavings,andreporttoCongress.Sec.1443.Multi‐stakeholderpre‐rulemakinginputintoselectionofqualitymeasures.Providesforstakeholderinputintotheuseofqualitymeasuresforpurposesofpayment.Eachyear,theSecretaryshallmakepublicalistofmeasuresbeingconsideredforusageforpaymentsystems.Underatransparentprocess,aconsensus‐basedentityshallconveneamulti‐stakeholdergrouptoproviderecommendationsfortheusageofmeasuresinatimelyfashion,andtheSecretaryshallconsidertheserecommendations.Sec.1444.Applicationofqualitymeasures.EnsuresthatqualitymeasuresselectedbytheSecretaryareendorsedbyaconsensus‐basedentitywithacontractwiththeSecretaryundersection1890,exceptincertaincircumstances,e.g.,themeasurehasnotbeenevaluatedandnocomparableendorsedmeasureexists.IftheSecretarychoosestouseameasurethattheentityconsidersbutdoesnotendorse,theSecretaryshallincludetherationaleforcontinueduseinrulemaking.Appliesthisstandardtoinpatienthospitals,physicianservices,andrenaldialysisservices.Sec.1445.Consensus‐basedentityfunding.Fortheconsensusbasedentitywithacontractundersection1890,thecontractamountisincreasedto$12millionfortheyears2010‐2012.SUBTITLED—PHYSICIANPAYMENTSSUNSHINEPROVISIONSec.1451.Reportsonfinancialrelationshipsbetweenmanufacturersanddistributorsofcovereddrugs,devices,biologicals,ormedicalsuppliesunderMedicare,Medicaid,orCHIPandphysiciansandotherhealthcareentitiesandbetweenphysiciansandotherhealthcareentities.RequiresmanufacturersordistributorstoelectronicallyreporttotheHHSOIGanypaymentsorothertransfersofvalueabovea$5deminimismadetoa“coveredrecipient”andrequireshospitals,manufacturers,distributors,andgrouppurchasingorganizationstoreportanyownershipsharebyaphysician.Failuretoreportissubjecttocivilmonetarypenaltiesfrom$1000to$10,000(max$150,000peryear)perpayment,transferofvalue,orinvestmentinterestnotdisclosed;penaltiesforknowingfailuretoreportrangefrom$10,000to$100,000perpayment,nottoexceed$1,000,000inoneyearor.1%ofrevenuesforthatyear.SUBTITLEE–PUBLICREPORTINGONHEALTHCARE‐ASSOCIATEDINFECTIONSSec.1461.Requirementforpublicreportingbyhospitalsandambulatorysurgicalcentersonhealthcare‐associatedinfections.Requireshospitalsandambulatorysurgicalcenterstoreportpublichealthinformationonhealthcare‐associatedinfectionstotheCentersforDiseaseControlandPrevention.

TITLEV—MEDICAREGRADUATEMEDICALEDUCATIONSec.1501.Distributionofunusedresidencypositions.DirectstheSecretarytoredistributeresidencypositionsthathavebeenunfilledfortheprior3costreportsanddirectthoseslotsfortrainingofprimarycarephysicians.Specialpreferencewillbegiventoprogramsthatsawareductionintheirslotsunderthissection,haveformalarrangementstotrainresidentsinambulatorysettingsorshortageareas,operatethree‐yearprimarycare

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residencyprograms,currentlyoperateresidencyprogramsovertheircap,orarelocatedinstateswithalowphysicianresidenttogeneralpopulationratio.Sec.1502.Increasingtraininginnonprovidersettings.Modifiesrulesgoverningwhenhospitalscanreceiveindirectmedicaleducation(IME)anddirectgraduatemedicaleducation(DGME)fundingforresidentswhotraininanon‐providersettingsothatanytimespentbytheresidentinanon‐providersettingshallbecountedtowardDGMEandIMEifthehospitalincursthecostsofthestipendsandfringebenefits.DirectstheHHSOfficeoftheInspectorGeneraltostudytheleveloftraininginnon‐providersettings.Establishesademonstrationprojectwherebyapprovedteachinghealthcenters(whichmaybenon‐providersettingssuchasruralhealthclinicsandfederallyqualifiedhealthcenters)maybecomeaprimarycaretrainingprogramandreceiveDGMEandtheDGMEofitscontractinghospitalsforsuchresidents.Sec.1503.Rulesforcountingresidenttimefordidacticandscholarlyactivitiesandotheractivities.ModifiescurrentlawtoallowhospitalstocountresidenttimespentindidacticconferencestowardIMEcostsintheprovider(i.e.,hospital)settingandtowardDGMEinthenon‐provider(i.e.,non‐hospital)setting.Sec.1504.Preservationofresidentcappositionsfromclosedhospitals.DirectstheSecretarytoredistributemedicalresidencyslotsfromahospitalthatclosesonorafterthedatethatis2yearsbeforetheenactmentofthisclausetootherhospitalsinthesameState,takingintoaccountrecommendationsbytheseniorhealthofficialintheState.Suchrecommendationsshallbesubmittednotlaterthan180daysafterthedateofthehospitalclosureinvolved,orinthecaseofahospitalthatclosedwithintwoyearsbeforedateofenactment,notlaterthan180daysafterenactment.Sec.1505.Improvingaccountabilityforapprovedmedicalresidencytraining.Setsgoalsforapprovedmedicalresidencytrainingprogramsbysettingbroadgoalsthatinclude:(1)trainingtoworkinnon‐acutetraditionalsettings;(2)coordinationofcarewithinandacrosssettings;(3)understandingcostandvalueofdiagnosticandtreatmentoptions;(4)workinginmulti‐disciplinaryteams;(5)participatinginqualityimprovementprojects;and(6)demonstratingmeaningfuluseofelectronichealthrecordsinimprovingqualityofpatientcare.DirectstheGAOtoevaluatetheextenttowhichresidencytrainingprogramsaremeetingthegoalscited.

TITLEVI—PROGRAMINTEGRITY

SUBTITLEA—INCREASEDFUNDINGTOFIGHTWASTE,FRAUD,ANDABUSESec.1601.Increasedfundingandflexibilitytofightfraudandabuse.Providesanadditional$100millionannuallyinfundingfortheHealthCareFraudandAbuseControlFund.AllowsexpandeduseoffundsbytheCMSMedicareIntegrityProgram.SUBTITLEB—ENHANCEDPENALTIESFORFRAUDANDABUSESec.1611.Enhancedpenaltiesforfalsestatementsonproviderorsupplierenrollmentapplications.Establishescivilmonetarypenaltiesof$50,000perviolationforproviders,suppliers,MedicareAdvantage,orPartDplansthatknowinglymakefalsestatementsormisrepresentationofmaterialfactonenrollmentapplicationsforanyfederalhealthcareprogram.Sec.1612.Enhancedpenaltiesforsubmissionoffalsestatementsmaterialtoafalseclaim.Establishescivilmonetarypenaltiesof$50,000perviolationfortheknowingsubmissionoffalsestatementsormisrepresentationofmaterialfactininformationsubmittedtosupportaclaimforpayment.

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Sec.1613.Enhancedpenaltiesfordelayinginspections.Establishescivilmonetarypenaltiesof$15,000perdayfordelayingorrefusingtogranttimelyaccesstotheHHSOIGforaudits,investigations,orevaluations.Sec.1614.Enhancedhospiceprogramsafeguards.RequirestheSecretaryofHHStotakeimmediateactiontoremedyanyviolationinahospicefacilitythatjeopardizesthehealthandsafetyofpatients.Allowsintermediatesanctionssuchascivilmonetarypenalties,suspensionorpartialpayments,appointmentoftemporarymanagementtooverseeoperation,plansofcorrection,orin‐servicestafftrainingforviolationsthatdonotendangerpatients.Sec.1615.Enhancedpenaltiesforindividualsexcludedfromprogramparticipation.Establishescivilmonetarypenaltiesof$50,000perviolationforanypersonwhoordersorprescribesanitemorservicewhileexcludedfromafederalhealthcareprogramifthatpersonknowsorshouldknowthattheprogramfromwhichtheyareexcludedwillbebilledfortheitemorservice.Sec.1616.EnhancedpenaltiesforprovisionoffalseinformationbyMedicareAdvantageandPartDplans.EstablishescivilmonetarypenaltiesformisrepresentationsorfalseinformationprovidedbyanMAorPartDplanofuptothreetimesthepaymentmadetotheplanorplansponsorbasedonthemisrepresentationorfalseinformation.Sec.1617.EnhancedpenaltiesforMedicareAdvantageandPartDmarketingviolations.Establishesnewcriteriafordeterminingmarketingviolations,andprovidesgreaterdiscretiontotheSecretaryortheCMSAdministratortoimposepenaltiesonMedicareAdvantageandPartDplansthatviolatemarketingrequirements.Sec.1618.Enhancedpenaltiesforobstructionofprogramaudits.Allowsforpermissiveexclusionofindividualsorentitiesfoundtohaveobstructedaninvestigationintoorauditoffraud.Sec.1619.ExclusionofcertainindividualsandentitiesfromparticipationinMedicareandStateHealthCarePrograms.ClarifiesdefinitionofexclusionofMedicareandMedicaidentitiesundersection1128tomeanexclusionfromallfederalhealthcareprograms.Sec.1620.OIGauthoritytoexcludefromFederalhealthcareprogramsofficersandownersofentitiesconvictedoffraud.ClarifiesOIGauthoritytoexcludefromFederalhealthcareprogramsindividualswhokneworshouldhaveknownofviolationsatthetimetheseviolationsoccurred.Sec.1621.Self‐referralvoluntarydisclosureprotocol.RequiresHHSSecretarytoestablishaprotocoltoallowhealthcareprovidersandsupplierstovoluntarilydiscloseanactualorpotentialviolationoftheSocialSecurityAct’sprovisionsagainstself‐referrals.SUBTITLEC–ENHANCEDPROGRAMANDPROVIDERPROTECTIONSSec.1631.EnhancedCMSprogramprotectionauthority.AllowstheSecretarytodesignateprogramareasof“significantrisk”inwhichenhancedoversightcanbeappliedtoprohibitwaste,fraud,andabuse.CallsfortheSecretarytoestablishscreeningproceduresfornewproviders,whichmayinclude:licensingboardchecks,screeninglistsofthoseexcludedfromotherfederalorstatehealthprograms,backgroundchecks,unannouncedpre‐enrollmentorothersitevisits.Allowsforenhancedoversightperiods(toincludesitevisits,prepaymentreview,enhancedclaimsreview)fornewprovidersorsuppliersintheseareasofhighrisk,andallowsforamoratoriumonenrollmentofnewsuppliersorserviceprovidersinareasofhighriskiftheSecretarydeterminesthattherewouldbenoadverseimpactonbeneficiaries.

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Sec.1632.EnhancedMedicare,Medicaid,andCHIPprogramdisclosurerequirementsrelatingtopreviousaffiliations.Requiresnewsuppliersorprovidersofservicestodiscloseaffiliationswithinthepast10yearswithanyproviderorsupplierthathasuncollecteddebtorhasbeensuspendedfromMedicare,Medicaid,orCHIP.Sec.1633.Requiredinclusionofpaymentmodifierforcertainevaluationandmanagementservices.Establishesa“paymentmodifier”whenserviceresultsinorderingadditionalservices,prescriptiondrugs,ordurablemedicalequipment,inordertoassisteffortstoidentifyfraud.Sec.1634.RequiredevaluationsandreportsunderMedicareIntegrityProgram.RequiresMIPcontractorstoconductperiodicevaluationsandreportontheeffectivenessoftheiractivities.Sec.1635.Requireprovidersandsupplierstoadoptprogramstoreducewaste,fraud,andabuse.Requiresallprovidersandsuppliers(otherthanphysicians)toadoptcomplianceprogramsandauthorizestheSecretarytodisenrollasupplierorimposecivilmonetarypenaltiesorotherintermediatesanctionsforfailuretoestablishsuchaprogram.Sec.1636.MaximumperiodforsubmissionofMedicareclaimsreducedtonotmorethan12months.ReducestheperiodforMedicareclaimssubmissioninordertoreduce“gaming”ofpaymentsystems.Sec.1637.PhysicianswhoorderdurablemedicalequipmentorhomehealthservicesrequiredtobeMedicareenrolledphysiciansoreligibleprofessionals.RequiresthatphysiciansorderingdurablemedicalequipmentorhomehealthservicesbillabletoMedicaremustbeMedicare‐enrolledphysiciansoreligibleprofessionals.AllowstheSecretarydiscretiontoexpandthisrequirementtootherareasifsuchanextensionwouldhelpreducewaste,fraud,andabuse.Sec.1638.Requirephysicianstoprovidedocumentationonreferralstoprogramsathighriskofwasteandabuse.RequiresphysicianorsuppliertomaintainandprovideuponrequestoftheSecretary,documentationrelatedtotheorderingofdurablemedicalequipment,homehealthservices,orotherareasofhighrisk.Sec.1639.Requiredface‐to‐faceencounterwithpatientbeforephysiciansmaycertifyeligibilityforhomehealthservicesordurablemedicalequipmentunderMedicare.Requiresaface‐to‐face(ortelemedicine)encounterwithapatientbeforeaphysicianmaycertifyhomehealthservicesordurablemedicalequipment.AllowstheSecretarydiscretiontoexpandthisrequirementtootherareasifsuchanextensionwouldhelpreducewaste,fraud,andabuse.Sec.1640.Extensionoftestimonialsubpoenaauthoritytoprogramexclusioninvestigations.ClarifiesthattheSecretary(ordesignee)maysubpoenadocumentsortestimonyforpurposesofaprogramexclusioninvestigation.Sec.1641.RequiredrepaymentsofMedicareandMedicaidoverpayments.Clarifiesthatwhenaproviderorsupplier,MA,orPartDplan,(butnotabeneficiary)becomesawareofaMedicareorMedicaidoverpayment,itmustbereportedandreturnedwithin60days.Sec.1642.ExpandedapplicationofhardshipwaiversforOIGexclusionstobeneficiariesofanyFederalhealthcareprogram.Clarifiesthatthehardshipwaiverprovisionappliesto“beneficiaries,”asdefinedelsewhereinthetitle.

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Sec.1643.Accesstocertaininformationonrenaldialysisfacilities.ProvidesauthorityfortheOIGtoaccessownershiporcompensationagreementsbetweenrenaldialysisfacilitiesandphysicians.Section1644.Billingagents,clearinghouses,orotheralternatepayeesrequiredtoregisterunderMedicareandMedicaid.Requiresbillingagents,clearinghouses,orotheralternatepayeesrequiredtoberegisteredunderMedicareandMedicaidinaformandmannertobespecifiedbytheSecretary.Section1645.ConformingcivilmonetarypenaltiestoFalseClaimsActamendments.ConformskeydefinitionsandcriteriaregardingcivilmonetarypenaltyauthorityundertheSocialSecurityActtomatchthosecontainedinthe2009FalseClaimsActamendments.Sec.1646.RequireproviderandsupplierpaymentsunderMedicaretobemadethroughdirectdepositorelectronicfundstransfer(EFT)atinsureddepositoryinstitutions.RequiresthatasofJuly1,2012,allMedicarepaymentstoprovidersofservicesandsuppliersbemadethroughdirectdepositorelectronicfundstransfer.Sec.1647.InspectorGeneralfortheHealthChoicesAdministration.EstablishedtheOfficeoftheInspectorGeneralfortheHealthChoicesAdministration,authorizingtheIGtoconduct,supervise,andcoordinateaudits,evaluations,andinvestigationsoftheExchangeandotherprogramsandoperationsoftheHealthChoicesAdministration.SUBTITLED–ACCESSTOINFORMATIONNEEDEDTOPREVENTFRAUD,WASTEANDABUSESec.1651.Accesstoinformationnecessarytoidentifyfraud,waste,andabuse.ClarifiesthattheDepartmentofJustice,workingwithOIGinconsultationwithCMS,hasaccesstoMedicareandMedicaidclaimsandpaymentdatabases,inamannerthatcomplieswithprivacyandsecuritylaws,includingHIPAA.Sec.1652.EliminationofduplicationbetweentheHealthcareIntegrityandProtectionDataBankandtheNationalPractitionerDataBank.DirectstheSecretarytoreduceduplicationbetweenthetwodatabases.AllowsaccesstotheNationalPractitionerDatabankbytheVA.Sec.1653.CompliancewithHIPAAprivacyandsecuritystandards.ClarifiesthatHIPAAappliestothesubtitleandallamendments.

TITLEVII—MEDICAIDANDCHIPSUBTITLEA—MEDICAIDANDHEALTHREFORMSec.1701.Eligibilityforindividualswithincomebelow150percentoftheFederalpovertylevel.(a)RequiresStateMedicaidprogramstocovernon‐disabled,childlessadultsunderage65noteligibleforMedicarewithincomesatorbelow150%ofFPL($16,200peryearforanindividual).Thefederalgovernmentwouldpay100%ofthecostsofMedicaidcoverageforthispopulationin2013and2014,then91%in2015andbeyond.(b)RequiresStateMedicaidprogramstocoverchildren,parents,andindividualswithdisabilitiesunderage65withincomeatorbelow150%ofFPL($33,100peryearforafamilyof4).ForindividualsinthesecategorieswithincomesbetweenthelevelsineffectinthestateasofJune16,2009and150%ofFPL,thefederalgovernmentwouldpay100%ofthecostsofMedicaidcoveragein2013and2014and91%in2015andbeyond.(c)RequiresStateMedicaidprogramstocovernewbornsuptothefirst60daysoflifewhodonototherwisehavecoverageuponbirth.Thefederalgovernmentwouldpay100%ofthecostsofMedicaidcoverageforthesenewborns.

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Sec.1702.RequirementsandspecialrulesforcertainMedicaideligibleindividuals.RequiresStateMedicaidprogramstoenterintoamemorandumofunderstandingwiththeHealthChoicesCommissionertocoordinateenrollmentoflow‐incomeindividuals,includingnewborns,intotheExchangeorMedicaidasappropriate.Sec.1703.CHIPandMedicaidmaintenanceofeligibility.(a)ProhibitsStatesfromadoptingeligibilitystandards,methodologies,orproceduresintheirCHIPprogramsthataremorerestrictivethanthoseineffectasofJune16,2009.MaintenanceofeligibilityendsuponexpirationofCHIPprogramonDecember31,2013.(b)ProhibitsStatesfromadoptingeligibilitystandards,methodologies,orproceduresintheirMedicaidprogramsmorerestrictivethanthoseineffectasofJune16,2009.Sec.1704.ReductioninMedicaidDSH.RequirestheSecretaryofHHStoreporttoCongressbyJanuary1,2016onthecontinuingroleofMedicaidDSHashealthreformisimplemented.DirectstheSecretarytoreducefederalMedicaidDSHmatchingpaymentstoStatesbyatotalof$10billion($1.5billioninFY2017,$2.5billioninFY2018,and$6.0billioninFY2019)usingamethodologythatfocusesonthepercentageofuninsuredandtheamountofuncompensatedcareprovidedbyhospitalsineachState.Sec.1705.Expandedoutstationing.RequiresStateMedicaidprogramstoallowallindividualstoapplyforcoverageinMedicaidatDSHhospitals,FQHCs,andotherlocationsthanwelfareoffices.ExtendsrequirementtoapplicationsforcoverageintheExchangebeginningin2013.SUBTITLEB—PREVENTIONSec.1711.Requiredcoverageofpreventiveservices.RequiresStateMedicaidprogramstocover,withoutcost‐sharing,preventiveservicesthatarerecommendedbytheU.S.PreventiveServicesTaskForceandappropriateforMedicaidbeneficiaries.Sec.1712.Tobaccocessation.ProhibitsStateMedicaidprogramsfromexcludingtobaccocessationproductsfromcoverage.Sec.1713.Optionalcoverageofnursehomevisitationservices.AllowsStateMedicaidprogramstocoverhomevisitsbytrainednursestofamilieswithafirst‐timepregnantwomanorchildunder2eligibleforMedicaid.Sec.1714.Stateeligibilityoptionforfamilyplanningservices.AllowsStateMedicaidprogramstocoverlow‐incomewomenwhoarenotpregnantforfamilyplanningservicesandsupplieswithoutobtainingawaiver.AllowsStateMedicaidprogramstocoversuchservicesforsuchwomenduringapresumptiveeligibilityperiod.SUBTITLEC—ACCESSSec.1721.Paymentstoprimarycarepractitioners.RequiresthatStateMedicaidprogramsreimburseforprimarycareservicesfurnishedbyphysiciansandotherpractitionersatnolessthan80%ofMedicareratesin2010,90%in2011,and100%in2012andafter.MaintainstheMedicarepaymentdifferentialsbetweenphysiciansandotherpractitioners.Thefederalgovernmentwouldpay100%oftheincrementalcostsattributabletothisrequirementthrough2014,then90%in2015andbeyond.Sec.1722.Medicalhomepilotprogram.Establishesa5‐yearpilotprogramtotestthemedicalhomeconceptwithMedicaidbeneficiariesincludingmedicallyfragilechildrenandhigh‐riskpregnantwomen.Thefederal

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governmentwouldmatchcostsofcommunitycareworkersat90%forthefirsttwoyearsand75%forthenext3years,uptoatotalof$1.235billion.Sec.1723.Translationorinterpretationservices.Providesa75%federalmatchingrateforthecostsoftranslationorinterpretationservicesforMedicaid‐eligibleadultsforwhomEnglishisnottheprimarylanguage.Sec.1724.Optionalcoverageforfreestandingbirthcenterservices.AllowsStateMedicaidprogramstocoverservicesprovidedbybirthcentersthatarenothospitals.Sec.1725.Inclusionofpublichealthclinicsunderthevaccinesforchildrenprogram.AllowschildrenwhodonothaveinsurancecoverageforimmunizationstoreceivevaccinesthroughtheVFCprogramatapublichealthclinic.Sec.1726.Requiringcoverageofservicesofpodiatrists.RequiresStateMedicaidprogramstocoverphysician’sserviceswhenfurnishedbyapodiatrist.Sec.1726A.Requiringcoverageofservicesofoptometrists.RequiresStateMedicaidprogramstocoverservicesfurnishedbyoptometriststotheextentpermittedunderstatelaw.Sec.1727.Therapeuticfostercare.ClarifiesthatfederalMedicaidlawdoesnotprohibitStateMedicaidprogramsfromcoveringtherapeuticfostercareforchildreninout‐of‐homeplacements.Sec.1728.Assuringadequatepaymentlevelsforservices.RequiresStateMedicaidprogramstosubmitannuallytotheSecretarypaymentratestobeusedtoreimburseprovidersforfurnishingcoveredservicesanddirectstheSecretarytoreviewsuchratesforsufficiency.Sec.1729.PreservingMedicaidcoverageforyouthsuponreleasefrompublicinstitutions.RequiresStateMedicaidprogramstosuspend,notterminate,eligibilityforbeneficiariesunderage19whoareincarceratedinapublicinstitutionduringtheperiodofincarceration.Sec.1730.QualitymeasuresformaternityandadulthealthservicesunderMedicaidandCHIP.Appropriates$40millionfor2010‐2015fortheSecretarytodevelopasetofmeasuresforthequalityofmaternitycareandotheradultcareprovidedunderMedicaidandCHIP,andtodevelopastandardizedformatforreportingsuchqualitymeasuresforusebythestates.Sec.1730A.Accountablecareorganizationpilotprogram.DirectstheSecretarytoestablishaprogramtoallowStateMedicaidprogramstopilotoneormoreofthemodelsusedintheMedicareACOpilotprogramestablishedbysection1301ofthebill.Administrativecostswouldbematchedat90%inthefirsttwoyearsofapilotproject,75%inthelastthree.Sec.1730B.CoverageofSchool‐basedhealthclinics.RequiresthatStateMedicaidprogramsreimburseschool‐basedhealthclinicsreceivingfundsundertheprogramestablishedbysection2511onthesamebasisastheyreimbursefederally‐qualifiedhealthcenters(FQHCs).SUBTITLED–COVERAGESec.1731.OptionalMedicaidcoverageoflow‐incomeHIV‐infectedindividuals.AllowsStateMedicaidprogramstocoverindividualswithHIVwithincomesandresourcesbelowstateeligibilitylevelsforindividuals

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withdisabilities.Thecostsofcoverageofsuchindividualswouldbematchedatanenhancedrate.Effectiveonenactment.SunsetsonJanuary1,2013.Sec.1732.ExtendingTransitionalMedicaidAssistance(TMA).Extendsthe1‐yeartransitionalMedicaidcoverageforfamiliesleavingcashassistancetoworkfromDecember31,2010throughDecember31,2012.Sec.1733.Requirementof12‐monthcontinuouscoverageundercertainCHIPprograms.Requiresstand‐aloneCHIPprogramstoprovide12‐monthcontinuouseligibilityforallenrolleeswithincomesbelow200%FPL.EffectiveJanuary1,2010.Sec.1734.PreventingtheapplicationunderCHIPofcoveragewaitingperiodsforcertainchildren.ProhibitsStateCHIPprogramsfromimposingeligibilitywaitingperiodsonchildrenwhoare(1)underage2,(2)infamilieslosingprivatehealthinsuranceduetounemployment,or(3)infamiliesthatpaymorethan10percentofincomeforhealthinsurancecoverage.Sec.1735.Adultdayhealthcareservices.ProhibitstheSecretaryfromdenyingfederalMedicaidmatchingfundstocertainStatesforthecostofadultdayhealthcareservices.Sec.1736.MedicaidcoverageforcitizensofFreelyAssociatedStates.RequiresStateMedicaidprogramstocovercitizensofMicronesia,theMarshallIslands,orPalauwhoarelawfullyresidingintheState(underthecompactofFreeAssociation)andotherwiseeligibleforMedicaidthere.Sec.1737.ContinuingrequirementofMedicaidcoverageofnonemergencytransportationtomedicallynecessaryservices.RequiresStateMedicaidprogramstocontinuecoveringnonemergencytransportationtomedicallynecessaryservicesasspecifiedinregulationsineffectonJune1,2008.Sec.1738.StateoptiontodisregardcertainincomeinprovidingcontinuedMedicaidcoverageforcertainindividualswithextremelyhighprescriptioncosts.AllowsStateMedicaidprogramstocoverindividualswithfamilyincomesupto$150,000whohaveorphandrugcostsexceeding$200,000andhaveexhaustedtheirprivatehealthinsurancecoverageforprescriptiondrugs.Sec.1739.Provisionsrelatingtocommunitylivingassistanceservicesandsupports(CLASS).RequiresStatestocomplywithprimaryandsecondarypayorrulesestablishedbytheSecretarywithrespecttotheCLASSprogramundersection2581.AlsorequiresStatestodesignateorcreatefiscalagentsforpersonalcareattendantworkersservingCLASSprogrambeneficiaries.SUBTITLEE–FINANCINGSec.1741.Paymentstopharmacists.ExtendscurrentrulesforMedicaidpaymentstopharmacistsformultiplesourcedrugsthroughDecember31,2010.Thereafter,limitsMedicaidpaymentsforsuchdrugsto130%oftheweightedaveragemanufacturerprice(AMP).RedefinesAMPtoexcludecertainpriceconcessions,includingthoseprovidedtopharmacybenefitmanagers,notpassedthroughtoretailpharmacies.Sec.1742.Prescriptiondrugrebates.Increasestheminimummanufacturerrebateforbrand‐namedrugspurchasedbyStateMedicaidprogramsfrom15.1%ofaveragemanufacturerpriceto23.1%ofaveragemanufacturerprice,andappliestheadditionalMedicaidrebatetonewformulationsofbrand‐namedrugs.EffectiveJanuary1,2010.

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Sec.1743.ExtensionofprescriptiondrugdiscountstoenrolleesofMedicaidmanagedcareorganizations.RequiresmanufacturerstopayrebatestoStateMedicaidprogramsfordrugsdispensedtoprogrambeneficiariesenrolledinMedicaidmanagedcareorganizations.EffectiveJanuary1,2010.Sec.1744.Paymentsforgraduatemedicaleducation.ClarifiesthatStateMedicaidprogramsmayreceivefederalmatchingpaymentsforthecostsofgraduatemedicaleducation.DirectstheSecretarytospecifyprogramgoalsfortheuseofsuchfundsbasedonworkforceneeds.Effectiveuponenactment.Sec.1745.TemporaryNursingFacilitySupplementalPaymentProgram.Establishesatemporary4‐yearprogramofsupplementalpaymentsdirectlyfromtheCentersforMedicare&MedicaidServicestonursingfacilitieswithhighpercentagesofMedicareandMedicaidpatientdaystoassisttheminmeetingthecostsofcaretoMedicaidbeneficiaries.Atotalof$6billionwouldbeavailableforsuchpaymentsovertheperiod2010through2013.TheMedicaidandCHIPPaymentAdvisoryCommittee(MACPAC)wouldberequiredtostudytheadequacyofpaymentratestonursingfacilitiesineachStateandreporttoCongressbyDecember31,2011.Sec.1746.ReportonMedicaidpayments.RequiresStateMedicaidprogramstosubmitannuallytotheCentersforMedicare&MedicaidServicesinformationonthedeterminationofratesofpaymenttoprovidersforcoveredservices.Sec.1747.ReviewsofMedicaid.DirectsGAOtostudyandreporttoCongressbyFebruary15,2011,on(1)thefederalMedicaidmatchingrateformulaand(2)theuseoffederalMedicaidfundsonadministrativeexpendituresandtheprocessfordeterminingthoserates.Sec.1748.Extensionofdelayinmanagedcareorganizationprovidertaxelimination.ExtendstoOctober1,2010,thegraceperiodfortheuseofrevenuesfromtaxesimposedonMedicaidmanagedcareorganizationsasstateshareforMedicaidmatchingpurposes.Sec.1749.ExtensionofARRAincreaseinFMAP.ExtendsthecurrentAmericanRecoveryandReinvestmentActincreaseinfederalMedicaidpaymentstoStateswithhighunemploymentratesforanadditionalsixmonths.SUBTITLEF–WASTE,FRAUD,ANDABUSESec.1751.Health‐careacquiredconditions.Prohibitsfederalmatchingpaymentsforthecostofhealthcareacquiredconditionsthataredeterminedtobenon‐coveredservicesforMedicarepurposes.Sec.1752.EvaluationsandreportsrequiredunderMedicaidIntegrityProgram.RequiresMedicaidIntegrityProgramcontractorstosubmittotheSecretaryanannualreportonintegrityactivities.Sec.1753.Requireprovidersandsupplierstoadoptprogramstoreducewaste,fraud,andabuse.RequiresprovidersandsuppliersparticipatinginMedicaid(otherthanphysiciansandnursingfacilities)toestablishcomplianceprograms.Sec.1754.Overpayments.AllowsStateMedicaidprogramsupto1yeartoreturnthefederalshareofoverpaymentstoprovidersduetofraud.Sec.1755.ManagedCareOrganizations.LimitsspendingbyMedicaidmanagedcareorganizationsonadministration,marketing,anddistributionstoshareholderstonomorethan15%ofMedicaidpremiumrevenues.

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Sec.1756.TerminationofproviderparticipationunderMedicaidandCHIPifterminatedunderMedicareorotherStateplanorchildhealthplan.RequiresStateMedicaidandCHIPprogramstoterminatetheparticipationofentitiesorindividualsiftheentityorindividualisterminatedunderMedicare,anyotherstateMedicaidprogram,oranyotherCHIPprogram.Sec.1757.MedicaidandCHIPexclusionfromparticipationrelatingtocertainownership,control,andmanagementaffiliations.RequiresStateMedicaidandCHIPprogramstoexcludeindividualsorentitiesfromparticipationiftheindividualorentityowns,controls,ormanagesanentitythathasunpaidoverpaymentsorissuspendedorexcludedfromparticipation.Sec.1758.RequirementtoreportexpandedsetofdataelementsunderMMIStodetectfraudandabuse.RequiresStateMedicaidprogramstoincludeintheirMedicaidManagementInformationSystems(MMIS)reportstotheSecretarydataelementsnecessaryforthedetectionofwaste,fraud,andabuse.Sec.1759.Registrationofalternatepayees.Requiresagents,clearinghouses,orotheralternatepayeesthatsubmitclaimsonbehalfofahealthcareprovidertoregisterwiththeStateandtheSecretary.Deniespaymentforanyclaimssubmittedbyanunregisteredalternatepayee.Sec.1760.Denialofpaymentsforlitigation‐relatedmisconduct.Prohibitsfederalmatchingpaymentsforcostsinlitigationinwhichacourtimposessanctionsforlitigation‐relatedmisconduct.Sec.1761.MandatoryStateuseofnationalcorrectcodinginitiative.RequiresStateMedicaidprogramstousemethodologiesspecifiedbytheSecretarytocontrolincorrectcodingofclaimsthatleadtoimproperpayment.SUBTITLEG–PAYMENTSTOTHETERRITORIESSec.1771.PaymentstotheTerritories.Raisesthefederalmatchingrateforallterritoriestothehighestrateforanystateandincreasestheceilingsonfederalmatchingpaymentstoeachterritorybyspecifiedamountswithinanoverallincreasetotaling$10.350billionovertheperiod2011through2019.SUBTITLEH—MISCELLANEOUSSec.1781.Technicalcorrections.Makestechnicalcorrectionsrelatingtotheadministrationofthelow‐incomesubsidyprogramunderMedicaidPartD,CHIPRA,andsections1905and1115oftheSocialSecurityAct.Sec.1782.ExtensionofQIprogram.Eliminatesthefundinglimitationandextendsfortwoyears(throughDecember2012)thequalifiedindividualsprogramtoassistlow‐incomeMedicarebeneficiarieswithpayingMedicarepremiums.Sec.1783.Assuringtransparencyofinformation.RequiresStates,asaconditionofreceivingfederalMedicaidmatchingfunds,toestablishandmaintainlawstorequiredisclosureofinformationonhospitalchargesandqualityandtomakesuchinformationpublic.Sec.1784.MedicaidandCHIPPaymentandAccessCommission.Providesstart‐upfundsfortheMedicaidandCHIPPaymentandAccessCommissionanddirectstheCommissiontostudyStateMedicaidpaymentpoliciesvis‐à‐visnursingfacilitiesandpediatricsubspecialists.

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Sec.1785.OutreachandenrollmentofMedicaidandCHIPeligibleindividuals.DirectstheSecretarytoissueguidanceregardingoutreachandenrollmentforMedicaidandCHIPtargetedtovulnerablepopulationssuchashomelessyouthandindividualswithHIV/AIDS.Sec.1786.ProhibitionsonFederalMedicaidandCHIPpaymentforundocumentedaliens.ClarifiesthatthisbilldoesnotchangecurrentprohibitionsagainstfederalMedicaidandCHIPpaymentsonbehalfofindividualswhoarenotlawfullypresentintheU.S.Sec.1787.Demonstrationprojectforstabilizationofemergencymedicalconditionsbyinstitutionsformentaldiseases.Provides$75millionfora3‐yeardemonstrationprojecttotestthereimbursementofpsychiatrichospitalsforthestabilizationofindividualsbetween21and65withemergencymedicalconditions.Sec.1788.ApplicationofMedicaidImprovementFund.AppliesamountsintheMedicaidImprovementFundtooffsetthecostsofthisbillforfiscalyears2014through2018.Sec.1789.TreatmentofcertainMedicaidbrokers.ExemptsenrollmentbrokersfromcertainrequirementsoftheMedicaidstatuteiftheInspectorGeneralfindsthatthebrokerhasprocedurestoensuretheindependenceofitsenrollmentactivitiesfromconflictsofinterest.Sec.1790.RuleforchangesrequiringStatelegislation.ProvidesagraceperiodforStatesthatneedlegislativeactioninordertocomplywitharequirementofthebill.

TITLEVIII–REVENUE‐RELATEDPROVISIONSSec.1801.Disclosurestofacilitateidentificationofindividualslikelytobeineligibleforthelow‐incomeassistanceundertheMedicareprescriptiondrugprogramtoassistSocialSecurityAdministration’soutreachtoeligibleindividuals.AuthorizestheIRStodisclosetoSSAcertaintaxpayerreturninformationtoassistSSAinitsoutreachprogramtoidentifyindividualswhoareeligibleforMedicarePartDassistance.Sec.1802.ComparativeEffectivenessResearchTrustFund(CERTF);financingforTrustFund.EstablishesthetrustfundforthecomparativeeffectivenessresearchprogramwithdedicatedamountsgoingtoboththeCenterforComparativeEffectivenessResearchandtheComparativeEffectivenessResearchCommission.Alsoestablishesafeethatisassessedonprivateinsuranceonthebasisofthenumberofinsuredindividualstofundtheresearchprogram,providesfortransfersfromtheMedicaretrustfundstotheCERTFinadditiontothefee.

TITLEIX–MISCELLANEOUSPROVISIONSSec.1901.Repealoftriggerprovision.RepealsSubtitleAofTitleVIIIoftheMedicarePrescriptionDrug,ImprovementandModernizationact,commonlyreferredtoasthe“45%trigger”.Sec.1902.Repealofcomparativecostadjustment(CCA)program.Repealssection1860‐1oftheSocialSecurityAct,asaddedbysection241(a)oftheMedicare,PrescriptionDrug,ImprovementandModernizationActof2003,commonlyreferredtoasthe“premiumsupportdemonstrationproject.”Sec.1903.Extensionofgainsharingdemonstration.ExtendsGainsharingDemonstrationoftheDeficitReductionActof2005fromDecember31,2009toSeptember30,2011.Sec. 1904.GrantstoStatesforqualityhomevisitationprogramsforfamilieswithyoungchildrenandfamiliesexpectingchildren.ProvidesgrantstoStatestosupportvoluntary,evidence‐basedhomevisitationprograms

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forpregnantwomenandforfamilieswithpre‐schoolagechildreninordertoimprovethewell‐being,healthanddevelopmentofchildren.Sec.1905.Improvedcoordinationandprotectionfordualeligibles.RequiresCMStoestablishadedicatedofficeorprogramtoimprovecoordinationofbenefitsandotherpoliciesforbeneficiariesduallyeligibleforMedicareandMedicaid.Sec.1906.AssessmentofMedicarecost‐intensivediseasesandconditions.DirectstheSecretarytoconsultwithrelevantresearchagenciesandconductanassessmentofthediseasesandconditionsthatareorcouldbecomemostcost‐intensivefortheMedicareprogram.DirectstheSecretarytoassesswhethercurrentresearchprioritiesareappropriatelyaddressingsuchconditionsandmakefundingrecommendationsconcerningresearchthatshouldbefundedtoimprovetheprevention,treatmentorcureofsuchconditions.DirectstheSecretarytobienniallyreviewandupdatetheassessmentandsubmitareportonthatassessmenttoCongress. Sec.1907.EstablishmentofCenterforMedicareandMedicaidInnovationwithinCMS.EstablisheswithintheCentersforMedicareandMedicaidServicesaCenterforMedicare&MedicaidInnovation.ThepurposeoftheCenterwillbetoresearch,develop,test,andexpandinnovativepaymentanddeliveryarrangementstoimprovethequalityandreducethecostofcareprovidedtopatientsineachprogram.DedicatedfundingisprovidedtoallowfortestingofmodelsthatrequirebenefitsnotcurrentlycoveredbyMedicare.Successfulmodelscanbeexpandedwithinbothprograms.Sec.1908.Applicationofemergencyserviceslaws.ClarifiesthatnothinginthisActshallbeconstruedtorelieveanyhealthcareproviderfromtherequirementtoprovideemergencyservicesaccordingtoanyStateorFederallaw,includingEMTALA.Sec.1909.DisregardundertheSupplementalSecurityIncomeprogramofcompensationforparticipationinclinicaltrialsforrarediseasesorconditions.Disregardsfromincomeuptothefirst$2,000peryearreceivedforparticipationinapaidclinicaltrialbyaSupplementalSocialSecurityIncome(SSI)recipientwithararediseaseorcondition.

DIVISIONC–PUBLICHEALTHANDWORKFORCEDEVELOPMENTSec.2201.TableofContents;references.Sec.2002.Publichealthinvestmentfund.EstablishesthePublicHealthInvestmentFundanddepositsatotalof$34billionforuseoverthenextfiveyears(FY2011–FY2015).ThesefundsareauthorizedtobeappropriatedbytheCommitteeonAppropriationsforactivitiesinthisDivision(describedbelow)andareoverandabovethelevelofappropriationsprovidedfortheseactivitiesforFY2008.Sec.2003.Deficitneutrality.EstablishesthatfundsareavailableonlyforthepurposesdescribedinDivisionC.Requires,forestimationpurposes,thatfundsbetreatedasdirectspending,thattheybeattributedtothisActandthatfutureappropriationsbeincludedinthelistofmandatoryappropriations.

TITLEI–COMMUNITYHEALTHCENTERS

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Sec.2101.Increasedfunding.Authorizesanadditional$12billionoverthenextfiveyears(FY2011–FY2015)forcommunityhealthcenterstobeappropriatedfromthePublicHealthInvestmentFund(underSec.2002).SuchfundsareoverandabovethelevelofappropriationsprovidedforFY2008.

TITLEII–WORKFORCESUBTITLEA–PRIMARYCAREWORKFORCEPART1–NationalHealthServiceCorpsSec.2201.NationalHealthServiceCorps.IncreasesloanrepaymentbenefitsforeachCorpsmembertoamaximumof$50,000peryear.AllowsfulfillmentofCorpsserviceobligationthroughpart‐timeserviceaswellasthroughclinicalteaching(forupto20%oftheperiodofobligatedservice).Sec.2202.Authorizationofappropriations.Authorizesanadditional$1.8billionoverthenextfiveyears(FY2011–FY2015)fortheNationalHealthServiceCorpstobeappropriatedfromthePublicHealthInvestmentFund(underSec.2002).SuchsumsareoverandabovethelevelofappropriationsprovidedforFY2008.PART2–PromotionofPrimaryCareandDentistrySec.2211.FrontlineHealthProviders.Establishesaloanrepaymentprogramtoaddresshealthcareneedsingeographicareas(“healthprofessionalneedsareas”)notcurrentlyrecognizedashealthprofessionalshortageareas.EligibleprovidersincludethosewhoqualifytoparticipateintheNationalHealthServiceCorpsaswellasothercategoriesofphysiciansandhealthprofessionals.Sec.2212.Primarycarestudentloanfunds.Revisescurrentguidelinespertainingtothesubmissionoffinancialinformationofastudent’sfamilyforthepurposeofdeterminingthefinancialresourcesavailabletothestudenttosupporthis/herhealthprofessioneducation.RequirestheSecretarytotakeintoaccounttheextenttowhichanindividualisfinanciallyindependentindeterminingwhethertorequireorauthorizethesubmissionoffinancialinformationoftheindividual’sfamilymembers.Sec.2213.Traininginfamilymedicine,generalinternalmedicine,generalpediatrics,geriatrics,andphysicianassistants.Providesfundingtosupportprimarycaretrainingprogramsandtobuildacademiccapacityinprimarycare.Sec.2214.Trainingofmedicalresidentsincommunity‐basedsettings.Establishesaprogramtoprovidesupportforthedevelopmentandoperationoftrainingprogramsformedicalresidentsincommunity‐basedsettingssuchascommunityhealthcenters.Sec.2215.Trainingforgeneral,pediatric,andpublichealthdentistsanddentalhygienists.Providesfundingtosupporttrainingprogramsforgeneral,pediatric,andpublichealthdentistsanddentalhygienists,includingfacultyloanrepaymentbenefits.Sec.2216.Authorizationofappropriations.Authorizesanadditional$1.3billionoverthenextfiveyears(FY2011–FY2015)forvariousprimarycareprogramstobeappropriatedfromthePublicHealthInvestmentFund(underSec.2002).SuchfundsareoverandabovethelevelofappropriationsprovidedforFY2008.Sec.2217.Studyoneffectivenessofscholarshipsandloanrepayments.RequiresGAOtoconductastudyontheeffectivenessofscholarshipsandloanrepaymentsofferedthroughboththeNationalHealthServiceCorps

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andtheFrontlineHealthProviderPrograminencouragingindividualstopursueandmaintaincareersinprimarycareandtopracticeinunderservedareas.SUBTITLEB–NURSINGWORKFORCESec.2221.AmendmentstoPublicHealthServiceAct.Makesanumberofimprovementsinnursingprograms,includingincreasingloanrepaymentbenefitsfornursingstudentsandfaculty;removingthecaponawardsfornursingstudentspursuingadoctoraldegree;andclarifyingthatnurse‐managedhealthcentersareeligibleforgrantawards.Authorizesanadditional$638millionoverthenextfiveyears(FY2011–FY2015)forvariousnursingprogramstobeappropriatedfromthePublicHealthInvestmentFund(underSec.2002).SuchfundsareoverandabovethelevelofappropriationsprovidedforFY2008.SUBTITLEC–PUBLICHEALTHWORKFORCESec.2231.PublicHealthWorkforceCorps.EstablishesaPublicHealthWorkforceCorpstoaddresspublichealthworkforceshortages.ModeledontheNationalHealthServiceCorps,theprogramprovidesscholarshipandloanrepaymentsupportforpublichealthprofessionalsservinginareasofneed.Sec.2232.Enhancingthepublichealthworkforce.Providesfundingtosupportpublichealthtrainingprograms.Sec.2233.Publichealthtrainingcenters.RevisesthegoalsforthepublichealthtraininggrantprogramstocomportwiththeSecretary’snewnationalpreventionandwellnessstrategy(underSec.3121).Sec.2234.Preventivemedicineandpublichealthtraininggrantprogram.Providesfundingtosupporttraininggrantprogramsforpreventivemedicinephysicians.Sec.2235.Authorizationofappropriations.Authorizesanadditional$283millionoverthenextfiveyears(FY2011–FY2015)forvariouspublichealthworkforceprogramstobeappropriatedfromthePublicHealthInvestmentFund(underSec.2002).SuchfundsareoverandabovethelevelofappropriationsprovidedforFY2008.SUBTITLED–ADAPTINGWORKFORCETOEVOLVINGHEALTHSYSTEMNEEDSPART1–HealthProfessionsTrainingforDiversitySec.2241.Scholarshipsfordisadvantagedstudents,loanrepaymentsandfellowshipsregardingfacultypositions,andeducationalassistanceinthehealthprofessionsregardingindividualsfromdisadvantagedbackgrounds.Providesscholarshipandloanrepaymentsupportforindividualsfromdisadvantagedbackgroundsservinginthehealthprofessions.ProvidesfundingfortheHealthCareersOpportunitiesProgramthatsupportshealthprofessionsschoolsthatrecruitandtrainindividualsfromdisadvantagedbackgrounds.Sec.2242.Nursingworkforcediversitygrants.ClarifiesrequirementsfortheSecretarytoconsultwithvariousnursingassociations.Sec.2243.Coordinationofdiversityandculturalcompetencyprograms.RequirestheSecretarytocoordinateworkforcediversityandculturalandlinguisticcompetencyactivitiestoenhanceeffectivenessandavoidduplicationofeffort.

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PART2–InterdisciplinaryTrainingProgramsSec.2251.Culturalandlinguisticcompetencetrainingforhealthprofessionals.Establishesanewprogramtopromoteculturalandlinguisticcompetenceamonghealthcareprofessionals.Sec.2252.Innovationsininterdisciplinarycaretraining.Establishesanewprogramtosupportthedevelopmentandoperationofinterdisciplinarytrainingprogramsforhealthprofessionalstoimprovecoordinationwithinandacrosshealthcaresettings,includingtraininginmedicalhomemodelsandmodelsthatintegratephysical,mental,ororalhealthservices.PART3–AdvisoryCommitteeonHealthWorkforceEvaluationandAssessmentSec.2261.Healthworkforceevaluationandassessment.CreatesanAdvisoryCommitteeonHealthWorkforceEvaluationandAssessmenttoassesstheadequacyandappropriatenessofthenation’shealthworkforce,andtomakerecommendationstotheSecretaryonfederalworkforcepoliciestoensurethatsuchworkforceismeetingthenation’sneeds.PART4–HealthWorkforceAssessmentSec.2271.Healthworkforceassessment.RequirestheSecretarytocollectdataonthesupply,diversity,andgeographicdistributionoftheNation’shealthworkforce,includingindividualsparticipatinginvariousfederalworkforceprograms.PART5–AuthorizationofAppropriationsSec.2281.Authorizationofappropriations.Authorizesanadditional$1.0billionoverthenextfiveyears(FY2011–FY2015)forvariousworkforceprograms(includingCentersofExcellence)tobeappropriatedfromthePublicHealthInvestmentFund(undersection2002).(SuchfundsareoverandabovethelevelofappropriationsprovidedinFY2008.)

TITLEIII–PREVENTIONANDWELLNESSSec.2301. Preventionandwellness.AmendsthePublicHealthServiceAct(PHSA)toestablishanewTitleXXXIthatincludes11newPHSAsections–Sec.3111,3121,3131,3132,3141,3142,3143,3151,3161,3162,and3171(describedbelow).SUBTITLEA–PREVENTIONANDWELLNESSTRUSTSec.3111.Preventionandwellnesstrust.EstablishesaPreventionandWellnessTrustthatauthorizesappropriationsfromthePublicHealthInvestmentFund(underSec.2002)of$15.4billionoverthenextfiveyears(FY2011–FY2015)tofundactivitiesunderSubtitleC(PreventionTaskForces),SubtitleD(PreventionandWellnessResearch),SubtitleE(DeliveryofCommunity‐BasedPreventionandWellnessServices)andSubtitleF(CorePublicHealthInfrastructureandActivities)ofnewPHSATitleXXXI.SUBTITLEB–NATIONALPREVENTIONANDWELLNESSSTRATEGY

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Sec.3121.Nationalpreventionandwellnessstrategy.RequirestheSecretarytodevelopandperiodicallyupdateanationalstrategydesignedtoimprovethenation’shealththroughevidence‐basedclinicalandcommunity‐basedpreventionandwellnessactivities.SUBTITLEC–PREVENTIONTASKFORCESSec.3131.TaskForceonClinicalPreventiveServices.ConvertstheexistingU.S.PreventiveServicesTaskForceintotheTaskForceonClinicalPreventiveServices.ThechargetotheTaskForceistoconductevidence‐basedsystemicreviewsofdataandliteraturetodeterminewhichclinicalpreventiveservices(i.e.,preventiveservicesdeliveredbytraditionalhealthcareprovidersinclinicalsettings)arescientificallyproventobeeffective.Sec.3132.TaskForceonCommunityPreventiveServices.CodifiestheexistingTaskForceonCommunityPreventiveServices.ThechargetotheTaskForceistoconductevidence‐basedsystematicreviewsofdataandliteraturetodeterminewhichcommunitypreventiveservices(i.e.,preventiveservicesthataredeliveredoutsidetraditionalclinicalsettingsandfrequentlyimplementedacrosstargetedgroups)arescientificallyproventobeeffective.SUBTITLED—PREVENTIONANDWELLNESSRESEARCHSec.3141.Preventionandwellnessresearchactivitycoordination.DirectstheCDCandNIHdirectorstotakeintoconsiderationthenationalstrategyonprevention(underSec.3121),recommendationsfromtheTaskForceonClinicalPreventiveServices(underSec.3131),andrecommendationsfromtheTaskForceonCommunityPreventiveServices(underSec.3132)inconductingorsupportingresearchonpreventionandwellness.Sec.3142.Communitypreventionandwellnessresearchgrants.ProvidessupportforCDCresearchoncommunitypreventiveservices.Sec.3143.Researchonsubsidiesandrewardstoencouragewellnessandhealthybehaviors.Providessupportforresearchonincentivizingprovenhealthybehaviorsandfortheinclusionofeffectiveincentiveprogramsintheessentialbenefitspackageorincommunitypreventionandwellnessprograms.SUBTITLEE–DELIVERYOFCOMMUNITYPREVENTIONANDWELLNESSSERVICESSec.3151.Communitypreventionandwellnessservicesgrants.Establishesagrantprogramtosupportthedeliveryofevidence‐based,community‐basedpreventionandwellnessservicesacrossthecountry.Eligibleentitiesincludestateandlocalgovernments,nonprofits,andconsortiasuchascommunitypartnershipsrepresentingHealthEmpowermentZones.Atleast50%ofgrantfundsmustbespentonimplementingserviceswhoseprimarypurposeistoreducehealthdisparities.SUBTITLEF–COREPUBLICHEALTHINFRASTRUCTURESec.3161.CorepublichealthinfrastructureforState,local,andtribalhealthdepartments.EstablishesagrantprogramatCDCtoimprovecorepublichealthinfrastructureatthestate,local,andtriballevel.Includesformulagrantstostatehealthdepartmentsandcompetitivegrantsforstate,localortribalhealthdepartments.Establishesapublichealthaccreditationprogramforpublichealthdepartmentsandlaboratories.Sec.3162.CorepublichealthinfrastructureandactivitiesforCDC.ProvidessupportforCDCtoaddressunmetandemergingpublichealthneeds.

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SUBTITLEG—GENERALPROVISIONSSec.3171.Definitions.DefinesvarioustermsforthepurposesofPHSATitleXXXI.ProvidesfortransitioningtheexistingU.S.PreventiveServicesTaskForceintothenewTaskForceonClinicalPreventiveServicesandfortransitioningtheexistingTaskForceonCommunityPreventiveServicesintothenewTaskForceonCommunityPreventiveServices.

TITLEIV—QUALITYANDSURVEILLANCESec.2401.Implementationofbestpracticesinthedeliveryofhealthcare.CreatesaCenterforQualityImprovementtoidentify,develop,evaluateandhelpimplementbestpractices.Sec.2402.AssistantSecretaryforhealthinformation.EstablishesthepositionofAssistantSecretaryforHealthInformationtoprovidehealthinformationonkeyhealthindicators;tofacilitatebetterdatasharing;andtodevelopstandardsforthecollectionofdatatostudyandaddresshealthdisparities.Sec.2403.Authorizationofappropriations.Authorizesanadditional$1.5billionoverthenextfiveyears(FY2011–FY2015)forqualityimprovementanddata‐relatedactivitiestobeappropriatedfromthePublicHealthInvestmentFund(underSec.2002).SuchfundsareoverandabovethelevelofappropriationsprovidedforFY2008.

TITLEV–OTHERPROVISIONSSUBTITLEA–DRUGDISCOUNTFORRURALANDOTHERHOSPITALS;340BPROGRAMINTEGRITYSec.2501.Expandedparticipationin340Bprogram.Extendsthesection340Bdiscountsonoutpatientdrugstoruralhospitals(includingcriticalaccesshospitals),children’shospitals,cancerhospitals,andotherentities.Sec.2502.Improvementsto340Bprogramintegrity.Establishesnewauditing,reporting,andothercompliancerequirementsfortheSecretary,andforpharmaceuticalmanufacturersand340Bcoveredentities.Sec.2503.Effectivedate.Establishestheeffectivedateofsections2501,2502(a)(1),and2502(b)(2)asthedateofenactmentofthisAct.SUBTITLEB–PROGRAMSPART1–GrantsforClinicsandCentersSec.2511.School‐basedhealthclinics.Establishesanewprogramtosupportschool‐basedhealthclinicsthatprovidehealthservicestochildrenandadolescents.Authorizes$50millionforFY2011andsuchsumsasmaybenecessaryforeachofFY2012throughFY2015tocarryoutthisprogram.Sec.2512.Nurse‐managedhealthcenters.Establishesanewprogramtosupportnurse‐managedhealthcenters(centersoperatedbyadvancedpracticenursesthatprovidecomprehensiveprimarycareandwellnessservicestounderservedorvulnerablepopulations).AuthorizessuchsumsasmaybenecessaryforeachofFY2011throughFY2015tocarryoutthisprogram.

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Sec.2513.Federallyqualifiedbehavioralhealthcenters.Setsforthcriteriaforthecertificationoffederallyqualifiedbehavioralhealthcentersandrecognizestheroleofsuchcentersassafetynetprovidersforindividualswithbehavioral,mentalhealth,andsubstanceabusedisorders.PART2–OtherGrantProgramsSec.2521.Comprehensiveprogramstoprovideeducationtonursesandcreateapipelinetonursing.EstablishesanewprogramattheDepartmentofLabortoaddressprojectednurseshortages;toincreasethecapacityforeducatingnurses;andtosupporttrainingprograms.AuthorizessuchsumsasmaybenecessaryforeachofFY2011throughFY2015tocarryoutthisprogram.Sec.2522.Mentalandbehavioralhealthtraining.Establishesanewtrainingprogramformentalandbehavioralhealthprofessionals(includingthosespecializinginsubstanceabusecounselingandaddictionmedicine)topromoteinterdisciplinarytrainingandcoordinationofthedeliveryofhealthcare.Authorizes$60millionforeachofFY2011throughFY2015tocarryoutthisprogram.Requiresthatnolessthan15%offundsbeusedfortrainingprogramsinpsychology.Sec.2523.Reauthorizationoftelehealthandtelemedicinegrantprograms.Reauthorizesprogramstosupporttelehealthnetworksandtelehealthresourcecentersandtoprovideincentivestocoordinatetelemedicinelicensureactivitiesamongstates.Authorizes$10millionforFY2011andsuchsumsasmaybenecessaryforeachofFY2012throughFY2015tocarryouteachofthethreeprograms.Sec.2524.Nochildleftunimmunizedagainstinfluenza:demonstrationprogramusingelementaryandsecondaryschoolsasinfluenzavaccinationcenters.Establishesnewprogramofdemonstrationprojectstostudythefeasibilityofusingelementaryandsecondaryschoolsasinfluenzavaccinationcenters.AuthorizessuchsumsasmaybenecessaryforeachofFY2011throughFY2015tocarryoutthisprogram.Sec.2525.ExtensionofWisewomanProgram.ReauthorizestheNIHWisewoman(“Well‐IntegratedScreeningandEvaluationforWomenAcrosstheNation”)Programandremovesthethree‐statelimitationonstateparticipationintheprogram.Wisewomanconsistsofdemonstrationprojectstoprovidepreventivehealth(andappropriatefollow‐up)servicestowomen.Authorizes$70millionforFY2011;$73millionforFY2012;$77millionforFY2013;$81millionforFY2014;and$85millionforFY2015tocarryoutthisprogram.Sec.2526.Healthyteeninitiativetopreventteenpregnancy.Establishesanewprogramforstatestoprovideevidence‐basededucationtoreduceteenpregnancyorsexuallytransmittedinfections.Permitsstatestoworkwithpublicorprivatenonprofitorganizations,includingschoolsandcommunity‐basedandfaith‐basedorganizations.Authorizes$50millionforeachofFY2011throughFY2015tocarryoutthisprogram.Sec.2527.Nationaltraininginitiativesonautismspectrumdisorders.Establishesanewprogramtosupporttrainingactivitiestoaddresstheunmetneedsofchildrenandadultswithautismandrelateddevelopmentaldisabilities.Authorizes$17millionforFY2011andsuchsumsasmaybenecessaryforeachofFY2012throughFY2015tocarryoutthisprogram.Sec.2528.Implementationofmedicationmanagementservicesintreatmentofchronicdiseases.Establishesanewprogramtoimplementmedicationtherapymanagement(MTM)servicesprovidedbylicensedpharmacistsaspartofacollaborativeapproachtothetreatmentofchronicdiseases.Sec.2529.Postpartumdepression.EncouragestheSecretarytoexpandandintensifyactivitiesonpostpartumconditions,includingresearch,epidemiologicalstudies,thedevelopmentofimprovedscreeninganddiagnostic

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techniques,andinformationandeducationprograms.RequirestheSecretarytoconductastudyonthebenefitsofscreeningforpostpartumconditions.ExpressesthesenseofCongressthattheDirectoroftheNationalInstituteofMentalHealthmayconductanationallyrepresentativelongitudinalstudyontherelativementalhealthconsequencesforwomenofresolvingapregnancy(intendedandunintended)invariousways.AuthorizessuchsumsasmaybenecessaryforeachofFY2011throughFY2013tocarryouttheseactivities.Sec.2530.Grantstopromotepositivehealthbehaviorsandoutcomes.Establishesanewtrainingprogramforcommunityheathworkerstopromotepositivehealthbehaviors(e.g.,improvednutrition,decreasedtobaccouse)amongpopulationsinmedicallyunderservedareas.Authorizes$30millionforeachofFY2011throughFY2015tocarryoutthisprogram.Sec.2531.Medicalliabilityalternatives.EstablishesanincentiveprogramforStatestoadoptandimplementalternatives(certificateofmeritor“earlyoffer”)asalternativestotraditionalmedicalmalpracticelitigation.Suchalternativesmaynotincludeprovisionsthatlimitattorneys’feesorimposecapsondamages.Authorizessuchsumsasmaybenecessarytocarryoutthisprogram.Sec.2532.Infantmortalitypilotprograms.Establishesanewprogramtosupportpilotprojectsdesignedtoreduceinfantmortality.Authorizes$10millionforeachofFY2011throughFY2015tocarryoutthisprogram.Sec.2533.Secondaryschoolhealthsciencestrainingprogram.Establishesanewprogramtosupporthealthsciencescurriculainpublicsecondaryschools,includingmiddleschools,topreparestudentsforcareersinhealthprofessions.AuthorizessuchsumsasmaybenecessaryforeachofFY2011throughFY2015tocarryoutthisprogram.Sec.2534.Community‐basedcollaborativecarenetworks.Establishesanewprogramtosupportcommunity‐basedcollaborativecarenetworks,aconsortiumofhealthcareprovidersofferingcoordinatedandintegratedhealthcareservicesforlow‐incomepatientpopulationsormedically‐underservedcommunities.AuthorizessuchsumsasmaybenecessaryforeachofFY2011throughFY2015tocarryoutthisprogram.Sec.2535.Community‐basedoverweightandobesitypreventionprogram.Establishesanewprogramtopreventoverweightandobesityamongchildrenthroughimprovednutritionandincreasedphysicalactivity.Authorizes$10millionforFY2011andsuchsumsasmaybenecessaryforeachofFY2012throughFY2015tocarryoutthisprogram.Sec.2536.Reducingstudent‐to‐schoolnurseratios.Establishesademonstrationprogramtoreducethestudent‐to‐schoolnurseratioinpublicelementaryandsecondaryschools.AuthorizessuchsumsasmaybenecessaryforeachofFY2011throughFY2015tocarryoutthisprogram.Sec.2537.Medical‐legalpartnerships.Establishesanationwidedemonstrationprogramtoevaluatetheeffectivenessofmedical‐legalpartnershipsinassistingpatientsandtheirfamiliesinnavigatinghealth‐relatedprogramsandactivities.AuthorizessuchsumsasmaybenecessaryforeachofFY2011throughFY2015tocarryoutthisprogram.PART3–EmergencyCare‐RelatedPrograms

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Sec.2551.Traumacarecenters.Establishesanewprogramtostrengthenthenation’semergencyroomandtraumacentercapacity.Authorizes$100millionforFY2011andsuchsumsasmaybenecessaryforeachofFY2012throughFY2015tocarryoutthisprogram.Sec.2552.Emergencycarecoordination.CreatesanEmergencyCareCoordinationCenterwithintheHHSOfficeoftheAssistantSecretaryforPreparednessandResponse.AuthorizessuchsumsasmaybenecessaryforeachofFY2011throughFY2015tocarryoutthevariousactivitiesoftheCenter.Sec.2553.Pilotprogramstoimproveemergencymedicalcare.Establishesapilotprogramforthedesign,implementation,andevaluationofinnovativemodelsofregionalized,comprehensive,andaccountableemergencycaresystems.Authorizes$12millionforeachofFY2011throughFY2015tocarryoutthisprogram.Sec.2554.AssistingveteranswithmilitaryemergencymedicaltrainingtobecomeState‐licensedorcertifiedemergencymedicaltechnicians(EMTs).Establishesanewprogramforstatestoassistveteranswithmilitaryemergencymedicaltraininginbecomingstate‐licensedorcertifiedmedicaltechnicians.AuthorizessumsasmaybenecessaryforeachofFY2011throughFY2015tocarryoutthisprogram.RequirestheGAOtoconductastudyonthebarriersexperiencedbyveteranswithmilitaryemergencytraininginbecominglicensedorcertifiedcivilianhealthprofessionals.Sec.2555.Dentalemergencyresponders:publichealthandmedicalresponse.ClarifiesthatdentalhealthfacilitiesaretobeincludedamongthemedicalproviderswhosepreparednessforpublichealthemergenciesistobeaddressedintheNationalHealthSecurityStrategy,andthatemergencycurriculaandtrainingprogramsmaybecarriedoutatfederaldentalhealthfacilities.Sec.2556.Dentalemergencyresponders:homelandsecurity.Clarifiesthattheterm‘‘emergencyresponseprovider’’includesemergencydentalpersonnel,agencies,andauthorities;thattheDepartmentofHomelandSecurity’sChiefMedicalOfficerservesastheDepartment’sprimarypointofcontactwiththedentalaswellasthemedicalcommunity;andthattheoperationalplansforacoordinatedfederalresponsetonaturalandman‐madedisastersandterrorismincludethepreparednessanddeploymentofdentalaswellaspublichealthandmedicalresources.PART4–PainCareandManagementProgramsSec.2561.InstituteofMedicineConferenceonPain.RequirestheSecretarytoseektoenterintoanagreementwiththeInstituteofMedicineoftheNationalAcademiestoconveneaConferenceonPain.Authorizes$500,000foreachofFY2011andFY2012tocarryouttheconference.Sec.2562.PainresearchatNationalInstitutesofHealth.EncouragestheNIHDirectortocontinueandexpand,throughthePainConsortium,aprogramofbasicandclinicalresearchonpain,includingresearchonthetreatmentofpain.Sec.2563.Publicawarenesscampaignonpainmanagement.RequirestheSecretarytoestablishandimplementanationaleducationoutreachandawarenesscampaignonpainmanagement.Authorizes$2millionforFY2011and$4millionforeachofFY2012throughFY2015tocarryoutthecampaign.SUBTITLEC–FOODANDDRUGADMINISTRATION

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PART1–InGeneralSec.2571.Nationalmedicaldeviceregistry.EstablishesanationaldirectoryforclassIIImedicaldevicesandclassIIdevicesthatarepermanentlyimplantable,life‐supporting,orlife‐sustaining.Deviceinformationintheregistrywouldbelinkedwithpatientsafetyandoutcomesdatafromvariouspublicandprivatedatabasestofacilitateanalysesofpost‐marketdevicesafetyandeffectiveness.Sec.2572.Nutritionlabelingofstandardmenuitemsatchainrestaurantsandofarticlesoffoodsoldfromvendingmachines.Requireschainrestaurantstoputthecaloriecontentoftheirmenuitemsdirectlyonthemenusandtomakeothernutritionalinformationavailablesothatconsumerscanmakeinformedchoicesaboutwhattheyeat.Sec.2573.Protectingconsumeraccesstogenericdrugs.Enhancescompetitioninthepharmaceuticalmarketbystoppingagreementsbetweenbrandnameandgenericdrugmanufacturersthatlimit,delay,orotherwisepreventcompetitionfromgenericdrugs.PART2–BiosimilarsSec.2575.Licensurepathwayforbiosimilarbiologicalproducts.EstablishesaprocessunderwhichtheSecretaryisrequiredtoapproveapplicationsforbiologicalproductsthathavebeenshowntobebiosimilarorinterchangeabletoanalreadylicensedbiologicalproduct(thereferenceproduct).RequiresnotificationtotheFederalTradeCommissionandtheAssistantAttorneyGeneralofcertaintypesofagreementsregardingbiosimilarorreferenceproducts.Sec.2576.Feesrelatingtobiosimilarbiologicalproducts.Allowsforthecollectionofuserfeesfortheapprovalofbiosimilarorinterchangeablebiologicalproducts.Sec.2577.Amendmentstocertainpatentprovisions.Establishesthatabiologicalproductapplicant'ssubmissionofastatementregardingpatentsidentifiedbythepatentholderconstitutesanactofinfringementofthepatentsthatclaimthebiologicalproduct.SUBTITLED–COMMUNITYLIVINGASSISTANCESERVICESANDSUPPORTSSec.2581.Establishmentofnationalvoluntaryinsuranceprogramforpurchasingcommunitylivingassistanceservicesandsupport(CLASSprogram).Establishesanew,voluntary,publiclong‐termcareinsuranceprogram,tobeknownastheCLASSIndependenceBenefitPlan,forthepurchaseofcommunitylivingassistanceservicesandsupportsbyindividualswithfunctionallimitations.RequirestheSecretarytodevelopanactuariallysoundbenefitplanthatensuressolvencyfor75years;allowsforafive‐yearvestingperiodforeligibilityofbenefits;createsbenefittriggersthatallowforthedeterminationoffunctionallimitation;andprovidescashbenefitthatisnotlessthananaverageof$50perday.SUBTITLEE–MISCELLANEOUSSec.2585.Statesfailingtoadheretocertainemploymentobligations.Conditionsastate’seligibilityforfundsunderthePHSAonastate’sagreementtobesubjectinitscapacityasanemployertoeachemployerobligationunderDivisionAofthislegislation.Assuresthatallpoliticalsubdivisionsinthestate,andtheiragenciesandinstrumentalities,willalsobesubjecttosuchemployerobligations.

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Sec.2586.HealthcentersunderPublicHealthServiceAct;liabilityprotectionsforvolunteerpractitioners.Extendsmedicalmalpracticeliabilityprotectioncurrentlyavailableforemployeesorlicensedorcertifiedhealthprofessionalsundercontractwithacommunityhealthcenterstovolunteerpractitionersprovidinguncompensatedservicesatsuchcenters.Sec.2587.ReporttoCongressonthecurrentstateofparasiticdiseasesthathavebeenoverlookedamongthepoorestAmericans.RequirestheSecretarytoconductastudyontheepidemiologyof,impactof,andappropriatefundingrequiredtoaddressneglecteddiseasesofpoverty,includingChagasDisease,cysticercosis,toxocariasis,toxoplasmosis,trichomoniasis,soil‐transmittedhelminthes.Sec.2588.OfficeofWomen’sHealth.CodifiestheHHSOfficeofWomen’sHealthandwithinthedirector’sofficeofeachofthefollowingHHSagencies:AgencyforHealthResearchandQuality,CentersforDiseaseControlandPrevention,FoodandDrugAdministration,HealthResourcesandServicesAdministration,andSubstanceAbuseandMentalHealthServicesAdministration.Sec.2589.Long‐Termcareandfamilycaregiversupport.Createsadvisorypanelandapilotprogramfocusedonimprovingtheworkingconditionsandtrainingforthelong‐termcareworkforce.IncreasestheauthorizationfortheFamilyCaregiverSupportProgramto$260millionforeachofFY2011throughFY2013.Sec.2590.Websiteonhealthcarelabormarketandrelatededucationalandtrainingopportunities.RequirestheSecretaryofLabortoestablishawebsitethatwouldserveasaclearinghouseofinformationonthehealthcarelabormarket,includingeducationalandtrainingopportunitiesandfinancialaidinformation.Sec.2591.Onlinehealthworkforcetrainingprograms.EstablishesanewprogramfortheSecretaryofLabortosupportonlinetrainingofhealthcareworkers.Authorizes$50millionforeachofFY2011throughFY2020tocarryoutthisprogram.Sec.2592.Accessforindividualswithdisabilities.Requiresthedevelopmentofstandardsforaccessiblemedicalequipment,andrequiresrelevantagenciestoensurethatallentitiescoveredbythislegislationmeettherequirementsoftheAmericanswithDisabilitiesActandSection504oftheRehabilitationAct.

DIVISIOND—INDIANHEALTHTITLEI–AMENDMENTSTOINDIANLAWS

Sec.3101.AmendmentstotheIndianHealthCareImprovementAct.ReauthorizesandamendstheentireIndianHealthCareImprovementActaslaidoutbelow.Sec.1.ShortTitle;TableofContents.DenotestheShortTitle,the“IndianHealthCareImprovementAct.”andcontainsthetableofcontents.Sec.2.Findings.SetsoutCongressionalfindingsthatfederalIndianhealthservicesarerequiredbythegovernment'shistoricalandlegalrelationshipwithIndianpeople.Sec.3.DeclarationofNationalIndianHealthPolicy.DeclaresthattheNationalIndianHealthPolicyistoassurethehighestpossiblehealthstatusforIndiansandtoprovideallresourcesnecessarytoeffectuatethepolicy.Sec.4.Definitions.Defines28termsusedthroughouttheIndianHealthCareImprovementAct.

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TITLEI—INDIANHEALTH,HUMANRESOURCES,ANDDEVELOPMENT

Sec.101.Purpose.StatesthatthepurposeofIHCIATitleIistoincreasethenumberofIndianhealthprofessionals,tothemaximumextentfeasible,andtoassureanoptimumsupplyofhealthprofessionalsforIHS,tribal,andurbanIndianhealthcareentities.Sec.102.HealthProfessionsRecruitmentProgramforIndians.Authorizesgrantstotribes,tribalorganizations,urbanIndianorganizations,andpublicandnonprofitentitiesforrecruitmentofIndiansintohealthprofessions.Sec.103.HealthProfessionsPreparatoryScholarshipProgramforIndians.AuthorizesscholarshipstoIndiansforcompensatorypre‐professionaleducationaswellaspre‐graduateeducationleadingtoabaccalaureatedegreeinapreparatoryfieldforahealthprofession.Sec.104.IndianHealthProfessionsScholarships.AuthorizesscholarshipstoIndiansenrolledfull‐orpart‐timeinaccreditedschoolspursuingcoursesofstudyinthehealthprofessions,inaccordancewithSec.338AofthePublicHealthServiceAct(42U.S.C.254l).Sec.105.AmericanIndiansintoPsychologyProgram.AuthorizesgrantsfordevelopingandmaintainingIndianpsychologycareerrecruitmentprograms.Sec.106.ScholarshipProgramsforIndianTribes.DirectstheSecretarytomakegrantstotribesandtribalorganizationsforscholarshipstoeducateIndianstoserveashealthprofessionalsinIndiancommunities.Sec.107.IndianHealthServiceExternPrograms.AuthorizesanexternprogramforenrolleesinhealthprofessionsrecruitmentprogramsunderSec.102(a),includinghighschoolprograms.Sec.108.ContinuingEducationAllowances.AuthorizestheSecretarytoprovideprogramsorallowancesforindividualstotransitionintoIndianHealthPrograms.ThissectionalsoauthorizesprogramsandallowancesforIHSandtribalhealthprofessionalstotakeleaveoftheirdutyforprofessionalconsultationandforrefreshertraining,professionalmanagement,andleadershiptrainingcourses.Sec.109.CommunityHealthRepresentativeProgram.DirectstheSecretarytoestablishthroughIHS,tribes,andtribalorganizationsaprogramofhealthparaprofessionals,calledCommunityHealthRepresentatives(CHRs),toprovidehealthcare,healthpromotion,anddiseasepreventionservicesinIndiancommunities.Sec.110.IndianHealthServiceLoanRepaymentProgram.DirectstheSecretarytoestablishaloanrepaymentprogramforhealthprofessionalswhocontracttoworkforaspecifiedtimefor,orarealreadyemployedby,IndianHealthProgramsorurbanIndianhealthprograms.Sec.111.ScholarshipandLoanRepaymentRecoveryFund.Establishesafund,consistingofsuchamountscollectedfromcontractbreachesunderSections104,106,and110,plusanyappropriationtotheFundandinterest.Thefundwillbeusedtofinancescholarships,recruitmenteffortsandtoemployhealthprofessionals.Sec.112.RecruitmentActivities.AuthorizestheSecretarytoreimbursecertaintravelexpensestohealthprofessionalsseekingeitheremploymentwithIndianHealthProgramsorurbanIndianhealthprograms,orloanrepaymentcontractsunderSec.110.

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Sec.113.IndianRecruitmentandRetentionProgram.RequirestheSecretarytofund,onacompetitivebasis,demonstrationprojectstoenableIndianHealthProgramsandurbanIndianorganizationstorecruit,place,andretainhealthprofessionalstomeettheirstaffingneeds.Sec.114.AdvancedTrainingandResearch.DirectstheSecretarytoestablishaprogramtoenablehealthprofessionalswhohaveworkedforanIHS,tribal,orurbanIndianhealthprogramforasubstantialperiodoftimetopursueadvancedtrainingorresearchinareasofstudywheretheSecretarydeterminesaneedexists.Sec.115.QuentinN.BurdickAmericanIndiansIntoNursingProgram.RequirestheSecretarytomakegrantstonursingschools,tribally‐controlled,communityandvocationalcolleges,andnursemid‐wifeandadvancedpracticenurseprogramstoincreasethenumberofnursesservingIndians,throughscholarships,recruitment,continuingeducationorotherprogramsencouragingnursingservicestoAmericanIndians.Sect.116.TribalCulturalOrientation.RequirestheSecretarytoestablishamandatorytrainingprogram,forappropriateIHSemployeesservingtribesineachIHSArea,inthehistoryandcultureofthetribestheyserveandthetribes’relationshiptoIHS.Sec.117.IndiansIntoMedicineProgram.AuthorizestheSecretarytoprovidegrantstocollegesanduniversitiestomaintainandexpandtheIndiansIntoMedicineProgram(INMED).Sec.118.HealthTrainingProgramsofCommunityColleges.RequirestheSecretarytoawardgrantstoaccreditedandaccessiblecommunitycollegestoassistinestablishinghealthprofessioneducationprogramsleadingtoadegreeordiplomaforindividualsdesiringtopracticeonornearanIndianreservationorinanIndianHealthProgram.Sec.119.RetentionBonus.AuthorizestheSecretarytopayretentionbonusestoanyhealthprofessionalemployedbyanIHSortribalorurbanIndianhealthprogramwhoagreestocontinuetheircurrentemploymentfornotlessthanoneyear.Sec.120.NursingResidencyProgram.RequirestheSecretarytoestablishaprogramtoenableIndianswhoarelicensedpracticalnurses,licensedvocationalnurses,andregisterednursesworkingforanIndianHealthProgramorurbanIndianhealthprogramforatleast1yeartopursueadvancedtraininginaresidencyprogram.Sec.121.CommunityHealthAideProgram.DirectstheSecretarytodevelopandoperateaCommunityHealthAideProgram(CHAP)inAlaska,underwhichIHStrainsAlaskaNativestoprovidehealthcare,healthpromotion,anddiseasepreventioninruralAlaskaNativevillages.Sec.122.TribalHealthProgramAdministration.RequirestheSecretarytoprovidetrainingtoIndiansintheadministrationandplanningofTribalHealthPrograms.Sec.123.HealthProfessionalChronicShortageDemonstrationPrograms.AuthorizestheSecretarytofunddemonstrationprogramsforTribalHealthProgramstoaddresschronicshortagesinhealthprofessionals.Sec.124.NationalHealthServiceCorps.ProhibitstheSecretaryfromremovingamemberoftheNationalHealthServiceCorpsfromanIHSortribalorurbanIndianhealthprogram,orwithdrawingfundingtosupportsuchmember,unlesstheSecretaryensuresthatIndianswillexperiencenoreductioninservices.Sec.125.SubstanceAbuseCounselorEducationalCurriculaDemonstrationPrograms.AllowstheSecretarytoenterintocontractswithormakegrantstoaccreditedandaccessibletribalcommunitycolleges,tribal

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vocationalcolleges,andeligiblecommunitycollegestoestablishdemonstrationprogramsdevelopingeducationalcurriculaforsubstanceabusecounseling.Sec.126.BehavioralHealthTrainingandCommunityEducationPrograms.Improvesaccesstobehavioralhealthservicesthroughtrainingandeducationsprograms.Sec.127.ExemptionfromPaymentofCertainFees.ExemptsemployeesofaTribalHealthProgramoranurbanIndianorganizationfromthepaymentoflicensing,registration,andotherfeesimposedbyaFederalagency,tothesameextentthatPublicHealthServiceCommissionedCorpsofficersorotherIHSemployeesareexemptfromthefees.Sec.128.AuthorizationofAppropriations.AuthorizesappropriationsofsuchsumsasarenecessarytocarryoutTitleIofthisAct.

TITLEII—HEALTHSERVICES

Sec.201.IndianHealthCareImprovementFund.Authorizestheuseoffunds,designatedthe“IndianHealthCareImprovementFund”(IHCIF),toeliminatetribes’healthstatusandresourcedeficiencies.Sec.202.HealthPromotionandDiseasePreventionServices.DirectstheSecretarytoprovidehealthpromotionanddiseasepreventionservicestoIndiansandtosubmittothePresidentanevaluationstatementoftheresourcesrequiredtoundertaketheseactivities.Sec.203.DiabetesPrevention,Treatment,andControl.Providesforthemonitoringandtreatmentofdiabetes,aswellasdatacollectionanddissemination.Sec.204.SharedServicesforLong‐termCare.AuthorizestheSecretarytoprovidelong‐termcareservicesatanylong‐termcareorrelatedfacilityownedoroperatedbyaTribalHealthProgramdirectlyorunderISDEAA.Sec.205.HealthServicesResearch.AuthorizesfundingforclinicalandnonclinicalresearchtofurthertheperformanceofIndianHealthPrograms’responsibilities.Sec.206.MammographyandOtherCancerScreening.RequirestheSecretarytoprovideforscreeningmammographyforIndianwomen,aswellascertainothercancerscreeningthatcomplieswiththerecommendationsoftheUnitedStatesPreventiveServicesTaskForce.Sec.207.PatientTravelCosts.AuthorizestheSecretarytoprovidefundsforspecifiedpatienttravelcostsassociatedwithreceivingIHS‐fundedhealthcareservices.Sec.208.EpidemiologyCenters.RequirestheSecretarytoestablishanepidemiologycenterineachIHSAreatocarryoutspecifiedfunctionsinconsultationwithtribesandtribalandurbanIndiancommunities.Sec.209.ComprehensiveSchoolHealthEducationPrograms.AuthorizestheSecretarytoprovidegrantstotribesandtribalorganizationstodevelopcomprehensiveschoolhealtheducation.Sec.210.IndianYouthProgram.AuthorizestheSecretarytomakegrantstotribesandtribalandurbanIndianorganizationsforinnovativementalandphysicaldiseasepreventionandhealthpromotionandtreatmentprogramsforIndianandurbanIndianpreadolescentandadolescentyouths.

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Sec.211.Prevention,Control,andEliminationofCommunicableandInfectiousDiseases.AuthorizestheSecretarytomakegrantstotribesandtribalandurbanIndianorganizationsforprojectstoprevent,control,andeliminatecommunicableandinfectiousdiseases.Sec.212.OtherAuthorityforProvisionofServices.AuthorizestheSecretarytoprovidefundingforhealth‐care‐relatedservicesandprograms(nototherwisespecifiedintheAct)forhospicecare,assistedliving,long‐termcare,andhome‐andcommunity‐basedservices.Sec.213.IndianWomen’sHealthCare.RequirestheSecretary,actingthroughIHS,tomonitorandimprovethequalityofIndianwomen’shealthcaredeliveredthroughprogramsadministeredbyIHS.Sec.214.EnvironmentalandNuclearHealthHazards.RequirestheSecretarytostudyandmonitorenvironmentalhazardsrelatedtominingwhichmayresultinchronicorlifethreateninghealthproblems.RequirestheSecretarytodevelophealthcareplanstoaddressthehealthproblemsstudied.Establishesanintergovernmentaltaskforce.Sec.215.ArizonaasaContractHealthServiceDeliveryArea.DesignatesArizonaasacontracthealthservicedeliveryarea.Sec.216.NorthDakotaandSouthDakotaasContractHealthServiceDeliveryArea.DesignatesNorthDakotaandSouthDakotaasonecontracthealthservicedeliveryarea.Sec.217.CaliforniaContractHealthServicesProgram.AuthorizestheSecretarytofundaprogramusingtheCaliforniaRuralIndianHealthBoard(CRIHB)asacontractcareintermediarytoimprovetheaccessibilityofhealthservicestoCaliforniaIndians.Sec.218.CaliforniaasaContractHealthServiceDeliveryArea.DesignatestheStateofCalifornia,excluding20specifiedcounties,asacontracthealthservicedeliveryarea.Sec.219.ContractHealthServicesfortheTrentonServiceArea.DirectstheSecretarytoprovidecontracthealthservicestomembersoftheTurtleMountainBandofChippewaIndiansthatresideintheTrentonServiceAreaofDivide,McKenzie,andWilliamscountiesinNorthDakotaandRichland,Roosevelt,andSheridancountiesinMontana.Sec.220.ProgramsOperatedbyIndianTribesandTribalOrganization.RequiresthatIHSprovidefundsforhealthcareprograms,functions,services,activities,informationtechnology,andfacilitiesoperatedbyTribalHealthProgramsonthesamebasisasfundsareprovidedtohealthcareprograms,functions,services,activities,informationtechnology,andfacilitiesoperateddirectlybyIHS.Sec.221.Licensing.RequiresthatlicensedhealthcareprofessionalsemployedbyaTribalHealthProgramshall,iflicensedinanystate,beexemptfromthelicensingrequirementsofthestateinwhichtheTribalHealthProgramprovidesitsservicesunderanISDEAAcontractorcompactwhileperformingsuchservices.Sec.222.NotificationofProvisionofEmergencyContractHealthServices.Allows30daysfornotificationtoIHSofanyemergencymedicalcareorservicesreceivedbyanelderlyordisabledIndianfromanon‐IHSproviderorinanon‐IHSfacility.

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Sec.223.PromptActiononPaymentofClaims.RequiresIHStorespondtonotificationofaclaimbyaproviderofacontractcareservicewithinfiveworkingdaysofreceiptofthenotification,witheitheranindividualpurchaseorderoraclaimdenial.Sec.224.LiabilityforPayment.ExemptsapatientwhoreceivesIHS‐authorizedcontracthealthcareservicesfrombeingheldliableforanychargesorcostsassociatedwiththoseauthorizedservices.Sec.225.OfficeofIndianMen’sHealth.AuthorizestheSecretarytoestablishtheOfficeofIndianMen’sHealthinIHS.Sec.226.CatastrophicHealthEmergencyFund(CHEF).Establishesanemergencyfundinordertopayforthemedicalcostsassociatedwiththetreatmentofvictimsofdisastersorcatastrophicillnesses.Sec.227.AuthorizationofAppropriations.AuthorizesappropriationsofsuchsumsasnecessarytocarryoutTitleIIofthisAct.

TITLEIII—FACILITIESSec.301.Consultation;ConstructionandRenovationofFacilities;Reports.LaysoutrequirementsfortheSecretarytofollowwithrespecttotheconstruction,renovationandoperationoffacilities.Sec.302.SanitationFacilities.Laysoutresponsibilitiesandrequirementspertainingtotheconstructionandmaintenanceofsanitationfacilities.Sec.303.PreferencetoIndiansandIndianFirms.AuthorizestheSecretarytousetheBuyIndianAct(25U.S.C.47)togiveIndiansandIndianfirms(asdefinedintheSec.)preferenceintheconstructionofIHShealthcareandsanitationfacilitiespursuanttoSections301and302.Sec.304.ExpenditureofNon‐ServiceFundsforRenovation.AuthorizestheSecretarytoacceptanymajorrenovation,expansions,ormodernizationbyanIndiantribeortribalorganizationofanyIHSfacilityoranyhealthfacilityoperatedunderISDEAAandinaccordancewithcriteriaestablishedbytheSecretary.Sec.305.FundingfortheConstruction,Expansion,andModernizationofSmallAmbulatoryCareFacilities.RequirestheSecretarytomakegrantstotribesandtribalorganizationsforTribalHealthProgramstoconstruct,expand,ormodernizesmallambulatorycarefacilities.Sec.306.IndianHealthCareDeliveryDemonstrationProject.AuthorizestheSecretarytomakegrantsto,orconstructioncontractsoragreementswith,tribesandtribalorganizationsunderISDEAAtoestablishdemonstrationprojectstotestalternativehealthcaredeliverysystemsthroughhealthfacilitiestoIndians.Sec.307.LandTransfer.AuthorizestheBIAandallotherfederalagenciestotransfer,atnocost,landandimprovementstotheIHSfortheprovisionofhealthcareservices,andauthorizestheSecretarytoaccepttheland.Sec.308.Leases,ContractsandOtherAgreements.AuthorizestheSecretarytoenterintoleases,contracts,orotheragreementswithIndiantribesortribalorganizationsfortheuseoffacilitiesownedorleasedbythetribesororganizationsandusedforthedeliveryofhealthservicesbyanIndianHealthProgram.

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Sec.309.StudyonLoans,LoanGuarantees,andLoanRepayment.RequiresthattheSecretary,inconsultationwiththeSecretaryofTreasuryandIndiantribesandtribalorganizations,carryoutastudytodeterminethefeasibilityofaloanorloanguaranteefundtoprovidetribesandtribalorganizationseitherdirectloansorloanguaranteesfortheconstructionofhealthcarefacilities.Sec.310.TribalLeasing.AuthorizesTribalHealthProgramstoleasepermanentstructurestoprovidehealthcareserviceswithoutpriorapprovalinappropriationActs.Sec.311.IndianHealthService/TribalFacilitiesJointVentureProgram.RequirestheSecretarytoestablishjointventuredemonstrationprojectswithtribesandtribalorganizationsunderwhichatribeortribalorganizationshallexpendfunds,fromtribalornon‐tribalsources,toacquireorconstructahealthfacilityforatleast10years,underano‐costlease,inexchangeforIHSagreementtoprovidestaffing,equipment,andsuppliesfortheoperationandmaintenanceofthefacility.Sec.312.LocationofFacilities.IdentifiesconditionswhenIHSandtheBIAarerequiredtogiveprioritytolocatingfacilitiesandprojectsonIndianlands,andonanylandsinAlaskaownedbyanAlaskaNativevillage,avillageorregionalcorporationundertheAlaskaNativeClaimsSettlementAct,orallottedtoanAlaskaNative.Sec.313.MaintenanceandImprovementofHealthCareFacilities.RequirestheSecretarytosubmittothePresidentareportonthebacklogofneededmaintenanceandrepairsatIHSandtribalhealthcarefacilities,andontherenovationandexpansionneedsofexistingfacilitiestosupportthegrowthofhealthcareprograms.Sec.314.TribalManagementofFederallyOwnedQuarters.AuthorizesTribalHealthProgramsoperatingahealthcarefacilityandtheassociatedfederally‐ownedquarterstoestablishreasonablerentalratesforthefederally‐ownedquarters,bynotifyingtheSecretary,andtocollecttherentdirectly.Sec.315.ApplicabilityofBuyAmericanActRequirement.RequiresapplicationoftheBuyAmericanActforallprocurementsmadewithfundsappropriatedunderSec.317oftheAct(authorizationofappropriationsforTitleIII),butexemptsIndiantribesandtribalorganizationsfromtherequirementsoftheBuyAmericanAct.Sec.316.OtherFundingforFacilities.AuthorizestheSecretarytoacceptfromanysource,includingfederalandstateagencies,fundsavailablefortheconstructionofhealthcarefacilities,tousesuchfundsfortheplanning,design,andconstructionofIndianhealthfacilities,andtoplacesuchfundsinISDEAAcontractsandcompacts.Sec.317.AuthorizationofAppropriations.AuthorizesappropriationsofsuchsumsasnecessarytocarryoutTitleIIIofthisAct.

TITLEIV—ACCESSTOHEALTHSERVICESSec.401.TreatmentofPaymentsunderSocialSecurityActHealthBenefitsPrograms.LaysoutrequirementsforthetreatmentofpaymentsreceivedbyanIndianHealthProgramoranurbanIndianorganizationfromMedicare,Medicaid,orCHIP.Sec.402.GrantstoandContractswiththeService,IndianTribes,TribalOrganizations,andUrbanIndianOrganizationstoFacilitateOutreach,Enrollment,andCoverageofIndiansunderSocialSecurityActHealthBenefitPrograms.RequirestheSecretarytomakegrantsorenterintocontractswithtribesandtribalorganizationstoassistindividualIndianstoenrollinMedicare,Medicaid,andCHIP,andpaypremiumsandcostsharingrequiredbytheprograms.

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Sec.403.ReimbursementfromCertainThirdPartiesofCostsofHealthServices.AllowstheUnitedStates,tribes,andtribalorganizationstherighttorecoverfromthirdpartypayorsreasonablechargesincurredforhealthservicesprovidedtoanindividualNativeAmericans.Sec.404.CreditingofReimbursements.RequiresthatallreimbursementsreceivedorrecoveredforprovisionofhealthservicebyIHS,atribe,oratribalorurbanIndianorganization,shallbecreditedtotherespectiveentity(includingtheserviceunitprovidingthehealthservice).Sec.405.PurchasingHealthCareCoverage.AuthorizesIndiantribesandtribalandurbanIndianorganizationstousefundsmadeavailableforhealthbenefitsforIHSbeneficiariestopurchasehealthbenefitscoveragethatmeetscertainrequirements.Sec.406.SharingArrangementswithFederalAgencies.AuthorizestheSecretarytoenterorexpandarrangementsforIHS,tribes,andtribalorganizationstosharemedicalfacilitiesandserviceswiththeDepartmentsofVeteransAffairs(VA)andDefense,butrequiresconsultationwithaffectedtribespriortofinalizinganarrangement.Sec.407.EligibleIndianVeteranServices.RequirestheSecretarytoprovideforpaymentforveteran‐related,VA‐authorizedtreatmentunderalocalmemorandumofunderstanding.Sec.408.PayorofLastResort.SpecifiesthatIndianHealthProgramsandhealthcareprogramsoperatedbyurbanIndianorganizationsshallbethepayoroflastresortforservicesprovidedtoeligiblepersons.Sec.409.Consultation.Cross‐referencesrelevantsectionsoftheSocialSecurityAct,regardingconsultationwithIndianHealthProgramsandurbanIndianorganizationswithrespecttoMedicare,Medicaid,andCHIP.Sec.410.StateChildren’sHealthInsuranceProgram(SCHIP).Cross‐referencesrelevantsectionsoftheSocialSecurityActregardingoutreachtoIndianfamilieswithchildrenlikelytobeeligibleforCHIP,andensuringthatCHIPassistanceisprovidedtotargetedlow‐incomeIndianchildrenandthatpaymentsaremadeunderCHIPtoIndianHealthProgramsandurbanIndianorganizationsprovidingsuchassistance.Sec.411.PremiumandCost‐SharingProtectionsandEligibilityDeterminationsunderMedicaidandSCHIPandProtectionofCertainIndianPropertyfromMedicaidEstateRecovery.Cross‐referencesprovisionsintheSocialSecurityActrelevanttoexemptionofIndiansfromMedicaidpremiumsandcost‐sharing,propertydeterminationsforMedicaidandCHIPeligibility,andMedicaidestaterecovery.Sec.412.TreatmentunderMedicaidandSCHIPManagedCare.Cross‐referencesprovisionsintheSocialSecurityActrelevanttotreatmentofIndiansenrolledinMedicaidandCHIPmanagedcareentitiesandtreatmentofIndianHealthProgramsandurbanIndianorganizationsthatareprovidersofhealthcareservicestoIndianenrolleesinsuchentities.Sec.413.NavajoNationMedicaidAgencyFeasibilityStudy.RequirestheSecretarytoconductastudytodeterminethefeasibilityoftreatingtheNavajoNationasastateforMedicaidpurposes,forIndianslivingwithintheNavajoNation'sboundaries.Sec.414.ExceptionforExceptedBenefits.DirectsthattherequirementsofthepreviousprovisionsofTitleIVofthisActshallnotapplytocertainexceptedbenefitsdefinedinspecifiedsectionsofthePublicHealthServiceAct.

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Sec.415.AuthorizationofAppropriations.AuthorizesappropriationsofsuchsumsasmaybenecessarytocarryoutTitleIVofthisAct.

TITLEV—HEALTHSERVICESFORURBANINDIANSSec.501.Purpose.StatesthatthepurposeofTitleVistoestablishandmaintainprogramsinurbancenterstomakehealthservicesmoreaccessibleandavailabletourbanIndians.Sec.502.ContractsWith,andGrantsTo,UrbanIndianOrganizations.RequirestheSecretarytoentercontractswithormakegrantstourbanIndianorganizationstoestablishinurbancentersprogramsthatmeetTitleV’srequirements.Sec.503.ContractsandGrantsfortheProvisionofHealthCareandReferralServices.Setsforththestandards,criteria,andusesoffundsforcontractsandgrantsforhealthcareservicesprovidedtourbanIndians.Sec.504.UseofFederalGovernmentFacilitiesandSourcesofSupply.AuthorizestheSecretarytopermiturbanIndianorganizationscarryingoutcontractsorgrantsunderTitleVtousefederallyownedproperty,facilitiesand/orequipment.Sec.505.ContractsandGrantsfortheDeterminationofUnmetHealthCareNeeds.AuthorizestheSecretarytoenterintocontractswithormakegrantstourbanIndianorganizationstodeterminehealthstatusandunmethealthcareneedsoftheIndiansinsuchurbancenters.Sec.506.Evaluations;Renewals.RequirestheSecretarytodevelopprocedurestoevaluatecompliancewithandperformanceofcontractsandgrants,whichmustincludeeitherannualonsiteevaluationsorevidenceoftheorganization’saccreditationbyarecognizedMedicarereviewentity.Sec.507.OtherContractandGrantRequirements.RequiresthatcontractswithurbanIndianorganizationsbemadeinaccordancewithfederalcontractinglawsandregulationsrelatingtoprocurement.Sec.508.ReportsandRecords.RequiresurbanIndiancontractorsandgranteesunderTitleVtosubmitsemi‐annualreportstotheSecretarycontainingspecifiedinformation,includingaminimumsetofdatausinguniformelements(specifiedbytheSecretaryafterconsultationwithurbanIndianorganizations).Sec.509.LimitationonContractAuthority.LimitstheSecretary’sauthoritytoenterintocontractsorawardgrantstotheamountsappropriated.Sec.510.Facilities.AuthorizestheSecretarytomakefundsavailabletocontractorsorgranteesforleasing,purchasing,renovating,constructing,andexpandingfacilities,includingleasedfacilities,tocomplywithapplicablelicensureorcertificationrequirements.Sec.511.DivisionofUrbanIndianHealth.EstablishesaDivisionofUrbanHealthProgramswithinIHS,responsibleforcarryingoutTitleVandoverseeingprogramsandservicesauthorizedunderthetitle.Sec.512.GrantsforAlcoholandSubstanceAbuse‐RelatedServices.AuthorizestheSecretarytomakegrantstourbanIndiancontractorsandgranteesfortheprovisionofalcoholandsubstanceabuseservicesinurbancenters.

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Sec.513.TreatmentofCertainDemonstrationProjects.RequiresthattheOklahomaCityandTulsademonstrationprojectsinOklahomabemadepermanentprogramswithinIHS’sdirectcareprograms.Sec.514.UrbanNIAAATransferredPrograms.RequirestheSecretarytomakegrantsorcontractswithurbanIndianorganizationsfortheadministrationofurbanIndianalcoholprograms.Sec.515.ConferringwithUrbanIndianOrganizations.RequirestheSecretarytoensurethatIHSconfersorconferenceswithurbanIndianorganizations,tothegreatestextentpracticable.Sec.516.UrbanYouthTreatmentCenterDemonstration.RequirestheSecretarytofundconstructionandoperationofatleastoneresidentialyouthtreatmentcenterineachIHSAreameetingcertainrequirementstodemonstrateprovisionofalcoholandsubstanceabusetreatmentservicesforurbanIndianyouthinaculturallycompetentresidentialsetting.Sec.517.GrantsforDiabetesPrevention,TreatmentandControl.AuthorizestheSecretarytomakegrantstourbanIndiancontractorsorgranteesfordiabetesprevention,treatment,andcontrol.Sec.518.CommunityHealthRepresentatives.AuthorizestheSecretarytocontractwithormakegrantstourbanIndianorganizationsfortheemploymentofIndianstrainedashealthserviceprovidersthroughtheCommunityHealthRepresentativesProgramunderSec.109.Sec.519.EffectiveDate.SetstheeffectivedatefortheamendmentsmadebythisActasthedateofenactment,regardlessofwhethertheSecretaryhasissuedregulations.Sec.520.EligibilityforServices.MakesurbanIndianseligiblefor,andtheultimatebeneficiariesof,healthcareandreferralservicesprovidedunderTitleV.Sec.521.AuthorizationofAppropriations.AuthorizesappropriationsofsuchsumsasarenecessarytocarryoutTitleVofthisAct.Sec.522.HealthInformationTechnology.AuthorizestheSecretarytomakegrantstourbanIndianorganizationsunderTitleVforthedevelopment,adoption,andimplementationofhealthinformationtechnology(asdefinedinSec.3000(5)oftheAmericanRecoveryandReinvestmentAct),telemedicineservicesdevelopment,andrelatedinfrastructure.

TITLEVI—ORGANIZATIONALIMPROVEMENTSSec.601.EstablishmentoftheIndianHealthServiceasanAgencyofthePublicHealthService.EstablishesboththeIndianHealthService(IHS)withinHHS’sPublicHealthServiceandthepositionofAssistantSecretaryforIndianHealth.Sec.602.AutomatedManagementInformationSystem.RequirestheSecretarytoestablishanautomatedmanagementinformationsystemforIHSandforeachTribalHealthProgram,andsetsrequirementsforthesystems,includingprivacyregulationsundertheHealthInsurancePortabilityandAccountabilityActof1996(HIPAA).Sec.603.AuthorizationofAppropriations.AuthorizesappropriationsofsuchsumsasnecessarytocarryoutTitleVIofthisAct.

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TITLEVII—BEHAVIORALHEALTHPROGRAMSSec.701.BehavioralHealthPreventionandTreatmentServices.DirectstheSecretarytodevelopacomprehensivebehavioralhealthcareprogramthatemphasizescollaborationamongalcoholandsubstanceabuse,socialservices,andmentalhealthprograms.Sec.702.MemorandaofAgreementwiththeDepartmentoftheInterior.RequirestheSecretaryandtheSecretaryoftheInteriortodevelopandenterintomemorandaofagreementtoassessthementalhealthcareneedsandservicesavailableorunavailabletoIndiansandhowtoensureandprotectIndians’rightofaccesstogeneralmentalhealthservices.Sec.703.ComprehensiveBehavioralHealthPreventionandTreatmentProgram.RequirestheSecretarytoprovidethroughIHSaprogramofcomprehensivebehavioralhealth,prevention,treatment,andrequiresthatthecomprehensiveprogramincludeprevention,education,specifiedtreatments,rehabilitation,training,anddiagnosticservices.Sec.704.MentalHealthTechnicianProgram.RequirestheSecretarytoestablishwithinIHSamentalhealthtechniciantrainingandemploymentprogramforIndians.Sec.705.LicensingRequirementforMentalHealthCareWorkers.Requiresthat,subjecttoSection221,anypersonemployedasapsychologist,socialworker,ormarriageandfamilytherapisttoprovidementalhealthcareservicestoIndiansinaclinicunderthisActbelicensedtoprovidethespecifiedservice.Sec.706.IndianWomenTreatmentPrograms.AuthorizestheSecretarytomakegrantstotribesandtribalandurbanIndianorganizationstodevelopandimplementacomprehensivebehavioralhealthprogramforprevention,intervention,treatment,andrelapsepreventionthatspecificallyaddressesthecultural,historical,social,andchildcareneedsofIndianwomen.Sec.707.IndianYouthProgram.EstablishesIndianyouthbehavioralhealthprograms.Sec.708.IndianYouthTele‐mentalHealthDemonstrationProject.AuthorizestheSecretarytocarryoutademonstrationprojectbymaking4‐yeargrantstonomorethan5tribesandtribalorganizationswithtele‐healthcapabilitiestousefortele‐mentalhealthservicesinyouthsuicidepreventionandtreatment.Sec.709.InpatientandCommunity‐BasedMentalHealthFacilitiesDesign,Construction,andStaffing.AuthorizestheSecretary,throughIHS,toprovideineachIHSarea,notlessthanoneyearafterenactmentofthisAct,atleast1inpatientmentalhealthfacilityforIndianswithbehavioralhealthproblems.Sec.710.TrainingandCommunityEducation.RequirestheSecretarytodevelopandimplementineachIHSserviceunitortribalprogramaprogramofcommunityeducationinbehavioralhealthissues.Sec.711.BehavioralHealthProgram.AuthorizestheSecretarytodevelopandimplementprogramstodeliverinnovativecommunity‐basedbehavioralhealthservicestoIndians,andauthorizesgrantstotribesandtribalorganizationsforsuchprograms.Sec.712.FetalAlcoholDisorderPrograms.AuthorizestheSecretary,throughIHS,todevelopandimplementfetalalcoholdisorderprograms.

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Sec.713.ChildSexualAbuseandPreventionTreatmentPrograms.RequirestheSecretarytoestablishineveryIHSAreatreatmentprogramsforchildvictimsofsexualabusewhoareIndiansormembersofIndianhouseholds.Sec.714.DomesticandSexualViolencePreventionandTreatment.AuthorizestheSecretarytoestablishprogramsineachIHSAreatopreventandtreatIndianvictimsofdomesticviolenceorsexualviolence,andrequiresprogramfundsbeusedforpreventionandcommunityeducationprograms,behavioralhealthservicesandmedicaltreatmentforvictims.Sec.715.BehavioralHealthResearch.RequirestheSecretary,inconsultationwithappropriatefederalagencies,tomakecontractswithorgrantstotribes,tribalandurbanIndianorganizations,andappropriateinstitutionsforresearchontheincidenceandprevalenceofbehavioralhealthproblemsamongIndiansservedbyIHS,tribes,ortribalorganizationsandinurbanareas.Sec.716.Definitions.DefinestermsusedinTitleVII.Sec.717.AuthorizationofAppropriations.AuthorizesannualappropriationofsuchsumsasnecessarytocarryoutTitleVIIofthisAct.

TITLEVIII—MISCELLANEOUS

Sec.801.Reports.RequirestheSecretarytosubmittoCongressreportsregardingthevariousactivitiesauthorizedunderthisAct.Sec.802.Regulations.RequirestheSecretary,within90daysofenactmentofthisAct,toinitiatenegotiatedrulemakingforregulationstocarryoutthisAct,exceptforsectionsoftheActforwhichrulemakingundertheAdministrativeProceduresActisauthorized.Sec.803.PlanofImplementation.RequirestheSecretary,notlessthanoneyearafterenactmentofthisAct,andinconsultationwithtribesandtribalandurbanIndianorganizations,tosubmittoCongressaplandetailingbytitleandsectionhowthisActwillbeimplemented.Sec.804.LimitationonUseofFundsAppropriatedtoIndianHealthService.ProvidesthatanylimitationcontainedinHHSappropriationsontheuseoffederalfundsforabortionsshallapplyforthatperiodwithrespecttofundsappropriatedforIHS.Sec.805.EligibilityofCaliforniaIndians.MakesspecifiedCaliforniaIndianseligibleforIHShealthservices.Sec.806.HealthServicesforIneligiblePersons.AuthorizesIHShealthservicesforcertainineligiblepersonswhoarechildrenorspousesofeligibleIndians.Sec.807.ReallocationofBaseServices.ProhibitsanyallocationofIHSfundinginafiscalyearthatreducesanIHSserviceunit’srecurringprograms,projects,oractivitiesby5%ormorefromthepreviousfiscalyearunlesstheSecretaryhassubmittedtoCongressareportontheproposedchange,thereasonsforthechange,andthelikelyeffects.Sec.808.ResultsofDemonstrationProjects.RequiresthatfindingsandresultsofdemonstrationprojectsconductedunderthisActbedisseminatedtotribesandtribalandurbanIndianorganizations.

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Sec.809.ProvisionofServicesinMontana.RequirestheSecretarytoprovideservicesandbenefitsforIndiansinMontanaconsistentwiththecourtdecisioninMcNabbv.Bowen,829F.2d787(9thCir.1987).Sec.810.Moratorium.RequiresIHStoprovideservicesaccordingtoeligibilitycriteriaineffectonSeptember15,1987,untilenactmentofspecifiedappropriationstopayforincreasedcostsofeligibilitycriteriaunderafinalrulepublishedintheFederalRegisteronSeptember16,1987.Sec.811.SeverabilityProvisions.RetainsremainingprovisionsofthisActifothersareheldinvalid.Sec.812.UseofPatientSafetyOrganizations.AuthorizesIHS,atribe,oratribalorurbanIndianorganizationtouseapatientsafetyorganizationtoprovideforqualityassuranceactivities,inaccordancewithTitleIXofthePublicHealthServiceAct.Sec.813.ConfidentialityofMedicalQualityAssuranceRecords;QualifiedImmunityforParticipants.MakesmedicalqualityassurancerecordscreatedbyanIndianHealthProgramoranurbanIndianhealthprogramconfidentialandprivileged,andprohibitstheirdisclosureexcepttospecifiedentitiesforspecifiedpurposes.Sec.814.ClaremoreIndianHospital.ProvidesthatClaremoreIndianHospital(inOklahoma)bedeemeda“dependentIndiancommunity”forthepurposesof18U.S.C.1151(whichdefines“IndianCountry”forpurposesofcertainfederalcriminallaws).Sec.815.SenseofCongressRegardingLawEnforcementandMethamphetamineIssuesinIndianCountry.DeclaresthatCongressencouragesmemorandaofagreementamongstate,local,andtriballawenforcementagenciestostreamlinelawenforcementandmaximizelimitedresourcesinordertoimprovelawenforcementservicesinIndiantribalcommunitiesandaddressproblemsrelatedtomethamphetamineuseinIndianCountry.Sec.816.PermittingImplementationthroughContractswithTribalHealthPrograms.ProhibitsconstruinganyprovisionofthisActaspreventingtheSecretaryfromcarryingouttheActthroughcontractswithTribalHealthPrograms,orfromcarryingoutspecifiedsectionsinTitlesIIandVIIofthisActthroughcontractswithurbanIndianorganizations.Sec.817.AuthorizationofAppropriations;Availability.AuthorizesannualappropriationsofsuchsumsasnecessarytocarryoutTitleVIII.

TITLEICONTINUED–AMENDMENTSTOINDIANLAWS

Sec.3102.SobobaSanitationFacilities.AuthorizessanitationfacilitiesfortheSobobaBandofMissionIndians.Sec.3103.NativeAmericanHealthandWellnessFoundation.DirectstheSecretarytoestablishtheFoundationandspecifiesthattheFoundation’sdutiesaretoencourage,accept,andadministerprivategiftsofpropertyandincomeforthebenefitof,orinsupportof,themissionofIHS;toundertakeactivitiesthatwillfurtherthehealthandwellnessactivitiesandopportunitiesofNativeAmericans;andtoparticipatewithandassistfederal,state,andtribalgovernments,agencies,entities,andindividualsinsuchundertaking.Sec.3104.GAOStudyandReportonPaymentsforContractHealthServices.RequirestheGAO,inconsultationwithIHS,tribes,andtribalorganizations,tostudytheuseofhealthcareservicesprovidedunderthecontracthealthservices(CHS)program.TITLEII.IMPROVEMENTOFINDIANHEALTHCAREPROVIDEDUNDERTHESOCIALSECURITYACT

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Sec.3201.ExpansionofPaymentsunderMedicare,MedicaidandSCHIPforAllCoveredServicesFurnishedbyIndianHealthPrograms.AmendstheSocialSecurityActtoprovidethatIndianHealthProgramsareeligibleforMedicareandMedicaidpaymentsforallitemsandservicesiftheprovisionofthoseservicesmeetsalltheconditionsandrequirementsgenerallyapplicabletothedeliveryofsuchcareundereachrespectiveprogram.Sec.3202.AdditionalProvisionstoIncreaseOutreachto,andEnrollmentof,IndiansinSCHIPandMedicaid.AmendstheSocialSecurityActtoensurepaymentforchildhealthservicesprovidedtoIndianchildrenwhoareCHIPeligible.Sec.3203.SolicitationofProposalsforSafeHarborsundertheSocialSecurityActforFacilitiesofIndianHealthProgramsandUrbanIndianOrganizations.DirectstheSecretary,throughtheHHSInspectorGeneral,topublishanoticesolicitingaproposal,notlaterthanJuly1,2010,onthedevelopmentofsafeharborsforhealthcareitemsandservicesprovidedbyIndianHealthProgramsorurbanIndianorganizations.Sec.3204.AnnualReportonIndiansServedbySocialSecurityActHealthBenefitPrograms.RequirestheSecretary,beginningJanuary1,2011,andactingthroughCMSandIHS,tosubmitanannualreporttoCongresscoveringtheenrollmentandhealthstatusofIndiansreceivingitemsorservicesunderthehealthbenefitprogramsfundedundertheSSAduringtheprecedingyear.Sec.3205.RecommendationstoImproveInterstateCoordinationofMedicaidandSCHIPCoverageofIndianChildren.RequirestheSecretarytoconductastudytoidentifybarrierstointerstatecoordinationofenrollmentandcoverageofMedicaid‐enrolledandSCHIP‐enrolledchildrenwhofrequentlychangetheirstateofresidenceormaybetemporarilyoutsidetheirstateofresidenceforavarietyofreasons(e.g.,educationalneeds,familymigration,andemergencyevacuations).